Every finding on record at Pontotoc Nursing Home

Based on observation, staff interview, record review and facility policy review, the facility failed to ensure the residents right to dignity was maintained by not providing privacy for a urinary catheter drainage bag for two (2) of 16 sampled residents. (Resident #1 and Resident #41)Findings include:Review of the facility policy titled Patient Rights and Responsibilities approved 4/7/26 revealed When providing medical care and treatment to patients. 1. A patient .has the right to: .be treated with courtesy, respect, individual dignity and privacy.Resident #1An observation on 7/7/26 at 10:55 AM and again at 4:35 PM revealed Resident #1's urinary drainage bag containing dark yellow urine hanging from the bed without a privacy cover and was visible to anyone entering the room.An observation on 7/8/2026 at 9:00 AM, upon entering Resident #1's room, the urinary drainage bag remained uncovered.Record review of Demographics revealed Resident #1 was admitted to the facility on [DATE].Record review of Medical Problems revealed Resident #1 was admitted with diagnoses that include an overactive bladder and renal carcinoma.Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 05/01/2026 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicates the resident is cognitively intact.Resident #41An observation on 7/07/2026 at 10:40 AM and again at 3:25 PM revealed Resident #41's urinary drainage bag was uncovered and visible upon entering the room.An observation on 7/08/2026 at 8:25 AM revealed Resident #41's urinary drainage bag remained uncovered and visible to anyone entering the resident's room. Record review of Demographics revealed Resident #41 was admitted to the facility on [DATE].Record review of Medical Problems revealed Resident #41 was admitted with diagnoses that include enlarged prostate with lower urinary tract symptoms, neuromuscular dysfunction of the bladder, and suprapubic catheter. Record review of the MDS Section C with an ARD of 05/29/2026 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicates the resident is cognitively intact.During an interview and observation on 7/08/2026 at 11:15 AM, Certified Nurse Aide (CNA) #1 revealed that residents with urinary catheter bags are supposed to have them kept in privacy bags. She confirmed Resident #1's urinary drainage bag was uncovered and stated it should have been covered. CNA #1 further revealed she was assigned to Resident #41 and had noticed earlier that the resident's drainage bag was uncovered, so she placed it in a privacy bag prior to the observation.During an observation and interview on 7/08/2026 at 11:25 AM, Licensed Practical Nurse (LPN) #1 confirmed Resident #1's urinary drainage bag was uncovered and visible to anyone entering the room. LPN #1 stated, I know it's a dignity issue, and when they go out in the hallway, we try to make sure and put them in a privacy bag, but I'm not sure we do when they are in their rooms. During an interview on 7/08/2026 at 12:00 PM, the Administrator (ADM) stated the facility had routinely used privacy bags only when residents left their rooms and had not consistently provided privacy bags while residents remained in their rooms. The Administrator acknowledged that visitors entering residents' rooms could view the urine in the drainage bags and could understand this was a dignity issue.

Based on observation, resident and staff interviews, record reviews, and facility policy review, the facility failed to provide a comfortable and homelike environment for two (2) of 42 residents. (Resident #12 and Resident #19) Findings include:Review of the policy on facility letterhead and signed by the Administrator, dated 7/8/2026 revealed, It is Proper Name of facility goal to provide a homelike environment for all residents.Resident #12During an observation and interview on 7/7/2026 at 10:35 AM, in Resident #12's room it was observed to be in disrepair. All four green walls contained numerous rough, white drywall repair patches that contrasted with the painted walls, creating an unfinished appearance. Baseboards were missing around the perimeter of the room, and discoloration was visible where they had previously been removed. Resident #12 stated, My room has looked like this for a long time. They started working on it back in October and were getting it ready to paint, and here we are with it still looking like this.Record review of Demographics revealed Resident #12 was admitted to the facility on [DATE].Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 04/17/2026 revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicates the resident is cognitively intact.Resident #19During an observation and interview on 7/7/2026 at 11:25 AM, in Resident #19's room, observation revealed numerous rough, white drywall repair patches on the tan walls. Baseboards were missing along the perimeter of the room, and discoloration was visible where they had previously been removed. Resident #19 stated, They were supposed to paint this room a long time ago. It's been looking like this since last year. I told the Administrator to just get me some paint, and I would take care of it myself.Record review of Demographics revealed Resident #19 was admitted to the facility on [DATE].Record review of the MDS Section C with an ARD of 05/01/2026 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicates the resident is cognitively intact.During an interview on 7/8/2026 at 11:50 AM, the Administrator stated the facility had been approved in October 2025 for a contractor to remodel several resident rooms at a time. The Administrator explained the remodeling project had been delayed, leaving the rooms in a pre-remodel condition. The Administrator acknowledged the rooms did not promote a homelike environment and agreed residents should not have had to continue living in rooms in that state of disrepair.

Based on observation, staff interviews, record review and facility policy review the facility failed to maintain infection control practices by failing to ensure respiratory equipment was stored in a sanitary manner to prevent contamination (Resident #39) for one (1) of thirteen sampled residents.Findings Include: Record review of facility policy titled Nebulizer Masks, Tubing, and Bag Protocol with a review date of 3/4/2025 revealed, It is the policy of (Proper Name) that nebulizer masks and tubing should be dried and stored when not in use.An observation on 7/9/2026 at 9:43 AM revealed staff had just exited Resident #39's room. After staff exited, Resident #39's nebulizer mask was observed lying on the floor. On 7/9/2026 at 9:46 AM, the Infection Preventionist confirmed the nebulizer mask was not in a protective bag. She acknowledged improper storage of the mask presented an infection control concern. During an interview on 7/9/2026 at 12:45 PM, Registered Nurse (RN) #1 revealed that Resident #39 was receiving ordered nebulizer treatments. RN #1 stated that following each treatment, the nebulizer mask should be rinsed, allowed to dry, and stored in a clean bag. RN #1 acknowledged that the nebulizer mask should not have been left on the floor and that doing so presented an infection control concern.Record review of the Demographics page revealed Resident #39 was admitted to the facility on [DATE].Record review of Resident #39's Medical Problems list revealed the resident had diagnoses which included Chronic Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease with Emphysema, and Influenza. Record review of Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 4/24/26 revealed a Brief Interview for Mental Status (BIMS) summary score of 15 which indicated Resident #39 was cognitively intact.

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to implement Activity of Daily Living (ADL) care plans for Residents #1, #17, and #30 and failed to implement a pressure ulcer care plan for Resident # 6 for (4) four of 16 resident care plans reviewed. Findings Include: Review of the facility policy titled, “Plan of Care,” last revised 06/27/24, revealed, Policy: It is the policy of “Proper Name” to properly provide patient care planning… Procedure: 2.) “An interdisciplinary collaborative manner as appropriate to the needs of the patient should be utilized to develop and implement the care plan . Resident #1 Record review of the Care Plan for Resident #1 revealed under, Problem/Need: I require assistance w/ (with) ADLs (activities of daily living) r/t (related to) weakness, debility, and dementia. Also revealed under, Approaches: Personal Hygiene- Limited-Extensive x (times) 1 (one). During an observation and interview on 7/21/2025 at 11:18 AM, Resident #1 was sitting in his wheelchair in his room. He was unshaven, with black and gray facial hair approximately 1/4 (one-fourth) inch in length. The resident stated he wanted to be shaved but preferred to keep his mustache. On 7/22/2025 at 10:36 AM, an interview with Certified Nurse Aide (CNA) #5 confirmed Resident #1 needed shaving. An interview with the Minimum Data Set (MDS) Nurse on 7/24/25 at 9:15 AM revealed the purpose of the care plan was to give staff instruction and paint a picture of the residents care to be provided. She confirmed Resident #1's care plan was not followed for shaving. Record review of the “Demographics” revealed the facility admitted Resident #1 on 4/14/25 with a medical diagnosis of Unspecified Dementia. Record review of Resident #1’s “Flowsheet History” dated 7/18/25 revealed a Brief Interview for Mental Status (BIMS) summary score of 3, indicating the resident was severely cognitively impaired. Resident #6 Review of the “Care Plan” for Resident #6 revealed under, “Approaches: Observe for s/sx (signs/symptoms) of new skin breakdown during daily care document and report as indicated . An interview with the Director of Nursing (DON) on 7/24/25 at 9:20 AM revealed Resident #6 transferred to the hospital on 3/1/25 and returned on 3/9/25. Record review of Resident #6’s hospital stay “Integumentary Flowsheet History” revealed documentation on 3/7/25 of deep tissue injury (DTI) left heel. Record review of the “Nursing Note” for Resident #6, dated 3/9/25 revealed, “Resident returned from proper name of hospital around 10 AM.” There was no documentation regarding any skin concerns. Record review of Resident #6’s body audits conducted on 3/9/25, 3/10/25, 3/13/25, 3/14/25, 3/15/25 revealed scattered bruising, no abrasion, no blister, no excoriation. There was no documentation regarding the left heel. Record review of Resident #6’s body audit conducted on 3/16/25 revealed, “Unstageable pressure injury to left posterior heel, dark purple, dry, hard, closed, without pain. Measures 4.5 x 2.2 x 0.” Record review of Resident #6’s “Integumentary Flowsheet History” dated 7/15/25 revealed, “Redness to buttocks.” Record review of Resident #6’s “Wound History” dated 7/17/25 revealed, “Sacrum stage III pressure wound, red, slightly moist measuring 1.8 cm (centimeters) x 0.5 cm (centimeters) x 0.1 cm (centimeters) full thickness tissue loss with slough. On 7/23/25 at 11:12 AM, an interview with the DON confirmed Resident #6 developed a pressure injury to her left heel while in the hospital, and the wound was not identified in the facility until eight days later. Additionally, she revealed that after the resident’s body audit conducted on 7/15/25 identified redness to her buttocks, there was no documentation to show the skin concern was addressed. She confirmed the plan of care was not followed. On 7/24/25 at 8:30 AM, an interview with Registered Nurse (RN) #2 reconfirmed that on 7/15/25, she assessed the resident’s skin and noted redness to the buttocks. She revealed that she applied pink cream and a bandage to the area but did not document it or initiate wound care orders. An interview with the MDS Nurse on 7/24/25 at 9:00 AM confirmed Resident #6's skin care plan was not followed. Record review of the “Demographics” revealed the facility admitted Resident #6 on 2/13/25 with diagnoses including Dementia with Anxiety. Record review of the “Flowsheet Data” dated 5/16/25 revealed a BIMS summary score of 6, indicating Resident #6 was severely cognitively impaired. Resident# 17 During an observation on 7/22/25 at 10:30 AM, with Registered Charge Nurse #1, it was confirmed that Resident #17’s nails were long and jagged and needed to be trimmed. She stated it was her responsibility to trim the nails but confirmed she had not gotten around to it. Record review of the ADL care plan for Resident #17, last revised 7/11/25, revealed the problem: “I require assistance with ADLs … Approaches: Nail care as indicated. … Personal hygiene – limited to extensive assistance . During an interview with the MDS nurse, on 7/22/25 at 11:30 AM, she confirmed that if staff had not trimmed Resident #17’s nails, they did not implement the resident’s ADL care plan. She revealed the purpose of the comprehensive care plan is to give staff a description of the type of care the residents require. Review of the “Demographic Report” for Resident #17 revealed the facility admitted the resident on 1/15/22 with a diagnosis of Hemiplegia affecting the left side as a late effect of Cerebrovascular Accident. Record review of Resident #17's BIMS, dated 7/11/25, revealed a score of 15, indicating the resident was cognitively intact. Resident #30 Record review of the Care Plan with a problem onset of 6/21/23 revealed, Problem/Need: ADL's I require assistance with my ADLs r/t Parkinson's .Approaches: Assistn with shaving as desired . On 7/21/2025 at 12:23 PM during an observation and interview with Resident #30 revealed that he had facial hair measuring one-half to one inch on his cheeks, chin, upper lip, and neck. During the interview, Resident #30 stated, I cannot shave myself and I would like to be shaved. During an interview with the MDS Coordinator at 12:41 PM on 7/22/25, confirmed that while Resident #30 was capable of taking showers independently with supervision, he has not been shaved in quite some time. She further confirmed there was no documentation indicating that Resident #30 had refused to be shaved. During an interview on 7/24/2025 at 9:37 AM, the MDS Coordinator confirmed that the ADL Care Plan, which includes assistance with shaving as desired, was not implemented. She verbalized that the purpose of this care plan was to serve as a guide for all staff involved in providing ADL care, ensuring consistency and quality across all shifts and personnel. A record review of Resident #30's Demographics revealed that the resident was admitted to the facility on [DATE], with diagnoses that included Parkinson’s Disease. A record review of Resident #30's Flowsheet History revealed a BIMS Summary Score of 13 with an Assessment Reference Date (ARD) of 5/30/25, which indicated that the resident was cognitively intact.

Based on observation, staff interview, record review, and facility policy review, the facility failed to assess and implement timely interventions to address skin integrity concerns, resulting in progression of a pressure injury and delayed wound healing for one (1) of three (3) residents reviewed for pressure ulcers. (Resident #6) Findings include: Review of the facility policy titled “Assessment and Reassessment of Patients” with a revision date of 5/12/25 revealed under, “Policy: It is the policy of (proper name of facility) that patients should be properly assessed and reassessed.” Also revealed under, “Procedure: … 6. Wound assessments and measurements should be performed at start of care, resumption of care, and recommended weekly. Reassessment should be performed any time there is a significant change noted .” Record review of Resident #6’s hospital “Integumentary Flowsheet History” revealed documentation on 3/7/25 of deep tissue injury (DTI) left heel. An interview with the Director of Nursing (DON) on 7/24/25 at 9:20 AM revealed Resident #6 transferred to the hospital on 3/1/25 and returned on 3/9/25. Record review of the “Nursing Note” for Resident #6, dated 3/9/25 revealed, “Resident returned from “proper name” of hospital around 10 AM.” There was no documentation regarding any skin concerns. Record review of Resident #6’s body audits conducted on 3/9/25, 3/10/25, 3/13/25, 3/14/25, 3/15/25 revealed scattered bruising, no abrasion, no blister, no excoriation. There was no documentation on the left heel. Record review of Resident #6’s body audit conducted on 3/16/25 revealed, “Unstageable pressure injury to left posterior heel, dark purple, dry, hard, closed, without pain. Measures 4.5 x 2.2 x 0.” Record review of Resident #6’s wound care “Work List Task Details” revealed an order dated 3/16/25, “Unstageable pressure injury to left, posterior heel. Clean with betadine and leave OTA (open to air) daily at 10:00 AM.” Record review of Resident #6’s “Integumentary Flowsheet History” dated 7/15/25 revealed, “Redness to buttocks.” Record review of Resident #6’s “Wound History” dated 7/17/25 revealed, “Sacrum stage III pressure wound, red, slightly moist measuring 1.8 cm (centimeters) x 0.5 cm (centimeters) x 0.1 cm (centimeters) full thickness tissue loss with slough. Record review of Resident #6’s wound care “Work List Task Details” revealed an order dated 7/17/25, “Cleanse stage III pressure ulcer to sacral area with NS (normal saline) or DWC (dermal wound cleanser), pat dry with 4 x 4 gauze, apply collagen with silver, cover with dry dressing. Change T (Tuesday)/Th (Thursday)/Sat (Saturday) and prn (as needed).” An interview with the Director of Nursing (DON) on 7/23/25 at 11:12 AM confirmed Resident #6 developed a pressure injury on her left heel while in the hospital, and the wound was not identified in the facility until eight days later, at which point it had progressed to an unstageable pressure injury. She revealed it would have been the charge nurse’s responsibility to assess the resident’s skin on readmission and then weekly thereafter. She confirmed there were no interventions implemented when the resident returned to address the skin concern. The DON explained that after the body audit conducted on 7/15/25 identified redness to the resident’s buttocks, no treatment was initiated. She confirmed interventions should have been implemented. She stated, I thought we were better than that. She acknowledged that the lack of assessment and follow-through with treatment could have caused both wounds to progress and worsen. An interview with Registered Nurse (RN) #2 on 7/24/25 at 8:30 AM revealed she was the charge nurse working on 3/9/25 when Resident #6 returned from the hospital. She confirmed she did not perform a body audit on readmission and stated, I don't remember doing one. She explained that on 7/15/25, she assessed the resident’s skin and noted redness to the buttocks. She revealed that she applied pink cream and a bandage to the area but did not document it or initiate wound care orders. She stated, As far as why I didn't, I get busy, and it just fell through the cracks. An observation on 7/24/25 at 9:50 AM with Resident #6 during wound care revealed the left heel (unstageable due to eschar) revealed a round eschar covered wound. The wound bed was black; peri wound intact with no redness or irritation. Edges were well defined. The sacral wound (stage III) was oval shaped, yellow adherent slough covered, edges well defined, peri wound without redness or irritation. Record review of the “Demographics” revealed the facility admitted Resident #6 on 2/13/25 with diagnoses including Dementia with Anxiety. Record review of the “Flowsheet Data” dated 5/16/25 revealed a Brief Interview for Mental Status (BIMS) summary score of 6, indicating Resident #6 was severely cognitively impaired.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to address resident equipment in disrepair, resulting in a resident continuing to use an unsafe and uncomfortable wheelchair for approximately one month for one (1) of 31 residents utilizing wheelchairs reviewed. Resident #4 Record review of the facility policy titled, “Medical Equipment Management Program Medical Equipment Repair” with a revision date of 4/22 revealed “Policy: The Biomedical-Clinical Services Department is responsible for providing safe, effective and timely repair of all Medical Equipment .” Record review of “(Proper Name) Biomed” record from 10/02/24 to 6/20/25 revealed no documentation regarding repair or replacement of Resident #4’s wheelchair. An observation and interview on 7/22/2025 at 8:55 AM, revealed Resident #4 sitting in a wheelchair in his room. The bilateral vinyl armrests were noted to be torn and tattered. Resident #4 stated, “The armrests are uncomfortable on my arms.” During an interview on 7/22/2025 at 10:40 AM, Certified Nurse Aide (CNA) #4 revealed that whenever resident equipment needs to be repaired or replaced, we put in a work order on the computer. The work order is called Biomed and goes to the maintenance department. After review of the Biomed work order for the past several months, she revealed that there was no order for the repair of Resident #4's wheelchair. An observation and interview on 7/22/2025 at 10:52 AM, the Administrator (ADM) confirmed that Resident #4's vinyl on both wheelchair armrests was tattered and torn. She stated, He has a new wheelchair that has been ordered. Resident #4 stated, “I’ve been waiting for a month for the new wheelchair. The Administrator confirmed that the wheelchair had been on order for about a month and revealed she would get him a new wheelchair right now. During an interview on 7/23/2025 at 8:30 AM, Maintenance worker #1 confirmed that he receives his work orders through a system called Biomed and checks the system several times throughout the day for any new work orders. He revealed that yesterday was the first time he was made aware that Resident #4's wheelchair needed to be replaced due to the armrest vinyl being torn. Record review of Resident #4's Demographics revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Type 2 diabetes with peripheral neuropathy. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/11/25 revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated Resident #4 was cognitively intact.

Based on observation, resident and staff interviews, record review, and facility policy review the facility failed to provide Activities of Daily Living (ADL) care for three (3) of 42 residents observed during the initial tour related to nail care for Resident #17 and failed to shave Residents #1 and #30. Findings Include: The facility provided a statement on letterhead signed by the Director of Nursing that revealed, “(Proper name) of the facility does not have a personal hygiene policy.” Review of the facility policy titled, Nails, Care of, last revised 08/06/24, revealed: “Policy: It is the policy of 'Proper Name' Nursing Home that nails should be properly cared for . Resident #1 On 7/21/2025 at 11:18 AM, an observation and interview with Resident #1 revealed he had black and gray facial hair approximately 1/4 (one-fourth) inch in length and stated he wanted to be shaved but preferred to keep his mustache. An interview with Certified Nurse Aide (CNA) #5 on 7/22/2025 at 10:36 AM revealed Resident #1 should be shaved every time he received a bath. She stated it was the shower aide’s responsibility to ensure this was done and confirmed the resident needed shaving. An interview with the Director of Nursing (DON) on 7/22/2025 at 10:40 AM revealed that male residents were to be shaved once weekly or as requested. She confirmed that Resident #1 was unshaven and acknowledged that this gave him an untidy appearance. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/18/25 revealed Resident #1 required substantial/maximal assistance with personal hygiene, including shaving. Record review of the “Demographics” revealed the facility admitted Resident #1 on 4/14/25 with a medical diagnoses including Unspecified Dementia. Record review of Resident #1’s “Flowsheet History” dated 7/18/25 revealed a Brief Interview for Mental Status (BIMS) summary score of 3, indicating the resident was severely cognitively impaired. Resident #17 An observation on 7/21/25 at 10:30 AM revealed Resident #17's nails were approximately 1/2 inch long and jagged in appearance. Resident #17 stated she could not remember the last time her nails were trimmed but stated she would like them trimmed. An observation of Resident #17's nails with CNA #1 on 7/22/25 at 10:28 AM revealed the resident's nails were long and jagged. CNA #1 confirmed the nails needed to be trimmed. An observation on 7/22/25 at 10:30 AM with Registered Charge Nurse #1 revealed Resident #17's nails were long and jagged and needed to be trimmed. She stated it was her responsibility to trim the nails but confirmed she had not gotten around to it. She stated a concern with the resident’s nails not being trimmed was that the resident could scratch herself. Record review of the “Demographics” for Resident #17 revealed the facility admitted the resident on 1/15/22 with a diagnosis of hemiplegia affecting the left side as a late effect of cerebrovascular accident. Record review of Resident #17's BIMS, dated 7/11/25, revealed a score of 15, indicating the resident was cognitively intact. Review of Section GG of the MDS – Functional Abilities, dated 7/11/25, revealed a code of 03 which indicated Resident #17 required partial/moderate assistance for personal hygiene. Resident #30 During an observation and interview on 7/21/2025 at 12:23 PM with Resident #30 revealed that he had facial hair measuring one-half to one inch on his cheeks, chin, upper lip, and neck. During the interview, Resident #30 stated, I cannot shave myself and I would like to be shaved, but (Proper Name of CNA#3) doesn't work here anymore, and she was the one who always shaved me. When asked if he would allow someone else to shave him, he agreed that he would. During an interview with CNA#2 on 7/22/25 at 10:43 AM concerning Resident #30, she confirmed that residents are typically shaved on their designated shower days, which for Resident #30 are Tuesday, Thursday, and Saturday nights. However, when the medical record was reviewed with CNA #2, it was noted that there was no documentation regarding personal hygiene, specifically shaving, for Resident #30. During an interview on 7/22/25 at 11:00 AM with the DON, she validated that it is standard practice for residents to be shaved during shower days. An interview with the MDS Coordinator at 12:41 PM on 7/22/25 confirmed that while Resident #30 was capable of taking showers independently with supervision, he has not been shaved in quite some time. The MDS Coordinator acknowledged that CNA#3 typically performed the shaving tasks but is currently on educational leave. She stated that the CNA's responsible for showering residents should have offered to shave Resident #30 during those times. She further confirmed there was no documentation indicating that Resident #30 had refused to be shaved. A record review of Resident #30's Demographics revealed that the resident was admitted to the facility on [DATE], with diagnoses that included Parkinson’s Disease. A record review of Resident #30's Flowsheet History revealed a BIMS Summary Score of 13 dated 5/30/25, which indicated that the resident was cognitively intact.

Based on staff interview and record review, the facility failed to submit accurate staffing data into the Payroll-Based Journal (PBJ) system for one (1) of four (4) quarters reviewed. First Quarter 2024. Findings Include: Record review of a typed document on facility letterhead dated 4/24/24, and signed by the Administrative Assistant revealed The facility does not have a written policy on accurate submission of staffing data into the Payroll Based Journal . Record review of the PBJ (Payroll Based Journal) Staffing Data Report CASPER Report 1705D FY (Fiscal Year) Quarter 1 2024 (October 1 - December 31), revealed No RN (Registered Nurse) Hours - Triggered. Triggered = Four or More Days Within the Quarter with no RN Hours. The CASPER Report also revealed Failed to have Licensed Nursing Coverage 24 Hours/Day - Triggered. Triggered = Four or More Days Within the Quarter with < (less than) 24 Hours/Day Licensed Nursing Coverage. On 04/23/24 at 2:20 PM, an interview with Administrator (ADM) revealed the Administrative Assistant was responsible for inputting the staffing data into the payroll based journal system and she manually entered the hours. The ADM revealed that they could only review the current PBJ data and were unable to look back on past quarters already submitted. The ADM revealed that she printed a trend tracker and reviewed staffing at each Quality Assurance Performance and Improvement (QAPI) meeting and had not identified any staffing issues. She revealed the triggers for low nursing coverage had to be from an input error because they had more than enough coverage for that timeframe. On 04/24/24 at 9:15 AM, an interview with Administrative Assistant, revealed that she was responsible for entering the staffing data. She revealed that she pulled the working schedules and timecards and went by the actual clock in and clock out times. The Administrative Assistant revealed that the triggers for low license nursing coverage were from an error with data entry because they always had more than the state required number of staff working there in the facility and it was entered incorrectly.

Based on observation, staff interviews, and record review, the facility failed to ensure that oxygen in use signage was visibly posted, and oxygen tubing was dated for three (3) of eight (8) residents observed. Resident #24, Resident #29, and Resident #32. Findings include: Record review revealed that the facility did not have a policy related to posting oxygen in use signage. The Administrator (ADM) provided documentation on the facility letterhead that noted, (Facility Name) does not currently have a policy addressing, No smoking Oxygen in Use signage, nor do they have a policy to address oxygen maintenance. Record review of the typed statement on facility letterhead dated 2/23/2023 revealed Pontotoc Nursing Home does not currently have a policy addressing Aqua pak or oxygen tubing maintenance but follows the procedure of changing the oxygen concentrators Aqua pak and oxygen tubing every Sunday at 2 PM as ordered and signed by the physician . Resident #32 An observation on 02/21/23 at 10:50 AM, revealed Resident #32's oxygen concentrator humidifier water bottle was dated 2/19/23. The tubing connected to the humidifier water bottle was not dated and there was no oxygen signage on the resident's door. An interview with Licensed Practical Nurse (LPN) #1 on 2/22/23 at 11:40 AM, revealed the oxygen and the tubing were changed weekly on Sunday and should both be dated. She confirmed that the tubing and the water bottle should be dated, but there was only a date on the humidifier water bottle and not on the tubing for this resident. She stated they do not put signage on the doors of residents with oxygen. An interview on 2/22/23 at 12:05 PM with Registered Nurse (RN) #1, revealed she serves as charge nurse and each week on Sunday, the charge nurse changes out the oxygen tubing and humidifier bottle. She confirmed that with the oxygen systems that they use is equipped for humidifier bottles. She dated only the humidifier bottles and not the tubing, and if an oxygen system with no water bottle is being used, she dates the tubing. She confirmed oxygen signage is not used on the residents' doors. Record review of Physician Order dated 1/12/21 for nasal cannula oxygen two (2) liters per minute as needed for shortness of breath. Record review of Physician Order dated 10/20/21 for nasal cannula oxygen two (2) liters per minute to be worn every night. Record review of Face Sheet revealed Resident #32 was admitted to the facility on [DATE]. Diagnoses included Pick's Disease, Shortness of Breath, Type 2 Diabetes Mellitus, and Hypertension. Record review of quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 12/30/22 section C revealed a Brief Interview of Mental Status (BIMS) score of 99 which indicated Resident #32 was unable to complete the interview. Record review of section O indicated the resident was on oxygen therapy. 46013 Resident #24 An observation on 02/21/23 at 10:25 AM, revealed Resident #24 lying in bed utilizing supplemental oxygen. No date was noted on the tubing or humidification bottle. There was no oxygen signage on the resident's door. An interview on 02/22/23 at 12:10 PM, with Registered Nurse (RN) #1 revealed the tubing and humidification bottles are changed out one time a week and she changed out Resident #24's bottle and tubing this past Sunday. She confirmed that the tubing did not have a date on it because she only labels the humidification bottle and not the tubing. She confirmed that the resident did not have a sign on the door alerting visitors of oxygen in use. An interview on 02/22/23 at 12:25 PM, the Administrator (ADM) revealed when the facility became a smoke-free facility it changed, and the oxygen signs were removed but she wasn't sure why. An observation by the State Agent (SA) on 02/22/23 at 12:30 PM, of the front main entrance doors revealed a sign that was posted, This is a tobacco-free facility campus. No signage of oxygen in use was noted. The Administrator revealed she could not find an oxygen policy because when the hospital went to a smoke-free facility, they removed the policy of having oxygen in-use signage. She confirmed that the front door said, tobacco-free facility campus and confirmed that there was no signage of oxygen in use, and it should be since that is a regulation. An interview on 02/23/23 at 9:35 AM The Administrator revealed they had no policy for changing the oxygen tubing or the water bottles, but that it is done on Sunday at 2 PM. She confirmed that the tubing and water bottle on the oxygen concentrators were to be labeled with the date. A record of Physician orders dated 9/21/22 for oxygen therapy Nasal Cannula, at 2 liters to treat and prevent hypoxemia. A record review of Resident #24's Face Sheet revealed the resident was admitted to the facility on [DATE] with diagnoses that included, Age-related physical debility, Shortness of breath, and Cerebral infarction. Record review of the MDS with an ARD of 2/22/23 revealed Resident #24 had a BIMS score of 11, which indicated the resident has a moderate cognitive impairment. 47874 Resident #29 An observation and interview on 02/21/23 at 10:30 AM, of Resident #29's room entrance, revealed that there was no Oxygen in use signage posted. There were no visible dates observed on the oxygen tubing or humidifier bottle. Resident #29 revealed that she used her nebulizer machine every day and used her oxygen every night. An observation on 2/22/23 at 9:30 AM, of Resident #29's room entrance, revealed that there was no Oxygen in Use sign posted to indicate that oxygen was being used. There were no visible dates observed on the nebulizer mouthpiece or tubing. An interview with RN #1 on 2/22/23 at 11:35 AM, revealed that she changed all nebulizer tubing, face mask, mouthpiece, and oxygen tubing every Sunday when she worked and that she used a sharpie marker to date the tubing. She revealed that if the resident used the humidified water bottle, she dated the bottle only and not the tubing, but if they did not use the humidified water bottle, she only dated the tubing. Record review of Resident #29's Face Sheet revealed an admitted [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Anxiety, Shortness of breath, and Vascular Dementia, unspecified. Record review of Physician's Orders for Resident #29 dated 1/24/23 revealed the following order: Oxygen (O2) therapy at (@) two (2) liters per minute (lpm) by nasal cannula (bnc) to be worn at hour of sleep (hs) and as needed for shortness of breath. Record review of the MDS for Resident #29 with an ARD of 1/31/23 revealed Resident #29 had a BIMS score of 7, indicating the resident has severe cognitive impairment. An interview on 02/22/23 at 12:20 PM with the Director of Nurses (DON) revealed that the resident doesn't have oxygen signage because we are a smoke-free facility. She revealed there is a sign that alerts everyone when they enter the building that this is a smoke-free facility. The DON revealed the oxygen tubing and humidifier bottle are to be changed weekly. She was aware the bottles were supposed to be labeled but wasn't sure if the oxygen tubing was to be labeled also.

Based on observation, staff and resident interviews, record review, and facility policy review, the facility failed to prevent the likelihood of infection as evidenced by improper storage of oxygen cannula and nebulizer tubing, and mouthpiece for one (1) of four (4) residents observed. Resident #29. Findings Include Review of the facility policy titled, Nebulizer Masks, Tubing, and Bag Protocol with a review date of 2/22/23 revealed, It is the policy of (Facility Name) that nebulizer mask and tubing should be dried and stored when not in use. Rationale: Provide infection control and protection for residents using nebulizer treatments. Procedure: 1. (Facility Name) provides clear plastic bags with a drawstring closure to store nebulizer mask and tubing. 2. The resident's room number and date should be written on the bag, tubing, and mask. Observation on 02/21/23 at 10:30 AM, Resident #29's oxygen concentrator was observed in the corner of the room with the nasal cannula wrapped around the right bedside rail. There was a nebulizer machine on the bedside table the nebulizer tubing was draped over the nebulizer machine with the mouthpiece laid directly onto the bedside table and there was no plastic bag to store the oxygen and nebulizer tubing appropriately. An interview on 02/21/23 at 10:30 AM with Resident #29 revealed that she used her nebulizer machine every day and used her oxygen every night. An observation on 2/22/23 at 9:30 AM, revealed Resident #29's oxygen cannula and tubing were observed laying on the floor. The nebulization mouthpiece was laying directly on the bedside table and not stored in a plastic bag. Observation and interview on 2/22/23 at 11:30 AM, with Registered Nurse (RN) #1 confirmed that the nebulizer mouthpiece was laying directly on the Resident's bedside table and that the oxygen cannula was laying on the floor. She confirmed that this could cause bacteria to enter the respiratory tract and cause infection. An interview with RN # 1 on 2/22/23 at 11:35 AM, revealed that they had placed oxygen and nebulizer tubing in a plastic bag in the past but had gotten out of the habit of doing this during the covid outbreak. An interview with the Infection Control Nurse on 2/23/23 at 9:05 AM, revealed that leaving the nebulizer mouthpiece and oxygen cannula open to air could cause all kinds of infections. She also revealed that respiratory equipment should be in a bag when not in use. Record review of Resident #29's Face Sheet revealed an admitted [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Anxiety, Shortness of breath, and Vascular Dementia, unspecified. Record review of Physician's Orders for Resident #29 dated 1/24/23 revealed the following order: Oxygen (O2) therapy at (@) two (2) liters per minute (lpm) by nasal cannula (bnc) to be worn at hour of sleep (hs) and as needed for shortness of breath. Record review of Physician's Orders for Resident #29 dated 1/24/23 revealed the following order: Budesonide inhalation 0.25 mg daily and ipratropium 0.5 mg/2.5-milliliter solution inhaled every four (4) hours as needed for wheezing. Record review of the Minimum Data Set (MDS) for Resident #29 with an Assessment Reference Date (ARD) of 1/31/23, had a Brief Interview for Mental Status (BIMS) score of 7, indicating the resident has severe cognitive impairment.

Based on staff interview, facility policy review and record review, the facility failed to notify the resident/Resident Representative (RR) when a resident was transferred to the hospital, for two (2) of two (2) residents reviewed for hospital transfers. Residents #10 and #37 Findings include: Record review of the facility's policy titled, Transfer of Residents to Acute Care, dated (MONTH) 2008, and reviewed on 10/17, revealed the family of the resident should be notified of the order to direct admit to (Name of Acute Care Hospital). The RN (Registered Nurse) should provide copies of the following to be presented to (Name of Acute Care Hospital): face sheet, current physician's orders [REDACTED]. The RN should call report to the assigned nurse at (Name of Acute Care Hospital). Review of the policy revealed there was no procedure/steps to notify the resident or the RR. On 9/5/19 at 1:30 PM, an interview with the Administrator (ADM), Director of Nursing (DON) and the Licensed Social Worker (LSW), revealed they were not aware of the regulation that required the facility to notify the resident and Resident Representative (RR) of any transfer to the hospital. The DON confirmed the facility was not sending a written notice of transfer to the responsible party or to the Ombudsman when a resident is transferred to the hospital. The ADM confirmed the facility does notify the family about the bed hold policy when the resident is transferred, and they call the RR when the resident is transferred to the hospital. Record review of Resident #10's Doctor's Orders revealed, on 7/31/19, an order was written to direct admit the resident to (Name of Acute Care Hospital ) related to nausea and vomiting, abnormal Computerized [NAME]ography (CAT) scan. Resident #37 Record review of the physician's orders [REDACTED].#37 was transferred to the local emergency room (ER) for evaluation. Record review revealed the facility did not notify the resident/Resident Representative in writing of the hospital transfer on 8/7/19. On 9/5/19 at 9:19 AM, an interview with the Director of Nursing (DON), the Administrator (ADM), and the Licensed Social Worker (LSW) revealed they were not aware of the requirement for notification of a resident or the resident representative in writing upon transfer and that it was not done.

Based on record review, staff interview and facility policy review, the facility failed to ensure the administration of as needed (PRN) [MEDICAL CONDITION] medications were limited to 14 days for two (2) of five (5) residents reviewed for unnecessary medications. Residents #15 and #21. Findings include: Review of the facility's policy titled, Medication Administration: [MEDICAL CONDITION] Use of, revised (MONTH) 2008, revealed, Rationale: To provide guidelines for the proper use of [MEDICAL CONDITION]/psychoactive medications. Policy: It is the policy of Pontotoc Nursing Facility that [MEDICAL CONDITION] medications should be used properly. Procedure: An interdisciplinary team approach should be utilized to develop an individualized care plan for each resident, in keeping with the facility practice of restraint conservative approach to both physical and chemical restraints. [MEDICAL CONDITION] medication should require physician approval and orders. Specific monitoring practices should be followed for the use of [MEDICAL CONDITION] medications as indicated for individual resident. Monitoring should be coordinated by Nursing staff and pharmacy. The policy did not address procedures/steps for the use of PRN [MEDICAL CONDITION] medications. Resident #15 Record review of the physician's orders [REDACTED]. Record review of the Patient Chart Report, from 8/15/19 through 9/5/19, revealed Resident #15 received [MEDICATION NAME] 0.5 mg on 8/28/19, 9/2/19, 9/3/19, and 9/4/19. At 09/05/19, at 10:50 AM, in an interview with the Director of Nursing (DON), she confirmed the physician's orders [REDACTED]. She stated she was aware of the regulation limiting PRN [MEDICAL CONDITION] medications to 14 days unless a longer timeframe is deemed appropriate by the physician. The DON stated Resident #15 was on hospice and the hospice doctor had ordered this. The DON stated she was not aware that it applied to hospice residents in Long Term Care. Record review of the Face Sheet revealed Resident #15 was admitted by the facility, on 3/10/17, with the included [DIAGNOSES REDACTED]. Review of the Significant Change in Status Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 6/28/19, revealed in Section C, a Brief Interview for Mental Status was conducted and the resident received a score of 07, indicating severely impaired cognitive skills for daily decision making. Resident #21 Review of the Doctor's Orders, dated 8/12/19, revealed [MEDICATION NAME] 0.25 mg po three times a day (TID) PRN for anxiety/agitation. Record review of the Doctor's Orders, dated 8/14/19, revealed an order to discontinue (D/C) the [MEDICATION NAME], and start [MEDICATION NAME] 1 mg po two times a day (BID) PRN agitation. On 09/05/19 at 11:58 AM, in an interview with the DON, she confirmed the PRN [MEDICATION NAME] order dated 8/14/19 was not written for 14 days initially. The DON stated Resident #21 cries a lot and is followed by the Psychiatrist for the crying spells and he had made several medication changes with her to see what combination would work for her. Record review of the Patient Chart Report for dates 8/15/19 through 9/5/19 revealed Resident #21 was given [MEDICATION NAME] 1mg 27 times for agitation, which included five (5) doses past the 14 day timeframe. Review of the Face Sheet for Resident #21 revealed she was admitted by the facility, on 7/5/19, with the included [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set Assessment, with an Assessment Reference Date of 7/12/19, revealed in Section C, a Brief Interview for Mental Status (BIMS) of 03, indicating severely impaired cognitive skills for daily decision making.

Based on observation, staff interview, and facility policy review, the facility failed to store and discard food items that were past their expiration dates for one (1) of two (2) dietary tours. Findings include: Review of the facility's policy, Food Storage Chart, revised 12/17/12, revealed: Cold storage foods, use by expiration date. Check expiration date of food on a daily basis. Discard out of date food. On 06/08/16 at 9:10 AM an initial tour of the dietary department with the Dietary Manager revealed the following expired food items in the refrigerator: 1. There were two (2) five (5) pound bags of macaroni and cheese with an expiration date of 06/03/16. 2. A five (5) pound container of potato salad with an expiration date of 06/02/16. 3. A five (5) pound bag of baked beans with an expiration date of 06/05/16. 4. A five (5) pound bag of vanilla pudding with an expiration date of 05/31/16. 5. Two 2.5 pound bags of ham with an expiration date of 06/03/16 and 6/7/16. 6. There were two (2) boxes of individual size sour cream containing 100 in each box with expiration dates of 4/15/16 and 05/30/16 and a box of 100 with 30 remaining that expired 05/23/16. 7. There were three (3) five (5) pound containers of sour cream that expired 05/23/16. 8. A five (5) pound container of cottage cheese with an expiration date of 05/12/16. 9. A container of pureed roast beef with an expiration date of 01/30/16. An interview on 06/08/16 at 9:20 AM with the Certified Dietary Manager (CDM) revealed the Supervisor is responsible for checking dates on food items and removing any that are out of date. The CDM stated it's obvious that staff have not been checking food items like they should. An interview on 06/09/16 at 11:20 AM with Dietary Worker #2 revealed, all staff are responsible for checking food to make sure it's not expired. The Dietary Worker stated when the truck comes in with food, new food is placed in the refrigerator and food items should be checked at that time for anything that might be expired and remove any expired food.

Based on observation, record review, staff interview and the facility's policy review, the facility failed to provide a therapeutic diet for one (1) resident, as ordered by the physician, for one (1) of two (2) meal observations, (Resident #4). Findings Include: Review of the facility's policy Tray Identification/Delivery/Pickup, dated 1/15, revealed accuracy of diet is verified by Nursing personnel prior to tray delivery and notify Food Services of any items missing. Review of the facility's policy Assistance with Meals, dated 02/02/15, revealed the facility staff will serve trays, validate correct diet and correct consistency of fluids. On 6/9/16 at 12:00 PM, an observation with Certified Nursing Assistant (CNA) #1 of the lunch meal for Resident #4 revealed a pureed diet with 'boost original' served. Review of the Physician orders [REDACTED].!!!!. Review of the Dietary tray card for Resident #4 revealed, Pureed diet and Boost Plus (caloric supplement). Review of the dietary nutrition labels revealed, the Boost (original) had 240 calories, and the Boost Plus had 360 calories. Review of the dietary recommendations for Resident #4, dated 3/31/(no year) revealed Pureed diet, Boost Plus all meals. On 6/9/16 at 2:05 PM, an interview with Dietary #1, revealed the kitchen staff didn't read the card correctly (for Resident #4's Boost). Dietary #1 stated she prints the tray cards every day. Dietary #1 stated when the CNA pulls the tray, she should look at the card and not just the name. If the tray is wrong staff should go to the kitchen and ask for the correct items. On 6/9/16 at 2:10 PM, an interview with Dietary #4, revealed the Boost was behind her on the tray line and she couldn't say how it got mixed up. Dietary #4 stated most of the time she separated the Boost and Boost PLUS, but must have reached back and picked up the wrong one for Resident #4. On 6/9/16 at 2:30 PM, an interview with Dietary #3, revealed she put the dessert, tea and water on the tray and looked at the tray and the ticket. Dietary #3 stated she should have made sure Resident #4's tray and tray card matched, along with everybody else. On 6/9/16 at 2:40 PM, an interview with RN #2, revealed, the Nurses and CNA's who pass out the tray are supposed to look at the tray and the tray card to check for the name, room number, diet, fluids, likes/dislikes and condiments. On 6/10/16 at 9:25 AM, an interview with Registered Nurse #1(RN) revealed, the aides are supposed to look at the tray card and make sure the tray is right. RN #1 stated Dietary and Nursing should be looking at all trays to ensure they are correct. On 6/10/16 at 9:35 AM, an interview with CNA #1, revealed she looks at the tray card ticket to make sure of the name. CNA #1 stated she had worked at the facility so long that she was familiar with resident diets. CNA #1 stated she may not have caught the Boost Plus for Resident #4 because the boxes looked a lot alike. Review of the facility's face sheet revealed, the facility admitted the resident on 6/4/14. Resident #4's [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/13/16 revealed Resident #4 had a Brief Interview of Mental Status (BIMS) score of four (4), indicating the resident had severely impaired cognition.

Based on record review and staff interview, the facility failed to develop a comprehensive care plan for activities for Resident #3; one (1) of 11 records reviewed. Findings include: Review of Resident #3's care plans revealed no care plan related to activities had been developed. Interview on 09/03/15 at 11:35 AM with the facility's Minimum Data Set (MDS) Registered Nurse (RN) revealed care plans related to activities were written either by the Activity Director or Social Services. Review of the facility's face sheet revealed Resident #3 was admitted by this facility on 06/11/15 with [DIAGNOSES REDACTED]. Review of the MDS with an Assessment Reference Date (ARD) of 06/09/15 revealed a Brief Interview of Mental Status (BIMS) with a score of 15 indicating the resident had no cognitive impairment.

Based on record review and staff interview, the facility failed to revise the care plan for wound care for Resident #3 and failed to revise level of assistance needed for Activities of Daily Living (ADLs) for Resident #6 for two (2) of 11 records reviewed. Findings include: Resident #3 Review of Resident #3's care plan for wound care revealed the care plan was last updated 8/05/15 with the following wound care: Clean with Normal Saline, pat dry, apply Vaseline gauze, wrap with gauze Monday, Wednesday, and Friday; and as needed. Review of Resident #3's physician's orders [REDACTED]. On 09/03/15 11:35 AM, an interview with Minimum Data Set (MDS) Registered Nurse (RN) stated care plans are updated each morning in daily meetings and the floor nurses also make changes to the care plans. Review of the facility's face sheet revealed Resident #3 was admitted by this facility 6/11/15 with [DIAGNOSES REDACTED]. Review of the MDS with an Assessment Reference Date (ARD) of 6/09/15 revealed a Brief Interview of Mental Status (BIMS) with a score of 15 indicating Resident #3 had no cognitive impairment. Resident #6 Review of Resident #6's care plan related to ADL assistance revealed the resident required assistance of one (1) person with dressing. Review of Resident #6's MDS with an ARD of 7/03/15 revealed this resident was assessed as needing extensive assistance of 2 people when dressing. Review of the facility's face sheet revealed Resident #6 was admitted by this facility 8/24/10 with [DIAGNOSES REDACTED]. Review of the MDS with an ARD of 7/03/15 revealed a staff assessment for decision making conducted revealed the resident had severely impaired cognition.

Based on observation, facility policy review and staff interview the facility failed to identify and remove an expired medication from Medication Cart AB for one (1) of two (2) medication carts observed. Findings include: Review of the facility's policy titled, Unusable and Outdated Drugs, with a review date of 4/15, revealed, It is the policy of (facility name) that all discontinued patient drugs, outdated drugs, contaminated drugs, improperly stored drugs and containers with worn, illegible or missing labels should be returned to the pharmacy department for proper disposal. All drug storage areas of the hospital should be inspected monthly, including automated dispensing machines and other patient care unit stock areas if applicable, for expired drugs, contaminated drugs, improperly stored drugs, and containers with worn, illegible or missing labels. The pharmacy staff member conducting the inspection should remove all of these types of drugs from the area. Observation of AB Medication Cart on 09/02/15 at 3:00 PM revealed 289 Oyster Calcium with D 500 milligram (mg) tablets with an expiration date of 9/2014 on the bottle. The label attached to the bottle on the medication reflected it was filled 1/29/15 with an expiration date of 1/29/16. An interview on 09/02/15 at 3:10 PM with Licensed Practical Nurse (LPN) #1 revealed the Oyster Calcium with D was floor stock and was filled in the hospital pharmacy. LPN #1 stated she was responsible for checking the medication cart for expired meds and had been referring to the label attached to the medication bottle for the expiration date. An interview on 09/02/15 at 4:30 PM with the Director of Nursing (DON) confirmed expiration of the medication. The DON stated nursing was responsible for checking the medication cart nightly. Pharmacy should be checking monthly and the Pharmacy Consultant checking the cart quarterly.

Based on observation, staff interview and facility policy review the facility failed to ensure confidentiality and privacy of residents as evidenced by failure to pull privacy curtains and close doors prior to medication administration for three (3) of 14 medication pass observations. (Resident #2, Unsampled Resident C) Findings include: Review of the facility's policy entitled, "General Dose Preparation and Medication Administration", dated May, 2010 revealed the staff should observe each resident's privacy by pulling privacy curtains. Observation on 08/01/14 at 7:40 AM with Licensed Practical Nurse (LPN) #1 during medication administration for Unsampled Resident C revealed LPN #1 did not pull the privacy curtain between the occupied beds before administrating insulin. Observation on 08/01/14 at 9:40 AM with LPN #1 during medication administration for Unsampled Resident C revealed LPN #1 did not close the resident's door before giving medications. Interview on 08/01/14 at 9:40 AM with LPN #1 revealed, "I guess I should have pulled the curtain and closed the door but I was just so nervous. I forget." Observation on 08/01/14 at 9:55 AM with LPN #2 during medication administration for Resident #2 revealed LPN #2 did not close the resident's door before giving medications. Interview on 08/01/14 at 9:55 AM with LPN #2 revealed "I just forgot". Interview on 08/01/14 at 4:30 PM with the Director of Nursing (DON) concerning privacy during medication pass revealed no comment by the DON. The DON wrote on paper and shook head.

Based on observation and staff interview, the facility failed to ensure dignity of residents as evidenced by residents were served meals on disposable dishware during two (2) of three (3) meal observations. Findings include: Observation of Resident #3's dinner meal on 07/31/14 at 5:15 PM, revealed the Dietary Department served greens to the resident in a disposable bowl. The Dietary Department also served four (4) residents on A Hall vegetables in disposable bowls during the dinner meal observation on 07/31/14 at 5:00 PM. Observation of the Dietary Department on 08/01/14 at 11:15 AM, revealed dietary staff served coleslaw in disposable bowls. Observation, during same date and time, revealed clean empty bowls in clean dish area. Interview with Dietary Staff #1 on 08/01/14 at 11:15 AM, confirmed coleslaw was prepared and placed in individual disposable containers for services to residents. Interview with Dietary Manager (DM) on 08/01/14, at 11:45 AM, confirmed the facility had enough bowls and dishes to serve residents during mealtime, but dietary staff instead utilized disposable dishware. The DM confirmed standard dishes should have been utilized instead of disposable dishware. The facility admitted Resident #3 on 06/18/13. Resident #3's [DIAGNOSES REDACTED]. Review of Resident #3's most recent Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 06/03/14, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 03, indicating impaired cognition. The facility failed to provide a policy regarding dignity during mealtime.

Based on observation, staff interview and facility policy review, the facility failed to properly secure medications during medication administration for one (1) of two (2) days of survey as evidenced by medication cart left unlocked with medications left unattended on top of the medication cart. Findings include: Review of the facility's policy entitled, "General Dose Preparation and Medication Administration", dated May, 2010, revealed facility staff should not leave medications unattended, and the facility should ensure medication carts are always locked when out of sight or unattended. Observation on 08/01/14 at 9:30 AM with Licensed Practical Nurse (LPN) #1 revealed LPN #1 failed to lock the medication cart ad left the cart unattended while giving medications to Unsampled Resident D. Interview on 08/01/14 at 9:30 AM with LPN #1 revealed the medication cart drawers open if the drawers not all lined up and the cart would not lock. LPN #1 stated she reported it to the Director of Nursing but could not recall the date. Observation on 08/01/14 at 9:55 AM with LPN #2 during medication administration for Resident #2 revealed LPN #2 left a container of MVI with M (Multivitamin with Minerals) on top of medication cart while cart was unattended. An interview on 08/01/14 at 9:55 AM with LPN #2 confirmed medication was left on top of cart. Observation on 08/01/14 at 4:00 PM with LPN #1 during medication administration for Unsampled Resident A revealed LPN #1 left the medication cart unlocked and unattended while giving medication.