Buchanan County Health Center

Based on observation, clinical record review, manufacturer's use guide, policy review and staff interview the facility failed to use one blood glucose meter per resident (a device used to monitor blood sugar levels) and properly disinfect shared blood glucose meters according to the Center for Disease Control and Prevention (CDC) and Food and Drug Administration (FDA) guidelines for 5 of 5 residents reviewed (Resident #8, #9, #11, #14 and #34). The facility identified a census of 35 residents.Findings include:1.Observation on 3/17/26 during the morning medication pass from 7:30 AM to 9:00 AM revealed Staff A, Registered Nurse (RN) performed a blood sugar for Resident #34. Staff A returned to the medication cart, wiped the blood glucose machine with an alcohol prep pad, and placed in the medication cart. Staff A was observed on the 400-hallway medication cart. 2.During an interview on 3/18/26 at 8:04 AM, Staff B, RN reported she was a newer nurse to the facility. The nurses had one blood glucose meter in each medication cart that they used for multiple residents. They used an alcohol…

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, policy review, and staff interviews the facility failed to ensure the commercial dishwasher reached hot water sanitizing levels. The facility reported a census of 34 residents. Findings include: During a follow up walk through of the kitchen on 3/18/25 at 12:45 PM, the [NAME] model CL44E hot water sanitizing commercial dishwasher had been operating. The dishwasher had a digital display at the top center displaying temperatures for wash and final rinse cycles. The placard on the left side of the dishwasher revealed the following for hot water sanitizing: * Wash temperature 160º Fahrenheit (F) (71º Celsius(C)) minimum * Final rinse temperature 180º F (82º C) minimum, 194º F (90º C) maximum Below the dishwasher to the left a booster heater with a gauge that measures the water temperature from the booster heater to the dishwasher. A line in black permanent marker had been drawn at the 180º F reading. During an interview on 3/18/25 at 1:15 PM with Staff C (Nutritional Services…

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, policy review, staff interview, and review of Kwik Pen Instructions for Use document, the facility failed to prime the needle of an insulin pen prior to the intent to deliver insulin to the resident (Resident #17). The facility reported a census of 34 residents. Findings include: Physician orders for Resident #17 include Humalog (Insulin Lispro) 5 units. During an observation of the morning medication pass on 3/20/25 at 8:34 AM, Staff H, Registered Nurse (RN) removed a KwikPen (Insulin Lispro) from the mediation cart. She removed the cap, cleansed the hub with alcohol and attached the needle. She turned the knob the prescribed dose of 5 units, showed the dose to the surveyor and started to apply gloves. When asked if she was committed to giving that dose, she confirmed she was. The surveyor stopped the dose from being given as the needle had not been primed. Staff H acknowledged she should have primed the needle. During an interview on 3/20/25 at 9:38 AM Staff B, RN, Nurse Manager explained she would expect the needle to be primed prior to administration.…

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 record review and staff interview the facility failed to implement a comprehensive care plan with resident specific interventions to assist with identified exit seeking behaviors for 1 of 4 residents reviewed (Resident #1). The facility reported a census of 35 residents. Findings include: The Minimum Data Set (MDS) for Resident #1 dated 8/8/2024 documented a Brief Interview for Mental Status of 3 out of 15 indicating severe cognitive impairment. The MDS also documented she was independent without assistive devices for walking, transferring, and toileting and had no impairment in her upper or lower extremities. The MDS also revealed she had Alzheimer's disease and anxiety disorder. Record review of Resident #1 Care Plan on 11/21/24 lacked resident specific approaches and interventions of what to do when exit seeking. During an interview on 11/26/24 at 12:26 PM Staff G, Licensed Practical Nurse (LPN) informed Resident #1 needed a lot of supervision because she could get upset at times and informed the facility recommended to Resident #1 family she needed to be place in a…

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 document review, employee file review, and staff interview the facility failed to employ a certified nutrition professional and/or director who met the required qualifications in the time frame allowed. The facility reported a census of 37 residents. Findings include: During an interview on 6/03/24 at 9:15 AM the Nutrition Manager reported she is not a Certified Dietary Manager (CDM). She is enrolled in the class but due to staffing issues she had to ask for an extension on the class so she has not completed the class at this time. A 6/05/24 9:15 AM review of the Nutrition Manager's employee file lacked documentation of a Certified Dietary Manager certificate. During an interview on 6/05/24 at 2:08 PM the Clinical Registered Dietician reported she only works part time for the hospital and they allow her 8 hours a week in the long-term care. She spends most of her time doing the Minimum Data Set (MDS) Assessments. The Nutrition Manager is the main one that would do anything kitchen related. She has done some training with the dietary staff in the long-term care but that 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.

Based on observation, policy review, document review, and staff interview, the facility failed to maintain a sanitary kitchen, date food when opened, promote safe food storage, prevent touching of food with dirty gloves, and ensure the proper use of hair restraints when in the kitchen. The facility reported a census of 37 residents. Finding include: During an initial kitchen tour on 6/03/24 at 8:37 AM the following observations were made: a. The microwave had yellow stuck down splatters all along the back wall of the microwave. b. The standing mixer had a yellow crusty substance 1.5 inches long stuck down to the back of the mixer which was not in use. c. The milk cooler had a 10 inch high by approximately 36 inch long by 1 inch in depth build up of frost on each side of the cooler and a 10 inch high by 1 inch high frost build up along the entire back of the milk cooler. d. The bulk rice, flour, and bread crumb bins all 1/4 full were undated. e. The Continental refrigerator contained the following undated items: 1. 1 carton of orange juice 1/4 full 2. 1 tub of chopped garlic in oil…

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 clinical record review, Long Term Care Facility Resident Assessment Instrument (RAI) review, and staff interview the facility failed to complete a significant change Minimum Data Set (MDS) within 14 days of determining a significant change for 1 of 1 resident reviewed for significant change (Resident #5). The facility reported a census of 37 residents. Findings include: The Progress Note dated 4/17/24 written at 2:00 PM documented during the completion of the quarterly MDS it was noted the resident had a decline in multiple areas. The note explained the overall decline was a significant change and an Assessment Reference Date (ARD) was set as 4/29/24. The significant change MDS with an ARD of 4/29/24 was signed as complete on 5/13/24 (26 days after determining a significant change). The RAI 3.0, version 1.17.1 dated October 2019, directs the significant change MDS be completed no later than the 14th calendar day after determining a significant change in resident status has occurred. During an interview on 6/6/24 at 8:57 AM, the MDS coordinator explained she had 14 days from…

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 physician order review, care plan review, and staff interview the facility failed to have anticoagulant, antibiotic, opioid, insulin, and diuretic medications and potential side effects to be monitored on the resident care plan for 4 of 7 residents reviewed (Residents #5, #6, #13, and #15). The facility reported a census of 37 residents. Findings include: 1. Resident #5's Order Review History Report electronically signed by the Advance Registered Nurse Practitioner (ARNP) on 4/26/24 listed medication orders including: Azithromycin (antibiotic) 250 milligrams (mg) by mouth Monday, Wednesday, and Friday Lasix (diuretic medication fluid pill) 20 mg by mouth daily Lorazepam (anxiety medication) 0.5 mg by mouth daily Resident #5's Care Plan lacked signs, symptoms, or side effects of the medications to be monitored for any of the medications listed. 2. Resident #13's Order Summary Report signed by the Medial Doctor (MD) on 5/6/24 listed medication orders including: Amoxicillin (antibiotic) 250 mg by mouth…

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 clinical record review, observation, and staff interview, the facility failed to ensure a resident with limited range of motion received the appropriate assistance to prevent decline or maintain mobility for 1 of 2 residents sampled (Resident #15). The facility identified a census of 37 residents. Findings include: Resident #15 Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status score of 11 indicating moderate cognitive loss. The MDS documented Resident #15 utilized a walker and a wheelchair and had a functional impairment in upper body range of motion on one side with diagnoses of neurologic neglect syndrome, foot drop of the right foot, effusion of the left ankle, pain in the left foot and ankle joint, and generalized muscle weakness. The MDS lacked documentation of a nursing restorative program. The Resident's electronic diagnosis list included a diagnosis of personal history of other diseases of the circulatory system. A Restorative Program Note dated 12/5/2023…

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.