The Healthcare Center At Buck Creek

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and a review of the facility's policy titled, Abuse, Neglect, Misappropriation, Exploitation Policy, the facility failed to protect Resident Identifier (RI) #4 from being physically abused by RI #5. On 05/16/2024 Certified Nursing Assistant (CNA) #5 witnessed RI #5 slap RI #4 on the face in their room. This deficient practice affected RI #4 and RI #5, two of 19 residents sampled for abuse. Findings Include: A review of the facility's policy titled, Abuse, Neglect, Misappropriation, Exploitation Policy, with an effective date of January 2019, revealed: .Purpose: To prohibit and prevent abuse . Definitions: Abuse: The willful infliction of injury . resulting physical harm, pain, or mental anguish.Willful, as use in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. 5. Identification . A resident to resident altercation will be reviewed as a potential situation of abuse. RI #4 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, the facility policy titled Abuse, Neglect, Misappropriation, Exploitation Policy, and review of facility reported incidents (FRIs) information submitted to the Alabama Department of Public Health (ADPH) via the Online Incident Reporting System; the facility failed to submit their five-day investigative summary or results of their investigations for two of 18 FRIs concerning allegations of abuse, neglect, or misappropriation of resident property reviewed for timely reporting. This deficient practice affected Resident Identifier (RI) #6 and RI #22 two of 19 residents reviewed for abuse concerns. Findings Include: A review of a policy titled Abuse, Neglect, Misappropriation, Exploitation Policy with an effective date of January 2019. documented the following: .7. Reporting/Response .The results of all investigations must be reported to the Administrator, designee to the appropriate state agency, as required by state law, within five (5) working days of the alleged violation . RI…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review and facility policies titled Room & Roommate Change Policy, the facility failed to notify Resident Identifier (RI) #5 of a room change prior to the move. This affected Resident Identifier (RI) #5, one of one resident who expressed dissatisfaction with their room change. This deficiency was cited as a result of the investigation of complaint/report number AL00047738. Findings include: A review of an undated facility's policy titled Room and Roommate Change Policy documented: .PROCEDURE .The Resident has the right to refuse to transfer to another room in the Center if the purpose of the transfer is . c. Solely for the convenience of staff . RI #5 was admitted to the facility on [DATE], with diagnoses to include Unspecified Dementia. A review of a progress note for RI # 5 documented . 04/29/2024 . This resident was transferred from North wing (he/she) was alert and oriented to person and place with some confusion noted . On 05/01/2024 at 5:30 PM, an interview was conducted with RI…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, interviews, and a facility policy titled Abuse, Neglect, Misappropriation, Exploitation Policy, and review of information from the Alabama Department of Public health's (ADPH) Online Reporting System, the facility failed to ensure staff implemented the facility's abuse policies and procedures when: staff failed to identify an allegation of abuse, protect residents from further potential abuse, and immediately report an allegation of verbal abuse on [DATE] involving Resident Identifier (RI) #5 and Licensed Practical Nurse (LPN) #12. Certified Nursing Assistant (CNA) #9, and CNA #10 became aware of the allegation, but did not report the incident for three days following the incident. On [DATE] Certified Nursing Assistant (CNA) #9 observed LPN #12 stand up and say she was going to go to RI #5's room and call his/her dead mother a bitch and she did not report the incident as LPN did not take any action only making a verbal threat. On either [DATE] or [DATE] CNA #10 overheard LPN #12 on the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on an interview, review of facility personnel files, review of a facility policy titled Abuse, Neglect, Misappropriation, Exploitation Policy, the facility failed to ensure Certified Nursing Assistant (CNA) #6 and CNA #7 had initial Alabama Certified Nurse Aide Registry and criminal background checks completed before being hired by the facility. This deficient practice affected CNA #6 and CNA #7, two of six CNAs whose personnel files were reviewed. Findings include: Review of a facility policy titled Abuse, Neglect, Misappropriation, Exploitation Policy, with an effective date of 1/2019, revealed the following: Purpose: To prohibit and prevent abuse, neglect, exploitation, misappropriation of resident property . 2. Screening Each center will follow any and all state specific requirements Potential team members shall, at a minimum, have the following screening checks conducted: . 2. Appropriate licensing board or registry check . 4. Criminal background check pursuant to company policy or state law . A review of personnel files for CNAs revealed CNA #6 was hired on 11/29/2022…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews, review of the facility's RECORD OF MEDICATION DISPOSAL sheets for the Non-Controlled Drugs, and review of a facility policy titled, RULES OF ALABAMA STATE BOARD OF HEALTH ALABAMA DEPARTMENT OF PUBLIC HEALTH CHAPTER 420-5-10 NURSING FACILITIES, the facility failed to ensure the required signatures were on the non-controlled medication destruction sheets. This deficient practice affected one of 12 months of non-controlled medication destruction sheets reviewed for 2023. Findings include: Review of an undated facility policy titled, RULES OF ALABAMA STATE BOARD OF HEALTH ALABAMA DEPARTMENT OF PUBLIC HEALTH CHAPTER 420-5-10 NURSING FACILITIES, revealed the following: 1. The nursing facility develops policies and procedures for the destruction of drugs and biologicals. 7. The pharmacist will verify that the list of drugs to be destroyed is accurate and with a Registered Nurse, will carry out destruction. 22 of 22 RECORD OF MEDICATION DISPOSAL forms reviewed for January 2023, marked for Non-Controlled Drugs disposal, contained only the Pharmacist's signature. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews and a review of a facility policy titled, Pain Assessment and Management, the facility failed to ensure Resident Identifier (RI) #11, a resident with a diagnoses of chronic pain, received pain medication as ordered by physician on 10/12/2022 at 10:00 PM and 10/13/2022 at 6:00 AM. This affected one of three residents sampled for pain concerns. Findings Include: A facility policy titled, Pain Assessment and Management, with an effective date of 05/2021, documented, . The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Implementing Pain Management Strategies: . 6. Implement the medication regimen as ordered, carefully…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, review of resident records, review of a facility policy titled Physician Medication Orders the facility failed to ensure medications were reordered from the pharmacy in a timely manner to have the medication available for administration to RI #55 on 10/13/2022 and RI #11 on 10/12/2022 and 10/13/2022. This had the potential to affect two of 28 sampled residents. Findings include: A facility policy titled Physician Medication Orders with an effective date of 5/2022 documented the following: . 9. Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy per community protocol. 1.) RI #55 was readmitted to the facility on [DATE]. RI #55's physician orders documented an order dated 9/5/2022 for Oxcarbazepine 600 mg one tablet to be given twice a day. On 10/13/2022 at 8:55 AM EI #5 Licensed Practical Nurse (LPN) was observed preparing medications to administer to RI #55. EI #5 said, Oxcarbazepine 600 mg was not in the medication cart and she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, and review of the facility policy titled Controlled Substances, the facility failed to ensure controlled medications were stored in the Building Two refrigerator in a permanently affixed compartment. This was observed on 10/14/2022 in one of four unit medication refrigerators observed. Findings include: A facility policy titled Controlled Substances with an effective date of 9/2022, documented the following: . The facility shall comply with all laws, regulations, and other requirements related to handling, storage, . of Schedule II and other controlled substances. On 10/14/2022 at 3:00 PM, the Building Two medication refrigerator was observed containing a controlled medication emergency kit, a small box with a lock from the pharmacy, with a label description of a Lorazepam Injection two milligrams (mg) per milliliter (ml) and a Lorazepam Intensol (ORAL) two mg/ml with 30 mls quantity, not in a permanently affixed compartment in the refrigerator. Employee Identifier (EI) #3 Building Two unit manager and EI #4 Rehabilitation unit manager both…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interviews and review of a facility procedure guide titled Perineal Care, the facility failed to ensure a staff member changed gloves and performed hand hygiene to prevent the spread of infection. On 03/16/2022, during incontinent care, Employee Identifier (EI) #3, a Certified Nursing Assistant (CNA), removed a dirty incontinent brief from Resident Identifier (RI) #15. The CNA failed to perform hand hygiene and put on clean gloves before placing a clean brief on the resident. This deficient practice affected RI #15, one of two residents observed for incontinent care. Findings Include: An undated facility procedure guide titled Perineal Care documented, . Hand Hygiene. Perform hand hygiene. Apply clean gloves . Prevents transmission of microorganisms. RI #15 was readmitted to the facility on [DATE] and had a history of Urinary Tract Infections. A review of RI #15's quarterly Minimum Data Set assessment with an Assessment Reference Date of 03/08/2022 revealed RI #15 was totally…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.