cms_MS
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8,794 rows
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| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 1 | JEFFERSON DAVIS COMMUNITY HOSPITAL ECF | 255050 | 1320 WINFIELD STREET | PRENTISS | MS | 39474 | 2017-07-26 | 225 | D | 0 | 1 | UP3C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review and interview, the facility failed to ensure an unusual occurrence was reported and investigated to ensure serial exposure/abuse didn't occur, for one (1) of 10 sampled residents, Resident #5. Findings include: Review of the facility policy for Reporting Abuse to Facility Management, revised 2014, revealed it is the responsibility of employees and others to promptly report any incident or suspected incident of resident neglect or abuse to facility management. Sexual Abuse is defined as, but is not limited to, sexual harassment, sexual coercion , or sexual assault. 5. Any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator, Director of Nursing Service, or Charge Nurse .8. The Administrator or Director of Nursing Services must be immediately notified of suspected abuse or incidents of abuse. If such incidents occur or are discovered after hours, the Administrator and Director of Nursing Services must be called at home or must be paged and informed of such incident. Review of the nurses notes revealed Resident #5 had been exhibiting new inappropriate sexual behavior starting 07/18/17, such as undressing, holding his penis in his hands and asking staff for sex. The nurse's notes dated 7/24/17 at 1:11 AM, 5:43 AM, and 5:50 AM, revealed Resident #5 had been found in two (2) female residents room taking his clothes off and looking at a female in the lobby with his penis in his hands saying come here. In an interview on 07/24/17, during the initial tour, Nurse #4 revealed that Resident #5 had a problem during the last night shift with undressing and going into two (2) female resident rooms. In an interview on 7/24/17 at 10:55 AM, RN #2 stated that Resident #5 had sexually inappropriate behavior during the night shift with staff and two (2) female residents. When asked if this was investigated or reported, RN #2 did not answer. … | 2020-09-01 |
| 2 | 2 | JEFFERSON DAVIS COMMUNITY HOSPITAL ECF | 255050 | 1320 WINFIELD STREET | PRENTISS | MS | 39474 | 2017-07-26 | 431 | E | 0 | 1 | UP3C11 | Based on observation, staff interview, record review and facility policy review, the facility failed to discard expired medications from one (1) of two (2) medication carts checked; Medication Cart for 700 and 800 Hall. Findings include: A review of the facility's policy entitled Storage of Medications with a revision date of (MONTH) 2007, reads, the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. Observation on 7/25/17 at 9:15 AM, revealed Medication Cart for 700 and 800 Hall had an expired medication of Q-Pap (Acetaminophen) Oral Solution 16 ounces with the bottle remaining one-half ( 1/2) full, with an expiration date of 12/2016. During an interview on 7/26/17 at 2:35 PM, the Director of Nursing (DON) stated that every medication nurse is responsible for ensuring no expired medications are on the medication cart. The DON also stated the Pharmacist checks the medication carts at least once a month. The DON stated: My clinical judgement is the medication would be ineffective, because it is only good for the dates indicated. Interview on 7/26/17 at 2:45 PM, with the Pharmacist, revealed, I think that the drug needed to be pulled and discarded, the drug may not be as effective, it depends on the drug itself. The pharmacist also stated, I spot check the medications once a month, but I don't check every individual medication. | 2020-09-01 |
| 3 | 3 | JEFFERSON DAVIS COMMUNITY HOSPITAL ECF | 255050 | 1320 WINFIELD STREET | PRENTISS | MS | 39474 | 2017-07-26 | 441 | E | 0 | 1 | UP3C11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review and facility policy review, the facility failed to provide care in a manner to prevent the possibility of cross contamination for one (1) of four (4) care observations; Resident #2. Findings include: A review of the facility's policy entitled Wound Care revised (MONTH) (YEAR) revealed: Do not directly touch any item that will come in contact with the wound. Discard soiled materials in plastic bag. Remove soiled material from room. A review of the facility's policy entitled Infection Control Guidelines for all Nursing Procedures, revised (MONTH) (YEAR), revealed: Standard Precautions apply to blood, body fluids, secretions, and excretions regardless of whether or not they contain visible blood, non-intact skin, and/or mucous membranes. Transmission-Based Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent the spread of infection. Resident #2 Observation on 7/24/17 at 10:35 AM, revealed when RN #3 attempted to place the gauze dressing and her soiled gloves into the wound trash bag, four (4) of the blood-stained gauze dressings and a soiled pair of gloves was noted to fall out of the trash bag onto the Resident's floor, leaving two (2) dime-sized blood stains and [MEDICATION NAME] on the floor. Observation on 7/24/17 at 11:15 AM, revealed RN #3 picked up a wedge cushion off Resident #3's floor and place it underneath Resident #3's right leg. After RN #3 cleaned Resident #2's right great toe, she then reached into the clean normal saline soaked gauze tray and squeezed the excess normal saline from the gauze back into the tray. RN #3 left the two (2) dime-sized blood stains and [MEDICATION NAME] on Resident #2's floor. Observation on 7/24/17 at 2:50 PM, revealed two (2) dime-sized blood stains and [MEDICATION NAME] remaining on Resident #2's floor. In an interview on 7/24/17 at 11:20 AM, RN #3 stated, I had already wiped the wedge cushion off… | 2020-09-01 |
| 4 | 4 | JEFFERSON DAVIS COMMUNITY HOSPITAL ECF | 255050 | 1320 WINFIELD STREET | PRENTISS | MS | 39474 | 2019-09-19 | 622 | D | 0 | 1 | S8KJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy review, the facility failed to convey to the receiving provider, the basis for the transfer from the facility for one (1) of six (6) residents with hospital transfers, Resident #3 Findings Include: Review of a statement on facility letterhead, dated 9/19/19, and signed by the Director of Nursing (DON) revealed,We do not have a policy and procedure that specifically addresses the information that is sent out with the resident to the hospital at time of discharge/transfer. Review of a document, provided by the facility, and signed by the DON, dated 9/19/19, revealed Sending residents to the ER- Transfer/discharge sheet once you fill it out in the computer (print). Record review of physician's orders [REDACTED].#3 was transferred from the facility to the hospital for evaluations. Record review of Resident #3's paper and computer chart revealed no documentation that a transfer summary containing Resident #3's medical status/ Resident Representative Contact information was sent to the receiving facility when Resident #3 was transferred to the hospital three (3) times. An interview on 09/17/19 at 1:25 PM, with the Director of Nursing (DON), revealed, We do not have a transfer summary that was sent to the hospital for Resident #3. We are supposed to send a transfer summary including the reason for transfer to the hospital, Medication Administration Record, [REDACTED]. | 2020-09-01 |
| 5 | 5 | JEFFERSON DAVIS COMMUNITY HOSPITAL ECF | 255050 | 1320 WINFIELD STREET | PRENTISS | MS | 39474 | 2019-09-19 | 623 | E | 0 | 1 | S8KJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy review, the facility failed to provide written documentation to the resident and/or resident's representative, of the reason for transfer/discharge to the hospital, for six (6) of six (6) hospitalization s reviewed out of 18 residents sampled, Residents #3, #21, #23, #28, #30, and #36. Findings include: A review of the facility's policy titled, Bed-Holds and Returns, with a revision date of (MONTH) (YEAR), revealed: Prior to a transfer, written information will be given to the residents and the resident representatives that explains the details of the transfer. Resident #36 Record review of the physician orders, dated 9/4/19, revealed an order to send Resident #36 to a local Behavior Hospital. The Nurse Progress Note, dated 9/4/19, indicated Resident #36 was observed walking up and down the hallway yelling and cursing staff, and when staff was trying to get the resident back to her room, the resident refused to put clothing on and refused to take medications as well. There was no documented evidence that a written notice was provided to the resident/resident representative regarding information of Resident #36's transfer to the hospital on [DATE]. On 9/17/19 at 1:45 PM, an interview with the Director of Nurses (DON) revealed the facility had not been notifying the resident or the Resident Representatives, in writing, of the reason for transfer to the hospital. On 9/17/19 at 2:07 PM, an interview with Resident #36's Resident Representative revealed no written notice of the reason for transfer to the behavior facility was provided. Resident #3 Record review of physician's orders [REDACTED].#3 was transferred from the facility to the hospital for evaluations. Review of Resident #3's medical record revealed no documentation of a transfer letter to the Resident Representative regarding Resident #3's transfers from the facility to the hospital, prior, during, or shortly after the transfer… | 2020-09-01 |
| 6 | 6 | JEFFERSON DAVIS COMMUNITY HOSPITAL ECF | 255050 | 1320 WINFIELD STREET | PRENTISS | MS | 39474 | 2019-09-19 | 625 | D | 0 | 1 | S8KJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy review, the facility failed to notify the resident and/or resident representative of the facility policy for bed hold, for two (2) of six (6) hospitalization s reviewed, Resident #23, and Resident #30. Findings Include: A review of facility policy titled Bed-Holds and Returns, dated (MONTH) (YEAR), revealed Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. Resident #23 Record review of a physician's orders [REDACTED].#23 was transferred from the facility to the hospital. Record review of Resident #23's medical record revealed no evidence of a bed hold letter delivered to Resident #23 or the Resident Representative. The facility failed to provide evidence of a documented bed hold letter for Resident #23. Res #30 Record review of a physician's orders [REDACTED].#30 was transferred from the facility to the hospital. Record review of Resident #30's medical record revealed no documented evidence of a bed hold letter delivered to Resident #30 or the Resident Representative. The facility failed to provide evidence of a bed hold letter for Resident #30. An interview on 09/17/19 at 12:00 PM, with the Social Service Director, regarding Resident #23 and Resident #30's transfers, revealed that she did not know of any transfer/bed hold letter that the facility mailed to the Resident Representative when the resident was transferred to the hospital. An interview on 09/17/19 at 1:25 PM, with the Director of Nursing (DON), regarding Resident #23 and Resident #30's transfers, revealed there was no documented transfer/bed hold sheet for the residents for when they went out of the facility to the hospital. The DON stated, We don't have any written transfer/bed hold letters that were given to the resident or mailed to the Resident Representative. We don't have proof we mailed anything. | 2020-09-01 |
| 7 | 7 | JEFFERSON DAVIS COMMUNITY HOSPITAL ECF | 255050 | 1320 WINFIELD STREET | PRENTISS | MS | 39474 | 2019-09-19 | 641 | D | 0 | 1 | S8KJ11 | Based on record review, staff interview, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) for one (1) of 18 MDS assessments reviewed, Resident #21. Findings include: Review of a facility statement, regarding the Resident Assessment Instrument (RAI) Policy: A comprehensive assessment of a resident's needs shall be made within 14 days of the resident's admission. According to the M0210: RAI Version 3.0 Manual, If a resident had a pressure ulcer/injury that healed during the look-back period of the current assessment, do no code the ulcer/injury on the assessment. Record review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/02/2019, Section M revealed documentation that Resident #21 had a Stage 2 Pressure Ulcer. Record review of the Physician's Progress note, revealed documentation that the Pressure Ulcer for Resident #21 was Healed on 6/20/19. Record Review of the Wound/Skin Management Documentation Record, revealed on 06/24/2019, the wound for Resident #21 was intact. On 09/17/19 at 11:24 AM, an interview with Director of Nursing (DON) revealed Resident #21 had no Pressure Ulcer. During an interview on 09/17/19 at 11:25 AM, Register Nurse #1 confirmed Resident #21's physician documented that #21's Stage 2 ulcer was healed on 6/20/19. On 09/17/19 at 3:30 PM, observation of Resident #21 revealed no pressure ulcers. On 09/18/19 at 09:08 AM, an interview with Licensed Practical Nurse #1/MDS Coordinator, and the Director of Nursing, revealed the Stage 2 wound for Resident #21 healed on 6/20/2019, and the MDS was inaccurately coded. Licensed Practical Nurse #1, stated, I did not observe the wound. On 09/18/19 at 10:56 AM, an interview with Resident #21's Physician revealed Resident #21's wound had healed on 6/20/2019, and orders should have been written to discontinue the treatment. | 2020-09-01 |
| 8 | 8 | JEFFERSON DAVIS COMMUNITY HOSPITAL ECF | 255050 | 1320 WINFIELD STREET | PRENTISS | MS | 39474 | 2019-09-19 | 657 | D | 0 | 1 | S8KJ11 | Based on record review, facility policy review, and staff interview, the facility failed to revise the Comprehensive Care Plan to reflect a soft wrist splint and interventions, for Resident #3 and the use of an indwelling catheter for Resident #38, for two (2) of 18 care plans reviewed. Findings Include: A review of facility policy titled, Care Plans-Comprehensive, (no date) revealed, Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. The Care-Planning interdisciplinary team is responsible for the review and updating of care plans. Resident #3 Record review of the Working Care Plan on the chart, and the most current care plan, initiated 12/12/18, through the review date of 9/30/19, revealed Resident #3's care plan was not revised to include a soft wrist splint and/or interventions related to the splint. Review of an incident report timeline, provided by the facility, revealed Resident #3 had a right wrist splint placed, per Primary Care Provider, on 8/13/19, for a non-displaced distal radial fracture. An observation on 09/16/19 at 8:53 AM, revealed a soft wrist splint noted on Resident #3's right wrist. During an interview on 09/18/19 at 11:07 AM, the Director of Nursing (DON) stated, after reviewing the current care plan and the working care plan on the chart, The right wrist splint interventions are not on the Resident's current care plan or on the working care plan in the chart. An interview on 09/18/19 at 11:20 AM, with LPN #1 MDS/Care Plan Nurse, revealed the soft wrist splint and interventions were not care planned, and they should have been. LPN #1 stated, The nurse who checks the orders when a resident returns from an appointment, is responsible to write the order and care plan the order if needed. An interview on 09/18/19 at 1:37 PM, with the DON, revealed, It is the RN Supervisor or the LPN's responsibility to check a resident back in after an appointment and they are supposed to write any orders that return with the res… | 2020-09-01 |
| 9 | 9 | JEFFERSON DAVIS COMMUNITY HOSPITAL ECF | 255050 | 1320 WINFIELD STREET | PRENTISS | MS | 39474 | 2019-09-19 | 842 | D | 0 | 1 | S8KJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and facility policy review, the facility failed to ensure accuracy of the medical record, related to a soft wrist splint and an indwelling urinary catheter, for two (2) of 18 resident medical records reviewed, Resident #3 and Resident #38. Findings include: A review of the facility's policy titled Medication Orders with a revision date of (MONTH) 2014, revealed a current list of orders must be maintained in the clinical record of each resident. A review of the facility's documented statement, signed by the Director of Nursing (DON), not dated, revealed the facility does not have a policy and procedure that specifically addresses the input of orders after a hospital return. Resident #38 A record review of the physician's orders for (MONTH) 2019, revealed there was no order for Resident #38's indwelling urinary catheter. The most recent Discharge-Return Anticipated Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 8/27/19, was coded to include an indwelling urinary catheter. The resident had a catheter for entire seven (7) day look-back period. On 9/17/19 at 9:15 AM, an observation revealed Resident #38 lying in bed with his eyes open. Resident #38 was observed with an indwelling urinary catheter. On 9/17/19 at 11:00 AM, an interview, with the Director of Nurses (DON), confirmed the medical record was inaccurate related to no physician's order for the indwelling urinary catheter for Resident #38. She also stated the physician orders did not reflect the resident's current status regarding the indwelling urinary catheter. The DON stated Resident #38 had the catheter upon his hospital return (8/19/19). On 9/18/19 at 8:54 AM, an interview, with Registered Nurse (RN) #3, revealed the resident returned from the hospital with the catheter, had poor kidney function, and is unable to urinate on his own. She also stated she would have to look at the chart to make sure of the … | 2020-09-01 |
| 10 | 10 | JEFFERSON DAVIS COMMUNITY HOSPITAL ECF | 255050 | 1320 WINFIELD STREET | PRENTISS | MS | 39474 | 2019-09-19 | 880 | E | 0 | 1 | S8KJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based of observation, record review, staff interview, and facility policy review, the facility failed to provide a Percutaneous Endoscopic Gastrostomy (PEG) tube dressing change in a manner to prevent cross contamination for two (2) of two (2) resident PEG tube care sites observed, for Resident #23 and Resident #38. This was evidenced by allowing resident clothing to touch/cover the PEG site, after cleaning and prior to applying a dressing, during treatment for [REDACTED].#38. The facility also failed to provide wound care in a manner to prevent cross contamination for one (1) of four (4) resident wound care observations, Resident #31. This was evidenced by the RN touching items with ungloved hands prior to performing the treatment. Findings include: A review of the facility's policy titled, Infection Control Guidelines for all Nursing Procedures, with a revision date of (MONTH) (YEAR), revealed: Standard Precautions will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious disease. A review of Perry and Potter Nursing Skills and Procedures, eighth edition, page 123, revealed: use of personal protective equipment reduces transmission of microorganisms. A review of facility policy titled, Policies and Practices-Infection control, dated (MONTH) (YEAR), revealed, The facility's infection control policies are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. A review of facility policy titled, Gastrostomy/Jejunostomy Site Care, dated (MONTH) (YEAR), revealed: The purpose of this procedure is to promote cleanliness and to protect the Gastrostomy or Jejunostomy site from irritation, breakdown and infection. Resident #31 On 9/18/19 at 9:48 AM, observation of wound care revealed RN #1 used her ungloved hands to place 10 dry 4 x 4 gauze dressings on a Styrofoam plate, sprayed the dressings … | 2020-09-01 |
| 11 | 11 | JEFFERSON DAVIS COMMUNITY HOSPITAL ECF | 255050 | 1320 WINFIELD STREET | PRENTISS | MS | 39474 | 2018-10-31 | 641 | D | 0 | 1 | 63N611 | Based on record review, facility policy review, and staff interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for falls for one (1) of 12 Resident MDS assessments reviewed, Resident #25 Findings Include: Review of the policy documentation on facility letterhead, provided by the facility, dated 10/31/2018, no signature, revealed the facility followed the Resident Assessment Instrument (RAI) for Minimum Data Set (MDS) coding. Review of Resident #25's Quarterly MDS with an Assessment Reference Date (ARD) of 09/27/2018, revealed Section J1800 coded that no falls, with or without injury, had occurred. Resident #25 had a prior MDS assessment, with an ARD of 07/03/2018, where no falls were coded. Review of a Resident Incident Report, dated 08/17/2018, signed by the Administrator, revealed Resident #25 had a fall with head injury on 08/16/2018. Review of Departmental Notes, dated 08/16/2018 at 1:14 PM, revealed that Resident #25 fell when attempting to go to the bathroom unassisted. During an interview with the Director of Nursing (DON), on 10/30/2018 at 02:15 PM, the DON confirmed that Resident #25 had a fall with head injury on 08/16/2018. An interview with Licensed Practical Nurse (LPN) #1/MDS Coordinator, on 10/31/2018 at 10:40 AM, confirmed that Resident #25's MDS Assessment on 09/27/2018 had been miscoded relating to Resident #25's fall on 08/16/2018. LPN #1 stated that there was nursing documentation on Resident #25's fall with a major injury after the 07/27/2018 MDS assessment and before the 09/27/2018 MDS assessment. LPN #1 stated she agreed that Section J1800 of the 09/27/2018 MDS assessment should have been coded Yes indicating Resident #25 indeed had a fall on 08/16/2018. During an interview on 10/31/2018 at 11:08 AM, the Director of Nursing (DON) confirmed that Resident #25's 09/27/2018 MDS assessment had been miscoded, because of Resident #25's fall on 08/16/2018. | 2020-09-01 |
| 12 | 12 | JEFFERSON DAVIS COMMUNITY HOSPITAL ECF | 255050 | 1320 WINFIELD STREET | PRENTISS | MS | 39474 | 2018-10-31 | 644 | D | 0 | 1 | 63N611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to refer a resident to the appropriate state designated authority for level 2 Pre-Admission Screening Resident Review (PASSR) evaluation and determination for one (1) of three (3) residents reviewed for PASSR, Resident # 4 Findings Include: A record review of the resident's physician's orders [REDACTED]. Resident #4 was not taking [MEDICAL CONDITION] medication upon admission. During an Interview on 10/31/2108 at 10:50 AM, Licensed Practical Nurse (LPN) #1 stated that she's responsible for the PASSR. LPN #1 stated that all newly diagnosed residents with mental or intellectual disorders should be sent to the appropriate agency (Agency Named) to decide whether a level 2 should be done, however, she was unable to get to it at this time. She stated she will take care of the PASSR for Resident #4 as soon as possible (ASAP). LPN #1 stated that the facility does not have a policy on PASSRs, but it is part of her job duty to make sure they are done correctly and timely. A review of the facility's face sheet revealed the facility admitted Resident #4 on 08/24/2017, with [DIAGNOSES REDACTED]. | 2020-09-01 |
| 13 | 13 | JEFFERSON DAVIS COMMUNITY HOSPITAL ECF | 255050 | 1320 WINFIELD STREET | PRENTISS | MS | 39474 | 2018-10-31 | 656 | D | 0 | 1 | 63N611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy review, and staff interview, the facility failed to develop a comprehensive care plan to include interventions of a catheter securing device to prevent tension and trauma; and failed to implement the care plan of providing catheter care in a manner to help prevent infection for one (1) of four (4) care plans reviewed, Resident #30. Findings include: Review of the facility policy, Care Plans, Comprehensive Person-Centered, revised (MONTH) (YEAR), revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Review of the facility policy, Perineal Care, revised (MONTH) 2010, revealed that the facility policy, if a resident had a catheter, was to gently wash the juncture of the tubing from the Urethra down the catheter about three (3) inches. The facility policy also noted that the catheter tubing should be held to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter. Review of the facility policy, Catheter Care, Urinary, revised (MONTH) 2014, revealed the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. The policy also included documentation to ensure that the catheter remains secure with a leg strap to reduce friction aandmovement at the insertion site. Record review revealed Resident #30's care plan, with an on-set date of 10/8/18, revealed a potential for complications related to an indwelling urinary catheter. Interventions included to keep the catheter and drainage bag lower than the bladder at all times and to provide catheter care with soap and water every shift. The care plan did not address the use of a securing device (leg strap). Review of Resident… | 2020-09-01 |
| 14 | 14 | JEFFERSON DAVIS COMMUNITY HOSPITAL ECF | 255050 | 1320 WINFIELD STREET | PRENTISS | MS | 39474 | 2018-10-31 | 690 | D | 0 | 1 | 63N611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, policy review, and staff interview, the facility failed to provide catheter care in a manner that would prevent infection and/or trauma for one (1) of two (2) resident observations of perineal care, Resident #30. Findings include: Review of Resident #30's face sheet revealed the facility admitted the resident on 9/27/18, with [DIAGNOSES REDACTED]. Review of the facility policy, Perineal Care, revised (MONTH) 2010, revealed if a resident had a catheter, to gently wash the juncture of the tubing from the Urethra down the catheter about three (3) inches. The facility policy also noted that the catheter tubing should be held to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter. Review of the facility policy, Catheter Care, Urinary, revised (MONTH) 2014, revealed the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. The policy also included documentation to ensure that the catheter remained secure with a leg strap to reduce friction and movement at the insertion site. On 10/31/18 at 10:36 AM, observation of catheter care for Resident #30, revealed Certified Nursing Assistant (CNA) #1 provided catheter care, along with assistance of CNA #2. There was no leg strap or catheter securing device observed, to prevent the catheter from pulling at the Urethra. CNA #2 held the catheter bag above the resident's bladder and was holding the catheter at the junction of where it meets the bag tubing, instead of securing it at the Urethra. Then observed CNA #1 wiped toward the Urethra, or urinary Meatus, instead of away from it. On 10/31/18 at 11:27 AM, an interview with the Director of Nursing (DON) revealed that she expected Resident #30 to have a leg strap to secure the catheter. The DON stated that she also expected the CNA to clean… | 2020-09-01 |
| 15 | 15 | WINSTON COUNTY NURSING HOME | 255072 | 17560 EAST MAIN STREET | LOUISVILLE | MS | 39339 | 2016-02-24 | 221 | D | 0 | 1 | MMRK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility policy review, record review and resident interview, the facility failed to ensure that a resident was free from physical restraints as evidenced by Resident #11 had a self release seat belt that she was unable to release upon command for one (1) of three (3) residents reviewed with a self release seat belt. (Resident #11). Findings Include: Facility policy titled, Restraint Use, with a revision date of 8/29/14 revealed, the purpose is to provide residents with physical safety if the resident is at risk to cause harm to themselves. Procedure #3 stated, physical restraints may be defined as a waist belt, roll belt, lap buddy or geri-chair with a tray. During an interview at 9:30 AM on 2/24/16, the Director of Nursing (DON) stated, Resident #11 can release the seat belt, so the facility does not consider it a restraint. At 10:40 AM on 2/24/16, an observation revealed Resident #11 sitting in her wheelchair in her room with the self release seat belt across her waist, attached to the wheelchair. LPN #1 asked Resident #11 to release the self release seat belt. Resident #11 stated, I rarely ever am able to release it. LPN #1 instructed resident to unhook the belt. Resident #11 stated, No. Resident #11 was observed pushing and pulling on the belt and buckle. Resident #11 stated, I can't do it, I'll give it to you, you do it. LPN #1 instructed Resident # 11 to push red button. Resident #11 attempted to push release button, but was unable to push in enough to release belt. Resident #11 attempted for four (4) minutes without releasing belt. LPN #1 stated, She is not going to be able today. She's having a bad day. A review of Resident #11's signed physician's orders [REDACTED]. At 10:45 AM on 2/24/16 an interview with the facility Administrator revealed, some days Resident #11 can remove the seat belt and some days she cannot. Administrator stated the facility is going to do a restraint reduction attempt t… | 2020-09-01 |
| 16 | 16 | WINSTON COUNTY NURSING HOME | 255072 | 17560 EAST MAIN STREET | LOUISVILLE | MS | 39339 | 2016-02-24 | 224 | D | 0 | 1 | MMRK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and the facility's policy review, the facility failed to properly screen new employees for abuse and neglect through the appropriate state agencies as evidenced by lack of fingerprints for one (1) of five (5) new employee records reviewed; (Employee #1). Findings Include: Review of the facility's policy titled, Abuse, Neglect, and Mistreatment of [REDACTED]. Record review for new hires revealed Employee #1 had a fingerprint background check for abuse and neglect through the Mississippi State Department of Health (MSDH) Criminal History Record Check Unit (MCIC) on 12/23/15. Review of a Letter from MCIC, dated 12/29/15, revealed, The fingerprints of (Employee #1) failed to meet quality standards and have been returned from MCIC. Please re-fingerprint and re-submit for processing. During an interview on 02/23/16 at 1:50 PM, the facility's Human Resources Employee (HR) stated she had not re- fingerprinted the Employee #1. It fell through the cracks. On 3/23/16 at 2:25 PM, an interview with the facility's Human Resource Employee revealed, I am leaving a note at the nurses' desk to be reprinted today, she (Employee #1) works 3-11. Review of the facility's Employee checklist, not dated, revealed, Employee fingerprinted and copy received. | 2020-09-01 |
| 17 | 17 | WINSTON COUNTY NURSING HOME | 255072 | 17560 EAST MAIN STREET | LOUISVILLE | MS | 39339 | 2016-02-24 | 252 | E | 0 | 1 | MMRK11 | Based on observation, staff interview, resident interview, and record review, the facility failed to (a) ensure a resident's wheelchair was maintained in good repair for one (1) of seven (7) sampled residents who utilized a wheelchair for locomotion and (b) ensure foam padding placed on resident beds was maintained in good repair for seven (7) of eight (8) beds with foam padding attached to side rails. Findings Include: On 02/24/16 at 11:45 AM, the Director of Nursing (DON) stated the facility did not have a policy related to the maintenance or repair of resident wheelchairs or foam padding secured to resident bed side rails. Observations on environmental tours of the facility on 02/22/16 from 10:30 AM to 11:40 AM and 02/23/16 from 9:30 AM to 10:00 AM revealed eight (8) beds identified to have gray foam attached to side rails secured with black electrical tape. Of the eight beds identified with foam attached, seven had torn, ripped foam including the A beds in Rooms 11, 14, 17, 23, the A and B beds in room 39, and the A bed in room 48. An observation and interview with Resident #12 on 02/23/16 at 11:25 AM revealed the resident was seated in his room in his wheelchair. The end of the left arm of the wheelchair was broken off and underlying cushion was exposed. The resident stated the arm had been broken for at least a month and he had reported it to staff. Resident #12, who is blind, stated he was unsure who he reported it to. Resident #12 stated the footrest was [NAME]ed up too; demonstrating that the right foot rest when pulled up would not stay up, but flopped back down making it difficult for resident to rise when transferring. An interview on 02/23/16 and 11:15 AM with Maintenance Staff #1 (MS #1) revealed the maintenance staff did rounds in the facility daily. Each of the two nurses' stations (B hall and C hall) had a work order book that the nurses or Director of Nursing (DON) would write work requests in for repair or maintenance. Wheelchair arm replacements or foam attached to side rails would be requeste… | 2020-09-01 |
| 18 | 18 | WINSTON COUNTY NURSING HOME | 255072 | 17560 EAST MAIN STREET | LOUISVILLE | MS | 39339 | 2016-02-24 | 253 | D | 0 | 1 | MMRK11 | Based on observation, staff interview, and facility policy review, the facility failed to properly store and label resident personal care items for five (5) of ten (10) shared resident bathrooms on B Hall. Findings Include: Review of the facility's policy, titled, Labeling Resident Items, dated 2/22/16 revealed, Purpose: Identify items for personal use to avoid sharing of personal items. Maintain personal items labeled for resident use. During the initial environmental tour on B Hall on 2/22/16 with Licensed Practical Nurse (LPN) #1 at 10:30 AM to 11:45 AM, the following shared bathrooms contained personal items that were unlabeled and not bagged. Room B1 shared bathroom contained all unlabeled: dishwashing detergent, hand sanitizer, mouthwash, two tubes of toothpaste, two toothbrushes, and a hairbrush on the lavatory. Room B3 shared bathroom contained an unlabeled toothbrush and drinking cup. Room B6 shared bathroom contained an unlabeled toothbrush and toothpaste. Room B10 shared bathroom contained all unlabeled: bottle of shampoo, shaving cream, urinal, perineal cleanser, and toothbrush. Room B16 shared bathroom contained an unlabeled urinal. Interview with LPN #1 on 02/22/16 at 10:30 AM revealed these items should not be in these bathrooms. LPN #1 stated these bathrooms are shared by two residents and we need to get the personal items out. Interview with the Administrator on 2/23/16 at 10:00 AM stated staff have been trained to label all personal items when placed in resident rooms. Stated personal items should not be shared. | 2020-09-01 |
| 19 | 19 | WINSTON COUNTY NURSING HOME | 255072 | 17560 EAST MAIN STREET | LOUISVILLE | MS | 39339 | 2016-02-24 | 278 | D | 0 | 1 | MMRK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and facility policy review, the facility failed to ensure an accurate comprehensive assessment related to coding of a restraint for one (1) of three (3) resident's Minimum Data Set's (MDS) reviewed for restraint use. Resident #11 Findings Include: Facility policy titled MDS Scheduling And Care Plan Updates, with revision date of 8/27/14 revealed: each discipline performs assessment related to their specific sections and address care area assessment (CAA) and related care planning for resident being assessed and changes are discussed with interdisciplinary team to determine if significant change of status has occurred and need of additional assessment with care plan review is required. At 10:40 AM on 2/24/16, an observation of Resident #11 revealed, resident in her room, sitting in her wheelchair with the self release seat belt across Resident #11's waist and attached to the wheelchair. Licensed Practical Nurse (LPN) #1 asked Resident #11 to release self release seat belt. Resident #11 stated I rarely ever am able to release it. Resident #11 attempted to release belt without success. LPN #1 instructed resident to unhook the self release seat belt. Resident #11 stated, NO. Resident #11 pushed in and pulled on belt and buckle without success. Resident #11 stated, I can't do it, I'll give it to you, you do it. LPN #1 instructed resident to push red release button. Resident #11 attempted to push red button on belt buckle but was unable to push in enough to release. Resident #11 attempted for four (4) minutes without success. LPN #1 stated, She's not going to be able to today. She's having a bad day. Review of Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/31/16 for Resident #11, revealed, in section P - Restraints, no restraints were coded. At 11:15 AM on 2/24/16 an interview with MDS Coordinator revealed that she did not see anything in the nurse's notes to indic… | 2020-09-01 |
| 20 | 20 | WINSTON COUNTY NURSING HOME | 255072 | 17560 EAST MAIN STREET | LOUISVILLE | MS | 39339 | 2016-02-24 | 279 | D | 0 | 1 | MMRK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy review, the facility failed to develop a comprehensive care plan related to use of a restraint for one (1) of 14 comprehensive care plans reviewed. (Resident #11). Findings Include: Review of the facility's policy titled, Care Plan, with a revision date of 9/4/14, revealed a purpose statement of: To direct resident care from admission to discharge. The policy stated: Revision of care plan is ongoing with updates by nursing staff as changes occur throughout the resident's stay, customize the care plan to address the resident's individual concerns and needs, and as changes occur, revise care plan as needed. Review of Resident #11's current care plans revealed the absence of a care plan to address the resident's self release seat belt. At 11:15 AM on 2/24/16, an interview with the Minimum Data Set (MDS) Coordinator revealed, the self release seat belt should have been included in Resident #11's care plan. At 11:30 AM on 2/24/16, an interview with Director of Nursing (DON)revealed a care plan for self release belt should have been developed for Resident #11. The facility admitted Resident #11 on 5/19/15 with [DIAGNOSES REDACTED]. A review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/31/16, revealed a Brief Interview for Mental Status (BIMS) score of one (1), which indicated severely impaired cognition. | 2020-09-01 |
| 21 | 21 | WINSTON COUNTY NURSING HOME | 255072 | 17560 EAST MAIN STREET | LOUISVILLE | MS | 39339 | 2016-02-24 | 282 | D | 0 | 1 | MMRK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review and facility policy review, the facility failed to follow the comprehensive care plan for incontinent care for two (2) of 14 resident care plans reviewed. (Resident #2 and #8). Findings Include: Review of the facility's policy titled Care Plan, dated 10/14, revealed the purpose was to direct care from admission to discharge. Resident #2 At 9:55 AM on 2/23/16, observation revealed Certified Nursing Assistant (CNA) #2 performing incontinent care on Resident #2. CNA #2 performed incontinent care on Resident #2's perineal area, but failed to turn the resident to his side to clean his buttocks before placing his clean brief. A review of Resident #2's comprehensive care plan titled, Bowel and Bladder Deficit, with a 1/18/16 revision date, revealed a goal that the resident was to be kept clean, dry and odor free. Interventions included to check resident every 2 hours to assure needs are being met. During an interview on 2/23/16 at 2:15 PM, CNA # 2 confirmed she failed to clean Resident # 2's buttocks while performing incontinent care. The facility admitted Resident #2 on 6/29/11, readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the Significant Change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/14/16, revealed a Brief Interview of Mental Status (BIMS) score of nine (9), which indicated that Resident #2 had moderately impaired cognition. Resident #8 At 9:35 AM on 2/23/16, an observation revealed CNA #1 performing incontinent care on Resident #8. CNA #1 cleaned Resident #8's perineal area, but failed to clean his buttocks before putting a clean brief on the resident. A review of Resident #8's comprehensive care plan titled Bowel and Bladder Deficit, with a 1/6/16 revision date, revealed a goal that stated the resident was to be kept clean, dry and odor free. Interventions included to check resident every 2 hours to assure needs are being met. At 2:00 PM on 2/23/16,… | 2020-09-01 |
| 22 | 22 | WINSTON COUNTY NURSING HOME | 255072 | 17560 EAST MAIN STREET | LOUISVILLE | MS | 39339 | 2016-02-24 | 315 | E | 0 | 1 | MMRK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, facility policy review, and record review, the facility failed to provide proper incontinent care as evidenced by buttocks not being cleaned during incontinent care for two (2) of four (4) observations for incontinent care. (Resident #2 and Resident #8.) Findings Included: The facility policy titled Incontinent/Perineal Care, with a revision date of 3/2/15 and the purpose stated to cleanse the perineum and provide comfort. The policy stated, It is the policy of this facility that incontinent care will be provided at a minimum of every 2 hours and after episodes of incontinence. Care will include a thorough cleansing of the perineal area. Resident #2 At 9:55 AM on 2/23/16, an observation of incontinent care revealed CNA #2's failure to cleanse the Resident #2's buttocks before putting on a clean brief. During an interview on 2/23/16 at 2:15 PM, CNA #2 confirmed she forgot to clean Resident #2's buttocks. CNA #2 stated she usually turns resident onto his side and cleans his buttocks but failed to do so this time due to being nervous. CNA #2 stated she has been checked off on incontinent care and nurses have observed her perform incontinent care. The face sheet revealed the facility admitted Resident #2 on 6/29/11 and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/14/16, for Resident #2, revealed a Brief Interview of Mental Status (BIMS) score of nine (9), which indicated moderately impaired cognition. Resident #8 On 2/23/16 at 9:35 AM, while performing incontinent care, Certified Nursing Assistant (CNA) #1 failed to cleanse Resident #8's buttocks. At 2:00 PM on 2/23/16 an interview with CNA #1 revealed she knew she had failed to cleanse Resident #8's buttocks. She stated she had attended inservices and had been checked off. At 2:20 PM on 2/23/16, an interview with the Director of Nursing (DON) revealed, … | 2020-09-01 |
| 23 | 23 | WINSTON COUNTY NURSING HOME | 255072 | 17560 EAST MAIN STREET | LOUISVILLE | MS | 39339 | 2016-02-24 | 323 | D | 0 | 1 | MMRK11 | Based on observation, staff interview, and facility policy review, the facility failed to ensure proper storage of chemicals, as evidenced by, bleach cleanser stored in unlocked cabinet in resident care area on B hall; one (1) of two (2) resident care halls; B Hall. Findings Include: Review of facility policy, titled, Hazardous Chemical Storage, effective date 2/22/16, revealed, Purpose: Environmental services shall maintain all hazardous chemicals in a safe, clean, and locked location when not in use. All hazardous chemical shall be in control of facility personnel while being used. Procedure: Hazardous chemicals will be maintained in a locked storage area at all times. During the initial environmental tour on 2/22/16 at 10:40 AM, with Licensed Practical Nurse (LPN) #1, an observation revealed a double cabinet with locking mechanisms on each cabinet to be unlocked. The left side cabinet contained resident personal care items for daily care and the cabinet on the right side contained personal care items and a bottle of capped bleach cleanser on the bottom shelf. The weight of the bottle indicated it was near full. A blue ice chest was noted in front of the cabinet containing the bleach cleanser and was partially blocking the cabinet but was easily moved to gain access to the cabinet contents. Interview with LPN #1 on 2/22/16 at 10:40 AM, revealed the cabinets should be locked at all times. LPN #1 stated all Certified Nursing Assistants (CNAs) have access to the cabinet and know to keep it locked at all times. LPN #1 stated there are no wandering residents on B Hall at this time. Stated all residents are both alert and oriented or wheelchair bound requiring assistance. An interview with the Administrator on 2/22/16, at 12:00 Noon, revealed the CNA's washed wheelchairs last night and used the bleach cleanser to clean the wheelchairs. The Administrator stated more than likely one of the CNAs put the cleanser in the cabinet instead of giving it to the nurse. The Administrator stated staff are trained to not put any c… | 2020-09-01 |
| 24 | 24 | WINSTON COUNTY NURSING HOME | 255072 | 17560 EAST MAIN STREET | LOUISVILLE | MS | 39339 | 2016-02-24 | 441 | D | 0 | 1 | MMRK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility policy review, the facility failed to prevent the possible spread of infection, as evidenced by, Certified Nursing Assistant failed to change gloves and wash hands properly while providing incontinent care for one (1) of four (4) Residents receiving incontinent care; Resident #2. Facility policy titled Hand Washing, with revision date of 8/19/14, revealed the purpose was to remove germs and prevent the spread of infection. The procedure included to vigorously scrub for 10 seconds (longer if soiled) all areas of the hands and hands would be washed before and after providing care to the residents. Facility policy titled Incontinent/Perineal Care, with revision date of 3/2/15, instructed CNA after cleaning the resident to discard soiled gloves and apply a clean pair of gloves and the next step was to apply clean brief and assist resident with clothing. While observing incontinent care of Resident #2 on 2/23/16 at 2:15 PM, Certified Nursing Assistant (CNA) #2 did not change her gloves for the entire care observation. She continued to place a clean brief on the resident, reposition, arrange bed linens, and raise bed rails with soiled gloves. At 2:15 PM on 2/23/16, an interview with CNA #2 revealed she failed to change her gloves properly after cleaning the resident. CNA #2 stated she wore contaminated gloves when she should have washed her hands and put clean gloves on. At 2:20 PM on 2/23/16, an interview with the Director of Nursing (DON) revealed, Certified Nursing Assistants (CNAs) are inserviced on incontinent care. The DON stated the CNAs have been inserviced on changing gloves when they finish cleaning the resident and definitely before putting the clean diaper on and repositioning the resident. At 2:30 PM on 2/23/16 an interview with the Staff Development Nurse revealed, they have incontinent care inservice every six (6) months, the CNAs have access to the policies, and we cover incontinen… | 2020-09-01 |
| 25 | 25 | WINSTON COUNTY NURSING HOME | 255072 | 17560 EAST MAIN STREET | LOUISVILLE | MS | 39339 | 2017-04-20 | 279 | D | 0 | 1 | 09RC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review and facility policy review, the facility failed to implement a care plan related to wound care for Resident #8. This was for one (1) of 15 care plan reviewed. Findings Include: Review of the facility policy titled, Nursing Care Plan, stated, Customize the care plan to address the Resident's individual concerns and needs. Review of the resident's care plan revealed the absence of a care plan to address the wound care to the area on the left buttock. Record review revealed a physician's order dated 10/28/16 that stated, Cleanse abrasion to left buttock with normal saline, apply duoderm every three days. Interview with Registered Nurse (RN) #1 on 04/19/17 at 11:10 AM confirmed that she had not implemented a care plan for the skin concern area to the left buttock that developed on 10/28/16. RN #1 also confirmed that it was her responsibility to develop a care plan when the wound care began on Resident #8 and stated that she just failed to do it. Resident #8 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. status was severely impaired and she was unable to complete the assessment. | 2020-09-01 |
| 26 | 26 | WINSTON COUNTY NURSING HOME | 255072 | 17560 EAST MAIN STREET | LOUISVILLE | MS | 39339 | 2017-04-20 | 371 | F | 0 | 1 | 09RC11 | Based on observation, staff interview, record review, and facility policy review the facility failed to store and serve food in a safe and sanitary manner as evidenced by wet nesting of dishware, excessive temperature in dry storage area, and excessive build-up of grease inside the Combi/ convection oven. Findings include: Facility policy titled Storage of Pots, Dishes, Flatware, and Utensils, dated 5/95 and revised 1/14, revealed it is the policy of the facility that pots, dishes and flatware are stored in such a way as to prevent contamination by splash, dust, pests, or other means. Procedures revealed dish handlers and tray-line associates are to air dry all food contact surfaces, including pots, dishes, flatware and utensils before storage or store in a self-draining position. Do not stack or store wet. Facility policy titled Food and Supply Storage Procedures, dated 5/95 and revised 1/14, revealed it is the policy of the facility that all food, nonfood items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. The procedure for dry storage revealed to maintain the temperature of dry storage areas between 50 and 70 degrees Fahrenheit. Review of the Production Cleaning Matrix, undated, revealed daily cleaning duties included to clean Combi/Convection oven inside and out to include insides of the oven, inside and outside glass. The Cleaning Procedure for Convection Oven revealed the cleaning frequency to be: Daily: Exterior, handles, doors, knobs, top, and side using a multi-purpose cleaner and monthly using a heavy duty oven cleaner. Observation of the dietary department on initial tour 4/18/17 at 10:15 AM and subsequent observations on 4/19/17 and 4/20/17 revealed four (4) ounce glasses, eight (8) ounce glasses, and tulip serving bowls stacked in a storage tray with visible moisture present. Observation at these times also revealed a light and dark brown build-up of grease covering the ins… | 2020-09-01 |
| 27 | 27 | WINSTON COUNTY NURSING HOME | 255072 | 17560 EAST MAIN STREET | LOUISVILLE | MS | 39339 | 2017-04-20 | 441 | F | 0 | 1 | 09RC11 | Based on observation, staff interview, facility policy review and record review the facility failed to clean glucometer and use a surface barrier when performing fingerstick glucose testing to prevent the potential spread of infection for three (3) of 3 finger sticks observed on one (1) of three 3 Units; C unit. Findings include: Record review of the facility policy titled Blood Glucose Monitor with a dated revision date of 3/6/15 revealed, no instructions to clean the glucometer or using a barrier for supplies to prevent the potential spread of infection. Observation on 4/19/17 at 11:10 AM revealed a finger stick performed during med pass by Licensed Practical Nurse (LPN) #1 in room C47[NAME] LPN#1 gathered supplies (glucometer, lancet, gauze, alcohol prep, strip, sharps container, wipes container and a box of gloves) at the med cart and carried them into the resident's room holding supplies against her scrubs top. LPN #1 laid all the supplies on the top of the over bed table, without cleaning the table or using a barrier. LPN #1 gathered all the supplies, carried them against her scrub top and returned them to her med cart without cleaning. An interview on 4/20/17 at 8:15 AM with LPN #1 confirmed she did carry the supplies up against her scrub top into the resident's room and laid them on an uncleaned table top and without a barrier. After the finger stick she gathered the supplies, carried against her scrub top and returned them to the med cart without cleaning. LPN #1 revealed she had been trained to use a barrier but was nervous. LPN #1 confirmed by not using a barrier for supplies, bringing supplies back to the med cart without cleaning could cause cross contamination and infection. Observation on 4/19/17 at 3:45 PM revealed a finger stick performed during med pass by LPN #2. LPN #2 gathered supplies at the med cart (glucometer, gauze, alcohol prep, lancet and strip), did not clean the glucometer before entering room C47A or before performing the finger stick. LPN #2 laid the supplies on the top of the over… | 2020-09-01 |
| 28 | 28 | WINSTON COUNTY NURSING HOME | 255072 | 17560 EAST MAIN STREET | LOUISVILLE | MS | 39339 | 2017-04-20 | 456 | D | 0 | 1 | 09RC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure that resident's Geri chair was maintained in good repair for one (1) of eight (8) residents sampled who required a wheelchair or Geri chair for locomotion, Resident # 6. Findings include: Observation on 4/18/17 at 10:40 AM revealed a brown, vinyl covered Geri chair with nine (9), four (4) to five (5) inch rips in the chair's seat with exposed foam padding, in Resident #6's room. The tears in the covering were sharp and rough to the touch. An interview with the Director of Nursing (DON) on 4/20/17 at 10:30 AM revealed that a maintenance log is kept at each nurse's station, the nurses are to log any needed repairs and maintenance checks the log daily. The log sheet is taken to the maintenance supervisor when repairs are completed. Nurses are instructed to report any equipment or furniture needing repair or replacement. An interview on 4/20/17 at 10:35 AM with Maintenance Staff #1 (MS#1) revealed he does not have a policy addressing the repair or replacement of resident equipment. MS #1 revealed he makes rounds in and out of all the rooms and checks the maintenance logs at the nurse's stations all day. MS #1 stated he was unaware of the tears in the seat of the Geri chair in Resident #6's room. An interview on 4/20/17 at 10:40 AM with the DON in Resident #6's room confirmed the Geri chair had tears in the seat bottom with exposed foam padding that could cause skin tears to the resident if sitting in the chair and is an infection control problem. The DON revealed she was not aware of the condition of the chair. Review of the facility face sheet revealed the facility admitted Resident #6 initially on 4/25/14 and readmitted on [DATE] with [DIAGNOSES REDACTED]. not ambulate but used a wheelchair for mobility. | 2020-09-01 |
| 29 | 29 | WINSTON COUNTY NURSING HOME | 255072 | 17560 EAST MAIN STREET | LOUISVILLE | MS | 39339 | 2019-06-06 | 812 | F | 0 | 1 | XJRB11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and policy review, the facility failed to ensure that all staff who were responsible for food and nutrition service, could safely and effectively carry out these functions. This included consistent monitoring of all freezer temperatures; dating Mighty Shakes (nutritional shakes) with thawing date to indicate when to discard per manufacturer's recommendations; ensuring food to be served was at holding temperatures and reheated; documentation of food temperatures prior to serving meals; and ensuring that food is stored away from soiled surfaces. This deficient practice affected four (4) of six (6) resident cottages. Findings include: Review of the facility policy titled Food Storage and Labeling, which became effective on [DATE], revealed the procedures included the following: 1. All food items that are not in their original containers must be labeled and date marked to indicate use by date. 2. Suggested labeling includes: a. Common Name b. Date of preparation or use by date 3. Monitoring Storage Temperatures a. A thermometer is kept in storage areas. b. Temperatures in food storage units are monitored daily. c. Documentation of Temp is recorded on appropriate form. Review of the facility policy #B007 titled Food Handling Guidelines (HACCP), revealed the following procedures: - Hot Holding Temperatures - Foods should be held hot for service at a temperature of 140 F or higher. - Cold Holding Temperatures - Foods should be held cold for service at a temperature of 41 F or less. - Reheating - If a food is being held hot for service falls below 140 F, corrective action is taken and documented, as described on the Production Station Worksheet Report. - Internal temperature of potentially hazardous foods being held hot must be maintained at 135 F according to the 2013 FDA Food Code. The Company's standard for hot holding is 140 F. Review of the facility manual for hot food holding drop-in electric we… | 2020-09-01 |
| 30 | 30 | LEXINGTON MANOR SENIOR CARE, LLC | 255091 | 56 ROCKPORT ROAD | LEXINGTON | MS | 39095 | 2017-06-28 | 280 | D | 0 | 1 | YQ7Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and the facility policy review, the facility failed to revise the comprehensive care plans as evidenced by omission of heel protectors, as ordered by the physician to prevent possible skin breakdown, for one (1) of nine (9) resident records reviewed (Resident #4). Findings include: Review of the facility's Comprehensive Care Plan policy, revised 2/2017, revealed: The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS (Minimum Data Set) assessment. Review of the facility's Pressure Injury Prevention policy, dated 04/2017, revealed, To prevent the formation of avoidable pressure injuries, interventions will be documented in the care plan and communicated to all relevant staff. Review of the comprehensive care plans, potential for skin breakdown and self care deficit, dated 5/9/17, did not include applying heel protectors to Resident #4 while in bed. Observation of Resident #4 on 6/26/17 at 1:50 PM, revealed the resident did not have heel protectors while in bed. Review of Resident #4's (MONTH) 2014 physician's orders [REDACTED]. On 06/26/17 at 2:55 PM, an interview with Registered Nurse (RN) #1 revealed, I do the care plans. The heel protectors should have been on the care plans. Review of the facility's face sheet revealed, the facility admitted Resident #4 on 9/24/13. Resident #4's [DIAGNOSES REDACTED]. Review of Annual Minimum Data Set with an Assessment Reference Date of 05/09/17, revealed Resident #4 had a brief Interview of Mental status (BIMS) score of 6, indicating the resident had severely impaired cognition. | 2020-09-01 |
| 31 | 31 | LEXINGTON MANOR SENIOR CARE, LLC | 255091 | 56 ROCKPORT ROAD | LEXINGTON | MS | 39095 | 2017-06-28 | 282 | D | 0 | 1 | YQ7Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interviews, and the facility policy review, the facility failed to follow the care plan for the problem of [MEDICAL CONDITION] related to unspecified [MEDICAL CONDITION], for one (1) of nine (9) records reviewed for care plans, Unsampled Resident #D, as evidenced by not administering medications as ordered, which included, per policy and recommended guidelines, waiting at least five (5) minutes between eye drops. Findings include: Review of the facility's Comprehensive Care Plans policy, with a revision date of 2/2017, revealed, 9. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. Review of the Nursing (YEAR) Drug Handbook, page 233, for [MEDICATION NAME] eye drops, revealed, If more than on ophthalmic product is being used, give them at least 5 minutes apart. Page 468 of the Nursing (YEAR) Drug Handbook, for Dorzolamide ([MEDICATION NAME]) eye drops, revealed if more than one ophthalmic drug was being used, give at least 10 minutes apart. Review of the care plan for Unsampled Resident D revealed a problem onset date of 11/29/2016. The care plan stated Unsampled Resident D was legally blind and could only see shadows and outlines of figures, did not wear glasses, and had a history of [REDACTED]. Review of a Specific Medication Administration Procedures policy, dated 5/1/09, revealed Wait at least five (5) minutes before applying additional medications in the eyes. Observation on 6/27/17 at 8:30 AM, during medication pass to Unsampled Resident #D, revealed Licensed Practical Nurse (LPN) #5 instilled [MEDICATION NAME] 0.15%, one (1) drop, in each eye, followed by [MEDICATION NAME] eye drops, one (1) drop in each eye, without waiting between each medication, per policy and care plan of medications as ordered, which includes the correct procedur… | 2020-09-01 |
| 32 | 32 | LEXINGTON MANOR SENIOR CARE, LLC | 255091 | 56 ROCKPORT ROAD | LEXINGTON | MS | 39095 | 2017-06-28 | 314 | D | 0 | 1 | YQ7Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and the facility policy review, the facility failed to prevent possible skin breakdown as evidenced by not applying heel protectors as ordered by the Physician for one (1) of nine (9) resident observations (Resident #4). Findings include: Review of the facility's Pressure injury Prevention policy, dated 04/2014, revealed: To prevent the formation of avoidable pressure injuries, interventions will be implemented in accordance with Physician orders. Review of the facility's Transcribing Physician order [REDACTED]. Review of the physician's orders [REDACTED]. On 06/26/17 at 1:50 PM, during an observation/interview of Resident #4, with Certified Nursing Assistant (CNA)#1 present, revealed Resident #4 laying supine in bed with bilateral heel protectors not in use. CNA #1 stated, They aren't in here, I should have gone to the laundry and got some. I put them on all the time, yes ma'am except today. On 06/26/17 at 3:20 PM, an interview with CNA #2 revealed, I did check his (Resident #4) heel protectors because they told me he didn't have them on, I don't know what time it was. He had them on then. On 06/26/17 at 2:10 PM, an interview with the Director of Nursing (DON) revealed, The orders should pull to the kiosk but the CNA's have a kardex (what the CNAs use as a care guide to care for the residents) they check everyday for changes. During an interview on 06/26/17 at 3:30 PM, the Administrator stated that the CNA's look at the kiosk, they only look at the kardex if there is a power failure. Everything for the care of the resident in on the kiosk and should be done. Review of the facility's face sheet revealed the facility admitted the resident on 9/24/13. Resident #4's [DIAGNOSES REDACTED]. Review of Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/09/17, revealed Resident #4 had a brief Interview of Mental status (BIMS) score of 6, indicating the resident had severely … | 2020-09-01 |
| 33 | 33 | LEXINGTON MANOR SENIOR CARE, LLC | 255091 | 56 ROCKPORT ROAD | LEXINGTON | MS | 39095 | 2017-06-28 | 332 | D | 0 | 1 | YQ7Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interviews, and the facility policy review, the facility failed to maintain a less than five (5) percent (%) medication error rate for two (2) of 34 medications administered, which caused an error rate of 5.8%, as evidenced by failure to wait at least five (5) minutes between eye drops for Unsampled Resident D. Findings include: Review of the facility's Specific Medication Administration Procedures policy, with an effective date of 05/01/2009, revealed K. Wait at least five (5) minutes before applying additional medication to the eye. Review of the Nursing (YEAR) Drug Handbook, page 233, for [MEDICATION NAME] eye drops, revealed, If more than on ophthalmic product is being used, give them at least five (5) minutes apart. Page 468 of the Nursing (YEAR) Drug Handbook, for Dorzolamide eye drops, revealed if more than one ophthalmic drug was being used, give at least 10 minutes apart. During medication pass observation on 6/27/2017 at 8:30 AM, Licensed Practical Nurse (LPN) #5 administered eye drops for Unsampled Resident D. LPN #5 placed one (1) drop of Dorzolamide ([MEDICATION NAME]) into each eye. LPN #5 then placed an addition drop of [MEDICATION NAME] at 8:32 AM, into each eye. The time sequence between eye medications was two (2) minutes. Review of the (MONTH) (YEAR) Physician Orders, for Unsampled Resident D, revealed an order dated 2/10/2015, for [MEDICATION NAME] for one (1) drop into both eyes twice a day and an order dated 4/10/2015, for Dorzolamide ([MEDICATION NAME]) one (1) drop in each eye twice a day. Interview on 6/27/2017 at 8:35 AM, with LPN #5, revealed she had not waited five (5) minutes between the eye medications but stated she should have. Registered Nurse (RN) #2, was also present during the administration of the eye medications, and when asked if giving both eye medications close together was a problem, she stated, I don't even know what they were. Interview on 6/28/2017 at 2:40… | 2020-09-01 |
| 34 | 34 | LEXINGTON MANOR SENIOR CARE, LLC | 255091 | 56 ROCKPORT ROAD | LEXINGTON | MS | 39095 | 2017-06-28 | 356 | C | 0 | 1 | YQ7Y11 | Based on record review, staff interview and the facility policy review, the facility failed to accurately post daily staffing as evidenced by posted staffing included scheduled, but not actual working staff for one (1) of three (3) days of survey. Findings include: Review of the facility's Posting Direct Care Daily Staffing Numbers policy, dated 04/2017, revealed: Within two (2) hours of the beginning of each shift the number of available staff will be posted. The posting will include the nursing staff working during that shift. On 6/28/17 at 10:40 AM, a review of the facility's Daily Nurses Staffing Form for 06/28/17, revealed the facility included the actual staff hours worked for 24 hours: Day shift 7:00 AM-7:00 PM and Evening Shift 7:00 PM-7:00 AM. On 6/28/17 at 10:50 AM, an interview with the Director of Nursing (DON) revealed that Licensed Practical Nurse (LPN) #3 documents the daily staffing sheet. On 6/28/17 at 10:55 AM, an interview with LPN #3 revealed she had been told the year before that it was okay to document the staffing sheet for the whole time period and if it wasn't right just to mark it out. On 6/28/17 at 11:00 AM, an interview with the Administrator revealed, We had two (2) complaint surveys about staffing and they were okay. | 2020-09-01 |
| 35 | 35 | LEXINGTON MANOR SENIOR CARE, LLC | 255091 | 56 ROCKPORT ROAD | LEXINGTON | MS | 39095 | 2017-06-28 | 431 | E | 0 | 1 | YQ7Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and the facility policy review, the facility failed to remove discontinued medications from Medication Cart #2, for one (1) of two (2) medication carts observed. Findings include: Review of the facility's Discontinued Medication Review policy, with a revision date of ,[DATE], revealed, It is the policy of this facility to monitor the med cart and med room for discontinued medication and ensure that discontinued medications are destroyed timely. Review of the Nurses Meeting, (MONTH) (YEAR) in-service record, revealed: Make sure carts are clean, everything open has a date and remove any discontinued medication on cart. Observation with Licensed Practical Nurse (LPN) #4, of Medication Cart #2 on [DATE] at 9:20 AM, revealed one (1) bottle of [NAME]fen Cough Syrup dated [DATE], with the label instructions to give three (3) times a day for seven (7) days, one (1) bottle of Ondansetron dated [DATE], with label instructions to give every six (6) hours for two (2) days, one (1) bottle of Nystatin dated [DATE], with label instructions to give four (4) times per day for five (5) days, one (1) bottle of Geri-Tussin Cough Syrup dated [DATE], with instructions to give every four (4) hours as needed for cough, and two (2) bottles of Megestrol dated [DATE], with label instructions to give twice per day for 30 days. LPN #4 stated the medications were no longer in use and should not have been on the Medication Cart. She further stated it was all the nurses' responsibility to remove discontinued medications. Interview on [DATE] at 2:40 PM, with Staff Development Nurse LPN #3, revealed she didn't have an explanation as to why the discontinued medications were still on the medication cart. Interview on [DATE] at 3:00 PM, with the Pharmacy Consultant, revealed she told the facility nursing staff to destroy the medications as soon as they were expired. | 2020-09-01 |
| 36 | 36 | LEXINGTON MANOR SENIOR CARE, LLC | 255091 | 56 ROCKPORT ROAD | LEXINGTON | MS | 39095 | 2017-06-28 | 441 | D | 0 | 1 | YQ7Y11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and facility policy review, the facility failed to prevent the possible spread of infection as evidenced by failure to wash hands when removing gloves, completing incontinent care without performing hand hygiene upon leaving resident's room, and when disposing of soiled care items in between residents for two (2) of six (6) care observations (Residents #1 and #2) Findings include: Review of the facility's Hand Hygiene Policy, with a revision date of 02/17, revealed staff involved in direct contact with the resident will perform proper hand hygiene procedures to prevent the spread of infection to residents. Hand hygiene refers to either hand washing or the use of an antiseptic hand rub, also known as alcohol based hand rub. The use of gloves does not replace hand hygiene. Wash hands after removing gloves. Antiseptic solution may be applied to hands after proper hand washing. Review of the facility's Hand Hygiene Table, not dated, revealed use either antimicrobial soap and water or alcohol based hand rub between residents, before applying and after removing protective equipment (PPE), including gloves, before and after handling clean or soiled linens, after assistance with personal body functions (elimination), and when in doubt. Observation during incontinent care on Resident #2, on 06/27/17 at 10:25 AM, with Certified Nursing Assistants (CNAs) #3 and #4, revealed CNA #3 removed her gloves after providing incontinent care, left the resident's room and went to the hallway where she obtained clean care supplies and a trash bag from the clean linen cart. CNA #3 took the clean items into Resident #1's room and left them on the night stand. She then went to another resident's room and retrieved a bedside table, then re-entered Resident #1's room to perform incontinent care, all without performing hand hygiene. Observation during incontinent care on Resident #1, on 06/27/17 at 10:40 AM, with CNAs #3 and #4, reve… | 2020-09-01 |
| 37 | 37 | LEXINGTON MANOR SENIOR CARE, LLC | 255091 | 56 ROCKPORT ROAD | LEXINGTON | MS | 39095 | 2016-08-17 | 246 | D | 0 | 1 | BYHQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and facility policy review, the facility failed to place call light within reach of a dependent resident for one (1) of 13 residents observed. (Resident #4) Findings include: Review of the facility's Call Lights policy, dated 7/14, revealed, the purpose of the procedure is to respond to the resident's requests and needs. While the resident is in bed or confined to a chair, the call light should be within easy reach. Observation of Resident #4 on 8/15/15, at 3:58 PM, revealed the resident in bed, alert and oriented. Resident #4 complained of itching all over and began feeling on top of his chest and around his bed with his hands, and was not able to locate his call light, which was located above his head, to the outer right edge of his pillow. Resident #4 said, I can't find it (call light), and confirmed he was completely blind. Staff interview and observation of Resident #4, with LPN (Licensed Practical Nurse) Staff Development Nurse #3 on 8/15/16 at 3:58 PM, confirmed the resident was not able to locate his call light. Staff interview with the Administrator on 8/15/16, at 4:05 PM, confirmed call lights should always be within reach of the resident, and confirmed that Resident #4 was blind. The Administrator said the staff who put the resident back to bed should have placed the call light within reach of the resident. Staff interview/observation with the Dietary Manager (DM) on 8/17/16, at 2:00 PM, revealed Resident #4 lying in bed, with his call light located to the upper right edge of his mattress. The DM asked the resident if he knew where his call light was located. The resident began feeling around his bed with his hands, and said, I can't find it. The DM asked him to reach up high over his bed pillow. Resident #4 held his right arm up onto his pillow and began feeling for the call light. The DM confirmed the resident was not able to locate his call light and that the call light was o… | 2020-09-01 |
| 38 | 38 | LEXINGTON MANOR SENIOR CARE, LLC | 255091 | 56 ROCKPORT ROAD | LEXINGTON | MS | 39095 | 2016-08-17 | 278 | E | 0 | 1 | BYHQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) assessment related to Activities of Daily Living (ADL) for Residents #1, #9, #10, #12; Hospice Services for Resident #13, for five (5) of 13 MDS assessments reviewed. Findings include: Review of the facility's Minimum Data Set (MDS) 3.0 Assessment Completion, Transmission and Validation policy, dated 07/14, revealed the facility uses an interdisciplinary approach to complete a comprehensive assessment of each resident's functional capacity. Members of the Interdisciplinary Team (IDT) will complete their assigned MDS sections and corresponding Care Area Assessments (CAA) within the specifications and timelines established by the Resident Assessment Instrument (RAI) Manual. Each IDT member is expected to use the RAI Manual as a resource during the assessment coding process. A review of the Centers for Medicare and Medicaid (CMS) RAI 3.0 Manual, dated 10/15, revealed under the section 1.3 Completion of the RAI, an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Sources must include the resident, direct care staff on all shifts, the resident's medical record, physician and family. Information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy by the IDT completing the assessment. A review of the RAI 3.0 Manual under Section G0110 Activities of Daily Living (ADL) Assistance, revealed to code total dependence, the resident must be unwilling or unable to perform any part of the activity over the entire 7 day look-back period. Resident #1 A review for Resident #1 revealed a quarterly MDS assessment with an Assessment Reference Date (ARD) of 05/16/16. Section G 120 revealed Resident #1 was totally dependent with bathing and required two (2) or more … | 2020-09-01 |
| 39 | 39 | LEXINGTON MANOR SENIOR CARE, LLC | 255091 | 56 ROCKPORT ROAD | LEXINGTON | MS | 39095 | 2016-08-17 | 280 | E | 0 | 1 | BYHQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and facility policy review, the facility failed to revise the comprehensive care plan to reflect the conditions of the resident related to Foley Catheter Care and Oxygen use for Resident #4, and bathing for Residents #2, #9 and #10, for four (4) of the 13 resident records reviewed. Findings include: A review of the facility's Care Plans-Comprehensive policy, dated (MONTH) (YEAR), revealed the facility develops a plan of care through the interdisciplinary team to coordinate and communicate care approaches and goals for the resident related to clinical [DIAGNOSES REDACTED]. Outcome objectives are reflective and the facility staff uses the objectives to monitor the resident's progress. The purpose includes the development and modification based on the resident's status. Review of the facility's Comprehensive Care Plans policy, dated 07/14, revealed the facility develops a comprehensive plan of care for each resident that includes measurable objectives and timetables to a meet a resident's medical, nursing and mental/psychosocial needs that are identified in the comprehensive assessment. The care plan will be reviewed and revised quarterly, annually, with significant change of status and as needed to enhance the residents ability's to meet his/her objectives. The facility also provided a document signed by the Administrator stating, It is our facility's policy to use the guidance from the CMS RAI manual for care planning. The RAI Manual, dated (MONTH) 2012, provided by the facility, revealed under section 4.4: Facilities use the findings from the comprehensive assessment to develop an individualized care plan to meet each resident's needs. Resident #4 Record review of Resident #4's physician's orders [REDACTED]. An order, dated 7/28/16, noted to irrigate Foley catheter with 30 to 60 milliliters (ml) of sterile water as needed for leakage or obstruction. Review of Resident #4's incontinent care plan with an … | 2020-09-01 |
| 40 | 40 | LEXINGTON MANOR SENIOR CARE, LLC | 255091 | 56 ROCKPORT ROAD | LEXINGTON | MS | 39095 | 2016-08-17 | 441 | E | 0 | 1 | BYHQ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and facility policy review, the facility failed to provide Foley/incontinent care in a manner to prevent the possible spread of infection, for two (2) of five (5) care observations. (Residents #4 and #8) Findings include: Observation of Foley catheter care on Resident #4, on 8/17/16 at 2:33 PM, with Certified Nursing Assistant (CNA) #2 and CNA #3, revealed CNA #3 removed the Foley catheter draining bag from the resident's bed frame and placed it on the resident's bed, adjusted the bed frame with bare hands, then donned gloves without hand hygiene. She then repositioned the Foley catheter bag on the bed and removed the catheter strap from the resident's left thigh. CNA #3 provided Foley catheter care. CNA #3 applied the leg strap back onto the resident's left thigh, while CNA #2 applied the Foley catheter tubing to the leg strap, and picked up the Foley catheter drainage bag from the bed linens, and hung it to the bed frame. CNA #2 and CNA #3 repositioned the resident in bed with the cotton pad without changing gloves and performing hand hygiene. CNA #3 pulled up the bed frame with while wearing the same soiled gloves used to clean the resident's perianal area. Staff interview with CNA #2 and CNA #3 on 8/17/16, at 2:50 PM, revealed both CNAs confirmed having a break in infection control during Resident #4's Foley catheter care. CNA #2 and CNA #3 both confirmed repositioning the bed rail, Foley catheter, resident and bed linens with soiled gloves. Staff interview with LPN #3/Staff Development Nurse, on 8/17/16 at 3:05 PM, confirmed there was a break in infection control when CNA #2 and CNA #3 provided Foley catheter care on Resident #4. She said CNA #2, and CNA #3, should have washed their hands when going from dirty to clean care during the resident's Foley catheter care. Review of the facility's face sheet revealed the facility readmitted Resident #4 on 7/05/15, with [DIAGNOSES REDACTED]. … | 2020-09-01 |
| 41 | 41 | BOYINGTON HEALTH AND REHABILITATION | 255092 | 1530 BROAD AVE | GULFPORT | MS | 39501 | 2017-01-13 | 164 | D | 0 | 1 | QXQE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to provide privacy by not closing the window blinds during incontinent care for one (1) of five (5) incontinent care observations, Resident # 13. Findings include: Review of the facility's policy titled, Perineal Care, dated 8/2014, revealed avoid unnecessary exposure of the resident's body. Review of the facility's Resident's Rights, no date, revealed the resident had the right to personal privacy. During an observation of an incontinent care for Resident #13 on 01/12/17 at 11:00 AM, provided by Certified Nurse Aide (CNA) #2, assisted by CNA #4, revealed CNA #2 removed the top sheet, and placed a towel over the resident's lap area. CNA #2 performed all of the incontinent care without closing the window blinds. CNA #2 pulled the privacy curtain between the bed and the door, and left the window blinds open. Interview with CNA #2 on 01/12/17 at 3:00 PM, confirmed the blinds were left open during incontinent care for Resident #13. Review of in-services provided by the facility dated 11/28/16 through 11/29/16, titled Privacy, revealed during resident care the room door should be closed, and the curtain should be pulled around the bed. The in-service did not address closing the window blinds. Review of the facility's Face Sheet revealed the facility admitted Resident #13 on 06/14/07. Resident #13's [DIAGNOSES REDACTED]. Review of Resident #13's Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/14/16, revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Resident #13 was able to understand others, and make herself understood to others. Resident #13 required extensive assistance with one to two person physical assist with bed mobility, transfers, toilet use, dressing, and bathing. Resident #13 was always incontinent of bowel and bladder. | 2020-09-01 |
| 42 | 42 | BOYINGTON HEALTH AND REHABILITATION | 255092 | 1530 BROAD AVE | GULFPORT | MS | 39501 | 2017-01-13 | 278 | E | 0 | 1 | QXQE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy review, the facility failed to accurately code the Minimum data Set (MDS) for two (2) of 23 MDS's reviewed. Resident #1 and Resident #2. Findings include: A review of the facility's policy titled Assessment Coordinator, dated (MONTH) 2001, revealed that each individual who completes a portion of the MDS assessment must certify the accuracy of that portion of the assessment. Resident #1 A review of the Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of (MONTH) 11, (YEAR), revealed under section H0100A, Resident #1 was coded as having an indwelling catheter, and Section H revealed Resident #1 as being occasionally incontinent of bladder. A review of the cumulative physician orders [REDACTED]. A review of the monthly Nursing Summary dated for (MONTH) 10, (YEAR) revealed Resident #1 was assessed, and required the use of an indwelling catheter related to a [DIAGNOSES REDACTED].#1. A staff interview on 01/13/2017 at 10:30 AM, with Registered Nurse (RN) #1, revealed it was confirmed the quarterly MDS with the ARD of 11/11/2016 was coded correctly under Section 0H0100A indicating an indwelling catheter, and coded incorrectly under Section 0H indicating the resident was occasionally incontinent of bladder. RN #1 confirmed she completed Section H for the quarterly MDS with the ARD of 11/11/2016, and electronically signed the MDS as complete on 11/23/2016 . During an interview on 1/12/2017 at 3:00 PM, with the MDS Coordinator/ Registered Nurse (RN) #2, it was confirmed Section H0100A was coded correctly, and section H was coded incorrectly. RN #2 stated the facility admitted Resident #1 with an indwelling catheter. A review of the Face Sheet revealed the facility admitted Resident #1 on 02/27/2014, with [DIAGNOSES REDACTED]. A review of Resident #1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/11/2016, revealed the Resident's Brief I… | 2020-09-01 |
| 43 | 43 | BOYINGTON HEALTH AND REHABILITATION | 255092 | 1530 BROAD AVE | GULFPORT | MS | 39501 | 2017-01-13 | 279 | D | 0 | 1 | QXQE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and policy review, the facility failed to develop a Comprehensive Care Plan for a Ureostomy for Resident #11, and bowel and bladder incontinence for Resident #8, for two (2) of 21 Care Plans reviewed. Findings include: Review of the facility's policy titled, Care Plan-Comprehensive, dated (MONTH) 2001, revealed the facility would develop a Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs for each resident. The comprehensive care plan had been designed to incorporate identified problem areas, incorporate risk factors associated with identified problems, reflect treatment goals and objectives in measurable outcomes, and identify the professional services that are responsible for each element of care. Resident #8 Review of Resident #8's Plan of Care revealed no Care Plan for bowel and bladder Incontinence was developed. An observation on 1/12/17 at 2:05 PM, revealed Certified Nursing Assistant (CNA) #1 and CNA #6 provided incontinent care for Resident #8 after an episode of incontinence. An interview with the Director of Nursing (DON) on 1/13/17 at 3:00 PM, revealed all residents should have a Care Plan reflective of identified needs. The DON confirmed Resident #8's Plan of Care did not address bowel and bladder incontinence. Review of the Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 10/31/16, under section H0300, revealed Resident #8 was frequently incontinent of bowel and bladder. This MDS revealed Resident #8 had a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated Resident #8 was cognitively intact. Review of the Face Sheet revealed the facility admitted Resident #8 on 9/14/15, with the [DIAGNOSES REDACTED]. Resident #11 Record review of Resident #11's Care Plan revealed a Focus initiated on 6/13/2016 for High Risk for Impaired Ski… | 2020-09-01 |
| 44 | 44 | BOYINGTON HEALTH AND REHABILITATION | 255092 | 1530 BROAD AVE | GULFPORT | MS | 39501 | 2017-01-13 | 281 | D | 0 | 1 | QXQE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, review of the facility's CNA (Certified Nursing Assistant) Scope of Practice/Orientation, Perry Potter Nursing Skills and Procedures Eighth Edition, Mississippi Board of Nursing Rules and Regulations, and facility policy review, the facility failed to follow professional standards of care related to the failure to check Resident #18's Percutaneous Endoscopic Gastrostomy (PEG) tube placement prior to medication administration for one (1) of two (2) PEG tubes observed during med (medication) pass, and failed to ensure licensed nursing staff applied Resident #13's medicated cream after completion of incontinent care for one (1) of five (5) incontinent care observations. Findings include: A review of the Mississippi Board Of Nursing Rules and Regulations in Chapter 3 section 1.3, revealed: medication administration may only be delegated to another registered nurse or licensed practical nurse and not to an unlicensed person. This would include medicated ointments, lotions and protective barriers, regardless of skin integrity. A review of the Perry Potter Nursing Skills and Procedures, eighth Edition, under the topic Topical Skin applications, revealed: The skill of administering topical medications cannot be delegated to nursing assistive personnel. Review of the facility's policy titled, Administering Medications Through An Enteral Tube, dated (MONTH) (YEAR), revealed the purpose of this procedure is to provide guidelines for the safe administration of medications through an Enteral tube. This policy revealed to check placement of the Nasogastric, Esophagostomy, or Gastrostomy Tube, auscultate the abdomen (approximately three inches (3) below the sternum) while injecting ten (10) milliliters (ml) of air into the tube, and listen for the whooshing sound in the stomach then gently pull back and aspirate stomach contents. Review of the facilities document titled, CNA Scope of Practice/Orientation… | 2020-09-01 |
| 45 | 45 | BOYINGTON HEALTH AND REHABILITATION | 255092 | 1530 BROAD AVE | GULFPORT | MS | 39501 | 2017-01-13 | 282 | E | 0 | 1 | QXQE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to follow Resident #8 and Resident #13's Care Plan for the risk of impaired skin integrity for one (2) of five (5) incontinent care observations, and Resident #18's Care Plan for risk of altered nutrition related to (r/t) a feeding tube, for three (3) of 21 care plans reviewed. Findings include: Review of the facility's policy titled, Care Plan-Comprehensive, dated (MONTH) 2001, revealed the facility would develop a Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs for each resident. The comprehensive care plan had been designed to incorporate identified problem areas, incorporate risk factors associated with identified problems, reflect treatment goals and objectives in measurable outcomes, and identify the professional services that are responsible for each element of care. Resident #8 Review of Resident #8's Care Plan initiated on 8/16/16, revealed the Focus for high risk for impaired skin integrity with the included intervention for prompt pericare after each incontinent episode. Observation of Resident #8's incontinent care provided by Certified Nursing Assistant (CNA) #1 and CNA #6 on 1/12/17 at 2:05 PM, revealed CNA #1 wiped down the middle of the vagina with an area of the washcloth that was previously used to wipe with. CNA #1 also wiped the anal area and left buttock upwards five (5) times with the same area of the washcloth. An interview on 1/12/17 at 2:20 PM, revealed CNA #1 stated she was not aware she had used the contaminated area of the cloth more than once. CNA #1 said she wiped the buttocks and the anal area multiple times with the same area of the cloth. Review of the facility's Face Sheet revealed the facility admitted Resident #8 on 9/14/15 with the [DIAGNOSES REDACTED]. Review of Resident #8's Quarterly Minimum Data Set (MDS) with an Assessment Ref… | 2020-09-01 |
| 46 | 46 | BOYINGTON HEALTH AND REHABILITATION | 255092 | 1530 BROAD AVE | GULFPORT | MS | 39501 | 2017-01-13 | 315 | E | 0 | 1 | QXQE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy review, the facility failed to provide incontinent care in a manner to prevent Urinary Tract Infections for two (2) of five (5) incontinent care observations, for Resident #8 and Resident #13. Findings include: Review of the facility's policy titled, Perineal Care, with a date of (MONTH) 2014, revealed the purposes of the procedure was to prevent infections. Instructions for care of the female resident were to separate the labia and wash area downward from front to back, continue to wash the perineum moving outward to and including thighs, wipe the rectal area thoroughly wiping from the base of the labia and extending over the buttocks. After wiping an area, fold the washcloth or use a new washcloth or pre-moistened wipe. A review of the facility's policy titled, Infection Control Policies/Practices, with a date of (MONTH) 2014 revealed all personnel will be informed of infection control policies and practices, and any changes thereof through orientation program and regularly scheduled in-service training programs. Resident #8 Observation of Resident #8's incontinent care provided by Certified Nursing Assistant (CNA) #1 and CNA #6 on 1/12/17 at 2:05 PM, revealed CNA #1 wiped down the middle of the vagina with an area of the washcloth that was previously used to wipe with. CNA #1 also wiped the anal area and left buttock upwards five (5) times with the same area of the washcloth. An interview on 1/12/17 at 2:20 PM, revealed CNA #1 stated she was not aware of she had used the contaminated area of the cloth more than once, and she confirmed she wiped the buttocks and the anal area multiple times with the same area of the cloth. Review of the facility's Face Sheet revealed the facility admitted Resident #8 on 9/14/15 with the [DIAGNOSES REDACTED]. Review of Resident #8's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/31/16, revealed a Brief I… | 2020-09-01 |
| 47 | 47 | BOYINGTON HEALTH AND REHABILITATION | 255092 | 1530 BROAD AVE | GULFPORT | MS | 39501 | 2017-01-13 | 322 | D | 0 | 1 | QXQE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy review, the facility failed to check the placement of Resident #18's Percutaneous Endoscopic Gastrostomy (PEG) tube by auscultation with air prior to medication administration. This was for one (1) of two (2) PEG tubes observed during the med (medication) pass. Findings include: Review of the facility's policy titled, Administering Medications Through An Enteral Tube, dated (MONTH) (YEAR), revealed the purpose of this procedure is to provide guidelines for the safe administration of medications through an Enteral tube. This policy revealed to check placement of the Nasogastric, Esophagostomy, or Gastrostomy Tube, auscultate the abdomen (approximately three inches (3) below the sternum) while injecting ten (10) milliliters (ml) of air into the tube, and listen for the whooshing sound in the stomach then gently pull back and aspirate stomach contents. During an observation of medication administration on 1/13/17 at 11:12 AM, Licensed Practical Nurse (LPN) #5 prepared to administer [MEDICATION NAME] 20 milligrams (mgs) and [MEDICATION NAME] 10 mg. via Resident #18's PEG tube. LPN #5 proceeded to check the PEG tube placement, and pushed 10 millimeters (ml)s of water instead of air into the PEG tube. LPN #5 checked the placement by auscultation with a stethoscope she placed below the Xyphoid Process (lower part of the sternum). An interview with LPN #5 on 1/13/17 at 11:30 AM, revealed LPN #5 stated, I was nervous, and she confirmed she used water instead of air to check placement of the PEG tube for Resident #18. Review of Resident #18's Order Summary Report physician's orders [REDACTED]. 2) [MEDICATION NAME] 20 mg. via [DEVICE] four times a day for muscle spasms. 3) [MEDICATION NAME] HCL Solution ([MEDICATION NAME]) 10 mg./10 ml (milliliter) give four times a day r/t (related to) Gastro-Esopheal Reflux Disease (GERD) without Esophagitis. Record review of the Face Sheet reve… | 2020-09-01 |
| 48 | 48 | BOYINGTON HEALTH AND REHABILITATION | 255092 | 1530 BROAD AVE | GULFPORT | MS | 39501 | 2017-01-13 | 441 | F | 0 | 1 | QXQE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, record review, facility policy review, the facility failed to ensure infection control measures were maintained to prevent the possibility of the spread of infection/contamination during incontinent care for Resident #7 for one (1) of five (5) incontinent care observations, during [MEDICATION NAME] care for Resident #11 for one (1) of three (3) wound care observations, during medication pass for Resident #2 for one (1) of twenty-seven(27) medication administration opportunties observed, and one (1) of two (2) blood glucose fingerstick checks observed, for Resident #2. Findings include: Review of the facility's policy titled, Infection Control Policies/Practices, dated (MONTH) 2014 revealed the primary purpose of the facility's infection control policies and practices are to establish guidelines to follow in providing a safe, sanitary, and comfortable environment, and to aid in preventing the development and transmission of diseases and infections. Review of the facility's policy titled, Care of Facility Property, dated (MONTH) 2014 revealed all equipment used during the course of a shift must be cleaned, and where indicated, disinfected prior to returning to use. Resident #2 An observation of Resident #2's Blood Glucose Fingerstick Check on 1/12/17 at 4:12 PM, revealed Licensed Practical Nurse (LPN) #4 failed to wash her hands prior to the finger stick, and placed the glucometer on Resident #4's bed without a surface barrier. LPN #4 returned to the med cart, and placed the contaminated Glucometer on the medication cart without disinfecting the machine. LPN #4 cleaned the Glucometer with two (2) alcohol prep pads instead of a germicidal/disinfectant wipe. In an interview with LPN #4 on 1/12/17 at 4:25 PM, LPN #4 revealed she had some in-service on infection control practices completed when she was hired four (4) months ago. LPN #4 stated she sometimes cleaned the Glucometer with the Bleach wipes located … | 2020-09-01 |
| 49 | 49 | BOYINGTON HEALTH AND REHABILITATION | 255092 | 1530 BROAD AVE | GULFPORT | MS | 39501 | 2019-03-08 | 640 | D | 0 | 1 | M3XR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility statement review, and staff interview, the facility failed to submit the Minimum Data Set (MDS) assessment within seven (7) days after completion of Resident #67's MDS assessment. This concern was identified for one (1) of 31 MDS assessments reviewed. Findings include: Review of a typed statement on the facility's letterhead, dated 03/08/19 and signed by the Administrator, revealed: The Boyington Health and Rehabilitation utilizes the RAI (Resident Assessment Instrument) manual for MDS (Minimum Data Set) assessments and guidelines for completion of MDS. Record review revealed Resident #67 was admitted by the facility on 10/13/18, and was discharged on [DATE]. Resident #67 had a one (1) day stay at facility. Review of the Casper Report revealed the MDS, with the target date of 10/14/18, was not submitted and accepted until 1/31/19. An interview, on 03/08/19 at 9:12 AM, revealed RN #1 stated, I saw that it was late when I returned from maternity leave. RN #4 did the assessment while I was out and she closed it, but did not lock it. I saw it and transmitted it 120 days late. I use the RAI manual for coding the MDS. An Interview, on 03/08/19 at 9:06 AM, with the Director of Nursing (DON) revealed the MDS assessment was submitted late. The DON stated it was identified, corrected, and we put it on our Quality Assessment and Assurance Concern (QAPI). The DON stated Registered Nurse (RN) #4 was filling in for RN #1 due to our regular MDS Nurse was on maternity leave. The DON stated RN #4 did the assessment, but failed to lock it in, and when RN #1 returned to work she found the error and corrected it by submitting the assessment. We knew it was late, but we submitted it anyway. An interview, on 03/08/19 with 9:15 AM, revealed RN #4 stated, I was doing MDS while RN #1 was out on maternity leave and I didn't lock the assessment. I guess I just over looked it somehow. | 2020-09-01 |
| 50 | 50 | BOYINGTON HEALTH AND REHABILITATION | 255092 | 1530 BROAD AVE | GULFPORT | MS | 39501 | 2019-03-08 | 656 | D | 0 | 1 | M3XR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, facility policy review, and staff interview, the facility failed to implement the comprehensive care plans related to Residents #2, #57, and #133's wound care, and for Resident #51's catheter care. This concern was identified for four (4) of 31 care plans reviewed. Findings include: Review of the facility's policy titled, Care Plans-Comprehensive, dated 11/2017, revealed that it is the policy of this facility that a Comprehensive Care Plan that includes measurable objectives and timetables to meet medical, nursing, mental and psychological needs is developed for each resident. The facility policy stated that each resident's Comprehensive Care Plan is designed to incorporate identified problem areas, incorporate risk factors associated with identified problems, and reflect treatment goals and objectives in measurable goals. The facility policy stated that the Comprehensive Care Plan has been designed to prevent declines in the resident's functional status/ functional levels. The Comprehensive Care Plan has been designed to reflect treatment goals and objectives in measurable outcomes. The policy further stated care plans are revised as changes in the resident's condition dictate and reviews are made at least quarterly. Resident #2 A review of the Comprehensive Care Plan for Resident #2, revealed a Focus problem, initiated on 01/15/15, for Stage 4 pressure wounds to the right and left ischiums, and a Stage 4 pressure wound to the sacrum initiated on 09/10/2018. The Care Plan revealed the measurable goals stated there will have been noted improvement in size and depth of the pressure wounds to the right and left ischiums by next review with no further signs of skin integrity alterations, and no pain with wound treatment. The Target Date was 06/03/19. The Care Plan included an intervention, dated 03/05/2019, for nursing department to cleanse the wound to the left ischium, right ischium, and sacrum with Normal… | 2020-09-01 |
| 51 | 51 | BOYINGTON HEALTH AND REHABILITATION | 255092 | 1530 BROAD AVE | GULFPORT | MS | 39501 | 2019-03-08 | 658 | D | 0 | 1 | M3XR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy review, the facility failed to administer Resident #61's multidose inhaler in a manner to prevent thrush for one (1) of three (3) residents observed for multidose inhaler administration. Findings include: Review of the Mississippi Nursing Practice Law, with an effective date of (MONTH) 1, 2010, revealed on pages three and four (3 & 4) of 26: 73-15-5 Definitions. (2) The practice of nursing by a registered nurse means the performance for compensation of services which requires substantial knowledge of biological, physical, behavioral, psychological, and sociological sciences, and of nursing theory as the basis for assessment, diagnosis, planning intervention, and evaluation in the promotion, maintenance of health; management of individual's responses, to illness, injury or infirmity; the restoration of optimum function; or the achievement of a dignified death. Nursing practice includes, but is not limited to, administration, teaching, counseling, delegation, and supervision of nursing, and execution of the medical regimen, including the administration of medications, and treatments prescribed by any licensed or legally authorized physician, or dentist. (5) The practice of nursing by a licensed practical nurse means the performance for compensation of services requiring basic knowledge of the biological, physical, behavioral, psychological, and sociological sciences, and of nursing procedures which do not require the substantial skill, judgement, and knowledge required of a registered nurse. These services are performed under the direction of a registered nurse, or a licensed physician, or licensed dentist, and utilize standardized procedures in the observation, and care of the ill, injured, and infirm; in the maintenance of health; in action to safeguard life and health; and in the administration of medications, and treatments prescribed by any licensed physician, or lic… | 2020-09-01 |
| 52 | 52 | BOYINGTON HEALTH AND REHABILITATION | 255092 | 1530 BROAD AVE | GULFPORT | MS | 39501 | 2019-03-08 | 686 | D | 0 | 1 | M3XR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, record review, and facility policy review, the facility failed to provide wound care in a manner to promote healing for three (3) of six (6) resident wound care observations: Resident #2, Resident #57, and Resident #133. Findings Include: A review of the facility's policy titled, Pressure Ulcer Treatment, dated (MONTH) (YEAR), revealed that it is the purpose of this facility's procedure to provide guidelines for the treatment of [REDACTED]. The Pressure Ulcer Treatment procedure outlined certain steps in the procedure as follows: Put on exam gloves, loosen tape and remove dressing, remove gloves, then wash hands, and now put on clean gloves. Observe the pressure ulcer, dress the pressure ulcer with the prescribed dressing, discard all disposable items into designated container, and remove gloves and discard into designated container. Wash hands. Resident #2 An observation, on 03/06/2019 at 8:46 AM, revealed Resident #2's wound care was provided by Registered Nurse (RN) #3. RN #3 performed the wound care on three (3) separate pressure wounds: A Stage 4 pressure wound to the left (L) Ischium, a Stage 4 pressure wound to the right (R) Ischium, and a Stage 4 pressure wound to the sacral area. RN # 3 performed the wound care to both of the Stage 4 pressure wounds to the (L) Ischium and (R) Ischium, without incident. During the wound care on the Stage 4 pressure wound to the sacral area, RN #3 discarded the soiled 4X4 gauze used for cleaning the wound, and then continued with the wound care by applying two (2) out of three (3) dressing ropes into the wound bed without changing her gloves and washing her hands. After applying the second dressing rope, it was then that RN #3 removed her gloves, washed her hands, put on new gloves, and then continued to apply the third dressing into the wound. During an interview, on 03/07/2019 at 11:00 AM, Registered Nurse (RN) #3 confirmed she did not wash her hands after she … | 2020-09-01 |
| 53 | 53 | BOYINGTON HEALTH AND REHABILITATION | 255092 | 1530 BROAD AVE | GULFPORT | MS | 39501 | 2019-03-08 | 690 | D | 0 | 1 | M3XR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy review, the facility failed to provide Resident #51 and Resident #109's catheter care in a manner to prevent the possibility of a Urinary Tract Infection [MEDICAL CONDITION], for two (2) of five (5) resident catheter care observations. Findings include: A review of the facility's policy titled Catheter Care, Urinary dated (MONTH) (YEAR) revealed: Equipment and Supplies included pre-moistened wipes. Steps in the Procedure: 1. Wash hands. 17. Clean from the least contaminated to most contaminated area. Review of the facility's policy titled, Perineal Care, dated (MONTH) (YEAR), revealed: Equipment and Supplies included pre-moistened wipes. 18. For Male Resident- Steps in the Procedure - b. Wash perineal area starting with urethra and working outward. (2) Wash and rinse urethral area using a circular motion. f. Instruct, or assist resident to turn on his side. g. Using new washcloth, apply soap or skin cleansing agent or use pre-moistened wipe and wash. h. Using new washcloth, rinse the rectal area thoroughly to include the area under the scrotum, the anus, and the buttocks. If pre-moistened wipes are used, rinsing is not necessary. On 03/07/19 at 2:05 PM, an observation revealed Certified Nursing Assistant (CAN) #1 provided Resident #51's catheter care. CNA #1 entered Resident #51's room, applied her gloves, pulled some clean wipes from the wipe container, and begin the catheter care. CNA #1 did not wash her hands prior to donning the gloves and beginning the catheter care. CNA #1 wiped around the catheter near the resident's penis three times using one wipe, and rotated the wipe as she wiped. She then used another wipe to wipe in a downward motion of the resident's groin areas, using a clean wipe for each side. CNA #1 held the catheter tubing near the meatus, and wiped away from the meatus three times. She then repositioned Resident #51 onto his left side and cleaned his… | 2020-09-01 |
| 54 | 54 | BOYINGTON HEALTH AND REHABILITATION | 255092 | 1530 BROAD AVE | GULFPORT | MS | 39501 | 2019-03-08 | 761 | D | 0 | 1 | M3XR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure the disposal of expired medications, for two (2) of three (3) medication storage room observations. Findings Include: Record Review of the facility's policy titled, Storage of Medications revealed drugs and biologicals should be stored in a safe, secure and orderly manner. No discontinued, outdated, or deteriorated drugs or biologicals are available for use in this center. All such drugs are destroyed. An observation, on 03/06/19 at 11:49 AM, revealed expired medication in the 100 Hall medication storage room. One (1) bottle of Geri-Mox (antacid), expired on 01/2019, and two (2) bottles [MEDICATION NAME] ([MEDICATION NAME]) expired on 01/2019. During an interview, on 03/06/19 at 11:52 AM, Registered Nurse (RN)# 5 confirmed the medications in the medication storage room on the 100 Hall were expired. RN #5 said she had just checked all of the meds to make sure there were no expired medications. An observation, on 03/07/19 at 11:54 AM, revealed the medication room on the 300 Hall had three (3) aspirin bottles with an expiration date of 01/2019, and two (2) [MEDICATION NAME] bottles expired on 02/2019. During an interview, on 03/07/19 at 11:59 AM, RN #7 confirmed the medications in the medication storage room on the 300 Hall were expired. During an interview, on 03/08/19 at 12:03 PM, the Director of Nursing (DON) confirmed the meds were expired. The DON said the meds should be checked daily to make sure they are not expired. | 2020-09-01 |
| 55 | 55 | BOYINGTON HEALTH AND REHABILITATION | 255092 | 1530 BROAD AVE | GULFPORT | MS | 39501 | 2019-03-08 | 880 | E | 0 | 1 | M3XR11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, record review, and facility policy review, the facility failed to ensure measures to prevent the possibility of a Urinary Tract Infection [MEDICAL CONDITION] and/or cross contamination during catheter care for Residents #51, for one (1) of six (1 of 6) catheter care observations. The facility also failed to prevent the possible spread of infection and cross contamination during wound care by failure to wash hands during Residents #2, #57, and #133's wound care, for three of six (3 of 6) wound care observations. Findings Include: Review of facility's policy titled, Infection Control Monitoring, dated (MONTH) (YEAR), revealed it is the policy of the center to investigate the cause of infections (nosocomial, community and hospital acquired) and the manner of spread. The records will be maintained and infectious trends or any identified problems or potential problems will be reported to the Administrator, Director of Nurses and the Quality Assurance Committee. Follow up action will be taken as necessary. The objectives of the facilities Infection Control Policies and Practices are to: prevent, identify, report, and control infections and other communicable diseases. Designed to provide safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Establish guidelines to follow in the implementation of isolation precautions. Maintain records of incidents and corrective actions related to infections. Establish guidelines to follow in implementing standard precautions/universal precautions of the handling of blood/ bodyguards and Antibiotic Stewardship Program. A review of the facility's policy titled, Hand Hygiene dated (MONTH) (YEAR), revealed that it is the policy of this facility handwashing/ hand hygiene shall be regarded by this center as a means of preventing the spread of infections. The policy stated that all personnel shall f… | 2020-09-01 |
| 56 | 56 | BOYINGTON HEALTH AND REHABILITATION | 255092 | 1530 BROAD AVE | GULFPORT | MS | 39501 | 2017-05-18 | 280 | E | 1 | 0 | UDH111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview and facility policy review, the facility failed to develop/revise Care Plans for Pressure Ulcers for seven (7) of seven (7) residents reviewed for Pressure Ulcers; Residents #7, #8, #9, #10, #11, #12 and #13. The facility also failed to revise Resident #1's Care Plan for continued treatment of [REDACTED].#1, one (1) of 13 sampled resident care plans reviewed; which involved eight (8) of 13 residents. Findings include: Review of the facility policy entitled Care Plan-Comprehensive, dated 11/01, revealed, Policy Interpretation and Implementation 1. An Interdisciplinary Team, in coordination with the resident, his/her family or representative develops and maintains a Comprehensive Care Plan for each resident and 4. Care plans are revised as changes in the resident's condition dictate. Resident #1 Review of Resident #1's Care Plan revealed a Focus, dated 02/25/17, for rash & (and) itching. The approaches included the use of the medication [MEDICATION NAME] Cream (medication for Scabies) 5 % (per cent) Apply from neck down topically one (1) time only for itching initiated 04/04/17, revised 05/10/17, and resolved 05/10/17. Resident #1 continued to have itching at the sites of the scabies, and an order, dated 04/19/17, was added for [MEDICATION NAME] 0.1% Ointment due to itching. The Care Plan was never updated with a Focus of Scabies, nor was there a Focus of history of Scabies. The approach for the [MEDICATION NAME] Cream had not been resolved until 05/10/17, even though it was only to be administered once, and the date it was initiated was 04/04/17. A Focus area of Infection, dated 02/25/17, revealed an Intervention for [MEDICATION NAME] 0.3% ointment, Instill one (1) inch in left eye every eight (8) hours, initiated 03/06/17. Review of the cumulative order summary report for 05/17 revealed the medication order was no longer in effect, since it was not on the cumulative orders. This medication had not bee… | 2020-09-01 |
| 57 | 57 | BOYINGTON HEALTH AND REHABILITATION | 255092 | 1530 BROAD AVE | GULFPORT | MS | 39501 | 2017-05-18 | 281 | D | 1 | 0 | UDH111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview, review of instructions for the Negative Pressure Wound Therapy (NPWT) and the Nurse Practice Act, the facility failed to obtain an order for [REDACTED]. Findings include: Resident #7 Review of the Pressure Settings instructions, provided by the facility for the NPWT, not dated, revealed the pressure can be adjusted in increments of 25 millimeters (mm) Hg ( mercury) from 25 to 200 mm Hg. The Default setting is 125 mm Hg. Review of the readmission orders [REDACTED]. The order did not include the negative pressure setting for the wound. In an interview, on 05/17/17 at 11:25 AM, the Medical Director confirmed all orders for NPWT should always contain the pressure to be used on the wound. Review of the Admission Record revealed the facility readmitted Resident #7 on 12/22/16, with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/18/17, revealed he scored 9 of 15 on the Brief Interview for Mental Status (BIMS), which indicated he had moderate cognitive impairment. Unsampled Resident D Review of the Mississippi Nursing Practice Law, effective 07/01/10, revealed, Definitions, 2. Nursing practice includes, but is not limited to, administration, teaching, counseling, delegation and supervision of nursing, and execution of the medical regimen, including the administration of medications and treatments prescribed by any licensed or legally authorized physician or dentist. Review of the discontinued physician's orders [REDACTED]. Review of the cumulative Order Summary Report for Physician order [REDACTED]. Observation of Unsampled Resident D's room, on 05/10/17 at 11:30 AM, revealed isolation supplies were on the door of the Resident's room. Unsampled Resident D's roommate was Unsampled Resident H, who had no order for isolation. During an interview on 05/11/17 at 3:40 PM, the Interim Director of Nursing (DON) confirmed Unsampled Resident D had be… | 2020-09-01 |
| 58 | 58 | BOYINGTON HEALTH AND REHABILITATION | 255092 | 1530 BROAD AVE | GULFPORT | MS | 39501 | 2017-05-18 | 441 | E | 1 | 0 | UDH111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, staff interview and facility policy review, the facility failed to maintain and monitor infection tracking for three (3) of six (6) sampled residents with isolation procedures and two (2) of eight (8) Unsampled residents with isolation procedures, Residents #1, #7, and #11 and Unsampled Residents #B and #C; for five (5) of eight (8) residents. Findings include: Review of the facility policy entitled, Infection Control Policies/Practices, dated 08/14, revealed, Policy Interpretation and Implementation, 2. d. Maintain records of incidents and corrective actions related to infections. Resident #1: Review of the Care Plan for Resident #1 revealed [MEDICATION NAME] Cream for Scabies had been initiated/administered to the Resident on 04/04/17. Review of the Monthly Infection Control Report revealed there was no entry for Scabies for the month of (MONTH) (YEAR). There was one (1) entry for Resident #1, on 04/13/17, for Symptoms -itching with an order for [REDACTED]. There was no Site, Care Plan or Date Resolved documented on the Infection Control Report. There was no indication as to why itching would have been included on the log as an infection. Interview with the Infection Control Registered Nurse (RN), on 05/12/17 at 1:10 PM, revealed she was responsible for the Monthly Infection Control Report as well as having tracked and trended infections in the facility. The Infection Control RN stated the Scabies had not been recorded on the Infection Control Report for Resident #1 because an antibiotic was not given. She also stated in hind sight she should have included the Scabies on the Infection Control Report. Review of the Admission Record revealed the facility admitted Resident #1 on 02/25/17, with diagnoses, which included Cerebral Infarction and [DIAGNOSES REDACTED]. Review of the 14 day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/10/17, revealed the Resident scored 13 of 15 on the … | 2020-09-01 |
| 59 | 59 | BOYINGTON HEALTH AND REHABILITATION | 255092 | 1530 BROAD AVE | GULFPORT | MS | 39501 | 2017-05-18 | 514 | E | 1 | 0 | UDH111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review the facility failed to ensure accurate and completely documented medical records as evidenced by conflicting information about wounds and whether they were acquired or admitted , where they were located and types of wounds for five (5) of seven (7) residents reviewed with pressure sores; Residents #7, #10, #11, #12, and #13. Findings include: Resident #7: Review of the Weekly Wound Information Sheet, for Resident #7, revealed the following wound assessments: 1. Right Ankle: weekly documentation present with conflicting information: 03/7/17- Right Ankle Pressure Ulcer, acquired 11/2/16, originally unstageable with current stage III. 03/28/17-Documentation changed to Right lateral ankle pressure ulcer, originally unstageable with current stage II. 05/10/17-Documentation goes back to Right Ankle pressure ulcer, admitted on [DATE] as a current stage II with no original staging. 2. Left Ankle: weekly documentation present with conflicting information: 3/7/17-Left ankle Pressure Ulcer, acquired 11/14/16, originally unstageable with current stage III. 3/28/17-Changed to Left lateral ankle pressure ulcer, originally unstageable with current stage III. 5/10/17-Goes back to Left ankle pressure ulcer, now as admitted with on 5/4/17, no original stage recorded, current stage II. 3. Sacrum: weekly documentation present with conflicting information: 3/7/17-Sacrum, Pressure Ulcer, admitted as stage IV on 10/14/16, with current stage IV and original Stage IV. 5/10/17-Sacrum, Pressure Ulcer, changed to admitted with on 5/4/17 with current stage of III and original stage was not documented. Review of Resident #7's current care plan did not reveal the type of wounds or stages of the ankle wounds. Interview, on 05/16/17 at 12:30 PM, with the MDS/CP LPN (Minimum Data Set/Care Plan Licensed Practical Nurse) confirmed neither pressure ulcers for the ankles on Resident #7 included the stage of the pressure ulcers. … | 2020-09-01 |
| 60 | 60 | BOYINGTON HEALTH AND REHABILITATION | 255092 | 1530 BROAD AVE | GULFPORT | MS | 39501 | 2019-08-29 | 656 | G | 1 | 0 | QXL511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview and facility policy review, the facility failed to implement Resident #3's Care Plan for high risk for skin impairment. The facility failed to perform weekly body audits to monitor, assess and prevent the reoccurrence of a pressure ulcer. The facility identified Resident #3 at high risk for pressure ulcers on admission, 02/06/19, due the presence of a Stage 3 sacral pressure ulcer. As a result, Resident #3 suffered harm due to the development of a Stage 3 sacral pressure ulcer identified, on 05/09/19, which required hospitalization for wound infection and debridement of the wound. This concern was identified for one (1) of six (6) wound care plans reviewed. Findings Include: Record review of the facility's policy titled, Comprehensive Care Plan Policy, dated (MONTH) (YEAR), revealed a Comprehensive Care Plan that includes measurable objectives and timetables to meet resident's medical, nursing, mental and psychological needs shall be developed for each resident. An interdisciplinary team, in coordination with the resident, his/her family or representative, develops and maintains a Comprehensive Care Plan for each resident. The Comprehensive Care Plan has been designed to incorporate identified problem areas, incorporate risk factors associated with identified problems, build on residents strength, reflect treatment goals and objectives in measurable outcomes, Identify the professional services that are responsible for each element of care, prevent declines in the resident 's functional status/functional levels, enhance the optimal functioning of the resident by focusing on a rehabilitative program, ensure care plan is individualized and person-centered and reflects the resident's goal for admission and desired outcomes, and discharge plans. Review of the facility's policy titled, Prevention of Pressure Ulcers, dated (MONTH) 2019, revealed the skin observation schedule would be completed as follows: C.… | 2020-09-01 |
| 61 | 61 | BOYINGTON HEALTH AND REHABILITATION | 255092 | 1530 BROAD AVE | GULFPORT | MS | 39501 | 2019-08-29 | 686 | G | 1 | 0 | QXL511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview and facility policy review, the facility failed to perform weekly body audits to monitor, assess and prevent the reoccurrence of a pressure ulcer. The facility identified Resident #3 at high risk for pressure ulcers on admission, 02/06/19, due the presence of a Stage 3 sacral pressure ulcer. As a result, Resident #3 suffered harm due to the facility's identification of an unstageable sacral pressure ulcer, on 05/09/19, which required hospitalization for wound infection and debridement of the wound. This concern was identified for one (1) of six (6) wound care plans reviewed. Findings Include: Review of the facility's policy titled, Prevention of Pressure Ulcers, dated (MONTH) 2019, revealed the skin observation schedule would be completed as follows: C.N.[NAME] (Certified Nursing Assistants) will complete total body observations at minimum on bath days. Charge Nurse will complete weekly skin observations on each resident, Licensed Nurse Weekly Skin Observation Form. Any residents with wounds will be documented on the Weekly Wound Information Sheet. The Care Plan will be revised/updated. Review of the hospital Emergency Department (ED) notes revealed Resident #3's service time and date was 05/22/19 at 12:59 PM. History of Present Illness: She was sent in because of change in hydration and alertness. Decreased diet and is refusing to take medications, meals, and fluids. Level of consciousness was alert, awake, and aware. Calm and cooperative. [DIAGNOSES REDACTED]. Review of the hospital Discharge Summary revealed Resident #3 was admitted to the hospital, on 05/22/19, and discharged on [DATE]. Resident #3 underwent an Excisional Debridement of a 15 cm X 15 cm sacral and bilateral gluteal stage IV (4) decubitus ulcer. Incision and drainage of a left medial abcess. The discharge [DIAGNOSES REDACTED].[MEDICAL CONDITION], unspecified organism. Initial blood culture was positive for Staphylococcus lugdunensis… | 2020-09-01 |
| 62 | 62 | BOYINGTON HEALTH AND REHABILITATION | 255092 | 1530 BROAD AVE | GULFPORT | MS | 39501 | 2017-11-16 | 280 | D | 0 | 1 | 212T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy review, the facility failed to revised the care plan related to incontinence for one (1) of 24 resident care plans reviewed, Resident #3. Findings included: A facility policy titled Care Plan-Comprehensive, dated (MONTH) (YEAR), revealed the care plans would be revised as changes were noted in the resident's condition. A review of Resident #3's current care plan revealed he did not have a care plan related to the resident's incontinence and peri-care. A care plan concern for Urinary Tract Infection was marked as resolved on 11/13/17, with an intervention to discontinue the Foley catheter. An observation 11/13/17 at 2:30 PM, revealed Resident #3 did not have a Foley catheter bag visible. In an interview, on 11/13/17 at 11:00 AM, Licensed Practical Nurse (LPN) #1 said Resident #3 was incontinent of bowel and bladder since the recent removal of a Foley catheter. In an interview, on 11/16/17 at 10:30 AM, Registered Nurse (RN) # 1, Care Plan Nurse, said she was responsible to edit the care plans for Resident #3. RN #1 said Resident #3 was incontinent now and confirmed it was not listed on the current care plan. RN #1 said she had not updated the care plan since 11/13/17, because she had not had time. A review of the facility's face sheet revealed the facility admitted Resident #3 on 05/06/16. Resident #3's [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/21/17, revealed staff assessed Resident 3 with severe cognitive impairment. | 2020-09-01 |
| 63 | 63 | BOYINGTON HEALTH AND REHABILITATION | 255092 | 1530 BROAD AVE | GULFPORT | MS | 39501 | 2017-11-16 | 282 | D | 0 | 1 | 212T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy review, the facility failed to follow the care plan related to incontinent care for one (1) of 16 care plans reviewed for incontinent care, Resident #9. Findings included: A facility Care Plan-Comprehensive policy, dated (MONTH) (YEAR), revealed the care plan would include measurable objectives to meet the medical, nursing, mental and psychological needs for each resident. A review of Resident #3's current Comprehensive Care Plan revealed the resident was at risk for skin break down related to incontinence of bowel and bladder. An intervention for this problem was to provide prompt peri-care after each incontinent episode. In an observation, on 11/15/17 at 9:45 AM, Certified Nursing Assistant (CNA) #1 and CNA #2 performed peri-care on Resident #9. CNA #1 completed care over the front of the perineum. CNA #1 and CNA #2 did not clean Resident #9's buttocks or the sacrum. In an interview, on 11/15/17 at 9:45 AM, CNA #1 said she had completed care on Resident #9 and said the policy was to clean the buttocks or the sacrum if the resident had an incontinent bowel movement. CNA #1 said she had completed training that included a check off for perineum care. CNA #1 confirmed she cleaned only the front perineal area. In an interview, on 11/16/17 at 10:15 AM, Registered Nurse (RN) #2, Staff Development, said the training for incontinent care included complete care which included to wash the front of the perineum and the buttocks and sacrum after each incontinence episode regardless of bowel movement. During an interview, on 11/16/17 at 10:35 AM, Registered Nurse (RN) #1, Care Plan Nurse, confirmed Resident 9's care plan included incontinent care. RN #1 said the care plan meant to complete peri-care by their training, which included the front and back of the perineal area. A review of the facility's face sheet revealed the facility admitted Resident #9 on 04/21/13. Resident 9's [DI… | 2020-09-01 |
| 64 | 64 | BOYINGTON HEALTH AND REHABILITATION | 255092 | 1530 BROAD AVE | GULFPORT | MS | 39501 | 2017-11-16 | 315 | D | 0 | 1 | 212T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy review, the facility failed to provide incontinent care to include the front perineal area, buttock and rectal areas, per policy, for one (1) of six (6) incontinent care observations. Findings included: A facility policy titled, Perineal Care, dated (MONTH) 2014, revealed the perineal care steps for a female resident would include to wipe the rectal area thoroughly, including the labia and the buttocks using the same technique as the perineal area. During an observation, on 11/15/17 at 9:45 AM, Certified Nursing Assistant (CNA) #1 and CNA #2 performed peri-care on Resident #9. CNA #1 completed care over the front of the resident's perineum. CNA #1 and CNA #2 did not clean Resident #9's buttocks or the sacrum. When interviewed, on 11/15/17 at 9:45 AM, CNA #1 said she had completed care on Resident #9 and said she thought the policy was to clean the buttocks or the sacrum if the resident had an incontinent bowel movement. CNA #1 said she had completed training that included a check off for perineum care. CNA #1 confirmed she only washed the front perineal area for Resident #9. During an interview, on 11/16/17 at 10:15 AM, Registered Nurse (RN) #2, Staff Development Nurse, said the training for incontinent care included complete care which included washing the front of the perineum and the buttocks and sacrum after each incontinence episode regardless of a bowel movement. During an interview, on 11/16/17 at 11:00 AM, the Director of Nursing (DON) confirmed the policy was to complete the peri-care, the front and the back because of the risk for skin breakdown, infection, and the resident may be still wet. A review of the facility's face sheet revealed the facility admitted Resident #9 on 04/21/13. Resident 9's [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/12/17, revealed staff assessed Resident #9 with severely impaired cogn… | 2020-09-01 |
| 65 | 65 | BOYINGTON HEALTH AND REHABILITATION | 255092 | 1530 BROAD AVE | GULFPORT | MS | 39501 | 2017-11-16 | 469 | D | 0 | 1 | 212T11 | Based on observation, resident interview, staff interview, record review, and facility policy review the facility failed to provide a pest free environment for two (2) out of nine (9) halls, and one (1) out of two (2) dining rooms. Findings include: A review of the facility policy, titled Housekeeping and Pest Control, dated (MONTH) 2001, revealed pest control services should be provided monthly and as necessary. An observation on 11/13/17, starting at 10:20 AM until 11:45 AM, during initial tour of 100 hall, revealed two (2) gnats flying around in room 113 [NAME] Residents in the room stated, They come and go, but we haven't complained. Also, during tour, a fly was observed flying around in room 114, landing on bedside table. Resident in room 114 was unable to interview. An observation on 11/14/17, at 12:20 PM, in the dining hall between 100 hall and 200 hall, revealed two (2) flies swarming around the table of Un-Sampled Resident [NAME] An observation on 11/14/17, at 12:20 PM, in the dining hall between 100 hall and 200 hall, revealed two (2) flies around a resident's food tray. Un-Sampled Resident B was observed swatting the flies with her hand several times. Un-Sampled Resident B stated she had seen several fruit flies flying in Dining hall 100 during the lunch meal. An observation on 11/15/17 at 12:00 PM, in room 221, revealed several gnats swarming around Resident #12's face and bed. An observation on 11/16/17 at 8:30 AM, revealed two (2) flies around the nursing desk on the 300 hall. During an interview, on 11/14/17 at 10:00 AM, during Group, three (3) of 10 residents complained of seeing bugs in rooms and showers. Resident Un-Sample D stated he sees fly's in the Dining Room and big roaches in the 100 hall shower room. Review of the most recent Minimum Data Set (MDS), revealed Un-Sample Resident D had a BIMS score of 15, indicating no cognitive impairment. Resident Un-Sample C reported seeing roaches in her room. Review of the most recent MDS, revealed Un-Sample Resident C had a BIMS score of 9, indicating… | 2020-09-01 |
| 66 | 66 | THE PILLARS OF BILOXI | 255093 | 2279 ATKINSON ROAD | BILOXI | MS | 39531 | 2020-01-24 | 600 | J | 1 | 0 | 17111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident interview, staff interview, record review, and facility policy review, the facility failed to ensure a resident was free from verbal abuse for one (1) of seven (7) residents reviewed for abuse, Resident #1. On [DATE], Certified Nursing Assistant (CNA) #1 was witnessed by staff being verbally abusive to Resident #1 in the dining room. CNA #1 was heard calling Resident #1 a mother [***] , told him not to put his mother [***] ing hands on her or she would box him. The incident was reported by Licensed Practical Nurse (LPN) #1 to the on-call nurse, LPN #2, on the day of the incident. LPN #2 spoke with the Director of Nursing (DON), who then instructed LPN #2 to assign CNA #1 to a different area and not have contact with Resident #1. CNA #1 continued to work on [DATE], as well as provided care to Resident #7, who was Resident #1's roommate. CNA #1 was allowed to work at the facility from [DATE] until 12/23/2019, without being suspended. The facility failed to report the verbal abuse to the appropriate State Agencies timely, and failed to protect Resident #1 and all other residents. The facility's failure to protect Resident #1 from verbal abuse and allowing a staff member to work in the facility, without reporting an incident of witnessed verbal abuse, placed Resident #1 and other residents in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on [DATE], when the verbal abuse occurred. The SA notified the facility of the IJ and SQC on 01/22/2020 at 4:20 PM, and the IJ template was provided to the Administrator. The facility provided a credible Removal Plan on 0[DATE]20, in which the facility alleged all corrective actions were completed as of 0[DATE]20 and the IJ was removed on 01/24/2020. The SA validated the Removal Plan and determined the IJ was removed on 01/24/2020, prior to exit. Th… | 2020-09-01 |
| 67 | 67 | THE PILLARS OF BILOXI | 255093 | 2279 ATKINSON ROAD | BILOXI | MS | 39531 | 2020-01-24 | 607 | J | 1 | 0 | 17111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview, record review and facility policy review, the facility failed to implement their Abuse policy for protection of residents from verbal abuse, failed to protect other residents, and failed to report the allegation of abuse in a timely manner, for one (1) of seven (7) residents, Resident #1. This was evidenced by the facility allowing Certified Nursing Assistant (CNA) #1 to return to work following an incident of witnessed verbal abuse toward Resident #1. The facility failed to report the allegation of abuse to the required state agencies within the two (2) hour timeframe, per policy, to ensure appropriate actions were taken. On [DATE], CNA #1 was witnessed being verbally abusive to Resident #1 in the dining room, by staff members. CNA #1 was overheard calling Resident #1 a mother [***] , told him not to put his mother [***] ing hands on her or she would box him. The incident was reported by Licensed Practical Nurse (LPN) #1 to the on-call nurse, LPN #2, on the same day of the incident. LPN #2 reported the incident to the Director of Nursing (DON), who then informed LPN #2 to assign CNA #1 to a different hall, and for CNA #1 not to have any contact with Resident #1. CNA #1 was allowed to continue working on [DATE], and provided care to Resident #1's roommate, Resident #7. CNA #1 continued to work at the facility from [DATE] until 12/23/2019, without being suspended. The facility failed to report the verbal abuse to the appropriate State Agencies in a timely manner and failed to protect Resident #1 and all other residents. The failure of the facility to protect residents from verbal abuse by allowing a staff member to remain working at the facility, and failure to report an incident of witnessed verbal abuse within to two (2) hours to the designated State Agencies, per facility policy, placed Resident #1 and other residents in a situation that was likely to cause serious injury, harm, impairment, or death. The situatio… | 2020-09-01 |
| 68 | 68 | THE PILLARS OF BILOXI | 255093 | 2279 ATKINSON ROAD | BILOXI | MS | 39531 | 2020-01-24 | 609 | J | 1 | 0 | 17111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview, record review, and facility policy review, the facility failed to report an allegation of staff to resident abuse within the two (2) hour required timeframe, for one (1) of seven (7) residents reviewed, Resident #1. On [DATE], Certified Nursing Assistant (CNA) #1 was witnessed by staff being verbally abusive to Resident #1 in the dining room. CNA #1 was heard calling Resident #1 a mother [***] , told him not to put his mother [***] ing hands on her or she would box him. The incident was reported by Licensed Practical Nurse (LPN) #1 to the on-call nurse, LPN #2, on the day of the incident. LPN #2 spoke with the Director of Nursing (DON), who then instructed LPN #2 to assign CNA #1 to a different area and not have contact with Resident #1. CNA #1 continued to work on [DATE], as well as provided care to Resident #7, who was Resident #1's roommate. CNA #1 was allowed to work at the facility from [DATE] until 12/23/2019, without being suspended. The facility failed to report the witnessed incident of verbal abuse to the appropriate State Agencies in a timely manner and failed to protect Resident #1 and all other residents. The facility's failure to notify the appropriate state agencies in a timely manner of an incident of witnessed verbal abuse, to ensure proper measures had been addressed, and allowing the staff member to continue working at the facility, placed Resident #1 and other residents in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on [DATE], when the verbal abuse occurred. The SA notified the facility of the IJ and SQC on 01/22/2020 at 4:20 PM, and the IJ template was provided to the Administrator. The facility provided a credible Removal Plan on 0[DATE]20, in which the facility alleged all corrective actions were completed as of 0[DATE]20 and the IJ was removed o… | 2020-09-01 |
| 69 | 69 | THE PILLARS OF BILOXI | 255093 | 2279 ATKINSON ROAD | BILOXI | MS | 39531 | 2020-01-24 | 610 | J | 1 | 0 | 17111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview, record review, and facility policy review, the facility failed to prevent further potential abuse and mistreatment from occurring, after a witnessed incident of staff to resident abuse, for one (1) of seven (7) residents reviewed, Resident #1. On [DATE], Certified Nursing Assistant (CNA) #1 was witnessed by staff being verbally abusive to Resident #1 in the dining room. CNA #1 was heard calling Resident #1 a mother [***] , told him not to put his mother [***] ing hands on her or she would box him. The incident was reported by Licensed Practical Nurse (LPN) #1 to the on-call nurse, LPN #2, on the day of the incident. LPN #2 spoke with the Director of Nursing (DON), who then instructed LPN #2 to assign CNA #1 to a different area and not have contact with Resident #1. CNA #1 continued to work on [DATE], as well as provided care to Resident #7 (Resident #1's roommate). CNA #1 was allowed to work at the facility from [DATE] until 12/23/2019, without being suspended. The facility failed to report the verbal abuse to the appropriate State Agencies timely and failed to protect Resident #1 and all other residents. The facility's failure to thoroughly investigate a witnessed staff to resident incident of verbal abuse, and prevent further potential abuse by allowing the staff member to continue working at the facility, placed Resident #1 and other residents in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on [DATE], when the verbal abuse occurred. The SA notified the facility of the IJ and SQC on 01/22/2020 at 4:20 PM, and the IJ template was provided to the Administrator. The facility provided a credible Removal Plan on 0[DATE]20, in which the facility alleged all corrective actions were completed as of 0[DATE]20 and the IJ was removed on 01/24/2020. The SA validated the Removal P… | 2020-09-01 |
| 70 | 70 | THE PILLARS OF BILOXI | 255093 | 2279 ATKINSON ROAD | BILOXI | MS | 39531 | 2020-02-19 | 689 | D | 1 | 0 | O7TC11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview, record review, and facility policy review, the facility failed to provide adequate supervision to prevent a resident from leaving the facility unsupervised, for one (1) of four (4) residents reviewed for risk of wandering/elopement. A review of the facility's, Elopement/Unsafe Wandering policy, dated 02/07/2012, revealed, it is the policy of the facility to protect the resident from harm while providing care in a manner that helps promote quality of life in a safe environment. Visual supervision may be necessary in some instances. The nursing staff will complete and document the visual checks as needed. A review of the Brief Interview for Mental Status (BI[CONDITION]), dated 11/18/2019, revealed Resident #1 had a score of 13, which indicated cognitively intact. The facility admitted Resident #1 on 11/18/2019. Review of Resident #1's Wandering Evaluation, dated 11/18/2019, revealed he was assessed and determined to be at risk for wandering/elopement. A review of Resident #1's comprehensive care plan, revealed a focused problem, initiated on 01/02/2020, for elopement risk/wanderer related to being mobile without assistance. The goal revealed the resident's safety would be maintained through the next review date. Interventions included to distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, etc., and intervene as appropriate. There were no interventions in place for visual checks until [DATE]20. Resident #1's care plan also revealed an intervention for a yellow arm band to remain in place at times indicating resident is at risk for wandering, initiated on 02/02/2020. A review of (Name of Hospital) Emergency Documentation, revealed, Resident #1 was seen at the facility on 02/02/2020 at 6:30 AM with the chief complaint of escaped from nursing home. The document revealed that Resident #1 was found down the road by the local ambulance service. The document revealed t… | 2020-09-01 |
| 71 | 71 | THE PILLARS OF BILOXI | 255093 | 2279 ATKINSON ROAD | BILOXI | MS | 39531 | 2017-03-10 | 157 | D | 0 | 1 | U1S311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy review, the facility failed to ensure the physician was notified of a resident's low blood glucose level per the facility's diabetic protocol regarding blood glucose parameters for reporting, and failed to ensure the physician was notified when routine insulin was withheld for one (1) of eight (8) insulin dependent residents reviewed. (Resident #10). Findings include: A review of the facility's policy titled, Physician Notification of Change of Condition or Status, dated (MONTH) 1, 2000, revealed it was the policy of the facility to provide a mechanism for informing the resident's physician of changes that affect the resident. The procedure included the attending physician would be notified when there was a significant change in the resident's physical, mental, or psychological status, or when there was a need to alter treatment significantly. A review of the facility's policy titled, Diabetic Therapeutic Protocol, dated 06/01/2000, revealed a [DIAGNOSES REDACTED] Protocol that if a resident was asymptomatic, alert, and the finger stick blood glucose was less than 50, staff was to give a form of carbohydrate that contained glucose, recheck the finger stick glucose in 15 minutes, and if it remained less than 50, and the resident remained asymptomatic, repeat the treatment then notify the physician. The physician was to be notified even if the resident improved. A review of Resident #10's (MONTH) (YEAR) physician's orders [REDACTED]. A review of Resident #10's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Further review of the MAR indicated [REDACTED]. A review of the Nurse's Notes for the month of (MONTH) (YEAR) confirmed the resident had an accucheck that read a low blood glucose level of 41 at 6:00 AM on 03/06/17. The note further indicated the resident was alert and responsive, was given a form of carbohydrate that contained glucose, and another accucheck was taken a… | 2020-09-01 |
| 72 | 72 | THE PILLARS OF BILOXI | 255093 | 2279 ATKINSON ROAD | BILOXI | MS | 39531 | 2017-03-10 | 159 | D | 0 | 1 | U1S311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Residents Trust Fund, Resident Council meeting interview, and staff interview, the facility failed to make resident funds readily accessible at all times for 73 of 73 residents participating in the trust fund account, and the facility failed to ensure the resident's account balances did not reach or exceed the applicable resource limit for three (3) of 73 resident accounts reviewed. This affected Unsampled Residents B, C, and D. Findings include: Review of the facility's policy titled, Resident Trust Fund Policy & Agreement, dated (MONTH) 17, 2007, revealed there was nothing addressed to make funds available at all times to residents who choose to participate in the trust fund. Further review of the policy revealed: The facility must notify each resident receiving medical treatment assistance under Title XIX (Medicaid) when the amount in the resident's account reaches $200.00 less than the SSI (Supplemental Security Income) limit of $2,000.00, and $500.00 less than the Medicaid resource limit of $4,000.00 to remain eligible for Medicaid long term care benefits. The notice must include the fact that if the amount in the account, in addition to the value of the resident's other nonexempt resources, reaches the applicable resource limits, the resident may lose eligibility for Medicaid or SSI. The facility must notify the Medicaid regional office of any resident receiving medical assistance under Title XIX when the resident's account balance reaches or exceeds the applicable resource limit to remain eligible for the Medicaid program. During the Resident Group meeting held on [DATE] at 2 PM, six (6) residents voiced a complaint that they usually got their money by the 3rd of each month, and they had not received it as of today. One resident spoke up and said the business office lady said it would be there tomorrow. She was new and didn't know she was supposed to request the money. Review of the residents', who attended the G… | 2020-09-01 |
| 73 | 73 | THE PILLARS OF BILOXI | 255093 | 2279 ATKINSON ROAD | BILOXI | MS | 39531 | 2017-03-10 | 160 | D | 0 | 1 | U1S311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Resident Trust Fund review, facility policy review, and staff interview, the facility failed to ensure all funds were disbursed 30 days after death for five (5) of 78 residents who participated in the resident trust fund. This affected Unsampled Residents E, F, G, H, and I. Findings include: Review of the facility's policy titled, Resident Trust Fund Policy & Agreement, dated (MONTH) 17, 2007, revealed: 5. Upon death of a resident who has a Resident Trust Fund on deposit with the facility, the facility must convey within 30 days the residents funds, and a final accounting of these funds, to the individual or probation jurisdiction administering the Resident's estate. Review of the Residents Trust Fund accounts revealed Unsampled Residents E, F, G, H, and I were expired. Review of the facility's Trial Balance sheet documented the following: Unsampled Resident [NAME] expired on [DATE], with a balance of $768.25 on [DATE]. Unsampled Resident F expired [DATE], with a balance of $2551.85 as of [DATE]. Unsampled Resident G expired [DATE], with a remaining balance as of $1938.92 on [DATE]. Unsampled Resident H expired on [DATE], with a balance of $66.81 as of [DATE]. Unsampled Resident I had a balance of $2181.64 as of [DATE], she expired on [DATE]. During an interview with the Business Office Manager on [DATE] at 10:10 AM, she revealed she's unsure why the money is there. She's working to find out where it needs to go. | 2020-09-01 |
| 74 | 74 | THE PILLARS OF BILOXI | 255093 | 2279 ATKINSON ROAD | BILOXI | MS | 39531 | 2017-03-10 | 253 | D | 0 | 1 | U1S311 | Based on observation, and staff interview, the facility failed to ensure a safe, and clean homelike environment for 20 of 102 resident rooms. Findings include: During the initial tour on 03/07/17, from 10:30 AM until 11:30 AM, the following environmental concerns were observed: A Hall: Room 108: The bed mattress was torn, and scuff marks were on the wall. Room 110 C: The wallpaper around the air conditioner had torn areas. Room 112 C: There was a hole in the bricks along the window. Room 123: Unable to see out of the windows on the left side due to a build up of dirt, the window sills were dirty, and the front of the air conditioner unit was off. Room 117: There was paint peeling, and scuff marks on the wall. D Hall [RM #]2 A: Knats were flying around the resident's head. [RM #]4 A: Scuff marks were on the wall behind the bed. [RM #]5 A: Scrape marks were on the wall behind the bed. Observations, and interviews during the initial tour, with Registered Nurse (RN) #6, on 3/7/17 from 11:00 AM to 12:20 PM, revealed the following environmental concerns identified on the Memory Care Unit: Room 411: There were two (2) bottles of mouthwash, and two (2) toothbrushes in a plastic cup on the back of toilet unlabeled. Interview with RN #6 at this time revealed she was unsure if it was OK. She also confirmed dementia residents could drink the mouthwash, and there was a risk of cross contamination due to the toothbrushes could get mixed up. Room 412: A empty intravenous piggy back (IVPB) medication bag was on the back of the toilet. The medication bag label revealed the IVPB was an antibiotic for (Name of Resident) in Room 412 [NAME] RN #6 stated at this time the IVPB bag should be in a biohazard container because it was an IV. Further observations revealed the bathroom shower curtain was ripped with only four (4) of the 13 curtain rings attached to the shower curtain. Room 413: There was two (2) lotions and body washes unlabeled. Room 414: There was two (2) bottles of shampoo, soap, body wash, and cleansing foam in the shower… | 2020-09-01 |
| 75 | 75 | THE PILLARS OF BILOXI | 255093 | 2279 ATKINSON ROAD | BILOXI | MS | 39531 | 2017-03-10 | 278 | D | 0 | 1 | U1S311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, facility policy review, and review of the Center for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual, revealed the facility failed to accurately code Resident #5's Minimum Data Set (MDS) related to Range of Motion (ROM) for one (1) of twenty four (24) MDS's reviewed. Findings include: A review of the facility's policy titled, Resident Assessment, dated (MONTH) 1, 2000, revealed the purpose of the resident assessment is to describe the resident's capability to perform daily life function, and to identify significant impairments in functional capacity. A review of the Center for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual dated (MONTH) (YEAR) in Section Z0400 revealed the person who completes any section or portion of the MDS is required to sign the statement indicating that it is accurate. A review of Resident #5's History and Physical dated 12/14/2016, revealed on the physical examination assessment relating to the extremities, Resident #5 had a bilateral [MEDICAL CONDITION]. A review of the cumulative Physician order [REDACTED]. A review of the Admission Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 02/02/2017, for Resident #5, revealed section GO400B for Functional Limitation in Range of Motion was coded a zero (0), thus indicating no bilateral lower extremity impairment. During an interview on 03/08/2017 at 3:45 PM, with the MDS Coordinator/Registered Nurse (RN) #2, it was confirmed the Admission MDS with the ARD of 02/02/2017 in Section GO400B for Resident #5 was not coded correctly. RN #2 stated the MDS for Range of Motion (ROM) of the lower extremities should be coded a two (2), thus indicating impairment on both sides. RN #2 confirmed she was the nurse who had completed section G of the MDS, and signed it as being accurate on 02/04/2017. RN #2 also stated the CMS's RAI 3.0 Version M… | 2020-09-01 |
| 76 | 76 | THE PILLARS OF BILOXI | 255093 | 2279 ATKINSON ROAD | BILOXI | MS | 39531 | 2017-03-10 | 280 | D | 0 | 1 | U1S311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy review, the facility failed to revise Resident #10's care plan upon return from the hospital to reflect the discontinuation of sliding scale insulin for one (1) of eight (8) insulin dependent resident care plans reviewed. Findings include: A review of the facility's policy titled, Goals and Objectives, related to the Comprehensive Care Plan, undated, revealed goals and objectives were to be revised when the resident had been readmitted to the facility from a hospital stay. A review of Resident #10's Comprehensive Care Plan revealed a revision date of 12/05/16, and included an intervention for administering sliding scale insulin initiated on 5/25/16. Resident #10 was readmitted by the facility on 3/6/17, from the hospital. A review of physician's orders [REDACTED]. An interview on 03/09/17 at 4:35 PM, with Registered Nurse (RN) #2/Minimum Data Set (MDS) Nurse, revealed the care plan should have been revised to remove the intervention for sliding scale insulin when the resident returned from the hospital without an order for [REDACTED]. An interview on 03/09/17 at 11:15 AM, with the Director of Nursing (DON) revealed she had written reconciled orders when Resident #10 returned from the hospital. She stated the care plan should have been updated upon return from the hospital to reflect the discontinuation of sliding scale insulin, but she overlooked it. A review of Resident #10's Face Sheet revealed Resident #10 was originally admitted by the facility on 06/18/10, and had current [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/17/17, revealed Resident #10 was assessed by staff for cognitive skills for daily decision making, and found to be moderately impaired, indicating decisions were poor, and cues/supervision were required. | 2020-09-01 |
| 77 | 77 | THE PILLARS OF BILOXI | 255093 | 2279 ATKINSON ROAD | BILOXI | MS | 39531 | 2017-03-10 | 282 | E | 0 | 1 | U1S311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility policy review, the facility failed to follow the plan of care related to diabetic care for Resident #10, for one of eight (1 of 8) insulin dependent resident care plans reviewed, and catheter care for Residents #6, #15, and #16, for three of six (3 of 6) residents with catheters care plans reviewed. Findings include: Review of facility's policy titled, Care Plan-Comprehensive, (no date), revealed it is the policy of this facility to develop comprehensive care plan for each resident that includes measurable objectives and time tables to meet the resident's medical, nursing and psychological needs. The comprehensive care plan has been designed to: Incorporate identified focus areas; Incorporate risk factors associated with identified problems; Build on the residents strengths; Reflect treatment goals and objectives in measurable outcomes that incorporate the resident's personal cultural practices and wishes; Identify the professional services that are responsible for every element of care; Enhance the optimal functioning of the resident by focusing on rehabilitative programs and sources as needed. Resident #10 A review of Resident #10's Care Plan revealed a care plan to address Diabetes originated on 09/15/16, with a revision date of 12/05/2016. The care plan had an intervention to, Monitor/document/report PRN (as needed) any s/sx (signs/symptoms) of [DIAGNOSES REDACTED]: Sweating, Tremor, Increased heart rate ([MEDICAL CONDITION], Pallor, Nervousness, Confusion, Slurred Speech, Lack of Coordination, Staggering Gait initiated on 09/15/2015. Further reveiw of the Care Plan revealed an intervention initiated on 9/15/15, to administer [MEDICATION NAME] (Detemir) insulin as ordered. An observation, and interview 03/07/17 at 4:20 PM, revealed Resident #10 was lying in bed. Certified Nursing Assistant (CNA) #4 was present in the room. There were clear plastic bags filled with linens, sheets and beds… | 2020-09-01 |
| 78 | 78 | THE PILLARS OF BILOXI | 255093 | 2279 ATKINSON ROAD | BILOXI | MS | 39531 | 2017-03-10 | 309 | D | 0 | 1 | U1S311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy review, the facility failed to monitor, and notify Resident #10's physician of low blood glucose levels to ensure appropriate treatment and management, for one of eight (1 of 8) insulin dependent Diabetic residents reviewed. Findings include: A review of the facility's policy titled, Diabetic Therapeutic Protocol, dated 06/01/2000, revealed the physician must approve the use of the Diabetic Therapeutic Protocol for each of his/her resident's use and write a corresponding order in the medical record. Nurses will be informed of this practice upon hire and regularly thereafter. [DIAGNOSES REDACTED] Protocol: If the resident is asymptomatic, alert, and the finger stick blood glucose is less than 50 (or as indicated by the physician): 1. Give a form of carbohydrate that contains glucose. Orange juice with 2 (two) teaspoons of sugar is acceptable. If the resident is unable to swallow due to other medical conditions, give [MEDICATION NAME] one milligram intramuscular ( 1 mg. IM) now. 2. Recheck the finger stick blood glucose in 15 minutes. 3. If the finger stick blood glucose remains less than 50, and the resident remains asymptomatic, repeat the treatment. 4. Notify the physician. The physician is notified even if the resident improves. 5. If the finger stick blood glucose returns to normal, have the resident eat a meal or snack containing a form of protein, (i.e. peanut butter or cheese sandwich, milk, cheese and crackers). An observation and interview on 03/07/17 at 4:20 PM, revealed when the State Agency (SA) surveyor entered Resident #10's room, Resident #10 was lying in the bed, and observed to be sweating profusely. Resident #10's eyes were casted to the left, she was not responsive when spoken to, her skin felt cool and clammy, and she was taking shallow, quick breaths. Certified Nursing Assistant (CNA #4) was in the room with the resident at this time. CNA #4 stated w… | 2020-09-01 |
| 79 | 79 | THE PILLARS OF BILOXI | 255093 | 2279 ATKINSON ROAD | BILOXI | MS | 39531 | 2017-03-10 | 315 | E | 0 | 1 | U1S311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and facility policy review, the facility failed to provide catheter care in a manner to prevent the potential for infection and injury, for three (3) of six (6) residents reviewed with catheters. (Residents #5, #15, and #16). Findings include: Review of facility's policy titled, Catheter Care, Urinary, dated 8/25/14, revealed the Foley Catheter should remain secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh). Use standard precautions when handling or manipulating the drainage system. Maintain a clean technique when handling or manipulating the catheter, tubing or drainage bag. The urinary drainage bag should be held or positioned lower than the bladder at all times. This prevents the urine in the tubing and drainage bag from flowing back into the urinary bladder. For the female, use a washcloth with warm water and soap to cleanse the labia. Use one area of the washcloth for each downward, cleansing stroke. Resident #16 An observation, and interview on 03/08/16 at 11:45 AM , revealed the State Agency (SA) surveyor and Licensed Practical Nurse (LPN) #3 observed Resident #16 lying in his bed with a Foley catheter in place, and without a leg strap to secure the Foley catheter tubing to his leg. An interview at this time with LPN #3 confirmed the finding, and revealed the use of a leg strap with a Foley catheter is needed to prevent damage by preventing pulling and tugging on the tubing. LPN #3 stated nurses and Certified Nursing Assistants (CNAs) were responsible for checking, and applying the leg straps while delivering care. During an interview on 03/10 17 at 09:30 AM, Registered Nurse( RN) #2 revealed nurses or Certified Nursing Assistants (CNAs) should know from their training that securing a Foley catheter to a resident's leg with a leg strap is part of catheter care. Review of Resident #… | 2020-09-01 |
| 80 | 80 | THE PILLARS OF BILOXI | 255093 | 2279 ATKINSON ROAD | BILOXI | MS | 39531 | 2017-03-10 | 356 | D | 0 | 1 | U1S311 | Based on observation, review of the facility's Nursing Staff Directly Responsible for Resident Care posting, and staff interview, the facility failed to ensure the nursing staff posting was not completed prior to the beginning of each shift as evidenced of staffing numbers being recorded prior to the beginning of each shift for three of four (3 of 4) days of the survey. Findings include: On 03/07/17 at 11:00 AM, an observation revealed the Nursing Staff Directly Responsible for Resident Care was posted near the front lobby. There were two days posted, 03/06/17 and 03/07/17, and both contained the numbers filled in for all three shifts. On the 03/06/17 sheet the hour numbers were crossed out and corrected. On the sheet for 03/07/17, the first, second and third shift hours were already written in for the day. At 03/07/17 at 5:10 PM, an interview with the Director of Nursing revealed she was unaware the hours could not be posted prior to the shift. She further revealed she would make the corrections on the sheet after the shift started. Observations on 03/08/17, and 03/09/17, revealed the numbers were again posted on the staffing sheets incorrectly | 2020-09-01 |
| 81 | 81 | THE PILLARS OF BILOXI | 255093 | 2279 ATKINSON ROAD | BILOXI | MS | 39531 | 2017-03-10 | 371 | F | 0 | 1 | U1S311 | Based on observation, staff interview, record review, and facility policy review, the facility failed to prevent the potential for food contamination and/or foodborne illness as evidenced by failure to remove soiled gloves during the tray line food service, to ensure all dietary staff was knowledgeable of how to calibrate food temp thermometers to ensure accuracy of food temperatures, and document temperature readings of all foods served, for one (1) of one (1) tray line observations. This deficient practice had the potential to affect all residents who received meals from the kitchen. Findings include: A review of ServSafe guidelines dated 2008, provided by the facility titled, When and How to Wash Your Hands, revealed you should wash your hands after you touch anything that may contaminate your hands. Review of ServSafe guidelines dated 2008, provided by the facility titled, How to Calibrate a Thermometer, revealed thermometers should be calibrated regularly to make sure the readings were correct, and thermometers should be calibrated to 32 degrees Fahrenheit. An observation of the tray line temperature readings on 03/08/17 at 11:20 AM, and interview, revealed Dietary Staff (DS) #2 placed a digital thermometer in a cup of ice water with gloved hands. The thermometer reached the reading of 34 degrees Fahrenheit (F). DS #2 stated the reading was 34 degrees F, and proceeded to test the temperature of the first food item on the line. When asked what the thermometer reading should be calibrated to prior to taking food temperatures, DS #2 stated, Anywhere from 34 degrees to 40 degrees. When asked what the facility policy was regarding calibration temperatures, DS #2 stated he wasn't sure, but he was ServSafe Certified, and that was what he learned from ServSafe. DS #2 then presented his ServSafe Certification Badge. DS #2 stated the digital thermometer could not be calibrated. DS #4 intervened at this time, and stated I will go get a thermometer that can be calibrated to 32 degrees F. DS #2 stated the digital thermom… | 2020-09-01 |
| 82 | 82 | THE PILLARS OF BILOXI | 255093 | 2279 ATKINSON ROAD | BILOXI | MS | 39531 | 2017-03-10 | 372 | E | 0 | 1 | U1S311 | Based on observation, and staff interview, the facility failed to ensure garbage and refuse was contained inside garbage dumpsters, and dumpsters were closed for one (1) of two (2) dumpsters observed. Findings include: An observation, and interviews during an environmental tour with the Dietary Manager on 03/07/17 at approximately 10:25 AM, revealed the following: There were two (2) dumpsters utilized by the facility located outside on a concrete surface approximately 50 yards from the South end of the facility, and directly connected to an approximately one half acre field with high grass, and a wooded area beyond the field. On approach to the dumpsters, Housekeeping Staff (HK) #2 was observed throwing garbage bags from a rolling cart into a dumpster, and walked back toward the facility with the empty cart leaving the side door of the dumpster open. The ground and field surrounding the dumpsters were littered with garbage and refuse, including two (2) fluorescent light banisters, a light switch, a wheelchair footrest, a clear garbage bag with an empty medication card (no name was on the card), Intravenous (IV) tubing, latex gloves, two (2) plastic cups, empty cigarette packages, empty Boost bottles, soda bottles, aluminum cans, an unopened pack of enzo barrier cream, one opened box of large latex gloves with one glove inside the box, 22 loose latex gloves, empty bottles of shampoo and body wash, and a fast food bag with chicken bones inside. An interview at this time with HK #2 revealed he had left the dumpster door open. He stated he had been employed for two (2) days, and had not been instructed to close the dumpster after disposing of garbage, and the dumpster door was open when he came out to throw away garbage. HK #2 stated he could see why the dumpster door should be closed to prevent animals from getting inside, and strewing the garbage all out and into the woods. He stated the smell from the garbage would attract animals from the woods. HK #2 stated he did notice all of the debris and garbage on the grou… | 2020-09-01 |
| 83 | 83 | THE PILLARS OF BILOXI | 255093 | 2279 ATKINSON ROAD | BILOXI | MS | 39531 | 2017-03-10 | 441 | D | 0 | 1 | U1S311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure infection control measures for the potential spread of infection were followed as evidenced by staff using gloves stored in uniform pockets to provide resident care, staff failure to change gloves, failure to dispose of medical waste, disinfect resident care equipment after use, and placing a nebulizer treatment on the floor during resident care. These deficient practices effected three of nine (3 of 9) residents observed during the med pass, Resident #15, Unsampled Residents J and K; one (1) of six (6) residents observed for Foley catheter care, Resident #6, one (1) of 102 resident rooms observed during the initial tour. Findings include: Review of the facility's policy titled, Gloves, dated (MONTH) 1, 2000, revealed hands should be washed immediately after removing gloves. Review of the facility's policy titled, Handwashing, dated (MONTH) 1, 2000, revealed personnel wash their hands to prevent the spread of infection and disease to other residents. Review of the facility's policy titled, Cleaning/Disinfection of Resident Care Items and Equipment, dated (MONTH) 15, 2010, revealed non-critical items were those in contact with intact skin and could be decontaminated when they are used. Review of the facility's policy titled, Intravenous Fluids (IV), Administration of, revealed: Infection Control: 6. Dispose of disposable equipment appropriately, 7. Dispose of hazardous materials appropriately. Resident #15 An observation during med pass on 03/08/17 at 9:10 AM, revealed License Practical Nurse (LPN) #4 performed a nebulizer treatment for [REDACTED]. LPN #4 dropped the intact plastic three (3) milliliter vial on the floor, then picked the vial up off the floor to use for the nebulizer treatment. LPN #4 placed the nebulizer machine on the floor beside the bed, and attached the nebulizer mask and tubing to the machine. LPN #4 told the re… | 2020-09-01 |
| 84 | 84 | THE PILLARS OF BILOXI | 255093 | 2279 ATKINSON ROAD | BILOXI | MS | 39531 | 2017-03-10 | 502 | D | 0 | 1 | U1S311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and facility policy review, the facility failed to obtain Resident #5's laboratory test in a timely manner for one (1) of fourteen (14) resident records reviewed for laboratory test orders. Findings include: A review of the facility's policy titled, Request for Diagnostic Services, dated (MONTH) 26, 2007, revealed it is the policy of the facility that all orders for diagnostics services for each resident will be carried out as instructed by the physician's orders [REDACTED]. A review of the cumulative Physician order [REDACTED]. Review of Resident #5's lab results revealed a weekly CBC was not located for Friday, 02/24/17. An interview on 03/08/2017 at 4:00 PM, with the Director of Nursing (DON) confirmed the physician's orders [REDACTED]. The DON stated she had called the laboratory, and they confirmed there was no record of any laboratory tests for Resident #5 on 02/24/2017. The DON stated she was the staff member that monitors the diagnostic testing ordered by the physicians. The DON stated she had notified the physician the morning of 3/8/2017, and made him aware of the missing CBC for 02/24/2017. A review of the Face Sheet revealed the facility admitted Resident #5 on 01/26/2017, with the included [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/02/2017, revealed the resident's Brief Interview for Mental Status (BIMS) score was fifteen (15), indicating intact cognition. | 2020-09-01 |
| 85 | 85 | THE PILLARS OF BILOXI | 255093 | 2279 ATKINSON ROAD | BILOXI | MS | 39531 | 2019-05-15 | 550 | D | 0 | 1 | 0E0S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy review, and interviews, the facility failed to ensure the residents' dignity was not compromised for two (2) of 24 sampled residents, Residents #21 and #37. Specifically, staff posted signage visible to others regarding a resident's personal care (Resident #21), and the facility staff failed to provide privacy for one (1) resident (Resident #37), leaving the resident's skin and/or body exposed. Findings include: Review of an undated facility policy tilted, Dignity and Respect, revealed, It is the policy of this facility to treat each resident with respect and dignity and care for each resident in a manner and environment that promotes maintenance or enhancement of his or her quality of life. 1. The staff shall display respect for residents when speaking with, caring for, or talking about them, as constant affirmation of their individuality and dignity as human beings .3. Residents shall be examined and treated in a manner that maintains the privacy of their bodies. A closed door or drawn curtains shields the residents from passer-by. People not involved in the care of the resident shall not be present without the resident's consent while they are being examined or treated. Staff members shall knock before entering the resident's room. 4. Privacy of a resident's body shall be maintained during toileting, bathing, and other activities of personal hygiene, except when staff assistance is needed for the resident's safety . Resident #21 Review of Resident #21's Minimum Data Set (MDS), Significant Change Assessment, dated 03/05/19, revealed the facility admitted the resident on 04/19/17. Both of Resident #21's legs were amputated above the knee, with the most recent amputation (right leg) occurring on 02/25/19. The resident also had [DIAGNOSES REDACTED]. According to the MDS assessment, the resident had impairment on both sides of his body; had an indwelling urinary catheter; was always incontine… | 2020-09-01 |
| 86 | 86 | THE PILLARS OF BILOXI | 255093 | 2279 ATKINSON ROAD | BILOXI | MS | 39531 | 2019-05-15 | 623 | D | 0 | 1 | 0E0S11 | Based on facility policy review, record reviews, and interviews, the facility failed to provide written notification to the Ombudsman regarding hospital transfers, for two (2) of six (6) residents who were reviewed for transfers, Resident #106 and Resident #46. Findings Include: Review of the facility's undated Documentation RE: Transfer/Discharge revealed, Policy Statement: It is the policy of this facility that when a resident is transferred or discharged his or her medical records be documented as to the reasons why such action was taken .Procedure 5. Facility will notify the local ombudsman of the discharge and reason for the discharge. Review of an undated, written statement provided, and signed by the Administrator, confirmed there are no discharge/transfer logs for (MONTH) and (MONTH) 2019. Resident #106 Review of the electronic health record for Resident #106 revealed in (MONTH) 2019, Resident #106 was discharged to the hospital for surgery. Further review of the record failed to produce any record of the Ombudsman being notified of the transfer of Resident #106 to the hospital. Resident #46 Review of the electronic health record for Resident #46 revealed in (MONTH) 2019, Resident #46 was discharged to the hospital due to an Acute Ischemic Stroke. Further review of the record failed to produce any record of the Ombudsman being notified of the transfer of Resident #46 to the hospital. An attempt was made to review the Ombudsman notification records for (MONTH) and (MONTH) of 2019, and the facility failed to produce the requested records by the survey exit. On 5/15/19 at 10:15 AM, an interview with the Business Office Manager (BOM) was conducted. The BOM stated someone else was responsible for notifying the Ombudsman in (MONTH) and (MONTH) 2019, and there were no records available for review to confirm the notifications were sent. On 5/15/19 at 10:20 AM, an interview with the RN Nurse Consultant (RNNC) was conducted. The RNNC confirmed there were no records available that documented the notification of the … | 2020-09-01 |
| 87 | 87 | THE PILLARS OF BILOXI | 255093 | 2279 ATKINSON ROAD | BILOXI | MS | 39531 | 2019-05-15 | 641 | D | 0 | 1 | 0E0S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Minimum Data Set (MDS) Assessments were completed accurately for two (2) Residents, Resident #112 and Resident #122, of 26 Residents reviewed for MDS accuracy. Specifically, the facility failed to accurately assess Resident #112's fall status and Resident #122's discharge status. Findings include: Review of an undated, written statement provided by the facility MDS Consultant documented, The Pillars of Biloxi does not have a policy for MDS coding, but it is expected that the RAI (Resident Assessment Instrument) manual is followed when coding resident MDS assessments. Resident #112 Review of Resident #112's admission MDS assessment, dated 4/26/19, revealed the resident had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS documented the resident had not had any falls in the last month prior to admission. Review of an Admission History and Physical, dated 4/16/19, revealed .The patient fell and broke her right wrist on 4/2/19 . During an interview on 5/15/19 at 11:31 AM, the MDS consultant stated the MDS was not coded correctly for the fall prior to admission. She stated the resident had a fall with fracture on 4/02/19, before being admitted to the facility. Resident #122 A closed record review for Resident #122 revealed the information provided in the discharge MDS assessment documented the resident was discharged to an acute care hospital from the facility on 3/15/19. However, a review of the discharge note, dated 3/15/19, and found in the medical record, revealed the resident was discharged to his/her home. The noted stated, Resident left the facility at 1500 (3:00 PM) via private automobile with family members present. During an interview, conducted on 5/15/19 at 5:25 PM, with the MDS Care Plan Coordinator (CPC), the MDS CPC confirmed the MDS discharge information for Resident #122 was coded incorrectly. MDS CPC did not provide an explanation for i… | 2020-09-01 |
| 88 | 88 | THE PILLARS OF BILOXI | 255093 | 2279 ATKINSON ROAD | BILOXI | MS | 39531 | 2019-05-15 | 644 | D | 0 | 1 | 0E0S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, record review, and staff interview, the facility failed to provide a Level II Pre-Admission Screening and Resident Review (PASRR) for one (1) of three (3) sampled residents, Resident #21, reviewed for PASRR screenings. Specifically, Resident #21 was diagnosed with [REDACTED]. Findings include: Review of the facility policy, titled Physician Certification for Nursing Facility and MI/MR Screening, revised 09/05/14, revealed the purpose of the screening was for the physician to certify that a resident was appropriate for admission to a long-term care Medicare/Medicaid facility. Additionally, the policy revealed Social Services (S.S.), the Admissions Coordinator, and Medical Records (MR) personnel (or MR designee) would be responsible for completing and submitting the PASRR screening documents to the State Agency. Review of the Admission Record in Resident #21's electronic clinical record, revealed an original admission date of [DATE], and a readmission date of [DATE]. The Pre-Admission Screening (PAS) Level I Application for Long Term Care was completed on 05/16/17. According to the responses entered on the PAS application, Part B-Criteria for referral for Level II screening, the resident did not meet the criteria for a Level II screen. At that time there was no [DIAGNOSES REDACTED]. Continued review Resident #21's Admission Record, revealed a [DIAGNOSES REDACTED]. Review of Resident #21's admission Minimum Data Set (MDS) Assessment, dated 04/21/17, revealed in Section I: Active Diagnoses: [REDACTED]. Review of Psychiatric Notes, dated 06/14/17, and 07/05/17, revealed the resident was assessed with [REDACTED]. The resident reported to the Psychotherapist that he believed staff were talking about killing him. Review of a MDS Significant Change Assessment, dated 03/05/19, revealed Paranoid [MEDICAL CONDITION] was listed among Resident #21's diagnoses. Review of Resident #21's current Physician Orders, dated 05/15/1… | 2020-09-01 |
| 89 | 89 | THE PILLARS OF BILOXI | 255093 | 2279 ATKINSON ROAD | BILOXI | MS | 39531 | 2019-05-15 | 645 | D | 0 | 1 | 0E0S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, record reviews, and interview, the facility failed to complete a Pre-Admission Screening (PAS) prior to the resident's admission to a long-term care facility, as required. The facility's failure affected one (1) of five (5) residents reviewed for Pre-Admission Screening applications for long term care, Resident #37. Findings include: Review of a facility policy, titled Physician Certification for Nursing Facility and MI/MR (Mental Illness/Mental [MEDICAL CONDITION]) Screening, dated 9/15/14, revealed, Policy: The Admission Coordinator or designee will obtain a current Medicare certification, Pre-Admission Evaluation PAE (TN) PAS (MS), and PASRR on all Medicare Part A admissions .The Pre-Admissions Evaluation PAE (TN), PAS (MS) and PASRR are to be completed for Medicare A admissions including: a. New/Initial Medicare A admissions. B. Facility long-term care residents with qualifying hospitalization converting to Medicare A admission into facility. Review of Resident #37's undated Face Sheet (a document that contains demographic and [DIAGNOSES REDACTED]. Resident #37's [DIAGNOSES REDACTED]. Further review of Resident #37's electronic record lacked evidence of a PAS being completed for the resident, prior to admission in the long term care facility, as required. On 5/13/19 at 2:44 PM, a copy of the Pre-Admission Screening (PAS) was provided by Medical Records Director with the PAS date of 5/13/19. During an interview on 5/13/19 at 2:55 PM, with the Business Office Manager (BOM), she stated she was responsible for the PAS on the residents. She indicated she had just completed the PAS on 5/13/19. The BOM confirmed this was the first PAS that had been completed for Resident #37. | 2020-09-01 |
| 90 | 90 | THE PILLARS OF BILOXI | 255093 | 2279 ATKINSON ROAD | BILOXI | MS | 39531 | 2019-05-15 | 656 | D | 0 | 1 | 0E0S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, record reviews, and interviews, the facility failed to ensure comprehensive, resident-centered care plans were developed and/or implemented for three (3) of 48 sampled residents, Residents #37, #89, and #112. Findings include: A review of an undated facility policy titled, Care Plan - Comprehensive, revealed, it is the policy of this facility to develop comprehensive care plans for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs. In addition, the policy stated, The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's assessment or within twenty-one (21) days after the resident's admission, whichever occurs first. Resident #37 Record review of the undated care plans for Resident #37, revealed no care plan for the pressure ulcer to the right ischium. There were no interventions or goals related to the care of the pressure ulcer. Review of Resident #37's undated Face Sheet (a document that contains demographic and [DIAGNOSES REDACTED]. Resident #37's [DIAGNOSES REDACTED]. Review of an admission Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 5/07/19, revealed Resident #37 scored a 15 on the Brief Interview for Mental Status, indicating the resident was cognitively intact. Further review of the MDS, indicated Resident #37 required limited two (2) staff assist for bed mobility; extensive two (2) staff assistance for transfers, dressing, toilet use and bathing; and extensive one (1) staff assistance for personal hygiene. The MDS documented Resident #37 had one (1) unstageable pressure ulcer due to coverage of wound bed by slough and/or eschar (dead tissue). The MDS indicated the pressure ulcer was present upon admission. Review of the Pressure Ulcer Report, dated 5/10/19, indicated the pressure ulcer to the right ischium measured 3.5 cm (centimeters) by … | 2020-09-01 |
| 91 | 91 | THE PILLARS OF BILOXI | 255093 | 2279 ATKINSON ROAD | BILOXI | MS | 39531 | 2019-05-15 | 657 | D | 0 | 1 | 0E0S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy reviews, record reviews, observations, and interviews the facility failed to ensure the care plan was updated to include all interventions to prevent falls and/or minimize injuries from falls for one (1) of 24 Residents, Resident #51, reviewed for safety, supervision and/or falls. Findings include: Review of an undated facility policy, titled Care Plans - Comprehensive, revealed, It is the policy of this facility to develop comprehensive care plans for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs .4. Care plans are revised as changes in the resident's condition dictates. Reviews are made at least quarterly . Review of an undated At risk for falls care plan, revealed interventions of: Bolsters on bed; Encourage resident to wear appropriate footwear when ambulating or mobilizing in wheelchair; Fall risk eval on admit, quarterly and prn (as necessary); PT (Physical Therapy) evaluate and treat as ordered and prn; Review information on past fall to determine cause of falls. Record possible root causes. Alter/remove any potential causes if possible. Educate resident/family/caregivers/IDT (interdisciplinary team) as to causes, tilt wheelchair to prevent forward leaning. The care plan lacked the interventions for a low bed and mats on the floor at her bedside, that were currently being implemented by facility staff. An observation of Resident #51 on 05/12/19 at 8:42 AM, revealed the resident laying in a low bed, with a mat on the floor, visiting with a family member. The family member stated she had asked the staff to place a mat on the floor because she did not want Resident #51 to be hurt from falling out of bed. Review of Resident #51's undated Face Sheet found in the electronic medical record, revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Assessment (MDS) with… | 2020-09-01 |
| 92 | 92 | THE PILLARS OF BILOXI | 255093 | 2279 ATKINSON ROAD | BILOXI | MS | 39531 | 2019-05-15 | 676 | D | 0 | 1 | 0E0S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, observation, and record review the facility failed to provide a means to communicate for one (1) of two (2) sampled residents reviewed for communication deficits. Specifically, Resident #41's primary language was not English. There was no interpreter in the facility who could translate, and the facility had not arranged for devices and/or services to communicate with the resident in a manner that the resident could understand. Findings Include: A communication policy was requested from the facility during the survey. The Registered Nurse Consultant (RNC) provided a written, signed statement, dated 5/15/19, that confirmed the facility does not have a policy related to interpreter phone usage. Review of Resident #41's quarterly Minimum Data Set (MDS), dated [DATE], revealed: Does the resident need or want an interpreter to communicate with a doctor or health care staff? Answer-No. There is no preferred language listed for Resident #41, but the resident speaks Vietnamese only. Review of the care plan with a revision date of 5/26/2017, read: Focus: I have a communication problem r/t (related to) speaks limited English/primary language Vietnamese. Goal: I will be able to make basic needs known through the review date revised on 03/27/2019. Intervention: COMMUNICATION: Resident prefers to communicate in Vietnamese. On 5/12/19 at 11:48 AM, an interview with Registered Nurse (RN) #4 was conducted. RN #4 stated Resident #41 speaks Vietnamese and does not speak English. RN #4 stated staff communicate with Resident #41 speaking in English and using hand gestures, and Resident #41 appeared to understand some English, but responds only in Vietnamese. RN #4 also stated no other type of communication (communication board, interrupter, language phone line) is used to communicate with Resident #41. RN #4 said there were no communication boards available in the facility for residents with communication concerns to use. On 5/12/19 at 2… | 2020-09-01 |
| 93 | 93 | THE PILLARS OF BILOXI | 255093 | 2279 ATKINSON ROAD | BILOXI | MS | 39531 | 2019-05-15 | 684 | D | 0 | 1 | 0E0S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of facility policies, and interview, the facility failed to ensure a resident with a [DIAGNOSES REDACTED].#102, in a sample of 24 residents. This had the potential to cause a delay and/or alteration in treatment for [REDACTED]. Findings include: Review of a facility policy, titled Weights; Obtaining and Documenting, dated 12/27/17, revealed .Timing of Weights: 1. Daily; Daily weights should be done if ordered by the physician . Record review of Resident #102's admission Minimum Data Set (MDS) assessment, dated 4/25/19, revealed the resident was readmitted to the facility on that date after an acute hospitalization . The MDS revealed in Section I the resident had [DIAGNOSES REDACTED]. An observation of Resident #102 on 5/13/19 at 9:38 AM, revealed the resident was lying in bed, in her room. Her hands and arms were observed to be [MEDICAL CONDITION] (swollen). During an interview on 5/13/19 at 9:41 AM, Registered Nurse (RN) #2 stated the resident had gone to the hospital recently, and had been [MEDICAL CONDITION] since she came back. Review of the Progress Notes, dated 5/02/19, revealed the Nurse Practitioner assessment, . Chief complaint [MEDICAL CONDITION], inadequate diuresis .resident with recent hospitalization .while admitted had [MEDICAL CONDITION] and put on #30 fluid at the time of discharge. I started her on [MEDICATION NAME] (a diuretic) 40 daily, increasing it to bid (twice a day), she has only lost #3 (pounds) . Plan: D/c (discontinue) [MEDICATION NAME] 40 bid, [MEDICATION NAME] (a diuretic) 1 mg(milligram) one po bid, daily weights . Review of the resident's physician's orders [REDACTED].Daily weight one time a day for fluid retention . Review of the resident's Daily Weight record revealed the resident's weight on 5/03/19 was 197 pounds. There was a lack of documentation of the resident's daily weights for 5/04/19, 5/05/19, and 5/06/19. Review of Resident #102's care plans, dated 8/17/18… | 2020-09-01 |
| 94 | 94 | THE PILLARS OF BILOXI | 255093 | 2279 ATKINSON ROAD | BILOXI | MS | 39531 | 2019-05-15 | 686 | D | 0 | 1 | 0E0S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, facility policy review, record reviews, and interviews the facility failed to provide the treatments as ordered for a pressure ulcer for one (1) of five (5) residents, Resident #104, reviewed for pressure ulcers, in a sample of 24 residents. Not providing treatment as ordered, had the potential for the pressure ulcer to deteriorate. Findings include: Review of a facility's policy titled Skin Care Process, dated 1/17/18, revealed, It is the policy of this facility to provide care and services with the goal of maintaining the resident's skin integrity and to provide care and services that meet professional standards to treat the loss of skin integrity should it occur .1. Provides treatment according to physician's orders [REDACTED]. Review of Resident #104's undated Face Sheet found in the electronic record, revealed the resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) with the assessment reference date of 4/30/19, revealed Resident #104 had a BIMS (Brief Interview for Mental Status) of 15, which indicated the resident was alert and oriented. The MDS indicated Resident #104 required extensive assist of two (2) staff for bed mobility, transfer, dressing toilet use and personal hygiene. The MDS documented Resident #104 did not have any pressure ulcers at the time of the assessment. Review of an undated care plan for pressure ulcers, revealed Resident #104 had a Stage 2 pressure ulcer to the left medial thigh. The interventions for the Stage 2 pressure ulcer were: Administer medications as ordered; Monitor/document for side effects and effectiveness; Administer treatments as ordered and monitor for effectiveness; Assess/record/observe wound healing; Measure length, width, and depth where possible; Assess and document status perimeter, wound bed and healing progress; Report improvements and declines to the MD (Medical Doctor). Observe nutritional stat… | 2020-09-01 |
| 95 | 95 | THE PILLARS OF BILOXI | 255093 | 2279 ATKINSON ROAD | BILOXI | MS | 39531 | 2019-05-15 | 698 | D | 0 | 1 | 0E0S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, record reviews, and staff interviews, the facility failed to maintain ongoing communication and collaboration with the [MEDICAL TREATMENT] facility for one (1) of one (1) residents reviewed for [MEDICAL TREATMENT] services (Resident #106) in a sample of 24 residents. Findings Include: Review of the [MEDICAL TREATMENT]-[MEDICAL TREATMENT] policy, Nursing Services-21, dated (MONTH) 23, 2010 read: Policy Statement: Residents with end stage [MEDICAL CONDITION] undergoing [MEDICAL TREATMENT] will receive care and services to attain or maintain the highest practicable physical, mental, and psychosocial well- being. The care and services will meet current standards of care .This facility will co-ordinate care with the [MEDICAL TREATMENT] provider .Medical and administrative information necessary for [MEDICAL TREATMENT] related care of the resident will be shared and communicated between the facility and the [MEDICAL TREATMENT] provider. The Clinical Practice Guideline [MEDICAL TREATMENT]-[MEDICAL TREATMENT], dated (MONTH) 24, 2010 read: Nutrition/Hydration, 5. Weight should be obtained weekly or as ordered by the physician. Pre and post [MEDICAL TREATMENT] weights will be obtained from the [MEDICAL TREATMENT] provider and sent to the facility for inclusion in the medical record. Review of Resident #106's Admission Record, dated 1/22/19, revealed the resident was initially admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED].#106 revealed, [MEDICAL TREATMENT] M-W-F (named clinic) Biloxi, chair time 12 PM. Review of the electronic medical record for Resident #106, dated 3/18/19 through 5/20/19, revealed four (4) completed [MEDICAL TREATMENT] Transfer Forms dated 3/18/19, 5/06/19, 5/08/19, 5/13/19. Based on the physician order [REDACTED]. On 5/14/19 at 3:30 PM, an interview with Licensed Practical Nurse (LPN) #1 was conducted. LPN #1 stated the [MEDICAL TREATMENT] sheets are collected … | 2020-09-01 |
| 96 | 96 | THE PILLARS OF BILOXI | 255093 | 2279 ATKINSON ROAD | BILOXI | MS | 39531 | 2019-05-15 | 812 | F | 0 | 1 | 0E0S11 | Based on facility policy reviews, observations, and staff interviews the facility failed to store, prepare, and serve food under sanitary conditions for 117 of 121 residents who receive food from dietary services in the facility. Specifically, food was improperly stored in the walk-in freezer, and prepared without staff wearing appropriate hair covers in the facility's kitchen. The facility reported a census of 121 at the time of the survey, with four (4) residents received tube feedings. Findings Include: The Staff Attire policy, Dining Services Policy and Procedure Manual, HCSG Policy 024, dated 9/17, read Policy Statement: All employees wear approved attire for the performance of their duties .Procedures: 1. All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained. The Food Storage: Cold Foods policy, Dining Services Policy and Procedure Manual, HCSG Policy 019, dated 9/17, read Policy Statement: All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated will be appropriately stored in accordance with guidelines of the FDA Food Code .Procedures .5. All foods will be stored wrapped or in covered containers, labeled dated, and arranged in a manner to prevent cross contamination. Observation on 5/12/19 at 9:01 AM, in the kitchen, revealed Dietary Aide (DA) #1 with facial hair on his chin approximately 0.25-0.50 inch in length. The DA was working in the food preparation area of the kitchen and plating fruit for lunch without wearing a facial hair cover. Observation on 5/12/19 at 9:20 AM, in the kitchen, revealed the Lead Supervisor (LS) who had a beard approximately 0.25-0.50 inch in length. The LS was working in the food preparation area of the kitchen not wearing a facial hair cover. Observation on 5/12/19 at 9:30 AM, in the kitchen, revealed the Dietary Manager (DM) who had a beard approximately 0.25-0.50 inch in length. The DM was also working in the food preparation area of the kitchen not wearing a facial hair cover. Observ… | 2020-09-01 |
| 97 | 97 | THE PILLARS OF BILOXI | 255093 | 2279 ATKINSON ROAD | BILOXI | MS | 39531 | 2019-05-15 | 924 | E | 0 | 1 | 0E0S11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of the facility policy the facility failed to ensure all corridors had handrails firmly secured and affixed to the corridor walls. Observations conducted on 5/12/19, and 5/15/19, revealed 15 loose handrails in four (4) of four (4) corridors of the facility. Findings include: Review of the undated facility policy titled Monthly Handrail Inspection indicated the facility was responsible for ensuring handrails were inspected monthly. The policy stated, Check all hand rails in hallways. Make sure that hand rails are secure, painted, and in proper repair. Review of the facility's checklist titled, Monthly Hand Rail Inspection Checklist, dated 8/16/18 through 4/16/19, revealed inspections documented for the past nine (9) months identified no loose handrails in the facility. Random observations conducted during an initial tour of the facility on 5/12/19 at 8:45 AM, revealed loose handrails located in all four (4) corridors of the facility. During environmental observations, conducted with the Maintenance Director present, on 5/15/19 at 11:29 AM, 15 handrails were identified as loose or broken, or not securely affixed to the wall. The following handrails were identified and confirmed to be in disrepair by the Maintenance Director: 1. Loose handrail located in front foyer entrance on the left side. 2. Loose handrail located between room [ROOM NUMBER]/110. 3. Loose handrail located between room [ROOM NUMBER]/111. 4. Loose handrail located between room [ROOM NUMBER]/104. 5. Loose handrail located between room [ROOM NUMBER]/112. 6. Loose handrail located between room [ROOM NUMBER]/106. 7. Loose handrail located between room [ROOM NUMBER] and corridor doorway. 8. Loose handrail located next to room [ROOM NUMBER]. 9. Loose handrail located outside the main dining unit. 10. Loose handrail located outside room [ROOM NUMBER]. 11. Loose handrail located outside room [ROOM NUMBER]. 12. Loose handrail located outside… | 2020-09-01 |
| 98 | 98 | THE PILLARS OF BILOXI | 255093 | 2279 ATKINSON ROAD | BILOXI | MS | 39531 | 2019-06-12 | 755 | D | 1 | 0 | WHQH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, policy review and staff and family interviews, the facility failed to obtain medications ordered for Resident #4 on admission. This was for one (1) of four (4) residents reviewed. Findings include: Review of the policy entitled, Ordering and Receiving Medications from Provider, dated 12/27/06, stated: Policy: Medications and related products are received from the provider pharmacy on a timely basis. Review of the Admission Record revealed the facility admitted Resident #4, on 05/15/19, with [DIAGNOSES REDACTED]. Review of the Admission/Five (5) day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/22/19, revealed Resident #4 scored 11 of 15 on the Brief Interview for Mental Status (BIMS), which indicated moderate cognitive impairment. Review of the Medication Review Report for Resident #4, in (MONTH) 2019, revealed the following medications were ordered: 1 An order, dated 05/15/19, for [MEDICATION NAME] Patch weekly 10 MCG/HR (micrograms per hour) 1 (one) patch trans dermally in the morning every 7 (seven) days for pain. 2. An order, dated 05/15/19, for [MEDICATION NAME] 5 MG (Milligrams) by mouth one (1) time a day. 3. An order, dated 05/15/19, for [MEDICATION NAME] Solution Pen-Injector 100 Units/ML (Milliliter), Inject 35 units subcutaneously two (2) times a day. 4. An order, dated 05/15/19, for [MEDICATION NAME] tablet 10-325 MG give 1 (one) tablet by mouth every 8 (eight) hours as needed for pain for 5 (five days). 5. An order, dated 05/15/19, for [MEDICATION NAME] tablet 5 (five) M[NAME] Give 1 (one) tablet by mouth at bedtime. Review of the Pharmacy receipts and Medication Administration Sheets (MARs) for Resident #4 revealed the following: 1. The facility did not order the [MEDICATION NAME] Patches, but received a patch from the Responsible Person/Party (RP), and documented on the MAR it had been applied on 05/16/19. 2. The facility did not order the strength of the [MEDICATION NAME], but … | 2020-09-01 |
| 99 | 99 | THE PILLARS OF BILOXI | 255093 | 2279 ATKINSON ROAD | BILOXI | MS | 39531 | 2015-12-17 | 248 | E | 0 | 1 | XQS711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident interview, record review and facility policy review, the facility failed to conduct resident activities as scheduled on the male locked unit for one (1) of two (2) locked dementia units. Findings included: A review of the facility Policy Statement revealed, Activity programs designed to meet the needs of each resident are available on a daily basis and Activities are scheduled 7 (seven) days a week and resident are given an opportunity to contribute to the planning, preparation, conducting, cleanup and critique of the programs. A Review of the POS [REDACTED]. The facility had scheduled activity Whamo at 10:00 AM, Room Visit for 1:00 PM and Mourning Star Baptist Church at 2:00 PM for Wednesday, (MONTH) 16 . An observation on 12/15/15 from 8:30 AM until 10:30 AM of the male locked dementia unit revealed no activities were held. Observation during this time revealed the residents residing on the locked unit were seated in the day area with their heads down. The facility staff had a television tuned to cartoons. In an interview on 12/15/15 at 12:25 PM, Certified Nursing Assistant (CNA) #1 confirmed no activity had been held this morning and said, We used to have someone assigned to do activities but there has not been anyone lately. An observation on 12/15/15 at 2:30 PM revealed residents seated in the day area and a few residents walking in the hallway on the male locked unit. There was no activity (Bingo) held at this time as scheduled. In an interview on 12/15/15 at 2:50 PM Resident #9 said, We haven't played Bingo today; I enjoy it when we do play. An interview on 12/15/15 at 3:00 PM revealed CNA # 2 said the activities on the locked male unit were infrequent and no one was assigned to do activities on their unit. CNA # 2 said, It's like we have been forgotten. On 12/15/15 at 3:10 PM, an interview with the Activities Director revealed the activities department was short a staff member and due to… | 2020-09-01 |
| 100 | 100 | THE PILLARS OF BILOXI | 255093 | 2279 ATKINSON ROAD | BILOXI | MS | 39531 | 2015-12-17 | 252 | D | 0 | 1 | XQS711 | Based on observation and staff interview, the facility failed to create a homelike atmosphere on the male locked unit for one (1) of five (5) halls observed. Findings included: Observation on 12/15/15 at 12:25 PM revealed the male locked dementia unit had blank walls on both hallways with no homelike decor on the unit. Observation on 12/16/15 at 3:40 PM revealed rooms 106, 107, 108, 110, 111, 113, 116, 117, 118, 119, 120, 122, 123 lacked evidence of residents' personal preferences and homelike decorations. Rooms 101 and 102 were occupied during the observation. An observation, during initial tour on 12/14/15 at 10:55 AM, revealed Rooms 101 and 102 shared bathroom had peeling non-slip strips and the wall was cracked and buckled at the door . Observation of shared bathroom for Rooms 111 and 112 revealed cracked and broken sheet rock wall near the door. An interview on 12/16/15 at 3:40 PM Account Manager and Housekeeping Supervisor confirmed the above observations. Housekeeping Supervisor said, I'm paying attention now; after comparing this (East male locked unit) with the women's locked unit, this place has no pictures or anything; nothing like the other units. | 2020-09-01 |
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CREATE TABLE [cms_MS] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );