Every finding on record at Stone County Rehabilitation and Nursing CTR Inc

Based on observation, interview, and facility policy review, the facility failed to store and serve food in accordance with professional standards for food safety related to two (2) opened spice bottles on the spice rack, changing gloves without hand washing and the cook dropping food on the service line counter then picking it up and placing it on the residents plate for 2 of 2 kitchen observations. Findings include: A review of the facility's policy, Preventing Foodborne Illness-Food Handling revised August 2018, revealed, .1. This facility recognizes that the critical factors implicated in foodborne illness are: a. Poor personal hygiene of food services employees . A review of the facility's policy, Food Receiving and Storage revised July 2014, revealed, Foods shall be .stored in a manner that complies with safe food handling practices .opened containers must be .sealed or covered during storage. On 05/27/25 at 10:14 AM, during an observation and interview of the kitchen with the Registered Dietician and Nutritionist (RDN), on the spice rack 2 bottles of spices were left opened, leaving the spices exposed. On 05/28/25 at 11:11 AM, during an observation and interview with the Cook, a piece of cubed chicken fell and landed on the service line counter. The [NAME] picked the chicken up from the service line counter and placed it on the resident's plate. Throughout the lunch service the [NAME] was observed changing gloves on three occasions without washing hands before donning new gloves. The [NAME] acknowledged that she dropped the cubed chicken pieces and placing them on the plate and that she failed to wash her hands before putting on new gloves. The [NAME] confirmed it is her responsibility to maintain a sanitary environment. The [NAME] stated she has been trained and knows the correct way to operate in the kitchen. The [NAME] affirmed that the staff receive in-service training once a month on the topic of food safety. On 05/28/25 at 12:34 PM, in an interview with the Interim Administrator revealed she acknowledged the opened spice bottles, the [NAME] failing to wash her hands between glove changes and the [NAME] picking up food from the counter of the food line and placing the food back on the resident's plate. The Administrator stated as the interim supervisor for the kitchen she is responsible for maintaining safety in the service and storage of food. The Interim Administrator stated the staff will be in-serviced and going forward she expects excellent service from the kitchen staff.

Based on interviews, record review, and facility policy review, the facility failed to honor a resident's rights by limiting the resident's visiting hours without clinical or safety reasons for doing so for one (1) of (12) sampled residents residing in the facility. Resident #22 Findings Include: Review of the facility's policy, Policy: Resident Right to Access and Visitation, revised 3/8/23, revealed .It is the policy of this facility to support and facilitate the resident's right to receive visitors of their choosing, at the time of their choosing, subject to the resident's right to deny visitation when applicable, and in a manner that does not impose on the rights of other residents. Visitation will be person centered, consider the residents' physical, mental, and psychosocial well-being, and support their quality of life .Policy Explanation and Compliance Guidelines .2 .Resident's family members are not subject to visiting hours limitations or restrictions not imposed by the resident, with the exception of reasonable clinical and safety restrictions, placed by the facility according to CDC (Centers for Disease Control) guidelines, and/or our local health department recommendations .11. The facility will ensure all visitors enjoy full and equal visitation privileges consistent with resident preferences . During an interview on 1/23/24 at 2:49 PM, Resident #22 complained that the facility refused to allow her husband to stay with her at night. The resident said she does not feel comfortable being in the facility by herself. During an interview on 1/23/24 at 2:52 PM, with Resident #22's husband, he stated that he received phone calls from his wife during the night because she had difficulty sleeping. He said that she was not accustomed to being by herself and he had requested a private room so he could stay with her more often without disturbing another resident. However, after his wife was moved to a private room, the facility still did not permit him to stay with his wife during the nighttime hours. He commented that he had talked to the Director of Nursing (DON), floor staff, the social worker, and everybody that would listen to him because he wanted to be able to stay during the night. He said his wife would call him at night very confused and upset and he would have to drive back to the facility at night to try to calm her down. During an interview on 1/24/24 at 8:00 AM, with License Practical Nurse (LPN) #1, she said Resident #22's husband had expressed that he wanted to stay with the resident at night because she was not used to sleeping alone. LPN #1 said the facility did not allow residents' families to stay in the facility at night and revealed the husband kept Resident #22 calm when she was confused or did not participate with care. LPN #1 stated that the husband did not bother anyone and he stayed in his wife's room and assisted with her needs. During an interview on 1/24/24 at 9:00 AM, with Resident #22's daughter, she said that her mother was confused, tried to get out of bed without assistance, and did not sleep unless there was family around. Her father had asked the facility to allow him to stay with her during the night to help Resident #22 sleep. The daughter said that previously Resident #22 was in a semiprivate room, but there was no other resident in the room. The facility complained because the husband slept in the empty bed, so he requested a private room so he could stay with the resident because of her confusion. The facility placed Resident #22 in a private room, so the daughter brought in a recliner for her father to have a comfortable chair, but the facility still did not allow him to stay. The daughter said her father would leave the facility during the night and sleep in his truck in the parking lot for two or three hours and come back into the facility just so the facility would not say he was staying overnight. The daughter explained that not only would Resident #22 call her father during the night, but the facility would also call her father at night when Resident #22 became confused and would not sleep. The daughter said that her father was [AGE] years old, and she did not like him to be driving up and down the road at all times of the night. The daughter commented that her mother was calm and rested better when her father was there. During an interview on 1/24/24 at 12:30 PM, with Certified Nursing Aide (CNA) #1, she said Resident #22's husband had complained that the facility would not allow him to stay with his wife during the night. CNA #1 said the facility does not allow families to stay all night. CNA #1 stated that Resident #22's husband assisted the resident with her needs and helped her to stay calm when she had periods of confusion. During an interview on 1/24/24 at 2:00 PM, with the Social Services Director (SSD), she confirmed Resident #22's husband had complained about not being able to stay with his wife during the night. The SSD stated that the resident was originally in a semiprivate room, which would have interfered with the privacy of a roommate. She confirmed that the resident was given a private room on 1/5/2024 at the husband's request and she was not aware that the facility staff were still not allowing the husband to stay with the resident. The SSD confirmed she had not talked with the Administrator or the other facility staff to ensure the resident's husband had been allowed to stay with the resident during the night since obtaining the private room and she would get with the Administrator, DON, and other staff members to have this corrected as soon as possible. During an interview on 1/24/24 at 2:15 PM, with the Care Plan Nurse/LPN #2, he confirmed Resident #22's husband complained in a care plan meeting about the facility not allowing him to stay in the room with his wife at night. LPN #2 said the Resident's husband had commented that the resident would not sleep without his being there and she was confused and acted out at night. LPN #2 said he advised the husband that he would need to work something out with the Administrator and the DON. During an interview on 1/24/24 at 2:30 PM, with the Administrator and the DON, they confirmed the facility limited the time Resident #22's husband could stay with her. The Administrator said she was under the impression the resident's husband wanted to move in. The Administrator also confirmed the resident was a short-term resident at the facility and was there for skilled therapy. The Administrator stated that families were discouraged from staying overnight with the residents. The DON stated that after Resident #22 was moved into a private room, her husband did not ask about staying overnight. The DON and Administrator confirmed they did not follow up with the resident's husband regarding staying with the resident overnight. A record review of the Face Sheet revealed the facility admitted Resident #22 on 12/15/23 with a diagnosis of Nontraumatic Hematoma of Soft Tissue. A record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/22/23 revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated her cognition was severely impaired.

Based on interviews, record review, and facility policy review, the facility failed to ensure residents had access to their personal funds on weekends for two (2) of 17 residents reviewed with a personal fund account (Resident #11 and Resident #34). This deficient practice had the potential to affect all 17 residents with a personal trust fund account. Findings include: Review of the facility's policy, Resident Trust Fund, revised 3/23/23, revealed, Policy: The resident has a right to manage his or her financial affairs .After Business Hours . 1. Residents will have reasonable access to their personal funds after business office hours. On 1/24/24 at 1:00 PM, during the Resident Council Meeting, Resident #11, and Resident #34 reported they were not able to withdraw their personal funds on Saturday and Sunday. They explained they were told to ask a certain nurse if they wanted money on the weekend but were unable to recall the nurse's name. Both residents reported they did not have clear information from the facility on how to get their money on the weekend. Record review of the Open Balance Report, with Balances as of 1/24/2024, revealed Resident #11 and Resident #34 had a personal trust fund account at the facility. On 1/24/24 at 2:02 PM, an interview with the Business Office Manager (BOM) revealed she worked Monday through Friday and was the only person designated to dispense funds to the residents from their personal accounts. The BOM revealed if a resident wanted money from their account for the weekend, they should get the money on Friday. The BOM stated if a resident requested money from their account on a weekend, she could be contacted by a nurse, and she would come to the facility to dispense the funds. The BOM acknowledged there was no staff member designated to dispense funds to the residents on Saturday and Sunday. On 1/24/24 at 2:07 PM, in an interview with the Administrator, she acknowledged there was no staff member designated to dispense funds to residents on Saturday and Sunday. The Administrator reported the facility once had a system in place to allow the residents to withdraw funds on Saturday and Sunday, whereby a designated nurse would have a locked box on the medication cart with $100 for residents who wanted to get their money. The Administrator stated the facility stopped this practice because it was seldom used. The Administrator stated her expectation was for residents to have access to their money on the weekends. The Administrator stated she would resume the facility's past practice of designating a nurse to keep a locked box with $100 on a medication cart in the event resident funds needed to be dispersed on the weekend. Resident #11 A record review of the Face Sheet revealed the facility admitted Resident #11 on 07/07/21 with diagnoses that included Parkinson's Disease. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/15/23 revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact. Resident #34 A record review of the facility's Face Sheet revealed the facility admitted Resident #34 on 08/18/21 with diagnoses that included Alzheimer's Disease. A record review of the Quarterly MDS with an ARD of 01/19/24 revealed Resident #34 had a BIMS score of 9, which indicated his cognition was moderately impaired.

Based on interview, record review, and facility policy review, the facility failed to provide written notification of the facility's bed hold policies to a resident or the Resident Representative (RR) upon the resident's transfer to the hospital for (1) of two (2) residents reviewed for hospitalization . Resident #10 Findings include: A review of the facility's Bed Hold Policy, revised 2/20/2023, revealed, Policy: It is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold policies prior to transferring a resident to the hospital or the resident goes on therapeutic leave .6. The facility will provide this written information to all facility residents . On 1/23/24 at 2:42 PM, a phone interview with RR revealed the facility did not provide her with written notification regarding the facility's bed hold policies when he was transferred to the hospital. A record review of the facility's Notice of Facility Initiated Transfer of Discharge, dated 7/22/23, for Resident #10, revealed he was sent to an acute care hospital for shortness of breath on 7/22/23. A review of the medical record revealed there was no documentation indicating the resident or the RR was provided with the facility's bed hold policies when Resident #10 was transferred to the hospital on 7/22/23. On 1/24/24 at 7:25 AM, an interview with the Director of Nursing (DON) revealed the facility sent a Transfer/Discharge Summary to the RR. The DON reported there was no bed hold notification provided to the RR in writing. The DON acknowledged the facility did not have an established written notification of the facility's bed hold policies to send to the resident or the RR in the event the resident is transferred to the hospital. On 1/25/24 at 8:35 AM, an interview with the Assistant Administrator (AA) revealed she was responsible for sending out Transfer/Discharge notifications to the resident or the RR. She stated that the bed hold policies are covered as part of the admission process when a resident is admitted to the facility. The AA reported that most of the time the RR would get a phone call regarding bed hold. The AA acknowledged that there was no written notification of the bed hold policies provided to the resident or the RR when resident is transferred to the hospital. On 1/25/24 at 10:00 AM, in an interview with the Administrator, she stated that her expectation moving forward was to provide clear communication regarding the facility's bed hold policies, in writing, to the resident or the RR when a resident is transferred to the hospital. The Administrator stated the facility will generate a form to be used immediately. A record review of the Face Sheet revealed the facility admitted Resident #10 on 06/23/22 with diagnoses that included Vascular Dementia.

Based on interviews, record review, and facility policy review, the facility failed to implement the baseline care plan interventions related to the equipment required for ambulating a resident and the assistance required for toileting for one (1) of four (4) residents care plans reviewed. Resident #1. Findings Include: A record review of the facility's Baseline Care Plan policy, dated 2/16/23, 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. The admitting nurse, or supervising nurse on duty, shall gather information from the admission physical assessment, hospital transfer information, physician orders .b. interventions shall be initiated that address the resident's current needs including i. Any health and safety concerns to prevent .injury, such as .fall . A record review of the Baseline Care Plan, dated 8/11/23, revealed Resident #1 required the assistance of one staff member for walking and toileting and indicated the equipment to be used as a wheelchair or Front Wheeled [NAME] (FWW). A record review of the PT (Physical Therapy) & Plan of Treatment, dated 8/11/23, revealed, .Prior Equipment Prior to Onset: Cane, rollator, tub chair and grab bars .Functional Mobility Assessment .Resident uses a wheelchair? = Yes . During an interview, on 8/31/23 at 11:40 AM, CNA #1 confirmed that on 8/13/23 she assisted Resident #1 to the restroom and did not use a walker or wheelchair. She explained that he ambulated himself but held on to her arm for stability and he had a slow, unsteady gait while walking to the toilet. She stated that she gave him the call bell and advised him to call when he needed assistance back to bed. She then closed the bathroom door for privacy and left the resident's room. CNA #1 explained that after approximately five (5) minutes, his call light came on and she returned to the resident's room. She opened the bathroom door and Resident #1 was sitting on the toilet. He stated that he had fallen off the toilet and had gotten himself back onto the toilet without assistance. He complained of left leg pain at that time. CNA #1 said that the staff reviewed the baseline care plan on the kiosk to determine how much assistance is required to safely ambulate and toilet residents. She confirmed that she did not review the kiosk because a night shift CNA had reported to her that the resident could ambulate without a walker or wheelchair. Record review of Departmental Notes, Category Nurses Notes dated 8/13/23 at 9:41 AM, revealed .Resident was sent out to (Proper Name of Local emergency room ) (ER) via (Proper Name of Ambulance Service) .ER nurse called back at 09:40 stating resident's hip was out of place . During an interview on 8/31/23 at 12:57 PM, with the Physical Therapist (PT), he stated Resident #1 needed the assistance of one staff member for toileting, transferring and ambulating and recommended the use of a wheelchair or walker for safety. He confirmed that he expected the facility staff to follow his recommendations. During an interview on 8/31/23 at 1:06 PM, with the Physical Therapy Assistant (PTA), she confirmed that she reviewed the Occupational Therapy and Physical Therapy recommendations and completed the base care plan to indicate the level of assistance required with ambulation, transfers, and mobility. The PTA recommended that Resident #1 have assistance from one person with either a walker or wheelchair for ambulation. She confirmed she expected that if a wheelchair or walker was recommended, then the staff should follow the care plan for the resident's safety. On 8/31/23 at 1:23 PM, an interview with the Director of Nurses (DON) revealed that it was her expectation that the nursing staff follow the care plans of all residents because the care plans provided a detailed and effective personalized outline of the care for the residents. On 8/31/23 at 2:21 PM, an interview with the Care Plan Nurse confirmed that staff should follow the care plans for residents' dignity, integrity, and safety. He reported that care plans were developed for individualized care and to ensure consistency in the nursing care of the resident, which helped improve services. He added that he expected all nursing staff in the facility to follow care plans for the residents. A record review of the Face Sheet revealed the facility admitted Resident #1 on 8/11/23 with diagnoses including Left Femur Fracture, Presence of Left Artificial Hip Joint, Hemiplegia following Cerebral Infarction affecting Left Side, and History of Falling.

Based on interviews, record reviews, and facility policy review, the facility failed to use the appropriate equipment during ambulation and provide adequate supervision to prevent an injury for one (1) of three (3) sampled residents, as evidenced by a resident who had a fall, sustained a left hip dislocation, and required hospitalization after he was ambulated without a walker or wheelchair and left unsupervised on the toilet. (Resident #1) Findings include: A review of the facility policy, Incidents and Accidents, dated 5/13/23, revealed .It is the policy of this facility for staff to report, investigate and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident . A record review of the facility-reported investigation, dated 8/16/23, revealed, .Summary: On 8/13/23 (Proper name of Resident #1) was assisted to the toilet by a CNA (Certified Nurse Aide). CNA left room and returned when his call light came on again. CNA went to his restroom where (Proper name of Resident #1) was seated on the toilet. (Proper name of Resident #1) stated that he fell off the toilet . A record review of the Resident Incident Report revealed the Incident Type as Fall/Unobserved and the Date/Time was listed as 8/13/23 08:00 AM. Further review revealed that the Narrative of incident and description of injuries indicated Resident stated after CNA put him on the toilet, he fell and had put himself back on the toilet before CNA returned to room. Resident Condition at Time of Incident revealed Mobility as WC (Wheelchair) - non-motorized. Medical risk factors indicated Fall History and Fracture/Amputee and Activity at time indicated To/frm (from) bathrm (bathroom)-alone . A record review of the Diagnostic Imaging report, dated 8/13/23, from a local acute care hospital revealed, History: Hip pain status post fall, with a history of recent surgery and Impression: Superior dislocation of a left hip arthroplasty, without discrete or displaced fracture . A record review of Departmental Notes, for Resident #1, dated 8/11/23 at 12:32 PM, revealed a Nurse Notes that indicated, .Weakness noted to BLE (Bilateral Lower Extremities) mobility via wheelchair . A record review of Departmental Notes, for Resident #1, dated 8/12/23 at 11:24 AM, revealed a Nurse Notes that indicated, .Transfer x 1. Needs assist with ADL's (Activities of Daily Living) . Record review of Departmental Notes, Category Nurses Notes dated 8/13/23 at 9:41 AM, revealed .Resident was sent out to (Proper Name of Local emergency room ) (ER) via (Proper Name of Ambulance Service) .ER nurse called back at 09:40 stating resident's hip was out of place . A record review of the PT (Physical Therapy) & Plan of Treatment, dated 8/11/23, revealed, .Patient Referral and History Current Referral Reason for referral/current illness: Patient is a 90 yo (year old) male who suffered a fall in his garden on 7/23/23 resulting in a L (Left) displaced femoral fx(fracture) .Medical Factors Precautions: Falls risk .Fall Risk Assessment History of Falls Has Patient fallen in past year? = Yes How many times? = 6 .Steadiness Does Patient feel unsteady when standing? = Yes Does Patient feel unsteady when walking? = Yes .Does Patient worry about falling? = Yes .Functional Mobility Assessment .Resident uses a wheelchair? = Yes .Reason for Therapy Clinical Impressions/Reason for Skilled Services: Skilled services required to address deficits in strength, endurance and balance affecting safety with functional mobility . Record review of the Nurse Data Collection and Screening document for Resident #1, dated 8/11/23, revealed, Risk: Fall Risk Form .History of Falls 3 or more falls in past 3 months . On 8/31/23 at 11:40 AM, in an interview with CNA #1, she confirmed that on 8/13/23, before breakfast trays were delivered, she assisted Resident #1 without his walker to the restroom. She said that he ambulated himself but held on to her arm for stability and he had a slow, unsteady gait while walking to the toilet. She stated that she gave him the call bell and advised him to call when he needed assistance back to bed. She then closed the bathroom door for privacy and left the resident's room. CNA #1 explained that after approximately five (5) minutes, his call light came on and she returned to the resident's room. She opened the bathroom door and Resident #1 was sitting on the toilet. He stated that he had fallen off the toilet and had gotten himself back onto the toilet without assistance. He complained of left leg pain at that time. CNA #1 said that the staff is supposed to review the baseline care plan on the kiosk to determine how much assistance is required to safely ambulate and toilet residents. She confirmed that she did not review the kiosk because a night shift CNA had reported to her that the resident could ambulate without a walker or wheelchair. On 8/31/23 at 12:57 PM, an interview with the Physical Therapist (PT) revealed that Resident #1 needed the assistance of one staff member for toileting, transferring and ambulating. The PT also recommended the use of a wheelchair or walker for safety and confirmed that he expected the facility staff to follow his recommendations. On 8/31/23 at 1:06 PM, an interview with the Physical Therapy Assistant (PTA) confirmed that she reviewed the Occupational Therapy and Physical Therapy recommendations and completed the base care plan to indicate the level of assistance required with ambulation, transfers, and mobility. The PTA recommended that Resident #1 have assistance from one person with either a walker or wheelchair for ambulation. On 9/1/23 at 11:28 AM, during an interview with the Director of Nurses (DON), she stated that Resident #1 was assisted without his walker to the bathroom by CNA #1 and he had been left alone in the bathroom. The resident reported that he had fallen and gotten himself back up to the toilet without any assistance. She revealed that according to CNA #1, the resident requested privacy and she felt she could leave him alone in the bathroom. The DON confirmed that CNA #1 should have used a walker or wheelchair as per the care plan to assist Resident #1 with walking to the restroom. On 9/1/23 at 11:48 AM, an interview with the Administrator revealed that on 8/13/23, Resident #1 was assisted to the toilet by CNA #1 and the resident stated that he had fallen and gotten back onto the toilet within approximately three (3) minutes. On 9/8/23 at 2:00 PM, in an interview with CNA #1, she confirmed that even though Resident #1 was a new admission, had a slow and unsteady gait, a history of falls, and a diagnosis of Hemiplegia, she thought that because he had asked for privacy and he was alert and oriented, she could leave him unsupervised while on the toilet, and walk away from the resident's room. CNA #1 also confirmed because Resident #1 reported that he had fallen and had left leg pain, she used a wheelchair and transferred the resident from the toilet to the wheelchair and assisted him to his bed. On 9/8/23 at 2:30 PM, an interview with the DON revealed that she expected new residents who required assistance with toileting to be supervised and not left alone. She confirmed that CNA #1 should not have left the resident in his bathroom alone and unsupervised. On 9/8/23 at 4:00 PM, during an interview with Registered Nurse (RN) #2 revealed, that on 8/13/23, LPN #1 informed her that Resident #1 had reported that he had fallen off the toilet, but that he put himself back on the toilet without any assistance. RN #2 said that Resident #1 was back in his bed at that time and complained of left hip pain. She described Resident #1 as weak and confused. RN #2 notified the Nurse Practitioner (NP) of the allegation of a fall and the resident's pain and the NP gave an order to send Resident #1 to the local Emergency Department (ED) for evaluation and treatment. A record review of the Face Sheet revealed the facility admitted Resident #1 on 8/11/23 with diagnoses including Left Femur Fracture, Presence of Left Artificial Hip Joint, Hemiplegia following Cerebral Infarction affecting Left Side, and History of Falling. A record review of the Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/13/23 revealed Resident #1 was admitted by the facility on 8/11/23 from an inpatient rehabilitation facility. He was discharged to an acute hospital on 8/13/23, which was two (2) days after his admission to the facility.

Based on interviews, record review, and facility policy review, the facility failed to notify the physician of blood glucose readings of 60 or below for one (1) of two (2) residents reviewed for glucose readings. Resident #4. Findings Include: Record review of the facility's policy, Hypoglycemia Management policy, dated 3/27/23, revealed, .It is the policy of this facility to ensure effective management of a resident who experiences a hypoglycemic episode .Compliance Guidelines .5. If the blood glucose reading is 60 mg/dL(milligrams/deciliter) or below, the nurse will utilize the hypoglycemia protocol as per the practitioner's orders, with follow up blood glucose as indicated, and notify the practitioner of the results as ordered . Record review of the Face Sheet revealed the facility admitted Resident #4 on 8/5/23 with a diagnoses that included Type 2 Diabetes Mellitus. Record review of the Physician Orders for the month of August 2023 revealed there were no physician orders for routine accu-checks after 8/16/23. Record review of the Therapeutic Protocols revealed there were standing Physician Orders for Hypoglycemia as follows: Obtain accu-check, if Blood Glucose (BG) less than 60 and resident is able to swallow, give four (4) ounces of milk/juice or one (1) pack of Insta Glucose. If resident is unable to swallow, give Glucagon one (1) Milligram (MG) Intramuscular (IM). Recheck accu-check in 15 minutes (mins). Notify Medical Doctor (MD)/Nurse Practitioner (NP) if BG is still less than 60. Record review of the Departmental Notes revealed there was a Nurse Notes, completed by Licensed Practical Nurse (LPN) #3, dated 8/26/23 at 3:15 AM, for .glucose reading was 49 . After about 30 minutes I rechecked his glucose and his reading at that time had increased to 72. Record review of the Departmental Notes revealed, on 8/31/23 at 6:11 AM, .Glucose this am was 55 . Rechecked @ 0600 and only increased to 56. 0600 this am A tube of Instaglucose was given and will inform oncoming nurse to recheck in about 30 minutes . Signed by: LPN #3 On 9/7/23 at 1:00 PM, an interview with the NP confirmed that when a resident has a BG of less than 60, she expected the staff to follow the therapeutic protocol, but to notify her when they use the protocol. She conveyed she was not notified of Resident #4's BG results of less than 60 at any time. On 9/8/23 at 12:28 PM, an interview with the Director of Nurses (DON), she revealed that on 8/26/23 and 8/31/23, Resident #4 had a BG result of less than 60 and although the staff followed the therapeutic protocols, or standing orders, a Physician's Order should have been written and the physician should have been notified. The DON stated that she expected staff to write a Physician's Order with the date and time and follow through with the order onto the medical record, including the Medication Administration Record (MAR) when they are utilizing therapeutic protocols. She confirmed the staff did not write orders for the therapeutic protocol or notify the physician. On 9/8/23 at 12:30 PM, an interview with License Practical Nurse (LPN) #3 revealed she used the Therapeutic Orders for Resident #4 when his blood sugar was less than 60 on 8/26/23 and 8/31/23. She explained that she did not get a repeat BG within 15 minutes as per the orders and did not notify the physician on 8/31/23 when his repeat BG reading was less than 60. She confirmed that she did not write a Physician's Order for the Therapeutic Protocol for Hypoglycemia. On 9/8/23 at 1:44 PM, an interview with the facility's Pharmacist revealed that if a resident had a BG result of less than 60, the nurse should notify the physician.

Based on observation, staff interviews, record review and facility policy review, the facility failed to follow the Comprehensive Care Plan by not providing pain medication prior to wound care for one (1) of three (3) wound care plans reviewed, Resident #31. Findings Include: Review of the facility's policy, Care Plans - Comprehensive, revision date June 2021, revealed, An individualized comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident .Policy Interpretation and Implementation: Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her familial representative (sponsor), develops and maintains a comprehensive care plan. The comprehensive care plan is based on an assessment that includes, but is not limited to, the Minimum Data Set (MDS). The comprehensive care plan must describe the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, and psychological well-being . A record review of Resident #31's Comprehensive Care Plan, dated 2/5/21, revealed he has an alteration in comfort related to mild pain, arthritis, a history of muscle spasms, and a history of wounds. The care plan goal is Resident #31 will express relief of pain after receiving pain relieving measures. The care plan interventions include: Pain assessment as needed, allow adequate time for pain medications to take effect prior to resuming care and/or treatment. Medications documented on the care plan include Tylenol and [MEDICATION(S)] and to document effectiveness of these pain medications as needed. On 8/4/21 at 11:05 AM, the SA observed wound care on Resident #31 by Registered Nurse #3 (RN). RN #3 was assisted by Certified Nursing Assistant #1(CNA). RN #3 did not assess Resident #31 for pain prior to beginning wound care. Resident #31 started to complain about pain during the wound care to his left hip. RN #3 continued with the wound care even though Resident #31 had complained of pain. Upon completing the wound care to the left hip, RN #3 began wound treatment to Resident #31's sacrum. Resident #31 had facial grimacing and stated repeatedly that his butt was hurting. RN #3 continued with the wound care to the sacrum and did not stop to offer pain medication to the resident. The SA asked RN #3 if Resident #31 had any pain medication and she replied that she knew he did not have any thing (pain medication) scheduled to take today. RN #3 continued with the dressing change to the sacrum after being asked by SA. RN #3 measured the wound with a ruler and used a cotton tipped applicator to check the depth of the wound. The wound measured 3.50 cm length x 2.50 cm width with depth of 0.2 cm. Resident #31 continued to repeat my butt hurts really bad. After RN #3 had completed the wound care, Licensed Practical Nurse (LPN) #1 entered the room with [MEDICATION(S)] 50 milligram (mg) crushed in chocolate pudding for Resident #31. LPN #1 asked Resident #31 what his pain level was on a scale of one (1) to ten (10) and he replied it was a ten (10). Resident #31 took [MEDICATION(S)] in the pudding. RN #3 and CNA #1 asked Resident #31 if they could change his brief after he received his pain medication, but he repeatedly declined and stated his butt was hurting. On 8/5/21 at 1:56 PM, in an interview with RN #3, she stated the Comprehensive Care Plan is used to see what kind of care we are going to provide to the resident. She stated she did not follow the care plan and confirmed that it is very important to follow the care plan. On 8/5/21 at 2:10 PM, in an interview with RN #4, she stated the care plan is used for communicating with the rest of the staff about resident care. She further explained the care plan tells the staff what they should be following and resident orders are on the care plan. RN #4 stated the care plan tells the staff everything that is going on with the resident. She confirmed RN #3 did not follow the care plan regarding wound care. She stated it is very important you follow the care plan. She also confirmed that an assessment for pain should be completed prior to wound care and it is important to follow up with the resident to ensure pain is relieved. On 8/5/21 at 2:24 PM, in an interview with the Assistant Director of Nursing (ADON), she stated the care plan is used for resident care and it tells you how to care for the resident and the goals for residents. She stated it is the process for taking care of the resident for their best interest. She confirmed RN #3 did not follow the care plan. On 8/5/21 at 2:35 PM, in an interview with the Director of Nursing (DON), she stated the care plan is used as a guide for the staff in the care of the resident. She confirmed RN #3 did not follow the care plan and stressed the importance of following the care plan.

Based on observation, interviews, record reviews and facility policy review the facility failed to medicate the resident prior to providing wound care for one (1) of three (3) wound care observations Resident #31. Findings Include: Review of the facility's policy, Pain Management , dated 2020, revealed, Policy: The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences . The facility will utilize a systematic approach for recognition, assessment, treatment and monitoring of pain .1. In order to help a resident attain or maintain his/her highest practicable level of physical, mental, and psychosocial well-being and to prevent or manage pain, the facility will: a. Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated. b. Evaluate the resident for pain upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurs (e.g., after a fall, change in behavior or mental status, new pain, or an exacerbation of pain) c. Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences .3. Facility staff will be aware of verbal descriptors a resident may use to report or describe their pain. Descriptors include but are not limited to: d. Hurting or aching .Pain Assessment: .2. Based on professional standards of practice, an assessment or evaluation of pain by the appropriate members of the interdisciplinary teams (e.g., nurses, practitioner, pharmacists, and anyone else with direct contact with the resident) may necessitate gathering the following information, as applicable to the resident: .b. Asking the patient to rate the intensity of his/her pain using a numerical scale, a verbal or visual descriptor that is appropriate and preferred by the resident. Review of Resident #31's Physician Orders, dated August 2021, revealed orders for the following, Acetaminophen 325 milligram (mg) tablet 650 MG by mouth every four (4) hours as needed for pain/ fever, dated 7/14/21; Pressure ulcer of sacral region, stage 2 to sacrum wound, cleanse with normal saline, pat dry, apply promogram to wound bed, cover with dry foam dressing, change every 72 hours; Pressure ulcer of left ankle, unstageable to left malleolus wound cleanse with normal saline pat dry, apply [MEDICATION(S)] to wound bed. Cover with dry foam dressing. Change every 72 hours, dated 7/30/21; Pressure ulcer of the left hip stage 2 Santyl ointment cleanse left hip wound with normal saline pat dry using 4X4 gauze, apply Santyl to wound bed daily and cover with dry dressing, dated 8/4/21. On 8/4/21 at 11:05 AM, the SA observed wound care on Resident #31 by Registered Nurse #3 (RN). RN #3 was assisted by Certified Nursing Assistant #1(CNA). RN #3 did not assess Resident #31 for pain prior to beginning wound care. Resident #31 started to complain about pain during the wound care to his left hip. RN #3 continued with the wound care even though Resident #31 had complained of pain. Upon completing the wound care to the left hip, RN #3 began wound treatment to Resident #31's sacrum. Resident #31 had facial grimacing and stated repeatedly that his butt was hurting. RN #3 continued with the wound care to the sacrum and did not stop to offer pain medication to the resident. The SA asked RN #3 if Resident #31 had any pain medication and she replied that she knew he did not have any thing (pain medication) scheduled to take today. RN #3 continued with the dressing change to the sacrum after being asked by SA. RN #3 measured the wound with a ruler and used a cotton tipped applicator to check the depth of the wound. The wound measured 3.50 cm length x 2.50 cm width with depth of 0.2 cm. Resident #31 continued to repeat my butt hurts really bad. After RN #3 had completed the wound care, Licensed Practical Nurse (LPN) #1 entered the room with [MEDICATION(S)] 50 milligram (mg) crushed in chocolate pudding for Resident #31. LPN #1 asked Resident #31 what his pain level was on a scale of one (1) to ten (10) and he replied it was a ten (10). Resident #31 took the [MEDICATION(S)] in the pudding. RN #3 and CNA #1 asked Resident #31 if they could change his brief after he received his pain medication, but he repeatedly declined and stated his butt was hurting. A review of the August 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/4/21 at 5:03 PM, in an interview with RN #3, the Wound Care Nurse, she admitted she should have asked Resident # 31 about his pain his level before she started wound care. She stated she does not know why she did not ask the resident. She stated, I don't if it was because I was nervous, and that she continued with wound care because she did not want to leave the wound open. She stated it is more important that the resident not be in pain during wound care than being concerned about the wound being uncovered. She stated she should have stopped the wound care and got the resident some pain medication immediately. She confirmed that pain can have a negative effect on the resident and she knew he did not have any scheduled or routine pain medications ordered by the physician. On 8/4/21 at 5:14 PM, in an interview with License Practical Nurse #1 (LPN), Admissions Coordinator, stated she contacted the Nurse Practitioner (NP) because she felt as if the resident needed something for pain and that is why she gave him the [MEDICATION(S)] 50 mg. The [MEDICATION(S)] 50 was a one time order. She stated she went back to check on the resident after giving him medication and he was fine. She stated RN#3 should have given him pain medication as soon as Resident #31 complained of pain. She stated she felt like the Tylenol that was ordered would not help with the pain and she believed something was hurting him since he said his pain level was a 10. She stated it is unusual for Resident #31 to yell out during wound care. She confirmed RN #3 should have stopped the care and gave the resident pain medication when he first complained of pain. She stated that during wound care when a resident is in pain, it can cause the resident to have mental changes. She stated the resident's wound cannot heal properly if he is in pain during care and may cause a resident to refuse wound care the next time. She stated when a resident refuses wound care that it can lead to an infection. On 8/4/21 at 5:43 PM, in an interview with RN#1, Director of Nursing (DON), stated she spoke with RN #3 regarding giving pain medication prior to wound treatments. She stated RN #3 told her she felt bad because she did not stop the wound care when Resident #31 was in pain. She stated RN #3 should have assessed the resident for pain before starting wound care. She stated when a nurse is doing wound care and the resident is in pain, the nurse should stop the wound care, and give pain medication, and then proceed after the resident has received medication. She stated the wound care nurse should have asked the resident's LPN to administer his pain medication and then let her know so that she may provide wound care. She stated by not administering pain medication before wound care., Resident #31 will probably refuse wound care. On 8/4/21 at 5:54 PM, in an interview with RN #2, the Assistant Director of Nursing (ADON), she stated if she was doing wound care on a resident and they complained of pain, she would stop and get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated RN #3, should have stopped the wound care and called the NP. RN #2 stated she completed a wound care check off (competency) with RN #3 and confirmed that was trained to assess residents for pain prior to beginning wound care. RN #2 confirmed RN #3 should have assessed the resident for pain before beginning wound care. She stated doing wound care on a resident in pain can cause the resident to have emotional pain. Review of Resident #31's Face Sheet revealed an initial admitted [DATE] and a readmitted [DATE]. Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #31's Comprehensive Care Plan, dated 2/5/21, with a goal target date of 11/4/21, revealed he has an alteration in comfort related to mild pain, arthritis, a history of muscle spasms, and a history of wounds. The care plan goal is that the resident will express relief of pain after receiving pain reliving measures. The care plan interventions include pain assessment as needed, allow adequate time for pain medications to take effect prior to resuming care and/or treatment. Pain medications include: Tylenol and [MEDICATION(S)] and to document the effectiveness of pain medication as needed. Record review of Physician orders, dated 8/4/21, revealed [MEDICATION(S)] 50mg PO (by mouth) q (every) 12 hours PRN (as needed) was ordered at 11:30 AM. A review of the facility's Emergency Drug Kit sign out slip reveals [MEDICATION(S)] 50 mg was signed out on 8/4/21. Record review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A Review of the significant change Minimum Data Set (MDS) with an Assessment Record Date (ARD)date of 7/20/21, revealed a Brief Interview of Mental Status (BIMS) score of seven (7). A BIMS of 7 indicates Moderately Cognitive Impaired.

Based on observation, record review, facility policy review, and staff interview, the facility failed to ensure a resident's right to privacy for one (1) of five (5) residents observed for medication administration; Resident #25; and for 1 of six (6) residents observed with a catheter; Resident #152. Findings Include: Resident #25 A review of the facility's policy titled, Resident Rights, dated (MONTH) (YEAR), revealed employees shall treat all residents with kindness, respect, and dignity. The facility's policy further revealed, federal and state laws guarantee certain basic rights to all residents of this facility, and these rights included the resident's right to privacy and confidentiality. A record review of the Resident #25's Physician Orders, dated (MONTH) 2019, revealed an order dated 1/11/2019 for [MEDICATION NAME] Five (5) percent (%) patch to be applied to the lower back daily. An observation of medication administration by Licensed Practical Nurse (LPN) #2, on 02/13/2019 at 9:30 AM, revealed LPN #2 failed to close the door and/or close the privacy curtain when applying a topical patch to Resident # 25's lower back, which allowed the resident's buttocks to be seen from the doorway. Resident #25's roommate was also present in the room at this time. An interview with LPN #2, on 02/13/2019 at 9:40 AM, confirmed Resident #25's door was left open and the privacy curtain was not pulled, when she applied the patch to Resident #25's lower back. LPN #2 stated, she usually does both, but was nervous and forgot to close the door and pull the privacy curtain. An interview with the Assistant Director of Nursing (ADON), on 02/13/2019 at 4:00 PM, revealed, she stated, LPN #2 should have closed the door and pulled the privacy curtain when she applied the topical patch to Resident #25's lower back. The ADON stated, Resident #25 should never be exposed, and privacy should always be maintained. During an interview, on 02/14/19 at 3:05 PM, with the Director of Nursing (DON), she confirmed LPN #2 should have closed the door and pulled the privacy curtain, when she applied the topical patch to Resident #25's lower back. The DON stated, That's our policy. A review of the Face Sheet revealed, Resident #25 was admitted by the facility on 01/10/2019, with [DIAGNOSES REDACTED]. Resident #152 An observation, during the initial tour of the facility, on 02/12/2019 at 11:00 AM, revealed Resident #152's catheter drainage container had no dignity bag, and was sitting on the floor. During a subsequent observation, on 02/12/2019 at 11:20 AM, Resident #152's catheter drainage container was still lying on the floor, without a dignity bag present. A record review for Resident #152 revealed, Physician Orders, dated (MONTH) 2019, with an order dated 2/11/2019, for a Foley catheter. During an interview, on 02/12/2019 at 11:28 AM, with Registered Nurse (RN) #1/ Resident Care Coordinator, she confirmed Resident #152's catheter drainage container was sitting on the floor, the two times she had entered the room. RN #1 stated, she entered Resident # 152's room at 11:05 AM to complete a body audit. RN#1 further revealed, she re-entered Resident # 152's room at 11:20 AM, to change the catheter drainage container out for a catheter drainage bag, and put a dignity bag in place. RN #1 stated, the catheter drainage bags should be in a dignity bags. A review of the Face Sheet, revealed Resident #152 was admitted by the facility on 1/29/2019, and re-admitted on [DATE], with [DIAGNOSES REDACTED].

Based on observation, record review, facility policy review, and staff interview, the facility failed to prevent the possible spread of infection as evidenced by (AEB), failure to maintain a catheter drainage system from lying on the floor for one (1) of six (6) residents observed with a catheter; Resident #152, and failure to wash hands between changing gloves during wound care for 1 of two (2) wound care observations; Resident #36. Findings Include: Resident #152 A review of the facility policy titled, Policies and Practices- Infection Control, dated (MONTH) (YEAR), revealed that the facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The facility policy revealed that the one of the objectives for the facility's infection control policies and practices is preventing infections in the facility. The facility policy states that all personnel will be trained on the facility's infection control policies and practices including how to use pertinent procedures related to infection control. An observation, during the initial tour of the facility, on 02/12/2019 at 11:00 AM, revealed Resident #152's catheter drainage container had no dignity bag, and was sitting on the floor. During a subsequent observation, on 02/12/2019 at 11:20 AM, Resident #152's catheter drainage container was still lying on the floor, without a dignity bag present. A record review for Resident #152 revealed, Physician Orders, dated (MONTH) 2019, with an order dated 2/11/2019, for a Foley catheter. During an interview, on 02/12/2019 at 11:28 AM, with Registered Nurse (RN) #1/ Resident Care Coordinator, she confirmed Resident #152's catheter drainage container was sitting on the floor, the two times she had entered the room. RN #1 stated, she entered Resident # 152's room at 11:05 AM to complete a body audit. RN#1 further revealed, she re-entered Resident # 152's room at 11:20 AM, to change the catheter drainage container out for a catheter drainage bag, and put a dignity bag in place. RN #1 stated, Catheter containers should not be sitting on the floor at any time. RN #1 stated, the catheter drainage bags should be in a dignity bags and not touching the floor. During an interview, on 02/13/2019 at 4:10 PM, with Assistant Director of Nursing (ADON)/ Licensed Practical Nurse (LPN) #1, revealed catheter drainage containers or bags are not to be lying on the floor. The ADON stated, allowing the drainage system to touch the floor is an infection control concern. During an interview, on 02/14/2019 at 3:10 PM, with the Director of Nursing (DON), she revealed Resident #152's catheter drainage system should not have been on the floor, because this was an infection control issue. A review of the Face Sheet, revealed Resident #152 was admitted by the facility on 1/29/2019, and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #36 A review of the facility's policy titled, Handwashing/Hand Hygiene, dated (MONTH) (YEAR), revealed the facility considers hand hygiene the primary means to prevent the spread of infections. Use an alcohol-based hand rub or soap and water after removing gloves. The use of gloves does not replace hand washing/hand hygiene and the integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. A review of the facility's policy titled, Wound Care, dated (MONTH) 2009, revealed this policy is to provide guidelines for the care of wounds to promote healing. Steps in the wound care procedure included: to wash and dry your hands thoroughly, before putting on gloves. An observation of wound care, performed by Registered Nurse (RN) # 1/ Resident Care Coordinator, on 02/13/19 at 11:20 AM, revealed the existence of two (2) Stage Four (4) wounds. The first wound was a Stage 4 pressure ulcer to the left inferior hip. The second wound was a Stage 4 pressure ulcer to the left hip. Upon completion of care to the first wound, RN #1 removed her gloves, but did not wash her hands. RN #1 put on another pair of gloves, and began wound care to the second wound. RN #1 did not wash her hands before leaving Resident #36's room. A review of Resident #36's Physician Orders, dated (MONTH) 2019, revealed two (2) wound care orders dated for 2/13/2019. The wound care orders were for a Stage 4 pressure ulcer on Resident #36's left hip and a Stage 4 pressure ulcer on Resident #36's left inferior hip. During an interview, on 02/13/2019 at 11:50 AM, RN #1 confirmed she had applied gloves without washing her hands between treatment of [REDACTED]. RN #1 stated, hand hygiene is important to controlling the spread of infection. During an interview, on 02/13/2019 at 4:25 PM, with Assistant Director of Nursing (ADON)/ Licensed Practical Nurse (LPN) #1, she revealed that failure to wash or sanitize your hands, after removing gloves and before applying new gloves, when moving from one wound to another, is an infection control concern. An interview, on 02/14/2019 at 3:10 PM, with the Director of Nursing (DON), revealed the RN performing wound care, should have washed her hands before applying new gloves to perform wound care on the second wound. A review of the Face Sheet, revealed Resident #36 was admitted by the facility, on 08/27/2018, and re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED].

Based on observation, record review, staff interview, and facility policy review, the facility failed to accurately access the range of motion (ROM) on a Minimum Data Set (MDS) for one (1) of 13 resident's MDS's reviewed, Resident #4. Findings include: A facility policy titled, Resident Assessment Instrument, revised June 2017, revealed the purpose of the assessment was to describe the resident's ability to perform activities of daily living and to assess the impairments in a resident's functional levels. A review of Resident #4's MDS's, Section G400A and G400B, with the dates of 06/12/17, 09/08/17, and 10/05/17 revealed the ROM was coded 0 and 0. The assessment coded 0 referred to no impairment in ROM for the resident in any extremity. In an observation, on 10/25/17 at 2:00 PM, Resident #4 was laying on her right side with her left leg pulled up at the hip to her waist and bent at the knee. Resident #4's right leg was straight underneath her left leg. In an interview, on 10/25/17 at 2:00 PM, Registered Nurse (RN) #3 said Resident #4 was not able to straighten her left hip or knee even with assistance and positioning. In an interview, on 10/26/17 at 11:30 AM, Licensed Practical Nurse (LPN) #1, MDS Nurse, confirmed all MDS's were coded 0 for ROM for Resident #4. LPN #1 said she had completed all three (3) of the MDS assessments and the code for the ROM should have addressed Resident #4's contracted left leg which would have been coded for impairment on one (1) side of the lower extremities. In an interview, on 10/26/17 at 12:45 PM, the Director of Nursing (DON) said the code of 0 for ROM would be an incorrect assessment for Resident #4. A review of the facility's face sheet revealed the facility admitted Resident #4 on 12/31/15. Resident #4's [DIAGNOSES REDACTED]. The MDS, with an Assessment Reference Date (ARD) of 10/06/17, revealed staff assessed Resident #4 with severely impaired cognition.

Based on record review, staff interview, and facility policy review, the facility failed to update the care plan related to medication changes for one (1) of 13 resident care plans reviewed, Resident #4. Findings include: A facility policy titled, Care Plans - Comprehensive, revised June 2017, revealed care plans were revised as information about the resident and the resident's condition changed. A review of Resident #4's Care Plan, initiated 10/31/15, revealed a problem for injury related to side effects of medications related to medications [MEDICATION NAME] and [MEDICATION NAME] while given together, with a target date of 12/16/17. A review of Resident #4's current Physician orders [REDACTED].>In an interview, on 10/26/17 at 12:00 PM, Registered Nurse (RN) #1, Care Plan Nurse, said she was responsible for updating the care plan when orders were changed. RN #1 said the nurses that were working on the floor would not change the care plans. RN #1 confirmed the care plan for Resident #4 should not have been continued since Resident #4 was no longer on the [MEDICATION NAME] with the [MEDICATION NAME] A review of the facility's face sheet revealed the facility admitted Resident #4 on 12/31/15. Resident #4's [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/06/17, revealed staff assessed Resident #4 with severely impaired cognition.

Based on staff interview, and facility policy review, the facility failed to establish a Hospice Coordinator for the facility, which affected one (1) out of 49 residents who received Hospice Care. Findings include: Review of the facility policy titled, Hospice Coordinator, dated November 2016, revealed the Hospice Coordinator is responsible for working with Hospice representatives to coordinate care to the resident provided by the facility and hospice staff. During an interview, on 10/25/17 at 10:00 AM, the Assistant Administrator (AA) stated that no one particular person carry the title of Hospice Coordinator. The AA revealed the facility had only one (1) resident at this time on Hospice care. An interview with the Administrator on 10/25/17 at 10:05 AM, revealed the facility does not admit residents receiving Hospice often. The Administrator confirmed the facility did not have a Hospice Coordinator.

Based on observation, staff interview, and facility record review, the facility failed to post daily nursing staffing data for all three (3) shifts for two (2) consecutive days of survey observation. Findings Include: During random observations on 10/24/17 and 10/25/17, the daily nursing staffing data was not posted anywhere in the facility. During an interview, on 10/26/17 at 9:10 AM, the Director of Nursing (DON) confirmed that the daily nursing staffing data was not posted for the first two (2) days of the survey. The DON stated that she knew the daily nursing staffing data information was to be posted daily. The DON stated that she thought the daily nursing assignments sheet that was being posted was okay to use in place of the daily nursing staffing hours data. During an interview on 10/26/17 at 10:05 AM, Licensed Practical Nurse (LPN) #2 / Staff Development Nurse confirmed that the daily nursing staffing data was not posted in the facility. LPN #2 also stated that she believed that posting the daily nursing assignment was the same as posting the daily nursing staffing data as required. LPN #2 stated that she was not sure how long the daily nursing staffing hour reports had not been used correctly, and she was not sure how long the reports were to be kept in the office.

Based on record review, facility policy review and staff interview, the facility failed to obtain a [MEDICATION NAME] and International Normalized Ratio (PT/INR) diagnostic laboratory test for one (1) of nine (9) resident records reviewed. Resident # 6. Findings include: A review of the facility policy titled Request for Diagnostic Services, dated February 2014, revealed orders for diagnostic services will be promptly carried out as instructed by the Attending Physician. Resident # 6: A review of the medical record for Resident #6, revealed a telephone order dated 11/06/2016, for a [MEDICATION NAME] and International Normalized Ratio (PT/INR) diagnostic laboratory blood work to be repeated on 11/10/2016. The telephone order was received and signed by Licensed Practical Nurse (LPN) #1. A review of the laboratory blood test results dated 11/06/2016, on the active chart for Resident # 6, revealed documentation, dated 11/06/2016, for an order for [REDACTED].#1 on 11/06/2016. An interview on 12/29/2016 at 9:00 AM, with Registered Nurse (RN) #1, Medical Records Coordinator, confirmed there was a telephone order signed and dated 11/06/2016, for a PT/INR to be repeated on 11/10/2016 and a new order for a PT/INR to be repeated on 11/10/2016, documented on the PT/INR lab test results dated 11/06/2016. RN #1 confirmed both was noted and received by LPN #1. RN #1 stated the process for receiving a lab order is that the nurse receiving an order for [REDACTED]. She stated the laboratory from the hospital next door draws labs for the facility. RN #1 stated a lab technician from the hospital comes on the night shift and gets the request forms out of the binder leaving a pick copy to show they have received the request form. She stated she had checked the binder for the pink copy of the lab request form for Resident # 6 dated for 11/10/2016, and could not find it. She stated she called the hospital lab and they had no record of a PT/INR being drawn on 11/10/2016 for Resident #6. An observation and record review of the binder titled Labs, revealed multiple pink copies of lab request as indicated by RN # 1. A pink copy for a PT/INR dated 11/10/2016 for Resident # 6 was not found in the binder. An interview with the Director of Nursing (DON), on 12/29/2016 at 11:00 AM, confirmed an order for [REDACTED].#1 on 11/06/2016. She confirmed that the lab from the hospital next door said they had no record of the test being drawn. The DON stated, It got missed. The DON confirmed the process of the nurse receiving a doctor's order for a lab test is to fill out a lab request form and put it in the binder for the hospital lab to pick up. She stated she had notified the Nurse Practitioner and the resident's primary physician of the missed lab test. A review of the face sheet revealed Resident # 6 was admitted to facility on 10/24/2014, with a [DIAGNOSES REDACTED]. A review of Resident #6's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/10/2016, revealed the Resident's Brief Interview for Mental Status (BIMS) score was 3, indicating severe cognitive impairment.

br>Based on observation, record review, staff interview, and facility policy review, the facility failed to ensure the resident received double meal portion as ordered for one (1) of three (3) Residents observed for meal service, Resident #1. Findings include: Review of the facility policy entitled, Therapeutic Diets, revised 01/14, revealed, Policy Interpretation and Implementation 7. Residents on the therapeutic diets will not receive extra or reduced portions of modifications that are not part of the diet, unless approved by the Attending Physician/NP (Nurse Practitioner) in conjunction with the Clinical Dietician. Review of the cumulative Physician Orders for Resident #1, for October 2015, revealed an order dated 02/02/15 for Diet: Regular. Resident to receive double portions for all meals. Observation, on 10/14/15 at 5:15 PM, revealed Resident #1 was seated in the dining room feeding himself. There was one (1) cheese omelet and one (1) fruit cup on Resident #1's tray. Interview, on 10/14/15 at 5:15 PM, with the Dietary Manager confirmed Resident #1 had only one (1) cheese omelet on his/her tray and stated the Resident could have another one if he/she wanted one. Interview, on 10/15/15 at 12:45 PM, with the Dietary Manager, when asked if Resident #1 should have received double portions as ordered, stated it depended on what the food item was as to whether the Resident received double portions. Review of the Face Sheet revealed the facility admitted Resident #1 on 02/02/15 with diagnoses, which included Dementia and Vitamin Deficiency. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/27/15, revealed Resident #1 had severely impaired decision-making abilities.

Based on record review, staff interview and facility policy review, the facility failed to discontinue the elevation of Resident #1's legs and failed to update Resident #1's clinical record related to side rails for one (1) of five (5) records reviewed. Findings include: Review of the facility policy entitled Transcribing Orders, revised 12/10, revealed Policy Statement: The facility shall have a system to ensure that medication orders are consistent with principles of safe and effective order writing. The policy did not address other types of orders. Review of the cumulative Physicians Orders for Resident #1, dated 10/15, revealed an order dated 02/02/15 for Side Rails up x 1 (times one) as enabler. Review of Resident #1's Care Plan dated 02/02/15 (the date of the order), revealed the facility staff failed to transcribe the order correctly on the care plan. The care plan read, Side rail up x 2 (times two) as enablers instead of X 1. Interview on 10/15/15 at 2:20 PM with Licensed Practical Nurse (LPN) #2 confirmed the Care Plan had the need for two (2) side rails, but the order specified one (1) side rail. LPN #2 also stated he/she had failed to indicate the need for one (1) side rail for Resident #1. Review of the Wound Center notes for Resident #1, dated 06/16/15, revealed Elevate legs 30 minutes 3 x (three times) a day. Review of the Wound Center notes, dated 10/13/15, also recommend, Legs should be elevated above heart as directed: 30 min TID (minutes three (3) times daily). The order had not been included in the cumulative Physician Orders for 10/15. Interview, on 10/15/15 at 1:10 PM, with Licensed Practical Nurse (LPN) #1 confirmed there was no order on the cumulative Physician Orders for 10/15 for the elevation of Resident #1's legs, and added he/she had received an order to discontinue the order to elevate Resident #1's legs, but failed to write the order. Review of the Face Sheet revealed the facility admitted Resident #1 on 02/02/15 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/27/15, revealed Resident #1 had severely impaired decision-making abilities.

Based on observation, staff interview, and facility policy review, the facility failed to adhere to sanitary practices and safe food storage as evidenced by persons not wearing hair restraints in the kitchen, open food items unlabeled and undated, and inaccurate dietary thermometer calibration for three (3) of four (4) kitchen observations. Findings included: Review of the facility's policy, dated January 2014, entitled "Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices" read "Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens." Review of the facility's policy, dated January 2014, entitled "Food Receiving and Storage" read "All foods stored in the refrigerator or freezer will be covered, labeled and dated". Review of the facility's policy, revised December 2009, entitled "Preventing Foodborne Illness-Food Handling" read "Thermometers will be calibrated daily and as needed." Review of the facility's instruction entitled "Ice-Point Method for Calibrating a Thermometer" read submerge the thermometer in ice water and rotate the head of the thermometer until it reads 32 degrees Fahrenheit or 0 (zero) degrees Centigrade. Observation on 10/08/14 at 7:40 AM revealed an unidentified nurse without hair covering exiting the kitchen. Observation on 10/08/14 at 7:45 AM revealed a Dietary Aide in the kitchen without hair covering. Interview, at the time of the 10/08/10 7:45 AM observation, with the Dietary Aide confirmed she was not wearing a hair net although hair covering was available. The Dietary Aid reported she and the Cook had prepared and served breakfast this morning. Observation of the kitchen on 10/08/14 at 7:50 AM revealed one (1) piece of red velvet cake, one (1) serving of mashed potatoes, a casserole bowl of peeled cantaloupe, one half gallon of buttermilk and approximately 12 ounces of turkey breast, unlabeled and undated in the walk-in cooler. Observation revealed 41 glasses (3 ounces) of juice and 40 glasses (6 ounces) of milk in the reach-in cooler, unlabeled and undated. There was six (6) half gallon pitchers of pink colored juice, five (5) half gallon pitchers of tea, one (1) half gallon of lemonade, one (1) gallon whole milk, one (1) gallon reduced fat (2%) milk, and one (1) gallon skim milk stored in the reach-in cooler, unlabeled and undated. The container of reduced fat (2%) milk had a use by date of 10/04/14. Observation revealed two (2) bags of frozen French fried potatoes (5 pound bags), one (1) bag of hash brown potatoes (5 pound bag, and two (2) dozen frozen yeast rolls, open and undated in the reach-in freezer. The above observations were confirmed by the Dietary Aide. Interview on 10/09/14 at 2:25 PM with the Dietary Manager revealed the facility policy read any opened food should be labeled and dated with a use by date. Observation on 10/08/14 at 8:10 AM revealed the Office Manager escorted a phone service employee into the kitchen. The Office Manager and phone service employee were not wearing hair covering. Observation, during initial tour of the kitchen on 10/08/14 at 8:15 AM, revealed dried food particles on the stationary can opener. The Assistant Dietary Manager confirmed the can opener had dried food particles and it had not been used this morning. Interview on 10/08/14 at 11:05 AM with the Dietary Manager revealed there was a lot of traffic through the kitchen and staff not wearing hair covering. Dietary Manager said, "I had already posted a sign about that outside the door; it is our policy to wear hair covering. Hair nets are available at both doors." Observation on 10/09/14 at 11:40 AM revealed Cook demonstrated thermometer calibration. Cook had a food thermometer submerged in ice water. The thermometer was calibrated to zero (0) degrees Fahrenheit. Cook and Dietary Manager could not demonstrate correct calibration of the thermometer.

Based on observation, staff interview, record review and facility policy review the facility failed to include the route for medication administration for 22 of 23 medication card instructions reviewed; the facility failed to properly secure Lorazepam liquid (schedule IV medication) in a permanently affixed refrigerated compartment for one (1) of two (2) medication refrigerators; and the facility failed to dispose of expired Phenergan Suppositories for one (1) of two (2) medication rooms. Findings Include: Review of the facility's policy entitled "Storage of Medications", revised [DATE], revealed the facility would return to the pharmacy and drug containers with incomplete or incorrect labels. This policy also indicated the facility would either destroy or return to the dispensing pharmacy any outdated drugs or biologicals. Review of the Mississippi State Board of Pharmacy requirements under section XIV for labeling requirements revealed the prescription label should include "directions for taking the medication". Review of the Nursing 2013 Drug Handbook, 33rd Edition, indicated one of the eight "rights" of medication administration is to check "The right route: Verify that the route by which the drug is to be given is specified by the prescriber and is appropriate for the patient". Review of the facility's policy entitled "Controlled Medication Storage", 2006, indicated Schedule III-V medications and other medications subject to abuse are stored in a permanently affixed compartment separate from all other medications and Schedule II medications are stored in a separate area under double lock. During the medication pass observations on [DATE] at 8:30 AM, [DATE] at 9:26 AM, [DATE] at 5:15 PM, [DATE] at 10:15 AM, there was 22 of 23 prescription labels that did not list the route the medication was to be given, therefore missing the needed information for proper medication administration. In an observation on [DATE] at 9:16 AM of the medication room at the main nurses station, the medication Lorazepam Liquid was not inside the permanently affixed compartment, inside the refrigerator, and not properly stored. There was also nine (9) Phenergan Suppositories, for the Emergency Kit, with the expiration date of [DATE]. In an interview with Registered Nurse #2 on [DATE] at 9:30 AM, RN #2 confirmed the Lorazepam liquid was not locked inside the lock compartment of the refrigerator and she verified there were nine (9) expired Phenergan Suppositories for the Emergency Kit that expired on [DATE]. In a phone interview on [DATE] at 10:15 AM with the dispensing pharmacy, the Pharmacy Director stated she was not aware the route the medication was to be administered was needed on the prescription label for the nursing home medications. In an interview with the Director of Nursing (DON) on [DATE] at 10:10 AM, the DON confirmed 22 of the 23 copied medication labels observed during medication pass had no route for the administration of the medication listed. She also confirmed the nurses are to verify route of medication administration during medication pass and the medication cards are to be checked against the Medication Administration Record [REDACTED]