Diversicare of Quitman

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure residents and their resident representatives (RRs) received written notice of hospital transfers, including the reason for the transfer, in a language and manner they could understand for three (3) of four (4) residents reviewed for discharges and hospitalization. Resident #1, Resident #3, and Resident #98.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to timely develop a comprehensive care plan with interventions related to an indwelling catheter placement for one (1) of (20) sampled residents reviewed for care planning. Resident #92.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident's call light remained accessible and within reach for one (1) of (20) sampled residents reviewed for call light accessibility. Resident #77.

Inspectors wroteBased on staff interview, record review, and facility guideline review, the facility failed to revise the comprehensive care plan to reflect Resident #29's current diabetic management orders and interventions for one (1) of (20) sampled residents reviewed for care plans. Resident #29.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to provide treatment and services according to professional standards of practice by failing to monitor, assess, and provide appropriate follow-up for abnormal blood sugar results, insulin holds/refusals, and glucagon administration for Resident #29 and by failing to timely implement physician orders related to indwelling catheter management for Resident #92 for two (2) of (20) sampled residents reviewed for treatment and services.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to store oxygen tubing and a nasal cannula in a manner to prevent possible contamination and respiratory complications for one (1) of (1) residents reviewed for respiratory care. Resident #29.

Inspectors wroteBased on observation, interview, facility policy review and record review, the facility failed to implement Enhanced Barrier Precautions (EBP) and infection prevention and control practices for one (1) of six (6) sampled residents. (Resident #2)

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to provide supervision to prevent a resident-on-resident altercation when Resident #61 wandered into another resident's room, which resulted in Resident #61 receiving a hematoma to her forehead and an emergency department (ED) visit for one (1) of 22 sampled residents, Resident #61.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to develop care plans related to a Continuous Positive Airway Pressure (CPAP) machine (Resident #2) and an indwelling catheter (Resident #74) for two (2) of 22 sampled residents.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure residents' rights to privacy by allowing wandering residents to enter resident rooms without invitation or permission (Resident #5 and Resident #57) and failing to cover a urinary drainage bag (Resident #74) for three (3) of 22 sampled residents.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to implement physician orders for the use of a Continuous Positive Airway Pressure (CPAP) machine (Resident #2) and for an indwelling catheter (Resident #74) for two (2) of 22 sampled residents.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure sufficient nursing staff to provide nursing and related services to meet residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being for one (1) of four (4) staffing quarters reviewed.

Inspectors wroteBased on staff interviews, record review, facility investigation, and policy review, the facility failed to protect a resident from verbal abuse for one (1) of four (4) residents sampled.

Inspectors wroteBased on observation, interviews, record review and facility policy review the facility failed to remove expired, undated, and spoiled food items from storage areas for one (1) of four (4) kitchen observations. This had the potential to affect all residents in the facility receiving food from the dietary department.

Inspectors wroteBased on observation, interview and record review the facility failed to provide percutaneous endoscopic gastrostomy (peg) feeding tube care in a manner to prevent complications for one (1) of three (3) residents reviewed with peg feeding tubes.

Inspectors wroteBased on interview, observation, record review, the facility failed to adhere to accepted standards of practice for the proper storage of a nebulizer mask for two (2) of three (3) observations.

Inspectors wroteBased on observation, interview, record review and facility policy review the facility failed to ensure recommended dental services were provided for one (1) of twenty (20) sampled residents.

Inspectors wroteBased on interview, observation, record review, and facility policy review, the facility failed to prevent the possible spread of infection when a nurse flushed and administered a medication via a percutaneous endoscopic gastrostomy (peg) feeding tube without wearing gloves for one (1) of three (3) residents reviewed with peg feeding tubes. Resident # 64. Findings Include: A record review of the facility's policy, Policies and Practices-Infection Control, dated 11/1/17, revealed, .This center's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and mange transmission of diseases and Infection . On 04/16/23 at 12:41 PM, during an observation and interview, Licensed Practical Nurse (LPN) #1 was in Resident #64's room using a syringe and water to flush his peg feeding tube. [...]