Humphreys Co Nursing Center

Inspectors wroteBased on resident representative (RR), Ombudsman, and staff interview, record review, and facility policy review the facility failed to communicate with a resident representative regarding discharge of a resident as evidenced by no notification of discharge provided to the resident/resident representative for (1) one of (3) three residents reviewed for transfer/discharge notice. (Resident #1)

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to maintain a clean ice machine as evidenced by multiple areas of a black substance inside the area that contained the ice for one (1) of two (2) kitchen tours.

Inspectors wroteBased on staff interviews and record reviews, the facility failed to submit accurate direct care staffing information to the Payroll Based Journal (PBJ) for the fourth (4th) quarter of the fiscal year (FY) 2024 (July 1-September 30) for one (1) of four (4) PBJ quarter reports reviewed. Findings Include: Review of the typed statement on company letterhead dated 12/12/24 signed by the Administrator revealed that the facility does not have a policy on PBJ. A record review of the facility's PBJ Staffing Data Report for the 4th quarter of FY 2024 revealed that the facility triggered for excessively low weekend staffing. In an interview on 12/11/24 at 2:00PM, the Administrator confirmed that the facility had not submitted accurate PBJ staffing data for the fourth quarter of FY 2024. [...]

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to ensure a resident's code status was accurate in the physician orders for one (1) of 24 sampled residents. Resident # 31 Findings Include: Review of the facility policy titled Advance Directives with a revision date of 7/15 revealed under, Procedure: . All staff providing care for the residents will: Review the Advance Directive and clarify any discrepancies between the Directive and current treatment plan. Record review of the Physician Order Details dated 8/27/24 revealed, Resident #31 was a full code. Record review of the Advance Directive Consent dated 9/11/24 revealed, Resident #31 signed a Do Not Resuscitate (DNR) in case of cardiac arrest. [...]

Inspectors wroteBased on staff interview and record review the facility failed to accurately code the Minimum Data Set (MDS) Assessment for discharge disposition for one (1) of 24 resident MDS assessments reviewed. Resident #47. Findings Include: Review of the facility policy, titled Resident Assessment, latest revision 09/19 revealed Any healthcare professional that completes a portion of the assessment must sign and certify the accuracy of the portion of the assessment that they have completed. Record review of the Discharge-Return Not Anticipated MDS with an Assessment Reference Date (ARD) of 10/18/24 for Resident #47 revealed Item A2105 Discharge Status was coded as Short-Term General Hospital. Record review of Progress Notes for Resident #47, dated 10/18/24 revealed Resident discharged home. [...]

Inspectors wroteBased on staff interview, record review, and facility policy review the facility failed to submit a Pre-admission Screening and Resident Review (PASRR) status change for a resident with a change in mental status for (1) one of four (4) residents reviewed for PASRR.

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review the facility failed to implement a person-centered care plan for providing nail care for two (2) of 24 sampled residents. Resident #8 and #30.

Inspectors wroteBased on observation, resident and staff interviews, record reviews and facility policy reviews, the facility failed to provide personal hygiene as evidenced by long, jagged nails with brown substance underneath nails for two (2) of 24 sampled residents. Resident #8 and #30.

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to provide appropriate care and services for resident with an indwelling catheter for one (1) of two (2)residents with indwelling catheters.

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to help prevent the possible transmission of infections when staff failed to perform hand hygiene during resident care observed for Resident #5 and #10 and failed to use Enhanced Barrier Pecautions (EBP) during catheter care for Resident #10 for two (2) of five (5) resident direct care areas observed.

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review, the facility failed to honor a resident's rights for one (1) of 24 sampled residents. Resident #30.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to maintain a clean kitchen area used to provide nutrition for 53 of 53 residents in the nursing facility.

Inspectors wroteBased on resident interviews, staff interviews, record review, and facility policy review, the facility failed to initiate and resolve grievances from the residents in the monthly Resident Council meetings for two (2) of eight (8) residents attending. Resident #19 and Resident #33.

Inspectors wroteBased on observation, resident and staff interview and facility policy review the facility failed to repair a wheelchair armrest for one (1) of 36 resident's wheelchairs observed. Resident # 35.

Inspectors wroteBased on observation, resident and staff interview, record review and facility policy review the facility failed to implement a care plan safe for safe smoking for Resident #23 and turning and repositioning for Resident #40 for (2) two of 16 care plans reviewed.

Inspectors wroteBased on observations, staff interviews, facility policy review, and record review, the facility failed to turn and reposition a resident every two (2) hours, who was unable to turn and position themselves, as evidenced by observation of the resident not being turned and positioned according to the instructions in the facility policy, the comprehensive care plan and the Certified Nursing Assistant's (CNA) Kiosk guidance for one (1) of three (3) residents investigated for positioning. Resident #40.

Inspectors wroteBased on observation, staff interviews, record review, and facility policy review, the facility failed to have a stop date for a PRN (as needed) psychotropic medication, Ativan, ordered by mouth and intramuscular for one (1) of three (3) residents reviewed for psychotropic medications. (Resident #25) Review of the facility policy titled, Screening for Use of PRN Psychotropic Medications, dated 04/06 and last revised on 11/17, revealed PRN orders for psychotropic drugs are limited to 14 days. If the attending physician or prescribing practitioner believes that is appropriate for the PRN order to be extended beyond 14 days, he or she shall document the rationale in the resident's medical record and indicate the duration of the PRN order. [...]