Village At Cook Springs Skilled Nursing Facility

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, resident record review, and a facility policy titled Perineal Care (Incontinent Care), the facility failed to ensure a Certified Nursing Assistant (CNA) #4 provided perineal care for Resident Identifier (RI) #6 to correctly and thoroughly clean RI #6 during incontinent care on 12/19/2023. This had the potential to affect one of three sampled residents with urinary incontinence. Findings include: A facility policy titled Perineal Care (Incontinent Care) with an effective date of 6/20214 documented: PURPOSE: Good perineal care helps prevent infections, irritation, and skin breakdown. STANDARD: Residents who are incontinent of urine or feces should receive perineal care as needed. Residents should receive perineal care during routine baths or showers. PROCESS: 1. General . b) Remove any fecal matter or urine wiping with tissue from front to back. c) Pre-moistened disposable wipes or washcloth should be used. 2. a) Wash pubic area first, washing from front to back; use a different…

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, resident record review, and review of the training book How to Be a Nurse Assistant a Quality Approach to Long Term Care the facility failed to ensure Certified Nursing Assistant (CNA) #3, did not create the potential for cross-contamination during incontinent care for Resident Identifier (RI) #8 on 12/19/2023 when she was observed not washing or sanitizing her hands after doffing dirty gloves before touching the clean gloves and not washing hands after perineal care was completed. This had the potential to affect one of three residents who were observed for incontinent care. Findings include: The training book American Health Care Association's HOW TO BE A NURSE ASSISTANT A QUALITY APPROACH TO LONG TERM CARE, eighth edition by [NAME], RN, used by the facility for training purposes, documented on page 68: . Hand Hygiene . Before and after contact with a resident or their environment . Before putting on gloves . After removing gloves . RI #8 was admitted to the facility 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.

Based on interviews, review of the facility's policy titled Abuse, Neglect, and Exploitation and Resident Identifier (RI) #61's and RI #141's medical record, the facility failed to timely report allegations of physical abuse to the State Agency involving RI #61 and RI #205 and RI #52 and RI #141. On 1/30/2019, RI #205 hit RI #61 in the face. The residents were immediately separated and no injuries were noted. The facility reported this allegation to the State Agency on 7/19/2019. On 5/3/2019, RI #141 hit RI #52 on the arm, twice before the Certified Nursing Assistant (CNA) could intervene.The facility reported this allegation to the State Agency on 7/10/2019. This affected two of five allegations of abuse reviewed the survey. Findings include: The facility's policy titled Abuse, Neglect, and Exploitation with an effective date of 11/2016 documented . Process . V. Response and Reporting of Abuse, Neglect, and Exploitation (including injuries of unknown souce, and misappropriation of resident property) The following outlines steps to be taken during an investigation. These steps may…

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 review of Resident Identifier (RI) #117's medical record, the facility failed to ensure Employee Identifier (EI) #11, a Certified Nursing Assistant (CNA) washed her hands after handling RI #117's wet incontinence brief and before touching the resident's clean incontinence brief. This affected RI #117, one of three sampled residents observed for incontinence care. Findings include: RI #117 was readmitted to the facility on [DATE]. RI #117's Significant Change in Status Assessment with an assessment reference date of 7/4/2019 indicated the resident was assessed as requiring extensive assistance with toileting and being frequently incontinence of bowel and bladder. During the provision of incontinence care on 7/11/2019 at 9:15 AM, EI #11, a CNA removed RI #117's wet incontinence brief. After EI #11 cleansed the resident, she went to the resident's closet and removed a clean incontinence brief. EI #11 did not wash her hands or remove her gloves before she touched RI #117's clean…

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 a review of a facility policy titled ,Food, Leftover-Storage and Use and a document titled, Food Code, the facility failed to ensure: 1. eleven honey thickener waters were not in the cooler passed the use by date of 2/5/18; 2. a worker washed her hands after dropping a thermometer cover to the floor and before taking the temperature of a milk and; 3. plates were free of debris in the plate warmer. This was observed on one of three days of the survey and had the potential to affect 151 of 151 resident who received meals from the kitchen. Findings Include: 1) A review of a facility policy titled Food, Leftover-Storage and Use, with an effective date of 7/2016 revealed: PURPOSE: To assure that food borne illnesses are avoided .PROCESS 9. Opened bulk items that require refrigeration once opened may be stored up to thirty (30) days but not beyond the best by or expiration date then discarded. On 8/14/18 at 8:40 a.m., the surveyor toured cooler #2 with EI #9, Dining Service Manager. The surveyor observed eleven Ready Care Lemon Flavored water Honey…

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, interview and record review, the facility failed to ensure the air conditioner temperature in Resident Identifier (RI) #37's room was not below 71 degrees. The temperature on the unit on 8/16/18 at 9:30 AM read at 69 degrees. Findings Include: RI #37 was admitted to the facility 10/14/16 with diagnoses of Unspecified Atrial Fibrillation and Other Abnormalities of Gait and Mobility. A review of RI #37's Quarterly Minimal Data Set (MDS) with an Assessment Reference Date of 5/31/18 revealed a Brief Interview for Mental Status score of 11, indicating minimal difficulty with cognitive status. RI #37 was also coded for extensive assistance with transfers. A review of a Daily Care Guide for RI #37 revealed: : .Interventions .8/15/2018 Resident representative has asked the room air conditioner unit to be set for 74 degrees as the resident allows. On 8/16/18 at 9:30 AM, the surveyor observed RI #37's daughter enter RI #37's room. RI #37 told the daughter it was cold. The daughter went to the unit opened the cover and the reading was at 69 degrees. The surveyor observed…

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 review a facility policy Medication Administration Medication Administration Guidelines the facility failed to ensure licensed staff did not prepare Potassium liquid for Resident Identifier (RI) # 81 when the Keppra was due to be given. The facility further failed to ensure medication was not left at RI #81's bedside while the staff returned to the medication cart for a stethoscope. This was observed on 8/14/18 and affected one of seven nurses observed for medication administration. Findings Include: A review of a facility policy Medication Administration Medication Administration - General Guidelines with a date of 3/11 revealed: .Procedures . 16. Read medication label and compare with medication administration record before pouring. RI # 81 was readmitted to the facility on [DATE] with a diagnosis of Seizures. A review of RI #81's August 2018 Physician's Order revealed: .POTASSIUM CL (chloride) 10% .GIVE 7.5 ML (milliliters) . EVERY DAY .6 AM .LEVETIRACETAM (Keppra) .GIVE 10…

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, interview and review of a facility policy : Medication Storage,the facility failed to ensure the secured medication box in the refrigerator on Hall I was locked. This was observed on 8/16/18 and affected one of two refrigerated secured medication storage boxes and had the potential to affect Resident Identifiers (RI) #2, 29, 56, 90, 113 and 136, six of six residents whose Lorazepam (Ativan) medication was stored in the refrigerated box. Findings Include: A review of a facility policy Medication Storage dated 3/11 revealed: .Procedures .7. Controlled medications are stored separately from other medications in a locked drawer or compartment designated for that purpose. On 8/16/18 at 10:15 AM, the medication room on Hall I was observed with Employee Identifier (EI) #8, Registered Nurse( RN). EI #8 opened the refrigerator and the surveyor asked her to remove the secured box. EI #8 replied the box did not come out. The surveyor asked if the secured box was locked. EI #8 replied, no. EI #8 was asked if the secured box should be locked. EI #8 replied, yes. EI #8 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 observation, interview, record review and review of facility policy Hand Washing (Infection Control) and Medication Administration the facility failed to ensure licensed staff: 1. did not carry a stethoscope used to check a gastrostomy tube placement with the same soiled gloves she had on to administer Resident Identifier (RI) #81's gastrostomy medication then return it to the medication cart, 2. washed her hands between gloves changes while performing wound care for RI #73; and 3. did not store packaged medication in a water cup in the medication cart then use the same cup for water to give to RI #138 the scheduled medication. These findings were observed on 8/14/18 and 8/15/18 and affected RI #81 one of one observed for Gastrostomy tube medication pass, RI #73 one of one observed for wound care, and RI #138 one of seven observed for medication pass observation. Findings Include: 1. A review of a facility policy titled, Medication Administration with a date of 3/11 revealed: . Procedures .3. The charge…

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.