Hutsonwood at Brazil

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control measures when handling clothing and waste for prevention of transmission of multidrug-resistant organisms (MDRO) for 4 of 4 residents reviewed for infection control. (Residents B, C, D, and E). This deficient practice had the potential to affect 75 of the 75 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide range of motion or appropriate interventions for 2 of 2 residents reviewed for range of motion (Residents 69 and 12) resulting in actual harm when a cognitively impaired dependent resident developed contractures of the left hand and arm (Resident 69).

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the dietary staff were trained and competent in infection control measures to prevent food borne illness during 4 observations of the dietary department. The deficient practice had the potential to affect 77 of 77 residents who received food and/or drinks from the kitchen.

Inspectors wroteA. Based on observations, record review, and interview, the facility failed to ensure frozen foods were dated prior to use and failed to ensure dishwasher was sanitizing dishes and utensils at the recommended temperatures for sanitation during 6 dietary observations. This deficient practice had the potential to affect 77 of 77 residents who receive food and drinks from the kitchen. B. Based on observation, interview, and record review, the facility failed to ensure ice was distributed in a safe and sanitary manner during 1 of 1 lunch meal service observations. This deficient practice had the potential to affect all residents that were being served in the main dining room on 1/5/26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that resident personal information was protected from exposure, during 1 of 2 medication administration observations (Residents 34, 78, and 8).

Inspectors wroteBased on observation, record review, and interview, the facility failed to initiate or revise interventions to prevent falls for 1 of 1 residents reviewed for accidents (Resident 12).

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a resident had physician's order and a care plan for an indwelling urinary catheter (a thin, flexible tube left inside the bladder, typically through the urethra, to continuously drain urine into an external collection bag), failed to ensure the catheter's external urine collection bag (catheter bag) and tubing were prevented from contact with the floor, and failed to ensure the catheter bag was maintained in a dignified manner, for 1 of 1 resident observed for urinary catheter (Resident 21).

Inspectors wroteBased on record review and interview, the facility failed to obtain a resident's medications in a timely manner after their admission to the facility for 1 of 6 residents reviewed for pharmaceutical services (Resident B).

Inspectors wroteBased on record review and interview, the facility failed to ensure documented physician rationale for a declination of a pharmacy recommendation and failed to ensure a pharmacy recommendation was addressed in a timely manner for 2 of 5 residents reviewed for unnecessary medications (Residents 11 and 13).

Inspectors wroteBased on observation, record review and interview, the facility failed to assess a resident for pain and administered narcotic medication without documentation of pain symptoms for 1 of 5 residents reviewed for unnecessary medications (Resident 13).

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure it was free of a medication error rate of greater than 5 percent for 3 of 7 residents observed during the medication pass. There were 26 opportunities for errors observed with 3 medication errors, resulting in a medication error rate of 11.54 percent (Residents 34, 78, and 8).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure multi-use vials of medication had open dates documented, for 1 of 3 medication carts reviewed.

Inspectors wroteA. Based on observation, interview, and record review, the facility failed to ensure a resident's indwelling urinary catheter (a thin, flexible tube left inside the bladder, typically through the urethra, to continuously drain urine into an external collection bag), external urine collection bag (catheter bag) and tubing were prevented from contact with the floor, for 1 of 1 resident observed for urinary catheter (Resident 21). B. Based on observation, interview, and record review, the facility failed to ensure proper hand hygiene during medication administration for 1 of 2 medication administration observations.

Inspectors wroteBased on interview and record review, the facility failed to transport a resident to a scheduled surgical procedure for 1 of 3 resident reviewed for quality of care. (Resident B)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for 1 of 9 residents' MDS assessments reviewed (Resident E).

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure limitations in range of motion were assessed, treated, and required interventions communicated to staff effectively for 3 of 3 residents reviewed for limitations in range of motion (Residents B, E, and F).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure contracted staff completed a resident assessment and vital signs in privacy for 1 of 1 resident reviewed for privacy (Resident 26).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a call light device was within reach for 1 of 16 residents observed for call lights (Resident 7).

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure a pharmacy recommendation was addressed for 1 of 5 residents reviewed for unnecessary medications (Resident 32).

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure proper handling of oral medications during the medication administration pass and failed to ensure medication was administered according to manufacture guidelines resulting in a medication error rate of greater than 5 percent for 2 of 4 residents reviewed for medication administration (Residents 10 and 217). Findings Include: On 10/22/24 at 7:10 a.m., during routine medication administration observation, Registered Nurse 18 placed medications for Resident 10 into her bare hand then placed the medications in a medication cup, and then administered medications to the resdient. The RN prepared Novolog insulin with an insulin pen (a pre-filled pen device filled with insulin. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure a multi-dose insulin vial was discarded within 28 days of use and insulin pens containing multiple doses of insulin were dated appropriately and discarded within 28 days of use for 2 of 2 medication carts observed.

Inspectors wroteBased on observation, interview, and record review, and record review, the facility failed to ensure snacks were served in a sanitary manner for 1 of 1 random snack distribution observations.

Inspectors wroteBased on record review the facility failed to document insulin administration for 1 of 5 residents reviewed for medication administration (Resident 23).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper handwashing was completed during for resident care, and failed to ensure proper handling of the glucometer meter (small portable machine that's used to measure how much glucose [type of sugar] is in the blood) during medication administration for 2 of 2 residents reviewed during medication administration observation (Residents 10 and 217).

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure wound care was provided for 2 of 2 residents reviewed for wound care (Residents S and C).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff sanitized their hands appropriately, the deep fryer and stove were cleaned, and a cup was not stored in the flour canister, for 2 of 2 kitchen observations and the facility failed to ensure hand hygiene was completed and safe handling of food during 2 of 2 meal observations.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from accidents for 1 of 2 residents reviewed for accidents (Resident 14).

Inspectors wroteBased on record review and interview, the facility failed to ensure pharmacy recommendations were completed for 1 of 5 residents reviewed for unnecessary medications (Resident 34).

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure fast-acting insulin medication was administered within a timely manner of meal service for 2 of 2 residents reviewed for significant medication error resulting in a medication error rate of 6.25 percent (Resident's 7 and 23).

Inspectors wroteBased on interview and record review, the facility failed to ensure the appropriate temperature and palatability of food served for 2 of 24 residents reviewed for dietary services (Residents 23, and 52), 1 of 1 resident council meeting reviewed for dietary concerns, and 1 of 1 test tray reviewed for temperature and palatability.