Village at Cook Springs Skilled Nursing Facility

In the surveyor’s words

From the most serious findings on record at Village at Cook Springs Skilled Nursing Facility, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Feb 4, 2021

  Based on interviews, review of Resident Identifier (RI) #1's facility and hospital medical records, the Emergency Medical Services (EMS) run report, a complaint received by the State Survey Agency and various facility documents, the facility failed to ensure the licensed nursing staff promptly identified and acted upon a change in RI #1's condition. During the 7:00 PM to 7:00 AM shift on [DATE], RI #1 was found to have a temperature of 99.1 that increased to 100.0, a heart rate of 135 and oxygen saturation of 81%. The licensed nurse did not assess the resident or notify the physician to address RI #1's declining status. The Charge Nurse assigned to care for RI #1 during the 7:00 AM to 7:00 PM shift on [DATE], noticed the resident looked sick. […]

• No harm, potential for more than minimal, isolatedF677Dec 20, 2023

  Based 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. Findings include: A facility policy titled Perineal Care (Incontinent Care) with an effective date of 6/20214 documented: PURPOSE: Good perineal care helps prevent infections, irritation, and skin breakdown. STANDARD: Residents who are incontinent of urine or feces should receive perineal care as needed. […]

• No harm, potential for more than minimal, isolatedF880Dec 20, 2023

  Based 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. […]

• No harm, potential for more than minimal, isolatedF842Apr 1, 2021

  Based on interviews, record review and review of the facility's policy titled Medication, Oral/Sublingual Administration, the facility failed to ensure that nurses documented administration of [MEDICATION(S)] 50mg (milligrams), an as needed (PRN) medication on Resident Identifier (RI) #1's Electronic Administration Record (EMAR). This deficient practice affected one of two residents sampled for administration of PRN medications. Findings include: Review of the facility's policy titled Medication, Oral/Sublingual Administration with an effective date of 5/2014 revealed, PURPOSE: To administer oral medications in an organized and safe manner. PROCESS: . 4. Administer medication . 7. […]

• No harm, potential for more than minimal, isolatedF580Feb 4, 2021

  Based on interviews, review of the facility's policy titled Notification of a Change in Medical Condition of Residents and Resident Identifier (RI) #1's medical record, the facility failed to notify RI #1's responsible party was notified of the results of x-ray done on 8/1/2020 which indicated the resident had sustained a mildly displaced oblique [MEDICAL CONDITION] metacarpal. This deficient practice affected RI #1, one of three sampled residents reviewed for notification of change in status. […]