Tidwell Living Center

Based on observation, record review, and interview, the facility failed to ensure assessments were accurate for indwelling catheters for 1 (#26) of 12 sampled residents reviewed for resident assessments. The DON identified 32 residents who resided in the facility. Findings: On 05/06/25 at 3:11 p.m., Res #26 was observed sitting in the lobby in a wheelchair. No indwelling catheter was observed. A diagnoses sheet, dated 03/04/20, showed Res #26 was admitted with diagnoses which included chronic obstructive pulmonary disease and convulsions. A quarterly assessment, dated 04/29/25, showed Res #26 had a brief interview for mental status score of 15 and was cognitively intact. The assessment showed Res #26 had an indwelling catheter. Res #26's medical record did not document an order for an indwelling catheter during the assessment review period of 04/23/25 through 04/29/25. On 05/06/25 at 3:13 p.m., Res #26 stated they did not have a catheter. They stated they had never had an indwelling catheter. On 05/07/25 at 12:57 p.m., LPN #1 stated Res #26 did not have an indwelling catheter…

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, record review, and interview, the facility failed to implement EBPs during catheter care for 1 (#21) of 2 sampled residents reviewed for EBPs. The DON reported seven residents required EBP. Findings: On 05/07/25 at 1:08 p.m. LPN #1 and certified nurse aide #1 were observed entering Res #21's room to perform catheter care. Neither staff was observed using EBPs when entering the room or while performing care. An undated policy titled Enhanced Barrier Precaution, read in part, Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include; device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator). An undated diagnoses list showed Res #21 had diagnoses of paraplegia and seizure disorder. On 05/07/25 at 1:15 p.m., LPN #1 was asked if they knew what EBPs were. LPN #1 stated a gown, gloves, and a mask. LPN #1 was asked if EBPs applied to performing catheter care. LPN #1 stated they did not think so with catheter care. On 05/07/25 at 1:40 p.m., the DON reported staff did not use EBPs with…

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 and interview, the facility failed to monitor for side effects of psychotropic medications for two (#12 and #133) of five residents sampled for the use unnecessary medications. The administrator reported the facility census was 31. Findings: An undated policy titled Documentation for Behavioral Medications and Side Effects, read in part, .When medication is ordered by the physician, for a resident to treat a behavioral condition the nurse will initiate the Behavior Drug Monitoring Record . 1. Resident #12 had diagnoses which included bipolar disorder and generalized anxiety disorder. A physician order, dated 07/10/23, documented the resident was to be given 60 mg of Cymbalta by mouth at bedtime. A physician order, dated 11/01/23, documented the resident was to be given 2 mg of Risperdal twice a day. A care plan, dated 12/06/23, documented to monitor for potential side effects of psychotropic medications. A review of the resident's MAR and TAR did not document the resident was being monitored for side effects. 2. Resident #133 had diagnoses which included…

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 and interview, the facility failed to have a program designed to help prevent the development of Legionellosis and Pontiac Fever caused by Legionella Bacteria. The administrator reported the census was 31. Findings: On 01/11/24 at 10:10 a.m., the administrator stated the water management program was a work in progress and they did not currently have a policy in place or a diagram of the facilities water system.

Based on record review and interview, the facility failed to ensure influenza vaccinations were offered for three (#5, #12, and #18) of five residents reviewed for immunizations. The administrator reported the census was 31. Findings: A review of Resident #5, #12, and #18's immunization records did not document the residents had been offered an influenza immunization in 2023. On 01/11/24 at 1015 a.m. the DON stated Residents #5, #12, and #18 were all receiving hospice care and the hospice company was supposed to provide them with vaccinations. They also reported there had been a miscommunication between hospice staff and facility staff and that hospice staff thought the facility had vaccinated all the residents. The [NAME] also reported hospice staff would offer the immunization on their next visit.

Based on record review and interview, the facility failed to implement a baseline care plan that met the professional standards of quality care for one (#133) of one resident reviewed for baseline care plans. The administrator reported the census was 31. Findings: Resident #133 was admitted with diagnoses including a fractured hip and depression. A physician order, dated 01/02/24, documented the resident was to be given 4 mg of warfarin (an anticoagulant) by mouth on Sunday, Wednesday, Friday, and Saturday and 6 mg by mouth on Monday Tuesday and Thursday. The baseline care plan, dated 01/02/24, did address the use of an anticoagulant. On 01/10/24 at 1:18 p.m., the MDS coordinator stated anticoagulant use should be included on the care plan.

Based on record review and interview, the facility failed to correct rejected resident assessments for six of 28 resident assessments submitted to CMS. The CMS Submission Report, dated 08/01/22, documented six of 28 resident assessments submitted from 06/19/22 to 07/28/22 were rejected by CMS. Findings: The CMS Submission Report, dated 08/01/22, documented six resident assessments were rejected for the submission period of 06/19/22 to 07/28/22. The MDS coordinator did not correct and resubmit the resident assessments for approval. On 09/21/22 at 10:45 a.m., the MDS coordinator reported the rejected assessments should have been corrected and resubmitted. On 09/21/22 at 11:00 a.m., the administrator reported the rejected assessments should have been corrected and resubmitted. On 09/21/22 at 11:10 a.m., the DON reported the rejected assessments should have been corrected and resubmitted.

Based on record review, observation, and interview, the facility failed to ensure sanitary conditions were maintained during food preparation. The Resident Census and Conditions of Residents, dated 09/19/21, documented 28 residents ate from the kitchen. Findings: A Daily/Weekly Dietary Cleaning Schedule, dated 08/19/22 to 08/25/22, showed no daily cleaning tasks were performed on 08/25/22 and no weekly tasks were performed A Daily/Weekly Dietary Cleaning Schedule, dated 08/26/22 to 09/01/22, showed no daily or weekly cleaning tasks were performed. On 09/19/22 at 9:25 a.m., a dry black substance was observed on a countertop near the hand washing station. On 09/19/22 at 9:25 a.m., a pack of cigarretes, a disposable lighter, and a cellular phone were observed on a countertop near the hand washing station. On 09/19/22 at 9:30 a.m., a brown, sticky, substance was observed on the bottom shelf of refrigerator number three. On 09/19/22 at 9:30 a.m., a brown, sticky, substance was observed on the door handle of freezer number five. On 09/19/22 at 9:35 a.m., a plastic bin labeled sugar 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 observation and interview, the facility failed to maintain an effective pest control program. The Resident Census and Conditions of Residents, dated 09/19/22, documented 28 residents resided in the facility. Findings: On 09/19/22 at 9:25 a.m., a brown insect was observed crawling on the countertop beside the hand washing station in the kitchen. On 09/19/22 at 9:25 a.m., three brown insects were observed crawling inside the cabinet beside the hand washing station in the kitchen. On 09/19/22 at 9:30 a.m., approximately five rodent droppings were observed inside the cabinet beside the hand washing station in the kitchen. On 09/19/22 at 9:35 a.m., approximately ten rodent dropping were observed in a plastic bin, in the dry food storage area, labeled jelly/reg jelly. On 09/19/22 at 9:40 a.m., approximately ten rodent droppings were observed on the floor in the corner of the dry food storage area. On 09/20/22 at 9:40 a.m., approximately five rodent droppings were observed inside the cabinet beside the hand washing station in the kitchen. On 09/20/22 at 9:40 a.m. approximately two…

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 and interview, the facility failed to ensure 19 resident assessments of 28 resident assessments reviewed were submitted in the required time frame. A CMS Submission Report, dated 08/01/22, documented 28 resident assessments were submitted. Findings: The CMS Submission Report dated, 08/01/22, read in part . Record submitted late. The submission date is more than 14 days . for 19 resident assessments between the dates of 06/18/22 through 07/16/22. On 09/21/22 at 10:45 a.m., the MDS coordinator reported the assessments were not submitted in the right time frame. On 09/21/22 at 11:00 a.m., the administrator reported the resident assessments should have been submitted within the required time frame. On 09/21/22 at 11:10 a.m., the DON reported the expectation was for the resident assessments to be submitted in the required time frame.

Based on observation, record review, and interview, the facility failed to perform bathing as scheduled for one (#20) of two residents reviewed for bathing. The administrator reported 14 residents required assistance with bathing. Findings: Res #20 was admitted with diagnoses which included anxiety, epilepsy, and heart failure. Res #20's care plan, dated 07/27/22, read in part, .I do require assistance with showering. A document titled, ADL Bathing, documented the resident received a bath on 08/13/22 and 08/27/22 for the month of August 2022. A document titled ADL Bathing, documented the resident received a bath on 09/03/22, 09/10/22, and 09/17/22 for the month of September 2022. Res #20's quarterly assessment, dated 09/15/22, documented the resident required assistance with activities of daily living and was cognitively intact. On 09/19/22 at 09:47 a.m., Res #20 was observed in bed. The resident stated they were not being bathed twice a week as scheduled. On 09/20/22 at 8:45 a.m., Res #20 was observed in bed. On 09/20/22 at 12:25 p.m., the DON reported Res #20's showers 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.