Hickory Vlg Nrsg & Rhb

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a clean, sanitary environment in the facility's common areas. These failures affect all 69 residents that reside within the facility.

Inspectors wroteBased on interview and record review the facility failed to follow their policy and maintain an accurate account of the resident personal funds for one of three residents (R14) reviewed for resident funds.

Inspectors wroteBased on interview and record review the facility failed to refer a resident with mental health diagnosis for PASARR level 2 screening for one of three residents (R61) reviewed for PASARR screening/assessments.

Inspectors wroteBased on interviews and record reviews, the facility failed to effectively supervise a resident with history of alcohol abuse. This deficient practice affected one resident (R1) out of three reviewed for supervision of an avoidable incident. R1 was able to go out into the community independently, while on a restricted community pass, somehow obtain two 1.0-liter bottles of mouthwash with alcohol, and being hospitalized later with an alcohol level of 183 (normal range is 0-10) and subsequently expiring the follow day. The Death Certificate documents the cause of death cardiopulmonary arrest due to acute kidney failure and alcohol abuse. The Immediate Jeopardy began on 1/12/25 when R1 was found yelling and screaming and with altered mental status. V1 (Administrator) and V2 DON (Director of Nursing) were notified of the immediate jeopardy on 02/04/2025 at 10:45AM. [...]

Inspectors wroteBased on interview and record review, the facility failed to supervise one resident who was identified as a high fall risk as well as dependent on staff for bed mobility and toileting, by leaving the resident on their side unattended on an elevated bed (approximately 3 feet). This affected one of three (R1) residents reviewed for falls. This failure resulted in R1 having an unwitnessed fall, being transferred to the hospital, and sustaining a pelvis fracture.

Inspectors wroteBased on interview and record review, the facility failed to follow their notification of change guidelines by not immediately reporting one resident's (R1) fall to the physician and resident representative for one of three residents reviewed for notification.

Inspectors wroteBased on interview and record review, the facility failed to adequately ensure a resident (R2) was free from abuse. This failure applied to two (R1, R2) of two residents reviewed for abuse.

Inspectors wroteBased on interviews and record reviews the facility failed to follow their policy and procedures for abuse prevention by not implementing approaches that would reduce the chances of abuse and by not identifying a resident's behaviors that can lead to abuse. This failure applies to four of six residents (R1, R2, R4, and R6) reviewed for abuse.

Inspectors wroteBased on interviews and record reviews the facility failed to follow their policy and procedures for abuse reporting by not ensuring an incident of resident-to-resident abuse was reported to the administrator or to the state agency. This failure applies to two of six residents (R4 and R6) reviewed for abuse.

Inspectors wroteBased on interviews and record reviews the facility failed to follow their policy and procedures for care planning by not preparing a comprehensive care plan including residents identified preferences, problems, risk factors, and needs. This failure applies to two of six residents (R1 and R4) reviewed for care planning.

Inspectors wroteBased on interviews and record reviews the facility failed to follow their policy and procedures for provision of social services by not ensuring there is a sufficient number of social services staff to serve the needs of their residents. This failure applies to one of six residents (R1) reviewed for behavioral health services.

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse policy by allowing a staff member to tease and laugh at a resident. This failure affected one of three residents (R2) reviewed for abuse. Findings Include: R2 is a [AGE] year old with the following diagnosis: bipolar disorder, schizophrenia, and drug induced parkinsonism. R3 is a [AGE] year old with the following diagnosis: bipolar disorder, anxiety, and spina bifida. The Final Incident Report dated 7/3/24 documents R2 reported to V1(Adminsitrator) on 6/27/24 that V5, V8, and V9 were verbally inappropriate to R2 on the overnight shift on 6/23 through 6/24/24. R2 reported staff were calling R2 names and talked about R2 ' s mom. R2 also stated staff laughed at R2. Upon interview, the three staff members denied the allegation. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed follow their policy and procedures to ensure food was prepared under sanitary conditions by not ensuring the kitchen was maintained in a clean and sanitary manner, not performing hand hygiene when necessary, not ensuring the kitchen environment was maintained in a manner to prevent contamination, and not ensuring food preparation equipment was dried properly in between uses to prevent food-borne illnesses. This failure affects all 66 residents receiving food from the facility.

Inspectors wroteBased on interviews and record reviews, the facility failed to designate an infection preventionist who had completed specialized training in infection prevention and control.

Inspectors wroteBased on observation, interview and record review, the facility failed to have a five percent (5%) or lower medication error rate and failed to ensure staff followed proper infection prevention practices during medication administration. There were four medication errors out of 27 medication opportunities, resulting in a 14.81% medication error rate and affected 2 residents (R27 and R39) observed for medication pass.

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse policy by not protecting /preventing a vulnerable resident from being sexually assaulted by another resident. This affected two of four residents (R1, R2) reviewed for sexual abuse. This failure resulted in R2 entering R1's room approximately 3 hours after being admitted to the facility and sexually assaulting R1 after R1 said no to sex. The Immediate Jeopardy began on 1/8/24 when R2 entered R1's room and sexually assaulted R1. V1 (Administrator) was notified on 1/18/24 at 2PM of the Immediate Jeopardy. The surveyor confirmed by observation, interview and record review the Immediate Jeopardy was removed on 1/18/24, but noncompliance remains at Level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings Include: [...]

Inspectors wroteBased on interviews and record reviews the facility failed to prevent an incident of staff to resident inappropriate sexual behavior, failed to prevent an incident of resident to resident sexual assault, and failed to prevent an incident of staff to resident verbal abuse. This affected four of four residents (R1, R9, R10 and R5) reviewed for sexual and verbal abuse. This failure resulted in V4 taking advantage of R1 with a diagnosis of major depression and traumatic brain injury by engaging in sexual intercourse with R1. This failure also resulted in R10 being touched and kissed inappropriately by R9. This was identified as an Immediate Jeopardy which began on 9/06/2023 when R1 was observed having sexual intercourse with V4. V3 (Administrator) was informed of the Immediate Jeopardy and the Immediate Jeopardy template was presented on 10/24//2023 at 10:25 am. [...]

Inspectors wroteBased on observation, and interview the facility failed to ensure that one of two shower rooms were in good repair, and without dark black substance on the walls and ceiling and without a foul smell. This has the potential to affect all residents utilizing the north shower room.

Inspectors wroteBased on interviews and records reviewed the facility failed to report an allegation of abuse. This affected one of three (R5) reviewed for reporting incident of abuse.

Inspectors wroteBased on interviews and records reviewed the facility failed to follow hospital instruction and ensure a resident has a follow up Gastroenterology appointment. This failure affected one of three residents (R13) reviewed for follow up appointments.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that foods are prepared and stored under sanitary conditions affecting all 60 residents receiving food from the facility's kitchen. The facility also failed to monitor and maintain the resident's refrigerators for two of three residents (R29, R55) reviewed for food storage in a sample of 15.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and ensure a risk assessment of water system components was done to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the water system. The facility also failed to implement control measures to address potential hazards. This failure has the potential to affect all 60 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain acceptable parameters of nutritional status for one of one resident (R50) reviewed for nutrition in a sample of 15.