Community Springs Healthcare Facility

Based on interview and record review, the facility failed to support each resident's right to self-determination related to care when staff failed to care plan and provide showers per residents' preference for three residents (Resident #3, #28, and #6). Review of the facility's policy titled, Personal Hygiene, revised 03/2023, showed the following: -Purpose to establish guidelines for ensuring the hygiene needs of residents are addressed and met; -Purpose to identify the roles of the nursing staff and the patients in maintaining the patients' and residents' personal hygiene; -Staff are to assist with personal hygiene tasks as patients need; -If a patient is unable to care for self, nursing staff will provide full assist with bathing, changing clothing, oral care and other needs; -Patients are expected to shower at two-day intervals or more frequently when requested or required, maintain dental hygiene, wear clean clothes, and take care of personal grooming. 1. Review of Resident #3's Patient Information, showed the following: -admission date of 07/13/22; -Diagnoses included of…

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 interview, the facility failed to ensure each resident's care plan was updated and review for accuracy timely when the care plans of five residents (Resident #37, #31, #33, #10, and #26) were not updated to reflect the residents' current conditions. Review of a facility's policy titled, Assessments in Long Term Care. dated 12/2024, showed the following: -The nursing care plan will be initiated according to identified needs from the admission assessment by a licensed nurse; -Licensed nursing personnel will update care plans as needs are assessed; -The dietitian, social worker, and rehabilitation personnel can assess patients, within the scope of their service and will integrate information into the medical record and assist in identifying and assigning priorities for the resident care needs via the care plan and progress notes. 1. Review of Resident 37's Patient Information showed the following: -admission date of 08/12/24; -Diagnoses included dementia. Review of the resident's Minimum Data Set (MDS - a federally mandated assessment completed by facility…

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 interview and record review, the facility failed to ensure all allegations of possible abuse were reported to the State Survey Agency (SSA - Department of Health and Senior Services (DHSS)) within two hours when staff failed to report an allegation of possible sexual abuse by one resident (Resident #37). Review of the facility policy titled, Patient Abuse/Neglect, Elder Abuse, and Persons with Disability Abuse, dated 08/2024, showed the following: -Purpose to guide staff, employees, physicians, and any mandated reporter in identifying victims of abuse and provide a reporting mechanism in accordance with all local, state and federal laws; -Purpose to provide safe and efficient care for the patients/residents; -Purpose to keep patients/residents free from abuse, mistreatment, and neglect. 1. Review of Resident #37's Patient Information showed the following: -An admission date of 08/12/24; -Diagnoses included dementia and agitation. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), with an Assessment…

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 interview, the facility failed to ensure all allegations possible abuse had documented complete investigations when staff failed to document a full investigation of an allegation of possible abuse by one resident (Resident #37). Review of a facility policy titled Patient Abuse/Neglect, Elder Abuse, and Persons with Disability Abuse, dated 08/2024, showed the following: -Personnel will complete an electronic Incident Report for further investigation by the designee(s), nursing administration, the Administrator, and/or other disciplines within the facility or outside to ensure resident safety and quality of care. 1. Review of Resident #37's Patient Information showed the following: -An admission date of 08/12/24; -Diagnoses included dementia and agitation. Review of a the resident's Behavior Monitoring, dated 12/28/24, showed the resident asked another resident to expose his/her breasts. Review of Department of Health and Senior Services (DHSS) records showed a written investigation regarding the allegation of possible abuse was not received. During 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.

Based on record review and interview, the facility failed to ensure the accuracy of all Minimum Data Sets (MDS - a federally mandated assessment completed by facility staff) when staff failed to accurately complete one resident's (Resident #56) MDS. Review of the RAI Manual, dated October 2023 showed the following: -Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions; -The hospice must be licensed by the state as a hospice provider and/or certified under the Medicare program as a hospice provider. 1. Review of Resident #56's Patient Information, showed the following: -An admission date of 06/22/24; -Diagnoses included Alzheimer's disease. Review of the resident's quarterly MDS, with an assessment reference date (ARD) of 12/12/24, showed the following; -The resident had cognitive impairment; -The resident independent with all activities of daily living (ADL); -The resident received hospice care. Review of the resident's medical record…

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 develop a person-centered comprehensive plan of care with measurable goals and plans for one resident (Resident #57) related to the resident taking antidepressant and an anti-anxiety medication. Review of the Minimum Data Set (MDS - a federally mandated assessment completed by facility staff) 3.0 Resident Assessment Instrument (RAI) Manual, dated 10/2024, showed the following: -The RAI process, which includes the federally mandated MDS, is the basis for an accurate assessment of nursing home residents; -The MDS information and the CAA (Care Area Assessment) process provide the foundation upon which the care plan is formulated; -There are 20 problem-oriented CAAs, each of which includes MDS-based trigger conditions that signal the need for additional assessment and review of the triggered care area; -Detailed information regarding each care area and the CAA process, including definitions and triggers; -After completing the MDS and CAA portions of the comprehensive assessment, the next step is to evaluate 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 record review and interviews, the facility failed to ensure services were provided per standards of practice for all residents when staff failed to document timely follow-up regarding a possible bruise and failed document regarding resident's wishes to have an area removed for one resident (Resident #5). 1. Review of Resident #5's Patient Information, showed the following: -admission date of 01/20/24; -Diagnoses included urinary tract infection. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), with an assessment reference date (ARD) of 11/20/24, showed the following: -The resident had cognitively impairment; -The resident required moderate assistance with dressing and toileting and setup with eating and oral hygiene; -The resident had no other skin problems present and did have a pressure reducing device for his/her bed. Review of the resident's Nurse Note, dated 11/22/24, showed upon resident return to facility from outing the family reported several concerns. The resident had a bruise on the back of…

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, record review, and interview, the facility failed to establish procedures to estimate the water needed and ensure that water was available to essential areas if there was a loss of normal water supply, such as in an emergency. The facility has a capacity of 120 and had a census of 60 at the time of survey. Review of a Centers for Disease Control and Prevention (CDC) document named Emergency Water Supply Planning Guide for Hospitals and Healthcare Facilities, dated 2019, showed that water needs can vary greatly from facility to facility, but general guidelines show a need of one to three gallons of water needed per person, per day for consumption and sanitary needs. 1. Review of the facility's Emergency Operation Plan (EOP) showed the EOP hazard assessment stated the risk of loss of water supply as moderate. The EOP did not show any calculation of water needed per person, in case of emergency. The EOP did not show a facility-specific manner on how to obtain sufficient water for residents and staff in case of emergency. Review of a letter to the facility 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.

Based on observation, interview, and record review, the facility failed to ensure food was protected from contamination at all times when staff touched resident food with bare hands and failed to complete hand hygiene after touching soiled surfaces during meal service. The facility census was 60. Review of the Food and Drug Administration (FDA) 2013 Food Code showed foods that are ready to eat should not be touched by staff's bare hands. Review of the facility Competencies for Food and Nutrition Services Employees checklist, undated, showed the following: -Practice appropriate hand hygiene and glove use when necessary during food preparation activities, such as between handling raw meat and other foods, to prevent cross-contamination; -Properly wash hands before serving food to resident after collecting soiled plates and food waste; -Prevent eating surfaces of dishware from coming into contact with staff clothing; -Handle cups/glasses on the outside of the container and knives, forks, and spoons by handles; -Practice hand hygiene after direct contact with resident's skin or…

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 all residents were cared for in manner that provided dignity and respect when staff failed to ensure catheter (tubing to drain the bladder) collection bags were placed inside a dignity bag (bag which prevents urine from being seen) for one resident (Resident #42). A sample of three residents with indwelling catheters was reviewed. The facility census was 60. Review of a facility policy entitled Urinary Catheterization, revised 08/2022, showed the policy did not include information pertaining to the use of a privacy bag for dignity. 1. Review of Resident #42's face sheet (a form that provides basic profile information) showed the following: -admission date of 05/18/21; -Diagnoses included urinary tract infection (UTI), prostate cancer, obstructive and reflux uropathy (prevents normal emptying of the bladder), and bladder infection. Review of the resident's significant change Minimum Data Set (MDS - a federally mandated assessment tool completed by facility staff), dated 06/13/23, showed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to complete a documented side rail assessment including risks versus benefits, obtain written consent, obtain a physician order, and complete gap assessments prior to installing side rails for two residents (Residents #53 and #45) in a sample of eight residents with bed rails in use. The facility census was 60. Review of the facility policy entitled Bed Rails and Support Device in Long Term Care, revised 02/2023, showed the following: -Side rails/support devices are utilized if an assessed need is identified by the interdisciplinary team (IDT); -The IDT should complete and document assessment of side rail need; -Staff may utilize the LTC Device Decision Guide to assist with determining whether or not the device is considered a support device or restraint; -Bed rails and support devices require a physician order; -Family or guardian will be notified and consent obtained for use of side rails; -Use of side rails should be added to the resident…

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 adhere to professional standards when staff failed to properly disinfect glucometers (small hand-held devices that check blood glucose (sugar) levels for residents) while collecting blood glucose samples on residents with a diagnosis of diabetes mellitus (a disease that affects how a person's body handles insulin and glucose levels in the blood). This practice affected six residents (Resident #7, #10, #12, #19, #23, and #35) out of a sample of 16. The facility census was 61. Record review of the Centers for Disease Control and Prevention (CDC) website showed the following information: -Blood glucometers approved for use for more than one person must be cleaned and disinfected. The CDC investigated multiple outbreaks of viral hepatitis (disease affecting the liver) among residents in long-term care (LTC) communities that were attributed to shared devices and other breaks in infection-control practices related to blood glucose monitoring devices. When blood glucose monitoring devices are shared between…

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.