Clarksdale Nursing Center

Inspectors wroteBased on staff interviews, record review, and facility policy review, the facility failed to notify a dialysis clinic of a significant change in a resident's status for one (1) of three (3) residents reviewed for notification of change (Resident #1).

Inspectors wroteBased on observation, resident and staff interview, record review, and facility policy review, the facility failed to implement care plans related to fluid restriction (Resident #11), nail care (Resident's #24 & #44) and following Enhanced Barrier Precautions (EBP) for (Resident #157) for four (4) of 19 care plans reviewed.

Inspectors wroteBased on observation, staff and resident interviews, facility policy review, and record review, the facility failed to ensure fingernails were clean and trimmed, as evidenced by long and jagged nails with a brown substance under nails for two (2) of eight (8) residents observed.

Inspectors wroteBased on record review and staff interview, the facility's Quality Assessment and Assurance Committee (QAA) failed to maintain implemented procedures and monitor the interventions the committee put in placing following the recertification survey on 4/6/2023 and the complaint survey on 6/26/2024. This was for deficiency recited during a recertification on 8/15/2024 in the area of F677 Activities of Daily Living (ADL). The continued failure of the facility during three State Surveys of record shows a pattern of the facility to sustain an effective QAA program. This was for one (1) of seven (7) deficient practice citations. Findings Included: This citation is cross-referenced to: [...]

Inspectors wroteBased on record review, staff interview, and facility policy review the facility failed to ensure that a fluid restriction was followed for one (1) of five (5) residents on fluid restrictions. Resident #11.

Inspectors wroteBased on observation, resident and staff interview, record review, and facility policy review, the facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a peripherally inserted central catheter (PICC) for intravenous antibiotic therapy on two (2) of five (5) care area observations requiring enhanced barrier precautions. (Resident # 157).

Inspectors wroteBased on staff interview, record review and facility policy review the facility failed to accurately code the Minimum Data Set Assessment (MDS) for the use of restraints for five (5) of five (5) resident MDS Assessments reviewed for accurate coding of restraints. Resident #5, #18, #25, #33, and #38.

Inspectors wroteBased on observation, staff and resident interview, and record review the facility failed to ensure that a resident received incontinent care during a night shift for one (1) of five (5) residents reviewed. Resident #1. Findings Include: Record review of a typed statement by the Administrator dated 06/26/24 on Company Letterhead revealed, Clarksdale Nursing Center does not have a policy specific to how frequent ADL (Activities of Daily Living) rounds are made or incontinent care provided. On 06/26/24 at 7:40 AM, an observation and interview with Licensed Practical Nurse #1 (LPN) revealed her entering Resident #1's room and confirmed that his brief was soaked with urine and that he should have been changed during the Certified Nursing Assistant's (CNA) last rounds. [...]

Inspectors wroteBased on observation, interview, facility policy review, and record review, the facility failed to develop and implement an elopement/wandering risk plan of care for Resident #1 who had worn a wander guard since 8/9/23. Resident #1 was one (1) of five (5) residents reviewed who wore a wander guard. Resident #1 was missing from the facility for approximately two (2) and a half (1/2) hours - three (3) and a half (1/2) hours prior to discovery. No facility staff saw the resident leave the facility and no facility staff were aware that Resident #1 was missing until approximately 9:30 PM when they received a call that Resident #1 was at a convenience store. It was also determined that Resident #1 was found at a convenience store approximately eight- tenths of a mile from the facility on a busy four (4) lane highway. [...]

Inspectors wroteBased on staff interviews, family interview, observations, facility security camera video review, record reviews, and facility policy review the facility failed to ensure Resident #1 had adequate supervision to prevent an elopement from the facility on 01/30/24 and failed to ensure the wander guard system was properly functioning for one (1) of five (5) residents who were elopement risk and wore wander guards. Resident #1. Resident #1 was missing from the facility for approximately two and a half (2 1/2) hours to three (3) and a half (1/2) hours prior to discovery. No facility staff saw the resident leave the facility and no facility staff were aware that Resident #1 was missing until approximately 9:30 PM when they received a call that Resident #1 was at a convenience store. [...]

Inspectors wroteBased on resident observation and staff interviews the facility failed to promote dignity related to a catheter bag stored without a privacy bag for one (1) of two (2) residents with urinary catheters. Resident # 13.

Inspectors wroteBased on record review, resident and staff interviews and facility policy review the facility failed to honor a resident's choice for showers for one (1) of 20 residents reviewed.

Inspectors wroteBased on staff interview, record review and facility policy review the facility failed to submit a Change in Status referral for a Level II Pre-admission Screening and Resident Review (PASRR) related to a new diagnosis of Schizophrenia and after a significant change from a psychiatric in-patient stay for one (1) of five (5) residents reviewed. Resident # 31.

Inspectors wroteBased on staff interview, record review and policy review the facility failed to accurately complete a Pre-admission Screening and Resident Review (PASRR) and failed to identify a mental disorder resulting in no Level II referral for evaluation for one (1) of five (5) residents reviewed. Resident # 31.

Inspectors wroteBased on resident and staff interview, and record review and the facility policy review the facility failed to develop and implement care plans for residents requiring diabetic nail care and residents who preferred showers for three (3) of 20 residents reviewed. Resident #16, #30 and #42.

Inspectors wroteBased on facility policy review, observation, staff interviews, and record review the facility failed to provide proper position a resident, in her wheelchair, who required feeding assistance for one (1) of 13 residents observed during the lunch dining observation. Resident # 46. Resident #46 Review of the facility policy titled, Feeding the Dependent Resident, with a latest revision date of 10/17, revealed Purpose: To ensure adequate nutrition for residents who are unable to feed themselves. 5. Ensure that resident is seated comfortable in upright position. 17. Position resident comfortably. An observation on 4/4/23 at 11:52 AM, of Resident #46 during lunch dining, in the main dining room revealed her sitting in her wheelchair with her upper body and left elbow extended over the left armrest of the wheelchair while being fed by Certified Nursing Assistant (CNA) #5. [...]

Inspectors wroteBased on observation, staff and resident interviews, facility policy review, and record review, the facility failed to ensure fingernails were clean and trimmed as evidenced by long and jagged nails with a brown substance under nails for three (3) of 54 residents observed. Resident #14, Resident #16, and Resident #42

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to check placement for a Percutaneous Enteral Gastrostomy (PEG) tube for one (1) of two (2) residents observed during administration of medication through a PEG tube (Resident #51).

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to ensure oxygen tubing was changed timely to prevent a potential infection for two (2) of five (5) residents with oxygen, failed to adhere to infection control practices related to donning (putting on) and doffing (removing) proper Personal Protective Equipment (PPE) (Residents #23 and 35), failure to disinfect a medication cart prior to removing from the COVID-19 Unit buffering zone for one (1) of four (4) days of observation and failed to administer eye drops in a manner to prevent infection for one (1) of seven (7) residents observed for medication administration ( Resident #1).