Henderson County Ret Center

In the surveyor’s words

From the most serious findings on record at Henderson County Ret Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF881May 10, 2024

  Based on record review and interview the facility failed to follow an Antibiotic Stewardship program. This failure has the potential to affect all 41 residents who currently reside in the facility. Findings Include: CMS form 671 signed by V1, Administrator, on 05/08/24 documents there are 41 residents living in the facility. On 5/8/24 at 10:30 AM V3 (Licensed Practical Nurse/Infection Preventionist) stated that the facility utilizes the McGreer Criteria which are written definitions of what constitutes an infection. […]

• No harm, potential for more than minimal, isolatedF757May 10, 2024

  Based on record review and interview the facility failed to ensure a prophylactic antibiotic was monitored for effectiveness and not prescribed in excessive duration for one of five residents (R8) reviewed for unnecessary medications in the sample of 18. Findings include: A Health Status Note dated 03/4/22 documents R8 received a new order for Cephalexin 250 milligrams for frequent UTIs (urinary tract infection). This order has no end date. A Consultant Pharmacist Communication to Physician signed by V8, Consultant Pharmacist, on 03/10/23 documents, Antibiotic use without symptoms - Cephalexin. […]

• No harm, potential for more than minimal, isolatedF880May 10, 2024

  Based on observation, interview, and record review the facility failed to perform hand hygiene during resident cares for two of 12 residents (R36 and R40) reviewed for infection control in a sample of 18. Findings include: 1) R36's current Care Plan, documents that R36 has an indwelling urinary catheter and that R36 requires staff assistance with all cares. On 05/08/24 at 8:30 am, R36 was sitting on the commode in R36's bathroom and V4 (Certified Nursing Assistant/CNA) was performing indwelling urinary catheter care. […]

• No harm, potential for more than minimal, isolatedF695May 4, 2023

  Based on observation, interview and record review, the facility failed to change oxygen tubing and humidification bottle as ordered for one resident (R4) out of one resident reviewed for oxygen administration in a sample of 15. Findings include: The facilities Oxygen Administration policy undated, documents 1. Verify there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Equipment and Supplies: 2. Nasal cannula, nasal catheter, or mask (as ordered) 3. Humidifier bottle. On 05/02/23 at 10:10 AM, R4's oxygen tubing was dated 10/29 and the humidification bottle was dated 10/22. R4's medical record documents R4 received oxygen via nasal cannula on 1/6/23 and 2/6/23. […]

• No harm, potential for more than minimal, isolatedF758May 4, 2023

  Based on observation, interview and record review the facility failed to provide informed consent for an antipsychotic medication, failed to identify target behaviors and failed to identify an appropriate supporting diagnosis for one resident (R22) with a diagnosis of Dementia of five residents reviewed for unnecessary medications in the sample of 15. Findings include: Facility Policy/Psychotropic Medication Policy dated 1/16/19 documents: Prior to the administration of a psychotropic medication, the following includes a process for the IDT (Interdisciplinary Team) and resident/resident representative to participate in the care process: The indication for any psychotropic medication will be thoroughly documented in the clinical record to include an appropriate supporting diagnosis and… […]