Village at Cook Springs Skilled Nursing Facility

Inspectors wroteBased on observation, interviews, resident record review, and a facility policy titled Perineal Care (Incontinent Care), the facility failed to ensure a Certified Nursing Assistant (CNA) #4 provided perineal care for Resident Identifier (RI) #6 to correctly and thoroughly clean RI #6 during incontinent care on 12/19/2023. This had the potential to affect one of three sampled residents with urinary incontinence.

Inspectors wroteBased on observations, interviews, resident record review, and review of the training book How to Be a Nurse Assistant a Quality Approach to Long Term Care the facility failed to ensure Certified Nursing Assistant (CNA) #3, did not create the potential for cross-contamination during incontinent care for Resident Identifier (RI) #8 on 12/19/2023 when she was observed not washing or sanitizing her hands after doffing dirty gloves before touching the clean gloves and not washing hands after perineal care was completed. This had the potential to affect one of three residents who were observed for incontinent care.

Inspectors wroteBased on interviews, review of Resident Identifier (RI) #50's medical record and RI #52's medical record, the facility's policy titled Abuse, Neglect, and Exploitation, the Alabama Department of Public Health Online Incident Reporting System and the facility's investigation files, the facility failed to ensure RI #50 and RI #52 were free from abuse perpetrated by a visitor of the facility, who is also the spouse of a resident residing in the facility. On 2/11/2019, without the consent of RI #50, the visitor came up behind RI #50 and placed his hands down the shirt of the resident, while the resident sat in the Dining room. RI #50 stated he/she was scared and shocked by the incident. [...]

Inspectors wroteBased on interviews, review of Resident Identifier (RI) #204's and RI #205's medical records, the Resident Incident Report, a typed statement and the hospital medical records, the facility failed to develop a care plan to address RI #204's use of a scoot chair and Dycem. On 3/21/2019, while sitting in the scoot chair at the nurses' station, RI #204 fell face forward onto the floor, hitting his/head. Employee Identifier (EI) #7, the Registered Nurse Supervisor who witnessed the fall, stated RI #204 slid from chair with cushion and Dycem still attached to resident's pants. The therapy staff indicated there should be two pieces of Dycem in RI #204's scoot chair. One piece of dycem was to be placed in the chair between the cushion and the chair. [...]

Inspectors wroteBased on interviews and review of Resident Identifier (RI) #204's medical record, RI #205's medical record, the Resident Incident Report, a typed statement, the hospital medical records and the facility's policy titled Mechanical Lift, the facility failed to ensure the Dycem was correctly placed in RI #204's scoot chair. On 3/21/2019, while sitting in the scoot chair at the nurses' station, RI #204 fell face forward onto the floor, hitting his/head. Employee Identifier (EI) #7, the Registered Nurse Supervisor who witnessed the fall, stated RI #204 slid from chair with cushion and Dycem still attached to resident's pants. The therapy staff indicated there should be two pieces of Dycem in RI #204's scoot chair. One piece of dycem was to be placed in the chair between the cushion and the chair. [...]

Inspectors wroteBased on interviews, review of the facility's policy titled Abuse, Neglect, and Exploitation and Resident Identifier (RI) #61's and RI #141's medical record, the facility failed to timely report allegations of physical abuse to the State Agency involving RI #61 and RI #205 and RI #52 and RI #141. On 1/30/2019, RI #205 hit RI #61 in the face. The residents were immediately separated and no injuries were noted. The facility reported this allegation to the State Agency on 7/19/2019. On 5/3/2019, RI #141 hit RI #52 on the arm, twice before the Certified Nursing Assistant (CNA) could intervene. The facility reported this allegation to the State Agency on 7/10/2019. This affected two of five allegations of abuse reviewed the survey.

Inspectors wroteBased on observation, interview and review of Resident Identifier (RI) #117's medical record, the facility failed to ensure Employee Identifier (EI) #11, a Certified Nursing Assistant (CNA) washed her hands after handling RI #117's wet incontinence brief and before touching the resident's clean incontinence brief. This affected RI #117, one of three sampled residents observed for incontinence care.

Inspectors wroteBased on observations, interviews and a review of a facility policy titled ,Food, Leftover-Storage and Use and a document titled, Food Code, the facility failed to ensure: 1. eleven honey thickener waters were not in the cooler passed the use by date of 2/5/18; 2. a worker washed her hands after dropping a thermometer cover to the floor and before taking the temperature of a milk and; 3. plates were free of debris in the plate warmer. This was observed on one of three days of the survey and had the potential to affect 151 of 151 resident who received meals from the kitchen. Findings Include: 1) A review of a facility policy titled Food, Leftover-Storage and Use, with an effective date of 7/2016 revealed: PURPOSE: To assure that food borne illnesses are avoided .PROCESS 9. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the air conditioner temperature in Resident Identifier (RI) #37's room was not below 71 degrees. The temperature on the unit on 8/16/18 at 9:30 AM read at 69 degrees. Findings Include: RI #37 was admitted to the facility 10/14/16 with diagnoses of Unspecified Atrial Fibrillation and Other Abnormalities of Gait and Mobility. A review of RI #37's Quarterly Minimal Data Set (MDS) with an Assessment Reference Date of 5/31/18 revealed a Brief Interview for Mental Status score of 11, indicating minimal difficulty with cognitive status. RI #37 was also coded for extensive assistance with transfers. A review of a Daily Care Guide for RI #37 revealed: : .Interventions .8/15/2018 Resident representative has asked the room air conditioner unit to be set for 74 degrees as the resident allows. [...]

Inspectors wroteBased on observation, interview and review a facility policy Medication Administration Medication Administration Guidelines the facility failed to ensure licensed staff did not prepare Potassium liquid for Resident Identifier (RI) # 81 when the Keppra was due to be given. The facility further failed to ensure medication was not left at RI #81's bedside while the staff returned to the medication cart for a stethoscope. This was observed on 8/14/18 and affected one of seven nurses observed for medication administration. Findings Include: A review of a facility policy Medication Administration Medication Administration - General Guidelines with a date of 3/11 revealed: .Procedures . 16. Read medication label and compare with medication administration record before pouring. RI # 81 was readmitted to the facility on [DATE] with a diagnosis of Seizures. [...]

Inspectors wroteBased on observation, interview and review of a facility policy : Medication Storage,the facility failed to ensure the secured medication box in the refrigerator on Hall I was locked. This was observed on 8/16/18 and affected one of two refrigerated secured medication storage boxes and had the potential to affect Resident Identifiers (RI) #2, 29, 56, 90, 113 and 136, six of six residents whose Lorazepam (Ativan) medication was stored in the refrigerated box. Findings Include: A review of a facility policy Medication Storage dated 3/11 revealed: .Procedures .7. Controlled medications are stored separately from other medications in a locked drawer or compartment designated for that purpose. On 8/16/18 at 10:15 AM, the medication room on Hall I was observed with Employee Identifier (EI) #8, Registered Nurse( RN). [...]

Inspectors wroteBased on observation, interview, record review and review of facility policy Hand Washing (Infection Control) and Medication Administration the facility failed to ensure licensed staff: 1. did not carry a stethoscope used to check a gastrostomy tube placement with the same soiled gloves she had on to administer Resident Identifier (RI) #81's gastrostomy medication then return it to the medication cart, 2. washed her hands between gloves changes while performing wound care for RI #73; and 3. did not store packaged medication in a water cup in the medication cart then use the same cup for water to give to RI #138 the scheduled medication.