Snu Armstrong Co Memorial Hosp

Inspectors wroteBased on review of facility policy, resident records, a facility tour, and staff interview it was determined that the facility failed to ensure enhanced barrier precautions (EBP) were ordered and implemented creating the potential for cross contamination for four out of four sampled residents (Residents R111, R112, R113, and R114).

Inspectors wroteBased on review facility polices, observations, clinical records, and staff interviews it was determined that the facility failed to make certain that appropriate treatments and services were provided for the use of a foley catheter required for two of three residents (Resident R112 and R114).

Inspectors wroteBased on observation and staff interview, the facility failed to make certain that a complaint/grievance could be filed anonymously for 13 of 13 residents.

Inspectors wroteBased on review of facility policy, observation, and staff interviews it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of two medication carts (Cart on wheels One).

Inspectors wroteBased on observations and staff interview, it was determined that the facility failed to maintain a safe, homelike environment for one of two elevators (Elevator 1).

Inspectors wroteBased on review of facility policy, newly hired personnel records, and staff interviews it was determined that the facility failed to properly screen an employment by completing a state background check prior to hire for two of five personnel records reviewed (Nursing Assistant (NA) Employee E2 and Registered Nurse (RN) Employee E3).

Inspectors wroteBased on review of clinical records and staff interviews, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for one out of three residents sampled with facility-initiated transfers (Closed record (CR) Resident R12).

Inspectors wroteBased on review of clinical records, and staff interviews, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for two of two residents (Closed Record (CR) Residents R7 and R12).

Inspectors wroteBased on review of clinical records and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for one of two resident hospital transfers (Closed Record (CR) Resident R12). Findings Include: Review of the clinical record indicated Resident 12 was admitted to the facility on [DATE]. Review of CR Resident R12's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 7/17/24, indicated diagnoses of peripheral vascular disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time. [...]

Inspectors wroteBased on review of facility documents, clinical record review, and staff interviews, it was determined that the facility failed to ensure residents who require dialysis (a machine filters wastes, salts and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) service receive such services consistent with professional standards of practice by failing to obtain a contract with a dialysis facility for one of three residents reviewed (Resident R68).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure a medication regime was free from potentially unnecessary medication for two of four residents reviewed (Residents R71 and R74).

Inspectors wroteBased on review of facility documents and staff interview, it was determined that the facility failed to submit direct care staffing information in the Payroll-Based Journal (PBJ) system for one of three quarters reviewed (Quarter 1).

Inspectors wroteBased on a review of facility policy, plans of correction, and the results of the current and former surveys, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and make certain that plans to improve the delivery of care and services effectively addressed recurring deficiencies.

Inspectors wroteBased on facility policy review, review of Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all of the required committee members for one of three quarterly meeting (October 2023 thru December 2023). Findings Include: The facility Quality Assurance and Performance Improvement (QAPI) Program policy dated 9/1/24, indicated that the facility is committed to maintaining an effective and comprehensive QAPI program that is data driven and focuses on outcomes of care and quality of life. The QAPI program is a multidisciplinary team approach. [...]

Inspectors wroteBased on facility policies, clinical record review, observation, and staff interviews, it was determined the facility failed to follow proper use of personal protective equipment (PPE) for one of five residents (Resident R65).

Inspectors wroteBased on observation and review of facility policy the facility failed to make certain that a grievance official is posted with contact information and that the facility had a policy and procedure that met federal guidelines for 15 of 15 residents.

Inspectors wroteBased on review of facility documentation and staff interview, it was determined that the facility failed to timely issue a Notice of Medicare Non-Coverage form published by the Centers for Medicare and Medicaid Services (NOMNC CMS-10123), for one of three residents (Resident R88).

Inspectors wroteBased on observations, and staff interviews, it was determined that the facility failed to maintain a safe, homelike environment for one of two elevators (Elevator 1).

Inspectors wroteBased on a review of Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that MDS assessments accurately reflected the resident's status for one five residents (Resident R80).

Inspectors wroteBased on a review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that a comprehensive resident care plan was implemented related to post traumatic stress disorder status for one of five residents (Residents R80).

Inspectors wroteBased on facility policy, clinical record review, observation, and staff interview, it was determined the facility failed to implement measures to prevent the potential for cross contamination during a dressing change for one of three residents (Resident R77).