Holmes County Long Term Care Center - Durant

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, resident representative interview, and facility policy review, the facility failed to ensure that each resident was treated with dignity as evidenced by failure to cover unclothed residents that were visible from the hallway, and failure to provide a privacy bag for a catheter for three (3) of twenty-two sampled residents. Resident #5, Resident #55 and Resident #228. Findings include: Review of the facility policy titled, Maintaining Privacy and Dignity for Residents with Foley Catheter Drainage Bags undated, revealed It is the policy of this facility to provide privacy and dignity to all residents that have a urinary drainage bag in use. The drainage bag will be maintained in a storage pouch to hide the contents and prevent embarrassment to the resident . Review of the facility policy titled Privacy/Dignity During Care with a revision date of 8/2015 revealed under, Policy: It is the policy of this facility to provide privacy and dignity to our residents while providing…

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, staff and resident interview, record review and facility policy review the facility failed to ensure a residents call light was within reach for one (1) of 22 residents sampled. Resident #24 Findings Include Review of the facility policy titled, Call Light, Answering with no revision date revealed under, Key Procedural Points .#5. When the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident. An observation and interview on 06/25/24 at 8:15 AM, revealed Resident #24 was sitting on the side of the bed receiving Oxygen (O2) via (by) nasal cannula. The resident stood up and said she needed to go to the bathroom, with no shoes on and nasal cannula still attached, she attempted to take two steps and stated she needed help, but admitted she did not know where her call light was located. An observation revealed the resident's call light was out of the residents reach and behind the privacy curtain on her roommate's side of the room, lying 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, record review, and facility policy review, the facility failed to develop and implement a comprehensive care plan for a resident with Activities of Daily Living (ADL) diabetic nail care and failed to implement a comprehensive care plan for a resident with ADL nail care for two (2) of the twenty-two sampled residents. Resident #63 and Resident #65 Findings include: A review of the facility's Care Plans-Comprehensive policy dated 10/2016 revealed, An individualized (person-centered) comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical nursing, mental and psychological needs is developed for each resident A review of the facility's Following the Care Plan Policy undated, revealed, It is the policy of this facility to follow a written and approved care plan for each resident. All employees will be trained upon hire and be required to follow the care plan . Resident #63 A record review of Resident #63's Comprehensive 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interviews, record review, and facility policy review, the facility failed to provide personal hygiene as evidenced by long, jagged nails with a brown substance underneath the fingernails for two (2) of the twenty-two sampled residents. Resident # 63, and Resident #65 Findings included: Record review of facility policy titled, Fingernails/Toenails, Care of undated, revealed, The purposes of this policy is to clean the nail bed, to keep nails trimmed, and to prevent infections . 6 .Nail care includes daily cleaning and regular trimming. Resident #63 An observation and interview on 06/25/24 at 8:40 AM, 12:05 PM, and 2:15 PM, revealed Resident #63 sitting in his wheelchair, bilateral fingernails approximately one-half (1/2) inch long and jagged past the tip of his fingers, and a brown substance was under each nail. Resident #63 revealed, No one has offered to cut and clean my nails in a long time, I would like them cut. An observation on 06/26/24 at 8:25 AM, of Resident #63…

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 and staff interview the facility failed to prevent the possibility of an accident and hazards as evidenced by not properly securing and storing chemicals for one (1) of three (3) survey days. Findings Include: Review of the typed statement on facility letterhead revealed the facility did not have a policy on chemical cleaners in the whirlpool room. However, they are expected to be in a locked cabinet when not in use and this was signed by the Administrator. An observation and interview on 6/26/24 at 10:45 AM with Licensed Practical Nurse (LPN) #1 revealed the shower room on the B-Hall had a coded lock on the door, but LPN #1 turned the door handle and walked in without using the keyed lock. Inside the shower room, the whirlpool tub was full of water with soap suds and there was an unlocked storage bin that held a can of bug spray, a spray bottle of bleach cleaner and two large bottles of disinfectant. LPN #1 confirmed that the door to the shower room should be locked and if a resident had accidentally come in here, they could have accessed or come in contact…

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, staff interview, record review, and facility policy review, the facility failed to ensure a controlled substance was signed out on a resident's narcotic administration log at the time of administration for one (1) of five (5) residents observed during medication pass (Resident #31) and during one (1) of two (2) narcotic log reconciliations. Findings include: Review of the facility policy titled Preparation and General Guidelines with a revision date of January 2018 revealed under, Policy: Medication included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations. Also revealed under, Procedures: . E. Accurate accountability of the inventory of all controlled drugs is maintained at all times. When a controlled substance is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview and record review, the facility failed to submit a status change for a resident with a new mental illness diagnoses for one (1) of four (4) Pre-admission Screening and Record Reviews (PASARR) reviewed. Resident #37 Findings include: Record review of facility letterhead signed by the Director of Nursing (DON), undated, revealed, (Proper name of facility) does not have a policy for submitting a second PASR while in the facility. Record review of the Pre-admission Screening (PAS) Application for Long Term Care dated 12/4/2020, revealed the Resident #37 had Depression (major) and Depression (other) listed as medical conditions. The physician certified that this person is appropriate for Medicaid long term care services. Record review of Resident #37's Diagnosis Information revealed the resident had a diagnosis of Major Depressive Disorder dated 12/4/2020 and a diagnosis of Major Depressive Disorder, recurrent, severe with Psychotic Symptoms dated 2/15/2023. An interview with Social 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, pharmacy consultant interview and record review, the facility failed to ensure a resident on a PRN (as needed) psychotropic medication had a stop date for one (1) of six (6) resident's medication reviewed. Resident #45 Findings include: The facility provided documentation on letterhead that read, (Proper Name of facility) does not have a policy for PRN psychotropic medications. Record review of Resident #45's Physician Orders Summary Report revealed an order dated 01/13/2023, Ativan oral tablet 1 MG (milligram) give 1 tablet by mouth every four (4) hours as needed for agitation An interview on 6/15/23 at 9:05 AM, with Registered Nurse (RN) #1 confirmed that Resident #45 did not have a stop date for his PRN Ativan, and she acknowledged that it should have one. She revealed that the resident has had this Ativan order since he was admitted into the facility on 1/13/2023. An interview on 6/15/23 at 9:20 AM, with the Director of Nursing (DON) confirmed that Resident #45 did not have a stop…

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 resident and staff interviews and record review the facility failed to ensure Saturday mail delivery to 1 out of 12 residents that voiced a concern during Resident council. FACILITY Resident Council Record review of the Mail Delivery Policy dated 2/2009 revealed under policy: It is the policy of this facility to deliver the Resident's mail timely. Under procedure: This mail will be delivered to the resident Monday thru Friday by the activity director. If the Resident receives mail on a Saturday, it will be delivered to the Resident by the week-end RN Unit Manager. Record review of the Resident's Rights policy with revised date of 8/16/16 revealed the center, through its Administrator, is responsible for establishing written policies that will safeguard the rights and responsibilities of medical assistance residents. The staff of the center is trained and involved in the implementation of these policies and procedures. The Administrator is responsible of adherence of the policies and procedures and for…

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 FACILITY Dining Observation An observation on 8/3/21 at 2:45 PM of Certified Nursing Assistant #1 passing out snacks to the residents on hall B. Snacks were on a plastic dining tray. CNA #1 entered Resident #24's room with the snack tray. She allowed Resident #24 to reach and take a bag of chips off the tray. Resident #24 reached over three bags of chips and picked up the third bag. While reaching to get the third bag of chips, her left lower arm drug over the other 2 bags of chips. Then CNA #1 took a snack cake off the snack tray and opened it and gave it to Resident #1. CNA #1 left that Resident's room and continued into Resident room #B14 and then to Resident room #B17. CNA #1 offered the Resident's a snack, and they did want a snack and CNA #1 handed the snack to them. An interview on 8/3/21 at 3:00 PM with CNA #1 revealed she should not have allowed Resident #24 to get a snack off the tray because it can cause an infection. An interview on 08/05/21 at 08:00 AM with the Director of Nursing (DON) revealed CNA…

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.