rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
8403,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2011-10-06,279,D,0,1,Z6CD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to develop a comprehensive care plan with appropriate interventions to address fluid restrictions and non-compliance for one (1) resident (# 30) on a sample of thirty-three (33) residents. Findings include: Record review revealed resident # 30 has a [DIAGNOSES REDACTED]. The resident was receiving [MEDICAL TREATMENT] three days a week. Review of the Physician order [REDACTED]. During an interview on 10/05/11 at 3:00 p.m.,the Director of Nurses stated the resident was non-compliant with her fluid restrictions and drinks fluids when she wants. Review of the comprehensive care plan revealed a care plan had been developed to address the nutritional needs for the resident on [MEDICAL TREATMENT], however there were no interventions to address the resident's fluid restrictions or her non-compliance. During an interview on 10/5/11 at 3:05 p.m. the Minimum Data Set (MDS) Coordinator confirmed the care plan for [MEDICAL TREATMENT] did not include interventions to address the resident's fluid restrictions or the resident's non-compliance. She further stated it had been addressed on a previous care plan, but had failed to include those interventions on the current care plan.",2016-01-01
8404,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2011-10-06,309,G,0,1,Z6CD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to assess and treat pain experienced during pressure sore treatments for two residents, #112 and #23 of thirty-three (33) sampled residents. This resulted in actual harm to residents #112 and #23. Findings include: 1. Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed resident # 112 was assessed at risk for pressure sores and was assessed as having a Stage II pressure sore which was present on admission. Review of the current Comprehensive Care Plan revealed the resident had a current Stage II pressure sore on the left lateral foot. The Treatment Nurse and Certified Nursing Assistants (CNAs) JJ and KK were observed on 10/05/11 at 10:15 a.m. while doing a pressure sore treatment to the resident's left lateral foot. The resident called out in pain each time the wound was touched. The resident also verbally expressed pain when the old dressing was removed. The Treatment Nurse acknowledged the resident's expressions of pain and stated she would check with the Medication Nurse after the treatment to find out when he was last medicated. CNAs JJ and KK proceeded with the treatment. The resident asked the Treatment Nurse to check with the Medication Nurse. The Treatment Nurse left the room and returned stating he had his last pain medication at 2:o'clock. The treatment was completed. Review of the resident's current Physician order [REDACTED]. Review of the MAR for October 2011 revealed the resident received this medication for the first time in October 2011 on 10/05/2011 following completion of the pressure sore treatment. Review of the current Comprehensive Care Plan revealed the resident was care planned to receive support related to pain. Interventions included medicate for pain as needed and monitor effectiveness. 2. Review of the quarterly Minimum Data Set (MDS) Assessments dated 4/27/11 and 7/27/11 revealed resident # 23 had a healing Stage IV on the right heel. Review of the current Comprehensive Care Plan also revealed the resident had a Stage IV, now presenting as a Stage II on the right heel. Interventions included monitoring for pain and medicating as needed. The Treatment Nurse and Certified Nursing Assistants (CNAs), JJ and KK were observed doing the treatment to the pressure sore on 10/05/11 at 10:40 a.m. The resident winced when her foot was raised to begin the treatment. The resident winced and verbalized pain when the area was cleansed. CNA JJ asked her if it hurt and the resident said it hurt when touched. CNA JJ proceeded with the treatment. When the treatment was complete the Treatment Nurse asked the resident if she wanted a pain pill. The resident said it stopped hurting once the treatment was completed. Review of the current Medication Administration Record [REDACTED] Review of the facility's policy on Pain Management revealed residents should be assessed and kept free of pain as much as possible. The facility's Pressure Sore Treatment Policy did not address pain The Treatment Nurse was interviewed on 10/06/11 at 11:20 a.m. and stated she did not feel resident #23 had pain during treatments, but acknowledged the resident did indicate pain when the area was touched. She further stated resident #112 did express pain during his treatment and that the treatment should have been stopped until the resident had pain medication with relief. During an interview on 10/06/11 at 12:25 p.m. the Director of Nursing (DON) stated she would have expected the nurse to stop the treatment, cover the wound with a dry sterile dressing (DSD), medicate the resident for the pain and wait an hour before resuming the treatment.",2016-01-01
8405,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2011-10-06,332,E,0,1,Z6CD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview the facility failed to achieve a medication error rate of less than five percent (5%). Four (4) errors were observed on three (3) residents (#30, #41 and #98). The errors were made by three (3) of six (6) nurses on three of six medication carts resulting in a medication error rate of 5.26 percent. Findings include: Observation of medication administration to resident #41 by Licensed Practical Nurse (LPN) CC on 10/05/11 at 10:00 a.m. revealed the nurse administered one puff of a [MEDICATION NAME] HFA 220 mcg inhaler to the resident. The observation revealed the nurse failed to shake the canister thoroughly before administration. Review of the manufacturers specifications indicated to shake the canister well before administration. The LPN confirmed she should have shook the canister before giving the medications. Review of the current physician's orders [REDACTED]. During an interview on 10/5/11 at 10:41 a.m. LPN CC confirmed the resident was supposed to receive the eye drops and she forgot to give them. Observation of medication pass on 10/5/11 at 11:40 a.m. on resident #30 by LPN BB revealed the resident was given Luminer (insulin) 100 units subcutaneous at 11:44 a.m. Review of the October 2011 physician orders [REDACTED]. Licensed Practical Nurse AA gave resident #98 synthoid,100 micrograms ( mcg) on 10/05/11 at 9:39 a.m. Review of the current physician's orders [REDACTED].",2016-01-01
8406,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2011-10-06,356,C,0,1,Z6CD11,"Based on observation, record review and staff interview the facility failed to accurately post nurse staffing in a location easily accessible to residents and visitors. Findings include: During initial tour of the facility on 10/03/11 at 11:30 a.m. posting of nursing staff hours was not observed on any unit by the survey team. During the remainder of the survey on 10/03/11 through 10/06/11 at 12 noon nursing staff hours were not observed on any unit. On 10/06/11 at 12:20 p.m. the Director of Nursing (DON) was interviewed and stated nursing hours were posted inside the nurses' stations, which are glassed in enclosures. This was observed with the DON on Unit 1. It was covered with paper. The DON also stated it was posted in the time clock room which had a sign on the door which read, employees only. She further stated it was an assignment posting for staff as well as residents, but agreed it was not accessible to residents and visitors in the present locations Review of the assignment sheet also revealed it did not include the number of hours each staff member worked per shift.",2016-01-01
8407,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2011-10-06,441,D,0,1,Z6CD11,"Based on observation, record review and staff interview the facility failed to appropriately dispose of a used lancet for one (1) resident (#30) on a sample of thirty-three (33) residents Findings include: During observation of glucometer testing for resident #30 on 10/05/11 at 11:30 a.m. with Licensed Practical Nurse (LPN) BB, the LPN was observed cleaning the resident's finger with an alcohol swab. She then stuck the resident's finger with a lancet. LPN BB removed her gloves and placed the used lancet inside of the glove then placed the glove in the regular trash can. During an interview at this time LPN BB confirmed she should have placed the lancet in the sharps container. During an interview on 10/05/11 at 3:00 p.m. the Director of Nursing stated the nurse should have disposed of the lancet in the sharps container. Review of the facility's policy for Sharps Containers revealed that needles and other sharp items should be placed directly into impervious, rigid leak-proof and puncture-resistant containers to reduce the hazard of physical injury.",2016-01-01
8408,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2011-10-06,465,B,0,1,Z6CD11,"Based on observation, record review and staff interview the facility failed to maintain the freezer compartments of two (2) refrigerators located in the snack pantries on two (2) of three (3) units free of a heavy buildup of ice. Findings include: During environmental tour on 10/05/11 at 3:30 p.m., on Unit 2, the refrigerator in the snack kitchen did not have a door on the freezer compartment and a heavy build-up of ice was observed. A thermometer in the freezer was covered with ice and could not be read. There was nothing stored in the freezer. At 3:40 p.m. the freezer compartment in the pantry refrigerator on Unit 3 was observed to have the same heavy build-up of ice and no door. A container of ice cream was soft to touch and a gel freezer pack was also not frozen solid. There were no other items in the freezer. The thermometer in the freezer read 15 degrees. Review of the temperature log on the front of the refrigerator revealed that from 10/01/11 through 10/0/2011 the freezer temperature range was 15-20 degrees. These two (2) freezer compartments were observed in the same condition again on 10/06/11 at 8:45 a.m. during an environmental tour of the facility with the Director of Nursing (DON). The temperature of the freezer on Unit 3 was 20 degrees.",2016-01-01
8411,SIGNATURE HEALTHCARE OF BUCKHEAD,115110,54 PEACHTREE PARK DRIVE N.E.,ATLANTA,GA,30309,2011-10-06,287,E,0,1,WK7T11,"Based facility staff interview, state agency staff interview and review of the state agency and facility records, the facility failed to ensure that forty one (41) Minimum Data Set (MDS) assessment information was transmitted in a timely manner. Findings include: Review of State survey agency records revealed that the facility had thirty four (34) late or missing MDS assessments, as of 10/3/11. Interview with the MDS Coordinator FF on 10/3/11 at 12:40pm revealed that she was not aware of thirty four (34) late or missing MDS. FF indicated that there had been an issue with changing over to 3.0, and some MDS transmittals did not link. On 10/4/11 at 7:50am FF revealed that she was working with the State agency MDS staff to resolve these assessments. Interview with the State agency MDS Transmittal staff on 10/6/11 at 8:45am revealed that the facility had at least forty one (41) current late or missing assessments. State agency staff further revealed that the facility had not communicated any difficulties to the state agency until 10/3/11 survey.",2016-01-01
8412,SIGNATURE HEALTHCARE OF BUCKHEAD,115110,54 PEACHTREE PARK DRIVE N.E.,ATLANTA,GA,30309,2011-10-06,425,D,0,1,WK7T11,"Based on observation and staff interview, the facility failed to ensure that expired medications were discarded in a timely manner for one (1) of three (3) medication refrigerators in the facility. Findings include: Observation conducted 10/4/11 at 9:30am revealed one (1) medication refrigerator had the following expired medications: [REDACTED] 1. One container of Atropine oral solution that had an expiration date of 9/12/11. 2. Two vials of Tuberculin Protein Derivative, one (1) dated as opened 8/26/11, one (1) with no puncture/open date. Review of the manufacture recommendations revealed that vials in use for more than thirty (30) days should be discarded. Interview with the unit manager AA on 10/4/11 at 9:55am revealed that medication refrigerators are to be checked by nursing for expired medications, this is usually done by the night shift, but no one is actually assigned.",2016-01-01
8413,SIGNATURE HEALTHCARE OF BUCKHEAD,115110,54 PEACHTREE PARK DRIVE N.E.,ATLANTA,GA,30309,2011-10-06,441,D,0,1,WK7T11,"Based on observations, staff interview and review of facility policy, the facility failed to store Continuous Positive Airway Pressure (CPAP) masks properly for two (2) of two (2) random residents. Findings include: During environmental rounds conducted on the third floor on 10/06/2011 at 11:39 a.m. Continuous Positive Airway Pressure (CPAP) masks in rooms # 321 and 310 were observed lying on the bedside table without being covered. The Administrator, Nurse Consultant, and 3rd floor unit manager were present during the observation and each indicated that the masks should be stored in a plastic bag. Review of facility policy for Respiratory Equipment revealed that all respiratory equipment should placed inside a plastic bag for storage.",2016-01-01
8528,MAGNOLIA MANOR OF ST SIMONS REHAB & NURSING CENTER,115582,2255 FREDERICA ROAD,SAINT SIMONS ISLAND,GA,31522,2011-10-06,156,D,0,1,XPEN11,"Based on record review and staff interview, it was determined that the facility had failed to provide two (S and T) of three sampled residents, who were discharged from Medicare Part A services, with the Skilled Nursing Advanced Beneficiary Notice (SNFABN) form (CMS - ) or a mandatory uniform Denial Letter to inform the resident of his/her potential liability for the non-covered services and the estimated cost of those non-covered services. Findings include: On 10/5/11 at 3:35 p.m., the Business Office manager stated that she had not provided the SNFABN form or a Denial Letter to residents who had been terminated from Medicare Part A services for coverage reasons. According to documentation provided by the Business Office manager, 32 residents had been discharged from Medicare Part A services for coverage reasons since 6/2011. 1. Resident S was notified by the facility on 4/11/11 that Medicare Part A coverage for skilled services would end on 4/12/11. However, the facility failed to provide the resident with the required SNFABN form or a uniform Denial Letter to inform the resident of his/her potential liability for the non-covered services and the estimated cost of those non-covered services if the resident chose to continue to receive them. 2. Resident T was notified by the facility on 5/9/11 that Medicare Part A coverage for skilled services would end on 5/13/11. However, the facility failed to provide the resident with the required SNFABN form or uniform Denial Letter to inform the resident of his/her potential liability for the non-covered services and the estimated cost of those non-covered services if the resident chose to continue to receive them.",2016-01-01
8529,MAGNOLIA MANOR OF ST SIMONS REHAB & NURSING CENTER,115582,2255 FREDERICA ROAD,SAINT SIMONS ISLAND,GA,31522,2011-10-06,167,C,0,1,XPEN11,"Based on observations and resident and staff interview, it was determined that the facility failed to post the results of the most recent survey. Findings include: During an interview on 10/4/11 at 9:30 a.m., resident A stated that he /she did not know where the survey results were posted. He/She said that he/she had not been informed of their location. It was observed on 10/4/11 at 11:30 a.m. and 10/5/11 at 4:10 p.m. that the notebook containing survey results was in a wall pocket in the front lobby. However, the most recent survey results (an 8/5/11 complaint survey) was not in that notebook. On 10/6/11 at 8:15 a.m., the Administrator stated she did not know that the complaint survey results had to be posted.",2016-01-01
8530,MAGNOLIA MANOR OF ST SIMONS REHAB & NURSING CENTER,115582,2255 FREDERICA ROAD,SAINT SIMONS ISLAND,GA,31522,2011-10-06,253,E,0,1,XPEN11,"Based on observations and staff interview, it was determined that the facility failed to maintain clean common showers in three of three common shower rooms in the facility (300 hall women's shower and 400 hall men's and women's shower) . Findings include: 300 Hall Observations in the women's shower room on 10/04/11 at 8:15 a.m. revealed trash on the floor and small flecks of brown material adhered to the toilet seat and toilet bowl. Licensed practical nurse (LPN) WW confirmed those observations at 10:40 a.m. 400 Hall During observations in the men's shower room on 10/04/11 at 10:59 a.m. with CNA II and CNAJJ, there was a wet wash cloth hanging over the shower rail. A bucket of soapy water was under the shower chair. The shower chair had yellow residue at the joint edges. There was a bedside toilet pail soiled with brown spots in the toilet room. There was a dark brown material on the floor tile along the edges of the shower room. During the Environmental tour with the Environmental Director on 10/06/11 at 9:20 a.m., the men's shower floor still had the brown material along the edge of the tile. The toilet was dirty with flecks of brown material on the sides of it. The grout in the women's shower had black material on it. There were two rough, spackled areas over missing wall tile in the shower stalls which were not sanded. There was a two foot long rust stain on the shower room tile wall. During an interview on 10/06/11 at 10:00 a.m., the Environmental Director acknowledged those concerns on the 300 hall.",2016-01-01
8531,MAGNOLIA MANOR OF ST SIMONS REHAB & NURSING CENTER,115582,2255 FREDERICA ROAD,SAINT SIMONS ISLAND,GA,31522,2011-10-06,279,D,0,1,XPEN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, it was determined that the facility had failed to develop a comprehensive plan of care to address the use of an indwelling urinary catheter for one resident (#158) of two sampled residents with indwelling urinary catheters and of a [MEDICAL CONDITION] medication for one resident (#31) from a total sample of 35 residents. Findings include: 1. Resident #158 was admitted on [DATE] under hospice services with [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED]. According to the 8/23/11 initial Minimum Data Set (MDS) assessment, licensed staff coded the resident as having an indwelling catheter. Licensed nursing staff had documented on the Care Area Assessment (CAA) Summary that the resident's indwelling catheter would be care planned. Although the interdisciplinary team developed plans of care for the resident on 8/26/11, they failed to develop a plan of care with interventions to address the use of an indwelling catheter for resident #158. See F315 for additional information regarding resident #158. 2. Resident #31 had a physician's orders [REDACTED]. However a review of the resident's care plan, most recently reviewed by facility staff on 8/16/11, revealed that staff had not developed a care plan with interventions to address the resident's use of the anti-anxiety medication or his/her [DIAGNOSES REDACTED].",2016-01-01
8532,MAGNOLIA MANOR OF ST SIMONS REHAB & NURSING CENTER,115582,2255 FREDERICA ROAD,SAINT SIMONS ISLAND,GA,31522,2011-10-06,282,D,0,1,XPEN11,"Based on observation and record review, it was determined that the facility failed to ensure that nursing staff provided personal hygiene for one resident (#31) as planned from a total sample of 35 residents. Findings include: Resident #31 had a care plan since 2/18/11 to address his/her Activities of Daily Living (ADL) deficit and need for total assistance with his/her care needs. The care plan included interventions for nursing staff to assist the resident with grooming and hygiene as needed and to assist the resident with bathing three (3) times per week and as needed. However, the resident was observed to have oily hair, oily facial skin, on his/her face, dry skin on his/her upper lip, and an unwashed body odor on 10/3/11 at 1:10 p.m., on 10/4/11 at 9:20 a.m. and 4:16 p.m., and on 10/5/11 at 8:30 a.m. and 10:49 a.m. The resident's fingernails were observed to be long on 10/4/11 at 4:16 p.m. and on 10/5/11 at 10:49 a.m. The resident's toenails were observed to be long and beginning to curve on 10/5/11 at 10:49 a.m. See F312 for additional information regarding resident #31.",2016-01-01
8533,MAGNOLIA MANOR OF ST SIMONS REHAB & NURSING CENTER,115582,2255 FREDERICA ROAD,SAINT SIMONS ISLAND,GA,31522,2011-10-06,309,D,0,1,XPEN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews with residents and staff, it was determined that the facility failed to monitor the [MEDICAL TREATMENT] and obtain weekly weights as ordered for one resident (B) from a sample of 35 residents. Findings include: Resident B had a current physician's orders [REDACTED]. There was no documentation in the resident's clinical record that nursing staff had monitored the resident's [MEDICAL TREATMENT] when the resident returned from [MEDICAL TREATMENT] on those days. During an interview on 10/5/11 at 9:15 a.m., resident B stated that staff never looked at his/her access site. At that time, a clean dressing was observed over the access site on the resident's left upper arm. During an interview on 10/5/11 at 11:15 a.m., licensed nurse AA stated that he/she monitored the resident's access site every day. He/she stated that the monitoring was documented in the nurses notes but, was unable to provide that documentation. During an interview on 10/5/11 at 11:15 a.m., the Director of Nursing (DON) stated that the nurses were expected to monitor the resident's access site upon his/her return from [MEDICAL TREATMENT]. However, she could not provide any evidence to verify that it had been done. The resident had a physician's orders [REDACTED]. However, an interview on 10/5/11 at 2:00 p.m., the DON stated that weekly weights were started for the resident last month (September) but, she was not able to provide any evidence that weekly weights had been done. She said that the [MEDICAL TREATMENT] clinic staff weighed the resident three times a week. However, those weights were not obtained from the [MEDICAL TREATMENT] clinic until after surveyor inquiry.",2016-01-01
8534,MAGNOLIA MANOR OF ST SIMONS REHAB & NURSING CENTER,115582,2255 FREDERICA ROAD,SAINT SIMONS ISLAND,GA,31522,2011-10-06,311,D,0,1,XPEN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff and resident interview, it was determined that the facility failed to provide services to maintain the positioning and support of an upper and lower extremity for one resident (Z) from a sample of 35 residents. Findings include: Resident Z had [DIAGNOSES REDACTED]. He/She was coded on the 7/25/11 Minimum Data Set (MDS) assessment as needing assistance with activities of daily living (ADLs). There was a physician's orders [REDACTED]. Although staff coded the resident as having received range of motion services (exercises), there was not any coding to indicate that the resident was using a splint and brace. There was a care plan to address the resident's need for assistance with ADLs because of his/her left sided weakness. However, there were not any interventions specific to his/her use of supportive devices for positioning of his/her left upper and lower extremity. There was a 5/2/11 skilled occupational therapy progress note that treatment was provided because of the resident's [DIAGNOSES REDACTED]. The occupational therapist noted that the resident had non-functional use of his/her left upper extremity. There was a 5/10/11 therapy progress note that the resident was seen for left upper extremity support. The therapist documented that the resident's shoulder was painful and needed support. The 5/19/11 therapy discharge summary documentation noted that the resident had been provided a shoulder sling for his/her heavy left flaccid upper extremity for use during ambulation. There was documentation that a left upper extremity arm trough had been added to his/her wheelchair for support of that arm. The 5/19/11 therapy discharge summary noted that the resident would be dependent for self care. He/She would need assistance with dressing -general with an AFO brace to his/her left lower extremity. Review of the Nurse's Aide's Information Sheet revealed that the sections for Special Equipment (braces, splints) and Restorative were blank. There were not any written directions to the certified nursing assistants about the resident's need for the use of an upper extremity sling or a lower extremity brace. Review of the restorative nursing services notes revealed that range of motion services (exercises) were provided for the resident and that he/she ambulated 35 feet with a rolling walker. However, there was no evidence that an upper extremity sling or lower extremity brace was being used for the resident. In an interview on 10/03/11 at 1:17 p.m., licensed practical nurse (LPN) GG stated that she did not know about the use of a sling (or a brace) for resident Z or about any physician's orders [REDACTED]. During observations on 10/03/11 at at 4:00 p.m., and on 10/04/11 at 8:50 a.m., staff had not applied an upper extremity sling and lower extremity brace on the resident. There was not a lower extremity brace in place on 10/05/11 when the resident was observed sitting in a wheelchair at breakfast, and at lunch in the dining room, or at 4:56 p.m During an interview on 10/04/11 at 9:30 a.m., resident Z demonstrated that he/she was not able to apply the lower extremity brace. The resident stated that it was used to help improve his/her balance when ambulating. The resident stated that he/she did not like the different arm support the facility provided when he/she was first admitted . He/She said his/her family had obtained another sling around June, 2011. Resident Z stated that staff did not put the sling on him/her unless he/she asked for it. He/She stated that he/she had to ask them about the brace because, it had to be put on before he/she was dressed. During interview on 10/04/11 at 4:20 p.m. , occupational therapist (OT) EE stated that resident Z needed the lower extremity brace for foot drop. He stated that the resident was assessed by therapy staff for the need for supportive devices including the AFO brace. He believed that the family obtained a different device after the first assessment and therapy had been provided. During an interview on 10/05/11 at 4:49 p.m., CNA DD stated that resident Z had an arm sling that they were supposed to put on him/her in the morning but, sometimes she forgot it. The CNA stated that the resident did not have any other braces or splints to be applied. During interview on 10/06/11 at 10:30 a.m., CNA CC stated that she had been employed at the facility for several years and had frequently worked with resident Z. She said that no one had verbally or in writing instructed her to apply a sling or brace on the resident.",2016-01-01
8535,MAGNOLIA MANOR OF ST SIMONS REHAB & NURSING CENTER,115582,2255 FREDERICA ROAD,SAINT SIMONS ISLAND,GA,31522,2011-10-06,312,D,0,1,XPEN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, it was determined that the facility failed to assist one resident (#31) to maintain good personal hygiene from a total sample of 35 residents. Findings include: Resident #31 had [DIAGNOSES REDACTED]. He/she was receiving oxygen continuously at a rate of 2 liters per minute through a nasal cannula. Nursing staff coded the resident on the most recent 7/29/11 Quarterly Minimum Data Set (MDS) assessment as needing extensive assistance with personal hygiene and dressing and, as dependent for bathing. There was a care plan since 2/18/11 to address his/her Activities of Daily Living (ADLs) deficit and needing total assistance with his/her care needs. There were interventions for nursing staff to assist the resident with grooming and hygiene as needed and to assist the resident with bathing three (3) times a week and as needed. The certified nursing assistant (CNA) care sheet (guide for CNAs to follow) documented the resident as being dependent for care and personal hygiene. According to the care sheet, the resident was scheduled for a bed bath on the 3 p.m. to 11 p.m shift on Tuesdays, Thursdays, and Saturdays. However, the resident was observed on 10/3/11 (Monday) at 1:10 p.m., on 10/4/11 (Tuesday) at 9:20 a.m. and 4:16 p.m. and, on 10/5/11 (Wednesday) at 8:30 a.m. and 10:49 a.m. with oily hair that had dandruff flakes, oily skin on his/her face, dry skin on his/her upper lip, and an unwashed body odor. On 10/5/11 at 12:50 p.m., the resident's day shift CNA, LL, stated that the resident's hair was supposed to be washed when he/she received a bath on the 3 p.m.-11 p.m. shift. The Director of Nursing (DON) stated on 10/5/11 at 3:50 p.m. that the resident's hair should be washed when his/her baths were given. The resident was observed with long fingernails on 10/4/11 at 4:16 p.m. and on 10/5/11 at 10:49 a.m. and at 11 a.m. The treatment nurse stated on 10/5/11 at 11 a.m., that the CNAs were responsible for clipping residents' fingernails. The Director of Nursing stated on 10/5/11 at 3:50 p.m., that it was not any one person's responsibility for clipping the resident's fingernails but, if the nails were observed to be long , then any nursing staff could clip them. The resident's toenails were observed to be long and starting to curve on 10/5/11 at 10:49 a.m. The treatment nurse stated on 10/5/11 at 11 a.m., that the podiatrist was responsible for cutting the resident's toenails. However, a review of the resident's clinical record revealed no evidence that a podiatrist had seen the resident since he/she was admitted to the facility on [DATE]. The Resident Care Manager confirmed on 10/5/11 at 4:50 p.m. that the podiatrist had not seen the resident. The treatment nurse stated, on 10/5/11 at 11 a.m., that the resident would sweat a lot. The DON also stated on 10/5/11 at 3:50, that the resident would sweat a lot. However, there was no evidence that staff had addressed the resident's individual problem of sweating and developed any additional interventions to help him/her maintain good hygiene/personal care.",2016-01-01
8536,MAGNOLIA MANOR OF ST SIMONS REHAB & NURSING CENTER,115582,2255 FREDERICA ROAD,SAINT SIMONS ISLAND,GA,31522,2011-10-06,315,D,0,1,XPEN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, it was determined that the facility had failed to ensure that the indwelling urinary catheter was secured to prevent potential trauma or infection for two (#158 and #31) of two sampled residents with indwelling urinary catheters from a total sample of 35 residents. Findings include: According to the American Medical Directors Association's Clinical Practice Guideline for Urinary Incontinence, indwelling catheters are to be secured to the upper thigh or lower abdomen to avoid bladder and urethral trauma. However, nursing staff failed to secure the indwelling catheters for residents #158 and #31. 1. Resident #158 was admitted on [DATE] under Hospice services with [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED]. On 10/3/11 at 4:05 p.m., the resident was lying in his/her bed. The resident's indwelling catheter was draining clear, yellow urine to the bedside drainage bag. On 10/6/11 at 7:55 a.m., the resident was assessed with [REDACTED]. However, the resident's indwelling catheter was not secured. The treatment nurse stated, at that time, that the resident's indwelling catheter should have been secured to the resident's leg with a leg strap. On 10/6/11 at 8:15 a.m., certified nursing assistant BB stated that the resident's indwelling catheter had not been secured for the last two days. 2. Resident #31 had [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED]. During an observation of personal care on 10/5/11 at 11:45 a.m., the catheter tubing was not secured. When CNAs LL and MM turned the resident during care, tension was observed on the catheter tubing.",2016-01-01
8537,MAGNOLIA MANOR OF ST SIMONS REHAB & NURSING CENTER,115582,2255 FREDERICA ROAD,SAINT SIMONS ISLAND,GA,31522,2011-10-06,334,D,0,1,XPEN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to offer the pneumococcal vaccine to one resident (#88) from a sample of five residents reviewed. Findings include: Review of resident #88's medical record revealed that he/she was admitted to the facility on [DATE] and signed the consent form on that date to receive the pneumococcal vaccine. However, a review of the facility's pneumococcal vaccine log documentation revealed that the resident was not administered the vaccine. He/She was given the vaccine on 9/8/10 during a hospitalization . During an interview on 10/6/11 at 10:10 a.m., the Director of Nursing confirmed that the facility had failed to administer the vaccine to resident #88.",2016-01-01
8538,MAGNOLIA MANOR OF ST SIMONS REHAB & NURSING CENTER,115582,2255 FREDERICA ROAD,SAINT SIMONS ISLAND,GA,31522,2011-10-06,371,E,0,1,XPEN11,"Based on observation, record review, and staff interview, it was determined that the facility failed to maintain holding temperatures for hot foods on a steam table above the minimal required temperature of 135 degrees Fahrenheit (F.) to prevent potential food born illness for 57 residents. Findings include: Observations with the dietary manager on 10/04/11 between 12:50 p.m. and 1:10 p.m. revealed that the gravy was held and being served at 128 degrees F. and the mechanical chopped meat (pork) was held and being served at 116 degrees F. During an interview on10/04/11 at 1:30 p.m., the dietary manager said that 25 residents had already been served in the Club dining room and 32 residents had been served in the main dining room. After surveyor observation, dietary staff reheated those food items to 148 degrees F",2016-01-01
8539,MAGNOLIA MANOR OF ST SIMONS REHAB & NURSING CENTER,115582,2255 FREDERICA ROAD,SAINT SIMONS ISLAND,GA,31522,2011-10-06,407,D,0,1,XPEN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, it was determined that the facility failed to provide a specialized rehabilitative services consultation as ordered for one resident (Z) in a sample of 35 residents. Findings include: Resident Z had [DIAGNOSES REDACTED]. There was a 6/30/11 physician's orders [REDACTED]. However, a review of the resident's clinical record revealed no evidence that an OT consultation had been done. During an interview on 10/03/11 at 1:17 p.m., Unit Manager licensed practical nurse (LPN) GG stated that she did not know about any physician's orders [REDACTED].",2016-01-01
8540,MAGNOLIA MANOR OF ST SIMONS REHAB & NURSING CENTER,115582,2255 FREDERICA ROAD,SAINT SIMONS ISLAND,GA,31522,2011-10-06,441,D,0,1,XPEN11,"Based on observation, it was determined that the facility failed to ensure that nursing staff changed soiled gloves during care for one resident (#31) from a total sample of 35 residents. Findings include: During an observation of incontinence care being provided for resident #31 on 10/5/11 at 11:45 a.m., CNA MM failed to change his/her soiled gloves after providing bowel incontinence care and before applying a clean brief on the resident and clean linens on his/her bed.",2016-01-01
9304,EMANUEL COUNTY NURSING HOME,115704,117 KITE ROAD,SWAINSBORO,GA,30401,2011-10-06,156,C,0,1,O4KP11,"Based on record review and staff interview, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) for three (3) of three (3) residents reviewed (#15, #33 and #44), who were discharged off skilled services and remained in the facility. Findings include: On 10/05/11 at 2:15 p.m., the Business Office Manager (BOM)/Social Services Director/Admissions Coordinator stated that residents #15, #33, and #44 were all discharged from Medicare Part A services, including skilled nursing and therapy, and all three remained in the facility. The Notices of Medicare Provider Non-Coverage (Generic Notice) were provided, but the BOM stated she never issued the SNFABN unless the resident or responsible party requested more information.",2015-08-01
9305,EMANUEL COUNTY NURSING HOME,115704,117 KITE ROAD,SWAINSBORO,GA,30401,2011-10-06,282,D,0,1,O4KP11,"Based on observation, record review and staff interview, the facility failed to follow the care plan related to documenting skin tears in the chart for one (1) resident (#4). The sample size was twenty-six (26) residents. Findings include: On 10/04/11 at 5:20 p.m., a dark linear area was noted across the skin of the left inner forearm of resident #4, approximately four (4) inches long and covered by steristrips. The resident did not know how or when it occurred. Record review revealed a care plan dated as original date of 5/02/11, with a problem of potential for skin tears and bruising related to thin and fragile skin. The first interventions included to document any skin tears or bruising in the chart. On 10/06/11 at 10:55 a.m., the Assistant Director of Nursing (ADON) stated that she was not aware of the steristrips to the left arm, and didn't know how the injury occurred. At 4:15 p.m., she stated a Certified Nursing Assistant told her that the resident's watch had dug into their skin about a week ago. At 4:39 p.m., the ADON stated that she looked through the resident's chart, and could not find documentation of when or how the skin injury occurred.",2015-08-01
9306,EMANUEL COUNTY NURSING HOME,115704,117 KITE ROAD,SWAINSBORO,GA,30401,2011-10-06,323,G,0,1,O4KP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, record review, family and staff interviews the facility failed to ensure that two (2) residents where supervised to prevent accidents during whirlpool and bed baths (""C"" and #62); one (1) resident was assessed for self-medication administration and the medications were stored safely (#51); one (1) resident had a properly fitting mattress (#15) and that chemicals were not left, unattended, on one (1) housekeeping cart with fifteen (15) cognitively impaired, independently mobile residents. Harm occurred to residents ""C"" and #62. The sample was twenty-six (26) and the census was forty seven=47. Findings include: 1. Record Review of the most recent Minimum Data Set (MDS) assessment for resident ""C"", dated 8/29/11, revealed the resident was totally dependent upon staff for all care and had impaired range of motion for both upper and lower extremities with severe cognitive impairment. Record review of the Nurses Notes and Incident Report for 9/28/11 revealed the resident received a whirlpool bath at 5:30 a.m. by two (2) Certified Nursing Assistants (CNA), ""AA and BB"". While the resident was still on the stretcher lift (bath trolley), in a flat position, the safety belt had been released to apply the resident's brief and not reapplied. When CNA ""BB"" left the side of the stretcher lift to retrieve the resident's socks, the resident fell from the stretcher lift, head first. The resident's head hit the bottom of the lift stabilizer legs resulting in a laceration of the resident's right ear. Review of the Incident Report and Investigation revealed statements from CNA ""AA and BB"" that the safety belt was not in place when the incident occurred. The resident was sent to the emergency room for care and received twelve (12) stitches to the right ear laceration. A family interview on 10/03/11 at 3:00 p.m. and on 10/04/11 at 2:45 p.m. revealed when they visited resident ""C"" on 9/30/11, the resident had been grimacing when the leg was moved and the resident's left leg was swollen. The family member brought this to the attention of the physician during rounds and the facility on 9/30/11 at which time an X-ray was done confirming a displaced fracture of the left femur. Observation and interview with CNA ""BB"" in the Hall II whirlpool room on 10/04/11 at 10:00 a.m. revealed that she had been trained in May 2011 when the facility received a new lift (same type) for use in the Hall III whirlpool room. She indicated that the safety belt should have been in place at all times. Interview with CNA ""AA"" on 10/05/11 at 7:55 a.m. revealed it was not usual practice to leave the safety belt off while providing a bath. CNA ""AA"" had attended an inservice on the lift last year and again after resident ""C"" fell . Review of the manufacture's instruction for use of the stretcher lift revealed that two (2) safety straps should be used (waist and feet) and should be in place at all times. The instructions also revealed the safety straps are positioned over the resident, not under the stretcher lift and over. Observation on 10/5/11 at 7:15 a.m. of a random resident, who is cognitively intact and gave permission for the surveyor to observed the resident's bath using the stretcher lift by CNA's ""AA"" and ""BB"", revealed that only one (1) safety strap was utilized for this resident which was applied by putting the safety strap under the stretcher from the vertical lift bar then across the resident's waist attached to the vertical lift bar. The stretcher lift was never placed into the locked position during the entire bath. An interview with the Director of Nursing (DON) on 10/05/11 at 11:30 a.m. revealed she had attended an inservice provided by a manufacture's representative. She understood that two (2) safety straps should be used and agreed that only one (1) strap was currently on the stretcher lift. She stated the lift was to be in the locked position except during transport. The DON supplied a copy of a sign in sheet for an inservice on 6/22/11 on how to use the tub and lift safely. CNAs ""AA"" and ""BB"" attended this inservice. 2. Review of the resident most recent MDS (annual) assessment revealed resident #62 was severely cognitively impaired and was totally dependent upon staff for transfers, dressing and bathing. The bath assessment was for a two (2) person assist. Record review for resident # 62 revealed had fallen 7/11/10 from the bed, during a bed bath, resulting in a laceration to the forehead. CNA ""CC"" was giving the resident a bed bath then she stepped away from the resident to get clean clothes. Resident #62 rolled off the bed onto the floor, resulting in a laceration to the forehead. The laceration was treated in the emergency room . Record review of the facility Incident Report revealed the resident had not been secured before CNA ""CC"" left the side of the bed. An interview with CNA ""CC"" on 10/06/11 at 8:18 a.m. revealed the mistake she made was going to the closet to get the resident's clothes and not making sure the resident was secure before walking away from the bedside. 3. Review of the facility's Incident/Accident Log revealed that resident #15 had four falls in 2011 that involved attempts to ambulate without staff assistance. Review of the Significant Change Minimum Data Set ((MDS) dated [DATE] revealed that the resident had short-and long-term memory problems, and severely impaired decision-making skills. [DIAGNOSES REDACTED]. On 10/04/11 at 12:08 p.m., a 5-1/2 inch gap between the end of the mattress and the footboard was noted. This was verified by the Assistant Director of Nursing (ADON), who said there was a gatch on the bed to prevent this. However, when she raised it, it increased the space to 6-1/2 inches. She stated they could put some pillows between the mattress and footboard to fill this space. On 10/05/11 at 7:05 a.m., the resident was noted in bed. The gap at the end of the bed was still present. At 9:20 a.m., the ADON was again notified. Review of the Guidance to Industry and Food and Drug Administration (FDA) Staff: Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment issued on 3/10/06 noted that the space between the inside surface of the head board or foot board and the end of the mattress may present a risk of head entrapment when taking into account the mattress compressibility, any shift of the mattress, and degree of play from loosened head or foot boards. 4. On 10/04/11 at 9:10 a.m., Housekeeper ""MM"" was noted to go into room 313 to clean, and closed the door behind her. The Housekeeping cart was left outside the room, and on top of the cart there was a caddy containing multiple bottles of various chemicals. There were no unattended independently mobile residents in the area at the time. Approximately two (2) minutes later the housekeeper came out of the room. At 9:40 a.m., Housekeeper ""MM"" verified that she had left her cart unattended in the hall, and added she did have the ability to lock the chemicals up in the cart. The chemicals were in spray bottles and included All-purpose cleaner; furniture polish; Best Bet liquid cream cleaner (in a squirt bottle); pH7Q ultra disinfect; and Oxy Fect disinfectant. On 10/06/11 at 10:05 a.m., the Assistant Housekeeping Supervisor stated that he would expect that any chemicals would be in eyesight of the housekeeper at all times. At 10:30 a.m. he provided the Material Safety Data Sheets for the chemicals listed above, and potential hazards included: mouth, throat, gastrointestinal, eye and skin irritation or corrosion; central nervous system depression; and respiratory irritation. On 10/06/11 at 10:25 a.m., the ADON provided a list of residents who were cognitively impaired and independently mobile, and fifteen residents met this criteria. 5. On 10/06/11 at 10:47 a.m., the following medication bottles were noted on top of the bedside table of resident #51: Vitamin D 1000 I.U. Senior Multivitamins with Minerals Avocado/Soy Extract The resident's medical record was reviewed, and no assessment was found for safety of self-administration, no care plan was noted for self-administration of meds, and no physician order to take these medications. On 10/06/11 at 10:49 a.m., the ADON verified this observation, and stated the facility did not do assessments for self-administration of medications.",2015-08-01
9307,EMANUEL COUNTY NURSING HOME,115704,117 KITE ROAD,SWAINSBORO,GA,30401,2011-10-06,325,D,0,1,O4KP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interview, the facility failed to provide nutritional interventions for one (1) resident (# 43) who had a significant weight loss and a low [MEDICATION NAME] level. The sample was twenty-six (26) residents. The findings included: Record review indicated resident # 43 was admitted with multiple [DIAGNOSES REDACTED]. The resident's BIM score was 4, indicating cognitive impairment. A review of the significant change MDS 3.0 dated 02/21/11 assessed the resident as having no weight loss concerns. The Care Area Assessment (CAA) did not trigger for nutrition and no decision was made to include it in the care plan. The Nutritional assessment dated [DATE] indicated the Ideal Body Weight to be +/- 110 (10%) and the resident eats 50% or greater. Resident # 43 [MEDICATION NAME] level was low at 3.0 g/dl (normal 3.4-5) on 5/17/11, prior to the significant weight loss in July. A review of the Weight Notebook revealed the resident weighed 112 lbs on 6/02/11 and three months later on 9/06/11, weighed 103. This represented a significant weight loss of 8.03 % in a 3 month period. Observation of the dinner meal on 10/04/11 at 6:00 p.m. and breakfast on 10/05/11 at 8:35 a.m. revealed the resident received a Regular diet. Consumption at these meals was from 45-75 %. On 10/05/11 at 11:15 am interview with the RN/ADON revealed the resident's weight loss was due to [MEDICAL CONDITION] in the lower extremities. The ADON observed the resident and stated there was no [MEDICAL CONDITION] at this time. At 11:32 am interview with ""HH"" dietitian confirmed the resident's significant weight loss in July and September. The Dietitian said she did not include any new interventions because the weight loss was due to a decrease in [MEDICAL CONDITION]. The Dietitian reviewed the physician's Progress Notes dated 5/28/11 included 2+ non [MEDICAL CONDITION], 6/21/11 included swelling of both legs (weight on 6/02/11=112), 7/17/11 included extremities 2+ [MEDICAL CONDITION] (weight on 7/5/11=102) and 8/21/11 included extremities 2+ [MEDICAL CONDITION] (weight on 8/04/11=103). The Dietitian indicated that the [MEDICAL CONDITION] should show an increase in the resident's weight and not a decrease. The Dietitian indicated she had discussed possible increases in the diet with the resident and felt she could not take in anything extra, but failed to document this intervention consideration.",2015-08-01
9308,EMANUEL COUNTY NURSING HOME,115704,117 KITE ROAD,SWAINSBORO,GA,30401,2011-10-06,334,D,0,1,O4KP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to offer the [MEDICATION NAME] vaccine again to a cognitively-impaired resident who refused it on initial attempt for one (1) resident (#15) of five (5) resident immunization records reviewed. Findings include: An Authorization to Give [MEDICATION NAME] and Flu Vaccines form dated 11/17/10 was noted on resident #15's chart, with the responsible party (RP) indicating that he would like for the resident to receive the [MEDICATION NAME] vaccine. Review of the Emanuel County Nursing Home Information Form noted that the resident refused the vaccine on 11/17/10. Review of the resident's Admission Minimum Data Set ((MDS) dated [DATE] noted a Brief Interview for Mental Status Summary Score of 02, indicating severe cognitive impairment. The resident was also assessed as rejecting care one to three days during the assessment period. The 14-day MDS, dated [DATE], noted that the rejection of care behavior had not been exhibited. On 10/06/11 at 3:30 p.m., the Assistant Director of Nursing (ADON) stated that at the time they attempted to give resident #15 the [MEDICATION NAME] vaccine last November, that he/she was agitated and refused. The ADON added that she did not contact the responsible party, and had not offered the vaccine since that time.",2015-08-01
9309,EMANUEL COUNTY NURSING HOME,115704,117 KITE ROAD,SWAINSBORO,GA,30401,2011-10-06,431,D,0,1,O4KP11,"Based on observation and staff interview, staff failed to ensure there was no expired medications in the supply room and one of three medication carts. Problems were identified in the stock medication storage room and one (1) of one (1) medication refrigerators. The census =44 residents. The findings included: Observation of the medication storage room on 10/04/11 at 10:20 a.m. revealed the following medications were expired: Two 23.3 ounce bottles of Metamucil (L) (Expiration date 3/2011) One bottle of Aspirin 325 mg 100 tablets (Expiration date 3/2011) Observation of the medication storage on 10/04/11 at 11:00 a.m. there were multiple syringes of Ativan, Benadryl and Haldol (ABH) in the refrigerator in 2 zip lock bags. One zip lock bag was labeled with the name and dosage for resident # 56 and included 22 unlabelled syringes of ABH. The second zip lock bag was for resident # 54 and had 25 unlabelled syringes of ABH. A white paper bag inside the medication refrigerator contained 26 unlabelled syringes. Inside the bag was a label for resident # 54 indicating it was ABH 1/12.5/1 mg/ml PLO. There was no medication label on the 26 syringes. Interview with Licensed Practical Nurse (LPN) ""II"" and LPN ""JJ"" revealed there was no expiration date on the label inside the white bag and none of the syringes were labeled with the name or dose of the medication.",2015-08-01
9310,EMANUEL COUNTY NURSING HOME,115704,117 KITE ROAD,SWAINSBORO,GA,30401,2011-10-06,514,E,0,1,O4KP11,"Based on observation, record review and staff interview, the facility failed to consistently document activities that were provided for three (3) residents (#4, #13 and #15); to document the presence of a skin injury for one (1) resident (#4); consistently document that personal care alarms were monitored for functionality for one (1) resident (#15); and ensure the accuracy of a Tracking Record for Improving Patient Safety (TRIPS) report for one (1) resident (#15). The sample size was twenty-six (26) residents. Findings include: 1. Review of resident #4's activity records revealed that only four activities were documented as provided from July to September. Review of resident #15's activity records revealed that only twenty activities were documented as provided from May to September. Both residents were totally dependent on staff for care, and assessed for provision of one-on-one activities. This was verified by the Activity Director on 10/05/11 at 2:34 p.m., who stated she provided the activities but had not kept up with documentation. 2. On 10/04/11 at 10:35 a.m., steristrips were noted covering a skin injury to resident #4's left inner forearm. On 10/06/11 at 4:39 p.m., the Assistant Director of Nursing (ADON) stated that she could not find documentation of when or how the injury occurred. 3. On 10/06/11 at 11:35 a.m., the Director of Nursing (DON) stated that they monitored the bed and personal care alarms for proper functioning every shift, and recorded it on a log. She stated that she was not able to find the Personal Care Alarm log for the month of February for resident #15, and so was unable to determine if the staff had checked the alarm on 02/07/11 to see if it was working when the resident fell on that day. 4. Review of resident #15's TRIPS report dated 3/10/11 noted that when the resident fell , full-length side rails were in use, and that the bed alarm sounded during the event. Review of the Nurse's Notes dated 03/10/11, written by the same nurse, noted that at 5:00 p.m. the patient was found on the floor beside the bed, and the alarm was not connected to patient. On 10/06/11 at 11:35 a.m., the DON verified that there was a discrepancy between the Nurse's Notes and the TRIPS report. She said at the time of this fall, a bed alarm was not in use for resident #15. She said if it was a personal care alarm, she doesn't know why the TRIPS report would say the alarm was sounding when the Nurse's Notes said the alarm was not attached. The DON added that the facility had not used full side rails since 2008, so that section on the TRIPS report was inaccurate. In addition, the DON was not able to locate a Personal Care Alarm log for resident #15 for March to ensure the alarm was being monitored for functionality. 5. An interview with Activity Aide ""DD"" on 10/5/11 at 3:30 p.m. revealed that due to resident #13's cognitive impairment the resident has not been participating in group activities but that she has been doing one (1) on one (1) visits with the resident and reading to the resident at least three times per week. Activity Aide ""DD"" says she keeps a record of activities for each resident and supplied Attendance records for this resident for May-September 2011. Activities were noted for May 2011 with no activities were recorded for the other months. The activities attendance sheets reveal that care plan issues include activity interventions of ""motion lotion, read Country Life, Farming, and wheeling outside.",2015-08-01