Quitman County Health & Rehab LLC

Based on observation, staff and resident interview, record review and facility policy review the facility failed to implement an Activity of Daily Living (ADL) care plan related to removal of facial hair (Resident #3) and nail care (Resident #44) for two (2) of 13 sampled residents. Findings Included: Record review of the facility policy, Care Plans, Comprehensive Person-Centered with revision date of March 2022 revealed, . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . Resident #3 Record review of Resident #3's Care Plan with a problem onset date of 04/19/2022 revealed .requires assistance with ADLs (Activities of Daily Living) . Approaches . Total assistance x 1 staff for all ADLs (Bed Mobility, Transfers, Locomotion, Dressing, Eating, Toileting, Hygiene, Bathing) . On 08/26/24 at 12:14 PM, an observation of Resident #3 revealed her sitting in her geri chair in the hall and she had scattered white facial hairs above her…

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 and resident interviews, record reviews, and facility policy review the facility failed to verify the documented advance directives signed by the Resident Representative (RR) were the preferences of a cognitively intact resident for one (1) of 16 Advance Directives reviewed. Resident #148. Findings Included: Review of the facility policy, titled Advanced Directives, revealed .Policy Interpretation and Implementation 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate and advance directive if he or she chooses to do so .4. If the resident becomes able to receive and understand this information later, he or she will be provided with the same written materials as described above, even if his or her legal representative has already been given the information . Record review of the Order Summary Report with active orders as of [DATE] revealed an order dated [DATE] Code Status; DNR (Do Not…

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 provide Activity of Daily Living (ADL) care related to removal of facial hair (Resident #3) and nail care (Resident #44) for two (2) of 13 sampled residents. Findings Included: Record review of the facility policy titled Activities of Daily Living (ADL)s with revision date of March 2018, revealed Policy Statement: Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . Resident #3 An observation on 08/26/24 at 12:14 PM, revealed Resident #3 sitting in her geri chair in the hall and she had scattered white facial hairs above her upper lip and two white chin hairs that were approximately one (1) inch long. An observation on 08/27/24 at 8:45 AM, revealed Resident #3 lying in her room asleep. She had scattered white facial hairs above her upper lip and two chin hairs that were…

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, staff interview and facility policy review the facility failed to ensure kitchen sanitation was maintained in a manner that meets professional standards for 44 of 49 residents whose meals are prepared in the kitchen. Findings include: Review of the facility policy titled Machine Warewashing, with a revision date of 6/14, revealed, .Procedure .3. The dishmachine operator documents the machine temperature and concentration of the sanitizing solution for warewashing after each meal on the Dishmachine Temperature/Chemical Log . Review of the facility policy titled, Manual Warewashing, with a revision date of 10/17, revealed, .Procedure . 6. The concentration of the sanitizing solution is checked with an appropriate test kit when the sink is filled .9. The employee using the three compartment sink documents temperature and concentration. A record review of the July Dish Machine and Pot/Pan Sink form revealed that there was no documentation of temperatures or chemical sanitation levels for the low temperature dish machine or the pot/pan sink from 7/1/23 through…

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 discard out of date Influenza vaccines and failed to secure injectable Lorazepam in a locked secured box in the refrigerator for (1) one of (1) one medication storage room. Findings include: Review of the facility policy titled, Storage of Medications with a revised date of April 2007, revealed, Policy Statement The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .Policy Interpretation and Implementation .The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed .Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurse's station or other secured location . An observation on 07/12/23 at 03:50 PM, with Licensed Practical Nurse (LPN) #2 revealed 10 Fluzone single dose vaccines with an expiration date of 5/20/23, 11 single dose flu vaccines with an expiration date of 5/11/22, one (1) multidose five…

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 implement the care plan for impaired respiratory function for (1) one of 16 resident care plans reviewed. Resident #10 Findings include: A review of the facility policy titled, Care plans, Comprehensive Person-Centered, revised December 2016 revealed, Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . Policy Interpretation and Implementation . 8. The comprehensive, person-centered care plan will: b. Describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . An observation of Resident #10 on 7/11/23 at 11:39 AM, revealed resident receiving oxygen (O2) via nasal canula and the O2 tubing and humidifier bottle with no date. A record review of the care plan for Resident #10 with a problem onset date of 3/22/22, revealed…

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, and record review the facility failed to sign out controlled medications prior to administration to a resident for (1) one of (6) six residents reviewed during medication pass. Resident #29. Findings include: An observation, on 7/12/23 at 9:20 AM revealed Licensed Practical Nurse (LPN) #1 set up medications for Resident #29. The medications included Lacosamide, Xanax, and Norco. LPN #1 did not sign out the controlled medications prior to administering them. An interview on 7/12/23 at 9:25 AM, with LPN #1 revealed that she really did not know when she was supposed to sign them (controlled medications) out. She stated that she does it after she gives them in case the resident does not take it. An interview on 07/13/23 at 08:30 AM, with the Director of Nursing (DON) revealed that all controlled medications should be signed out when the nurse punches it out. If the nurse waits to sign out controlled medications, she could forget to do it and the count would be wrong or could lead to drug diversion. Record review of the July 2023 Physician Orders…

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 label and date oxygen tubing and a humidifier bottle (Aquapack) for (1) one of (7) seven residents receiving oxygen therapy. Resident #10. Findings include: A review of the facility policy titled, Oxygen Administration, with a revised date of October 2022, revealed Purpose The purpose of this procedure is to provide guidelines for safe oxygen administration .Equipment and Supplies: The following equipment and supplies will be necessary when performing this procedure .6. Label oxygen supplies (tubing, mask. Etc.) with date and initial. Supplies should be changed at least weekly while in use . On 7/11/23 at 11:39 AM, an observation of Resident #10 revealed the resident was receiving oxygen (O2) per nasal canula and the oxygen tubing and humidifier bottle were not dated. An observation of Resident #10's O2 tubing and humidifier bottle with Licensed Practical Nurse (LPN) #1 on 7/12/23 at 8:30 AM, confirmed there was not a date on the oxygen tubing or humidifier bottle. State Agency…

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, staff interviews, and facility policy review the facility failed to perform hand hygiene upon removing gloves, failed to dispose of a pill after it fell on the medication cart, and failed to use a barrier when administering eye drops for (2) two of (6) six residents reviewed during medication pass. Resident #15 and #29. Findings include: Review of the facility policy titled, Handwashing/Hand Hygiene, revised 2015, revealed, Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infection. Policy Interpretation and Implementation .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: .m. After removing gloves . Review of the facility policy titled, Installation of Eye Drops, undated, revealed, Purpose The purpose of this procedure is to provide guidelines for installation of eye drops to treat medical conditions, eye…

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, facility policy review, and record review, the facility failed to perform medication administration in a manner to prevent the likelihood of the spread of infection, as evidenced by failure to disinfect a plastic tray barrier and stethoscope, and to perform hand hygiene appropriately between residents during medication administration observations for three (3) of six (6) residents observed during medication administration. Findings include: Record review of the facility policy titled Administering Medications revised December 2012 revealed Medications shall be administered in a safe .manner . 22. Staff shall follow established facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable. Record review of the facility policy titled Administering Medications through an Enteral Tube revised March 2015 revealed .Steps in the Procedure 1. Wash your hands .34. Wash your hands . Record review of the facilities Infection Control Guidelines 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.