Yalobusha County Nursing Home

Based on observations, interviews and facility policy review, the facility failed to ensure the residents' food was stored, thawed and monitored under sanitary conditions for two (2) of four (4) kitchen tours. Findings Include Review of the facility policy titled, Refrigerator/Freezer Temperature Checks with no revision date, revealed, The kitchen supervisor and/or the Dietary Manager shall check all refrigerator temperatures and freezer temperatures at least twice daily . Review of the facility policy titled, Food Preparation and Service' with no revision date, revealed, .Thawing Frozen Food 1. Foods will not be thawed at room temperature. Thawing procedures include. a. thawing in the refrigerator.b. completely submerging in cold running water.c. thawing in the microwave, then cooking and serving immediately.d. thawing as part of a continuous cooking process. An observation on 10/06/2025 at 10:30 AM, during the initial kitchen tour revealed there was no refrigerator temperature log for the month of October and approximately 200 raw chicken drumsticks were sitting directly in 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, record review and facility policy review, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for four (4) of 26 MDS assessments reviewed. Resident #10, #15, #16, and #92 Findings Include: Review of the facility policy titled MDS Assessment Accuracy and Correction undated, revealed, The facility shall submit a correct MDS assessment as required by scheduling requirements. The MDS shall be completed and verified by the Registered Nurse and to be accurate to the best of that nurse's knowledge . Resident #10 Record review of the Bowel and Bladder Program Screening dated 8/11/25, revealed Resident #10 always voids without incontinence, she never was incontinent of stool and that she was independent with toileting. Record review of the admission MDS assessment with an Assessment Reference Date (ARD) of 8/12/2025 revealed, under Section H - Bladder and Bowel, revealed Resident #10 was frequently incontinent of bladder and was occasionally incontinent 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 interview, record review, and facility policy review, the facility failed to ensure residents were invited and given the opportunity to participate in their Care Plan meetings for three (3) of five (5) residents reviewed for care planning. Resident #3, Resident #9, and Resident #38. Findings Include: Review of the undated facility policy titled Care Plan Meeting revealed, The MDS (Minimum Data Set) Coordinator shall notify the resident/resident representative in writing or telephone of the upcoming care plan conference and The MDS coordinator shall make arrangements for each resident/representative to actively attend a care plan conference with IDT (Interdisciplinary Team) members if the resident/representative desires during a time that accommodates the resident/representative Resident #3 Record review of Care Plan Report for care conference review dated 8/4/25, revealed no signatures noted for resident or family indicating participation in care conference review. During an interview on 10/06/2025 at 10:26 AM, with Resident #3, she revealed that she had never been invited…

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 ensure that drugs and biologicals were stored in a secure manner to prevent unauthorized access for two (2) of four (4) days of survey. Findings include: Review of the facility policy titled, Medication Cart Security/Medication Room Security undated, revealed, The nurse shall ensure the medication care always remains secured to prevent unauthorized entry. The medication cart shall be locked when not in use or within the nurse's reach . An observation and interview on 10/7/2025 at 11:37 AM, revealed an unattended medication cart in the South Hall with the drawers unlocked and no staff present in the immediate area. An interview with Licensed Practical Nurse (LPN) #1 confirmed the cart should never be left unlocked and unattended because a resident could get into it. An observation and interview on 10/08/2025 at 11:20 AM, revealed an unattended medication cart at the D wing nurses station with the drawers unlocked and no staff present in the immediate area. An interview with LPN #2 confirmed…

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 interview, record review and facility policy review, the facility failed to allow a resident to exercise his right to take a shower as evidenced by the resident not being offered a shower for one (1) of 24 residents reviewed during survey. Resident #61. Findings Include. A review of the facility policy titled Resident's Rights with no revision date revealed Each and every resident has the right to .9. Receive adequate and appropriate health care and protective support services . An interview on 03/04/24 at 2:22 PM, with Resident #61 revealed that he gets a bed bath automatically without being asked about a shower and that he would love to have a shower and have water running on him. The resident revealed that he can't remember the last time he has had a shower. The resident revealed that he has asked for a shower before and was told that they don't have a chair to get him in there. An interview on 03/05/24 at 10:38 AM, with Certified Nursing Assistant (CNA) #1 revealed that 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 resident and staff interview, record review and facility policy review, the facility failed to ensure the residents code status on the advance directive matched the residents code status order on one (1) of 24 residents advanced directives reviewed. Resident #17. Findings include: A review of the facility policy titled (Proper Name of Facility) Advanced Directive Policy , with no revision date, revealed, Purpose: To respect the resident's right to determine the course of treatment; to provide at the time of admission written information on rights under state law to make decisions regarding medical care, including the right to accept or refuse treatment and the right to formulate advance directives; to implement the requirements of the Patient Self-Determination Act; and to educate the public and staff regarding advance directives . A record review of Resident #17's Advance Directive in the electronic record revealed the resident's code status was Do Not Resuscitate (DNR). A record review of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility policy review the facility failed to provide a safe, clean environment, as evidenced by a dirty wheelchair with torn armrest for Resident #10 and dirty privacy curtains for room numbers 118 and 120 for three (3) of four (4) survey days. Findings include: Record review of facility policy titled Equipment Needs and Maintenance undated, revealed, The equipment shall be kept and maintained in good repair and optimal level of cleanliness. Equipment shall be monitored for cleanliness and good repair. Wheelchairs shall be cleaned on the night shift per the wheelchair washing schedule. Record review of facility policy titled, Resident Room Deep Cleaning undated, revealed The deep cleaning shall include ensuring the privacy curtains are maintained clean and in good repair . Resident #10 An observation on 03/04/24 at 10:42 AM, revealed Resident #10 sitting in a wheelchair that had a brown and gray substance on the frame and the spokes of the wheels. The vinyl on 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 staff interview, record review, and facility policy review, the facility failed to incorporate a Preadmission Screening and Resident Review (PASARR) recommendation for specialized mental health services for a resident admitted with a mental illness for one (1) of four (4) residents reviewed for PASARR. Resident #73 Findings Include: Review of the facility's undated policy titled PASSAR [Preadmission Screening and Resident Review] and Resident Status Changes Policy revealed, The facility shall complete the pre-admission screening and resident review upon admission to the facility. The facility shall maintain these records within the resident chart at all times. The facility shall proceed with PASARR [Preadmission Screening and Resident Review] level II [two] screenings as indicated in the initial assessment. The results of the PASARR [Preadmission Screening and Resident Review] level II [two] screenings shall be incorporated in the resident's care planning process to provide optimal care for the resident. Record review of the Face Sheet revealed the facility admitted…

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, resident and staff interview, record review and facility policy review the facility failed to implement a care plan for a physician ordered brace for one (1) of 24 residents care plans reviewed. Resident #26 Findings Include: A review of the facility policy titled Care Plan Policy , with no revision date, revealed. Purpose: To ensure the facility establishes a guide to resident care to promote the physical and psychological well-being of residents newly admitted and long-term residents residing within the facility . Record review of the Care Plan with a problem on set date of 6/19/19 revealed .requires maintenance of ADL (Activities of Daily Living) functions with risk for decline .Approaches .Brace to left upper extremity to be donned in AM (morning) upon awakening and removed before going to bed in PM (evening). An observation and interview on 03/04/24 at 02:49 PM, revealed Resident #26 sitting up in his wheelchair. Resident #26's left arm was hanging down to the inside of the wheelchair.…

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, resident and staff interview, record review and facility policy review, the facility failed to apply a physician ordered brace for one (1) of six (6) residents sampled for range of motion. Resident #26. Findings include: A review of the facility policy titled Range of Motion with no revision date, revealed: . The facility shall assist the resident to maintain the highest level of functional ability and range of motion. Devices shall be donned and doffed as ordered by the physician. The use of the devices shall be documented in the residents' medical records and shall be reflected on the resident's care plan. During an observation and interview on 03/04/24 at 02:49 PM, of Resident #26 revealed the resident sitting up in his wheelchair. The residents' left arm was hanging down to the inside of the wheelchair. The resident stated, I have a brace for my arm over in the chair in the corner. Therapy will put it on me when I ask for it, but nobody else knows how to apply it. Record review 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 staff interview and record review, the facility failed to include the required components in the arbitration agreement for three (3) of 3 arbitration agreements reviewed. Findings include: Record review of facility letterhead notice dated 3/7/24, and signed by the Administrator revealed, [Proper name of facility] does not have a policy on Arbitration Agreements. During an interview on 3/7/24 at 9:20 AM, the Administrator revealed during the entrance conference, the facility did not offer arbitration agreements and she was unaware that the facility's admission packet contained an arbitration agreement. The Administrator confirmed the facility failed to include required components into the arbitration agreement which included that signing the arbitration agreement was not a requirement for admission to the facility, that the resident or representative had the right to rescind the agreement within 30 calendar days of signing, and the right for the resident or representative to communicate with federal and state officials including the Ombudsman. Record review of the admission…

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 report an allegation of abuse for one (1) of three (3) incidents reviewed. Resident #6 Findings include: Record review of facility policy titled, Abuse Policy and Procedure, revised date 8/18/2017, revealed, Policy: To ensure all employees interviewed and/or hired are adequately trained in all areas of abuse, not found guilty of abuse, and if occurrence suspected, the facility handles it according to the law and/or license requirements. During a phone interview on 3/1/2024 at 2:30 PM, the State Long Term Care (LTC) Ombudsman revealed that during a Resident Council meeting on 2/26/24, Resident #6 voiced concern about physical abuse. She revealed after the Resident Council meeting, she met with the Director of Nurses (DON) and informed her of the allegation and the need to report it to the State. An interview with the DON on 03/04/24 at 04:30 PM, revealed she was made aware of the allegation 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.