Henry County Health and Rehabilitation Facility

Inspectors wroteBased on observations, interviews, resident record review, and the facility's Proper Use of Side Rails policy, the facility failed to perform ongoing assessments for the use of side rails for Resident Identifier (RI) #7 to ensure the side rails used met RI #7's needs. This deficient practice affected RI #7, one of one resident reviewed for side rail use.

Inspectors wroteBased on resident record review, interviews, and review of the facility's Antipsychotic Medication Use policy, the facility's Behavior Assessment and Monitoring policy, and the facility's Depression - Clinical Protocol policy, the facility failed to ensure Resident Identifier (RI) #31, was monitored for behaviors for which antipsychotic medication was administered and the facility further failed to ensure RI #31 and RI #47 were monitored for side effects of psychotropic medications to include: antipsychotic and antidepressant medications. This affected two of 4 sampled residents reviewed for unnecessary medications who received antipsychotic and antidepressant medication.

Inspectors wroteBased on observation, resident record review, interviews, and review of the facility's Administering Medication policy, the facility's Administration of Metered-Dose Inhaler policy, and manufacturer's instructions for use, the facility failed to ensure a medication error rate of less than 5%. The facility had a medication error rate of 9.38%, which resulted from three errors in 32 opportunities and affected Resident Identifier (RI) #52 one of five residents observed receiving medications during the medication administration observation on 02/03/2022. Sixty-nine residents resided in the facility.

Inspectors wroteBased observation, interview and review of a facility policy titled, Food Storage in Freezer, the facility failed to ensure that tater tots, okra and sweet potato patties where sealed properly while in the freezer. This was observed on 5/13/2019 and had the potential to effect 101 residents receiving meals from the kitchen.

Inspectors wroteBased on record review, interviews, and review of a facility policy titled, Acute Condition Changes- Clinical Protocol 3.12 the facility failed to ensure licensed staff notified the physician of blood glucose greater than 450. This affected Resident Identifier (RI) #88, one of one residence whose blood glucose levels were reviewed.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the treatment nurse removed her gloves and sanitized her hands after cleaning the wounds for Resident Identifier (RI) #77 and RI #4, and before placing the clean treatment and outer coverings. This affected two of two residents observed for wound care. Findings Include: RI #77 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease. A review of RI #77's May 2019 Physician Orders revealed .5/13/19 .Clean Stage II to coccyx with Vashe cleanser, apply Multidex powder and cover with border dressing QD (everyday) . On 5/14/19 at 10:18 AM, the surveyor observed wound care for RI #77 performed by Employee Identifier (EI) #2 , Licensed Practical Nurse, Treatment nurse. EI #2 prepared the needed supplies and entered the resident's room. EI #2, washed her hands and put on gloves. [...]

Inspectors wroteBased on observations, interviews and a review of facility policies Dry Storage Areas, Record of Food Temperatures, and Temperature Sheet, the facility failed to ensure: 1) peanut butter was not on the lid of the peanut butter container; 2) an opened and used by date was on a container of gravy mix and; 3) the temperature of the pork chops was taken on the tray line before serving to the residents. This had the potential to affect 100 of 107 residents receiving meals from the kitchen. Findings Include: 1) A review of a facility policy titled, Dry Storage Areas (undated) revealed: Policy: Dry storage areas will be kept in a condition which protects stored food from infestation. .Care of Storeroom .Food storage containers are cleaned after each use. On 06/12/18 at 9:16 a.m., the surveyor along with (Employee Identifier) EI #4 Dietary Director, toured dry storage. [...]

Inspectors wroteBased on record review, interview and review of a facility policy Resident Assessment Instrument , the facility failed to ensure the Minimum Data Set (MDS) dated [DATE] and 12/9/17 was coded for hospice care. This affected Resident Identifier (RI) #9, one of three residents sampled for hospice care. Findings Include: A review of a facility policy Resident Assessment Instrument (MDS) with a revised date of 1/18 revealed: .Policy Interpretation and Implementation . 4. The purpose of the assessment is to describe the resident's capability to perform .5. Information derived from the comprehensive assessment enables the staff to plan care . RI #9 was admitted to the facility 9/0/17 with a diagnosis to include Alzheimer's Disease. A review of RI #9's Physician Order dated 9/18/17 revealed .Admit patient to .Hospice with terminal diagnosis of Alzheimers . [...]

Inspectors wroteBased on observations, interviews and a review of a facility policy titled, Posting Direct Care Daily Staffing Numbers, the facility failed to ensure staffing report was posted for 6/12/18 and the evening shift was posted on 6/13/18. This had the potential to affect all residents and their family members. Findings Include: A review of a facility policy titled, Posting Direct Care Daily Staffing Numbers (undated) revealed: .Policy: It is the policy of this facility to make staffing information readily available in a readable format to residents and visitors at any given time. Policy Explanation and Compliance Guidelines: .2. The facility will post the nurse staffing at the beginning of each shift On 6/12/18 at 5:50 PM, an observation of the posted [NAME] County Health and Rehabilitation Facility Direct Care Staff Daily Report revealed the report posted was dated 6/11/18. [...]

Inspectors wroteBased on observation and interview, this facility failed to ensure that infection control practices were utilized in the preparation of medications for medication delivery for one of 9 residents (Resident Identifier [RI]) #30 observed during medication pass. This deficient practice involved one of five nurses during the medication pass observed to stir crushed medication with her index finger. Findings Include: RI #30 was readmitted to the facility on [DATE] with a diagnosis of Gastrostomy status. A review of RI #30's June 2018 Physician Orders revealed : .Two Tums tablets crushed and give .Feosol liquid .CALTRATE D 600 Milligram TABLET . On 6/12/18 at 11:02 AM Employee Identifier (EI) #3, Licensed Practical Nurse, was observed giving RI #30's medication by way of gastrostomy tube. EI #3 prepared each of the medications in separate medication cups. [...]

Inspectors wroteBased on observation, interview and a review of a facility policy titled, Disposal of Garbage and Refuse Policy the facility failed to ensure: the dumpsters door lid and door was closed. This had the potential to affect all residents residing at the facility. Findings Include: A reviewer of a facility titled, Disposal of Garbage and Refuse Policy (undated) revealed: Policy: The facility shall properly dispose of kitchen garbage and refuse. Procedures: 7. Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, door, or covers. Containers and dumpsters shall be kept covered when not being loaded. On 6/12/18 at 9:42 a.m., the surveyor along with EI #4 ( Employee Identifier), Dietary Director, observed four dumpsites located outside behind the kitchen. Dumpster number one's door was opened at the side. [...]