Independence Care Center of Perry County

Inspectors wroteBased on interview and record review, the facility failed to electronically transmit Minimum Data Set assessments (MDS, a federally mandated assessment completed by the facility) in a timely manner and in accordance with guidelines for five residents (Resident #1, #2, #3, #33, and #36) of 18 sampled residents and one resident (Resident #8) outside the sample. The facility census was 76. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a quarterly Minimum Data Set (MDS-a federally mandated assessment tool completed by the facility) within the required timeframes for two residents (Resident #3 and #33) out of 18 sampled residents. The facility's census was 76. [...]

Inspectors wroteBased on interview and record review, the facility failed to document an accurate Minimum Data Set (MDS-a federally mandated assessment completed by the facility staff) for eight residents (Resident #1, #2, #4, #5, #6, #33, #36, and #52) out of 18 sampled residents and one resident (Resident #25) outside the sample. The facility's census was 76. Review of the facility's policy, MDS Assessments, revised March 2024, showed: - The facility will ensure accurate, timely, and compliant completion and electronic transmission of MDS in accordance with Center for Medicare and Medicaid Services (CMS) regulations, supporting resident care planning, quality outcomes, and reimbursement accuracy; - MDS assessments are scheduled according to the CMS-required timeframes, including admission, quarterly, annual, and significant change; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to serve food in a manner to reduce the risk of cross contamination and food borne illness by touching the residents' items and food with bare hands. The facility census was 76. Review of the policy, Infection Control with Meals, undated, showed:- The facility maintains strict infection control practices during all aspects of meal service to protect residents, staff, and visitors. Proper hand hygiene, personal protective equipment (PPE), food handling techniques, and environmental sanitation shall be followed in accordance with Centers for Disease Control (CDC) and Centers for Medicare and Medicaid (CMS) regulations;- Hand hygiene must be performed before handling food or meal trays; before and after assisting a resident with eating; after contact with bodily fluids or contaminated surfaces; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices to prevent the development and transmission of infection during medication administration for four residents (Resident #2, #4, #15 and #16) out of nine sampled residents. The facility's census was 76. Review of the facility's policy, Glove-Technique-non-sterile, undated, showed:- The facility will use glove technique to prevent the transmission of infectious organisms, provide personal protection and adhere to Occupational Safety and Health Administration (OSHA) regulations dictating staff safety. Review of the facility's policy, Handwashing, revised 03/29/23, showed:- Soap and water are required for hand hygiene when: hands are visibly soiled, and/or after caring for a resident with diarrheal infection such as (C. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to conduct regular inspections of all bed frames, mattresses, side rails, and enabler bars as part of a regular maintenance program for three residents (Residents #2, #4, and #5) out of 7 sampled residents. The facility's census was 76. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assess and document for the use of a position change alarm (a device intended to monitor a resident's movement) to determine it if was a restraint (a device that limits a person's movement) and failed to obtain a physician's order for the device for five residents (Residents #59, #68, #84, #86, and #242) out of six sampled residents. The facility census was 91. Review of the facility's policy titled, Restraint Protocol, not dated, showed: - Contraindications for restraint use to include, at the very least, clinical contraindications, convenience of staff, or discipline of the resident; - Practices for informing the resident and obtaining consent when clinically feasible, and documenting the consent in the resident's record; [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a facility-initiated transfer when six residents (Resident #7, #47, #68, #71, #79, and #81) out of seven sampled residents transferred to the hospital. The facility's census was 91. Review of the facility's policy titled, Transfer/Discharge Notice, dated 05/2017, showed: - Before the facility transfers or discharges a resident, the facility will send a written notice to the resident in a language and manner reasonable calculated to be understood by the resident for planned and emergency discharges; - The notice will also be sent to any resident representative. 1. Review of Resident #7's medical record showed: - The resident transferred to the hospital for medical evaluation on 07/07/24, and readmitted to the facility on [DATE]; [...]

Inspectors wroteBased on interview and record view, the facility failed to inform the resident and family or legal representative of their bed hold policy at the time of transfer to the hospital for seven residents (Resident #7, #17, #47, #68, #71, #79, and #81) out of seven sample residents. The facility's census was 91. Review of the facility's policy titled, Bed Hold and Return to Facility, revised 12/07/20, showed: - It is the policy of of the facility that residents who are transferred to the hospital or go on a therapeutic leave are provided with written information about the State's bed hold duration and payment amount before the transfer; - The facility will provide the resident and resident representative a written notice which specifies the duration of the bed-hold policy at the time of transfer for hospitalization or therapeutic leave; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #6) out of six sampled residents was transferred with safe transfer techniques. The facility census was 91. Review of the facility's policy titled, Two Person Transfer Using Gait Belt, not dated, showed: - Adjust bed height if needed to ensure bed is in locked position; - Position chair/geri-chair/wheelchair at side of the bed, facing head of the bed; - Lock chair wheels; - Apply gait belt; - Stand with one staff on each side of the resident; - Place your hands underneath the belt with one hand in the back and one hand in the front. Inform the resident that you will assist to stand/transfer; - Pivot your body and the resident's body toward the bed; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assess residents for the risk of entrapment and review possible risks and benefits of bed rails prior to installation or use. The facility also failed to obtain informed consent from the resident or if applicable, the resident representative for six residents (Resident #1, #14, #19, #40, #55, and #68) out of 19 sampled residents. The facility census was 91. The facility did not provide a bed rail policy. Review of the Federal Drug Administration (FDA) documents entitled, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated [DATE], showed 413 people died as a result of entrapment events in the United States. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain proper infection control practices during wound care for two residents (Residents #14 and #71) out of three sampled residents, catheter (a tube that inserted into the bladder to drain urine) care for one resident (Resident #14) out of two sampled residents, and while passing trays during meal time. The facility's census was 91. Review of the facility's policy titled Infection Control, dated 08/12/19, showed: - Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug resistant organisms (MDRO's) that employ targeted gown and glove use during high contact resident care activities; [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to conduct regular inspections of all bed frames, mattresses and side rails as part of a regular maintenance program for six residents (Residents #1, #14, #19, #40, #55, and #68) out of 19 sampled residents. The facility's census was 91. The facility did not provide side rail maintenance policies. Review of the Federal Drug Administration (FDA) documents entitled, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated [DATE], showed 413 people died as a result of entrapment events in the United States. Further review revealed those among the most vulnerable for these entrapment type events are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement care plans with specific interventions to meet individual needs for two residents (Resident #53 and #80) out of 18 sampled residents. The facility's census was 89. Record review of the facility's care plan titled, Care Plans, revised 12/7/20, showed: - To ensure uniformity of concern and approach by nursing home team members and to help residents and their families be part of a team approach to answering resident's needs and assisting with problems; - Nursing home staff, with a representative from each discipline, the resident, the resident's family, and other concerned and involved individuals will meet within twenty-one (21) days of the resident's admission to the facility to determine problems, needs, goals, and approaches for meeting needs and solving problems; [...]

Inspectors wroteBased on interview and record review, the facility failed to update and revise care plans with specific interventions to meet individual needs for one resident (Resident #26) out of 18 sampled residents. The facility's census was 89. Record review of the Alzheimer's Special Care Services Disclosure, completed by the facility and given to the resident representative/guardian upon admission, showed: - All staff are made aware of the interdisciplinary plan of care; - The special care unit staff readily communicate resident changes to appropriate personnel, i.e. the charge nurse and the unit coordinator. The plan of care, therefore, changes consistently in response to changes in resident needs and condition. 1. Review of Resident #26's medical record showed: - Discharge to the hospital on [DATE] related to a fall and readmission to the facility on [DATE]; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices to prevent the development and transmission of infection when staff did not wash or sanitize hands and wear gloves during medication administration for three residents (Resident #9, #22 and #57) out of 18 sampled residents and five residents (Resident #8, #16, #55, #82, and #86) outside the sample. The facility's census was 89. Record review of the facility's undated policy titled, Infection Prevention and Control, showed: - Good handwashing using soap and water or waterless antiseptic before and after each resident contact; - Gloves should be worn during resident-care procedures including injections; - Wearing gloves and changing them between resident contacts does not replace the need for handwashing. [...]