Every finding on record at Adams Rehabilitation and Healthcare Center

Based on interview, review of Resident Identifier (RI) #39's medical record and the facility's policy, the facility failed to ensure the estimated cost to continue to receive physical therapy services was listed on the Advance Beneficiary Notice of Noncoverage (ABN) for RI #39; one of three residents reviewed for beneficiary notices. Findings include: The facility's policy titled, Advance Beneficiary Notices last revised 7/13/2020 stated, Policy To provide timely notices regarding Medicare eligibility and coverage. Procedure . 7. Additional notices shall be issued to Medicare beneficiaries when appropriate. a. A liability notice shall be issued to Medicare beneficiaries before the facility provides: . For Part A items and services, the facility may use either the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), CMS Form # , or one of five SNF denial letters as the liability notice . 9. The current CMS-approved version of the forms shall be used at the time of issuance to the beneficiary (resident or resident representative). Contents of the form shall comply with related instructions and regulations regarding the use of the form . The SNF Beneficiary Protection Notification Review indicated RI #39 began receiving Part A Medicare services on 1/18/2021 and the resident's last covered day of Part A services was 4/15/2021. The form indicated The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. The Advance Beneficiary Notice of Noncoverage (ABN) indicated RI #39 had reached the maximum level of physical therapy. The form did not include the estimated cost of services if the resident or their representative wanted to continue receiving the physical therapy services without assistance from Medicare. During an interview on 6/2/2021 at 12:47 PM, Employee Identifier (EI) #1, a Restorative Nurse stated she completed and issued the ABN notices to the residents. EI #1 stated the facility practice was to identify the estimated cost only after a resident or resident representative requested to continue receiving Part A services.

Based on observation, interview and review of a facility policy titled, Diabetes - Insulin Injections, the facility failed to ensure Resident Identifier (RI) #19's vial of insulin contained an opened date on the vial and box containing RI #19's insulin. This deficient practice affected RI #19, one of 15 sampled residents. Findings Include: A review of a facility policy titled, Diabetes - Insulin Injections with a Revised date of 02.01.15, revealed: .Procedure A. Procedure to prepare the insulin for an injection. .4. When opening new vial of insulin - the date opened should be documented on the vial and the box with an indelible pen. 5. Open vials of insulin should be replaced within 28 days of being opened, or according to manufacturer's guidelines whichever comes first. RI #19 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 8:21 a.m. during medication pass observation, Employee Identifier (EI) #3, Licensed Practical Nurse (LPN), was observed administering medications to RI #19. EI #3 took a box containing [MEDICATION NAME]from her medication cart, took out vial of insulin and drew up 44 units of [MEDICATION NAME] in a syringe. There was no opened date observed on the box or on the vial of insulin. On [DATE] at 2:15 p.m., an interview was conducted with EI #3, LPN. EI #3 was asked, what should be done when a box of insulin is opened. EI #3 said, she should date and initial the box and vial of insulin. EI #3 was asked, did the box and/or vial of [MEDICATION NAME] for RI #19 have a opened date on it. EI #3 replied, no. EI #3 was asked, was the policy for insulin followed since RI #19's box or vial did not have an opened date. EI #3 answered, no. EI #3 was asked, what was the concern with no opened date being on the insulin. EI #3 said, it could be expired, because it should be used within 28 days of the opened date.

Based on interview, record reviews and review of a facility policy titled, ALABAMA Advance Directives - Do Not Resuscitate Orders - DNR, the facility failed to ensure DNR - Do Not Resuscitate Consent forms were completed for Resident Identifier (RI) #12, RI #36, and RI #49. This deficient practice affected RI #12, RI #36 and RI #49, three of four residents sampled with Do Not Resuscitate orders. Findings Include: A review of a facility policy titled, ALABAMA Advance Directives - Do Not Resuscitate Orders - DNR with a Revised date 04/01/03, revealed: .1. The Attending Physician determines, to a reasonable degree of medical certainty, that (a) the resident is unable to understand, appreciate, and direct his or her medical treatment, and (b) the resident has no hope of regaining such ability; 2. Two physicians, one of whom is the Attending Physician and one of whom is qualified and experienced in making such diagnosis, have personally examined the resident and have diagnosed and certified in the medical record that the resident has a Terminal Illness or Injury or is in a state of Permanent Unconsciousness; . 1. RI #12 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #12's medical record revealed a DNR - Do Not Resuscitate Consent form dated 9/30/16. The form did not contain pertinent information regarding RI #12's terminal diagnosis, signs and symptoms or competence status. 2. RI #36 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #36's medical record revealed a DNR - Do Not Resuscitate Consent form dated 3/27/17. The form did not contain RI #36's name, terminal diagnosis, signs and symptoms or competence status. 3. RI #49 was readmitted [DATE] with [DIAGNOSES REDACTED]. A review of RI #49's medical record revealed a DNR - Do Not Resuscitate Consent form dated 11/7/17. The form did not contain RI #49's terminal diagnosis, signs and symptoms or competence status. On 02/08/18 at 8:37 a.m., an interview was conducted with Employee Identifier (EI) #1, Administrator. EI #1 was asked, who was responsible for completing the DNR - Do Not Resuscitate Consent forms in the medical record. EI #1 said, Social Services is responsible for initiating the form and nursing is responsible for completing it. EI #1 was given RI #36's medical record containing the consent form. EI #1 was asked, should the form have RI #36's name on it. EI #1 replied, yes. EI #1 was asked, should the form contain RI #36's [DIAGNOSES REDACTED].#1 answered, yes. The surveyor asked EI #1, should the consent forms in the resident's medical records be completed. EI #1 said, yes, the doctor is here in the facility and they will be completed while he is here.

Based on observations, interviews and review of facility policies titled, Standard Precautions, Personal Protective Equipment - Gloves Usage, Handwashing - Hand Hygiene and Catheter - Care - Suprapubic, the facility failed to ensure: 1. Licensed Practical Nurse (LPN) cleaned her stethoscope and pulse oximeter after obtaining vital signs for RI #19, 2. an LPN washed her hands after removing her gloves when cleaning RI #30's glucometer and putting on a clean pair of gloves, 3. an LPN did not touch the paper towel dispenser handle after washing her hands and prior to applying clean gloves during administration of RI #49's medications via gastrostomy tube and and LPN cleaned a stethoscope before and/or after using the stethoscope to auscultate RI #49's gastrostomy tube placement, and 4. a Certified Nursing Assistant (CNA) did not place a garbage bag containing items used during catheter care for RI #51 on the floor in RI #51's room. These deficient practices affected two of two nurses observed during medication pass observations and one of one CNA observed during catheter care. Findings Include: A review of a facility policy titled, Standard Precautions with an Effective date of 11.01.09 revealed: Policy Standard Precautions will be used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status. Standard Precautions presume that all blood, body fluids, secretions and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. Procedure 1. Standard Precautions shall apply to the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. .Standard precautions include the following practices: .1. Hand hygiene .d. Wash hands after removing gloves . 2. Gloves .g. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident and wash hands immediately to avoid transfer of microorganisms to other residents or environments.5. Resident-Care Equipment .b. Ensure that reusable equipment is not used for the care of another resident until it has been appropriately cleaned . A review of a facility policy titled, Personal Protective Equipment - Gloves Usage with a Revised date 02.27.13, revealed: .Procedure .8. Wash and dry hands thoroughly after removing gloves. A review of a facility policy titled, Handwashing - Hand Hygiene with a Revised date 03.01.17 revealed: Purpose To prevent the spread of infections. .7. Hand hygiene is always the final step after removing and disposing of personal protective equipment. 8. The use of gloves does not replace handwashing/hand hygiene. A review of a facility policy titled, Catheter - Care - Suprapubic with a Revised date 02.01.15, revealed: .Procedure .10. Discard disposable items and soiled gloves in plastic bag and tie. 11. Place plastic bag in appropriate container. 1. RI #19 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 02/07/18 at 8:21 a.m., during medication pass observation, Employee Identifier (EI) #3, LPN, was observed obtaining RI #19's blood pressure and oxygen saturation with a blood pressure cuff, stethoscope and pulse oximeter off her medication cart. After obtaining RI #19's vital signs, EI #3 was observed putting the items back on her medication cart without cleaning them. 2. RI #30 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 02/07/18 at 11:05 a.m., during medication pass observation, EI #4, LPN, was observed cleaning RI #30's glucometer. EI #4 was observed removing her gloves and applied a clean pair of gloves without washing her hands. 3. RI #49 was readmitted [DATE] with [DIAGNOSES REDACTED]. On 02/07/18 at 3:30 p.m., during medication pass observation, EI #3 was observed washing her hands in the sink in RI #49's room during gastrostomy tube medication administration for RI #49. After she washed her hands, she was observed to manipulate the paper towel dispenser handle with her clean hands without re-washing her hands before applying her gloves. EI #3 was observed taking a stethoscope off her medication cart to auscultate placement of RI #49's gastrostomy tube without cleaning the stethoscope before and/or after auscultating placement of the tube. On 02/08/18 at 2:11 p.m., an interview was conducted with EI #4, LPN. EI #4 was asked, when was she supposed to wash her hands during a medication pass. EI #4 said, before she puts her gloves on and after she takes her gloves off. EI #4 was asked, did she wash her hands after cleaning RI #30's glucometer and removing her gloves before putting on a clean pair of gloves. EI #4 replied, no. EI #4 was asked, what was the concern with not washing her hands when removing her gloves. EI #4 answered, infection control. On 02/08/18 at 2:15 p.m., an interview was conducted with EI #3. EI #3 was asked, what was she supposed to do after using a stethoscope, blood pressure cuff and pulse oximeter to obtain RI #19's vital signs. EI #3 said, clean them before and after use. EI #3 was asked, did she clean these items before and/or after using them to obtain RI #19's vital signs. EI #3 replied, no. EI #3 was asked, did she clean her stethoscope before and/or after using it to auscultate RI #49's gastrostomy tube placement. EI #3 said, no. EI #3 was asked, how should she retrieve a paper towel from RI #49's paper towel dispenser after washing her hands. EI #3 answered, she should pull the paper towel down without touching the turn knob. EI #3 was asked, did she touch the turn knob on the paper towel dispenser in RI #49's room. EI #3 said, yes. EI #3 was asked, what she she have done after touching the turn knob. EI #3 answered, washed and dried her hands again before applying gloves. EI #3 was asked, what was the concern with not cleaning the items and touching the turn knob after washing her hands. EI #3 said, infection control. On 02/08/18 at 3:27 p.m., an interview was conducted with EI #2, Registered Nurse, Director of Nursing, Infection Control Coordinator. EI #2 was asked, when should nursing staff wash their hands when using gloves. EI #2 said, before putting them on and when taking them off. EI #2 was asked, what should be done when a nurse is using a stethoscope, blood pressure cuff and/or pulse oximeter on a resident. EI #2 answered, clean them. EI #2 was asked, should an employee use the handle of the paper towel dispenser after washing her hands. EI #2 said, no. EI #2 was asked, what was the concern with these things. EI #2 answered, infection control. 4. RI #51 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 02/08/18 at 1:28 p.m. during observation of catheter care for RI #51, EI #5, a CNA, was observed placing a garbage bag containing items used during catheter care for RI #51 on the floor in RI #51's room. On 02/08/18 at 4:24 p.m., a telephone interview was conducted with EI #5. EI #5 was asked, should a garbage bag containing items used during catheter care be put on the floor. EI #5 said, no. EI #5 was asked, did she put the garbage bag on the floor in RI #51's room after she provided RI #51's catheter care. EI #5 replied, yes. EI #5 was asked, what concern was placing the garbage bag containing the catheter care kit she used for RI #51's catheter care on the floor. EI #5 answered, infection control. On 02/08/18 at 3:27 p.m., an interview was conducted with EI #2, Registered Nurse, Director of Nursing, Infection Control Coordinator. EI #2 was asked, when should nursing staff wash their hands when using gloves. EI #2 said, before putting them on and when taking them off. EI #2 was asked, what should be done when a nurse is using a stethoscope, blood pressure cuff and/or pulse oximeter on a resident. EI #2 answered, clean them. EI #2 was asked, should an employee use the handle of the paper towel dispenser after washing her hands. EI #2 said, no. EI #2 was asked, should a CNA place a garbage bag in the floor containing items used during catheter care. EI #2 replied, no. EI #2 was asked, what was the concern with these things. EI #2 answered, infection control.

Based on interviews record review and observations, the facility failed to ensure the residents had access to the current Ombudsman information provided to the facility by the State Ombudsman Agency. This had the potential to affected all 65 residents and visitors in the facility. Findings include: The Ombudsman poster posted on the bulletin boards on both units in the facility provided the name of an Ombudsman that no longer worked as a State Ombudsman. The surveyor called to notify the Ombudsmen office of the current survey in progress and ask for the person identified on the poster. The secretary stated she was no longer with that office assigned to the facility. The surveyor was given the name of the current Ombudsman assigned to the facility. The Social Worker (Employee Indentifer) EI #9, was interviewed on 11/30/16 at 3:00 PM, and asked who was responsible for updating the Ombudsman posters to ensure the accuracy of information for the residents. EI #9 stated, That would be me. EI #9 was asked who is the current Ombudsman assigned to the facility. EI #9 was able to identify the current Ombudsman. The surveyor asked whose name was posted on the bulletin boards for the residents to notify if they need to discuss something with the Ombudsman? EI #9 replied the former Ombudsman name. EI #9 and surveyor checked the name on both Bulletin Boards. EI #9 stated she was responsible for following up with the Ombudsman office to ensure the information was current for the residents.

Based on observation, interview and record review 1) the facility failed to ensure a box of grapes and a bag of frozen chicken in the refrigerator were dated. This was observed during the initial tour of the kitchen. 2) the facility failed to ensure a dietary staff member did not place the hub of the thermometer into the food while checking the temperatures of the food items on the tray line. The staff member failed to clean the food off of the hub of the thermometer and continued to check the temperatures of other food items. This had the potential to affect 60 residents receiving food/meals from the kitchen. Findings Include: A facility policy titled, Storage of Food - Supplies Policy No.DPP 608 with a revised date of 12.01.13 documented Purpose To maintain high quality and prevent spoilage and contamination. Policy .Refrigerated items should be covered, labeled and dated . On 09/29/15 at 9:10 AM during the initial tour of the facility's kitchen the surveyor was unable to identify an open date or use by date for a box of grapes observed in the refrigerator. Employee Identifier (EI) #4 the Dietary Manager who was with the surveyor was also unable to identify a date on the grapes. Furthermore, in another refrigerator a bag of frozen chicken was observed without an open date or use by date. The surveyor asked EI #4 if the frozen chicken had an open date or use by date. EI #4 looked for a date and was unable to find a date. On 09/30/15 at 10:35 AM EI #5 a dietary cook was observed checking the temperatures of food items on the tray line. EI #5 placed the thermometer in the barbeque chicken and the hub of the thermometer touched the chicken. She cleaned the gauge of the thermometer but did not clean the hub of the thermometer. She continued to check the green beans, baked chicken and puree chicken. EI #5 touched the puree chicken with the hub of the thermometer. She continued to check the mashed potatoes, puree green beans and chopped barbeque chicken. EI #5 was asked if there were any cold items to be served. She obtained some puree potato salad and regular potato salad from the refrigerator and checked these items with the contaminated thermometer. At this time EI #6 the Dietitian was asked if she observed any food still on the hub of the thermometer. EI #6 stated, Yes. During an interview on 09/30/15 at 10:45 AM EI #4 was asked if she was aware the grapes and the frozen chicken observed in the refrigerator on 09/29/15 had no date. EI #4 replied no ma'am I wasn't. She was then asked if these items should have been dated. EI #4 stated,Yes ma'am. EI #4 was asked what the potential for harm would be if items were not dated in the refrigerator. She replied you can serve something that is old or ruined and people could get sick or the food not taste good. On 09/30/15 at 12:55 PM EI #5, Cook was asked how long she had worked in the kitchen. She stated one year. EI #5 was asked when she was last inserviced for checking temperatures. She replied about a week ago. EI #5 was asked why she had inserted the thermometer down in the barbeque chicken and the puree chicken until it touched the food contents. EI #5 stated, I know not to but I was just nervous when someone watches me. EI #5 was asked if she should have left food on the thermometer while checking temperatures on the tray line. She stated, No. EI #5 was asked what the potential for harm was if food was left on the thermometer an other food items were checked. EI #5 stated, Cross Contamination. EI #5 was asked if she should have noticed the food on the thermometer. She replied yes. EI #5 was then asked what she should have done before checking other food items with food remaining on the thermometer. EI #5 stated, wipe it off with alcohol pads. On 09/30/15 at 1:15 PM EI #6 a Dietitian was asked if she was aware that the grapes and frozen chicken were not dated during the initial tour of the kitchen on 09/29/15. EI #6 stated, EI # 4 told me you found that. EI #6 was asked what the potential for harm would be if food items were not dated. She stated, It could make someone sick if it was out of date. EI #6 was asked should the hub of the thermometer touch food items when checking temperatures. She stated, No ma'am. EI #6 was asked what the potential for harm was if the hub of the thermometer touched the food item. EI #6 stated,cross contamination. EI #6 was then asked if there was food remaining on the thermometer when EI #5 finished checking the tray line. She stated, yes ma'am.

Based on observations, interviews and record reviews the facility failed to ensure: 1) A Certified Nursing Assistant (CNA) performed foley catheter care to Resident Identifier (RI) #2, a resident with a history of Urinary Tract Infections [MEDICAL CONDITION] in a manner in which to decrease risks for UTIs. The CNA wiped from the end of the catheter toward the insertion site. This was observed on 9/29/15 during an observation of foley catheter care. This affected 1 observation of foley catheter care. 2) A CNA performed incontinent care to RI #9, a resident with a history of UTI's in a manner in which to decrease the risks for UTI's. The CNA touched the resident with soiled gloves after performing incontinent care. This was observed on 9/30/15 during an observation of incontinent care. This affected one of one observation of incontinent care and one of one observation of foley catheter care. Findings Include: 1) A review of a facility policy titled Catheter Care - Male with a revised date 1/23/09 revealed Purpose To keep meatus and surrounding area clean and bacteria free and to decrease incidence of infection .Procedure .6. Use wet washcloth by circling around meatus with downward stroke toward the end of tubing . RI #2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a laboratory report dated 4/19/15 revealed urine .Bacteria 3+ . A review of RI # 2's most recent Minimum Data Set with an Assessment Reference date of 4/29/15 revealed Urinary Tract Infection [MEDICAL CONDITION] Last 30 days . On 9/29/15 EI #1 CNA was observed performing foley catheter care on RI #2. EI #1 removed the brief then cleaned the foley first. Using a wipe EI #1 cleaned from the end of the tubing towards the urethral opening. On 9/29/15 at 3:50 PM an interview was conducted with EI #1, she was asked how was she taught to wipe during foley care. EI #1 replied up, she was then asked what she meant by up. EI #1 replied foam the tip of the penis to the catheter end. EI #1 was asked how did she wipe, she replied from the catheter end towards the penis. EI #1 was asked what was the potential harm in wiping incorrectly. EI #1 replied spread germs and give infection. On 10/1/15 an interview was conducted with EI #3, Infection Control Nurse, she was asked what infections the facility was currently monitoring. EI #3 replied Urinary tract Infections. EI #3 was asked how could infections be prevented. EI #3 replied handwashing. EI #3 was asked when performing catheter care how was staff trained to clean the foley catheter. EI #3 replied after cleaning the body part they were to clean down the tubing away from opening. EI #3 was what was the potential harm if a CNA wiped incorrectly. EI #3 replied urinary tract infection. 2) A review of a facility policy titled Perineal Care with a revised date of 03.03.14 revealed Purpose .assist in preventing infection, .Procedure .6. Remove soiled gloves place in plastic bag, .wash hands .apply clean gloves. Apply clean brief .7. Cover resident . RI #9 was admitted to the facility 7/08/13 with Diagnose to include Urinary Tract Infections. A review of a Laboratory report dated 11/8/14 revealed .organism Escherichia Coli .3 + bacteria . On 9/30/15 at 10:40 AM, EI #2, CNA was observed performing incontinent care to RI #9. EI #2 wiped the front then rolled RI #9 to the right side and rolled the soiled pad toward the resident. EI #2 then removed her gloves washed her hands and donned clean gloves and continued with incontinent care. EI #2 cleaned the buttocks then placed the clean pad under the resident and removed the soiled pad. EI #2 then touched RI #9 and assisted to position the resident. EI #2 then placed the top sheet with same soiled gloves she cleaned the resident with. On 9/30/15 at 10:50 AM an interview was conducted with EI #2, she was asked when should she change gloves. EI #2 replied I changed gloves after I cleaned the front. The surveyor explained, you then wiped the buttocks and removed the soiled pad, then placed the new pad and the top sheet with the same gloves. EI #2 was asked should she have changed gloves before placing the clean items. EI #2 replied yes. EI #2 was asked what was the harm in not changing gloves. EI #2 replied contamination. On 10/1/15 an interview was conducted with EI #3, Infection Control Nurse, she was asked what types of infections the facility was currently monitoring. EI #3 replied urinary tract infections. EI #3 was asked how was staff trained on when to wash hands and change gloves during incontinent care. EI #3 replied, during incontinent care before putting on clean items. EI #3 was asked if it would be acceptable for a CNA to touch clean items with same soiled gloves she had on to clean resident with. EI #3 replied no. EI #3 was asked what was potential for harm in a CNA handling clean items with the same soiled gloves. EI #3 replied spread infection.

Based on observation, interview and record review the facility failed to ensure an oxygen order was obtained for Resident Identifier (RI) #3. RI #3 was observed with oxygen in place at 2 liter/minute on 2 days of the survey. This affected 1 of 2 residents observed for oxygen use. Findings Include: A facility policy titled, Oxygen - Administration with with a revised date of 02.01.15 documented Purpose To provide guidelines for safe oxygen administration. Policy Oxygen therapy is administered as ordered by the physician. RI #3 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #3's Physician order [REDACTED]. No Oxygen order was documented on the current orders. A review of RI #3's most recent Significant Change Minimum Data Set (MDS) with and Assessment Reference Date (ARD) of 06/23/2015 documented RI #3 as having a Brief Interview for Mental Status (BIMS) score of 15 which indicted RI # 3 was cognitively intact. Section I documented a [DIAGNOSES REDACTED]. During the initial tour on 09/29/2015 at 9:30 AM an oxygen concentrator with nasal cannula tubing was observed in RI #3's room. RI #3 was not in the room at this time. On 09/29/2015 at 2:00 PM RI #3 was observed in the room with oxygen in use per nasal cannula at 2 liter/minute. On 09/30/2015 at 2:30 PM RI #3 was observed sitting on the bed with oxygen in use per nasal cannula at 2 liters/minute. The surveyor asked RI #3 if he/she used oxygen a lot. RI #3 replied oh yes off and on. RI #3 was asked how long he/she had used oxygen. He/She replied a long time, ever since I've been here. During an interview on 09/30/15, at 3:00 PM with Employee Identifier (EI) #7 a Registered Nurse Supervisor. EI # 7 was asked if RI #3 used oxygen. EI #7 stated, Yes as needed. EI #7 was asked to review RI #3's Physician order [REDACTED].#3 should have a Physician order [REDACTED].#7 was asked what the potential for harm would be if a resident did not have a Physician Order. EI #7 replied RI #3 needed an order because she needed her oxygen. EI #9 a facility Care Plan Coordinator was interviewed on 09/30/15, at 2:30 PM she was asked if RI #3 had a Physician order [REDACTED].

Based on observations, interviews and record reviews the facility failed to ensure: 1) a Certified Nursing Assistant (CNA) did not touch three bedside cabinet drawers and then touch clean items with the same soiled gloves she had on while performing foley catheter care to Resident Identifier (RI) #2; and 2) a CNA did not touch RI #9, a clean pad and linens with same soiled gloves she had on to provide incontinent care to RI #9. This was observed during one observation of foley catheter care on 9/29/15 and incontinent care on 9/30/15. This affected one of one observation of foley catheter care and one of one observation of incontinent care. Findings Include: 1) A review of a facility policy titled Catheter Care - Male with a revised date 01/23/09 revealed Procedure .2. Take equipment to bedside .6. Use wet washcloth by circling around meatus with downward stroke toward end of tubing .9. Discard gloves . RI #2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/29/15 at 3:40 PM Employee Identifier (EI) #1, CNA was observed performing foley catheter care on RI #2. EI #1 was observed removing the brief then she used the first wipe and cleaned from the end of the catheter tubing toward the urethral opening. EI #1 then turned RI #2 to the right side to clean the buttocks. She cleaned the stool from RI #2 using three wipes then reached into each drawer of the bedside cabinet with the same soiled gloves. The surveyor asked what was she looking for; she replied wipes. She then removed her gloves washed her hands and left the room to retrieve more wipes. EI #1 returned to the room washed her hands donned gloves and completed the foley catheter care to RI #2. On 9/29/15 at 3:50 PM an interview was conducted with EI #1, she was asked how was she taught to wipe during foley care. EI #1 replied up, she was then asked what she meant by up. EI #1 replied from the tip of the penis to the catheter end. EI #1 was asked how did she wipe, she replied from the catheter end towards the penis. EI #1 was asked what was the potential harm in wiping incorrectly. EI #1 replied spreading germs and infections. EI #1 was asked what was the harm in touching the bedside cabinet with the soiled gloves. EI #1 replied spreading germs. On 10/1/15 at 9:00 AM an interview was conducted with EI #3, Infection Control Nurse. EI #3 was asked how could infections be prevented. EI #3 replied handwashing. EI #3 was asked how was staff trained on when to wash hands and change gloves during incontinent care. She replied before starting and after completing, with incontinent care before putting on clean items or touching clean items. EI #3 was asked if it would be acceptable for a CNA to reach inside a bedside cabinet with the same soiled gloves she had on to clean the resident with. EI #3 replied no, absolutely not. EI #3 was asked what was the potential for harm in a CNA touching cabinet drawers with the same gloves used to clean a resident with. EI #3 replied, spread infection; could spread infection from one resident to another. 2) A review of a facility policy titled Perineal Care with a revised date of 03.03.14 revealed Purpose .assist in preventing infection, .Procedure .6. Remove soiled gloves place in plastic bag, .wash hands .apply clean gloves. Apply clean brief .7. Cover resident . RI #9 was admitted to the facility 7/08/13 with [DIAGNOSES REDACTED]. On 9/30/15 at 10:40 AM, EI #2, CNA was observed performing incontinent care to RI #9. EI #2 wiped the front then touched RI #9 to aid in turning to the right side. EI #2 then rolled the soiled pad toward the resident. EI #2 then removed her gloves washed her hands and donned clean gloves. EI #2 then wiped the buttocks five times changing the wipe each time, she then placed the clean pad under the resident and removed the soiled pad. EI #2 then positioned the resident and placed the top sheet with the same soiled gloves she had cleaned the resident with. On 9/30/15 at 10:50 AM an interview was conducted with EI #2, she was asked when should she change gloves. EI #2 replied I changed gloves after I cleaned the front. EI #2 was asked should she have changed gloves after cleaning the buttocks and before placing the clean items under RI # 9. EI #2 replied yes. EI #2 was asked what was the harm in not changing gloves. EI #2 replied contamination. On 10/1/15 an interview was conducted with EI #3, Infection Control Nurse. EI #3 was asked how was staff trained on when to wash hands and change gloves during incontinent care. EI #3 replied, during incontinent care before putting on clean items. EI #3 was asked if it would be acceptable for a CNA to touch clean items with the same soiled gloves she had on to clean the resident with. EI #3 replied no. EI #3 was asked what was potential for harm in a CNA handling clean items with the same soiled gloves. EI #3 replied spread infection.

Based on observation, record review and interview the facility failed to maintain RL's (Room Locater's) #'s 1 - 37 free of scuffed and scraped areas on room walls and doors. This was observed on 3 days of the survey and affected 2 units in the facility. Findings Include: A review of a policy titled Daily Maintenance Compliance Rounds dated 02/01/07 documented the following: .Policy Routine inspection of buildings .shall be made to ensure that all property is inspected not less than once every three months .These inspections shall serve as a basis for scheduling, painting, caulking, equipment repairs or replacement and other repair work as needed .These inspections shall focus on providing a safe, comfortable and home-like environment for all residents . The following observations were made of the general environment of the building: On 9/29/15 between 9:15AM and 9:30AM, 9/30/15 between 8:30AM and 10:30AM and 10/1/15 at 9:00AM RL# 1, 21, 22, 23, 24, 25, 26, 27 and 28 were observed to have scuffed and scrapped areas on the entry room doors and bathroom doors. On 9/29/15 at 10:00AM, 9/30/15 at 10:45AM and 10/1/15 at 9:00AM RL # 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 36 and 37 were observed to have scuffed areas on the entry door to the rooms. A hand rail in need of repair and the entry door to the unit was observed to have scuffed and scrapped areas. On 9/29/15 at 9:15AM, 9/30/15 at 9:00AM and 10/1/15 at 10:00AM RL # 29, 30, 31, 32, 33, 34 and 35 were observed to have scuffed areas on the entry door to the resident rooms and to the walls on the inside of the rooms. An interview was conducted with EI (Employee Identifier) # 10, Maintenance staff on 10/1/15 at 10:30 AM. EI # 10 was asked if the rooms observed need to be replaced/repaired. EI # 10 stated yes painting or repaired. EI # 10 was asked what could be done to repair the hand rail. EI # 10 stated either sanding or replacement of the rail. EI # 10 was asked how do you know when to make repairs in the building. EI # 10 stated through the computer system or verbally. EI # 10 stated he completed inspections of the building at least quarterly and when the rooms become vacant.

Based on record review,observations and interviews the facility failed to ensure that a licensed staff member closed the door and pulled the privacy curtain when administering medications to UR (Un-sampled Resident ) #1 and RI (Resident Identifier) #5 during the medication administration pass on 10/08/2014. This affected 1 of 3 nurses observed during the medication administration pass. Findings Include: UR #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of UR #1's most recent Annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 08/05/2014 revealed that UR #1 had severely impaired cognitive skills for daily decision making. A review of a facility document titled,"Residents These are YOUR Rights" not dated revealed: "You have the right to be treated with dignity, privacy, respect, and to live in a safe, clean,comfortable and homelike environment...You have the right to privacy including accommodations, medical treatment..." A review of UR#1's physician's orders [REDACTED]. a [MEDICATION NAME] ([MEDICATION NAME]) Tablet 75mg Give 1 Tablet by mouth twice daily, [MEDICATION NAME] Tablet 64.8 mg Give 1 tablet by mouth twice daily, [MEDICATION NAME] Tablet 1 gm (gram) Give 1 Tablet by mouth twice daily..." On 10/08/2014 at 8:10 AM, EI #3 ,LPN (Licensed Practical Nurse) was observed by the surveyor placing the above medications in a medication cup. EI#3 entered UR #1's room with the medications,explained that she would be administering medications to UR #1 and gave the medications to the resident. UR#1's roommate was in the room. EI #3 did not pull the privacy curtain or close the door. EI #3 exited the room and sanitized her hands. RI #5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #5's most current quarterly MDS with an ARD of 08/11/2014 revealed that RI #5 had a BIMS (Brief Interview Mental Status) of 15 which indicated the resident was cognitively intact. A review of RI #5's physician's orders [REDACTED]., [MEDICATION NAME] Capsule 100mg Give 1 Capsule by mouth twice a day, [MEDICATION NAME] Powder 17 GMs (Grams) Give in 8 oz (ounce) of water by mouth twice a [MEDICATION NAME] Tablet 100mg Give 1 Tablet by mouth once a day, Klonopin Tablet 0.5mg Give 1 Tablet by mouth once a day. On 10/08/2014 at 8:25 AM, EI #3, LPN was observed by the surveyor placing the above medications in a medication cup. EI#3 entered RI#5's room with the medications,explained that she would be administering medications to RI #5 and gave the medications to RI #5. EI #3 did not close the door. EI#3 exited the room and sanitized her hands. On 10/08/2014 at 10:10 AM, an interview was conducted with EI #3, LPN. EI #3 was asked should the curtain be pulled and the door be closed in a semi-private room when administering medication. EI #3 said,"Yes." EI #3 was asked why didn't she close the door or pull the privacy curtain when administering medications to UR #1. EI #3 said "I was nervous". EI #3 was asked did she close the door when giving RI #5's medications. EI #3 said , "No I did not ". EI #3 was asked did this provide privacy/confidentiality when she didn't close the door or pull the privacy curtain when giving UR #1's and RI #5's medications. EI #3 said, "No". EI #3 was asked what was the potential harm in not closing the door or pulling the privacy curtain. EI #3 said, "It invades their privacy." On 10/09/2014 at 10:25 AM, an interview was conducted with EI #1, DON (Director of Nursing ). EI #1 was asked what would she expect the nurse to do when administering medication in a semi-private room when the roommate was present. EI #1 said, "pull the privacy curtain." EI #1 was asked what would she expect the nurse to do when she enters the room of any resident to administer medication. EI #1 said, " they should knock on the door and introduce self and close the door." EI #1 was asked should the nurse close the door and pull the privacy curtain when administering medications. EI #1 said, "Yes". EI #1 was asked what was the potential harm in not pulling the privacy curtain or closing the door when the nurse was administering medication. EI #1 said, "It may embarrass the resident and it is a dignity issue."

Based on record review, observations and interviews, the facility failed to ensure that a licensed staff member washed her hands or changed her gloves after cleaning the wound of UR (Unsampled Resident) #2 and before touching the measuring device and clean dressing. This occurred on 10/8/14 while performing the wound care of UR #2. This affected 1 of 1 residents observed during the provision of wound care. Findings Include: UR #2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. UR #2's most recent Significant Change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 09/26/2014 revealed that UR #2 had a BIMS (Brief Interview for Mental Status) score of 12 which indicated the resident was moderately impaired for daily decision making. The MDS also indicated the resident was at risk of developing pressure ulcers. A review of UR #2's care plan with a problem onset date of 10/01/2014 revealed: "Problem/Need I have two stage two pressure ulcers to my bil (bilateral) inner buttocks...Approaches...Provide my tx (treatment) as ordered..." A review of a facility policy titled, "Skin & (and) Wound Care Protocol Pressure Ulcer Treatment Open Pressure Ulcers" with a revised date of 03/03/14 revealed: "...9. Cleanse wound... 10. Wash hands with soap and water. 11. Measure pressure ulcer... 12. Wash hands with soap and water. 13. Apply clean gloves. 14 Apply appropriate dressing..." On 10/8/14 at 9:20 AM, EI (Employee Identifier) #2, LPN (Licensed Practical Nurse) was observed providing wound care for UR #2. EI #2 washed her hands, donned gloves and cleaned the Stage 2 wound to UR #2's left buttock. EI #2 then dried the wound, measured the wound, applied a barrier wipe around the wound and then applied the dressing to the wound; all without washing her hands or changing her gloves. EI #2 then repeated the same steps for the Stage 2 wound located on UR #2's right buttock. On 10/8/14 at 9:45 AM, an interview was conducted with EI #2, LPN. EI #2 was asked after she cleaned the wound of UR #2 and before she touched the clean dressing, what should she have done. EI #2 said she should have put on new gloves. EI #2 was asked if she had washed her hands or changed her gloves after cleaning UR #2's wound and before she touched the clean dressing. EI #2 said no. EI #2 was asked should she have washed her hands or changed her gloves after cleaning UR #2's wound and before she touched the clean dressing. EI #2 said that she should have changed gloves. EI #2 was asked what was the potential harm if she did not wash her hands or change her gloves after cleaning a wound and then touching a clean dressing. EI #2 said it was cross contamination and the risk of transferring germs from a dirty area to a clean area. On 10/9/14 at 9:17 AM, an interview was conducted with EI #1, DON (Director of Nursing). EI #1 was asked what she would expect a nurse to do when performing wound care, after cleaning a wound and before touching the measuring device and clean dressing. EI #1 said that she would expect them to wash their hands. EI #1 was asked if the nurse performing wound care should wash their hands or change their gloves after cleaning a wound and before touching a measuring device and a clean dressing. EI #1 said yes. EI #1 was asked what was the potential harm if the nurse did not wash their hands or change their gloves after cleaning a wound and then touching a measuring device and a clean dressing. EI #1 said the same bacteria could be transferred to a clean bandage. EI #1 was asked who instructed the staff during infection control inservices. EI #1 said the infection control nurse, but the usual infection control nurse left the faciity on [DATE] and the new infection control nurse would start on 10/15/14. EI #1 was asked what type of information was taught in the infection control classes. EI #1 said hand hygiene, catheter care, incontinent care, perineal care and the use of personal protective equipment. EI #1 was asked how often were the infection control classes held. EI #1 said at least annually and they liked to do them at least quarterly. On 10/9/14 at 9:22 AM, an interview was conducted with EI #1, DON, interim infection control nurse. EI #1 was asked how were infections prevented in the facility. EI #1 said through hand hygiene and education. EI #1 was asked how were infections controlled in the facility. EI #1 said that residents are isolated when needed. EI #1 was asked if direct care staff were washing their hands and changing their gloves according to facility protocol. EI #1 said as far as she knew, they were. EI #1 was asked how she monitored direct care staff to ensure they were washing their hands and changing their gloves according to facility protocol. EI #1 said that when inservices were done, staff were observed during spot checks to make sure the information that was received made sense to the staff.

Based on observations, record review and interview the facility failed to ensure RI (Resident Identifier) #7, a resident with weight loss, received an ordered supplement on 10/22/2013. This affected 1 of 2 residents sampled for weight loss. Findings include: RI #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of RI #7's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 10/14/2013, revealed RI #7 suffered both short and long term memory problems and severely impaired cognition. Further review revealed RI #7 was totally dependent on staff for eating, requiring a one-person physical assist and received a mechanically altered therapeutic diet. Review of the October 2013 "Physician Orders" revealed an order dated 09/05/2012 for the following: "...MILKSHAKES BID (twice a day) B/T (between) MEALS AT 9 AM AND 2 PM..." RI #7's Physician order [REDACTED]. Review of the "PHYSICIAN'S TELEPHONE ORDERS" for RI #7 dated 10/07/2013 revealed an order for [REDACTED]. Review of RI #7's "Care Plan" for "...Problem Onset: 05/12/2011... ALTERATION IN NUTRITION... MECHANICALLY ALTERED/ THERAPEUTIC DIET..." revealed the following approach: "... * PROVIDE MY SNACKS/SUPPLEMENTS TO ME AS ORDERED. ..." Review of RI #7's "Departmental Notes" prepared by Employee Identifier (EI) # 4, Registered Dietician, revealed the following: "...10/22/2013 5:30 PM... Role: Dietary... Progress Note: ...Wt (weight) down gradually x (times) 6mos (months)... Wt down gradually x past 2wks (weeks)... Diet: ...Milkshakes BID b/t meals @ 9/2 (at 9 AM and 2 PM) ... Ensure and milkshakes in place for extra cals/prot (calories and protein) needed for wt stability..." Review of the facility's policy titled "Nourishment - Supplemental Feedings," with a revision date of 06/01/02 revealed the following: "... Purpose To provide proper nutritional intervention to the resident ...with nutritional or dietary deficiencies, weight loss of other needs... Policy Supplemental nourishments shall be provided as ordered by the physician Procedure...2. Nourishments/Supplemental Feedings shall be served promptly when received from the Dietary Department... 9. Record the amount consumed ..." Review of the facility's "Weight Change History" documentation for RI #7 revealed the following weights: 10/07/2013 143.80 pounds (lbs); 10/15/2013 142.80 lbs and 10/22/2013 141.80 lbs. On 10/22/2013 during a continuous observation from 7:30 AM until 10:16 AM, the surveyor observed the following: At 7:30 AM RI #7 was in the Dining Room consuming her breakfast meal. RI #7 remained in the Dining room until 8:05 AM. At that time RI #7 was taken to the Nursing Station by staff. The surveyor observed RI #7 to remain at the Nursing Station until 8:25 AM when a staff member took her to the Activity Room. RI #7 was placed in a circle with 4 other residents. Activities were provided to RI #7 by Activity Staff until 9:10 AM. RI #7 and three other residents remained in the circle in front of the television. The Activity Staff assisted another group of residents to play dominoes. The surveyor observed RI #7 from 9:10 AM until 10:12 AM without any staff assisting her. At 10:12 AM, the surveyor observed EI # 5, Certified Nursing Assistant (CNA), ask RI #7 if she needed anything. EI #5 left RI #7 in the Activity Room and did not provide RI #7 the ordered supplement. At 10:16 AM, EI #5 took RI #7 out of the Activity Room to her room. On 10/22/2013 at 2:35 PM the surveyor, EI #4, Registered Dietician, and EI #6, CNA, observed an unopened milkshake in the facility's refrigerator containing resident supplements labeled with RI #7's name and dated 10/22/2013 for 9:00 AM. EI #6 explained RI #7 was in an activity and staff was unable to give her the 9:00 AM milkshake. On 10/23/2013 at 10:50 AM the surveyor interviewed EI #3, Director of Nursing (DON) regarding RI #7's order for milkshakes. The surveyor asked EI #3 what were RI #7's orders regarding supplements. EI #3 stated RI #7 was supposed to get a milkshake at 9 AM and 2 PM. The surveyor asked EI #3 what was the potential for harm if RI #7 did not receive the ordered supplements. EI #3 explained if it was a continuous problem of RI #7 not receiving the supplements, RI #7 could have a weight loss. The surveyor asked EI #3 if RI #7 had had a weight loss. After EI #3 reviewed RI #7's "Weight Change History", EI #3 stated RI #7 lost one pound between 10/7/2013 and 10/15/2013 and lost another pound between 10/15/2013 and 10/22/2013.

Based on observation, interview and record review the facility failed to ensure Resident Identifier (RI) #9's oxygen (O2) was delivered at 2 liters a minute by concentrator as ordered by the physician. This was observed 2 of 3 days of the survey. This affected 1 of 2 sampled residents for specialized care. Findings Include: A review of the facility policy titled "Oxygen Therapy" with a Revised date of 04/01/2002 and 04/01/2006 documented "... Policy Oxygen therapy is administered only as ordered by the physician or as an emergency measure until an order can be obtained. The physician's order shall specify the rate of flow of oxygen. ..." Resident Identifier (RI) # 9 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #9's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/24/2013 identified RI #9 as a resident receiving oxygen treatment. A review of RI #9's Physician Orders for the month of October 2013 revealed "...02/2L (liters) MIN (minutes) VIA (by) NC (nasal cannula) PER CONCENTRATOR ..." RI #9's Physician Orders were signed by Employee Identifier (EI) #2 Registered Nurse (RN)/Unit Manager indicating she had reviewed the Physician's Orders. On 10/21/2013 at 5:00 PM, the surveyor observed RI #9 in the Dining Room eating her evening meal without receiving her oxygen treatment. RI #9 remained in the Dining Room until 5:26 PM without O2 in place. On 10/22/2013 at 3:15 PM, the surveyor observed RI #9 sitting at the Nursing Station with the nasal cannula in her nostrils and the tubing connected to an oxygen concentrator. The surveyor observed the concentrator turned off. RI #9 remained at the Nursing Station. At 4:20 PM, the surveyor asked Employee Identifier (EI) #2, RN/Unit Manager, to observe EI #9's concentrator which was still turned off. EI #2 stated the nurse should have turned it back on after lunch. When the surveyor asked EI #2 if the resident had been without it since lunch, EI #2 stated she did not know what RI #9's order was. EI #2 further explained RI #9 goes to lunch without the oxygen treatment. On 10/23/2013 at 10:50 AM the surveyor interviewed EI #3, Director of Nursing (DON). The surveyor asked EI #3 what RI #9's order for O2 was before the surveyor's observations on 10/21/2013 and 10/22/2013 . EI #3 stated O2/2 liter per minute by nasal cannula. The surveyor asked EI #3 if she was aware of RI #9's concentrator turned off during the afternoon on 10/22/2013. EI #3 stated, "Yes". The surveyor asked EI #3 if the doctor's order was followed when her O2 was turned off in the afternoon of 10/22/2013 and when RI #9 went to the Dining Room on 10/21/2013 without the O2 treatment. EI #3 said "No".

Based on observation, interviews and record review the facility failed to maintain Room Locator (RL) #1 in a manner to prevent a build up of dust and cobwebs. This was observed on 2 of 3 days of the survey. This had the potential to affect all residents who consumed their meals in RL #1. Findings Include: A review of the facility's policy titled "Room - Dining Room" with an effective date of 08/01/2006 documented "Purpose To provide a clean and sanitary dining room for residents. Policy The dining room should be cleaned after each meal by the Housekeeping Department ... Responsibility The Dietary Director is responsible for monitoring the cleanliness of the dining room(s) and notifying the Administrator of necessary cleaning. ..." On 10/21/2013 at 5:05 PM during the evening meal, the surveyor made an observation of RL #1. The surveyor observed a table with 4 residents eating their evening meal beside a window and the outside exit door. Two other table areas in RL #1 were also being used by other residents to consume their evening meal. The surveyor observed brown dust on the air conditioner under the window, dust and cobwebs along the frame of the window and the outside exit doorframe. Surveyor observed a combination of dust and cobwebs in the 4 corners of the glass sections on the outside exit door. Cobwebs were also observed between the wall and the television located in the back of the Dining Room. At 5:35 PM, another group of residents (4 residents) were served their meal in RL #1. The areas were not cleaned before they were served. On 10/22/2013 at 7:30 AM during the breakfast meal, the surveyor made an observation of RL #1. The surveyor observed residents eating their breakfast at the table beside the window and the outside exit door as well as two other table areas. The surveyor observed the same unclean areas as observed during the 10/21/2013 observation made at 5:05 PM and 5:35 PM. On 10/22/2013 at 8:25 AM, the surveyor and Employee Identifier (EI) # 1 Director of Environmental Services made an observation of RL #1. When the surveyor showed EI #1 the unclean areas, EI #1 stated the areas should be cleaned. On 10/23/2013 at 12:20 PM, the surveyor interviewed EI #1 regarding the cleaning of RL #1. The surveyor asked EI #1 what areas of RL #1 had he observed that needed to be cleaned during the observation made on 10/22/2013 at 8:25 AM. EI #1 stated, "Behind the TV, the window sill and the 2 corners of the door". The surveyor asked EI #1 if RL #1 had been cleaned before it was used for the breakfast meal on 10/22/2013. EI #1 explained RL #1 is only cleaned after breakfast and lunch meals. The surveyor asked EI #1 should the cobwebs still be on the corner of the window or on the outside exit door's frame and window if RL #1 had been cleaned. EI #1 stated, "No". The surveyor asked EI #1 should the cobwebs still be on the television and wall if RL #1 had been cleaned. EI #1 stated, "No".

The facility failed to ensure meals were prepared in a sanitary manner by: 1. Affixing a thaw date and a use by date on a box of thawed mighty shakes that were stored in the refrigerator, 2. Handling clean metal bowls, lids and utensils without touching the areas where residents food would be placed. 3. Touching rolls with bare hands while plating residents food. This had the potential to affect 62 of 62 residents who were served food from the Dietary Department. Findings include: 1. The facility Policy/Procedure for, "Milkshake Protocol," with a revision date of 7/26/ 11, indicated, "Policy to thaw, date and use milkshakes within appropriate time frame. Procedure 1. Milkshakes are to arrive from vendor frozen and be stored in freezer until needed for use. ...3. The date milkshakes are put in refrigerator to thaw is to be written on each individual milkshake carton. This is to be identified as the thaw date. 4. The milkshake is to be disposed of 14 days after thawing, this is to be identified as the use by date. A use by date is to be written on each individual milkshake carton also...." During the initial tour of the Dietary Department, a box of mixed sized Mighty Shakes were stored in the refrigerator. The container (cardboard box) was dated 10/16/12. When Employee Identifier (EI) #6 was asked if there was a thaw date or use by date she replied , "All its got is 10/16- the day they came in." There were no other dates found therefore EI #6 discarded the shakes. In an interview on 11/1/12 at 8:15, EI #5 was asked when the Mighty Shakes were supposed to be dated. She replied the should be dated when they come in, when they are taken out of the freezer- the thaw date and the use by date- 14 days after the thaw date. 2. On 10/31/12 at 10:45 AM, during the tray line observation, the EI # 4 was observed to be removing the clean bowls, lids and utensils from the clean area of the dishwashing area. She was noted to be holding the lids with her hands and touching the food side of the lids and also the bowls. She was also noted to have several cooking utensils including spoons and whisks in one hand. As she was carrying these items to the shelves, she touched her clothing with the lids and utensils. In an interview on 11/1/12 at 8:15, EI # 5 stated the cooking utensils should be held by handles or the outside of them. When asked why these should not be carried next to your clothing she said she should only carry the things she knows she can carry- so it's not against her body. 3. On 10/31/12 at 5:15 PM, the tray line was observed as the supper meal was plated. At that time a tray with double portions was being plated and two rolls were put in a bowl on the tray. A roll fell from the bowl onto the tray and a EI #3 picked up the roll and placed it on the bowl with her bare hand. Seeing that it was falling again , EI # 7 touched the roll to steady it from falling, again with her bare hand. When EI #5 was asked about handling the rolls she stated they are not supposed to do that, they should use gloves or tongs. When asked what problems could be associated with this practice, she stated it would be cross contamination.

Based on observation, interviews, and record review, the facility failed to ensure nursing staff maintained privacy of a resident's medical record by leaving a resident's MAR (Medication Administration Record) open unattended during medication pass. This was observed on 1 of 2 units during medication pass on RI (Resident Identifier) #16, one of 14 sampled residents. Findings include: On 10/30/12 at 4:10 PM, EI #8 (LPN-Licensed Practical Nurse) was observed preparing medications on the medication cart for RI #16. She then entered RI #16's room to administer the medications. EI #8 left the MAR indicated [REDACTED]. RI #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #16's Significant Change MDS (Minimum Data Set), dated 10/06/12, indicated the resident had a BIMS (Brief Interview for Mental Status) score of 5, indicating the resident was cognitively impaired. On 10/31/12 at 10:05 AM, EI #10 (RN-Registered Nurse) was interviewed and asked how should MARS be maintained during medication pass. She stated to make sure no resident name or information on resident was showing. The MAR indicated [REDACTED]. She was asked why and EI #10 stated that it would be breaking HIPAA (Health Insurance Portability and Accountability Act) law. She stated that anyone could walk up and see the information and that it was a privacy issue. At 2:10 PM on 10/31/12, EI #11 (LPN) was interviewed and asked how should MARS be maintained during medication pass. She stated the MAR indicated [REDACTED]. She was asked why and EI #11 stated it was to keep the resident's privacy so that people could not see what kind of medications the resident takes. A review of "MEDICATION GUIDE for the Long-Term Care Nurse," 6th Edition, page 68, indicated, "...9. Remember to protect confidentiality of patient records, including the MAR book. The nurse should flip the MAR pages face down when the book is unattended...."

Based on observation and interviews, the facility failed to ensure residents were fed in a manner to preserve their dignity by standing to feed the residents. This affected two residents on the east wing, RI (Resident Identifier) #13 and URI (Unsampled Resident Identifier) #1. 1) RI (Resident Identifier) #13 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to his most recent MDS (Minimum Data Set), with an Assessment Reference Date of 09/06/2012, RI #13 required total assistance of one person for eating. On 10/31/2012 at 11:35 AM RI #13 was observed lying in bed being fed by EI (Employee Identifier) #1, RN (Registered Nurse) Supervisor. RI #13's bed was observed to be elevated. EI #1 was observed to be standing next to the bed feeding RI #13. On 11/01/2012 at 1:18 PM, EI #1 was interviewed. EI #1 was asked what she had been taught about how to feed residents. EI #1 stated she gets everything together at the same time. She then sits with the resident at all times, making sure the resident has his/her clothing protector on. She makes sure the resident has at least three beverages of choice and that they have whatever their tray card says they are supposed to have. She stated that she sits at eye level with the resident and she makes sure they know what they are eating. EI #1 was asked why would she sit to feed a resident. EI #1 stated to be at eye level with the resident. EI #1 was asked why wouldn't you stand to feed a resident. EI #1 stated "I don't want to be looking down at my residents." 2) URI (Unsampled Resident Identifier) #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to her most recent MDS (Minimum Data Set) with an Assessment Reference Date of 10/12/2012, URI #1 required extensive assistance of one person with eating. On 10/31/2012 at 11:35 AM URI #1 was observed lying in bed being fed by EI (Employee Identifier) #2, COTA (Certified Occupational Therapist Assistant). URI #1's bed was observed to be elevated. EI #2 was observed to be standing next to the bed feeding URI #1. On 11/01/2012 at 1:00 PM EI #2 was interviewed. EI #2 was asked what she had been taught about how to feed residents. EI #2 stated to have at least 3 beverages on the tray. To ask if they want an alternative and condiments on their food. To make sure to have their bib on and napkins available. To be sure utensils are available for them to use if they are able and within easy reach. To make sure their tray is within easy reach and close to them. And if she is to feed them to feed them a little at a time of each thing and not all of one thing at one time. EI #2 was asked why would you sit down to feed a resident. EI #2 stated to reach them better or for it to be more comfortable for the resident. EI #2 was asked why wouldn't you stand to feed a resident. EI #2 stated she would do which ever was best for the resident so they would not have any coughing incidents.

Based on observation, interviews, and record review, the facility failed to ensure professional nursing staff: 1) Cleaned a glucometer after use; 2) Wiped the top of an open insulin vial prior to drawing up insulin, and 3) Washed hands in a manner to prevent cross-contamination. This was observed on two nurses observed and three of nine residents observed during medication pass. Findings include: 1) On 10/30/12 at 3:47 PM, EI (Employee Identifier) #8 (LPN-Licensed Practical Nurse) was observed during medication pass. She gathered the supplies for a blood glucose check on RI (Resident Identifier) #1. A small clear plastic box was located next to the sink in RI #1's room. The plastic box contained a glucometer and lancets. EI #8 obtained blood glucose from RI #1 and placed the glucometer back into the clear plastic box without cleaning or disinfecting the glucometer. EI #8 stated that all residents who get a blood glucose have an individual glucometer. RI #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's quarterly MDS (Minimum Data Set), dated 9/02/12, revealed he required total assistance with all ADLs (Activities of Daily Living) and was incontinent of bowel and bladder. RI #1's November 2012 Physician order [REDACTED]. On 10/31/12 at 10:05 AM, EI #10 (RN-Registered Nurse) was interviewed and asked when should glucometer be cleaned/disinfected. She stated it should be cleaned after each use. EI #10 was asked who was responsible for cleaning the glucometer and she stated each charge nurse working the medication cart. She indicated that night shift checks the meter and cleans it but the day shift nurse also cleans it. EI #10 was asked what was the potential for harm if the glucometer was not cleaned. She stated the glucometer may not get an accurate reading and there was no telling what could have landed on it. EI #10 stated each individual has their own glucometer and has to be cleaned after each use. At 2:10 PM on 10/31/12, EI #11 (LPN) was interviewed and asked when should glucometers be cleaned/disinfected and she stated after each use. She was asked who was responsible for cleaning the glucometers. She stated night shift do the levels to make sure they match but during the day the nurse cleans it. EI #11 was asked what was the potential for harm if the glucometer was not cleaned. She stated the nurse could get a wrong blood sugar reading or could be contaminated with someone else's blood. EI #11 stated something could have gotten on the glucometer that may have not been on there before and could have blood on it. Nurses have to make sure it's not contaminated. A review of the facility's policy and procedure titled, "Blood Sampling-Capillary-Finger Sticks," revised 10/07/10, revealed the following, "Policy The purpose of this procedure is to guide the safe handling of capillary-blood sampling devices to prevent transmission of bloodborne diseases to residents and employees. Equipment & Supplies ...5. Disinfectant wipe General Guidelines ...2. The meter should be disinfected using a disinfectant wipe after each use cleaning all surface areas of the meter. 3. The meter should be allowed to air dry for at least 2 minutes or by manufacturer guidelines (whichever more stringent) before re-use. Procedure ...8. Disinfect meter after each use using disinfectant wipe, cleaning all surface areas of the meter...." 2) On 10/30/12 at 4:40 PM, EI #9 (LPN) was observed preparing medications for RI #4. After checking RI #4's blood sugar, EI #9 prepared the insulin. EI #9 pulled RI #4's open vial of [MEDICATION NAME]from the top drawer of the medication cart. EI #9 drew air into the syringe and then placed the syringe into the vial of [MEDICATION NAME]without first wiping the top of the vial with alcohol. She drew up the 28 units of [MEDICATION NAME] as ordered and administered the insulin to RI #4. 3) After administering the insulin to RI #4 and removing her gloves, EI #9 washed her hands at the sink in RI #4's room. She turned on the water, used soap to wash hands, rinsed her hands under the running water, and, using her right hand, turned the red dial on the paper towel dispenser to obtain paper towels. After drying her hands with paper towels, EI #9 threw the paper towels into the trash can and used her bare right hand to turn off the water faucet. RI #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #4's quarterly MDS, dated [DATE], revealed the resident had a BIMS (Brief Interview of Mental Status) score of 13, indicating the resident was cognitively intact. RI #4 required extensive assistance with ADLs but only required set-up for eating. The resident was incontinent of bowel and had a catheter. RI #4's October 2012 Physician order [REDACTED]. On 10/30/12 at 4:57 PM, EI #9 was asked how should insulin be drawn up. She stated get syringe, pull up air, inject into vial amount of air to insulin needed, pull back on syringe and draw out insulin. She was asked what should be done prior to drawing insulin on open vial. EI #9 stated clean the top of the vial with alcohol before drawing insulin. She was asked why and she stated the vial could be dirty or contaminated. At 10:05 AM on 10/31/12, EI #10 (RN-Registered Nurse) was interviewed and asked how should a nurse handle an open vial of insulin. EI #10 stated wipe the top of the vial and then pull the amount of air needed, push the air into the vial, and then pull out the insulin. She was asked why does she wipe the top of the vial and EI #10 stated anything could have touched it or fell on the vial. EI #10 stated it's going into someone's body. There could be particles on the vial that could get on the needle and be injected into that person. EI #10 was asked how should hands be washed and she stated make sure paper towels are down, turn water on, get soap, was 2 to 3 minutes, rinse hands under water, get paper towel to dry hands and a paper towel to turn off sink. Use a paper towel to open the door and discard the paper towel. She was asked what was the potential for harm if hand washing not done correctly. EI #10 stated there could still be germs on the hands. On 11/01/12 at 10:45 AM, EI #9 was interviewed and asked how should she have washed her hands. She stated she should have gotten the paper towels ready first. She was asked how should she have turned off the water after washing her hands. EI #9 stated she should have used a paper towel to turn off the faucet. She stated she should always turn sink off with a clean paper towel and then throw it away. She was asked why and EI #9 stated because there was a risk of recontaminating the hands. She indicated it was like she didn't wash her hands at all. A review of the facility's policy and procedure titled, "Injections/Insulin," revised 10/16/08, revealed, "Procedure A. Procedure to prepare the insulin for an injection. 1. Remove insulin vials from the medication refrigerator. Store securely in medication cart. Wipe off the top of the insulin vial with alcohol before each use...." The facility's policy and procedure titled, "Handwashing/Hand Hygiene," revised 1/11/07, revealed, "Policy Handwashing/hand hygiene is regarded by this facility as one of the single most important means of preventing the spread of infections. Procedure 1. Check for adequate paper towels before starting the handwashing procedure. Wet hands with water. 2. Apply soap to hands. Using friction, rub hands together, cleaning under nails and between fingers thoroughly. Wash up to the wrist as well. Do this for at least 20-25 seconds. 3. Rinse hands well without touching the inside of the sink or the faucet (these are always considered soiled). Leave water running. 4. Dry hands well. When finished, turn off faucet with a clean paper towel. Discard the towel in an appropriate trash container. ...To prevent recontamination your hands on the faucet handles, cover each one with a dry paper towel when turning off the water."

Based on interviews, record review and review of a facility policy titled "Abuse Prevention Program Identification & Investigation of Resident Incidents & Accidents" the facility failed to report an allegation of sexual abuse to the Alabama State Agency within 24 hours. This deficient practice affected two sampled residents (RI #1) and RI #2. Findings Included: Review of a facility policy titled, "Abuse Prevention Program Identification & Investigation of Resident Incidents & Accidents" effective 01/01/04, revised 04/05/11, documented, Procedure Subject: Investigation, Reporting Obligations, and Response to the Results of Investigations I. Investigation and Reporting Steps A. Notify the Administrator their designee and/or supervisor of any unusual situation in the facility, whether reportable or not. The Administrator/designee shall notify the appropriate state agency no later than 24 hours of the alleged occurrence ... " The facility submitted a 24 hour report to the Alabama State Agency on September 26, 2012. In this report the facility documents, "...On 9/26/12 C.N.A (CNA #3) ....came to the administrator to talk about residents (RI #1 and RI #2)... On 9/26/12 (CNA #3) told the administrator that (RI #2) alleged that (RI #1) molested her on 9/14/12. CNA #3 stated she did not report the incident to the administrator previously because there did not seem to be any evidence that RI#1 touched RI#2. At this point, administrator told (CNA #3) that no one had reported that RI #2 said molested and this constitutes an allegation of abuse..." During an interview with the Administrator on 10/6/12 at 2:20PM the Administrator was asked what would you consider it to be if a resident says he or she has molested me, regardless of the resident's cognitive status. The Administrator stated if it's alleged, it's an allegation. The surveyor asked the Administrator what prompted her to report the allegation of 9/14/12. The Administrator stated when I received new information from CNA #3 that the resident said help help he molested me. On 10/01/12 at 4:30 p.m., the surveyor conducted an interview with a CNA, EI #3. CNA #3 stated that on 9/14/12 RI #2 told her that RI#1 was molesting her. The surveyor asked EI #3 who reported the incident to EI #5. EI #3 stated she spoke to EI #5 on September 26, 2012. On 10/3/12 at 9:05 a.m., the surveyor conducted an interview with EI #1, the LPN who worked the shift when the allegation was made. EI #1 stated she was notified of the allegation by EI #3. The surveyor asked EI #1 did she report the allegation to the Administrator on 9/14/12. EI #1 stated, "No, I did not because I didn't think anything had happened." This deficiency was written as a result of the investigation of complaint/report # AL 580.