Genoa Community Hospital/LTC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY D. Review of the facility policy Hand Hygiene, undated revealed the purpose was to provide guidelines for effective hand hygiene to prevent the transmission of bacteria, germs, and infections. Staff were to: -follow standard precautions, -change gloves and discard after each resident contact, and -change gloves when moving from contaminated body site to a clean body site. Staff were to perform hand hygiene: -before coming on duty, -when hands were soiled, -before each resident encounter, -after coming in contact with resident's skin, -after working on a contaminated body site then moving to a clean body site, -after coming in contact with bodily fluids, dressings, mucous membranes, -always after removing gloves or facemasks, -after toileting, -soap and water must be used when hands were visibly soiled, and -if hands are not visibly soiled, hands could be disinfected with either an alcohol-based hand rub or soap and water. Review of Resident 21's MDS dated [DATE] revealed the resident had cognitive impairment;…

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 Licensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview; the facility failed to submit a completed investigation of Resident's 139's hip fracture and Resident 26's fall with an ankle fracture to the State Agency in 5 working days. The sample size was 14 and the facility census was 36. Findings are: A. Review of the facility policy Abuse and Neglect revealed the following: -The facility recognized the importance of assuring residents were free from all forms of abuse and implemented safeguards and practices to ensure resident safety. -Potential employees were screened for a history of abuse, mistreatment of residents as allowed by law, including checking with former employers, with appropriate licensing boards, and registries. -Employees were trained on issues related to abuse and what constituted abuse, neglect, mistreatment, and misappropriation. -Events, such as suspicious bruising of residents, occurrences, patterns, and trends that could constitute abuse were identified.…

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 Licensure Reference Number 175 NAC 12-006.09(E) Based on record review and interview; the facility failed to ensure Resident 26's Activity of Daily Living (ADL) needs and Resident 1's Post Traumatic Stress Disorder (PTSD) triggers were identified in the resident care plans. The sample size was 14 and the facility census was 36. Findings are: A. Review of the undated facility Care Plan Policy revealed the facility provided individualized, interdisciplinary plans of care for all resident that were appropriate to the resident's needs, strengths, and results of diagnostic limitations and goals. Results of assessment were used to develop, review, and revise the care plan. Services provided met professional standards of quality including culturally competent and trauma-informed care. Review of the undated facility policy Trauma Informed Care revealed that all residents received care in a manner that recognized and responded to the effects of trauma in accordance with federal regulation which required facilities to…

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.

Licensure Reference Number 175 NAC-006.09 Based on record review and interviews; the facility failed to address Resident 1's diagnosis of Post Traumatic Stress Disorder (PTSD) through evaluation and care planning of potential triggers or situations that could lead to re-traumatization. The sample size was 1 and the facility census was 36. Findings are: Review of the undated facility policy Trauma Informed Care revealed that all residents received care in a manner that recognized and responded to the effects of trauma in accordance with federal regulation which required facilities to provide trauma informed care that met professional standards of practice. Care was delivered in a safe, empathetic, and supportive environment that avoided re-traumatization and fostered recovery and empowerment. Residents were assessed upon admission and during care plan development for a history of trauma, and care plans were individualized and included strategies to minimize triggers and promote safety. Review of Resident 1's Minimum Data Set (MDS-federally mandated comprehensive assessment used to…

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.

Licensure Reference Number 175 NAC 12-006.11E Based on observation, record review and interview; the facility failed to ensure 1) food was stored under sanitary conditions and 2) outdated food was not available for consumption to prevent the potential development of food borne illness. This had the potential to affect all residents. The facility census was 36. Findings are: Review of the undated facility policy Food Storage revealed all food will be stored off the floor and leftover food is clearly labeled and dated. In addition, leftover food is to be used within 3 days of the date prepared or discarded. Observation during the initial kitchen tour on 5/8/24 at 8:40 AM revealed the following: -Walk-in cooler had 2 large trays of macaroni salad in Styrofoam bowls with plastic wrap covering the trays. There was no label or date on the trays. -Walk-in cooler had a large bowl of orange colored Jello labeled with a date of 4/15/24 (23 days ago). -Walk-in freezer had 3 stacks of food in packages sitting directly on the floor of the freezer. An interview with the Dietary Manager on 5/8/24…

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.

Licensure Reference Number 175 NAC 12-006.02(8) Based on record review and interview; the facility failed to report a fall with significant injury to the state agency within the required time frame for Resident 15. The sample size was 4 and the facility census was 36. Findings are: Review of the facility policy Abuse and Neglect, undated, revealed the following: -when an incident or suspected incident of abuse was reported to the Director of Nursing (DON) or Director of social services or his/her designee they would investigate the incident which included interviews with the resident, staff, family, and any witness, a review of the medical record, and a review of all circumstances surrounding the incident, -any alleged violations would be reported to the state agency and all other agencies as required, and -the results of the investigation would be documented and submitted to the State Agency within five working days. Review of Resident 15's Minimum Data Set (MDS-a federally mandated assessment tool used in care planning) dated 2/28/24 revealed the following: -the resident had…

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 Licensure Reference Number 175 NAC 12-006.05(5) Based on record review and interview, the facility failed to provide a written notice of transfer to 1 resident (Resident 24) or the resident's legal representative upon transfer to the hospital. The facility census was 36. Findings are: Review of the undated facility policy Notice of A Transfer and/or Discharge revealed the facility would provide a 30 day written notice of transfer or discharge to a resident and/or the resident's representative, except when an immediate transfer or discharge is required by the resident's urgent medical needs. The following information will be provided: -the reason for the transfer or discharge; -effective date of transfer or discharge; -the location the resident is transferred to; -the name, address, and telephone number of the state long-term care ombudsman; -the name address, and telephone number of each individual or agency responsible for the protection of mentally ill or developmentally disabled; and -the name, address, 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.

Licensure Reference Number 175 NAC 12-006.05(1) Based on record review and interview, the facility failed to provide Resident 24 or the resident's representative, written bed hold information when the resident was transferred to the hospital emergency room (ER). The sample size was 1 and the facility census was 36. Findings are: Review of the undated facility policy Holding Bed Space revealed the facility will inform residents and/or resident representatives of the bed-hold policy upon admission and prior to a transfer for hospitalization or therapeutic leave. The Bed Hold Policy Notification and Acknowledgement will be completed at the time the bed hold is needed. Review of Resident 24's Nursing Progress Note dated 5/3/24 revealed the resident was transferred to the local hospital emergency room (ER) for manic (showing wild, apparently deranged, excitement and energy) behaviors that were unable to be controlled. The resident was then transferred and admitted to Faith Regional Behavioral Health Unit for psychosis and mania on the same day. Review of the Resident 24's medical record…

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.

Licensure Reference Number 175 NAC 12-006.09D Based on record review and interview; the facility failed to ensure there was an approved diagnosis for the use of an antipsychotic medication (a type of psychoactive medication which alters chemicals in the brain to effect changes in behavior, mood, and emotions) for Resident 33. The sample size was 5 and the facility census was 36. Findings are: Review of the facility policy Psychotropic Medication Usage, undated, revealed the following: -psychotropic drugs included antipsychotics, -attending physicians would certify that a psychotropic medication was necessary to treat a specific condition/behavior, and -the consulting pharmacist would report any irregularities to the Medical Doctor or Director of Nursing (DON) which included not having an adequate indication for use. Review of Resident 33's Minimum Data Set (MDS-a federally mandated assessment tool used in care planning) dated 4/22/24 revealed the following: -the resident had severe cognitive impairment, -had diagnoses of heart failure, anxiety, and depression, and -required moderate…

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 Licensure Reference Number 175 NAC 12.006.02(8) Based on interview and record review, the facility failed to complete and submit a written investigation to the state agency related to a fall with a fracture for Resident 22 and a resident to resident altercation for Resident 11. The total sample size was 18 and the facility census was 37. Findings are: A. Record review of the facility policy dated 8/12/16 titled Abuse and Neglect Prevention Policy revealed the following; -all allegations of abuse (the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish) and/or neglect (failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness) would be investigated, -all staff would be trained annually, -knowledge provided for prevention included assessment, care planning and monitoring of residents with needs and behaviors that might lead to conflict or neglect; such as history of aggressive…

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.