Hudson Springs Nursing and Rehab

Inspectors wroteTHIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review and interview, the facility failed to ensure Resident #3 was appropriately dressed for an outside appointment. This finding affected one (Resident #3) of three residents reviewed for dignity and respect. The facility census was 66.

Inspectors wroteBased on observation and interviews, the facility failed to serve food at hot and palatable temperatures, with accurate portion sizes to meet nutritional needs, and in timely meals. This affected nine residents (Residents #7, #17, #18, #29, #38, #57, #62, #72 and #75) and had the potential to affect 67 residents who received food from the kitchen. There were six residents (Residents #8, #13, #14, #31, #64 and #84) who received no food or beverages from the kitchen. The facility census was 73.

Inspectors wroteBased on observation and interviews, the facility failed to ensure its kitchen area was maintained in a clean and sanitary condition. This had the potential to affect 67 residents who received food from the kitchen. There were six residents (Residents #8, #13, #14, #31, #64 and #84) who received no food or beverages from the kitchen. The facility census was 73.

Inspectors wroteBased on observation and interview, the facility failed to maintain its dumpster area in a clean and sanitary manner. This had the potential to affect all 73 residents residing in the facility.

Inspectors wroteBased on record review and interview the facility failed to ensure the advanced directives were consistently documented in the medical record. This failure resulted in conflicting code status information for one resident (Resident #57) of 28 residents reviewed for advanced directives. The facility census was 73.

Inspectors wroteBased on observation, interview, record review, facility policy review, and review of guidelines from the Centers for Disease Control and Prevention (CDC), the facility failed to use appropriate infection control practices by performing hand hygiene and changing gloves during incontinence care. This affected one resident (Resident #51) out of one resident observed for incontinence care. The facility identified 45 residents (Residents #2, #5, #8, #10, #12, #14, #19, #20, #21, #22, #23, #24, #29, #30, #32, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #45, #47, #48, #50, #51, #52, #56, #57, #58, #59, #60, #61, #62, #63, #65, #70, #71, #73, #74, and #75) who required incontinence care. The facility census was 73.

Inspectors wroteBased on observation, record review, interview and review of facility policy, the facility did not ensure timely notification to the physician of a change in condition for Resident #78. This affected one resident (#78) of three residents reviewed for change of condition. The facility census was 75.

Inspectors wroteBased on record review and interview, the facility failed to develop a comprehensive and individualized care plan for Resident 78 to address turning and repositioning needs and interventions for pain. This affected one resident ( Resident #78) of four residents reviewed for care plans. The facility census was 75.

Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to ensure sufficient linens were available for resident care and ensure residents have a clean and sanitary homelike environment. This affected one (Resident #25) of the residents reviewed for hygiene and linens. The facility census was 69.

Inspectors wroteBased on review of video camera footage, interviews with staff and a police detective, and record review, the facility failed to implement the comprehensive, person-centered care plan for Resident #2. This affected one (#2) of three residents reviewed for care plans. The facility census was 69.

Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to provide timely assistance to residents who were dependent on staff for activities daily living with incontinence care. This affected one (Resident #25) of three residents reviewed for incontinence care. The facility census was 69.

Inspectors wroteBased on record review and interview, the facility failed to ensure respiratory treatments were administered and performed as ordered. This affected one (Resident #38) of three residents reviewed for respiratory care. The facility census was 74.

Inspectors wroteBased on observation, policy review, diet order list review, and interview, the facility failed to store food in a sanitary manner. This had the potential to affect all residents who received food from the kitchen except Residents #19, #28 and #73 who were ordered nothing by mouth. The census was 75.

Inspectors wroteBased on observation, medical record review, staff interview and review of facility policy, the facility failed to develop and implement a comprehensive pressure ulcer program for Resident #40 to prevent the development of a pressure ulcer and to ensure timely and necessary treatment was implemented. Actual harm occurred on 07/29/24 when Resident #40, who was cognitively impaired and dependent on staff for activities of daily living was identified to have an in-house acquired unstageable pressure ulcer (occurs due to prolonged pressure on a specific area of the skin resulting in the lack of blood and the wound cannot be properly staged until the layers of dead skin are removed) to his right leg. [...]

Inspectors wroteBased on observation, staff interview and review of facility policy, the facility failed to ensure dietary staff performed hand hygiene prior to handling food and beverage items. This had the potential to affect all residents who received food from the kitchen. The facility identified two residents (#53 and #63) as receiving nothing from the kitchen. The facility census was 65.

Inspectors wroteBased on resident interview, observation, review of resident fund account records, staff interview and review of facility policy, the facility failed to ensure residents who had a financial account with the facility received quarterly statements as required. This affected five residents (#7, #31, #40, #48, and #57) of five residents reviewed for personal funds. The facility census was 65.

Inspectors wroteBased on review of the Internet Quality Improvement and Evaluation System (iQIES) Minimum Data Set (MDS) 3.0 Validation Report and staff interview, the facility failed to ensure MDS assessments were submitted in a timely manner. This affected 11 residents (#7, #9, #13, #15, #21 #23, #24, #33, #39, #41, and #48) of 23 residents reviewed for MDS submission. The facility census was 65.

Inspectors wroteBased on observation, resident interviews, staff interviews, review of staff schedules and punch detail, review of Resident Council meeting minutes and review of the facility assessment, the facility failed to have sufficient staff to meet the acuity needs of each resident. This affected two (#57 and #29) of two residents reviewed for staffing with the potential to affect all 41 residents residing on the 100 and 200 halls. The facility census was 65.

Inspectors wroteBased on observation, staff interviews, review of the facility menu, review of the dietary spreadsheet and review of facility policy, the facility failed to ensure the spreadsheet was followed for residents on a mechanically altered diet. This affected eight (#5, #7, #13, #29, #32, #46, #59 and #76) of eight residents identified by the facility as being on a mechanically altered diet. The facility census was 65.

Inspectors wroteBased on observation, resident interview and staff interview, the facility failed to ensure residents were not left in their rooms without visual or audio stimulation. This affected one resident (#62) of three residents reviewed for preferences. The facility census was 65.

Inspectors wroteBased on review of beneficiary notices and staff interview, the facility failed to ensure the appropriate beneficiary notices were provided at the end of Medicare services and failed to ensure beneficiary notices were provided timely. This affected three residents (#1, #47, and #169) of three residents reviewed for beneficiary notices. The facility census was 65.

Inspectors wroteBased on staff interview and review of personnel files, the facility failed to ensure Nurse Aide Registry (NAR) checks were completed on employees upon hire. This had the potential to affect all resident residing in the facility. The facility census was 65.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were accurately completed. This affected three residents (#24, #52, and #66) of 23 residents reviewed for accuracy of assessments. The facility census was 65.

Inspectors wroteBased on medical record review, resident interview, staff interview and review of facility policy, the facility failed to ensure care plans were updated timely and care conferences were held. This affected two residents (#44 and #7) of two residents reviewed for care planning. The facility census was 65.

Inspectors wroteBased on medical record review, family interview, guardian interview, review of shower documentation and review of the facility policy and procedure, the facility failed to ensure showers were provided as scheduled for dependent residents. This affected two residents (#4 and #53) of seven residents reviewed for activities of daily living (ADLs). The facility census was 65.

Inspectors wroteBased on observation, resident interview, staff interview, medical record review and review of facility policy, the facility failed to ensure Intravenous (IV) dressings were changed per physician order and as needed. This affected one resident (#74) of one resident reviewed for IV dressings. The facility identified one resident with IV access. The facility census was 65.

Inspectors wroteBased on medical record review, staff interview, dialysis center staff interview and review of facility policy, the facility failed to ensure ongoing communication and collaboration with the dialysis center. This affected one (#24) of one resident identified by the facility as receiving dialysis. The facility census was 65.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview and review of facility policy, the facility failed to ensure residents with a history of trauma were appropriately assessed to identify triggers to potentially minimize re-traumatization. This affected one resident (#48) of one resident reviewed for post-traumatic stress disorder (PTSD). The facility census was 65.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure non-pharmacological interventions were attempted prior to the administration of as needed (PRN) anti-anxiety medication. The facility further failed to document the effectiveness of PRN medication use or the rationale for extended use past 14 days for the PRN anti-anxiety medication. This affected one resident (#44) of five residents reviewed for unnecessary medications. The facility census was 65.

Inspectors wroteBased on observation, staff interview, Power of Attorney (POA) interview and medical record review, the facility failed to ensure residents were free of significant medication errors. This affected two residents (#17 and #28) of five residents reviewed for medication errors. The facility census was 65.

Inspectors wroteBased on resident interview, observation, review of the dietary meal ticket, staff interview and medical record review, the facility failed to ensure resident food preferences were honored. This affected one resident (#74) of two residents reviewed for food preferences. The facility census was 65.

Inspectors wroteBased on observation, staff interview, family interview, medical record review and review of facility policy, the facility failed to ensure appropriate personal protective equipment (PPE) was donned prior to providing care to a resident on Enhanced Barrier Precautions (EBP) and further failed to ensure contact precautions were implemented timely for a resident identified with a transmissable infection. This affected two resident (#4 and #74) of two residents reviewed for infection control. The facility census was 65.

Inspectors wroteBased on medical record review, staff interview and review of the facility policy, the facility failed to ensure influenza and pneumococcal vaccinations were offered to all residents. This affected one resident (#4) of five residents reviewed for immunizations. The facility census was 65.

Inspectors wroteBased on record review of the facility medication storage policy, the manufacturer's instructions for use for insulin, interviews and observations the facility failed to ensure medications were appropriately labeled and dated once opened. This affected nine residents (Residents #14, #21, #27, #47, #48, #49, #55, #256 and #257) on two of two medication carts observed in the facility. The facility census was 59.