Life Care Center Of Bruceton-Hollow Rock

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, control drug record review, and interview, the facility failed to properly document the disposal of controlled medications for 5 of 5 (Resident #41, #72, #74, #75, and #76) sampled residents reviewed for controlled medication disposition. The findings include: 1. Review of the facility policy titled, Management of Controlled Substances, dated 3/4/2025, revealed .The facility will maintain a system to account for controlled medications' receipt and disposition in sufficient detail to enable an accurate reconciliation, and that the facility conduct periodic reconciliation.facility must employ or obtain the services of a licensed pharmacist who .Establishes a system of records of receipt and disposition of all controlled drugs.and that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.Disposition - the process of returning and/or destroying unused medications.Reconciliation - system of recordkeeping that ensures an accurate…

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 policy review, medical record review, observation, and interview the facility failed to ensure that medications were properly and securely stored when medications were left in a resident's room for 1 of 71 (Resident #60) sampled residents. The findings include: 1. Review of the facility policy titled, Storage and Expiration Dating of Medications, Biologicals dated 8/7/2023, revealed .Facility should ensure that medications and biologicals are stored in an orderly manner in cabinets, drawers, carts, refrigerators/freezers of sufficient size .Store all drugs and biologicals in locked compartments .permanently affixed compartments, permitting only authorized personnel to have access .Facility should ensure that all medications and biologicals, including treatment items are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors .Facility should not administer/provide bedside medications or biologicals without a Physician/Prescriber order 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.

Based on policy review, observation, and interview, the facility failed to ensure 1 of 4 (Licensed Practical Nurse [LPN] A) nurses followed proper infection control measures to prevent the potential spread of infection and cross contamination while performing blood glucose monitoring during Medication Administration. The findings include: 1. Review of the facility's policy titled Cleaning and Disinfection of the Glucometer dated 9/20/2023, revealed .To prevent the spread of infection, specifically blood borne pathogens through the use of point of care blood glucose monitoring, by cleaning and disinfecting glucometers after each resident use . 2. Observation in Resident #6's room on 7/23/2024 at 7:37 AM, revealed Licensed Practical Nurse (LPN) A gathered supplies, removed the glucometer from the medication cart drawer, and placed it on top of the medication cart. LPN A preceded to perform a blood glucose check on Resident #6 and returned the glucometer to the medication drawer. LPN A failed to clean the glucometer in accordance with the facility policy. During an interview on…

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 policy review, observation, and interview, the facility failed to ensure food was served under sanitary conditions when 2 of 18 staff members (Activity Assistant and Certified Nursing Assistant (CNA) #9) failed to perform proper hand hygiene during meal service and failed to ensure temperatures for the nutrition freezers were documented daily in 2 of 2 nutrition refrigerators observed in the facility's Nutrition Rooms. The findings include: 1. Review of the facility's policy titled, Sanitation and Food Safety, dated 9/8/2022, revealed .Temperatures are recorded at least twice daily on the Refrigerator/Freezer Temperature Log using an inside thermometer placed near the door . Review of the facility's policy titled, .Hand Hygiene, with a revised date of 6/13/2023, revealed .Associates perform hand hygiene (even if gloves are used) in the following situations .Before and after contact with the resident .After contact with objects and surfaces in the resident's environment . 2. Observation in the resident's room on 8/28/2023 at 7:51 AM, revealed the Activity Assistant entered…

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 policy review, observation, and interview, the facility failed to ensure infection control practices to prevent the spread of infection were used when 4 of 5 (Licensed Practical Nurses (LPN) #1, #9, #10, and Registered Nurses (RN) #1) nurses failed to perform hand hygiene during medication administration. The findings include: 1. Review of the facility's policy titled, Hand Hygiene, dated 6/13/2023, revealed .The facility has adopted the CDC [Centers for Disease Control] Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings for indications for hand hygiene .Associates perform hand hygiene (even if gloves are used) in the following situations .Before and after contact with the resident .After contact with objects and surfaces in the resident's environment .After removing personal protective equipment .Before performing a procedure . 2. Observation at the C Hall Medication (Med) Cart during medication administration on 8/29/2023 at 5:05 PM, revealed LPN #9 unlocked her med cart, removed each of Resident #13's medications, and placed them in a…

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 Amended 9/24/2023 Based on policy review, medical record review, observation, and interview, the facility failed to ensure all residents' right to be treated with dignity and respect when 1 of 6 staff member (Licensed Practical Nurse (LPN) #9) failed to provide privacy for Resident #225 during administration of medication through a Percutaneous Endoscopic Gastrostomy tube. The findings include: 1. Review of the facility's policy titled, .Dignity, dated 9/30/2022, revealed .Each resident has the right to be treated with dignity and respect. Interactions .with residents by staff .must focus on maintaining and enhancing the resident's self-esteem, self-worth . 2. Review of the RESIDENT admission AGREEMENT .Section 11: Resident Rights .The resident has a right to personal privacy includes .medical treatment .personal care . 3. Review of the medical record revealed Resident #225 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Diabetes, Sepsis, Congestive Heart Failure, Polyneuropathy,…

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 policy review, medical record review, observation and interview, the facility failed to ensure residents' right to be free from verbal and physical abuse for 1 of 7 (Resident #39) sampled residents reviewed for an allegation of abuse. The findings include: 1. Review of the facility's RESIDENT admission AGREEMENT, revised 2022, revealed, .The resident has the right to be free from abuse, neglect . Review of the facility's policy titled, Abuse - Conducting an Investigation, dated 7/18/2023, revealed .It is the policy of this facility that allegations of abuse .are promptly and thoroughly investigated. The facility will prevent further abuse, neglect .and mistreatment from occurring while the investigation is in progress .The facility must develop and implement written policies and procedures .Prohibit and prevent abuse, neglect . 2. Review of medical record, revealed Resident #39 was admitted [DATE] with a readmission on [DATE], with diagnoses of Rhabdomyolysis, Crohn's Disease, Dysphagia, Anxiety…

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 facility policy review, medical record review, and interview, the facility failed to report an allegation of abuse for 1 of 4 (Resident #39) sampled residents reviewed for allegation of abuse. The findings include: 1. Review of the facility's policy titled, Abuse - Protection of Residents, revised 7/18/2023, revealed .The facility will ensure that all residents are protected from physical and psychosocial harm during and after the investigation .Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident . 2. Review of medical record revealed Resident #39 was admitted [DATE] with a readmission on [DATE], with diagnoses of Rhabdomyolysis, Crohn's Disease, Dysphagia, Anxiety Disorder and Chronic Kidney Disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #39 had a Brief Interview for Metal Status (BIMS)…

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 facility policy review, medical record review, and interview, the facility failed to thoroughly investigate an allegation of abuse for 1 of 4 (Resident #39) sampled residents reviewed for allegation of abuse. The findings include: 1. Review of the facility's policy titled, Abuse - Conducting an Investigation, dated 7/18/2023, revealed .It is the policy of this facility that allegations of abuse .are promptly and thoroughly investigated. The facility will prevent further abuse, neglect .and mistreatment from occurring while the investigation is in progress .When an incident or suspected incident of resident abuse .is reported, the administrator .will investigate the occurrence .The facility must thoroughly collect evidence to allow the Administrator to determine what actions are necessary .The administrator .will review the Incident Report for completeness .The written summary of the investigation should include, but is not limited to .A review of the Incident Report .An interview with the person (s)…

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 policy review, medical record review, and interview, the facility failed to conduct Care Plan meetings which included the Interdisciplinary Team (IDT) for 1 of 3 sample resident (Resident #35) reviewed for care plan meetings. The findings include: 1. Review of the facility's policy titled, Comprehensive Care Plans and Conferences, dated 8/22/2023, revealed .Interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative .is involved in developing the care plan and making decision about his or her care .The IDT [Interdisciplinary Team] must, at a minimum, consist of the resident's attending, physician, a registered nurse and nurse aide with responsibility for the resident, a member of the food and nutrition services staff .the resident and resident representative .The facility should provide the resident and resident representative if applicable with advance notice of care planning conferences to enable…

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 facility policy review, medical record review, observation, and interview, the facility failed to administer medications as prescribed by the physician and as recommended for 1 of 3 (Resident #52) sampled residents reviewed for medication administration. The findings include: 1. Review of the facility policy titled, Administration of Medications, dated 8/25/2022, revealed, .The facility will ensure medications are administered safely and appropriately per physicians order to address resident' diagnoses and signs and symptoms .Staff who are responsible for medication administration will adhere to the 10 Rights .Right Drug .Every drug administered must have an order from the provider. Compare the order with the medication administration record (MAR) for accuracy. Compare the label of the drug to the information on the M. A. R. [Medication Administration Record] three times .Right Resident .Right Dose .Right Route .Right Time and Frequency .Right Documentation .Right Assessment .Right to Refuse .Right…

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 facility policy review, observation, and interview, the facility failed to ensure that medication records were in order and that an account of all controlled medications were maintained and reconciled for 1 of 6 (Registered Nurse (RN) #1) nurses for 5 of 7 (Resident #14, #34, #35, #63, and #71) residents. The findings include: 1. Review of the facility policy titled, Management of Controlled Substances dated 8/28/2022, revealed .disposition of all controlled drugs .enable an accurate reconciliation .an account of all controlled drugs is maintained . 2. Observation and interview at the B Hall Medication (Med) Cart on 8/30/2023 at 11:37 AM, revealed RN #1 was asked to review Resident #14's narcotic reconciliation. Review of the Controlled Drug Record for Resident #14 revealed, .GABAPENTIN (used to treat seizures and nerve pain) .300 MG [Milligram] CAPSULE .Amount Remaining .11 . Review of Resident #14's narcotic card revealed a count of 10 Gabapentin capsules remained. RN #1 was asked about the difference in the number and stated, I just gave her one, let me sign it out. RN…

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 policy review, observation and interview, the facility failed to ensure medications were properly stored when opened and undated medications and expired formula were observed in 2 of 5 (D Hall Medication Storage Room and D Hall Medication Cart) medication storage areas. The findings include: 1. Review of the facility's policy titled, Storage and Expiration Dating of Medications, Biologicals dated [DATE], revealed .Facility staff should record the date opened on primary medication container . 2. Observation of the D Hall Medication Cart on [DATE] at 5:03 PM, revealed: One opened and undated box of Ipratropium Bromide and Albuterol Sulfate 0.5/3mg (milligrams) (medication used to treat asthma, chronic bronchitis, and emphysema). One opened and undated bottle of Potassium Chloride 20 milliequivalents (used to treat low potassium). 3. Observation of the D Hall Medication Storage Room on [DATE] at 1:19 PM, revealed the following: 202 individual cartons of Glucerna 1.0 calorie (high calorie nutrition) with an…

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 policy review, medical record review, observation, and interview, the facility failed to maintain an effective pest control program in 3 of 60 (Resident #7, Resident #13, and Resident #35) resident rooms, failed to prevent parasites or possible maggots for Resident #22, and 1 of 4 (C Hall) Halls on 3 of 4 (8/29/2023, 8/30/2023, and 8/31/2023) days of onsite observations. The findings include: 1. Review of the facility policy titled, Pest Control, dated 6/4/2023, revealed .The facility will maintain an effective pest control program that provides frequent treatment of the environment for pests so that the facility is free of pests .The facility's staff will do monitoring of the environment. Pest control problems will be reported to the Director of Maintenance promptly . 2. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses of Chronic Respiratory Failure, Dementia, Schizophrenia, and Severe Protein-Calorie Malnutrition. Review of the quarterly Minimum…

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.