Etowah Health And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observations, and interviews, the facility failed to maintain a safe, clean, homelike environment for 9 resident rooms (room [ROOM NUMBER], #201, #214, #209, #106, #212, #205, #111, and #206) of 28 resident rooms observed on 2 of 2 hallways observed. The findings include: Review of the facility's policy titled, Room Audit, dated 9/1/2014, revealed .PURPOSE .To assess resident rooms to identify items that should be repaired .or addressed to ensure a home-like standard that meets acceptable standards .Lights including over-bed lighting should be checked for proper function .General Room Appearance .should be noted and reported .Damage .should be noted .and addressed according to priority . 1. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes, Osteoporosis, and Hypertension. Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #20 scored a 14 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, observations, facility document review, and interviews, the facility staff failed to provide hand hygiene prior to meal services for 5 residents (Resident #10, Resident #2, Resident #21, Resident #25, Resident #53) of 5 residents observed for dining on 2 of 2 hallways and 1 dining room observed. The findings include: Review of the facility's policy titled, Hand Washing/Hand Hygiene, dated 11/1/2017, revealed .Use an alcohol-based hand rub or, alternatively, soap (antimicrobial or non-antimicrobial) and water .Before and after eating or handling food . Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including Muscle Weakness, Nausea and Vomiting, and Adult Failure to Thrive. Review of a comprehensive care plan dated 12/3/2025, revealed Resident #10 .ADL [Activities of Daily Living] Self Care Deficit due to .Impaired cognition/dementia .EATING: provide this support . Dependent . Review of a significant…

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, temperature log reviews, observations, and interviews, the facility failed to obtain and record temperatures of the refrigerators and freezers in 2 of 2 nourishment rooms which had the potential to affect 55 of 56 residents. The findings include: Review of the facility policy titled, Monitoring of Cooler/Freezer Temperature/Refrigerator Temperatures, revised 11/2017, revealed .Logs for recording temperatures for each refrigerator or freezer will be posted in a visible location outside the freezer or refrigerator unit .Temperatures will be checked and logged by designated personnel (nursing/dietary) .Logs will be changed out and filed each month .Thermometers shall be placed inside each cooler/freezer/refrigerator .All refrigerated storage must be maintained at or below 41 . degrees Fahrenheit .All frozen storage must be maintained at or . -4 degrees Fahrenheit . Review of the Daily Freezer and Refrigerator Temperature Logs, dated 6/2022 for the A/B Hall, showed .Instructions: This log will be maintained for each refrigerator and freezer .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 facility policy review, facility investigation review, record review, and interview, the facility failed to prevent the misappropriation of narcotic medications for 11 Residents (#1, #5, #7, #16, #23, #35, #36, #46, #48, #58, and #163) of 22 residents reviewed for narcotic medications use. The findings include: Review of the facility policy titled, Controlled Drug Policy and Procedure For Licensed Personnel, undated, showed .Any suspicion of substitutions or tampering with controlled drugs must be reported to the supervisor immediately .Controlled drug distribution if [is] for use of patients only. The charge nurse is not authorized to give narcotics to any nurse or physician who requests them for personal use . Review of a facility policy titled, Abuse, Neglect and Exploitation Policy and Procedures, dated 4/25/2016, showed .Residents have the right to be free from misappropriation of property .by facility staff .It is the policy of this facility to provide protections for the health, welfare 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, facility reporting review, medical record review, and interview the facility failed to submit investigative findings of allegations of abuse to the State Survey Agency timely for 11 residents (#1, #5, #7, #16, #23, #35, #36, #46, #48, #58, and #163) of 16 residents reviewed for abuse. The findings include: Review of a facility policy titled, Abuse, Neglect and Exploitation, dated 11/2017, showed .The facility will have written procedures that include .Administrator .will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies . Resident #1 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes, Peripheral Vascular Disease, and Parkinson's Disease. Resident #5 was admitted to the facility on [DATE] with diagnoses including Hypertension, Dementia, and Chronic Osteomyelitis. Resident #7…

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, interview, and observation, the facility failed to assess 1 resident (#46) for self-administration of medications of 5 residents reviewed for medication administration. The findings include: Review of the facility policy titled, Medication Administration, updated 12/2011, showed .Residents may be allowed to self-administer medications only when specifically authorized by the attending physician and in accordance with procedures for Self-Administration of Medications . Review of the facility policy titled, Self-Administration of Drugs, undated, showed .The care planning team will assess each resident's mental, physical, visual ability to determine if the resident is capable of self-administration of drugs and medications . Medical record review revealed Resident #46 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Hypertension, Chronic Kidney Disease Stage 3, and Dyspnea. Review of Resident #46's 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, reportable event form review, medical record review, and interview the facility failed to ensure 1 resident (#23) was free from physical abuse of 21 residents reviewed for abuse. The findings include: Review of a facility policy titled ABUSE, NEGLECT & EXPLOITATION POLICY & PROCEDURES dated 4/25/2016, showed the facility .will promote the rights, comfort, safety and well being of its residents . The facility .recognizes that residents have the right to be free from verbal, sexual, physical, and mental abuse, mistreatment, neglect .Residents are not to be subjected to abuse, neglect, and/or exploitation by anyone, including but not limited to, facility staff, other residents . Resident #23 was admitted to the facility on [DATE] with diagnoses including Heart Disease, Chronic Pain Syndrome, Major Depressive Disorder, Osteoarthritis, Chronic Systolic Heart Failure, Type 2 Diabetes Mellitus, Hypertension, and Anxiety Disorder. Review of the comprehensive care plan dated 7/31/2021,…

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, observations, and interview the facility failed to provide an ongoing re-evaluation of the need for a physical restraint for 1 resident (#49) of 1 resident reviewed for restraints. The findings include: Review of the facility policy titled Restraint Guidelines dated 8/30/2019, showed .A physician's order alone is not sufficient to warrant the use of a physical restraint. The facility is responsible for the appropriateness of the determination to use a restraint .At a minimum, quarterly evaluations should be completed to determine if the restraint is still needed or another less restrictive device could be used to address the medical symptom . Resident #49 was admitted to the facility on [DATE] with diagnoses including Depression, Dementia, Hypertension, Altered Mental Status, Adult Failure to Thrive, Anxiety Disorder, History of Falls, Muscle Weakness, and Difficulty in Walking. Review of a physician's order dated 8/16/2021, showed .Apply lap buddy…

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 medical record review and interview the facility failed to resubmit a timely Level I (one) Preadmission Screening and Resident Review (PASARR) after 180 days for 1 resident (#10) of 8 residents reviewed for PASARR. The findings include: Medical record review of a PASRR dated 3/31/2021 for Resident #10 revealed .you are approved for admission for or up to 180 days in a nursing home .If you or your care provider thinks you need to stay longer than 180 days, a nursing home staff member must submit a new Level I screen .This must be done by or before the 180th day after your admission to the nursing home . Medical record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including Psychoactive Substance Abuse, Dementia without Behavioral Disturbance, and Schizophrenia. Medical record review of a PASARR for Resident #10 dated 11/16/2021 revealed .Your level I screen has been canceled .The screen was canceled because your health care professional did not .submit requested…

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, facility investigation review, and interview, the facility failed to ensure a Certified Nursing Assistant (CNA) performed job duties within her scope of practice for 1 resident (Resident #46) of 5 residents reviewed for medication administration. The findings include: Review of the facility policy titled, Medication Administration, updated 12/2011, showed .Only licensed or legally authorized personnel who prepares a medication may administer it . Medical record review revealed Resident #46 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Hypertension, Chronic Kidney Disease Stage 3, and Dyspnea. Review of Resident #46's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident had a Brief Interview for Mental Status (BIMS) assessment score of 15, which indicated the resident was cognitively intact. Review of Resident #46 's Medication Administration Record (MAR) dated 6/1/2022-6/22/2022, showed…

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 review of the Centers for Disease Control (CDC) Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 (the virus that causes COVID-19 -a respiratory infection) Spread in Nursing Homes, review of the CDC COVID Data Tracker Levels of Community Transmission, review of the facility testing logs, and interview, the facility failed to ensure exempt unvaccinated employees were tested for the COVID-19 virus per CDC guidelines for 4 of 7 unvaccinated employees reviewed for COVID-19 testing potentially affecting 56 residents. The findings include: Review of the .Centers for Disease Control (CDC) Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes . last updated 2/2/2022, showed .In nursing homes, HCP [Health Care Providers] who are not up to date with all recommended COVID-19 vaccine doses should continue expanded screening testing based on the level of community transmission as follows .In nursing homes located in counties with substantial to high community transmission, these HCP should have a viral test…

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 medical record review and interview the facility failed to resubmit a timely Level I (one) Preadmission Screening and Resident Review (PASRR) for 1 resident (#19) of 4 residents reviewed for PASRR of 22 sampled residents. The findings include: Review of facility policy Resident Assessment - Coordination with PASRR Program, undated, revealed .All applicants to this facility will be screened .in accordance with the State's Medicaid rules for screening . Medical record review revealed Resident #19 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Paranoid Schizophrenia, Schizoaffective Disorder, and Bipolar Disorder. Medical record review of a PASRR dated 11/22/17 revealed .Your level I screen is good for 60 calendar days .After the 60 calendar days, any nursing home you admit to must submit a new Level I screening form .He is approved for a 60-day exemption. If more time is required, a new PASRR .will need to be submitted . Medical record review from 1/22/18 -…

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, review of a facility incident report, and interview, the facility failed to develop and implement interventions after a fall for 1 Resident (#56) of 8 residents reviewed for falls of 22 sampled residents. The findings include: Review of facility policy Fall Risk Assessment, undated, revealed .the facility will develop and implement resident specific interventions .each resident fall will be reviewed .by a licensed nurse .new intervention .to address the new root cause identified . Review of facility policy Fall Guidelines, dated 2018, revealed .when any resident experiences a fall, the facility will .Document interventions . Medical record review revealed Resident #56 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including Dementia with Behavioral Disturbance, Major Depressive Disorder, Weakness, Difficulty in Walking, and Anxiety Disorder. Medical record review of Resident 56's Quarterly Minimum Data Set (MDS) dated [DATE]…

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.