Dermott City Nursing Home

Inspectors wroteBased on record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. This failed practice resulted in actual harm for one (Resident #1) of three sampled residents reviewed for neglect. It was determined the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The immediate Jeopardy (IJ) was related to CFR 483.25 (Quality of Care) at a scope and severity of J. The IJ began on [DATE], when facility staff failed to identify and properly respond on behalf of a resident experiencing a medical emergency resulting in avascular necrosis and subsequent death. The Administrator was notified of the IJ on [DATE] at 1:22 PM. [...]

Inspectors wroteBased on interviews, record review and facility document review, it was determined the facility failed to ensure that a resident's transfer or discharge was reported to the ombudsman for one (Resident #3) of one resident reviewed for discharge process.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure Certified Nursing Assistants (CNAs) #1 and #2 demonstrated competency in the care of a resident by moving a resident prior to a nurse assessment following a fall, and by not following the resident's care plan, which indicated the use of a mechanical stand-up lift with two-person assist for transfers, for one (Resident #1) of three residents reviewed for falls. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.35 (Nursing Services) at a scope and severity of J. [...]

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure a Licensed Administrator was hired to oversee the day-to-day functions of the facility in accordance with current federal, state and local standards, guidelines and regulations that govern nursing facilities for one of one facility reviewed for administrative duties.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure a comprehensive care plan was consistently implemented for one (Resident #1) of three residents whose care plans were reviewed.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure the required staffing data was posted daily as evidenced by the daily staffing logs did not display the total number and actual worked hours for Registered Nurses (RNs), Licensed Practical Nurses (LPNs), Certified Nursing Assistants (CNAs) and resident census.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 2 of 2 meals observed. This failed practice had the potential to affect 21 residents who received mechanical soft diets from 1 of 1 kitchen.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure dietary staff washed their hands and changed their gloves before handling food items; foods stored in the dry storage area, refrigerator, and freezer were covered and sealed; expired food items were promptly removed from stock; 1 of 2 ice machines was maintained in clean and sanitary condition; hot food items were maintained at or above 135 degrees Fahrenheit on the steam table.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to provide appropriate bedding for 1 (Resident #1) of 1 sampled resident observed for bedding.

Inspectors wroteBased on Observation, Interview, Record Review and Facility Policy Review; the facility failed to transfer one (Resident #1) of five (Resident #1, #2, #3, #4 and #5) sampled residents safely and in accordance to the care plan, resulting in a major injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to operate under the direction of a licensed Administrator, which had the potential to affect all 45 residents who resided in the facility.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure foods stored in the freezer, refrigerator and dry storage areas were covered, sealed and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; expired food items were promptly removed/discarded on or before the expiration or use by date to prevent the growth of bacteria; leftover foods were in a manner to maintain food quality; dietary staff washed their hands between dirty and clean tasks and before handling clean equipment or food items to prevent potential for cross contamination; 1 of 2 ice scoop holders was maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages for residents who received meals from 1 of 1 kitchen; and the ceiling tiles were free of stains and walls were free of peeling paint. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a janitor closet on the 500 Hall containing chemicals remained locked to prevent accidents. This failed practice had the potential to affect 25 residents who were ambulatory or self-propel in a wheelchair as documented on a list provided by the Administrator on 01/05/2024 at 09:41 AM.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed. This failed practice had the potential to affect 4 residents who received pureed diets and 20 residents who received mechanical soft diets from 1 of 1 kitchen according to a list provided by the Dietary Supervisor on 01/05/2024.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure meals were served at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. The failed practice had the potential to affect 8 residents who received their meal trays in their rooms on the 500 Hall, 8 residents who received meals in their rooms on the 100 Hall, as documented on a list provided by the Dietary Supervisor on 01/05/2024 at 10:51 AM.

Inspectors wroteBased on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. This failed practice had the potential to affect 4 residents who received pureed diets, as documented on the Diet List provided by the Dietary Supervisor on 01/05/2024.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Quality Assurance and Performance Improvement program (QAPI) Committee developed and implemented appropriate plans of action to prevent repeated deficiencies to ensure residents with Mental Health Diagnosis received a Level II Pre-admission Screening and Resident Review (PASARR) before being admitted to the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a multi-resident use glucometer (a machine to check glucose levels) was properly disinfected after use to prevent potential spread of infection for 3 (Residents #10, #12 and #14) sampled residents who had physician orders for capillary blood glucose monitoring as documented on a list provided by the Administrator on 1/05/23 at 9:31 AM.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident records, care plans, and physician orders contained accurate documentation of a residents' Cardio-Pulmonary Resuscitation (CPR) status for 1 (Resident #39) of 1 sampled resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Ombudsman was notified of a transfer to the hospital for 1 (Resident #42) of 1 sampled resident.

Inspectors wroteBased on record review and interview, the facility failed to notify the State Agency for a Pre-admission Screening and Resident Review (PASARR) for a new mental illness diagnosis for 1 (Resident #19) sampled resident to ensure the resident received appropriate mental health services.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a care plan to address cigarette smoking for 1 (Resident #33) of 6 (Residents # 5, #9, #18, #26, #33 and #35) sampled residents who smoke documented on a list provided by the Administrator on 01/02/2023.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure rehabilitative services were carried out according to the physician's orders for 1 (Resident #19) of 1 sampled resident who have a contracture.

Inspectors wroteBased on observations, record review and interview, the facility failed to follow a therapeutic diet by ensuring the nutritional interventions ordered by the physician were served and offered when the resident's weight continued to decline from week to week in order to minimize further weight loss and maintain nutritional status to the extent possible for 1 (Resident #36) of 1 sampled resident.

Inspectors wroteBased on interview and record review, the facility failed to notify the state agency for a Pre-admission Screening and Resident Review (PASRR) for a new mental illness diagnosis for 1 (Resident #34) sampled resident to ensure the resident received appropriate Mental Health Services.

Inspectors wroteBased on record review and interview, the facility failed to ensure that the Person-Centered Comprehensive Care Plan was reviewed and revised by the interdisciplinary team who had knowledge of the resident and the resident's needs, for 1 (Resident #34) of 1 sampled resident that had a diagnosis of Unspecified Psychosis not due to substance or known psychological condition.

Inspectors wroteBased on record review, and interview, the facility failed to ensure 1 resident (Resident #14) of 1 (Resident #14) case mix residents was not left unattended following a doctor's appointment, as evidenced by the resident having a fall outside the doctor's office. The resident was left alone outside of the doctor's office while the Transport Assistant (TA) went to get the van. While waiting on the van to arrive the resident unlocked her wheelchair and rolled down to the curb where the wheelchair tipped over with the resident in it. The failed practice had the potential to affect all residents who require transportation by the facility van to outside appointments.

Inspectors wroteBased on record review and interview the facility failed to ensure a Facility-Wide Assessment was updated on an annual basis to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. This failed practice had the potential to affect all 44 residents according to the Census and Conditions provided by the Administrator on 10/10/22 at 2:38 pm.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure a resident's rights for dignity were maintained as evidenced by 1 Resident (Resident #41) had a urinary catheter bag being in full view of others.