Hendrick Skilled Nursing Facility

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 staff (CNA-A) reviewed for infection control procedures. 1. The facility failed to ensure CNA-A performed proper hand hygiene while performing resident transfer, foley care and incontinent care.2. The facility failed to ensure CNA-A followed EBP during foley catheter care.3. The facility failed to ensure staff were notified of EBP for Resident #10 and failed to have a disposable gown readily accessible to staff outside of Resident #10's room. These failures could place residents at risk for the transmission of communicable diseases.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity for one (Resident #107) of three residents reviewed for rights, in that: The facility failed to ensure Resident #107's ostomy drainage bag was placed in a privacy bag while performing physical therapy in the facility's hallway area. Ostomy (an opening (stoma) from an area inside the body to the outside). This failure could place residents with catheters at risk for embarrassment and reduced self-esteem.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection control program designed to prevent the development and transmission of infections for 1 (Resident #59) of 3 residents reviewed for infection control. The facility failed to ensure: PTA B cleaned the counter prior to setting up a barrier for setting up wound care supplies for Resident #59. PTA B used a non-permeable barrier when setting up wound care supplies for Resident #59. PT A cleaned scissors between dirty procedure and clean procedure during wound care for Resident #59. PT A used the same scissors after cutting off Resident #59's dirty [NAME]-boot dressing (plaster dressing used to squeeze fluid out of a closed wound) to cut his clean [NAME]-boot dressing. These failures could place resident's at risk for cross contamination and the spread of infection.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan with necessary information within 48 hours of the resident ' s admission for 3 of 3 residents (Resident #101, Resident #51, Resident #103) reviewed for baseline care plans. The facility failed to include physician orders for medications and diets in Resident #101, Resident #51, and Resident #103 ' s baseline care plan. This failure placed residents at risk of not receiving continuity of care and communication among nursing staff and residents as well as increased risk of resident safety and safeguard against adverse events that are most likely to occur after admission.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 3 of 3 residents (Resident #101, Resident #51, Resident #103) reviewed for dignity. The facility did not ensure nursing staff entered Resident #101, Resident #51, and Resident #103 ' s rooms with permission prior to administering medications and providing ADL care. This failure could place residents at risk for decreased quality of life and quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post in a place readily accessible to residents, and family members and legal representative of residents, the results of the most recent survey of the facility reviewed for resident rights. The facility failed to ensure the most recent survey results was posted for residents, family members, and visitors to review. The failure placed residents and their family members and representatives at risk for violation of the right to review the findings from State surveys and investigations conducted in the facility without asking to review the reports.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure staffing information was posted in a prominent place readily accessible to residents and visitors that included: The facility name, the current census, the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift(Registered nurses, Licensed practical nurses or licensed vocational nurses or Certified nurse aides) for 1 of 1 Staffing Log reviewed for nursing services. The facility failed to ensure the Direct Care Nursing/Staff Daily Log dated July 25, 2023, was completed with the facility name, current census, and the total number of hours worked and the actual hours worked by the RN and the LVN. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS . The facility failed to submit staffing information to CMS for FY Quarter 2 2023 (January 1- March 31). The facility's failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment.