Every finding on record at Forrest General Hospital Skilled Nursing Unit

Based on observation, interviews, and record review, the facility failed to follow appropriate infection prevention practices by not ensuring oxygen tubing was stored in a clean and sanitary manner when not in use for one (1) of two (2) residents reviewed for oxygen therapy, Resident #140. Findings Included: On 05/05/25 at 11:29 AM, during an observation and interview, Resident #140 was lying in bed. There was a nasal cannula (NC) and oxygen tubing wrapped around the side rail. Resident #140 stated that she usually wears oxygen at night, and sometimes during the day if she needs it. She confirmed that she had wrapped the NC and oxygen tubing around the side rail because she did not want it to fall to the floor. There was no bag available to place the tubing in while it was not in use. On 05/06/25 at 10:55 AM, during an observation and interview with Registered Nurse (RN) #1, Resident #140 was observed lying in bed with the NC and oxygen tubing resting on the floor. RN #1 stated that when oxygen is not in use, the NC and tubing should be stored in a clean plastic bag and kept within reach of the resident. She confirmed there was no plastic bag available in the resident's room for proper storage and acknowledged the tubing was not stored according to infection control standards. RN #1 immediately retrieved the tubing from the floor, discarded it, and stated she would replace it with a new NC and tubing. On 05/06/25 at 11:10 AM, during an interview with the Director of Nursing (DON) and the Administrator, the DON explained that the Respiratory Therapy department provides drawstring plastic bags for residents to store their oxygen tubing when not in use. She stated the tubing should be placed in the bags and stored in a wire basket mounted on the wall above the resident's bed. The DON confirmed that Resident #140 did not have a storage bag available at the bedside and stated she would ensure one was provided. She further acknowledged that the facility did not have a specific policy addressing the storage of nasal cannulas or oxygen tubing as it relates to infection control. A record review of the facility's Patient Information document revealed Resident #140 was admitted by the facility on 5/1/25 with current diagnoses including Right Total Knee Arthroplasty. A record review of the Assessment and Plan, dated 5/1/25, revealed a Physician's Order for Oxygen three (3) liters nightly and as needed.

Based on staff interview, record review, and the facility policy review, the facility failed to electronically submit a discharge Minimum Data Set (MDS) assessment for three (3) of 20 sampled residents. Resident #3, Resident #13, and Resident #15. Findings Include: Record review of the facility's Skilled Nursing Unit Policy, undated, revealed, .F640 Automated data processing requirement .Transmitting Data .2. Within 14 days after the SNU (Skilled Nursing Unit) completes a resident's assessment, the SNU electronically transmits encoded, accurate, and complete MDS data . Resident #3 Record review of the resident information document revealed the facility admitted Resident #3 on 07/05/23. Record review of the facility's After Visit Summary revealed Resident #3 was discharged from the facility on 7/19/23. Review of the medical record revealed there was no Discharge MDS completed or submitted for Resident #3. Resident #13 Record review of the resident information document revealed the facility admitted Resident #13 on 6/24/23. Record review of the After Visit Summary revealed Resident #13 was discharged from the facility on 7/13/23. Review of the medical record revealed there was no Discharge MDS completed or submitted for Resident #13. Resident #15 Record review of the resident information document revealed the facility admitted Resident #15 on 6/28/23. Record review of the After Visit Summary revealed Resident #15 was discharged on [DATE]. Review of the medical record revealed there was no Discharge MDS completed or submitted for Resident #15. During an interview on 11/21/23 at 1:30 PM, with Registered Nurse (RN)#1, she confirmed the discharge assessments for Residents #3, #13 and #15 were not submitted in the last 120 days. RN #1 said she had just started as the MDS nurse and did not realize those residents' discharge assessments were due. RN #1 confirmed Resident #3's Discharge MDS Assessment was due 8/2/23, Resident #13's was due 7/27/23, and Resident #15's was due 8/2/23. She stated the Discharge assessments are due within 14 days after the resident's discharge date from the facility. During an interview on 11/21/23 at 1:45 PM, with the Director of Nursing (DON), she confirmed that Residents #3, #13 and #15 Discharge MDS assessments were not submitted in a timely manner. The DON said she expected the assessments to be completed and submitted 14 days after the residents are discharged . The DON explained that she was not working at the facility at that time and was unaware the Discharge MDS Assessments were not completed and submitted. An interview on 11/21/23 at 2:00 PM, with the Administrator, confirmed the Discharge MDS assessments were not submitted in a timely manner. The Administrator said those assessments occurred during a transition when the care plan nurse and the MDS nurse changed responsibilities and the nurses should have communicated to prevent the assessments from being missed. 41680

Based on observations, interviews, record review, and facility policy review, the facility staff failed to perform hand hygiene after glove removal during medication administration for one (1) of seven (7) medication administration observations. Resident #125. Findings Include: Review of the facility's policy, undated, Section: QM-Infection Prevention and Control, Hand Hygiene, Fingernails and Gloves, revealed, .Healthcare Workers will use waterless alcohol hand rub to clean their hands .Before donning gloves and after removing gloves .Healthcare Workers will follow these glove guidelines: .Perform hand hygiene immediately after glove removal . On 6/1/22 at 9:35 AM, the State Agency (SA) observed Licensed Practical Nurse (LPN) #1 during medication administration for Resident #125. LPN #1 removed a topical patch from Resident #125's left knee while wearing gloves. She removed and discarded the gloves and donned a clean pair of gloves without washing or sanitizing her hands. On 6/1/22 at 9:42 AM, in an interview with LPN #1, she confirmed she should have sanitized her hands after removing her gloves and her actions was an infection control issue because she could spread infection by not washing her hands. On 06/02/22 02:06 PM, in an interview with the Director of Nursing (DON), she confirmed the nurse should have used hand sanitizer after she removed her gloves and before applying clean gloves and the nurse's actions could spread infection. On 6/2/22 at 2:15 PM, in an interview with the Administrator, she stated LPN #1 should have sanitized her hands before applying new gloves and there was potential of spreading infection. A record review of Resident #125's Face Sheet revealed an Encounter Date (admitted ) of 5/28/22 with a medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on interview, record review and facility policy review the facility failed to accurately document on the discharge Minimum Data Set (MDS) for Resident #12 for one (1) of 11 records reviewed. (Resident #12) Findings include: Review of the facility's policy, Skilled Nursing Unit, undated, revealed the facility assessments will be signed by the health care participants to certify the accuracy of their portion of the assessment. Assessments are to be completed timely and accurately. Record review revealed Resident # 12 was discharged home with Home Health on 4/13/19. A review of the Discharge Assessment with the Assessment Reference Date of 4/17/19, noted in Section A that this Resident #12 was discharged to Acute Hospital. Interview with Registered Nurse (RN) #1 on 06/13/19 at 10:57 AM, revealed the Minimum Data Set (MDS) Assessment with the ARD of 4/17/19, noted Resident #12 was discharged to an Acute Hospital. RN #1 confirmed Resident #12 was discharged home with Home Health and the Discharge Assessment was not correct.

Based on interview, record review and facility policy review, the facility failed to provide written notification of discharge for Resident #112 at the time of discharge for one (1) of three (3) residents reviewed for discharge notice. (Resident #112) Findings include: A review of the facility policy titled, Skilled Nursing Unit, without a date, revealed the unit would notify the representative as soon as possible for transfers/discharge. A review of Resident #112's discharge summary, dated 6/10/19, revealed [DIAGNOSES REDACTED]. The discharge summary revealed Resident #112 was admitted to Intensive Care Unit from the Skilled Nursing Unit on 5/27/19. A review of the medical record revealed no documentation regarding notification of the discharge to the hospital on [DATE]. A review of a signed statement provided by Registered Nurse (RN) #2, dated 6/13/19, revealed she had informed informed Resident #112's son verbally when the resident was discharged to acute care. An interview on 06/11/19 at 11:46 AM, with Resident # 112, revealed he had been back and forth to the hospital several times. Resident #112 said he was ready to go home and thought they got it right this time. An interview on 06/12/19 on 11:37 AM, with Social Services (SS), revealed she sends a written notification to the Ombudsman every month. When asked if written notification was sent to the resident or resident representative (RR) for a facility-initiated transfer or discharge, she confirmed the facility only did a verbal notice. An interview on 06/13/19 at 9:56 AM, with the Director or Nursing (DON), confirmed that the facility did not send written notification to the resident or resident representative because this was a short term stay facility, and the residents did not usually stay 30 days. During an interview on 06/13/19 at 11:10 AM, Social Services confirmed the facility did not notify residents or the representative at time of discharge to acute care, because they sign a paper with the admission paperwork about a possibility of an emergency discharge. Social Services said the facility did not send written notification to the resident/representative specific for the emergency transfer of Resident #112. The DON, in the presence of Social Services, said the facility would have to adjust or come up with a form to notify the family.

Based on observation, staff interview, and policy review, the facility failed to ensure the kitchen area, kitchen equipment, utensils and dishes were maintained in a sanitary manner and free from food particles, water residue and/or standing water; ensure opened foods in food storage areas were dated and labeled; ensure all clean and dirty supplies were stored in each respective area; and, ensure the environment was clean and sanitary with properly secured areas to prevent the spread of infections on two (2) of three (3) environmental tours. Findings include: Observation of the facility's kitchen area and interview with four (4) dietary staff members on 5/8/14 from 7:25 AM until 8:19 AM, and 11:05 AM until 12:10 PM, on 5/8/14 at 10:35 AM until 11:10 AM revealed: Six (6) plate warmers used for the stored clean dish had dried food particles along the sides and in the base. Food particles were observed in the bottom of and underneath the meat slicer in the area. Food particles were observed in the grooves of drawers in the kitchen area. Opened food items stored in the dry food storage areas and frozen food areas were not dated and labeled after opening, and were not properly covered. There was a build-up of dust, debris and/or a black colored substance observed on walls, on pipes, in the vents of the ice machine, and on each ceiling vent in the area. Shelves used to store clean equipment were coated with a dusty, yellow colored, sticky film. Wax build-up and/or dirt were observed along the floor area and in the corners in the kitchen area. An accumulation of ice was observed on the pipes and along the ceiling of the walk-in freezer. Cleaning chemicals and spices were on the same shelf in the food preparation area. An accumulation of water was observed on the floor work area. An accumulation of dust and paper products were observed on the floor area behind six (6) trash bins. An accumulation of dust was observed on the bottom and sides of trash can. Door facings in the kitchen area were marred and scarred. Soiled serving equipment and utensils were stored on top of clean bowls being used to prepare desserts for distribution during the lunch meal. The Dietary Manager confirmed these areas of concern. Observation and interview on 5/9/14 from 10:35 AM until 11:10 AM with six (6) dietary staff members confirmed the listed findings.

Based on observation, record review, staff interview, and facility policy review, the facility failed to administer two (2) of 29 medications as ordered which resulted in a medication error rate of seven percent (7%). Findings include: Unsampled Resident #A Review of the facility's policy entitled "Pharmacy", not dated, revealed "Standard Time for Administration of Medicine, Daily 10am ". Observation of the 10:00 AM medication pass on 5/8/14 at 10:30 AM, revealed [MEDICATION NAME] 40 mg (milligrams) and [MEDICATION NAME] 0.4 mg were not given during this medication pass. Record review revealed a physician's orders [REDACTED]. Interview on 5/8/14 at 3:00 PM with Registered Nurse (RN #1) revealed "I didn't give the [MEDICATION NAME] or the [MEDICATION NAME]; but, I have them right here. I'm on my way to give them right now."

Based on observation, record review, staff interview and policy review, the facility failed to develop comprehensive Care Plans with problems and approaches specific to each Resident. This was evidenced by Resident #2's Care Plan did not include specific wound care or admission Diagnosis; Resident #3's Care Plan did not include TLSO ([MEDICATION NAME] Lumbar Sacral Orthotic) or admission Diagnosis; and, Resident #5's Care Plan did not include wound care and the admission [DIAGNOSES REDACTED].#2, #3 and #5). Findings include: Resident #2 Observation of Resident #2 on 6/6/13 at 11:55 a.m., revealed that she was lying in bed, neatly dressed. Record review for Resident #2 revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Although the admission Minimum Data Set (MDS) had not been completed, the Brief Interview for Mental Status (BIMS) had been completed with a score of 15, which indicated that she was cognitively intact. Further record review for Resident #2 revealed the following: 1. Physician Order, dated 6/5/13, to "Clean abdominal incisional wound with normal saline and gauze then apply [MEDICATION NAME] Ag (silver) ribbon to wound and over with Abd. (Abdominal) Pad and change every other day and prn (as needed)." 2. A Care Plan which included "Patient exhibits no sign of infection" and "Follow protocol for central lines/IVs (Intravenous)/dressing changes". The Care Plan did not contain specific wound care instructions. 3. The Care plan did not include the [DIAGNOSES REDACTED]. Interview on 6/7/13 at 9:40 a.m. with Registered Nurse (RN) #1, confirmed that Resident #2's Care Plan included no signs and symptoms of infection, and that the Care Plan did not include wound care specific to the Resident. Review of the facility's policy "Patient Care Policies", dated 3/26/13, "Section III, 8. Care Plan: B. Reflect the patient's comprehensive physical and behavioral assessment and environment". Resident #3 Observation of Resident #3 on 6/6/13 at 11:15 a.m., revealed that he was seated in a reclining chair. Record review for Resident #3 revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The initial MDS had not yet been completed. Review of the Physical Therapy Notes revealed that the TLSO Brace was applied while the Resident was out of bed. Further record review for Resident #3 revealed the following for his 6/2/13 Care Plan: 1. The Activities of Daily Living Care Plan included an approach of "Encourage the use of bed alarm". This Resident did not use the bed alarm. 2. There was no Problem for the Resident's Fractured Lumbar # 4 Vertebrae and fractured Coccyx, nor was the use of the TLSO Brace included in the Care Plan. Interview on 6/6/13 at 11:30 a.m. with RN #1 confirmed "The Care Plan does not mention the Brace." Resident #5 Observation of Resident #5 on 6/6/13 at 11:05 a.m., revealed that she was neatly dressed and seated in a chair. Record review for Resident #5 revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS, with an ARD of 5/28/13, revealed that she scored 15 of 15 on the BIMS, which indicated that she was cognitively intact. Further record review for Resident #5 revealed the following in her Care Plan: 1. "Skin integrity, 9. Collaborate with Wound Care Nurse (PRN)." 2. "Activities of Daily Living, 2. Encourage use of bed alarm." The Resident did not use a bed alarm. 3. "No Signs and Symptoms of Infection, 5. Follow protocol for central lines/IVs/dressing changes (PRN)." 4. The Care Plan did not include the specific dressing order, nor did it include the Resident's left [MEDICAL CONDITION]. Interview on 6/6/13 at 11:45 a.m. with RN #1, confirmed that the Care Plan included protocol for wound care instead of the specific wound care.

Based on observation, record review, staff interview and policy review, the facility failed to apply urinary drainage bag privacy covers for one (1) of two(2) days of survey (Resident #3 and Unsampled Resident A). Findings include: Resident # 3 Observation of Resident #3 on 6/6/13 at 11:15 a.m., revealed that he was seated in a reclining chair. The urinary drainage bag did not have a privacy cover. Record review for Resident #3 revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The initial Minimum Data Set (MDS) had not yet been completed. Review of the Physician order [REDACTED]. Interview on 6/7/13 at 1:10 p.m., with RN (Registered Nurse) #1, confirmed that the urinary drainage privacy cover had been applied until 6/7/13. Review of the facility's "Patient Care Policies", dated 3/26/13, confirmed "H. Standards of Practice: 1) Customers will be treated with dignity at all times." Unsampled Resident A Observation of Unsampled Resident A on 6/6/3 at 8:30 a.m., revealed that she was lying in bed. The urinary drainage bag did not have a privacy cover. Another observation of Unsampled Resident A on 6/6/13 at 9:35 a.m., revealed that she was lying in bed with the head of the bed elevated. The urinary drainage bag did not have a privacy cover. Record review for Unsampled Resident A revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS, with an Assessment Reference Date (ARD) of 6/4/13, revealed that she scored 9 (nine) of 15 on the Brief Interview for Mental Status, which indicated that she had moderate cognitive impairment. Interview on 6/7/13 at 1:15 p.m. with RN #1 confirmed that the privacy bag was placed on the urinary drainage bag on 6/7/13.

Based on observation, staff interview, record review and policy review, the facility failed to ensure that the kitchen area, kitchen equipment, utensils and dishes were maintained in a sanitary manner as evidenced by the facility's failure to ensure that staff washed their hands after changing gloves between handling of soiled dishes and clean dishes; failed to ensure that there was documented evidence that the water temperatures were checked, and failed to ensure that the acidity/alkalinity of the chemicals used to sanitize dishes and cooking equipment was documented prior to the dishes being used by residents, staff and the public on one (1) of two (2) tours of the kitchen. Findings include: Observation of the facility's kitchen area and interview with the Director of Food and Nutrition Services on 4/11/12 from 9:45 a.m. until 10:33 a.m. revealed Dietary Staff #1 failed to change his apron and failed to wash his hands after changing gloves and going from soiled to clean dishes on two (2) occasions (4/11/2012 at 10:15 a.m. and at 10:30 a.m.). The Food Service Manager observed the lack of hand washing during the 10:30 a.m. incident. Interview with Dietary Staff #1 on 4/11/12 at 10:30 a.m. revealed Dietary Staff #1 confirmed that he did not change his apron or wash his hands between moving from dirty to clean areas. Observation and interview on 4/11/12 at 10:30 a.m. revealed that Food Service Manager placed one (1) test strip on one (1) soiled dish cart in order to test the acidity/alkalinity of the chemical in the water; however, the one (1) test strip was not attached to the cart when the cart rotated to the finished cycle. Then, the Food Service Manager placed two (2) test strips to one (1) soiled cart to test the acidity/alkalinity of the chemical in the water; however, the two (2) test strips were not attached to the cart when the cart rotated to the finished cycle. Review of the documentation binder used to document acidity/alkalinity checks of the chemical in the dish machine on April 11, 2012, at 10:20 a.m. revealed there was no documented evidence of the checks recorded since August 15, 2011. Review of the documentation of water temperature checks of the dish machine on 4/11/2012 at 9:45 a.m. revealed there were no results documented for April 5, 2012, April 6, 2012 and April 7, 2012. Interview on April 11, 2012 at 10:35 a.m. with the Administrator regarding concerns in the kitchen area revealed the Administrator stated that Director of Food Services was looking for documentation of checks of the dish machine. Interview on April 11, 2012 at 11:01 a.m. with the Director of Food and Nutrition confirmed that there was no documented evidence that the facility checked the acidity/alkalinity of dishes since August 15, 2011 and that there was no documentation of water temperature checks for April 5-7, 2012. Review of the facility's "Personal Health and Grooming of Dietetic Employees" policy, reviewed June 30, 2011, noted: " ...c. Hand washing ....3 Required TIMES for hand washing include: .... d. Between handling of soiled dishes or equipment and handling clean dishes or equipment ...." Review of the facility's "Service ware Sanitation System" policy, reviewed 7/1/11, noted: " ... C. REGULAR WARE WASHING PROCESS....1. h. The temperature of the power-wash water will have reached 140 degrees F. (Fahrenheit), the power rinse water will have reached 160 degrees F., and the final rinse water will have reached 180 degrees F. before washing begins. These minimum temperatures will be maintained at all times during the ware washing period. Temperatures will be logged at each meal ....3. a. The worker will remove soiled apron and put on a clean disposable plastic apron. b. Worker will wash hands, using proper hand washing technique, before catching clean service ware .... "

Based on observation and policy review the facility failed to utilize infection control practices during medication pass for one (1) of three (3) residents (Resident #3). Findings include: An observation during medication pass on 4/11/12 at 9:35 a.m. with Registered Nurse (RN) #1 revealed RN #1 gave Resident #3 a cup of six (6) medications while she held her bare hand under the cup. Resident #3 dropped two (2) medications and RN #1 caught the medications in her bare hand. Then RN #3 proceeded to pick the pills up with her other hand and gave the medications to Resident #1. A review of the medication administration policy on 4/11/12 at 11:30 a.m. revealed no instructions on wearing gloves when touching medications.