Every finding on record at Attala County Nursing Center

Based on observation, staff interviews, and facility policy review, the facility failed to ensure medications were stored in a properly secured refrigerator for (1) of (3) medication storage rooms. Findings include: Review of the facility’s policy titled “Medication Storage”, revised 11/17, states: “Medication storage shall meet all applicable federal, state and local guidelines.” An observation on 08/20/25 at 2:30 PM revealed the medication storage room on the second floor contained a narcotic lock box located inside the refrigerator door, locked, but not secured/affixed to the refrigerator. The lock box was easily removable and contained a bottle of Lorazepam. During an interview conducted on 08/20/25 at 2:35 PM with Registered Nurse (RN) #2, she confirmed that she thought the lock box was supposed to be secured to the refrigerator and not removable. During an interview conducted on 08/20/25 at 2:45 PM with the Director of Nursing (DON), she confirmed the narcotic lock box was not secured, explained that the refrigerator was new, and stated the box had not yet been properly installed.

Based on staff interviews, record reviews, and facility policy review, the facility failed to accurately code a Medicare five (5) day and a Significant Change Minimum Data Set (MDS) assessment for one (1) of 25 MDS assessments reviewed. (Resident #41) Findings include:Review of the facility policy titled, Resident Assessment revised 9/19, revealed, .The completed assessment guide the staff in identifying key information about the resident and serves as a basis for identifying resident specific issues and objectives in order to develop a care plan. This process assists the resident in reaching the highest practicable physical, mental and psychosocial well-being .Any healthcare professional that completes a portion of the assessment must sign and certify the accuracy of the portion of the assessment that they have completed .An observation and interview with Resident #41 on 8/18/25 at 11:02 AM revealed that Resident #41 did have an indwelling catheter and has had it since 5/1/25.Review of Resident #41's Medicare five (5) day and Significant Change MDS, with an Assessment Reference Date (ARD) of 6/6/25, noted that Section H - Bladder and Bowel, H0100 Appliances was coded that the resident did not have an indwelling catheter.Record review of the Order Summary Report with active orders as of 8/21/25 revealed an order dated 5/1/25 for an indwelling catheter.During an interview on 8/21/2025 at 10:04 AM with the MDS Coordinator, she acknowledged the incorrect coding, stating, I don't know how I missed that. That was my mistake. She further confirmed the purpose of accurate assessments is to provide a correct picture of the residents to deliver appropriate care. During an interview with the Director of Nursing (DON) on 8/21/2025 at 10:09 AM, she expressed her expectation that MDS assessments accurately reflect the resident's condition. She stated, It is very important for the assessment to be coded correctly for various reasons such as care planning, billing, look-backs, etc.Record review of the admission Record revealed that facility admitted Resident #41 originally on 4/23/25 with a readmission date of 5/31/25. Her medical diagnoses included Pressure Ulcer of Sacral Region, Stage 4 and Pressure Ulcer of Other Site, Stage 3.Record review of the Medicare five (5) day MDS with an ARD of 6/6/25 revealed, under Section C, a Brief Interview for Mental Status (BIMS) score of 14, indicating that the resident was cognitively intact.

Based on observation, staff and resident interviews, record review and facility policy review, the facility failed to provide a homelike environment for four (4) of 103 residents residing in the facility. Resident #11, Resident #20, Resident #38, and Resident #99. Resident #11 On 8/18/25 at 8:37 AM, an observation and interview revealed Resident #11's door was dragging the floor when opening and closing. Resident #11 stated his door is hard to open and close and that it has been this way for a while.During an interview on 8/19/25 at 11:00 AM, the Maintenance Supervisor stated he was aware of the issue with Resident #11's door and explained the door frame was bent. He said the door would have to be replaced and acknowledged there were other environmental concerns in the facility that he was working on repairing them.Record review of Resident #11's admission Record revealed the facility admitted the resident on 6/16/25 with medical diagnoses that included Diabetes Mellitus.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/08/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #11 is cognitively intact.Resident #20 An interview and observation with Resident #20 and Licensed Practical Nurse (LPN #4) on 8/19/25 at 1:00 PM revealed her room door was difficult to open. She stated her door had been hard to shut for two years and staff members were aware of the problem. LPN #4 entered the room briefly during this interview and observation confirmed the resident's room door was difficult to open.During an interview on 8/19/25 at 1:40 PM, the Administrator acknowledged being aware of a couple of doors that were difficult to open and close. She confirmed this could present a safety hazard if the residents needed to evacuate the room in an emergency.Record review of Resident #20's admission Record revealed the facility admitted the resident on 4/24/25 with medical diagnoses that included Chronic Obstructive Pulmonary Disease.Record review of the MDS with an ARD of 7/10/25 revealed a BIMS score of 15, indicating Resident #20 is cognitively intact.Resident #38An initial tour on 8/18/25 at 11:30 AM revealed Resident #38's overbed table with a thick black substance scattered over the base of the table. An observation and interview on 8/19/2025 at 9:00 AM, revealed Resident #38 sitting on the side of her bed with her bed overbed table in front of her. The metal base of the overbed table had a thick black substance scattered over ninety percent (90%) of the base. Resident #38 admitted this table looks pretty bad and needs cleaning.An observation and interview on 8/19/2025 at 2:50 PM, the Director of Nurses (DON) and the Administrator (ADM) confirmed that Resident #38's overbed table was corroded with a rust-like substance and needed to be replaced. The ADM stated that with her furniture being in this shape, it doesn't represent a home-like environment. Record review of Resident #38's admission Record revealed the facility admitted the resident on 4/11/22 with medical diagnoses that included Congestive Heart Failure.Record review of Resident #38's MDS with an ARD of 6/24/25 revealed in Section C a BIMS score of 12, which indicates the resident has moderate cognitive impairment. Resident #99During an observation on 8/18/25 at 10:49 AM, and again on 8/19/2025 at 9:28 AM, it was noted that Resident #99's intravenous (IV) pole had a scattered thick substance on the base of the pole.During an interview and observation on 8/19/25 at 2:05 PM, Certified Nurse Aide (CNA) #2 revealed if we see any equipment that needs to be cleaned, we can clean it ourselves, but if it needs to be disinfected, we let the housekeepers know. She confirmed that Resident #99's IV pole needed to be cleaned, and that Resident #38 needed a new overbed table since it looked rusty. She stated she thought housekeeping was responsible for cleaning the IV poles. She revealed that if any furniture or anything needs to be repaired or replaced, we fill out the sheet on the wall at the nurses' station for maintenance to address. In an interview and observation on 8/19/25 2:40 PM, with LPN #1 and the facility ADM, LPN #1 revealed that nursing is supposed to clean the IV poles that are used for the Percutaneous Endoscopic Gastrostomy (PEG) tube feedings, especially when the milk drips down and splatters on the base. LPN #1 and the ADM confirmed that the IV pole base for Resident #99 was dirty with a thick substance. In an interview on 8/19/25 at 3:10 PM, the DON confirmed that it is the responsibility of all nursing staff that find any equipment that is dirty or needs to be replaced to either clean it themselves or notify maintenance for a replacement. During an interview on 8/19/2025 at 3:37 PM, the Housekeeping Supervisor revealed that he tells his housekeeping staff that any IV poles that need cleaning should be done by the nursing staff. He stated that we don't want to get any chemicals around their feedings or medicines. He revealed there is a maintenance log that the nurses or CNA's fill out regarding any issues that need to be addressed, and we look at them daily. He revealed he was unaware of any overbed tables needing to be replaced before the ADM asked me to replace some today.Record review of Resident #99's admission Record revealed the facility admitted the resident on 12/28/23 with medical diagnosis that included Cerebral Infarction due to Thrombosis of Right Middle Cerebral Artery.

Based on observations, resident and staff interviews, record reviews, and facility policy review, the facility failed to implement comprehensive care plans for two (2) of 25 sampled residents. (Resident #42 and #67) Findings Include:Review of the facility policy titled, Care Plan Process with a revision date of 12/24 revealed, .The facility shall develop and implement a Baseline Careplan . for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care .Resident #42Record review of the Activities of Daily Living (ADL) care plan revealed, .PERSONAL HYGIENE: The resident needs partial/moderate assistance with personal hygiene. Date Initiated: 06/06/2025.On 8/18/25 at 10:39 AM and again on 8/19/25 at 4:22 PM, observations and interviews with Resident # 42 revealed her fingernails were one-half inch in length, jagged, and had a brown substance underneath. Resident #42 expressed a desire to have her nails trimmed, stating she preferred them to be trimmed short. During an interview on 8/19/25 at 4:22 PM, Licensed Practical Nurse (LPN) #3 confirmed Resident #42's fingernails should have been trimmed by the nursing staff. During an interview on 8/20/2025 at 12:00 PM, with the Director of Nursing (DON), she confirmed that nursing staff should perform nail care on diabetic residents as needed.During an interview on 8/20/2025 at 12:27 PM with the Minimum Data Set (MDS) Coordinator, she confirmed that hand and nail care was listed on the task for the Certified Nurse Assistant (CNA) to perform daily as needed. She agreed the care plan was not being implemented as directed since the resident had long, dirty fingernails. She stated that the care plan was to be used as a guide for the staff to provide individualized care for the residents. Record review of the admission Record indicated that the facility admitted Resident #42 on 6/6/2025 with a medical diagnosis that included Type Two (2) Diabetes Mellitus with Diabetic Chronic Kidney Disease and Unspecified Dementia, Moderate, with Psychotic Disturbance. A record review of the MDS with an Assessment Reference Date (ARD) of 6/13/25 revealed under section C, a Brief Interview for Mental Status BIMS summary score of 15 which indicated Resident #42 was cognitively intact. Resident #67Record review of Resident #67's Care Plan Report revealed that he needs assistance with ADLs (Activities of Daily Living) with interventions that included, The resident needs substantial/moderate assistance with personal hygiene. Date initiated 5/23/25. An observation and interview on 08/19/2025 at 8:47 AM with Resident #67 revealed long, jagged fingernails approximately one-half inch long on both of his hands. Resident #67 stated that the staff had clipped his nails one time since he was admitted . He admitted that he would like his nails to be trimmed. An observation and interview on 08/19/25 at 4:17 PM with CNA #1 confirmed that Resident #67's fingernails were long and jagged and had a brown substance underneath his thumbnail and index fingernail of his right hand. CNA #1 confirmed that fingernail care was part of their daily care and that they should have been taken care of. During an observation and interview on 08/19/25 at 4:25 PM with LPN #1, she confirmed that Resident #67's fingernails were long and had a brown substance underneath. She also confirmed that cleaning fingernails was part of their daily care and should have been taken care of. On 08/19/25 at 4:30 PM, an interview with the DON revealed that the purpose of the comprehensive care plan was to identify specific needs of the residents that needed to be addressed so that all staff knew how to take care of them. She confirmed that Resident #67's nail care was included in his comprehensive care plan and that by leaving his nails long and dirty, it was not followed. Record review of Resident #67's admission Record revealed the facility admitted the resident on 05/23/25 with medical diagnoses that included Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side and Type 2 Diabetes Mellitus. Record review of Resident #67's MDS with ARD of 06/04/25 under Section C revealed a BIMS score of 14 which indicated that he was cognitively intact.

Based on observations, resident and staff interviews, record reviews, and facility policy review, the facility failed to provide Activities of Daily Living (ADL) care to maintain personal hygiene for two (2) of 25 sampled residents. (Resident #42 and #67) Findings IncludeReview of the facility policy titled, Nail Care with a revision date of 07/10 revealed under Purpose .to promote cleanliness, safety and a neat appearance; to observe skin condition on fingers and toes. Resident #42An observation and interview with Resident #42 on 8/18/25 at 10:39 AM and again on 8/19/25 at 4:22 PM revealed that the resident's fingernails were dirty with a brown substance underneath the nailbeds, they were approximately one-half inch past the fingertip and jagged. Resident #42 expressed a desire to have her nails trimmed, stating she preferred them to be trimmed short. An observation and interview on 8/19/25 at 4:22 PM with Licensed Practical Nurse (LPN) #3 confirmed that Resident #42's fingernails should have been cleaned and trimmed by the nursing staff. An interview on 8/20/2025 at 12:00 PM, with the Director of Nursing (DON) expressed her expectations that residents' nails should be kept clean and trimmed as necessary. She then confirmed that nursing staff should perform nail care on diabetic residents as needed. Record review of the admission Record indicated that the facility admitted Resident #42 on 6/6/2025 with a medical diagnosis that included Type Two (2) Diabetes Mellitus with Diabetic Chronic Kidney Disease and Unspecified Dementia, Moderate, with Psychotic Disturbance. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/13/25 revealed under section C, a Brief Interview for Mental Status BIMS summary score of 15 which indicated Resident #42 was cognitively intact. Resident #67 On 8/19/25 at 8:47 AM, an observation and interview with Resident #67 revealed the resident to have fingernails that were approximately one-half inch long past the fingertip with a brown substance under both the thumbnail and the index fingernail on the right hand. Resident #67 admitted that the staff had only clipped his fingernails one time since he had been there. He stated that he would like to have them trimmed. During an observation and interview on 08/19/25 at 4:17 PM with Certified Nursing Assistant (CNA) #1, she confirmed that Resident #67's fingernails were long, jagged and had brown substance underneath his right thumbnail and index fingernail on his right hand. CNA #1 revealed that fingernail care was part of their daily care and that his nails should have been taken care of. She also revealed that long, jagged dirty nails could cause a resident to scratch himself. An observation and interview with LPN #1 and Resident #67 confirmed that the resident's nails needed cleaning and trimming. She admitted that the resident's nails were long and had a brown substance underneath some of the nailbeds. She revealed that long dirty fingernails were a safety issue that could lead to inflammation of the skin. She stated that both CNA's and nurses could clean diabetic resident's fingernails and that the nurses were responsible for trimming. She acknowledged that the staff that see this should get their supplies and take care of them. Record review of Resident #67's admission Record revealed the facility admitted the resident on 05/23/25 with medical diagnoses that included Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side and Type 2 Diabetes Mellitus. Record review of Resident #67's MDS with ARD of 06/04/25 under Section C revealed a BIMS Score of 14 which indicated that he was cognitively intact.

Based on resident and staff interviews, record review, and facility policy review, the facility failed to assess and identify potential triggers for a trauma survivor for one (1) of five (5) residents reviewed for post-traumatic stress disorder (PTSD). Resident #5. Findings Include:Review of the facility policy Social Documentation-Progress Notes with revision date of 10/23 under Purpose revealed, To record observations, outcomes and responses in relation to social services as well as interventions, including trauma informed care, as identified in the comprehensive care plan, and the delivery of direct social services . An observation and interview on 08/19/2025 at 8:50 AM with Resident #5, revealed him lying in bed in his room. He revealed that back in May of 1977 when he was a teenager, he witnessed his father shoot his mother with a gun and this led to her death. He revealed that he ran to a nearby neighbor's house because he feared for his life. Resident #5 revealed that loud noises often scared him, and people need to let me know ahead of time what is going on. He revealed that things like hammers, loud tools or anything that might sound like a gunshot gets his attention. He again stated that no one ever warned him or prepared him for anything loud about to take place in the facility, and he would appreciate it if they would. Resident #5 revealed that he had told staff at the facility about this past experience he had and stated, I didn't want them to be in the dark. He also confirmed that no one had talked to him about any possible triggers that he might have related to this. An interview on 08/19/25 at 3:07 PM with the Social Worker (SW) confirmed that a trauma informed care assessment had not been completed on Resident #5. She admitted that she was responsible for conducting the trauma-informed care assessments. She stated that she was not aware of Resident #5's traumatic past until today but admitted that they had a certified SW from an outside therapy group come to see him in February 2025 and he revealed this trauma to her. She stated that the Minimum Data Set (MDS) nurse found out about it and created a care plan regarding his past trauma. She admitted that despite that she should have completed a trauma informed assessment on the resident in order to inform staff about his past traumatic event and any potential triggers. An interview on 08/19/25 at 3:50 PM with the Director of Nursing (DON), revealed that she found out about Resident #5's traumatic event back in February of this year when he saw the social worker from an outside therapy group that came into the facility. The DON agreed that they should have evaluated him and completed a trauma informed care assessment on him to identify any trauma, possible triggers, and what might set him off. DON revealed that she didn't know how it was missed but would make sure they completed the assessment on him. An interview on 08/21/25 at 9:00 AM with MDS Coordinator revealed that in February of this year, 2025, Licensed Certified Social Worker (LCSW) from an outside therapy group, reported to her that Resident #5 told her (LCSW) in therapy about his history of trauma. MDS Coordinator revealed that Resident #5 had witnessed his father's attempt to kill his mother which resulted in her death. MDS Coordinator revealed that she marked trauma on the MDS assessment and generated a care plan. She confirmed that she did not report this to the facility SW and should have so the appropriate trauma-informed care assessment could have been completed.Record review revealed the facility did not complete a trauma-informed care assessment for Resident #5.Record review of Resident #5's Biopsychosocial Assessment Progress Note dated February 7, 2025, completed by provider Licensed Certified Social Worker (LCSW) from (Proper Name) therapy group revealed that he was experiencing depression and anxiety. This progress note also revealed, The patient has a significant history of trauma, including witnessing his father attempt to kill his mother when he was[AGE] years old, resulting in his mother's death . Record review of Resident #5's admission Record revealed an admission date of 11/21/24 with diagnoses that included Depression and Anxiety Disorder. Record review of Resident #5's MDS with Assessment Reference Date (ARD) of 06/13/25 under Section C revealed a Brief Interview for Mental Status (BIMS) Score of 14 which indicated that he was cognitively intact.

Based on staff interviews, record review, and facility policy review, the facility failed to provide adequate weekend staffing for one (1) of two (2) quarterly Payroll-Based Journal (PBJ) reviews. Quarter 2 2025 (January 1-March 31) Findings Include Record review of the facility policy titled, “Nursing Services – Staffing” with a revision date of 11/17 revealed, “Staffing – The facility will have sufficient nursing staff twenty-four hours every day to provide nursing and nursing related services to attain or help maintain the highest practicable physical, mental and psychosocial well-being of each resident as is determine in the comprehensive assessment and the resident care plan.” Record review of “PBJ Staffing Data Report CASPER Report 1705D FY (Fiscal Year) Quarter 2 2025 (January 1 – March 31)”, revealed “Excessively Low Weekend Staffing – Triggered. Triggered = Submitted Weekend Staffing data is excessively low.” During an interview on 8/20/2025 at 9:10 AM, the Staff Development nurse revealed she is responsible for compiling the nursing schedule to ensure they have sufficient staff to care for their residents. She revealed they had adequate staff on the schedule; however, during the 2nd quarter, January through March, they had many weekend call-ins and were trying to utilize Agency staff. She stated, “It was a really rough time for us”. Record review of the staffing grid for Quarter 2 2025 (weekends January 1-March 31) with the Staff Development nurse confirmed the facility had low weekend staffing for five days. In an interview on 8/21/2025 at 11:16 AM, the Administrator (ADM) revealed she wasn’t aware that the facility had triggered excessively low weekend staffing for the 2nd Quarter 2025 PBJ. She admitted that it was her expectation that they remain adequately staffed at all times to ensure the best care possible for their residents. During an interview on 8/21/2025 at 12:09 PM, the Director of Nurses (DON) revealed she was aware they were having staffing issues during January-March but wasn't aware that they triggered the PBJ for excessively low weekend staffing. She revealed they were having excessive call-ins and some no-call-no-shows. It was just a bad time. She stated that they were using agency and on-call staff to help cover shifts and admitted that their main issues were the Certified Nurse Assistants (CNA) calling in.

Based on staff interviews, record reviews, and facility policy review, the facility failed to ensure that the physician was contacted for an order approval regarding psychotropic drug dosage recommendations for one (1) of four (4) residents reviewed for psychotropic drug dosage reduction. (Resident #10)Findings include:Review of the facility policy titled, Physician Orders review date 1/25 revealed, .When new or revised orders are requested due to consultant recommendations .the attending physician or nurse practitioner .shall be contacted for the order approval. The response of the attending physician or nurse practitioner .shall be documented in the resident clinical record. Additional follow-up may be needed until a response is received.Record review of the Behavioral Medicine Evaluation and Management Note dated 5/21/25 for Resident #10, revealed recommended dosage increase for Risperdal 1mg to three times a day (TID). The order was not implemented until 6/19/25.Record review of the Behavioral Medicine Evaluation and Management Note dated 6/24/25 for Resident #10, revealed recommended dosage increase for Risperdal 2mg twice a day (BID), which was never implemented.Record review of the Behavioral Medicine Evaluation and Management Note dated 7/28/25 for Resident #10, revealed recommended dosage decrease for Risperdal 1mg twice a day (BID), which was also never implemented.Record review of Resident #10's Clinical Physician Orders for active orders revealed that Risperdal 1mg three times a day (TID) was the only active order, with a start date of 6/19/2025.An interview with the Director of Nursing (DON) on 8/20/25 at 10:00 AM confirmed that the recommendation dated 5/21/25 was not implemented until 6/19/25, and the recommendations dated 6/24/25 and 7/28/25 were neither implemented nor documented in the medical record as having been reviewed by the physician. The DON confirmed that facility policy states the physician should review consultant recommendations timely and if necessary, the staff should make follow-up contact with the physician until the recommendation was addressed.Record review of the admission Record revealed Resident #10 was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Dementia, Unspecified Severity, with Behavioral Disturbance.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/30/25 revealed under Section C a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident's cognition was moderately impaired.

Based on staff interview, facility policy review, and record review, the facility failed to ensure a resident's right to be free from misappropriation of property as evidenced by a medication diversion affecting four (4) of six (6) residents reviewed for misappropriation of medication. Residents #1, #2, #3, and #4. Findings Include: Record review of the facility policy titled, Incident Investigation & Reporting revised [DATE] revealed Purpose: 1. Each resident residing in this facility has the right to be free from any type of abuse including: verbal, sexual, mental, physical abuse, neglect, exploitation, misappropriation of resident property . Record review of the facility policy titled, Destruction of Unused, Expired, or Discontinued Medications revised ,d+[DATE] revealed, A. Destruction of Non-Controlled Non-Hazardous Pharmaceutical Waste. The facility will maintain all unused medications and destroy them routinely in compliance with the State and Federal guidelines. Once a prescription is dispensed for a specific person, it is illegal for use for anybody else . A review of the facility investigation dated [DATE] revealed that the Administrator (ADM) received a phone call from the local police department regarding an employee of the facility. According to the police, Licensed Practical Nurse (LPN) #1 was involved in an investigation that led to a search of her home. During the search, authorities discovered multiple blister packs of non-controlled medications belonging to residents of the facility. The facility investigation determined that LPN #1 had removed residents' medications from the medication room after they were discontinued or after a resident expired. Facility staff were re-educated on policies related to ordering, receiving, and discontinuing medications. An Ad Hoc Quality Assurance (QA) meeting was held at the conclusion of the investigation. LPN #1 was terminated and reported to the Board of Nursing. The medication that was taken included Cardizem, Pravastatin, Glucophage, Cipro and Lasix. The only current resident that was affected was assessed with no adverse findings noted. During an interview with the Administrator on [DATE] at 9:55 AM she verified that the facility was notified by the local police department that multiple blister packs of non-controlled medications belonging to residents of the facility were found in LPN #1's home. She stated that they believed that LPN #1 removed the medications from the medication room after the medications had been discontinued or the resident had expired. During an interview on [DATE] at 10:00 AM, LPN #2 stated that when a medication was discontinued, changed, or when a resident expired, the floor nurse was responsible for removing the medication from the medication cart, logging it onto the Discontinued Medication Log and placing the medication into the secured cabinet in the medication room. She further stated that as far as she knew, only the Director of Nursing (DON) had a key to the cabinet. She added that the DON and another nurse were responsible for destroying medications, although she did not know how often this was done. LPN #2 stated that Administrative Nurses occasionally performed medication reconciliations on the medication carts to ensure there were no discontinued medications left, but she was unsure how frequently this occurred. On [DATE] at 10:30 AM, during an interview with the Medical Records Nurse (MRN), she confirmed that she occasionally worked the medication cart when on call. She verified that the process for handling discontinued medications was the same as described by LPN #2. She further stated that she assisted with random medication reconciliations on medication carts but did not keep a record of them. A full medication reconciliation was conducted after the discovery of LPN #1's theft. She did not recall when the last reconciliation was done before the incident and confirmed no reconciliations had been conducted since. In a telephone interview on [DATE] at 11:49 AM, with the former DON, she verified that while she was the DON it was the practice of a facility that when a medication was discontinued, changed or the resident expired the floor nurse was responsible for removing the medication from the med cart, logging it on to the Discontinued Medication Log and placing it into the secured cabinet in the medication room. She stated that she was the only one with a key to the discontinued medication cabinet and that she destroyed the medications monthly and as needed. She verified that based on the facility investigation they felt that LPN #1 took the identified medications out of the medication room after they were discontinued, or the resident expired. She stated that sometimes the newer nurses will just lay the cards on the counter and not log them in or put them in the secured cabinet and that is how they felt LPN #1 gained access to the medications. The DON stated that she did not identify which nurses specifically were not following the protocol she just in serviced everyone on how it was to be done. The DON further stated that she did not initiate any audits to ensure that the staff was following the protocol and did not perform any further medication reconciliations on the med carts. During an interview on [DATE] at 11:56 AM, the Administrator (ADM) stated that she was not aware of any audits or follow-up medication reconciliations being performed. Resident #1 Record review of the medication card, with the MRN, for Resident #1 revealed that it was labeled with the residents name, the medication name Metformin Hydrochloride (HCL) 500 milligram (mg) tablet, and a delivery date of [DATE]. There were 53 tablets left on the card. Record review of the Physicians Order List for Resident #1 revealed an active order for Metformin 500 mg tablets from [DATE] through [DATE], when the medication was discontinued. Record review of the Face Sheet revealed the facility admitted Resident #1 on [DATE] with a diagnosis of Diabetes Mellitus and the resident discharged on [DATE]. Resident #2 Record review of the medication card #1, with the MRN, for Resident #2 revealed that it was labeled with the residents name, the medication name Diltiazem 24 Hour Extended Release (ER) 240 mg capsule , and a delivery date of [DATE]. There were five (5) capsules left on card. Record review of the medication card #2, with the MRN, for Resident #2 revealed that it was labeled with the residents name, the medication name Diltiazem 24 Hour Extended Release 240 mg capsule, and a delivery date of [DATE]. There 12 capsules left on card. Record review of the Physicians Telephone Order for Resident #2 revealed an active order for Diltiazem ER 240 mg tablet extended release 24 hour, take by mouth every day from [DATE] through [DATE] when the medication was discontinued. Record review of the Face Sheet revealed the facility admitted Resident #2 on [DATE] with a diagnosis of Atrial Fibrillation and Heart Failure. The resident was discharged [DATE]. Resident #3 Record review of the medication card, with the MRN, for Resident #3 revealed that it was labeled with the residents name, the medication name Ciprofloxacin HCL 500 mg tablet, and a delivery date of [DATE] with six (6) tablets left on card. Record review of the Physicians Order List for Resident #3 revealed an active order for Ciprofloxacin 500 mg tablet twice a day daily for seven (7) days from [DATE] through [DATE] when it was discontinued. Record review of the Admission Record revealed the facility admitted Resident #3 on [DATE] with a diagnosis of Diabetes Mellitus. The resident remains in the facility. Resident #4 Record review of the medication card, with the MRN, for Resident #4 revealed that it was labeled with the residents name, the medication name Pravastatin Sodium 40 mg tab with a delivery date of [DATE], with 29 tablets left on the card. Record review of the Physicians Order List for Resident #4 revealed an active order for had an active order for Pravastatin 40 mg tablet. Administer 1 tablet by mouth at night daily from [DATE] through [DATE] when it was discontinued. Record review of the Face Sheet revealed the facility admitted Resident #4 on [DATE] with a diagnosis of Hyperlipidemia, and the resident discharged on [DATE]. On [DATE] at 1:30 PM, during an interview and review of delivery dates and active order dates of the medications discovered at LPN #1's home with the ADM, she verified that they had no logs showing if or when the medication cards were removed from the cart. She stated that based on the dates there was no way to determine when LPN #1 removed the medication cards from the facility; or if she removed them from the medication cart or the medication room after they were discontinued. She stated that it was her expectation that the nurse would not have taken the residents' medications. She agreed that misappropriation of a resident's medication could lead to a resident not receiving medications ordered by their physician.

Based on observation, staff interview, record review, and facility policy review the facility failed to implement a fluid restriction care plan for one (1) of 27 care plans reviewed. Resident #72 Findings include: A review of the facility policy titled, Care Plan Process, revised 08/17, revealed The comprehensive care plan is an interdisciplinary communication tool .The care plan must include measurable objectives and timeframe's and must describe the services that are to to be furnished to maintain the residents highest practicable physical, mental, and psychosocial well-being . A record review of the care plan for Resident #72 titled, .Receives Hemodialysis .Problem Onset: 08/02/2023 .Approaches .Fluid restriction as ordered .1500 ml (milliliter) Fluid Restriction: Dietary to provide 1080 ml with meals. Nursing allowed to provide 180 ml day shift, 120 ml in the evenings, and 120 ml on night shift . An observation with Resident #72 on 11/6/23 at 11:00 AM, revealed six (6) eight (8) ounce bottles of water and seven (7) eight-ounce Shasta [NAME] on the resident's bedside table. An interview with the Director of Nursing (DON) on 11/07/23 at 9:29 AM, she revealed the purpose of the care plan is to direct the residents care and after review of Resident #72's care plans staff were not following the care plan for fluid restriction. An interview with the Minimum Data Set (MDS) Registered Nurse (RN) on 11/07/23 at 10:51 AM, she revealed the purpose of the care plans are to direct resident specific care and not following the care plan could lead to a resident not receiving the specific care they need. Record review of the Facesheet revealed that the facility admitted Resident #72 to the facility on [DATE] with diagnoses that included End Stage Renal Disease and Heart Failure. Record review of the open quarterly MDS Section C with an Assessment Reference Date (ARD) of 11/03/23, revealed that Resident #72 had a Brief Interview of Mental Status (BIMS) score of 13 which indicated that she was cognitively intact. A record review of the admission MDS Section O dated 8/09/23, revealed Resident #72 received dialysis while a resident at the facility.

Based on observation, resident and staff interview, record review, and facility policy the facility failed to follow a physician prescribed fluid restriction for one (1) of five (5) residents on fluid restriction. Resident #72. Findings include: A review of the facility policy titled, Fluid Restriction, revised 02/22, revealed Policy: Fluids will be restricted as directed by physician's orders. An observation and interview with Resident #72 on 11/6/23 at 11:00 AM, revealed six (6) eight (8) ounce bottles of water and seven (7) eight-ounce Shasta cola's on the bedside table. Resident #72 stated she keeps the drinks left on her meal trays so she can drink them later. Resident #72 confirmed she was on Dialysis but was unsure if she was on a fluid restriction and stated, I drink as much as I want because I don't pee very much and even drinking more, I still don't pee very much, I just don't know why. A review of the Physician's Telephone Order dated 8/02/23 for Resident #72 revealed, an order for 1500 ml (milliliter) Fluid Restriction: Dietary to provide 1080 ml with meals. Nursing allowed to provide 180 ml day shift, 120 ml in the evenings, and 120 ml on night shift. An observation and interview with Licensed Practical Nurse (LPN) #2 on 11/07/23 at 7:45 AM, she confirmed Resident #72 had several bottles of water and Shasta drinks on her bedside table and revealed that Resident #72 was on fluid restriction because she is on Dialysis and should not have all those drinks in her room. LPN #2 revealed it was possible for Resident #72 to consume over her recommended fluid restriction with all the drinks on her bedside table and staff would not know the total amount of fluids consumed and a potential concern would be fluid overload. An interview with Certified Nurse Assistant (CNA) #1 on 11/7/23 at 7:55 AM, she confirmed Resident #72 was on a fluid restriction and revealed she knew the drinks were in Resident #72's room because the resident likes to keep the drinks left on her meal trays. CNA #1 also revealed she did not remove the drinks from the room because the nurse did not tell her to. An interview with the Director of Nursing (DON) on 11/07/23 at 9:29 AM, she confirmed Resident #72 was on a fluid restriction and should not have fluids left in her room and a possible concern would be the resident could drink extra fluids leading to fluid overload related to her End-stage Renal Disease. Record review of the Facesheet revealed that the facility admitted Resident #72 to the facility on [DATE] with diagnoses that included End Stage Renal Disease and Heat Failure. Record review of the open quarterly Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) on 11/03/23, revealed that Resident #72 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated that she was cognitively intact. A record review of the admission MDS Section O dated 8/09/23, revealed Resident #72 received dialysis while a resident at the facility.

Based on observation, staff and resident interview, and facility policy review the facility failed to maintain a safe environment as evidenced by a splintered chair rail molding for one (1) of 62 resident rooms observed. Resident #70. Findings include: Record review of the facility policy titled, Maintenance and Repairs, with a revision date of 12/22, revealed Purpose, To reduce risks and vulnerabilities . An observation on 11/7/23 at 8: 20 AM, revealed an 18 inch section of wooden chair rail molding, located on the wall beside the residents bed that was splintered, jagged and sticking out toward the foot of Resident #70's bed. During an interview with Licensed Practical Nurse (LPN) #1 on 11/7/23 at 8:22 AM, she stated that if there was something broken in a residents room, they put the information on the log at the nurses station for Maintenance Staff #1. She stated he has to check and sign it daily. During an interview with Resident #70 on 11/7/23 at 8:30 AM, she stated that she did not know how long the wood had been splintered. During an observation and interview with LPN #1 on 11/7/23 at 8:32 AM, she confirmed the wooden chair rail molding was splintered and sticking out. She stated that she was not aware it was broken and stated that it could cause resident injury. A record review of the facility's Maintenance and Repair Log for 9/6/2023 through 11/7/2023 revealed no documentation that the chair rail molding in Resident #70's room was in disrepair. During an interview with Maintenance Staff #1 on 11/7/23 at 8:38 AM, he stated he was not aware that the wooden chair rail molding was in disrepair. During an interview on 11/7/23 at 12:46 PM, the Administrator stated that the facility makes periodic safety rounds in rooms, but missed the splintered chair rail molding in Resident #70's room. A record review of the facility's most recent Safety Checklist, dated 10/27/23, for Resident #70's room revealed no documentation that the chair rail molding was in disrepair. During an interview on 11/7/23 at 1:43 PM, with the Administrator revealed that the splintered wood on the chair rail molding could cause an injury to the resident. Record review of Resident #70's Facesheet revealed that she was admitted to the facility on [DATE], with diagnoses of Cerebral Infarction and Diabetes Mellitus. Record review of Resident #70's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/25/23 revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident is cognitively intact.

Based on observations, staff, resident and resident representative's interviews, record review and facility policy review the facility failed to ensure a resident was free from physical restraints as evidenced by a full side rail used without an assessment, medical symptom, or ongoing evaluation for one (1) of seven (7) residents reviewed with full side rails. Resident # 16 Findings include: Record review revealed the facility policy titled, Restraints with a revision date of 09/18 revealed, It is the philosophy of this facility that a resident has the right to be free from any physical or chemical restraints not required to treat the resident's medical symptoms. Restraints may not be used for the convenience of the nursing staff or as punishment to the resident. This policy review revealed under Physician Restraint Definition .The use of a restraint will require a determination of need to be completed by a licensed nurse, a signed consent and a physicians order prior to applying restraints. An observation on 9/12/22 at 10:20 AM, revealed Resident #16 sitting in the hall in her wheelchair with multiple dried blood areas in her hair and on the front of her gown. This observation revealed that Resident # 16 had a raised purple area on the top left side of her forehead and a brace on her left wrist. During this observation Registered Nurse (RN) # 1 and a maintenance staff member were removing Resident # 16's manual crank bed with full side rails and replacing it with an electric bed with half side rails. Record review of Resident # 16's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident # 16's Device/Physical Restraint Consent, undated, revealed it was not signed by the resident or resident representative. Record review of the medical record revealed there was no Side Rail/Restraint Assessment's for Resident # 16 An interview on 9/12/22 at 10:25 AM, with Certified Nurse Assistant (CNA) # 5 revealed that Resident # 16 had fell out of the bed early this morning before she got to work. She revealed she is not sure what happened or the extent of her injuries. An attempted interview on 9/12/22 at 10:28 AM, with Resident # 16 revealed the resident is soft spoken but able to answer simple yes or no questions. When inquired what had caused her injuries, Resident # 16 did not respond. An interview on 9/12/22 at 2:30 PM, with Licensed Practical Nurse (LPN) # 2 revealed Resident # 16 fell out of the bed around 4:30 AM, was sent to the emergency room (ER) and returned with a broken wrist and bruising. An interview on 9/13/22 at 3:17 PM, with Resident # 16 revealed the resident was able to answer simple yes or no questions. When ask if she remembered what happened when she fell , Resident # 16 mumbled something that I could not understand. An observation on 9/14/22 at 8:30 AM, revealed Resident # 16 lying in bed with dark purple bruising to her right shoulder that continued down her arm to her elbow, dark purple bruising to her left arm from her elbow that continued through her left hand, dark purple bruising noted to the top left side of the resident's forehead with a scar across the bruising that is approximately two (2) inches long with dried blood. This observation revealed the resident was wearing a wrist brace to her left arm. An interview on 9/14/22 at 8:32 AM, with Resident # 16's Daughter in Law, revealed they were notified that the resident had fallen out of bed and was sent to the ER. She revealed the resident has always been bad to fall, she has fallen here before and at home. She revealed the other bed had full rails that went to the foot of her bed, and we liked that and this one does not. She revealed it seems like she should have full rails. An interview on 9/14/22 at 10:30 AM, with LPN-Infection Control Nurse revealed she was Resident # 16's nurse on the night of her fall on 9/12/22. She revealed she was called to the room by CNA # 10 and when she got to the room the resident was lying on her right side in the floor with her head on the end by the head of the bed, legs straight out and arms crossed in front of her. She revealed the resident was holding her left wrist with her right hand. She revealed the resident had a laceration to her head that was bleeding. She confirmed the left side of the resident's bed was against the wall and a full side rail was up on the right. She revealed the CNA told her that they heard a loud noise like a boom as if something had fallen and that is when CNA # 10 found her around 3:30 AM. She revealed she does not know why the full side rail was ordered or for how long, but the resident was still able to get her legs over the rail because it was short in height. She revealed that the preventative measures that were in place prior to the 9/12/22 fall included, checked, and turned every two (2) hours and the nurse usually does rounds in between those 2 hours, and a full side rail. An attempted interview on 9/14/22 at 11:01 AM, with CNA # 10 revealed no answer and no voice mail. An interview on 9/14/22 at 2:28 PM, with CNA # 5 revealed that Resident # 16's care included that she have a full side rail up X (times) one (1) and the other side of her bed was against the wall. She revealed that when the resident was in the bed her full side rail stayed up all the time on the side that was not against the wall and the resident could not let her bed rails down on her own. An interview on 9/14/22 at 2:42 PM, with LPN # 2 revealed that Resident # 16's care included repositioning every 2 hours and a full side rail. She revealed that the full side rail was used for repositioning, and she could not let them down herself. An interview on 9/15/22 at 9:45 AM, with the Director of Nursing (DON) revealed that the resident's left side of her bed was against the wall and the right side had a full rail when the fall occurred on 9/12/22. She revealed she is not sure why the full side rail X 1 was ordered on 3/15/22. She revealed she does not like the full rail beds and will argue with families about having it if they request it, because they just don't understand what it can cause. She revealed that the side rail did not prevent her from getting out of the bed but can understand how the full side rail could be considered a restraint and could increase the severity of an injury when the resident has to climb over it to get out of the bed. An attempted phone interview on 9/15/22 at 12:42 PM, with Doctor (Dr.) # 1 revealed no answer for his office. Record review and interview on 9/15/22 at 1:15 PM, with LPN-Medical Records Nurse revealed that RN-Minimum Data Set (MDS) nurse wrote the order for the full side rail on 3/15/22 and Dr. # 1 signed it in 4/2022. An interview on 9/15/22 at 1:20 PM, with the Administrator revealed she did not know the resident had a bed with a full rail and if she had of known then the resident would not have had it, because we do not use those. An interview on 9/15/22 at 1:25 PM, with RN-MDS nurse revealed she completed Resident # 16's quarterly assessment on 3/15/22 and when she walked in the resident's room, the resident had a full side rail up. RN-MDS revealed that she wrote the order for the full side rail at that time, so that it would match what the resident physically had, and her MDS assessment would be correct. RN-MDS revealed she did not report to the DON or anyone else that the resident had a full side rail, because they had several of those beds in the facility at the time and she assumed that was why she had it. She revealed she is not aware of how long the resident had a full side rail prior to her finding it on her 3/15/22 MDS assessment. An interview on 9/15/22 at 3:15 PM, with Doctor (Dr) # 1 revealed he does not recall without doing a chart review why he ordered a full side rail X 1 on Resident # 16. Dr. # 1 revealed he recalls that the resident had dementia, had some falls in the past and had been trying to get out of bed. Record review of Resident # 16's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident # 16's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/14/22 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 09 which indicates Resident #16 has moderate cognitive impairment.

Based on observations, staff, resident and resident representative's interviews, record review and facility policy review the facility failed to ensure a resident was free from accident hazards as evidenced by the facility's failure to identify a full side rail as a hazard. Resident #16 sustained a fall from the bed and a fractured wrist. Resident #16 was one (1) of two (2) residents reviewed for falls. Findings include Record review of the facility policy titled, Accident Prevention with a revision date of 11/17 revealed, Each resident shall receive adequate supervision and assistive devices to prevent accidents. Review of the facility policy with a revision date of 09/18 titled, Fall Prevention and Management Program revealed under Prevention .The staff will identify and implement interventions related to a resident's specific risk factors to try to prevent falls from occurring . Observation on 09/12/22 at 10:20 AM, revealed Resident # 16 was sitting in the hall in her wheelchair with multiple dried blood areas in her hair and on the front of her gown. This observation revealed that Resident # 16 had a raised purple area on the top left side of her forehead and a brace on her left wrist. During this observation Registered Nurse (RN) # 1 and a maintenance staff member were removing Resident # 16's manual crank bed with full side rails and replacing it with an electric bed with half side rails. During an interview on 9/12/22 at 10:25 AM, with Certified Nurse Assistant (CNA) # 5 revealed that Resident # 16 fell out of the bed early this morning. She revealed she is not sure what happened or the extent of her injuries. In an interview on 9/12/22 at 10:28 AM, with Resident # 16 revealed the resident is soft spoken but able to answer simple yes or no questions. When inquired what had caused her injuries, Resident # 16 did not respond. Record review of the Resident Incident Report revealed that Resident # 16 had an unwitnessed fall on 9/12/22 at 3:29 AM and was discovered on the floor on her right side next to her bed with her head against bedside nightstand and blood noted to head and floor with a laceration noted to her head, a bruise to her right lower leg, a bruise to her right elbow and a bruise to her right arm. This review revealed the resident was sent to the ER. Record review from Resident incident follow up dated 9/12/22 revealed CNA # 10's last round on Resident # 16 was at 3:10 AM and at that time the resident's full side rail was up and she was resting. Licensed Practical Nurse (LPN) # 2 reported during an interview on 9/12/22 at 2:30 PM, that Resident # 16 fell out of the bed around 4:30 AM, was sent to the emergency room (ER) and returned with a broken wrist and bruising. On 9/13/22 at 3:17 PM, during an interview with Resident # 16 revealed that the resident was able to answer simple yes or no questions. When asked if she remembered what happened when she fell , Resident # 16 mumbled something that the SA could not understand. On 9/14/22 at 8:30 AM, during an observation revealed Resident # 16 lying in bed with dark purple bruising to her right shoulder and it continued down her arm to her elbow, dark purple bruising to her left arm from her elbow that continued through her left hand, dark purple bruising noted to the top left side of the resident's forehead with a scar across the bruising that is approximately two (2) inches long with dried blood. This observation revealed the resident was wearing a wrist brace to her left arm. During an interview on 9/14/22 at 8:32 AM, with Resident # 16's daughter-in-law, revealed they were notified that the resident fell out of bed, was sent to the ER and had broken her wrist. She revealed the resident has always been bad to fall, she has fallen here before and at home. She revealed the other bed had full rails that went to the foot of her bed, and we liked that and this one does not. She revealed it seems like she should have full rails. In an interview with LPN-Infection Control Nurse on 9/14/22 at 10:30 AM, revealed she was Resident # 16's nurse on the night of her fall on 9/12/22. She revealed she was called to the room by CNA # 10 and when she got to the room the resident was lying on her right side in the floor with her head on the end by the head of the bed, legs straight out and arms crossed in front of her. She revealed the resident was holding her left wrist with her right hand. She revealed the resident had a laceration to her head that was bleeding. The left side of the resident's bed was against the wall and a full side rail was up on the right. She revealed the CNA told her that they heard a loud noise like a boom as if something had fallen and that is when CNA # 10 found her around 3:30 AM. She revealed she does not know why the full side rail was ordered or for how long, but the resident was still able to get her legs over the rail because it was short in height. She revealed the resident had falls in the facility before and thinks she has had some injuries. She revealed that the preventative measures that were in place prior to the 9/12/22 fall included checking on and turning the resident every two (2) hours and a full side rail. The nurse usually does rounds in between those 2 hours. On 9/14/22 at 11:01 AM, an interview was attempted with CNA # 10. There was no answer and no voice mail at this time. CNA #5 reported during an interview on 9/14/22 at 2:28 PM, that Resident # 16's care interventions included that she has a full side rail up X (times) one (1) and the other side of her bed was against the wall. She revealed that when the resident was in the bed that one full side rail stayed up all the time and the resident could not let her bed rail down on her own. During an interview on 9/14/22 at 2:42 PM, LPN # 2 stated that Resident # 16's care interventions included one full side rail. She revealed that the full side rail was used for repositioning and confirmed that the resident could not let it down herself. The resident had frequent falls in the past, but it has been a while since her last fall. She revealed the resident was mobile in the bed and could move around. She revealed she has caught her scooted down to the end of the bed with the full side rail up. She would report that to the oncoming nurse, so they could keep a closer eye on her, but she never reported it to the Director of Nurses (DON). She revealed that CNAs had reported that the resident had tried to go over the rail by putting her leg or arm on the rail or was sitting at the foot of her bed and she would just have the CNA's keep a closer eye on her. She revealed she did not think that the resident scooting to the end of the bed or putting her leg or arm on the rail should have been reported to the DON because she had not had an accident like this before. The DON reported during an interview on 9/15/22 at 9:45 AM, that Resident # 16 had three (3) falls prior to this fall since her admission on 4/6/21. She confirmed that the resident's left side of her bed was against the wall and the right side had a full rail when the fall occurred on 9/12/22. She revealed she is not sure why the one full side rail was ordered on 3/15/22. She revealed she does not like the full side rail on beds and will argue with families about having it if they request it, because they just do not understand what those type of siderails can cause. She revealed no staff member had ever reported to her that the resident had attempted to climb over her bed rail. She revealed that the side rail did not prevent her from getting out of the bed but can understand how the full side rail could be considered a restraint and could increase the severity of an injury when the resident has to climb over it to get out of the bed. The LPN-Infection Control Nurse revealed during an interview on 9/15/22 at 12:15 PM, that she had spoken with one of Resident # 16's CNAs after the fall on 9/12/22 and asked if she had ever seen the resident try to climb over her full bed rail. The CNA confirmed that she had but had never reported it to anyone. An attempted phone interview on 9/15/22 at 12:42 PM, with Doctor (Dr.) # 1 revealed no answer for his office at this time. An interview on 9/15/22 at 1:20 PM, with the Administrator revealed she was not aware that Resident # 16 had a bed with a full side rail and if she had known then the resident would not have had it, because we do not use those. Record review and interview on 9/15/22 at 1:15 PM, with LPN-Medical Records Nurse revealed that RN-Minimum Data Set (MDS) nurse was the nurse that wrote the order for the full side rail on 3/15/22 and Dr. # 1 signed it in 4/2022. An interview on 9/15/22 at 1:25 PM, with RN-MDS nurse revealed she completed Resident # 16's quarterly assessment on 3/15/22 and when she walked in the resident's room the resident had a full side rail up. RN-MDS revealed that she wrote the order for the full side rail so that it would match what the resident physically had, and her assessment would be correct. RN-MDS revealed she did not report to the DON or anyone else that the resident had a full side rail, because they had several of those beds in the facility at the time and she assumed that was why she had the full side rail. She revealed she does not know how long the resident had a full side rail prior to her finding it on her 3/15/22 MDS assessment. An interview on 9/15/22 at 3:15 PM, with Doctor (Dr) # 1 revealed without doing a record review then he does not recall why he ordered a full side rail for Resident # 16. Dr. # 1 revealed he does recall that the resident had dementia, had some falls in the past and had been trying to get out of bed. Record review of Resident # 16's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Primary generalized [CONDITION(S)], Spondylosis without [CONDITION(S)] or radiculopathy, Alzheimer's disease, and Unspecified dementia without behavioral disturbance. Record review of Resident # 16's Physician Orders List revealed an order dated 3/15/22, SIDERAIL (FULL) X 1 FOR BEDMOBILITY. Record review revealed there was no Side Rail/Restraint Assessment's for Resident # 16 Record review of Resident # 16's X-ray (XR) report from 9/12/22 revealed, XR Wrist Left PA Lateral and Oblique .Reason for exam: Fall, Swelling .There is an impacted fracture of the distal radial metaphysis and epiphysis and suspected intra-articular extension centrally. There is also a minimally displaced partially impacted fracture at the distal ulnar metaphysis and epiphysis but the styloid appears intact . Record review of Resident # 16's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/14/22 revealed in Section C a Brief Interview for Mental Status (BIMS) of 09 which indicates the resident is moderately cognitively impaired.

Based on observation, interviews, record review and facility policy review the facility failed to prevent the likelihood of contamination of food utensils as evidenced by a black substance on the wall in the dishwasher area with buildup, debris on a shelf used for drying plate covers and dirty fans for three (3) of four (4) kitchen tours. Findings include: Review of the facility policy titled, Cleaning and Sanitizing Equipment, with a revision date of 10/17, revealed all equipment is kept clean and food contact surfaces are cleaned and sanitized. All food contact surfaces and work tables are cleaned and sanitized at any time that contamination may occur. An observation on 09/12/22 at 11:05 AM, revealed a buildup of black substance approximately six (6) inches up the wall to the left of the door opening and behind the dishwasher area. A two-tiered [MEDICATION(S)] chloride (PVC) shelf in the dishwasher room had brown spatters on the bottom PVC pipe and the two (2) shelves were coated with a whitish gray film and brownish debris. An observation, on 09/13/22 at 09:49 AM revealed black buildup on the wall behind the dishwasher area, the 2 tiered shelf continued to have grayish buildup and debris on the shelves and brownish splatters on the bottom PVC pipe of the shelving and two (2) operating fans in the dishwasher room, mounted on the wall had black buildup and rust on the covers. Dietary staff #1 was observed washing dishes and placing the clean plate covers on the dirty shelf to dry. An interview on 09/14/22 at 9:10 AM, with Dietary Staff #1 confirmed the black buildup on the wall and she thought it was supposed to be cleaned every day. She stated that she would give the shelf a 6 out of 10 for cleanliness and the shelf should not be dirty because that could cause cross contamination. Dietary Staff #1 confirmed that she was putting clean dishes on the dirty shelves. An interview, on 09/14/22 at 9:15 AM with the Dietary Manager (DM) confirmed the black buildup on the wall and the shelves needed cleaning. The DM washed a small area of the wall and the shelf confirming the buildup could be removed and that this should be cleaned daily. The DM stated that this could cause contamination and confirmed that the plate covers were contaminated and instructed the dietary staff to rewash the plate covers. The DM confirmed the fans needed cleaning and could be blowing causing cross contamination. The DM stated that they had done a deep cleaning of the kitchen on Monday and these issues should have been taken care of Monday. An observation and interview, on 09/14/22 at 9:30 AM, with the Administrator (ADM) confirmed the black buildup on the wall in the dishwasher room and it should be sprayed with bleach and cleaned daily. She confirmed the plate covers were contaminated due to the dirty shelves and that the fans were dirty and could cause contamination and these things could lead to pests. An interview on 09/14/22 at 10:20 AM, with the Infection Control Nurse (ICN) revealed that contaminated dishes in the kitchen could cause resident illnesses like upset stomach, nausea, vomiting and diarrhea. The ICN confirmed there had not been any gastrointestinal infection outbreaks in the facility. Record review of the Daily Cleaning Sanitizing Schedule revealed that the dish machine area should be cleaned three times a day and the cleaning schedule had not been followed for 11 of 13 days reviewed from 9/1/22 through 9/13/22.

Based on observation, staff and resident interviews, and record review, the facility failed to honor the residents' rights to self-determination with their choice to smoke according to the facility's smoking schedule, for two (2) of five (5) smokers interviewed. Resident #58 and #80 Findings include: Record review revealed there was no facility policy related to resident smoke breaks and the facility's responsibility to ensure residents are taken out for a smoke break. The Administrator (ADM) provided documentation on the facility letterhead that noted, We do not currently have a policy in place for transporting residents to the smoking area or one for smoking times available to the residents. An interview on 9/12/22 at 11:24 AM, with Resident #58 revealed she was not getting to go out and smoke on all the smoke breaks on the weekend and the smoke breaks through the week happened late most times. Resident #58 revealed it was very important that she got to go out and smoke. Resident #58 revealed she had spoken to the Administrator about being able to smoke on the weekends. An interview on 9/12/22 at 11:55 AM, with Resident #80 revealed he had a problem with the smoke breaks because he never gets to smoke on time through the week and does not get all his smoke breaks on the weekend. Resident #80 revealed he had talked to the ADM about getting someone to start back taking them out on time to smoke. Resident #80 revealed it just got bad lately not being able to get our smoke breaks. An observation and interview on 9/12/22 at 4:50 PM, with Resident #80 revealed the smoking break was scheduled for 4:30 PM, the smoke break was late again and no staff was able to take the smokers out. Resident #80 revealed the smokers must stay in the hallway waiting for someone to show up and take them out to avoid missing the smoke break. Resident #80 revealed the Director of Nursing (DON) told the smokers she will find someone to take the smokers out. An interview on 9/12/22 at 4:55 PM, with the DON, revealed she was trying to find a staff member to take the smoking residents out, that she was not aware of the location of the person that was scheduled to take the smokers out at the 4:30 PM scheduled time. An interview 9/13/22 at 9:30 AM, with Resident #58 revealed she had to go to get the ADM to take the smoking residents out for a smoke break after 5:00 PM yesterday (9/12/22). An interview on 9/14/22 at 1:55 PM, with the Licensed Practical Nurse, (LPN) #4, revealed there was difficulty getting staff members to take the smoking residents out for a smoke break at the scheduled times, and the smoke breaks are often completed late. LPN #4 revealed a smoking schedule posted at the nurse's station had different department disciplines designated to take smokers out, and with an assigned staff member that was to assist with the smoking residents to get to and from the smoking area. LPN #4 noted the schedule was not followed the way it was typed because there was a Floor Tech previously employed by the facility that took the residents on almost all the smoke breaks, Monday - Friday. LPN #4 revealed the Floor Tech's supervisor would be the back-up person if the Floor Tech was not available for a smoke breaks and the nursing staff only had to do the 7:00 PM smoke break Monday - Friday. LPN #4 noted the Floor Tech resigned 2 weeks ago and his supervisor had been too busy to come and help with the smoke breaks. LPN #4 revealed she did not know who was responsible to ensure the schedule of staff members assigned to help with the smoke breaks was followed and the nurses did not assign the task of taking the smoking residents out on breaks to the Certified Nursing Assistants (CNAs) when daily resident assignments were done. An interview on 9/14/22 at 2:10 PM, with Registered Nurse (RN)#1, revealed it was difficult to get residents out to smoke on the weekends, and tried to help as much as she could to get them to as many breaks as possible. RN #1 revealed usually she only worked to 1:00 PM on Saturdays and Sundays and it was difficult to get staff to assist with the resident smoke breaks, and residents did miss some of the weekend smoke breaks. An interview on 9/14/22 at 2:16 PM, with LPN #5, revealed the residents do not get out timely to smoke breaks through the week, and she assisted to get them out when she could. An interview on 9/14/22 at 02:40 PM, with the ADM revealed she ensured that the residents went out for every smoke break when she was in the building, but it was the responsibility of the charge nurse to ensure the residents smoked on the weekends. The ADM confirmed she took the smokers out on Monday, 9/12/22, confirmed that the break was late, and confirmed the smoke breaks are often completed late. The ADM revealed there was a schedule posted for employees to take the smokers out, the staff was aware of the schedule. The ADM did not identify a responsible staff member that ensured the schedule was followed, could not recall who completed the schedule and confirmed no changes had been made to the schedule since the Floor Tech left 2 weeks ago. The ADM revealed if Resident #80 and Resident #58 felt that their choice to go out and smoke at the scheduled times was not being honored, then the facility was not honoring their choices and their Resident Rights. An interview 9/14/22 at 04:42 PM, with CNA #7, revealed the CNAs do not know when they are on the schedule to take smokers out. She noted they had never followed a schedule to take smokers out before and the Floor Tech did all the smoke breaks. An interview on 9/15/22 at 10:40 AM, with the Housekeeping Supervisor, revealed he helped to get the resident's out to smoke breaks. The Housekeeping Supervisor revealed he was only scheduled for Tuesdays to take the residents out to smoke, remembers his assigned time, and would fill in when he could for the area that was assigned to the Floor Tech. An interview on 9/15/22 at 11:20 AM, with CNA #6, revealed the CNAs are used as back-up for taking the smoking residents out. CNA #6 revealed the CNAs are on the schedule to take the smoking residents out but are not responsible to do more than assist in getting residents in and out of the smoking area. An interview on 9/15/22 at 11:23 AM, with CNA #8 revealed she would help get them to and from the smoking area but cannot be responsible to stay outside with the smokers. CNA #8 revealed she was made aware of the schedule for the staff members to take residents out for a smoke break from other staff members, but no specific person told them to follow the schedule. An interview on 9/15/22 at 11:26 AM, with CNA #9, revealed she knows the smoking residents have a hard time getting out for smoke breaks, but the 7-3 shift CNAs have all the work to do in the mornings and cannot get to take residents outside to smoke. CNA #9 revealed the staff schedule for the smoke breaks does not apply to the 7-3 shift and the 7-3 shift CNAs are only to assist as they can. Record review of the Smoking Schedule revealed the staff members assigned to take the smoking residents out for the scheduled smoke breaks and In the event the person who is supposed to smoke is unable to do so, they are responsible for finding a replacement. The Smoking Scheduled also revealed the schedule was for the entire week, listed all the designated smoking times, listed a primary staff member responsible for the task of monitoring the smokers during the breaks, and a staff member to assist to get the smoking residents to and from the smoking area. The Smoking Schedule reflected the Housekeeping Supervisor was scheduled primary for Tuesdays at 1:30 PM and the Floor Tech was scheduled primary for Mondays, Wednesdays, and Fridays at 9:30 AM. It noted the CNAs were scheduled primary daily at 4:30 PM and 7:30 PM, but a CNA was scheduled to assist the primary on Monday, Tuesday, Wednesday, Thursday, Saturday, and Sunday for all smoke breaks. The Smoking Schedule did not reveal the date it was initiated. Record review of the Smoker Worksheet revealed Resident #58 and Resident #80 are listed as smokers and the facility's daily smoking times are 9:00 AM, 11:00 AM, 1:30 PM, 4:30 PM, and 7:00 PM. Record review of the Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 5/10/22 for Resident #58, revealed Resident #58 has a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #58 is cognitively intact. Record review of a Quarterly MDS Assessment, with an ARD of 8/4/22 for Resident #80, revealed Resident #80 has a BIMS score of 09, indicating Resident #80 is moderately cognitively impaired.

Based on observation, staff interview, record review and facility policy review the facility failed to provide nail care for a resident dependent on staff for Activities of Daily Living (ADL's) as evidenced by a brown substance under the resident's nails for one (1) of five (5) residents reviewed for ADL's. Resident # 56 Findings Include. Review of the facility policy titled, Nail Care with a revision date of 10/17 revealed under Purpose .To promote cleanliness, safety and a neat appearance . An observation on 09/12/22 at 11:00 AM, revealed Resident # 56 lying in bed, fingernails long with a brown substance under every fingernail. An observation on 09/13/22 at 08:59 AM, revealed Resident # 56 had a brown substance under all of her fingernails. An observation on 9/13/22 at 12:08 PM, revealed Resident # 56 had a brown substance under all of her fingernails. An observation on 9/13/22 at 2:00 PM, revealed Resident # 56's fingernail's had a brown substance under every nail. An observation and interview on 9/13/22 at 4:10 PM, with the Director of Nurses (DON) confirmed the resident's nails were dirty and needed to be cleaned and it was the responsibility of the nurse to file and trim her nails, but it was the responsibility of the CNA to clean this resident's nails and that would be documented on the Electronic Treatment Administration Record (ETAR). An interview on 9/13/22 at 2:30 PM, with Certified Nurse Assistant (CNA) # 1 revealed that the CNA's are responsible for providing baths to the residents. CNA #1 revealed that when the residents get a bath that includes having their hair washed and combed, nails cleaned and shaved if needed. CNA #1 revealed that if the resident is a diabetic then the nurse does the resident's nail trimming, otherwise the CNA can do it. An interview on 9/13/22 at 3:02 PM, with Licensed Practical Nurse (LPN) # 1 revealed it is the responsibility of the CNA to provide the residents with a bath of some sort every day. LPN #1 revealed it is the responsibility of the CNAs to do nail care and shaving along with the resident's bath unless the resident is a diabetic and then the nurse does it. An interview and observation on 9/13/22 at 3:20 PM, with CNA # 3 confirmed the resident's nails had a brown substance under every nail and it had an odor. CNA #3 confirmed that the resident's nails needed to be cleaned and she was not sure what that brown substance was. An interview on 9/14/22 at 8:35 AM, with CNA # 4 revealed the CNAs are responsible for cleaning the resident's nails and confirmed she has seen brown stuff under the resident's nails before. An interview on 9/15/22 at 11:44 AM, with the DON confirmed the brown substance under Resident # 56's nails could have caused the resident to have an upset stomach and diarrhea. An interview on 9/15/22 at 1:22 PM, with the Administrator revealed that the brown substance under Resident # 56's nails could have made her sick if she put her hands in her mouth. Record review of Resident # 56's Face Sheet revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Diabetic Nail Care Assignments revealed that the 7 AM-3 PM LPN was responsible for diabetic fingernail care. Record review of Resident # 56's ETAR revealed that the resident had no nail care performed by the nurse for the month of August or September 2022. Record review of Resident # 56's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/14/22 revealed in Section C a Brief Interview of Mental Status (BIMS) of 03, which indicates the resident is severely cognitively impaired.

Based on observations, staff and resident interviews, record reviews, and facility policy review, the facility failed to ensure that oxygen (O2) in use signage was on the door, nasal cannula storage bags were provided, and that nasal cannula storage bags, oxygen tubing, and humidifier bottles were labeled and dated for two (2) of five (5) residents reviewed for oxygen. Residents #29 and #58. Findings include: Review of the facility policy titled, Oxygen-Administration, Concentrator, Storage, Assemblage, with the latest revision date of 10/17, revealed, . 13. Post the NO SMOKING - OXYGEN IN USE sign on the door of resident's room. Review of the facility policy titled, Infection Control Oxygen Equipment Cleaning, with the latest revision date of 08/21, revealed, . 10. When not in use, store the mask/cannula in a plastic bag clearly labeled with the resident's name and date. When sterile water container is opened, the date will be placed on the container. An observation and interview on 09/12/22 at 11:02 AM, with Resident #29 revealed an O2 concentrator with tubing in the room. There was not an O2 in use sign on the door and no storage bag for nasal cannulas. Resident #29 revealed he had not been given a storage bag for the nasal cannulas but had gotten one in the past when he used oxygen before. An observation and interview on 09/12/22 at 11:27 AM with Resident #58 revealed an O2 concentrator in the room. There was no date on the O2 tubing and the O2 tubing had no storage bag. Resident #58 revealed she does not remember being given a storage bag for her nasal cannulas and she does not wear the oxygen all day. An observation and interview on 9/13/22 at 04:00 PM, with Resident #29 revealed a staff member came to his room and put an O2 In Use signage on his door and a staff member had taped a storage bag on his concentrator. The SA did observed the O2 storage bag on the oxygen concentrator with no date, a date on the humidification bottle, but no date on the oxygen tubing. An observation and interview on 9/13/22 a 04:00 PM, with Resident #58 revealed a staff member had taped an O2 tubing storage bag on her oxygen concentrator today. The SA did observe the O2 tubing storage bag on the oxygen concentrator, but it was not labeled. There was not a date on the humidification bottle or the oxygen tubing. An observation and interview on 9/14/22 at 02:00 PM, with Licensed Practical Nurse (LPN)#5, revealed an O2 in use sign was placed on Resident #29's door when she replaced the humidifier bottle for Resident #29 and Resident #58 on 9/13/22. LPN #5 confirmed Resident #29's and Resident #58's O2 tubing and nasal cannula storage bag was not dated. LPN #5 noted she had not paid attention to there not being any labeling on the O2 tubing and the humidifier bottles and did realize the Resident #29 had not been given a storage bag as of 9/12/22. LPN #5 revealed the nurses are to place an O2 in Use signage outside residents' doors that are on O2 therapy, are to date the humidifier bottle, date the O2 tubing, and date the storage bags when replaced and this process should have been done for Resident #29 and Resident #58. An interview on 9/14/22 at 03:00 PM, with LPN #4, revealed residents on O2 therapy should have an Oxygen in Use sign on the outside of their door, the O2 tubing, humidifier bottle, and O2 tubing storage bag should be labeled. An interview on 9/14/22 at 03:30 PM, with the Director of Nursing (DON) revealed, the nurses were to place a Oxygen In Use sign on the outside of residents' doors who are on oxygen therapy, the humidifier bottle and the O2 tubing must be dated, and a storage bag should be provided for nasal cannula storage. The DON revealed she did not think the storage bag required labeling. An interview and O2 policy review on 9/14/22 at 3:50 PM, with the DON revealed, the O2 policy noted the oxygen tubing storage bags be labeled with the resident's name, date, and time. The DON confirmed the nurses should have followed the policy for Resident #29 and Resident #58 to ensure each staff member would know the date that the O2 tubing, humidifier bottles, and storage bag was changed to ensure the O2 supplies are changed as scheduled. An interview on 9/14/22 at 3:50 PM, with the Administrator (ADM) confirmed the Federal Regulations noted that the oxygen tubing and humidification bottles should be labeled and there should be a storage bag provided to the residents on oxygen therapy to store the oxygen tubing or masks when not in use. She also confirmed the nurses should have followed the O2 policy, should have provided Resident #29 with oxygen signage, should have dated the humidifier bottles, should have dated the O2 tubing, and should have provided and labeled storage bags for the oxygen tubing for Resident #29 and Resident #58, to ensure all nurses knew when the O2 supplies were last changed. Record review of the for Electronic Treatment Administration Records (ETAR) for Resident #29 and Resident #58 revealed Label and date tubing, store in plastic bag when not in use. Record review of the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Physician Orders List for Resident #29 revealed, Oxygen at 2 Liters via nasal cannula as needed for Shortness of Breath, dated 8/17/22. Record review of a quarterly Minimum Data Set (MDS) Assessment, with an ARD of 6/29/22 for Resident #29, revealed Resident #29 has a BIMS score of 14, indicating Resident #29 is cognitively intact. Record review of the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Physician's Orders List for Resident #58 revealed, Oxygen at 2 Liters per nasal cannula as needed for Shortness of Breath, dated 8/15/22. Record review of an annual MDS Assessment with an Assessment Reference Date (ARD) of 5/10/22 for Resident #58, revealed Resident #58 has a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #58 is cognitively intact.

Based on staff interview, record review, and facility policy review, it was determined the facility failed to develop a comprehensive care plan to address Resident #25's catheter tube positioning, for one (1) of three (3) residents reviewed for catheters, and Residents #12 and #51's use of side rails, for two (2) of four (4) residents reviewed for use of side rails. Resident #25 had an indwelling catheter and the comprehensive care plan did not include interventions to prevent trauma, and promote adequate drainage by ensuring the catheter tubing was positioned below the level of the bladder. Resident #12 and Resident #15 were care planned for he use of one (1) side rail; however, observations during the survey revealed the staff utilized two (2) full side rails for these residents. Findings include: Review of the facility's Comprehensive Care Clan policy, revised 08/2017, documented the care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. The overall care plan should be oriented towards: Managing risk factors to the extent possible. Applying current standards of practice in the care planning process. Further review of the policy revealed the facility staff shall follow the care plan. Resident #25 Review of Resident #25's Face Sheet, dated 06/05/19, revealed he had [DIAGNOSES REDACTED]. Review of Resident #25's most recent Minimum Data Set (MDS) Assessment, dated 03/11/19, revealed the resident had an indwelling catheter. Review of Resident #25's comprehensive care plan, dated 08/10/16, revealed Resident #25 had an indwelling catheter, and was at risk for urinary tract infections. The care plan did not address how the position of the catheter tubing must be maintained in order to ensure adequate urinary drainage. An observation, on 06/04/19 at 9:25 AM, revealed Resident #25 was in bed. Resident #25 had side rails on his bed. His catheter tubing was laying on top of the side rail, above the level of his bladder. An observation, on 06/05/19 at 8:38 AM, revealed Resident #25 was in bed, and the side rails were up. The resident's catheter tubing was on top of the side rail above the level of the bladder. Urine was in the tubing, but not draining into the catheter bag. An observation, on 06/05/19 at 4:20 PM, revealed Resident #25 was in bed with the side rails up. His catheter tubing was on top of the side rail, above the level of the bladder. In an interview, on 06/06/19 9:58 AM, Registered Nurse (RN) #21/MDS Coordinator, stated the MDS Coordinators update the residents' care plans. She said they will put changes into the care plan, and the Nursing Assistant's charting system. In an interview, on 06/06/19 at 10:53 AM, the Director of Nursing stated catheter tubing should be put under the side rail, below the level of the bladder. She said keeping the catheter below the level of the bladder should be in the care plan and on the Nursing Assistant's charting system. The facility failed to develop comprehensive care plan interventions that included the proper positioning of Resident #25's catheter tubing to promote drainage. Resident #12 Review of the care plan, dated 03/14/19, revealed Resident #12 required assistance with Activities of Daily Living (ADLs) as she was very confused and difficult to redirect at times related to [MEDICAL CONDITION]. The resident wandered in and out of rooms, and required redirection. The interventions included verbal cues as needed; no mechanical lift required; handheld or manual assist times one (1); and side rail up times one (1), initiated on 03/27/19. Review of Resident #12's clinical record documented the following [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) for Resident #12, dated 03/11/19, revealed the resident's Brief Interview for Mental Status (BIMS) score was 3, indicating severe cognitive impairment. The MDS revealed the resident required limited assistance with bed mobility, transfers, walking and locomotion and did not utilize a mobility device. Review of the Nurse's Note, dated 04/17/19 and timed 3:50 PM, revealed the side rails were up times two (2). Review of the Nurse's Note, dated 4/19/19 and timed 3:29 PM, revealed the side rails were up times two (2). An observation, on 06/3/19 at 10:04 AM revealed Resident #12 was in her room lying in bed with her eyes closed. The left side of the bed was against the wall, and two (2) full side rails were in the raised position. An observation, on 06/05/19 at 8:58 AM, 10:15 AM, 11:01 AM and 1:19 PM, revealed the resident was in her room, lying in bed with her eyes closed. The left side of the bed was against the wall, and two (2) full side rails were in the up position. An observation, on 06/06/19 at 9:01 AM, revealed the resident was in her room, lying in bed with her eyes closed. The bed was against the wall on the left side, and a three-fourth (¾) length side rail was in the raised position on the right side of the bed. An interview with Registered Nurse (RN) #21/MDS Nurse, on 06/06/19 at 10:49 AM, revealed the nurse who received the order was responsible for putting the order on the care plan in the resident's chart. The next day the MDS staff run a copy of all the orders, and add them to the care plan in the computer. At MDS time the MDS nurses compared the paper care plan with the computer care plan, and made updates as needed. RN #21/MDS Nurse said she was unaware the Resident #12 had bilateral full side rails, and the bilateral full side rails were not listed on the care plan. An interview with the Director of Nursing (DON), on 06/06/19 at 11:05 AM, revealed the MDS nurses revised the care plan when new orders were received. If a change in treatment that did not require a physician order [REDACTED]. The 24 Hour Report Book was reviewed in the morning meetings, and the MDS staff would then update the care plan in the computer. The DON also stated she was unaware the staff were using bilateral full side rails for this resident. The facility failed to follow the comprehensive care plan interventions for the use of side rails for Resident #12. Resident #51 Review of the care plan, updated 05/26/19, revealed the interventions for a side rail to be up times one (1) for bed mobility. The care plan did not reflect the size of the side rail to be utilized as indicated in the Device/Physical Restraint Consent. The care plan did not identify the use of two (2) full side rails as observed during the survey. Review of Resident #51's clinical record revealed the following Diagnoses: [REDACTED]. Review of Resident's #51 Admission Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. The resident required limited assistance with bed mobility, transfers, ambulation, and locomotion and did not utilize a mobility device. Review of the Nurse Data Collection and Screening last completed on 04/11/19, revealed under Restraint/Necessity/Positioning Device, the use of half bed rail, but did not specify the number of half bed rails. Review of the Device/Physical Restraint Consent, dated 05/26/19, revealed a consent for a reclining Geri-chair and a side rail times one (1). However, the consent form did not identify the type of side rail (i.e. half, three quarters, or full rail). An observation, on 06/05/19 at 9:00 AM, revealed the resident was not in her room, but the left side of her bed was against the wall and a full side rail was up on the left side of the bed, next to the wall. An observation, on 06/05/19 at 10:18 AM, 11:03 AM and 1:19 PM, revealed the resident was in her room lying in bed with the left side of the bed against the wall, and full side rails on both sides of the bed. An interview with Certified Nurse Aide (CNA) #14, on 06/06/19 at 12:16 PM, revealed Resident #51 does not have short-term memory loss, and does have some long-term memory loss. CNA #14 said we use full side rails for her to prevent her from getting out of bed. An interview with the Director of Nursing (DON), on 06/06/19 at 11:05 AM, revealed the DON was unaware the staff utilized bilateral full side rails for Resident #51. The facility failed to follow the comprehensive care plan interventions for the use of side rails for Resident #51.

Based on record review, staff interview, and facility policy review, it was determined the facility failed to review and revise Care Plans for two (2) of 20 sampled residents. (Resident #70 and Resident #80). Resident #70 was assessed to have a right-hand contracture and the resident's care plan was not revised to reflect the use of a right-hand splint to prevent further contractures. Resident #80's activity care plan was not revised to reflect the changes in the resident's activity preferences. Findings include: Review of the facility's Care Plan Policy, dated 06/2015, and revised 08/2017, revealed the facility shall develop and implement a Baseline Care Plan and Summary NS-813 for each resident that includes the instructions needed to provide effective and person centered care of the resident that meet professional standards of quality of care. The baseline care plan shall: - Be developed within 48 hours of resident's admission - Include the minimum healthcare information necessary to properly care for a resident immediately upon their admission, which address resident-specific health and safety concerns, including: - Initial goals based on admission orders [REDACTED] - Physician orders - Therapy orders The facility may develop a comprehensive care plan in place of the baseline care plan. The comprehensive care plan shall be completed within 48 hours of the resident admission an comply with all requirements of a comprehensive care plan according to the Resident Assessment Instrument (RAI) with the exception of completion within seven (7) days of the comprehensive assessment. A written summary of the comprehensive care plan must be provided to the resident and resident representative if applicable, and in a language that the resident/resident representative can understand. Review and revise the current care plan as needed in preventing avoidable declines in functioning or functional level. Resident #70 Review of Resident #70's plan of care, dated 11/15/18, revealed [MEDICAL CONDITION] affecting transfers, bed mobility, locomotion, eating, toileting, dressing, and personal hygiene. The resident required extensive assistance with all Activities of Daily Living. Therapy consult as needed. Further review of the resident's plan of care, dated 06/04/19, revealed limited range of motion in upper extremities related to stroke, splint device ordered for right hand to prevent further contracture. The resident's care plan was not revised to reflect the intervention for the hand splint device to prevent further decrease in limitation deficit until 12 days after the 05/23/19 physician's orders [REDACTED].>A review of the resident's Face Sheet revealed Resident #70 was admitted by the facility, on 05/05/17, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 04/23/19, revealed Resident #70 to have a Brief Interview Mental Status (BIMS) score of 8, which indicated moderate cognitive impairment. The resident was assessed not to resist or reject care and/or treatments. The assessment identified the resident as having Range of Motion (ROM) limitation impairment to the upper and lower extremities. It was identified no orthotics/prosthetics devices were used and the resident received Occupational Therapy three (3) days a week with start date 04/12/19 -05/16/19. Review of physician's orders [REDACTED]. Additional review revealed a physician's orders [REDACTED]. Review of the resident's skilled Occupational Therapy (OT) progress notes, dated 04/12/19- 05/2/19, revealed Resident #70 would demonstrate a reduction in gross physical/mobility of dysfunction to 50% via improvement in orthotic/splinting needs. Patient with slight contracture of third to fourth digit requiring and awaiting on resting hand splint. Review of skilled OT progress notes, dated 05/9/19-05/16/19, revealed Resident #70 would demonstrate a reduction in gross physical/mobility dysfunction to 75% via improvement in orthotic/splinting needs. Orthotic/splinting needs 75%. An interview was conducted, on 06/04/19 at approximately 3:00 PM, with Occupational Therapist (OT) #1, who provided skilled therapy services to Resident #70. OT #1 revealed Resident #70 was on the case load from 04/12/19-05/02/19. OT #1 confirmed Resident #70 did have some improvement, but required a hand splint for her right hand. OT #1 stated initially the request was for Resident #70 to wear the splint at night while sleeping, but the facility felt she should wear it during the day. OT #1 also said Resident #70 would remove the splint at times and the facility changed the order for the resident to wear the splint during the day. An interview conducted, on 06/05/19 at approximately 2:40 PM, with Certified Nursing Assistant (CNA) #2, revealed the resident required total care for all activities of daily living including feeding. CNA #1 confirmed she was aware of Resident #70's needs, and the resident was not care planned for a splint device. An interview was conducted, on 06/05/19 at 2:45 PM, with CNA #3. CNA #3 confirmed she overheard the Staffing Coordinator talking this morning about the resident needing a hand splint device. CNA #3 stated she tried looking for it, but could not find it. CNA #3 said the resident does not have a Care Plan for one, and she was not aware of the times Resident#70 was supposed to wear it. An interview conducted, on 06/06/19 at approximately 8:20 , with Minimum Data Set (MDS) Nurse #21, revealed when the initial order for the splint device is received, the nurse on that unit is responsible for placing it on the care plan. MDS Nurse #21 stated the MDS Nurse was responsible for placing the order in the computer system. MDS Nurse #21 confirmed the initial order for the splint device was not placed on the nurses' care plan until 06/04/19, but was placed on the smart chart under Resident #70's Activities of Daily Living Care plan. Resident #80 Review of Resident #80's care plan, updated 04/29/19, revealed the activity goal for the resident will be assisted to at least two (2) group activities weekly, and if the resident is not able to attend she will have room visits three (3) times a week. The interventions included post calendar in room; the resident was very forgetful, assist her to attend and participate as needed; encourage socialization and participation in groups; respect her rights to refuse activity participation and let her know that you will take her out of the activity when she is ready; walk and talk with her to and from activities; invite her to church, bingo, and group discussion; invite her to parties, and entertainment events; and invite her family/friends to attend selected activities with resident. Review of Resident #80's Significant Change MDS, dated [DATE], revealed the Brief Interview for Mental Status score 3, indicating severe cognitive impairment. The MDS revealed the resident's activity preferences included it was very important to listen to music she liked; be around animals such as pets; and do her favorite activities; it was somewhat important to do things with groups of people and participate in religious services or practices; and not very important to have books, newspapers, and magazines to read; keep up with the news; or go outside to get fresh air. Review of the Social Assessment, dated 04/29/19, revealed the resident enjoyed her realistic animals in her room; had good family support and Social Services would visit with the resident for social interactions and to see how she is doing. Review of the Activity Screening, dated 05/27/19, revealed Resident #80 had the interest of music, tv/radio, reading, enjoyed being outdoors, wished to attend group activities, required persuasion to attend activities, needed assistance to go to activities and to participate in the activities. The Activity Screening further revealed the resident was provided with in-room activities, enjoyed sitting in her room listening to the radio, rubbing on her companion pet cat, (stuff animals), and was assisted to out of room activities. An observation, on 06/03/19 at 10:07 AM, and 2:45 PM, revealed the resident sat in a chair in her room, with a hinged brace to her left elbow, and no activity offered. The resident's companion animals were on the end of her bed, out of reach of the resident. An observation, on 06/05/19 at 8:54 AM, 10:11 AM, 11:04 AM, and 1:17 PM, revealed the resident was in her room and no activity offered. The resident's companion animals were at the end of her bed. An observation, on 06/06/19 at 8:58 AM, revealed the door to the resident's room was closed. The resident was laying in the bed with no activity offered, and no staff in the room. The (MONTH) Activity Calendar was on the bulletin board behind the head of the bed. An interview with Registered Nurse (RN) #21/MDS Nurse, on 06/06/19 at 10:49 AM, revealed the Activity Department completed the activity portion of the care plan. An interview with the Activity Director (AD) #23, on 06/04/19 at 4:08 PM and 06/06/19 at 12:40 PM, revealed Resident #80's family wanted the resident to remain in her room. The AD further stated she talked with the resident about her family and the pictures on her walls, the resident liked listening to music and her companion cats, and she does the resident's nails. After reviewing the care plan, the AD stated the activity goals were not right for the resident at this time. The AD further stated the resident no longer went to church and did not include the music she liked and the companion animals she liked. She agreed the care plan needed to be revised. The facility failed to revise Resident #80's care plan to reflect her choice of activities.

Based on observation, record review, staff and physician interview, the facility failed to adequately assess the transfer needs for one (1) of three (3) Resident's reviewed. Resident #2 was hosptalized on [DATE] and had a [MEDICAL CONDITION] hip prosthesis to the left hip. Resident #2 returned to the facility on [DATE]. On 2/10/12, Resident #2's daughter asked the Physical Therapist Assistant to come to Resident #2's room because she was in pain. Resident #2 was noted to have an abnormal rotation of the resident's left hip. Resident #2 was transferred back to the hospital on [DATE] with a dislocation to the left hip. Findings include: Record review revealed that Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed that Resident #2 had a fall on 1/31/12 and sustained a left [MEDICAL CONDITION]. Resident #2 was admitted to the hospital and had a [MEDICAL CONDITION] hip prosthesis placed on her left hip. The resident returned to the facility on [DATE]. Review of the Nursing Notes dated 2/6/12 on the 3:00 p.m. to 11:00 p.m. shift revealed that Resident #2 returned to the facility and was in a gerichair. Review of the Nursing Notes dated 2/7/12 on the 7:00 a.m. to 3:00 p.m. shift revealed: "Legs continue to be stiff, grimacing when leg is moved. Requiires bed lift for transfer with 2+ staff members... in gerichair will cont (continue) to monitor." There was no documentation on the 3:00 p.m. to 11:00 p.m. shift of the exact time that Resident #2 was transferred to the bed. Review of the Nursing Notes dated 2/8/12 on the 7:00 a.m. to 3:00 p.m. shift revealed: "Resident (up) in gerichair. Dependent with transfers." "1:30 p.m. new order received from MD (Medical Doctor) to give [MEDICATION NAME] 5 mg q (every) 4 (hours) prn (as needed). There was no indication on the 3:00 p.m. to 11:00 p.m. shift as to when Resident #2 was placed back in the bed. Review of the Nursing Notes dated 2/9/12 revealed that at 2:00 p.m. revealed: "Tylenol 325 mg (2) (by mouth) given at 10:45 a.m. r/t (related to) (L) hip pain." "Leans to the (right) in gerichair." On the 3:00 - 11:00 p.m. shift there was documentation stating: "C/o (complains of) (L) hip pain given Lortaqb 5/500 (1) at 4:30 p.m." Review of the Nursing Notes dated 2/10/12 for the 7:00 a.m. to 3:00 p.m. shift revealed that Resident #2 was given [MEDICATION NAME] 5 mg at 9:25 a.m. Review of the Nursing Notes dated 2/18/12 at 4:40 p.m. stated: "Late entry for 9:30 a.m. PTA reported internal rotation noted to (L) hip and resident guarding hip, called (Name of Hospital), received return call around 11:30 a.m. On 2/10/12 at 2:45 p.m. revealed the Nursing Note stated that Resident #2 was transferred by ambulance to the hospital. A review of the "Operative Report" dated 2/11/12 stated, "Indications for procedure: The patient is an [AGE] year-old female who had a [MEDICAL CONDITION] hip prothesis placed on her left hip 8 days ago by my partner (Doctor's name). She was lifted with a Hoyer type lift at the nursing home in (city name) resulting in extreme flexion and abduction, and resulted in a hip dislocation as would be expected with this type of maneuver." A review of the "Lift Transfer Assistance Screening" form revealed that Resident #2 was screened for transfer needs on 2/7/12. Resident #2 was screened for the use of a total lift with manual assist of one (1) . The screening form failed to address the transfer needs for a resident with a hip replacement. On 4/25/12 at 3:35 p.m. an interview with the Physical Therapy Aid (PTA) revealed that on the afternoon of 2/9/12 at approximately 4:30 p.m., she was summoned by Resident #2's daughter that her mother was in extreme pain and would she come and check on her. The PTA stated when she got to the resident's room she noted the resident to be in severe pain and also noted the left leg had an abnormal internal rotation of the resident's left hip. The PTA stated she immediately notified the nursing staff. On 4/25/12 at 4:30 p.m. an interview with the DON revealed the resident had been screened for transfers on 2/7/12. The DON stated at the time of the screening the resident was unable to bare weight or follow directions. She felt the best method of transfer would be the total lift. She stated that since the return orders from the hospital did not specify any hip precautions, there should not have been a problem. She stated the facility follows the physician's recommendations for any precautions and since no precautions were ordered, the facility did not use hip precautions. On 4/26/12 at 10:30 a.m. an interview with CNA #1 revealed the CNA works the 3-11 shift. The CNA stated she did not remember using the lift when the resident returned from the hospital on [DATE] through 2/9/12. CNA #1 stated Resident #2 was always already in the bed when she came to work. The CNA stated she did not remember the resident calling out in pain during her shift. On 4/26/12 at 10:45 am an interview with CNA #2 stated she remembered Resident #2 had an abduction pillow sent back with the resident the second time she returned from the hospital. The CNA stated she works the 7-3 shift did not transfer the resident with the lift on her shifts. The CNA stated the therapy department were the ones to get the resident up. She stated the 7-3 shift always left the resident up in the gerichair during the day and the 3-11 shift put the resident back to bed. CNA #2 stated the resident always leaned to one side while in the gerichair so a lap tray was used. On 4/26/12 at 11:00 a.m. an interview with LPN #1 revealed when the resident was readmitted from the hospital on [DATE], the resident's husband brought wedge cushions from the hospital to use for positioning. LPN #1 stated the resident had been in a lot of pain on the 3-11 shift when she worked. The LPN stated she had medicated the resident for complaints of hip pain and bladder spasms. The LPN also stated she remembered the resident moved around in the bed a lot because the resident was uncomfortable. The LPN stated she does not rememberthe resident getting hurt by falling or anything else during that time. LPN #1 stated the resident was always in the bed when she arrived for work each day at 2:45 p.m. The LPN stated she usually started her rounds by 3:00 p.m. and Resident #2 room was the first room on her rounds. On 4/26/12 at 11:10 a.m. an interview with LPN #2 revealed she works the 7-3 shift. The LPN stated she did not have to medicate the resident for pain during her shift. She stated the resident had been confused and restless at timesand had been noted to put her legs over the side rails but not on a daily basis. LPN #2 stated she did not remember the resident getting hurt or having any accidents prior to the dislocation of the hip. She stated when she returned to work on 2/11/12, she was told the resident had been sent out due to her hip being internally rotated. She stated she was told this happened because the hospital did not send the resident back with an abduction pillow. On 4/26/12 at 12:55 p.m. an interview with LPN #3 revealed she had worked the 3-11 shift on 2/9/12. She stated when she had arrived to work Resident #2 was already in the bed. She stated the resident did not ask for a lot pain medication,and the resident did not seem confused. LPN #3 stated she did not remember the resident putting her legs over the side rails. The LPN stated she did not remember the resident having any accidents prior to the hip dislocation. On 4/26/12 at 1:20 p.m. an interview with LPN #4 revealed she had worked the 7-3 shift on 2/9/12. The LPN stated the resident was gotten up and sent to therapy. She did not recall how the resident was gotten up. She stated when she saw the resident she was already in the chair. She stated she did not remember what type of chair the resident was sitting in. The LPN also stated the resident seemed confused most of the time and complained a lot of pain. LPN #4 stated during the shift she worked on 2/9/12, she never noticed anything abnormal about Resident #2's left leg and/or hip. On 4/26/12 at 3:00 p.m. a second interview with the DON confirmed an interim care plan addressing Resident #2's [MEDICAL CONDITION] and replacement was not initiated on the resident's return to the facility on [DATE]. She stated the decision to use the total lift was made because the resident could not bare weight or follow directions. On 4/26/12 at 3:30 p.m. an interview with Resident #2's attending Physician revealed he did not recall any special hip precautions upon the resident's return to the facility on [DATE]. The Physician confirmed that taking care of a resident with a hip replacement would differ from care of a resident without a replacement. He stated recommendations change all the time with different Orthropedic Surgeons. The physician further confirmed the facility should have clarified what the surgeon wanted for his patient.