Jefferson Davis Community Hospital Ecf

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure food was stored in a manner that maintained freshness and quality and was properly labeled and dated in accordance with professional standards for food safety for one (1) of two (2) kitchen observations. Findings include:A review of the facility's policy, Storing: Food and Equipment, revealed, Team members must store food in a manner that ensures quality, freshness and safeguards against foodborne illnesses.Scope of Responsibility.All team members must follow food and temperature guidelines, labeling, use-by-dates, food storage chart, freezing and leftover guidelines to ensure food and equipment criteria are met.A record review of the Safe Training, dated 2/1/25, revealed, All Food must be properly labeled and dated.Ensure all food is labeled, including: Food stored in its original container, Food not stored in original container.When to Discard.by use-by-date indicated when storing or sooner if quality is an issue or by manufacturer's use-by-date.How Long to Keep.Food…

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, record review, and facility policy review, the facility failed to ensure a resident's right to privacy during medication administration for one (1) of five (5) residents reviewed for medication administration. Resident #5.Findings include:A review of the facility's policy, Resident Rights Guidelines for all Nursing Procedures, revised 10/2010, revealed, .To provide general guidelines for resident rights while caring for the resident. Preparation 1. Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on resident rights, including.b. Resident dignity and respect.On 4/21/26 at 11:01 AM, during an observation, Licensed Practical Nurse (LPN) #1 entered Resident #5's room to perform an accucheck and insulin administration. She gathered supplies, explained the procedure, and performed a finger stick to obtain a blood glucose level. The door remained open and the privacy curtain was not pulled during the entire procedure. Staff and other residents were observed passing in the hallway while care 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 staff interview, record review, and facility policy review, the facility failed to ensure the Level I Preadmission Screening and Resident Review (PASRR) was completed accurately to reflect a diagnosis of Schizophrenia and the use of an antipsychotic medication for one (1) of (16) sampled reviewed. Resident #41.Findings include:A review of the facility's policy, admission Criteria, revised December 2016, revealed, Our facility will admit only those residents whose medical and nursing care needs can be met. Policy Interpretation and Implementation.8. Nursing and medical needs of individuals with mental disorders or intellectual disabilities will be determined by coordination with Medicaid Pre-admission Screening and Resident Review program (PASARR) to the extent practicable. 9. Potential residents with mental disorders or intellectual disabilities will only be admitted if the State mental health agency has determined (through the preadmission screening program) that the individual has a physical or mental condition that requires the level of services provided by 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 observation, interview, record review, and facility policy review, the facility failed to implement care plan interventions related to wound care for one (1) of 16 sampled residents. Resident #1.Findings include:A review of the facility's policy, Care Plans, Comprehensive Person-Centered, dated 12/2016, revealed, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is.implemented for each resident.A record review of the Care Plan Report revealed Resident #1 had a Focus of Resident has actual skin breakdown. with an Interventions including, Cleanse Stage 4 pressure ulcer to left ankle with Vashe and pat dry. Apply A&D ointment to peri wound. Apply Aquacel AG to wound bed and cover with gauze and ABD pad. Wrap with conform daily and prn for soilage and dislodgement.A record review of the Order Summary Report revealed Resident #1 had a Physician's Order, dated 4/21/26 to Cleanse Stage 4 pressure ulcer to the left ankle with Vashe and pat dry. Apply A&D Ointment to per…

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, record review, and facility policy review, the facility failed to follow physician orders for treatment of a pressure ulcer for one (1) of (1) resident reviewed for wound care. Resident #1.Findings include:A review of the facility's policy, Wound Care, revised June 2018, revealed, .The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation 1. Verify that there is a physician's order for the procedure.Steps in the Procedure.8. Apply treatments as indicated.A record review of the Order Summary Report revealed Resident #1 had a Physician's Order, dated 4/21/26 to Cleanse Stage 4 pressure ulcer to the left ankle with Vashe and pat dry. Apply A&D Ointment to per wound. Apply Aquacel AG to wound bed and cover with gauze and ABD pad. Wrap with conform daily and prn (as needed) for soilage and dislodgement.On 4/21/26 at 2:20 PM, during an observation, Registered Nurse (RN) #1, assisted by a Certified Nurse Aide (CNA), provided wound care for Resident #1's Stage 4 pressure ulcer to the left ankle. RN #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.

Based on record review, staff interview, and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain corrective actions to prevent recurrence of previously cited deficiencies, specifically, the facility was cited for failing to ensure food was stored, labeled, and dated in accordance with professional standards for food safety during an annual recertification survey on 11/21/2024 and was cited again for the same deficiencies during the current survey, demonstrating that QAPI failed to sustain ongoing monitoring and oversight to prevent recurrence for one (1) of seven (7) deficiencies cited. F812Findings include: A review of the facility's policy, Quality Assurance and Performance Improvement (QAPI) Program, revised August 2017, revealed, .This facility shall implement, and maintain an ongoing, facility-wide Quality Assurance and Performance Improvement (QAPI) program that builds on the Quality Assessment and Assurance Program to actively pursue quality of care and quality of life goals . A record review of the Provider…

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, record review, and facility policy review, the facility failed to perform hand hygiene to prevent the potential spread of infection during medication administration for one (1) of five (5) residents reviewed for medication administration. Resident #4.Findings include:A review of the facility's policy, Infection Control Guidelines for All Nursing Procedures, revised April 2024, revealed, .To provide guidelines for general infection control while caring for residents .General Guidelines 1. Standard precautions will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious disease. 5. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol based hand rub.for all the following situations.i. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident.On 4/21/26 at 1:14 PM, during an observation, Licensed Practical Nurse (LPN) #2 administered medication via Percutaneous Endoscopic…

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 facility policy review, the facility failed to store food in accordance with professional standards for food safety related to expired foods, overly ripe produce, and scoops stored in dry bins touching food items for one (1) of two (2) kitchen observations. Findings included: A review of the facility's policy titled Storing: Food and Equipment revealed, .Team members must store food in a manner that ensures quality, freshness, and safeguards against foodborne illness . Items to Label. Ensure all food items are labeled .How Long to Keep .Generally, food should be discarded or used by the use-by date. The use-by date is the last date the manufacturer recommends use of the food and also may be referred to as the expiration date .Containers .Cover, label, and date all leftovers . Store scoops in a covered area .not in food containers. A review of the facility's policy titled HACCP (Hazard Analysis and Critical Control Points) and Food Preparation Guidelines, revised 01/2024, revealed, Fruits and Vegetables . Inspect for signs of spoilage,…

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, record review, and facility policy review, the facility failed to provide care and services consistent with professional standards of practice for a pressure ulcer for one (1) of two (2) pressure wound care observations. Resident #11. Findings Include: Review of the facility's procedure Wound Care, revised June 2018, revealed, .The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .Steps in Procedure .7. Use no-touch technique . A record review of the Physician Orders for February 2023 revealed a treatment order with an order date of 1/20/23 for Resident #11 for Wound care for RT (Right) buttock: Cleanse wound w/(with) wound cleanser. Pack wound w/dry gauze. Cover w/5x5 foam border. Change daily or PRN (as needed) or soilage or dislodgement. DX (Diagnosis): Stage 4 Pressure Ulcer Rt Buttock. A treatment order with an order date of 1/26/23 also revealed, Wound care orders for RT buttock: for 9 o'clock (position of area as related to the face of a clock) tunneling (passageway of tissue destruction underneath…

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 licensed nurse had the specific competencies and skill set to stage pressure wounds for two (2) of two (2) residents reviewed for pressure wounds. Resident #11 and Resident #13. Findings Include: A review of the facility's policy, Competency of Nursing Staff, revised October 2017, revealed, Policy Statement .2. In addition, licensed nurses and nursing assistants employed (or contracted) by the facility will: b. demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in the plans of care .Policy Interpretation and Implementation 1. The staff development and training program is created by the nursing leadership .and is designed to train nursing staff to deliver individualized, safe, quality care and services for the residents 2. The following factors are considered in the creation of the competency-based staff development and training program .c. Specialized skills 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.