The Care Center of Dequincy

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident who was unable to carry out Activities of Daily Living (ADLs) received the necessary services to maintain good grooming and personal hygiene for 1 (#41) out 1 resident investigated for ADLs.

Inspectors wroteBased on interviews and record reviews, the provider failed to administer medications as ordered by the physician for 1 (#42) out of 5 residents investigated for medication regimen review.

Inspectors wroteBased on record review and interview, the facility failed to electronically transmit a completed Minimum Data Set (MDS) Quarterly Assessment to the CMS (Center for Medicare and Medicaid Services) system within 14 days after completion for 1 ( #56) out of 1 resident investigated for resident assessment submission activities.

Inspectors wroteBased on interviews and record reviews, the facility failed to protect the residents' right to be free from physical abuse for 2 (#3 and #8) of 2 (#3 and #8) sampled residents investigated for abuse. The facility failed to protect: 1. Resident #8 from physical abuse by Resident #3 2. Resident #3 from physical abuse by Resident #63 This deficient practice resulted in physical harm for Resident #8 on 11/17/2024 at 4:22 p.m. when Resident #3 hit him multiple times. On 11/17/2024 at 4:22 p.m. when Resident #3 hit him multiple times, Resident #8 sustained skin tears to his left forearm and left lower leg.

Inspectors wroteBased on review of the facility's Quality Assurance and Performance Improvement (QAPI) Program and interview, the facility failed to take actions aimed at performance improvement and after implementing those actions, measure its success and track performance. This was evidenced by lack of evidence of: 1. Measuring or tracking success of actions implemented; and 2. collection and analysis of data; This deficient practice had the potential to affect a census of 61 residents.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure alleged violations of abuse were reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency for 2 (Resident #3, Resident #8 ) of 2 (Resident #3, Resident #8) residents reviewed for Abuse.

Inspectors wroteBased on record review and interviews, the facility failed to initiate an investigation of an alleged violation of abuse for 1 (Resident #8) of 2 (Resident #3, Resident #8) sampled residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles. The facility failed to ensure schedule IV controlled medications were stored in a locked, permanently affixed compartment and/or a single unit package drug distribution system for 1 (Room A) of 1 medication storage room reviewed.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that the recipes for pureed foods were followed by the S6DC (Dietary Cook) failing to follow the recipes when preparing pureed foods. This deficient practice had the potential to affect the six residents in the facility who received a pureed diet.

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to ensure the resident was treated with respect and dignity as evidenced by the facility failing to keep a resident's urine collection bag covered and private for 1 (Resident #113) out of 1 resident (#113) investigated for dignity.

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident's Minimum Data Set (MDS) assessment accurately reflected the discharge status for 1 (Resident # 60) out of 31 sampled residents.

Inspectors wroteBased on observations, interview, and record review, the facility failed to provide necessary care and services that is in accordance with professional standards of practice for 2 (Resident #34, Resident #58) out of 5 (Resident #11, Resident #17, Resident #19, Resident # 34, Resident #58) residents reviewed for respiratory care, with the potential to effect 23 residents receiving oxygen therapy.

Inspectors wroteBased on record reviews and interviews, the facility failed to obtain the most recent recertification of terminal illness and most recent POC (plan of care) for 1 (Resident #26) out of 1 resident (#26) sampled residents reviewed for hospice. Review of Resident #26's EHR (Electronic Health Record) revealed he was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, senile degeneration of brain, personal history of colon polyps and vascular dementia. Review of Resident #26's Quarterly MDS (Minimum Data Set) dated 01/07/2025 revealed in part, Section O: Special Treatments, Procedures, and Programs checked for Hospice Care. Review of Resident #26's physician's orders revealed an order entry with a start date of 10/07/2024 read in part, Admit to contracted hospice under the care of physician with Terminal dx (diagnosis) of senile degeneration of brain. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure its medication error rate was not 5 percent or greater, as evidenced by a calculated medication error rate of 72 percent.

Inspectors wroteBased on observations and interviews, the facility failed to ensure medications were stored properly for routine medications, medication refrigerator temperature logs were up to date, disposal of expired medications and schedule II-V medications being maintained in separately locked, permanently affixed compartments. The deficiency had the potential to affect a census of 65.

Inspectors wroteBased on observations and interviews, the facility failed to maintain privacy and confidentiality of residents' medical records observed during a medication pass. The facility had a total census of 65 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the status of 1 (#1) out of 33 sampled residents, by failing to ensure that the resident's fall status was coded.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure residents who need respiratory care were provided care consistent with professional standards for 1 (#20) of 1 residents investigated for respiratory care out of a total of 33 sampled residents, by failing to ensure that the resident's oxygen tubing was labeled stored in a sanitary manner when not in use.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide appropriate, treatment and care to prevent urinary tract infections for residents who had indwelling urinary catheters for 2 (#6, #7) out of 7 sampled residents as evidenced by: 1. Failing to follow the physician orders for changing the suprapubic catheter q (every) month for Resident #6 and; 2. Failing to ensure a split gauze dressing was applied to the resident's suprapubic catheter; failing to ensure the catheter drainage bag was not on the floor; and failing to replace a soiled catheter stabilization device for Resident #7.

Inspectors wroteBased on records reviewed, interviews, and observations, the facility failed to ensure the resident's care plan and physician's orders were followed for 1 (#1) of 7 sampled residents. This was evidenced when facility failed to follow the physician's orders for fall mat to the right side of the bed, between the bed and the bathroom for Resident #1.