Clay County Health and Rehabilitation

Inspectors wroteBased on staff interviews, the facility failed to designate a qualified Infection Preventionist (IP) who had completed specialized training in infection prevention and control, to be responsible for the facility's Infection Prevention and Control Program. This had the potential to affect all the residents residing in the facility.

Inspectors wroteBased on record review, staff, Pharmacist, and Medical Director interview, the facility failed to transcribe and implement orders for diabetes care according to the hospital discharge summary for a resident with diabetes. Additionally, the facility failed to transcribe and implement orders for the same resident's Coreg (used to treat heart failure and hypertension) according to the hospital discharge summary. This deficient practice occurred for 1 of 5 residents reviewed for significant medication errors (Resident #23).

Inspectors wroteBased on record review, and staff and Registered Dietitian (RD) interviews, the facility failed to follow Registered Dietitian recommendations for nutritional supplement for a resident with significant weight loss for 1 of 5 residents reviewed for nutrition (Resident #44).

Inspectors wroteBased on record review, and staff and Medical Director interviews, the facility failed to ensure the physician visit included a plan to address an abnormal low thyroid laboratory test from the hospital discharge summary. This deficient practice occurred for 1 of 3 residents reviewed for physician visits (Resident # 1).

Inspectors wroteBased on record review and interviews with staff, Consultant Pharmacist, and Consultant Pharmacist Supervisor, the Consultant Pharmacist failed to identify irregularities regarding laboratory monitoring for 1 of 1 resident with a diagnosis of diabetes reviewed for unnecessary medication (Resident #12).

Inspectors wroteBased on record review and staff, Physician, Consultant Pharmacist, and Consultant Pharmacist Supervisor interviews, the facility failed to ensure monitoring for medication management was completed as recommended by the medical provider for 1 of 6 resident with a diagnosis of diabetes reviewed for unnecessary medications (Resident #12).

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to discard expired medication from the medication room for 1 of 1 medication room observed for medication storage and labeling. Additionally, the facility failed to keep unattended medications in a secured medication cart for 1 of 4 medication carts (300-hall medication cart) observed for medication storage.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to implement their policy and procedures for glucometer disinfection, standard precautions, and hand hygiene when Medication Aide #1 failed to disinfect Resident #23's assigned glucometer after performing a capillary blood glucose (CBG) test. Additionally, Medication Aide #1 failed to wear gloves when she performed the CBG test and failed to perform hand hygiene before and after performing the CBG test. This deficient practice occurred for 1 of 3 glucometer infection control observations and 1 of 3 hand hygiene observations (Medication Aide #1).

Inspectors wroteBased on record review and staff interviews, the facility failed to document a resident or Responsible Party (RP) were provided education regarding the benefits and potential side effects of the pneumococcal immunization or if the resident received the pneumococcal immunization or did not receive it due to a medical contradiction or refusal. In addition, there was no documentation the resident was offered the pneumococcal immunization. This occurred for 1 of 5 residents reviewed for immunizations (Resident #6).

Inspectors wroteBased on record review and staff interviews, the facility failed to assess a resident for eligibility and ensure a resident was offered the COVID-19 vaccination for 1 of 5 residents reviewed for immunizations (Resident #6).

Inspectors wroteBased on record review and staff and physician interviews, the facility failed to ensure physician visits were performed at least once every sixty days for 3 of 3 sampled residents reviewed for physician visits (Residents #62, #44 and #9). 1. Resident #62 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, dementia and diabetes. Resident #62's annual Minimum Data Set (MDS) assessment dated [DATE] indicated she was severely cognitively impaired and was dependent on staff for most activities of daily living. A review of Resident #62's electronic health record revealed a Nurse Practitioner (NP) progress note dated 12/18/25 and a Physician's annual wellness visit dated 3/31/26. No further documentation was found to show the Physician or NP had visited or assessed the resident between 12/18/25 and 3/31/26. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code Minimum Data Set (MDS) assessments in the areas of bed rails and diagnoses for 7 of 12 sampled residents reviewed for physical restraints, respiratory care and unnecessary medications (Residents #1, #51, #63, #13, #65, #24, and #47).

Inspectors wroteBased on record review and staff interviews the facility failed to complete Care Area Assessments (CAA) comprehensively to address the underlying causes and contributing factors of the triggered areas for 2 of 8 residents reviewed for pressure ulcers and unnecessary medications (Residents #46 and #51). Findings Included: a. Resident #46 was admitted to the facility on [DATE] with diagnoses that included diabetes, stroke and end-stage renal disease. Review of Section V (CAA Summary) from the admission Minimum Data Set (MDS) dated [DATE] revealed the care area for pressure ulcer triggered for Resident #46. The MDS Coordinator who completed the assessment did not provide any information in the analysis of findings that described the nature of Resident #46's problem, possible causes, contributing factors, and risk factors for the triggered care area. [...]

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to complete bed rail assessments to determine the need for bed rail use for 3 of 5 sampled residents (Resident #1, #51 and #13). Findings Included: 1. a. Resident #1 was admitted to the facility on [DATE] with diagnoses that included history of falling, generalized muscle weakness and left shoulder pain. Review of Resident #1's electronic medical record on 02/26/25 revealed the last completed bed rail assessment was dated 11/08/23. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had intact cognition and required substantial/maximum assistance with bed mobility. During an observation and interview on 02/25/25 at 9:15 AM, quarter bed rails were observed in the upright position on each side of Resident #1's bed. [...]

Inspectors wroteBased on record review and interviews with the resident, staff, Consultant Pharmacist, and the Medical Director (MD), the Consultant Pharmacist failed to identify drug irregularities and provide recommendations for 1 of 4 residents reviewed for diabetes management (Resident #39).

Inspectors wroteBased on record review and interviews with the resident, staff, Consultant Pharmacist, and the Medical Director (MD), the facility failed to prevent significant medication errors when 5 nurses failed to follow the physician's parameter as ordered during insulin administration. As a result, Resident #39 had received 2 doses or unnecessary Humalog insulin and her insulin had been held against the parameter 17 times within 112 days. This affected 1 of 4 residents reviewed for diabetes management (Resident #39).

Inspectors wroteBased on record reviews, observations and staff interviews, the facility failed to implement their infection control policy when Nurse #1 did not perform hand hygiene after removing soiled dressings with drainage and before donning new gloves to cleanse the wound for 3 of 5 wound care observations on 2 of 3 residents reviewed (Resident #53 and Resident #33).