Diversicare Of Big Springs

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, a review of the, Grievance Log and a facility policy titled, Customer Concern (Grievance) Policy, the facility failed to ensure the grievance process was followed when RI (Resident Identifier) #149's sponsor filed a grievance on 07/30/21. This deficient practice affected RI #149 one of three residents whose grievances were reviewed. Findings include: On 11/03/21, the State Agency received a complaint which alleged RI #149's missing clothes would be replacement and mailed to the complainant, however, the complainant had not received them. A review of a facility policy titled, Customer Concern (Grievance ) Policy, with an effective date of July 2018 revealed: .PURPOSE Support each customer's (patient's/resident's) right to voice concerns (grievances) and to ensure after receiving a concern, the center actively seeks a resolution and keeps the customer appropriately apprised of its progress toward resolution. PROCESS: . It is best practice for the Administrator to follow up with…

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 observations, interviews and record review, the facility failed to ensure Resident Identifier (RI) #45's 02 (Oxygen) tubing/humidifier water bottle was dated and labeled; and the resident's nebulizer mask was stored in a covering on three of three days of survey. These deficient practices affected RI #'s 45 one of four residents sampled for oxygen therapy. Findings include: (1) RI #45 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Acute and Chronic Respiratory Failure and Dependence on Supplemental Oxygen. RI #45's January 2022 Order Summary Report (Physician Orders) revealed RI #45 had physicians orders to apply oxygen at 3 liters via (by way) nasal cannula as needed for SOB (shortness of Breath), and Albuterol Sulfate Nebulization Solution 1 vial via nebulizer three times a day. On 01/25/2022 at 5:35 PM, the surveyor observed RI #45's 02 infusing by way of a nasal cannula/concentrator. RI #45's 02 tubing was not dated/labeled, and RI #45's nebulizer face mask…

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 and facility documents titled Team Member In-Service Record the facility failed to include DementiaTraining in the required 12 hour annual training for CNAs (Certified Nursing Assistants), Employee Identifiers' (EI) EI #1 and EI #2. This deficient practice affected 2 of 9 CNA's whose training records were reviewed for Dementia Training. Findings Include: Review of EI #1 and EI #2 Team Member In-Service Record revealed the CNAs had not received Dementia Training as required to be included in their annual training for the year 2020. EI #1 was hired 01/04/2018. EI #2 was hired 01/07/2020. On 03/26/21 at 10:40 AM, an interview was conducted with EI #9, Director of Clinical Operations. EI #9 was asked what Dementia Training have EI #1 and EI #2 received. EI #9 said they had not received any. EI #9 was asked why was there no CEU (Continue Education Units) training for EI #1and EI #2. EI #9 said because their corporate office called back and stated that the 2020 training had dropped off for 2020 and they did not complete the program. EI #9 was asked who was responsible…

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 observations, interviews, and the Food and Drug Administration (FDA) 2017 Food Code, the facility failed to ensure: 1. the three-compartment sink and the food preparation sink drain pipes did not extend into the floor drains to create potential for backflow; 2. condensation from an air conditioning ventilation duct did not drip onto the surface of a food assembly area and onto individually wrapped ready-to-eat food; and 3. milk in the milk cooler was not expired. This had the potential to affect 108 residents receiving meals from the kitchen, 108 of 112 residents. Findings Include: 1. A review of the FDA 2017 Food Code revealed: . 5-402.11 Backflow Prevention. (A) . a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. An observation made on 7/15/19 at 4:19 PM, revealed the food preparation sink's drain pipe descending into the floor drain. The pipe descended below the floor grade. An observation on 7/16/19 at 9:13 AM, was made of the three-compartment sink. The drain…

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, and review of the document titled, Resident Assessment Instrument User's Manual Version 3.0,the facility failed to ensure a timely Minimal Data Set (MDS) quarterly assessment was completed for Resident Identifier (RI) #2. This affected one of twenty-four sampled residents. Findings Include: A review of a document titled, Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.16 , with a revised date of October 2018, page 2-17, revealed: RAI OBRA (Omnibus Budget Reconciliation Act)-required Assessment Summary .Quarterly (Non-comprehensive) . Assessment Reference Date (ARD) .No later than .ARD of Previous OBRA assessment of any type + 92 calendar days .Regulatory Requirement .(every 3 months) . RI #2 was admitted to the facility on [DATE] with a diagnosis of heart failure, unspecified. On 7/18/19 at 11:13 AM a review of RI #2's MDS revealed no MDS assessments were completed since the 3/07/2019 Significant Change in Status MDS. On 7/18/19 at 11:43 AM an…

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, interview and record review, the facility failed to ensure that Oxygen cannula tubing was provided with a date when changed out by nursing. This affected Resident Identifier (RI) #6, one of two residents who were observed with utilizing oxygen therapy. Findings include: RI #6 was admitted to the facility on [DATE]. Diagnoses included chronic respiratory failure and chronic obstructive pulmonary disease. A review of RI #6's physician's orders included Oxygen 3 liter per nasal cannula . On 07/17/19 at 03:38 PM, an observation was made of RI #6's oxygen in use per nasal cannula with oxygen concentrator. The oxygen concentrator machine was set on 3 liters per nasal cannula. The water bottle was dated 7/15/19, however, the nasal cannula tubing was not dated. On 07/18/19 at 09:33 AM, a second observation was made of the oxygen in use by nasal cannula with oxygen concentrator. The oxygen concentrator machine was set on 3 liters per nasal cannula. The water bottle was dated 7/15/19, however, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, interview and review of a facility document titled, Medication error, the facility failed to ensure Resident Identifier (RI) #107's order for Eliquis 5 milligrams (MG) by mouth (PO) twice a day (BID) with no end date was not discontinued in error by a licensed nurse on 07/08/19. The medication error was significant due to the drug's classification as an anticoagulant. This affected RI #107, one of 24 sampled residents whose medications were reviewed. Findings Included: A review of a facility document titled, Medication error, with the Date: 7/17/2019, documented: .Incident Description Nursing Description: Resident's eliquis was discontinued in error by nursing caring for (him/her) on 7/8/19 . Immediate Action Taken Description: Contacted M.D., received verbal order for eliquis 5mg, 2 tabs(tablets) PO BID x (times) 7 days, then eliquis 5mg PO BID x 6 months . RI #107 was admitted to the facility on [DATE]. A review of RI #107's medical record revealed a Doppler Report with a Date…

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 interview, and review of Resident Identifier (RI) #260's medical record, the facility failed to ensure that the Code Status for RI #260 matched through-out the medical record. This deficiency affected one of one resident reviewed for accurate code status. Findings include: RI #260 was admitted to the facility on [DATE] with diagnosis to include small cell lung cancer. On [DATE] at 4:06 PM a more thorough investigation of RI #260's medical record revealed that the code status differed in multiple areas. The first page of the medical record had a page with a stop sign and DNR, the second page was the resuscitation order depicting No Cardiopulmonary resuscitation (CPR), and the third page noted was a bright green paper with big bold letters spelling Full Code. The Care Plan revealed that RI #260 was care planned for full code, while the Physicians orders dated [DATE] included Do not resuscitate (DNR) On [DATE] at 04:50 PM, an interview with Employee identifier (EI) #6 Registered Nurse, Unit Manager 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 observations, interviews, medical record reviews and review of a facility policy titled, Handwashing/Hand Hygiene, the facility failed to ensure: 1. a Certified Nursing Assistant (CNA) changed gloves after providing incontinence care for Resident Identifier (RI) #107 before touching the resident's bed covers and washed her hands after removing her gloves before leaving RI #107's room; and 2. a CNA washed her hands after removing her gloves and applying clean gloves during incontinence care for RI #34. These deficient practices affected RI #107 and #34, two of 24 sampled residents. Findings Included: A review of a facility policy titled, Handwashing/Hand Hygiene, with an Effective Date: November 1, 2017, documented: . Policy Interpretation And Implementation . 2. All team members shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other team members, residents, and visitors.5. Use an alcohol-based hand rub or, alternatively, soap . and water for the following…

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.