Nhc Healthcare, West Plains

Based on observation, interview, and record review, the facility failed to ensure an environment free from accident hazards. Staff failed to secure access to soiled laundry and chemicals in an unlocked soiled linen laundry room. The room contained a sink basin of bleach water and an open container of multipurpose cleaner solution. The unlocked, unlatched soiled linen room presented a potential hazard to all residents who were able to move freely around the facility with 14 residents at increased risk due to their mental capacity from a diagnosis of dementia (a group of thinking and social symptoms that interferes with daily functioning) or Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). The facility census was 61. Review of the facility policy titled, Chemical Storage, undated, showed: - Keep chemicals locked up away from patients when not in use. Review of the Product Specification Document titled, Rapid Multi-Surface Disinfectant Cleaner, dated 10/19/23, showed: - Keep out of reach of children; - Precautions: Concentrate is…

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 maintain proper infection control practices during incontinent care for two residents (Residents #5 and #16) out of four sampled residents, catheter (a tube inserted into the bladder to drain urine) care for one resident (Resident #21) out of one sampled resident, and wound care for two residents (Residents #5 and #58) out of two sampled residents. The facility failed to ensure proper infection control measures during administration of insulin for one resident (Resident #37) out of one sampled resident and touched medications with bare hands for one resident (Resident #118) out of five sampled residents. The facility also failed to ensure proper infection control measures during laundry services. The facility census was 61. Review of the facility's policy titled, Safety and Sanitation Best Practice Guidelines, dated 11/2017, showed: - Glove use should never take the place of the first and primary barrier against germs, proper handwashing;…

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 a urinary indwelling catheter (a tube inserted into the bladder to drain urine) drainage bag was kept off the floor for one resident (Resident #61) out of three sampled residents. The facility census was 61. Review of the facility's policy titled, Catheter Care, undated, showed: - The policy didn't address catheter tubing or drainage bags not touching the floor. 1. Review of Resident #61's medical record showed: - admitted on [DATE]; - Diagnosis of urine retention. Review of the resident's Physician Order Sheet (POS), dated February 2025, showed: -An order to change the indwelling/suprapubic (catheter inserted through the abdomen into the bladder for urine drainage) catheter every 30 days. Insert the catheter size 16 French (Fr- the measurement used to measure sizes of urinary catheters) and bulb size 5-10 cubic centimeter (cc) on the 1st of the month, during day 6:00 AM - 06:00 PM. Diagnosis of urinary retention, dated, 01/23/25;…

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 record review, the facility failed to provide documentation of ongoing assessments, monitoring, and communication between the facility and the dialysis (a process for removing waste and excess water from the blood) center for one resident (Resident #264) out of one sampled resident. The facility census was 61. Review of the facility's policy titled, Care of a Hemodialysis Patient, undated, showed: - Will communicate concerns with dialysis center of any pertinent information/changes with communication observation sent with resident; - The hemodialysis access site will be observed every shift to ensure the dialysis dressing is intact and if there are any signs and symptoms of infection. Should signs and symptoms of infection be noted, the physician will be contacted; - The hemodialysis access site will be palpated (to feel or exam the body with hands or fingers) for the presence of a thrill (a vibration caused by blood flow) or auscultated (use a stethoscope to listen to the sounds inside 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, interview, and record review, the facility failed to ensure the medication cart was locked while unattended and failed to ensure a safe medication system when leaving medications unattended and unsupervised for one resident (Resident #16) out of ? sampled residents during a medication pass. This had the potential to affect all residents. The facility census was 61. Review of the facility policy titled, Specific Medication Administration Procedures, dated 01/01/19, showed: - All medication storage areas (carts) are locked at all times unless in use and under direct observation of the medication nurse/technician. Review of the facility policy titled, Medication Storage in the Facility, dated 01/01/19, showed: - Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access; - Schedule II medications are stored in an affixed, double locked compartment separate from all other non-controlled medications; - Bedside medication storage is permitted for residents who wish to self-administer medications, upon the written…

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 keep food safe from potential contamination when staff did not air dry dishes and stacked dishes while still wet which could potentially contaminate any food prepared for residents. The facility census was 61. Record review of the facility's policy, titled Safety and Sanitation Best Practice Guidelines, dated 2003 and revised 11/2017, showed the following information: -Air-dry all items; -Towels may contaminate items; -Make sure all items are completely dry before stacking to prevent wet-nesting (when dishes are stacked wet and promote bacterial contamination). Record review of the 2013 Food Code, issued by the Food and Drug Administration, showed the following information: -After cleaning and sanitizing, equipment and utensils shall be air-dried or used after adequate draining before contact with food. -Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. 1.…

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 and interview, the facility failed to notify the resident and/or the resident's representative in writing of a transfer to a hospital, including the reasons for the transfer, for five residents (Residents #10, #43, #57, #59, and #210). The facility census was 61. Record review of a facility's policy entitled Transfer/Discharge, revised 2/2021, showed the following: -A resident may be transferred or discharged to another health care institution or discharged home upon the written order of the attending physician; -Sufficient information will be provided to the patient to assure continuity of care, regardless of the destination of the patient or the reason for the transfer. (The policy did not give information pertaining to a written notification to the resident and/or resident's representative of a transfer to a hospital.) 1. Record review of Resident #10's nurses' progress notes showed the following information: -On 11/9/2021, staff reported critical laboratory results to the physician and…

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 give written information to the resident and/or resident's representative of the facility's bed hold policy for three residents (Residents #10, #43, and #57) who were transferred out to the hospital. The facility census was 61. Record review of a facility's policy entitled Transfer/Discharge, revised 2/2021, showed the following: -A patient may be transferred or discharged to another health care institution or discharged home upon the written order of the attending physician; -Sufficient information will be provided to the patient to assure continuity of care, regardless of the destination of the patient or the reason for the transfer. (The policy did not address staff providing a written notification of the facility's bed hold policy to the resident and/or resident's representative upon transfer to a hospital.) 1. Record review of Resident #10's nurses' progress notes showed the following information: -On 11/9/2021, staff reported critical laboratory results to the physician and followed orders to send him/her to 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 observation, interview, and record review, the facility failed to complete a a risk/benefit review and document alternatives attempted prior to side rail use for two residents (Resident #43 and #58); failed to obtain informed consent for the use of side rails for four residents (Resident #43, #57 #58 210); and failed to complete a side rail safety check to include measurements of the bed frame and all bed rails for risk of entrapment for four residents (Residents #6, #26, #57, and #210). The facility failed to care plan the use of the side rails for four residents (Resident #6, #26, #43, and #210). The facility census was 61. Record review of a facility policy statement entitled Bed Safety, revised December 2007, showed the following information: -The facility shall strive to provide a safe sleeping environment for the resident; -The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as…

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, and interview, the facility failed to ensure a medication error rate of less then 5% when staff made five errors out of 27 opportunities resulting in an 18.51% error rate. Staff failed to correctly dilute intravenous (administered into a vein) antibiotic and start the antibiotic infusion at the correct time for one resident (Resident #57), failed to prime insulin pens for two residents (Residents #1 and #46), and administered insulin outside of accepted time parameters for two residents (Residents #19 and #20), during random medication pass observations. The facility had a census of 61. 1. Record review of the facility provided policy titled Medication Administration-General Guidelines, dated 2006, showed the following information: -Personnel authorized to administer medications should do so only after they have familiarized themselves with the medication; -Prior to administration, the medication and dosage schedule on the resident's medication administration record (MAR) is…

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 maintain an effective infection control program when the facility failed to ensure staff wore face coverings (masks) appropriately to prevent the potential spread of the coronavirus disease (COVID-19 -an infectious disease caused by the SARS-CoV-2 virus); when the facility failed to properly clean and disinfect glucometers (digital machine used to test the glucose/sugar level in blood) after use for five residents (Resident #1, #19, #31, #46, and #59); when the facility staff continued to administer medications to three residents (Residents #7, #12 and #20) after the medications had fallen onto unclean surfaces; and when staff failed to administer and read tuberculosis (TB - potentially serious infectious disease that mainly affects the lungs) tests for three staff members (Housekeeping Aide M, Activity Director, and Laundry Aide N) at hire. The facility census was 61. 1. Record review of the CDC (Center for Disease Control and Prevention) guidance for Healthcare Workers, titled Facemask Do's and Don'ts,…

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 staff treated all residents with dignity and respect when they did not provide a dignity bag for one resident's (Resident #57) catheter (sterile tube inserted into the bladder to drain urine) bag. The facility census was 61. Record review of the facility's policy titled Urinary Catheter Care, dated October 2010, showed the following information: -Purpose of the policy is to prevent catheter-associated urinary tract infections; -The policy did not address use of catheter bag privacy covers. Record review showed the facility did not provide a policy regarding dignity and respect. 1. Record review of Resident #57's face sheet (a brief resident profile sheet) showed the following: -admission date of 1/19/2022; -Diagnoses included urinary tract infection (infection in any part of the urinary system, kidneys, bladder), bacteremia (bacteria in the blood) and chronic kidney disease stage 4 (kidneys are moderately or severely damaged and are not working as they should). Record review of the resident's care…

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 ensure residents were free of significant medication errors when staff administered insulin (medication used to help control blood sugar levels) without priming the insulin pen prior to administration and without following manufacture recommendations to ensure the full dose of insulin was administered for two residents (Resident #1 and #46). The facility had a census of 61. Record review of the facility's undated policy, titled How to Use an Insulin Pen, included the following information: -Remove pen cover; -Get the needle ready and screw the needle onto insulin end of pen; -Prime the pen and clear air from the needle. This adjusts the pen and needle for good accuracy when it is time to measure the insulin dose. Turn the dose selector knob at end of the pen to one or two unit; -Hold the pen with needle pointing upward, press knob up completely while watching for insulin drop or stream to appear. Repeat, if necessary, until insulin is seen at needle tip. The dial should be back at zero after completing 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.