Every finding on record at Bedford Alzheimer's Care Center

Based on observation, staff interviews, and facility policy review, the facility failed to ensure that foods were stored safely by leaving food opened and exposed on the self, not dating foods with a use-by date, storing foods without an identifying label, and not discarding food items after their use-by date for one (1) of two (2) kitchen observations. Findings include: Record review of the facility's policy, Food Safety Requirements, revised [DATE], revealed, .Foods will be stored, in accordance with professional standards for service safety. Policy Interpretation and Implementation .3. c. iv. Labeling, dating and monitoring refrigerated food .so it is used by its use-by date .discarded, and .v. Keeping foods covered or in tight containers . An observation on [DATE] at 8:42 AM, of one of the refrigerators revealed (1) opened bag of lettuce, with the date [DATE] handwritten on the bag, with no indication that the date was a use-by or an opened-on date. There was (1) opened bag of lettuce-purple cabbage-carrot salad mix with an unreadable date handwritten on the bag. There was (1) opened bag of chocolate chip morsels with a date of [DATE] handwritten on the package with no indication if the date was a use-by or an opened-on date noted on the package. There was (1) opened bag of Monterey [NAME] cheese, with [DATE] handwritten on the package, with no indication if the date was a use-by or opened-on date noted on the package. There was (1) opened package of Swiss and American blend cheese slices, with a date of [DATE] handwritten on the package with no indication if the date was a use-by or opened-on date noted on the package. There was (1) gallon sized plastic storage bag containing 2 green bell pepper halves, one of the halves contained a nickel sized black spot with a white ring around the spot, a date of ,d+[DATE] was handwritten on the bag with no use-by or opened-on date noted on the package. There was one-half (,d+[DATE]) of a tomato wrapped in aluminum foil, with a yellow substance smeared on the inside of the foil, with no date written on the package. There were forty-two (42) one half (,d+[DATE]) cup sized packs of pre-sliced apples, stored in the original box, with a manufacturer's use thru date of [DATE]. The apple slices were brown and soft to the touch. An observation of the freezer revealed one opened plastic bag of tater tots with no date, (1) plastic bag of breaded okra with no date, one plastic bag containing 23 frozen pre-made omelets with a hand written date of ,d+[DATE], with no indication if the date was a use-by or opened-on date noted on the package. An observation of the pantry revealed (1) 16-ounce box of cornstarch, with the lid opened and the product exposed. There was also one (3.24)-pound carton of instant mashed potatoes opened and the contents exposed. On [DATE] at 8:42 AM, during an interview with the Dietary Manager (DM), she acknowledged there were expired foods, foods dated with no indication of what the date meant and opened, exposed foods on pantry shelves. The DM was unable to definitively state the meaning of the dated foods that did not indicate opened-on or use-by. The DM stated it is the responsibility of the staff who opens the food to date it properly. The DM commented the staff are in-serviced monthly on food safety. On [DATE] at 7:40 AM, during an interview with the Administrator, he acknowledged there were improperly stored, dated and exposed foods found in the kitchen. The Administrator stated the facility should not have expired foods, and that all foods should be sealed and dated. The Administrator stated the DM and the kitchen staff should routinely check food items at the beginning of the day.

Based on observation, interviews, record review, and facility policy review, the facility failed to protect residents' rights to be free from resident to resident physical abuse for four (4) of seven (7) sampled residents. Resident #1, Resident #2, Resident #3, and Resident #4. Resident #1 was initiated physical altercations on 12/9/23 and 12/19/23 which resulted in: a. Resident #1 receiving bruising and a skin tear. b. Resident #2 receiving bruising and skin discoloration under the right eye. c. Resident #3 receiving redness to her cheek. d. Resident #4 receiving bruising, skin tears, and a hematoma. Findings include: A review of the facility's policy Abuse Prevention Program, undated, revealed Our residents have the right to be free from abuse, neglect . This includes but is not limited to .physical abuse . As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to . other residents . Resident #2 Record review of the facility's investigation, dated 12/9/23 at 3:02 PM, revealed, Nursing Description: Observed resident (Resident #1) standing in another resident's room near doorway with face, shirt, and glasses wet .Injuries Observed at Time of Incident . (Resident #1) Bruise Right Forearm, Bruise Left Forearm, Skin Tear Left Elbow .Notes 12/17/2023 Resident #1 wandered into another resident room and . (Resident #2) was trying to force him out and began pulling on Resident #1 before she hit this resident and threw water on him. Record review of the Progress Notes, revealed a Nurses Note, for Resident #1, dated 12/9/23 at 3:19 PM, Resident #2 stated get out. Observed resident (Resident #1) standing in another resident's room hold his pants with wet shirt, face and glasses. Other resident (Resident #2) yelling at resident . Record review of the Progress Notes, revealed a Nurses Note, for Resident #2, dated 12/9/23 at 3:55 PM, .Observed resident #2 walking down the hallway towards her room, but then heard Resident #2 yelling get out and was pointing her finger towards Resident #1 stating again, Get out of here Resident #2 was bleeding from right middle finger and chin area .Resident #2 stated, I was trying to get that man out of a room because he has no business in her room .Resident #2 stated she did not know what happened to Resident #2's face and hand. Asked if she was hit by other resident or did she hit him. Resident #2stated, I might have hit him I can't remember, and he might hit me, I don't know . Record review of the Progress Notes, revealed a Nurses Note, for Resident #2, with an Effective Date of 12/10/23 at 6:17 AM, .Resident noted with bruising under right eye, just above right temple, a bandaid across right side of chin. When asked what happened resident stated it was Resident #1 the new man. Resident #2 stated she had follow Resident #1 into another female's room to get him to come out. Resident #2 stated they argued, then it came to blows. Resident #1 hit her and she hit him. At 8:15 PM on 12/27/23, during an observation and interview with Resident #2, she was sitting alone at a table. Observed red purple bruising discoloration under right eye and to cheek bone. Resident explained she was not exactly sure what happened between her and Resident #1 but when he popped her, she popped him back. She doesn't remember him coming into her room, but stated it would not surprise her that he did, because he walked around and went into everyone's rooms. A record review of the Admission Record revealed the facility admitted Resident #2 on 01/31/17 with a diagnoses that included Alzheimer's Disease. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/08/23 revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Resident #3 A record review of the facility's investigation, dated 12/9/23 at 9:10 PM, revealed, (Resident #1) was down at the end of the hallway exit seeking and trying to go into other residents rooms was trying to shove his way into a room and when other resident was trying to push door closed, Resident #1 turned around and hit Resident #3 in the face, on the left side . A record review of the Progress Notes revealed a Nurses Note, dated 12/9/23 at 10:40 PM for Resident #3, that read, Resident #3 was in her room, when Resident #1 came into her room. Resident #3 was trying to tell Resident #1 to get out of her room, she tried to close the door when Resident #1 swung and hit her in the face. Review of the Progress Note revealed Resident #3 was assessed and found redness to the left cheek, but resident denied pain. A record review of Resident #1's Progress Notes dated 12/09/23 10:46 PM revealed was verbally aggressive with staff and at times combative. Resident was attempting to enter the room of another resident (Resident #3) when he opened door other resident reached for door and yelled get out of my room and began to try to close the door, as Resident #3 was trying to push the door closed, Resident #1 turned around and hit Resident #3 in the face, on the left side on the cheek area. A record review of the Admission Record revealed the facility admitted Resident #3 on 10/06/22 with a diagnosis of Alzheimer's Disease. A record review of the Quarterly MDS, with an ARD of 11/08/23, revealed Resident #3 had a BIMS score of 10, which indicated her cognition was moderately impaired. On 12/27/23 at 7:45 PM, during an interview with Licensed Practical Nurse (LPN) #2, she explained Resident #1 was admitted with Alzheimer's and Dementia and was having a hard time adjusting to the new atmosphere. She stated she was working on the evening shift when Resident #1 had a physical altercation with Resident #3. She was on the phone with the Registered Nurse (RN) supervisor due to Resident #1 had been exhibiting physical aggression toward staff. Resident #1 was attempting to go into Resident #3's room, and a CNA was trying to redirect him. While the CNAs were getting Resident #1 out of the room, Resident #1 turned and hit Resident #3 on the side of the face. Resident #3 did have some redness only to her left cheek but nothing else. Resident #1 was placed on one-on-one (1:1) observation. At 8:10 PM on 12/27/23, during an observation and interview with Resident #3, she explained she doesn't remember the man or that he hit her. There were no bruises or discolorations observed on the resident's face. Resident #4 A record review of the facility's investigation, dated 12/19/23 at 9:45 PM, revealed, Resident went into room across the hall .found (Initials of Resident #1) on top of another resident (Resident #4) pulling his hair with his left hand and punching him in the neck with his right hand . Record review of the Progress Notes revealed a Skin Only Evaluation, dated 12/19/23 at 10:24 PM, revealed Resident #4 had a skin tear and bruising to the right forearm, bruising to the left forearm and elbow, a scratch to the upper back, redness to his head, and his right forearm had a hematoma. Skin note revealed, .Hematoma noted to right forearm. Knot noted next to area. A record review of Resident #1's Progress Notes dated 12/19/23 at 10:27 PM revealed . writer found resident on top of another resident (Resident #4) pulling his hair with his left hand and punching him in the neck with his right hand . at 10:45 PM resident was found in another resident room when tried to remove he punched the aide in the jaw . On 12/27/23 at 8:05 PM, during an interview with Certified Nurse Aide (CNA) #1, she explained she was working on the night Resident #1 had an altercation with Resident #4. She heard a nurse yelling for help, so herself and another CNA went down the hall and found Resident #1 in Resident #4's room. Both residents were locked together with Resident #1 on top of Resident #4, and Resident #1 was punching Resident #4. The staff separated them and Resident #1 hit staff members during the separation. A record review of the Admission Record revealed the facility admitted Resident #4 on 02/21/23 with a diagnoses that included Alzheimer's Disease. A record review of the Quarterly MDS with an ARD of 11/15/23 revealed Resident #4 had a BIMS score of 06, which indicated he had severe cognitive impairment. Resident #1 A record review of the Admission Record revealed the facility admitted Resident #1 on 11/28/23 with diagnoses of Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. A record review of the MDS, with an ARD of 12/4/23, revealed Resident #1 had a BIMS score of 01, which indicated he had severe cognitive impairment. Further review of record revealed he had Physical and Verbal behavioral symptoms directed towards others, his behavior impacted others, and exhibited Wandering behaviors that intruded on the privacy of others. At 7:30 PM on 12/27/23, during an interview with Licensed Practical Nurse (LPN)#1, she explained Resident #1 was sent out to Behavioral Unit on 12/21/23 and was no longer in the facility. She explained she never saw any physical incidents with Resident #1 with other residents, but he would go in and out of other resident's rooms cursing the other residents, which caused the residents to become uncomfortable. He would get aggressive towards staff and he was admitted to the facility because his wife could no longer handle him at home. At 10:45 AM on 12/28/23, during an interview with the Social Services Director (SSD), she explained she was aware that Resident #1 had some behaviors and she offered suggestions to the staff on how to manage those behaviors. The SSD did not have staff to sign an in-service related to her suggestions, she would pull them over to the side and talk to them. The SSD stated that the facility reviewed documentation in the morning meetings and interventions were discussed for Resident #1, including placing signs on the doors of the rooms Resident #1 would try to enter. However, the signs were not an effective intervention and Resident #1 continued to try to enter other resident's rooms. Resident #1 was referred to Mental Behavioral Health services, but he would not participate in the services. The SSD stated that many interventions were attempted, but most were not effective because Resident #1 was difficult to redirect. At 11:30 AM on 12/28/23, during an interview with the Director of Nursing (DON), she explained that Resident #1 had not been taking his medication at home and that he was placed in the facility so the staff could ensure he took his medications and manage his dementia because his wife was unable to get him to take his medications. She stated that although the staff would often provide 1:1 supervision, it was not a documented intervention until after the incident with Resident #4 on 12/19/23. She said that she expected 1:1 supervision to mean that the staff would get between Resident #1 and the residents' room doors and intervene before Resident #1 got into the rooms. She explained that the Psychiatric Nurse Practitioner (NP) visits the facility two times a month, but the facility's general NP visits the facility more often and had ordered medication changes for Resident #1. After the incident with Resident #4, the facility decided that Resident #1 would benefit from an inpatient behavioral health stay, and he was placed on 1:1 observation until he was able to be transferred. At 12:45 PM on 12/28/23, during an interview with the Administrator, he confirmed the facility was aware that Resident #1 would require an adjustment period after admission. He explained that he had provided education to the staff regarding how to successfully conduct 1:1 supervision and observation for Resident #1. He stated he would stay after hours with the staff on the Unit to demonstrate how to engage the resident and how to walk with him, keeping him out of other resident's rooms. He said that most of the time, Resident #1 would go to doors and just rattle the door handles. Sometimes he would go into other resident rooms and immediately turn around and walk out, and sometimes he would stay in the room longer. He explained that some staff were better at managing his behaviors than others. He had provided instructions on how to approach Resident #1 and if his behaviors were not bothering anyone, to let him be. The Administrator admitted there was no official in-service sign in sheet or documentation of the training that he provided that would indicate which staff received the training. After the incident between Resident #1 and Resident #4, extra staff were put on the schedule for 1:1 supervision until the resident could be transferred to a behavioral facility. The facility tried to let Resident #1 adjust to the new situation of being in a facility and had attempted medication changes to manage his behaviors.

Based on interviews, record review, and facility policy review, the facility failed to develop a baseline care plan within 48 hours that addressed safety concerns, identified the resident's need for supervision, or included behavioral interventions for a resident with behavioral aggression, for one (1) of seven (7) sampled residents. Resident #1. Resident #1 was involved in a physical altercations on 12/9/23 and 12/19/23 which resulted in: a. Resident #2 receiving bruising and skin discoloration under the right eye and bleeding to the right middle finger and chin area. b. Resident #3 receiving redness to her cheek. c. Resident #4 receiving bruising, skin tears, and a hematoma. Findings include: A record review of the facility's policy Baseline Care Plan, revised 11/06/23 revealed . The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Policy Explanation and Compliance Guidelines . 2 . b. Interventions shall be initiated that address the resident's current needs including i. Any health and safety concerns to prevent decline or injury . ii. Any identified needs for supervision, behavioral interventions . A record review of the Admission Record revealed the facility admitted Resident #1 on 11/28/23 with diagnoses of Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. A record review of the Baseline Careplan and Summary for Resident #1 revealed Admission: 11/2/2023. Review of Section 4. Dietary, Therapy and Social Services revealed . Section C. Social Services . 3. Behavioral Concerns Resident has potential to be verbally and physically aggressive . Signed by Social Services on 12/08/23 . The Baseline Care Plan did not include any interventions to address health and safety concerns to prevent injury and did not identify needs for supervision or behavioral interventions for Resident #1. At 3:30 PM on 12/28/23, during an interview with Licensed Practical Nurse (LPN) #1/Care Plan nurse, she explained the baseline care plans are completed within 48 hours and every department completed their own sections. The Social Services Director completed the Behavioral Section of the care plan and documents any interventions needed. At 4:15 PM on 12/28/23, during an interview with the Social Services Director (SSD), she explained she completed the Social Services portion of Resident #1's Baseline Care Plan and confirmed the date completed was 12/08/23. The SSD stated that the Baseline Care Plan was based off the resident's history and life story and was a User Defined Assessment (UDA) in the computer software. She stated there was nowhere on the UDA to input interventions for resident behaviors, but there was an area to input concerns. At 4:45 PM on 12/28/23, during an interview with the Administrator and the Director of Nursing (DON), they both explained they thought the Baseline Care Plan included everything, including interventions, to care for the resident and they were not aware that it did not include interventions that addressed the resident's current needs including any identified needs for supervision or behavioral interventions. Resident #2 Record review of the Facility Investigation dated 12/9/23 at 3:02 PM, revealed Resident #1 was found standing in another resident's room near the doorway. Resident #2 attempted to remove Resident #1 from the other resident's room by pulling on him and threw water on his face, shirt and glasses causing Resident #1 to sustain bruising on his right and left forearm and a skin tear to his left elbow. Resident #2 had bleeding to the right middle finger and chin area. Resident #3 Record review of the Facility Investigation dated 12/9/23 at 9:10 PM, revealed Resident #1 was attempting entry into Resident #3's room while she was trying to prevent it by pushing on the door. Resident #1 turned around and hit Resident #3 in the face on the left side, receiving redness to her cheek. Resident #4 Record review of the Facility Investigation dated 12/19/23 at 9:45 PM, revealed Resident #1 was found in Resident #4's room, on top of Resident #4, punching him in the neck with his right hand and pulling his hair with his left hand. Resident #4 received a hematoma to the right forearm, a skin tear and bruising to the right and left forearm and elbow, a scratch to the upper back, and redness to his head.

Based on staff interview, record review, and facility policy review, the facility failed to notify the family, in writing, of the reason residents were sent to an acute hospital for two (2) of two (2) resident hospitalization s, Resident #47 and Resident #60. Findings Include: The facility failed to provide a policy/protocol for written notice of transfer. During an interview on 10/03/19 at 09:41 AM, the Administrator stated the facility does not have a policy regarding notification of transfers. Resident #47 Review of Resident #47 Nurse's Notes, dated 6/17/2019, revealed Resident #47 was admitted to the hospital, and a bed hold notice was provided, however, there was no written notification to the resident representative of the reason for the transfer. During an interview on 10/02/19 at 03:08 PM, Licensed Practical Nurse (LPN) #2 stated Resident #47 was sent to the hospital, due to altered mental status on 6/17/2019. Resident #60 Record Review of the facility's Bed Hold Report revealed Resident #60 was admitted to the hospital on [DATE], 3/29/19, 7/1/19, and 7/17/19. Bed hold letters and letters to the Ombudsmen were completed, however, the facility failed to notify the resident representative, in writing, the reason Resident #60 was sent to the hospital. During an interview on 10/02/19 at 04:27 PM, LPN #2 revealed Resident #60 had problems with swallowing and was sent to the hospital for evaluation and feeding tube placement. During an interview on 10/03/19 at 9:14 AM, the Director of Nursing (DON) confirmed the the family was not notified, in writing, of the reason the residents were sent to the hospital. The DON said her interpretation of the regulation was the facility should notify the family in writing that the resident went to the hospital or left the facility; not the reason the resident went to the hospital.

Based on record review, facility policy review, and staff interview, the facility failed to accurately reflect the resident's status on the Minimum Data Set (MDS) for two (2) of 26 MDS(s) reviewed for accuracy, Resident #31 and Resident #51. Findings include: Review of the facility policy entitled, Resident Assessment Instrument, dated (MONTH) 2019, revealed that it is the policy of this facility that a comprehensive assessment of a resident's needs shall be made upon the resident's admission and periodically as mandated by the Omnibus Budget Reconciliation Act (OBRA) and Medicare guidelines. The facility policy noted that the Nursing department will be responsible for completing and entering section(s) A, G, GG, H, I, J, L, M, N, O, P, S, V, and Z of the Minimum Data Set (MDS) into the computer system. The facility policy noted that any flags for this MDS section will be reviewed and resolved prior to submission of the MDS, to ensure accuracy of the MDS. The facility policy also noted that all persons who have completed any portion of the MDS Resident Assessment Form MUST sign such document attesting to the accuracy of such information. Resident #31 Review of Resident #31's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/20/2019, revealed in Section I4200, [MEDICAL CONDITION] is not checked as an active [DIAGNOSES REDACTED]. However, Resident #31's medical records document, [DIAGNOSES REDACTED].#31 had a [DIAGNOSES REDACTED]. During an interview, on 10/2/2019 at 9:47 AM, the facility's Director of Nursing (DON) revealed that the MDS for Resident #31 was not coded correctly on the [DIAGNOSES REDACTED]. During an interview, on 10/2/2019 at 9:51 AM, Licensed Practical Nurse (LPN) #1/ MDS Coordinator, confirmed that the MDS for Resident #31 was not coded for the [DIAGNOSES REDACTED].#1 stated that Resident #31 does have the [DIAGNOSES REDACTED]. Resident #51 Review of Resident #51's Significant Change MDS, with an ARD of 9/3/2019, revealed that Section A1500 should have been coded as to indicate one (1) Yes for the Preadmission Screening and Resident Review (PASRR); and section A1510 should have been coded as to indicate that Resident #51 had a Serious Mental Illness, as evidenced by the active [DIAGNOSES REDACTED]. Review of Resident #51's medical records document, [DIAGNOSES REDACTED].#51 had [DIAGNOSES REDACTED]. Review of Resident #51's, Mississippi PASRR Level II Change in Status Request, dated 1/4/2019, revealed that Resident #51 was previously evaluated through Pre-Admission Screening and Resident Review (PASRR) on 2/18/2016. The document revealed that a PASRR Level II change in status request was being made, due to an increase in behavioral, psychiatric, or mood-related symptoms. The document revealed in Section C that there is a known mental illness. The document revealed that Resident #51 had the following two (2) Major Mental Illnesses: [MEDICAL CONDITION] and Delusional Disorder. The document also revealed that the resident has the following mental disorder: Depression. During an interview, on 10/2/2019 at 9:47 AM, the DON confirmed the PASARR Level II for Resident #51 was completed on 2/22/2016, and the Resident #51 was approved for Long Term Care (LTC) with written notification from the state designated authority. During an interview, on 10/2/2019 at 9:51 AM, LPN #1/ MDS Coordinator, confirmed that the Significant Change MDS with an ARD of 9/3/2019, was coded incorrectly. She stated Resident #51 did have a Level II PASRR completed and did have mental illness diagnoses. LPN #1 stated that she thought that Sections A1500 and A1510 only had to be addressed one time, and that the PASARR would only be coded one time, and that would be on the first comprehensive MDS.

Based on record review, staff interview, and policy review, the facility failed to refer residents to the appropriate state designated authority for Level II Preadmission Screening and Resident Review (PASARR) for two (2) of 24 sampled resident's reviewed for Preadmission Screening and Resident Review (PASARR), Resident #11 and Resident #27. Findings include: Review of the facility's Admission Criteria policy, revised (MONTH) 2019, Resident #11 The facility admitted Resident #11 on 10/23/2013, with [DIAGNOSES REDACTED]. The facility completed the Preadmission Screening and Resident Review (PASARR) on 10/18/2013. The facility failed to refer Resident #11 to the appropriate state designated authority for Preadmission Screening and Resident Review PASARR Level II, related to the [MEDICAL CONDITION] Disorder. Review of Resident #11's Annual Minimum Data Set Date (MDS), with the Assessment Reference Date (ARD) date of 7/23/2019, revealed Resident #11 was coded for a [DIAGNOSES REDACTED]. Resident #27 The facility admitted Resident #27 on 11/6/2017, with [DIAGNOSES REDACTED]. The facility completed the PASARR on 11/6/2017. The facility failed to refer Resident #27 to the appropriate state designated authority for Preadmission Screening and Resident Review PASARR Level II. Review of Resident #27's Annual MDS, with an ARD of 8/13/2019, coded Resident #27 as having a [DIAGNOSES REDACTED]. During an interview on 10/2/2019 at 2:39 PM, Social Worker #1, stated, There are no Level II's because they were taught in training if they had a [DIAGNOSES REDACTED].

Based on record review, staff interview and policy review, the facility failed to draw labs, diagnostic services, as ordered by the physician for one (1) of 14 residents reviewed (Resident #4). Findings include: Review of the facility's Diagnostic Services policy, dated January 2017, noted, 3. Orders for diagnostic services will be promptly carried out as instructed by the physician's orders [REDACTED]. Review of the facility's physician's orders [REDACTED]. Physician orders [REDACTED]. Review of Resident #4's March 2017 physician's orders [REDACTED]. Record review revealed documentation of labs for BMPs collected on 5/6/16 and 9/14/16 for Resident #4. There was no documentation of the BMP being drawn every three (3) months per the physician's orders [REDACTED].>Interview on 3/15/17 at 4:08 PM, with the Director of Nursing, revealed labs were drawn on 5/6/16 and 9/4/16 for Resident #4 and stated We missed it. It should have been dc'd (discontinued) on the day of admission. The DON stated that no other labs were drawn since the resident was not on any medication that required a BMP to be drawn. Interview on 3/16/17 at 4:18 PM, with the Administrator, confirmed Resident #4's labs were not drawn every three (3) months per the physician's orders [REDACTED]. Record review revealed the facility admitted Resident #4 on 3/21/16, with [DIAGNOSES REDACTED].

Based on staff interview, record review, and facility policy review, the facility failed to obtain a clear criminal background check and document the State Abuse Registry's findings timely for one (1) of five (5) new hire personnel records reviewed. Employee #5. Findings Include: A review of the Policies and Procedures for Prevention, Investigation and Reporting of Abuse policy, dated 01/31/2005, revealed it is the policy of the facility to conduct a criminal record check according to the state law as part of the hiring process. The State Abuse Registry(s) will be checked upon hire and again in four (4) months after hire with the findings documented. A review of Employee #5's personnel record revealed the employee was hired on 10/12/2016, as a full-time Licensed Practical Nurse (LPN). The LPN's time card record shows a total of 810.95 working hours from 12/12/2016 through 03/13/2017. A review of the letter from Mississippi Department of Health (MSDH) Criminal History Record Check Unit dated 12/22/2016, revealed that the fingerprints of Employee #5 failed to meet quality standard and have been rejected by the Federal Bureau of Investigation (FBI). The letter requested that the employee be re-fingerprinted and the results be re-submitted for processing. There was no documented evidence of a State Abuse Registry finding for Employee #5. An interview on 03/16/2017 at 10:00 AM, with the Business Office Manager (BOM), confirmed that Employee #5 had been employed at the facility since 10/12/2016, and had been notified of the results of the fingerprint failure from MSDH. The BOM stated she had attached an interoffice memorandum, dated 01/06/2017, to the employee's payroll check stub for her first payroll check in January 2017. The BOM stated she was aware the employee had not had her fingerprints re-printed and re-submitted to MSDH as of this interview. During an interview on 03/16/2017 at 10:10 AM, with the Administrator (ADM), it was confirmed the facility had received a letter from MSDH that Employee #5's fingerprints failed to meet quality standards and had been rejected. The letter stated a need to be re-fingerprinted and the results to be re-submitted. The ADM confirmed that Employee #5 had been employed since 10/12/2016, and had not completed the screening portion and criminal background check of the new hire policy. The ADM stated a second letter of notification had been sent to the employee on 03/15/2017, notifying the employee of the need to re-fingerprinted and that it must be done no later than 03/24/2017. The ADM stated It had been overlooked but we are in the process of having the employee come in as soon as possible (ASAP) and be re-fingerprinted. The ADM stated that the employee was informed that the failure to do so will result in further disciplinary action leading up to and including termination.

Based on staff interview, record review, and facility policy review the facility failed to assure labs were obtained only when ordered by the physician for one (1) of seven (7) records reviewed for labs. (Resident #3) Findings include: A review of the facility's policy entitled, "Diagnostic Services", dated January 2013, indicated all diagnostic services must be ordered by a physician. Resident #3 Record review for Resident #3 revealed there was no physician's order for the laboratory test Lipoprotein obtained on 4/4/14 with the reported result on 4/6/14. A review of the "Laboratory Requisition Form" for the date of 4/4/14 revealed only a Sodium level was ordered for Resident #3. The facility indicated by checkmark Sodium and handwritten, "Serum Sodium", with the [DIAGNOSES REDACTED]. In an interview on 7/30/14 at 4:10 PM with Registered Nurse (RN) #1 confirmed the lab had reported a result for a Lipoprotein on 4/6/14 that had not been ordered by Resident #3's physician. RN #1 confirmed the facility had not identified this lab result had not been ordered until notified by the State Agency (SA). A signed statement dated 7/30/14 at 4:25 PM by RN #1 confirmed the above findings. On 7/31/14 at 9:10 AM, an interview with the Director of Nursing (DON) confirmed there was no physician's orders for the Lipoprotein that was reported for Resident #3 on 4/6/14. He stated all labs are checked against the orders when they are reported and "this one must have fell through the cracks". A review of a signed statement, with the reference date of 7/30/14, by the providing laboratory services indicated a processing error was made on 4/4/14 for Resident #3 and the Lipoprotein test was ordered in error and the charge for the test was credited for the resident. Review of Resident #3's Face Sheet revealed the facility admitted Resident #3 on 2/7/2012 with the [DIAGNOSES REDACTED]. Review of Resident #3's Quarterly Minimum Data Set (MDS), with the Assessment Reference Date of 5/26/14, revealed the Brief Interview For Mental Status (BIMS) score of two (2) that indicated severe cognitive impairment.

Based on observation, interview, record review, and facility policy review, the facility failed to assure a physician's order for the medication, [MEDICATION NAME], contained the frequency of administration for (1) one of eight (8) records reviewed (Resident #12). Findings include: Review of facility's policy entitled "Administering Medications", revision date 01/14, documented, "Medications shall be administered in a safe and timely manner, and as prescribed. Medications must be administered in accordance with the orders, including any required time frame". Review of Resident #2's printed compiled physicians order's for June and July 2014 contained a physicians order, dated 04/29/14, that read "[MEDICATION NAME] 2 Mg/ML Sol (give 0.5 mg equals 0.25 ml sol) intramuscular. This order failed to inform the caregiver how often(frequency) the medication was to be administered. Review of Resident #2's Physicians Orders, dated 09/30/13, revealed a hand written entry that read "[MEDICATION NAME] 0.5 mg PO/IM Q 6 hours PRN" ([MEDICATION NAME] one half milligram by mouth or intramuscular injection every six (6) hours as needed). During an interview on 09/31/14 at 3:17 PM, License Practical Nurse (LPN) #1 confirmed the order was incomplete because it did not contain a frequency to instruct the caregiver how often the medication should be administered. She stated the original order had to be broken down into two separate orders because the order contained two routes of medication administration. The mistake was made while typing the order in the computer.

Based on observation, staff interview, record review and policy review, the facility failed to properly post the current date for daily staffing information for one (1) of two (2) days of the survey. Findings include: Observation on 08/15/13 at 9:05 a.m. revealed that the daily Nurse staff information revealed the following information: "(Facility Name) today's date, 8/14/13, today's census-20. Shift, DAY SHIFT Time 7AM to 3PM Registered Nurses: 1, Licensed Practical Nurses/Licensed Vocational Nurses: 1, Certified Nurse Aides: 3. EVENING SHIFT: Time: 3PM to 11PM Registered Nurses: 0, Licensed Practical Nurses/Licensed Vocational Nurses: 1, Certified Nurse Aides: 3. NIGHT SHIFT: Time: 11PM to 7AM Registered Nurses: 0, Licensed Practical Nurses/Licensed Vocational Nurses: 1, Certified Nurse Aides 2." Staff interview with the Director of Nursing (DON) on 08/15/13 at 1:45 p.m. confirmed the aforementioned findings. The (DON) posted the correct daily staffing for 08/15/13. Review of the facility's policy entitled "Posting Direct Care Daily Staffing Numbers", with a revision date of January 2013, revealed the following: "Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents."

Based on observation, staff interview, record review and policy review, the facility failed to correctly implement a plan of care for one (1) of eight (8) residents reviewed (Resident #3). Findings include: Resident #3 A Significant change in status assessment Minimum Data Set (MDS), with a reference date of 5/13/13, indicated that Resident #3 reentered the facility on 4/25/12 with the [DIAGNOSES REDACTED]. This assessment documented the Brief Interview for Mental Status (BIMS) score of 03, indicating that Resident #3 was severely cognitively impaired. Observation during incontinent care on 8/16/13 at 8:35 a.m. for Resident #3, Certified Nursing Assistant (CNA) #1 wiped from the top downward instead of from the anal area upward on the right and left buttock using a new cloth with each side and changing gloves between sides and applied protective cream to right and left buttock from top to bottom instead of from the anal area upward and changed gloves between sides. Interview on 8/16/13 at 8:50 a.m. with CNA #1, stated if she could have done anything different during incontinent care of Resident #3, "I would not have wiped from top to bottom when I turned her over and wiped her bottom." Record review of Resident #3' care plan, dated 2/7/13, with the identified problem: Has history of UTI with a goal dated 2/7/13 did not address incontinence of urine and/or perineal care. Record review of Resident #3's care plan, dated 5/20/13, with the identified problem: Resident is at risk for skin impairment related to incontinent episodes of bladder and thin fragile skin, 6/14/13 wound right great toe. This care plan listed as an intervention, dated 5/20/13, incontinent care after each incontinent episode and as needed. A problem, dated 2/7/13, Resident at risk for decline in activities of daily living function related to short term memory/long term memory decision making impaired, resident is at risk for further decline related to the [DIAGNOSES REDACTED]. Dated 2/7/13 the interventions listed, to check every two hours and as needed for incontinent episodes with incontinent care after each incontinent episode and as needed. Review of the facility's policy entitled "Perineal Care", dated May 2012, noted: "(10). (e). Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks." Review of the Mississippi Nurse Aide Candidate Handbook, dated January 2011, noted "Provides perineal care (peri-care) for female, (11). After washing genital area, turns to side, then washes and rinses rectal area moving from the front to back using a clean area of washcloth for each stroke. Dries with towel."

Based on observation, staff interview and facility policy review, the facility failed to maintain infection control procedures by laying the accuchek machine on the unclean medicine cart, then laying it on the unclean bedside table. The facility also failed to do appropriate handwashing during administration of eye drops for two (2) of seven(7) residents reviewed (Residents #6 and #7). An observation of the 9-9-12 night medication pass at 6:35 p.m. revealed Licensed Practical Nurse #1 took the accuchek machine out of the medication cart and cleaned the machine with an antimicrobial wipe. Then she laid it on the unclean medication cart. Then she got all her equipment together and we (LPN #1 and surveyor) entered Resident #6's room. Then LPN #1 laid the accuchek machine on the unclean bedside table without a barrier. After checking the blood sugar she left the room and again placed the unclean machine on the medication cart without a barrier on the cart. An observation on 9-9-12 at 6:55 p.m. revealed LPN #1 put on gloves without washing her hands or using hand sanitizer. She then took the top off the eye drop medication bottle and laid it on the unclean bedside table without placing a barrier down. After administering the first eye drop, Pantonol 0.1%, one (1) drop in each eye, she did change gloves but did not wash her hands. Then she replaced the top back on the eye drop medication bottle. Then she washed her hands and put on gloves for the second eye drop, [MEDICATION NAME] eye drop, one (1) drop each eye. She removed the top and laid it on the same unclean bedside table. She administered both drops then put the top back on the eye drop medication bottle. A review of the hand washing/hand hygiene policy states: #8. The use of gloves does not replace Handwashing/hand hygiene. A staff interview on 9-9-12 at 6:55 p.m., revealed to LPN #1 the infection control practices that were not followed and she stated, "Ok, I should have put down paper towels."

Based on observation, staff interview and policy review, the facility failed to maintain housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior in four(4)of 20 resident rooms and one (1) of one (1) common linen area. Findings include: An initial tour of the facility was conducted on 9/9/12 from 5:15 p.m. to 5:35 p.m.; and a second tour was conducted on 9/10/12 from 10:40 a.m. to 11:10 a.m. with RN #1 revealing the following concerns: Room 107 - The paint was chipped on the entrance door to the resident's room. There was a stained ceiling tile in the bathroom. Room 109 - There was no name to identify the owner of denture cup for A-bed. There was a black discoloration noted at the toilet base in bathroom. There was brown discoloration noted at the bottom of the door frame to the bathroom. The footboard on B-bed was scuffed. Room 111 - There was no name to identify the owner of denture cup for A-bed. Room 117 - The paint was chipped on the entrance door to the resident's room. Clean Linen Closet - There were two (2) discolored sheets noted and two (2) pads with torn, frayed edges. On 9/10/12 at 4:10 p.m. in an interview with the Administrator, the policy for cleaning and maintenance of the facility was requested. On 9/10/12 at 4:25 p.m. an interview with the Maintenance Director was conducted and the findings of the environment of care rounds were discussed and reviewed in entirety. The Surveyor asked the Maintenance Director what the facility's policy was for identifying repair needs and he stated, they have a Maintenance Request Log at each nursing station for the staff to log repairs and they check the logs twice daily. He stated, they prioritize as related to resident care needs. On 9/10/12 at 5:10 p.m., review of the facility's policy for "Facility Practice Regarding Building Maintenance" revealed the following: "1. Immediate need issues are addressed by phoning or paging the Maintenance Director. 2. Routine maintenance concerns are logged on the Maintenance Log located on a clip board kept at the nurses station. 3. The Maintenance Director will address the issue and then note the completion of the task on the log. "

Based on observation, facility policy and staff interview, the facility failed to promote resident's dignity by giving medications while resident was eating breakfast. Unsampled Resident "A". An observation of the morning medication pass and meal observation on 9-10-12 revealed LPN #2 giving medications to Unsampled Resident "A" at 7:25 a.m. The resident was eating her breakfast and LPN #2 interrupted breakfast to give nine (9) pills and two (2) liquids to the resident. A staff interview with LPN #2 at 12:30 p.m. on 9-10-12 revealed, "I usually give the medications before or after breakfast but yeah, usually I give while they are eating." A Staff interview with the Director of Nurses on 9-10-12 at 1:00 p.m. revealed, "If we didn't give medications while they are eating we would be out of our time frame because as you saw our residents take a long time to eat. We don't have a policy that says don't give with meals, we give as ordered." A review of the Quality of Life-Dignity facility's policy reveals: Each resident shall be cared for in a manner that promotes and enhance quality of life, dignity, respect and individuality.

Based on record review, policy review and staff interview, the facility failed to properly screen employees for a history of abuse/neglect and mistreatment as required by the state agency through background check for one (1) of five (5) new hires reviewed (Employee #4). Findings include: Review of new hire packets on 9/10/12 reviewed Employee #4 was hired on 1/24/12 and did not have a criminal history background check or clearance letter in the file. Interview on 8/10/12 at 4:25 p.m. with the Administrator revealed that Employee #4 did not have a clearance letter from the state agency prior to hire as policy required. Review of facility's "Abuse and/or Neglect Prevention Plan", noted, "The following will be completed and documented with each prospective employee prior to employment: Fingerprints and criminal background check."