Every finding on record at Albertville Nursing Home

Based on observation, interview, and facility policy review, the facility failed to ensure dryer lint traps did not contain an abundance of lint for 2 of 4 dryers observed as part of the environment task.Findings included:The facility's undated policy titled, Laundry Dryer Lint Trap Cleaning Policy and Procedure, indicated, Purpose - To ensure the safe operation of laundry equipment by preventing lint accumulation. The policy further indicated. Clean each dryer lint trap every two (2) hours while dryers are in operation and Clean immediately if excessive lint accumulation is observed. The policy further indicated, Record each lint trap cleaning on the Dryer Lint Trap Cleaning Log.The facility's manual titled, Tumble Dryers Preventative Maintenance, dated 07/2015, indicated, 1. Inspect the area surrounding tumble dryers, remove all combustible materials, including lint, before operating the machine. The manual further indicated, 3. Clean lint from compartment and screen(s) to maintain proper airflow and avoid overheating.The facility's Dryer Cleaning Schedule, for the timeframe from 07/01/2026 through 07/29/2026, revealed the first shift had not documented cleaning of the dryer on 07/19/2026, 07/21/2026, 07/22/2026, 07/23/2026, 07/26/2026, 07/27/2026, 07/28/2026, and 07/29/2026.During an observation on 07/29/2026 at 2:01 PM, the third of four dryers had a lint trap below the tumbler of the dryer. The front covering was removed by the Environmental Director (ED) and revealed a lint filter on top of the compartment with approximately 1/4-inch-thick lint and hanging down from the filter due to the weight of the accumulation. The vent was no longer able to suck and hold the lint attached to the filter, with gravity causing it to hang down. On the bottom of the compartment, lint had accumulated below the filter, resulting in a thick accumulation of lint at the base of the compartment. During an interview on 07/29/2026 at 2:01 PM, Laundry Staff (LS) #7 stated it had been a few hours since the third dryer's lint was last cleaned. She was unable to clarify just how long it had been since the filter was last cleaned. During an observation on 07/29/2026 at 2:04 PM, the fourth of four dryers had a lint trap below the tumbler of the dryer. The front covering was removed by the ED and revealed a lint filter on top of the compartment with approximately 1/4-inch-thick lint hanging down from the filter due to the weight of the accumulation. The vent was no longer able to suck and hold the lint attached to the filter with gravity causing it to hang down. On the bottom of the compartment, lint had accumulated below the filter, resulting in a thick accumulation of lint at the base of the compartment. During an interview on 07/29/2026 at 2:06 PM, LS #7 stated the dryer lint was supposed to be cleaned every two hours. During an interview on 07/29/2026 at 2:07 PM, the ED provided the Dryer Cleaning Schedule and stated the staff were supposed to sign off that the lint had been removed from the dryers every two hours. The ED stated that the Dryer Cleaning Schedule did not have documentation for that day. During an interview on 07/29/2026 at 3:18 PM, the ED stated that the accumulation of lint for the third and fourth dryer was not normal and it was a lot. The ED stated lint needed to be cleaned for safety. The ED stated he was responsible for reviewing the Dryer Cleaning Schedule for completeness. The ED stated he did not know the form had not been completed for first shifts on 07/19/2026, 07/21/2026, 07/22/2026, 07/23/2026, 07/26/2026, 07/27/2026, 07/28/2026, and 07/29/2026. During an interview on 07/31/2026 at 2:58 PM, the Director of Nursing (DON) stated her expectation for the removal of dryer lint was to follow the facility policy. During an interview on 08/01/2026 at 8:00 AM, the Administrator (ADM) stated she was aware that the Dryer Cleaning Schedule log was missing documentation, and her expectation was that the dryers were cleaned and the log was signed off every two hours.

The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to this survey.Based on facility policy review, record review, facility document review, and interview, the facility failed to protect the resident's right to be free from verbal abuse perpetrated by a staff member (Hospitality Aide [HA] #9) for 1 (Resident #42) of 2 residents reviewed for abuse.Findings included: A facility policy titled, Abuse Prevention, dated 05/01/2026 indicated, This facility does not condone or tolerate resident abuse by anyone including staff members, other residents, consultants, and volunteers, individuals of other agencies serving the resident, family members, legal guardians, sponsors, friends, or any other individuals. The policy revealed, IV. Identification included 3. Staff are trained on actual activities that would constitute abuse and they are but not limited to, which included e. Verbal abuse- Using any oral, written, or gestured language that includes disparaging, derogatory or condescending language to a resident or resident's family. It includes taking [sic] about a resident in a rude distasteful manner, cursing at a resident, causing pain by your spoken words or actions. An admission Record revealed the facility admitted Resident #42 on 11/16/2016. According to the admission Record, the resident had a medical history that included diagnoses of vascular dementia, spastic hemiplegia, and major depressive disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/10/2024, revealed Resident #42 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. Resident #42's Care Plan(s) included a focus area initiated 03/11/2024, that indicated the resident had socially inappropriate behavior. Interventions initiated 03/11/2024 directed staff to interrupt the resident during a behavior and redirect with verbal cues, assist the resident to a more private area, and try to determine if there was an unmet need the resident was trying to communicate and assist to meet that need. The Care Plan(s) also included a focus area initiated 06/26/2023, that indicated that the resident was at risk of injury related to going outside to smoke, lack of coordination, and intentionally falling out of their chair. Interventions initiated 06/26/2023 directed staff to monitor the resident's whereabouts frequently while outside and remind the resident of planned activities that were going to be held outdoors. A facility document titled, Investigative Summary provided as the facility's investigation summary of an allegation of verbal abuse that occurred on 04/14/2024, indicated that on 04/15/2024, Licensed Practical Nurse (LPN) #8 witnessed HA #9 yelling at Resident #42 and pointing her finger in the resident's face. The Investigative Summary indicated that the resident had made remarks to the staff under their breath and HA #9 told Resident #42 the resident would have to go back to their room and would not be allowed to smoke if they kept talking like that. The document indicated that HA #9 was immediately separated from the resident and suspended. The document indicated that HA #9 was interviewed and stated that while waiting to go smoke, Resident #42 began yelling and cursing that they wanted to go smoke, she told the resident that they were going to have to quit talking like that or she would take the resident back to their room and the resident would go smoke. The document revealed the Findings indicated that the incident was substantiated and the staff member's employment was terminated. A typed witness statement, dated 04/15/2024 and signed by LPN #8, indicated that LPN #8 escorted HA #9 out of the building and informed her that her actions were unacceptable in that she could not speak to residents in that tone or treat residents like they were children. The document indicated that HA #9 apologized and left the building. A handwritten statement, dated 04/15/2020 [sic] and signed by Certified Nurse Aide (CNA) #10, indicated that he took Resident #42 to go smoke, but was told by a lady it was too early, which upset Resident #42. Resident #42 starting saying things. The statement indicated that HA #9 got in Resident #42's personal space and told them to stop, or they were going to get sent back to their room. An undated handwritten statement signed by CNA #11 indicated he heard a lady screaming at a resident because they wanted to go outside to smoke, but she did not let them go. An undated, typed statement signed by the former Administrator in Training (AIT), indicated HA #9 provided a statement via phone. The statement indicated that HA #9 stated that it was 15 minutes until smoking time and residents were gathering in the activity room in preparation. The statement indicated Resident #42 was yelling, appeared very agitated, and demanded to be let out to smoke. The statement indicated that HA #9 told Resident #42 to stop cursing and screaming, or they would not be allowed to smoke and would be taken back to their room. The statement indicated that she apologized and said she should not have said what she did or how she said it. During an interview on 07/29/2026 at 1:58 PM, in regard to the 04/15/2024 incident, HA #9 stated she had been in the process of bringing residents in wheelchairs to the activity room before smoking time when she heard Resident #42 speaking with a raised voice and cursing. She stated that she had never seen the resident that irate, and she got close, over Resident #42 in their wheelchair, and raised her voice to get their attention. She stated she got down on their level and had her finger up but denied it was in the resident's face. She stated she told the resident she would take them back to their room if they kept misbehaving, and they would not get to smoke. During an interview on 07/29/2026 at 2:57 PM, LPN #8 stated she did not recall the exact details of the incident on 04/15/2024 with Resident #42 and HA #9, but she did remember the incident. She stated that HA #9 had spoken to the resident very rudely and discourteously. She stated she immediately intervened and verbally verified with all residents present they were okay, including the alleged victim, Resident #42. She stated that HA #9 had been standing in Resident #42's personal space and shaking her finger at the resident. During an interview on 07/29/2026 at 5:08 PM, in regard to the 04/15/2024 incident, CNA #11 stated that he did not recall the name of the staff member or specifics, but he did witness Resident #42 being screamed at by a female staff member. He stated he was in the activity room taking residents to the smoking area when it happened, and the staff member appeared mad. He stated he considered the incident he witnessed to be abuse and it needed to be reported. During an interview on 08/01/2026 at 8:32 AM, the Director of Nursing stated she had been made aware of the incident at the time in April 2024, because she discussed all abuse allegations with the Administrator (ADM). She stated the facility did substantiate verbal abuse because the incident was witnessed. She stated that her expectation was that staff would never commit abuse and that all staff on the floor knew that was the expectation. She stated she expected that verbal abuse to not happen. She stated staff were educated on their tone and to understand they must always speak to residents in a respectful manner. During an interview on 08/01/2026 at 8:59 AM, the ADM stated she expected staff to not abuse residents. She stated the facility did screen for abuse prior to hiring, completed background checks on all staff, and trained all staff on abuse prohibition. She stated she expected if there was an allegation of abuse, the staff was suspended, and their employment was terminated if the allegation was substantiated. The facility initiated corrective actions on 04/15/2024 to correct the failed practice as follows: Following the incident on 04/15/2024 HA #9 was escorted off the property and suspended pending investigation. HA #9 did not return to the facility and was terminated on 04/16/2024.Resident #42 was assessed by the Floor Administrator/social services on 04/15/2024, the results of the assessments were reported to behavior health services on 04/15/2024. The behavior health services also assessed Resident #42 on 04/15/2024. On 04/15/2024 by nursing staff initiated Behavior Monitoring for Resident #42.Administrator and Ombudsman visited and assessed resident on 04/16/2024.CRNP assessed resident on 04/16/2024.The Floor Administrator assessed residents on the hall on 04/16/2024.QA Monitoring begin 04/16/2024 and ended with the QA meeting on 05/10/2024.On 04/15/2024-04/16/2024 all staff, including nursing, activities, therapy, laundry, housekeeping, admissions, central supply, maintenance, and business office were in-serviced on Abuse prevention and facility's Abuse Policies.Care plan was reviewed on 04/15/2024 by Administrator and Care Plan Coordinator in which current care plan met resident needs due to resident reporting no adverse effects came to the resident. Resident #42 was re-assessed by the Floor Administrator/social services on 04/29/2024 and 05/06/2024. The incident and corrective actions were reviewed during QA on 05/10/2024.After review and verification of the facility's corrective actions, to include the facility's investigation, monitoring tools, staff education, and interviews with facility staff, the survey team determined the facility implemented the above corrective actions beginning on 04/15/2024 and conducted ongoing education and monitoring; therefore, past noncompliance was cited. The deficiency was corrected as of 05/10/2024.

The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to this survey. Based on observation, interview, record review, facility document and policy review, the facility failed to prevent an elopement for 1 (Resident #169) of 3 cognitively impaired residents who had a departure alert system. Specifically, Resident #169 eloped from the facility on 05/04/2026 at approximately 6:30 PM and was found an hour and 24 minutes later (at 7:54 PM) approximately 0.23 miles away at a church.Findings included:A facility policy titled, Wandering Residents, dated 02/02/2019, indicated, Every effort will be made to prevent wandering episodes while maintaining the least restrictive environment for residents who are at risk for elopement. The policy continued, 2. If a resident is deemed an elopement risk after assessment a wanderguard [departure alert system] will be placed on resident and the wanderguard will be monitored routinely for placement by nursing. The wanderguard system will also be monitored routinely to ensure proper functionality. A facility document titled, Allegation Tracking Log, undated, revealed an allegation of elopement for Resident #169 on 05/04/2026.An admission Record indicated the facility admitted Resident #169 on 04/30/2026. According to the admission Record, the resident had a medical history that included urinary tract infection, vascular dementia, unsteadiness on feet, difficulty walking, and weakness.An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/05/2026, revealed Resident #169 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognition. The MDS indicated Resident #169 had not exhibited any wandering behavior and indicated that the resident used a wander/elopement alarm daily.Resident #169's Care Plan Report, revealed a focus area initiated on 04/30/2026 and revised on 06/01/2026, that indicated the resident was at risk for injury related to wandering. Interventions directed staff to check the placement of the departure alert system every shift (initiated 04/30/2026), redirect the resident away from exits and other residents' rooms (initiated 04/30/2026), inform staff on the other units of the potential for elopement (04/30/2026), and that the departure alert system was on the resident's left ankle (initiated 04/30/2026). Additionally, an intervention was initiated on 05/04/2026 for a sitter to be with the resident until the resident discharged . Resident #169's Progress Note dated 04/30/2026 at 1:34 PM, revealed the resident had no history of elopement at home and the resident's elopement score was documented as 0. Resident #169's Progress Note, dated 04/30/2026 at 2:29 PM, revealed the resident was noted to wander aimlessly, non-goal directed, and the wandering was likely to affect the privacy of others. Resident #169's Order Summary Report included an order dated 04/30/2026 to check placement of a departure alert system to the resident's left ankle every shift. A heath care facility report submitted to the Alabama Department of Public Health, revealed an incident of elopement involving Resident #169 had occurred on 05/04/2026 at 7:10 PM. The report indicated Resident #169 was last seen eating supper by a certified nurse aide and later, facility staff could not locate the resident. Per the report, the facility initiated the elopement protocol, contacted the local police department, and the resident was found sitting down close to the front parking lot of the facility. The report indicated Resident #169 was transported to the emergency room for evaluation. The facility's Investigative Summary, submitted to the Alabama Department of Public Health on 05/11/2026, revealed that on 05/04/2026 at approximately 6:30 PM, Resident #169 eloped from the facility and was found uninjured .23 miles away at a local church at 7:54 PM by the local police department. The Investigative Summary revealed the resident had last been seen ambulating in the hallway between 5:00 PM to 5:10 PM. Per the Investigative Summary, Receptionist (REC) #1 assigned to the front desk, had stepped away from the front desk a few times during her shift. The Investigative Summary included a documented interview with REC #1 that revealed she did not hear an alarm, nor did she have to turn off an alarm at any point during her shift. The Investigative Summary revealed the resident may have exited the facility when a visitor entered or exited the facility. The Investigative Summary indicated Resident #169 received a departure alert system on 04/30/2026 and the device was activated and working properly on that date. The Investigative Summary revealed a documented interview with the Corporate Maintenance Director (CMDR) that indicated when Resident #169 returned from the hospital on [DATE], their departure alert system was tested and found not to activate the alarm system. The staff replaced the battery, and the device functioned properly. On 05/05/2026, the maintenance team activated a new departure alert system and the device initially functioned properly but failed after a few hours. The battery was replaced, and it operated properly. The Investigative Summary revealed that the CMDR discovered the departure alert systems ordered on 01/14/2026 had batteries that were not functioning properly. During an interview on 07/29/2026 at 1:52 PM, the Business Office Administration (BOA) stated she scanned Resident #169's departure alert system and confirmed it was activated and working on 04/30/2026. During an interview on 07/29/2026 at 2:57 PM, Restorative Nurse #2 stated that the departure alert systems were checked once a week. She stated that currently, the restorative aides checked them on Wednesdays, and prior to 05/04/2026 they checked them on Sundays. She stated that the departure alert systems were tested on Sunday, 05/03/2026. A facility document titled, Wonder Guard Checks, dated 05/03/2026, revealed Resident #169's name was not on the list as having their departure alert system checked for functionality. During a phone interview on 07/29/2026 at 4:15 PM, Certified Nurse Aide (CNA) #3 stated that the restorative aides checked the departure alert systems once a week. She stated that prior to 05/04/2026 they would check the functionality of the departure alert systems on Sundays. She stated that with the old elopement alarm system, they checked the functionality of the departure alert systems by walking a resident to a door, and if the alarm went off it was fine; if there was an issue with it not working then they would take it to their supervisor (Restorative Nurse #2). CNA #3 stated Resident #169's departure alert system was not checked on 05/03/2026 because the device was placed on the resident on 04/30/2026 and the resident did not have the device on for a week yet at that time. During a phone interview on 07/29/2026 at 4:08 PM, REC #1 stated she worked from 11:30 AM to 8:00 PM on 05/04/2026. She stated that she was not sure how Resident #169 left the facility, and she never saw Resident #169 in the lobby or by the front desk on 05/04/2026. She stated that after 4:30 PM if she had to leave the desk, she would do so to use the restroom, get her lunch, or deliver a meal that was ordered to a resident. She stated if she left the desk after 4:30 PM she would not tell anyone that she was leaving the desk; she would just go quickly. She stated that on 05/04/2026 there was a green button by the front door that Resident #169 could have pressed to open the front door. REC #1 said she no longer worked at the facility. During an interview on 07/31/2026 at 3:53 PM, the Therapy Director stated she went to the location where Resident #169 was found on 05/04/2026. She stated the resident was not dirty or injured and was sitting by a fence. The Therapy Director stated Resident #169 was receiving therapy while at the facility, did not exhibit exit seeking behaviors, and was easily redirected. During an interview on 07/31/2026 at 3:55 PM, Physical Therapist (PT) #5 confirmed she was at the location where Resident #169 was found on 05/04/2026. PT #5 stated Resident #169 said they had rolled down a hill at the location where they were found. PT #5 stated the resident returned to the facility following an emergency room visit with no injuries and was at the same level of functioning that the resident was prior to exiting the facility on 05/04/2026. During an interview on 07/31/2026 at 3:57 PM, Occupational Therapist (OT) #6 stated she went to the location where Resident #169 was found on 05/04/2026. She stated Resident #169 was not dirty, and the way the resident was observed sitting would not indicate the resident had fallen or rolled. During an interview on 07/29/2026 at 2:33 PM, the Maintenance Director (MDR) stated that audits of the departure alert systems were weekly, audits of the alarms on the doors were checked every two weeks, and the elopement system reports were located on the BOA's computer. He stated they looked at the reports daily on the BOA's computer to make sure the doors were checked green, and if a door showed it was red that indicated it was not working. He stated a new elopement alarm system was installed on 06/12/2026. During an interview on 07/30/2026 at 11:00 AM, the CMDR stated that with the old departure alert system they replaced a battery based on the weekly testing of the device, and it was considered fine unless the resident walked near a door and the device did not set off the door alarm. He stated there was no data from the old system to show the departure alert system activity and weekly door checks due to a system loss. During a follow-up interview on 07/31/2026 at 11:41 AM, Restorative Nurse #2 stated that the weekly functionality test for the departure alert systems was previously conducted on Sundays and now was conducted on Wednesdays. She stated that previously (before 05/04/2026) when a departure alert system was placed on a resident, the resident's device would be checked the following week. She stated now they checked the functionality of all departure alert systems on Wednesdays regardless of when the device was placed on a resident. During an interview on 07/31/2026 at 4:29 PM, the Director of Nursing (DON) stated Resident #169 exhibited no exit-seeking behaviors. She stated that the resident wandered. She stated that at the time of the elopement her expectation was that the receptionist was not expected to be at the front desk 24 hours a day/seven days a week. She said they could take breaks, and they would sometimes leave the front desk. She stated they still checked the functionality of the departure alert systems weekly, but now if they placed a departure alert system on a resident on Monday, that resident would still be part of the device check on Wednesdays. The DON stated her expectation since the incident, was that the receptionists were now required to stay at the front desk until someone relieved them, the button for the front door was not accessible to others, the receptionist locked and unlocked the front and back doors, and visitors received an orange sticker to identify them. She stated her expectation was that if a departure alert system ever indicated it had a low battery, the battery be changed immediately. The DON stated she expected the staff to know and to monitor residents with a departure alert system closely, and when a resident was observed spending extra time at a door, staff were to redirect them. During an interview on 07/31/2026 at 4:52 PM, the Administrator (ADM) stated her expectation to prevent an elopement was that staff know their residents and behaviors. She stated if there were identified issues, the staff would report the issues. She stated that in the event they could not locate a resident, they would start the elopement protocol. She stated that since the incident, her expectation now was that the receptionists always remain at the front desk and if they had to leave the front desk, they would tell someone so the front desk could always be covered. The ADM stated her expectation for the departure alert system was that the batteries were functional, and the departure alert system was working. She stated she expected the restorative staff to check the departure alert systems weekly and correct any identified issues. She stated her expectation was to ensure testing of the departure alert system was conducted, even if the application of the device fell within the week of the functionality test date. The ADM explained that if a resident's departure alert system were applied on Monday, they would still test the device on Wednesday. Review of [facility name] Plan of Correction dated 05/04/2026, revealed the facility initiated corrective actions on 05/04/2026 to correct the failed practice as follows: Step 1:Resident was observed not to be in room by nurse. Code W was called, family, police and Physician notified. Resident was located by [town name] Police Department on 5.4.26 Resident was taken to hospital immediately to be assessed for injury and safety. The resident's care plan was reviewed and updated. Education of staff began immediately on elopement prevention, wander guards and monitoring responsibilities. Residents wander guard was working properly when placed on 4.30.26 and deemed to be in proper working condition. Step 2:Alt residents were checked and accounted for per census. Wander guard devices for all otherresidents identified as a high-risk wanderer and requiring a wander guard device were checked on 5.4.26. These residents with a wander guard were placed on 15-minute checks for 24 hours.Elopement and Bims assessments will be done on all residents to assess safety risk. This will be completed on 5-5-2026. Step 3:All staff, including nursing, activities, therapy, laundry, housekeeping, admissions, central supply, maintenance, and business office, have been educated on the proper wander guard placement, elopement prevention and response and code W. Inservice started on 5.4.26 and completed on 5.5.26. All new hires shall be educated during new hire orientation. Step 4:Beginning on 5.4.26, all facility doors with wander guard sensors and residents with wander guards will be audited by the restorative staff or designated staff member to ensure proper functioning. Audits will be conducted daily for 6 weeks beginning on 5.4.26, The administrative staff will do random alarm checks at exit doors to monitor staff response and efficiency to missing resident. Audits will be conducted 3 times weekly for 12 weeks. All results will be discussed during Stand-up meeting, Admin [Administration] Meeting and QA/QAPI [Quality Assurance/Quality Assurance and Performance Improvement] meetings. After review and verification of the facility's corrective actions, to include the facility's investigation, facility audits, monitoring tools, staff education, interviews with facility staff, installment of a new departure alert system on 06/12/2026, the survey team determined the facility implemented the above corrective actions beginning on 05/04/2026 and conducted ongoing education and monitoring; therefore, past noncompliance was cited. The deficiency was corrected on 06/12/2026.

Based on interviews, record reviews and a facility policy titled Comprehensive Person Centered Careplanning/ Baseline Careplan, the facility failed to ensure RI (Resident Identifier) RI #125 received a copy of his/her Baseline Careplan Summary within 48 hours of admission. The facility further failed to ensure RI #350's Baseline CarePlan was developed within 48 hours of admission. This deficient practice affected two out of six sample residents whose baseline care plans were reviewed. A review of a facility policy titled Comprehensive Person Centered Careplanning / Baseline Careplan, dated 11/28/17 document: . Procedure 1. Care will be customized based on the resident needs and values within 48 hours of admission. 3. The interdisciplinary team will work together to develop a baseline care plan within 48 hours of admission . 6. Provide the resident and the resident representative, . with a written summary of the baseline care plan . RI #125 was admitted to the facility on [DATE]. On 11/20/19 at 4:58 p.m, an interview was conducted with RI #125. RI #125 was asked if he/ she received a written copy of the baseline careplan within 48 hours of admission. RI #125 said no he/she had not received any paper about his/ her care. On 11/21/2019 at 10:22 a.m., an interview was conducted with EI #2, LPN ( Licensed Practical Nurse). EI #2 was asked who was responsible for developing RI #125's baseline careplan. EI #2 said, I was was responsible. EI #2 was asked when should the baseline careplan be developed. EI #2 said it should be started on admission and completed within 48 hours. EI #2 was asked did RI #125 or his/ her representative receive a copy of the baseline careplan. EI #2 said, No. EI #2 was asked what was the potential concern with RI #125 or his/ her representative not receiving a copy of the baseline care plan. EI #2 said, the patient should be able to be included in the care plan and voice any concerns about his/ her care. RI #350 was admitted to the facility on [DATE]. On 11/21/19 at 10:51a.m., a review of RI #125's medical record revealed no Baseline Careplan was developed. An interview was conducted with RI #125. RI #125 was asked if she/ he received a written summary of his/ her baseline careplan within 48 hours of admission. RI #125 said, No, I did not. On 11/21/19 at 11:01a.m, an interview was conducted with EI #3 LPN. EI #3 was asked who was responsible for developing RI #350's baseline careplan. EI #3 said the weekend administrator, because RI #350 was admitted late Friday night on 11/15/19. EI #3 was asked was RI #350's baseline careplan developed within 48 hours. EI #3 said, No. EI #3 was asked when was RI #350's baseline careplan developed. EI #3 said that morning, 11/21/19. EI #3 was asked what was the concern with RI #350's baseline careplan not developed within 48 hours of admission. EI #3 said RI #305 would have not had the opportunity to be involved in his/her care. On 11/21/19 at 11:09 a.m., an interview was conducted with EI #2, LPN. EI #2 was asked who was responsible for developing RI #350's baseline careplan within 48 hours of admission. EI #3 said, I was responsible. EI #2 was asked was RI #350's baseline careplan developed within 48 hours of admission. EI #2 said, No Ma'am it did not. EI #2 was asked should RI #350's baseline careplan have been developed within 48 hours. EI #2 said yes it should have been done. EI #2 was asked what was the potential concern with RI #350's baseline careplan not completed within 48 hours. EI #2 said the resident did not have any input into his/her care.

Based on interviews, record reviews and a review of the document titled, Centers for Medicare & (and) Medicaid Services, the facility failed to ensure Resident Identifier (RI) #1, #2, #3, #5, #25, #36, and #38's Minimum Data Set (MDS) Assessments were transmitted in a timely manner. This affected nine of nine residents reviewed for MDS transmissions. Findings Include: A review of the document titled, Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.15, (MONTH) (YEAR), Chapter 2 Assessment for the Resident Assessment Instrument (RAI), page ,[DATE] revealed: . The MDS must be transmitted (submitted and accepted) into the the MDS database electronically no later than 14 calendar days after the care plan completion date. A review of resident medical records revealed: RI #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #1 expired in the facility on [DATE]. RI #1's Death MDS, with an Assessment Reference Date (ARD)/ target date of [DATE], was indicated on the MDS transmittal data sheet as not transmitted until [DATE], submitted late. RI #2 was re-admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #2's Significant Change MDS with an ARD of [DATE], RI #2's Quarterly MDS with an ARD/target date of [DATE], and RI #2's Discharge MDS with an ARD/ target date of [DATE] were all indicated on the MDS transmittal data sheets as not being submitted timely, submitted late. As indicated on the transmittal sheets, the [DATE] MDS was submitted on [DATE], the [DATE] MDS was submitted on [DATE] and the [DATE] MDS was submitted on [DATE], all submitted late. RI #3 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #3's Quarterly MDS with an ARD/target of [DATE], as indicated on the MDS transmittal data sheet, was not transmitted until [DATE], submitted late. RI #3's Quarterly MDS with an ARD/target date of [DATE] was not transmitted until [DATE], submitted late. RI #5 was readmitted to the faility on [DATE] with [DIAGNOSES REDACTED]. RI #5's Quarterly MDS with an ARD/target date of [DATE], as indicated on the MDS transmittal data sheet, was not transmitted until [DATE]. RI #5's Yearly MDS with an ARD/target date of [DATE], was not transmitted until [DATE], both submitted late. RI #25 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #25's Quarterly MDS with an ARD/target date of [DATE], as indicated by the MDS transmittal data sheet, was not transmitted until [DATE], submitted late. RI #36 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #36's Quarterly MDS with an ARD/target date of [DATE], as indicated by the MDS transmittal data sheet, was not transmitted until [DATE], submitted late. RI #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #38 Quarterly MDS with an ARD/target date of [DATE], as indicated by the MDS transmittal data sheet, was not transmitted until [DATE], submitted late. An interview was conducted on [DATE] at 9:00 a.m. with Employee Identifier (EI) #1, the Registered Nurse/ MDS Coordinator. EI #1 was asked, why was RI #1's Death MDS still open. EI #1 stated, It was overlooked. It's my fault, I should have closed it. It should have been transmitted [DATE]. An interview was conducted on [DATE] at 1:25 p.m.,with EI #2, a Licensed Practical Nurse/ MDS Transmitter. EI #2 was asked, why was RI # 2, #3, #5, #25, #36 and #38 MDS Assessments not transmitted on time. EI #2 stated, They were completed late. EI #2 was asked why were they completed late. EI #2 stated, I didn't know they were late. EI #2 explained that the RN that was responsible for completing the MDS assessments had been out intermittently for the last several months with a terminally ill husband, and the RN had not informed her. EI #2 said, since the assessments were not complete, she could not transmit them. EI #2 was asked, who was covering for the third employee while she was out. EI #2 replied, as of Tuesday of that week, the employee was taking four to six weeks off, short term disability and they would be dividing up her work.

Based on interview, medical record review and the Resident Assessment Instrument User Manual Version 3.0 Chapter 4, the facility failed to ensure RI ( Resident Identifier)'s #16 and #95 attended their care plan conferences so that they were involved in making decisions about their care and treatment. The deficient practice affected two of two sample residents whose care plan attendance forms was reviewed. Findings Include: A review of a document, Resident Assessment Instrument User Manual Version 3.0, revealed: . Chapter 4: .CARE PLANNING .4.7 Care Planning A well developed .care plan: .Reflects the resident/resident representative input and goals for health care: . The overall care plan should be orient towards .Involving resident, . RI # 95 was admitted readmitted to the facility on [DATE]. A review of RI #'s 95's care plan attendance form revealed no documentation of his/her attendance for (YEAR). On 09/18/18 at 9:45 a.m., an interview was conducted with RI # 95. RI #95 was asked if he/she was invited to participate in care plan meetings to make decisions about his/her care and treatment. RI #95 said he/she had never been to a care plan meeting. An interview was conducted on 09/20/18 at 1:33 p.m. with EI (Employee Identifier) #, RN (Registered Nurse), MDS Coordinator. EI #1 was asked if RI # 95 attended his/her care plan conference according to the care plan meeting form. EI #1 said, No. EI #1 was asked if residents should be involved in their care plan meetings. EI #1 said, Yes. EI #1 was asked why was it important for residents to be involved in their care plan meetings. EI #1 said, So they (residents) can be knowledgeable about his or her care plan. RI # 16 was readmitted to the facility on [DATE]. A review of RI #16's care plan attendance form revealed no documentation of his/her attendance for (YEAR). On 09/18/18 at 4:06 p.m., an interviewed was conducted with RI #16. RI#16 was asked if he/she was invited to participate in his/her care plan meetings to make decisions about his/her care and treatment. RI #16 said, I don't remember the last time I was invited to a care plan meeting. On 09/20/18 at 1:39 p.m., an interviewed was conducted with EI (Employee Identifier) #1, RN (Registered Nurse), MDS Coordinator. EI #1 was asked did RI #16 attend his/her care plan meetings, according to the care plan attendance form. EI # 1 said, No. EI #1 was asked if residents should be involved in making decisions about their care and treatment. EI # 1 said, Yes. EI #1 was asked what was the importance of residents being involved in making decisions about their care and treatment. EI #1 said, so they could know about their care and make their desires and wishes known.

Based on observation, interviews, record review, and a review of the facility's policy titled, Quality of Life; Dignity, the facility failed to ensure a Certified Nursing Assistant (CNA), Employee Identifier (EI) #1, transported Resident Identifier (RI) #8 to the shower and maintained his/her dignity. This affected one of five sampled residents observed for incontinence care. Findings Include: A review of the facility policy titled, QUALITY OF LIFE; DIGNITY revealed: . 9. shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed. RI #8 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #8's Quarterly Minimum Data Set ((MDS) dated [DATE], revealed RI #8 was always incontinent of urine and feces. On 9/20/2017 at 9:35 a.m., the surveyor observed EI #1 transport RI #8 to the shower in a shower chair, without the waste receptacle in place, dropping feces and urine in the hallway. An interview was conducted on 9/21/2017 at 8:30 a.m. with EI #1. EI #1 was asked, what happened yesterday when she was transporting RI #8 to the shower. EI #1 replied, I forgot to put the shower bucket under the shower chair. EI #1 was asked if there were any concerns related to dignity while transporting RI #8 to the shower. EI #1 replied, Infection and dignity, everyone else would be able to see. EI #1 was asked how she thought that affected RI #8 and the other residents. EI #1 replied, It probably would be embarrassing for him/her and for the other residents. They would feel like it's not very clean. An interview was conducted on 9/20/2017 at 4:15 p.m. with EI #2, a Licensed Practical Nurse (LPN), the Infection Control/ Staff Development Coordinator. EI #2 was asked what was the facility's policy concerning providing privacy/dignity for a resident when transporting in a shower chair down the hall to the shower. EI #2 replied, they should be wrapped/covered up with no exposed sensitive areas of the body and a bucket should be placed under the shower chair for incontinence issues. EI #2 was asked if she would consider a resident without a bucket under the shower chair, defecating and urinating in the floor a dignity issue. EI # 2 replied, yes.

Based on staff interviews, medical record review, and review of Centers for Medicare & Medicaid Services (CMS), Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.13 October 2015, the facility failed to ensure Resident Identifier (RI) #9's Quarterly Minimum Data Set (MDS) assessments dated 05/02/2017 and 07/25/2017 were accurately coded for Oxygen (O2) use. This deficient practice affected RI #9, one of 20 sampled residents whose MDS assessments were reviewed. Findings Include: A review of CMS's RAI 3.0 Manual revealed: .Special Treatments, Procedures, and Programs . Planning for Care . Reevaluation of special treatments . the resident received in the 14-day look-back period is important to ensure the continued appropriateness of the treatments .the resident received in the 14-day look-back period is important to ensure the continued appropriateness of the treatments . Oxygen therapy Code continuous or intermittent oxygen administered via (by way of) mask, cannula, etc. (and so on), delivered to a resident to relieve [MEDICAL CONDITION] (low oxygen in tissues) in this item. RI #9 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #9's Quarterly MDS assessment with an Assessment Reference Date (ARD) of 05/02/2017, indicated RI #9 received no oxygen therapy during that assessment period. A review of RI #9's Quarterly MDS assessment with an ARD of 07/25/2017 indicated RI #9 received no oxygen therapy during that assessment period. A review of RI #9's Physician order [REDACTED]. O2 VIA N/C (Nasal Cannula) AT 2L/M (Liters per Minute) . A review of RI #9's Medication Administration Record [REDACTED]. During an interview on 09/20/2017 at 5:05 p.m., EI #3, Licensed Practical Nurse (LPN), MDS Coordinator, was asked how long had RI #9 been receiving oxygen therapy. EI #3's response was, since April 26, 2017. EI #3 was asked if oxygen therapy was coded on RI #9's 05/02/2017 Quarterly MDS assessment. EI #3's response was, No it's not coded on( RI #9's) 5/2/2017 assessment. EI #3 was asked if oxygen therapy was coded on RI #9's 07/25/2017 Quarterly MDS assessment. EI #3's response was, And it is blank on (his/her) 7/25/17 assessment. EI #3 was asked, what blank meant. EI #3's response was, It was not checked, that means it was not coded. EI #3 was asked if oxygen therapy should have been coded on the 05/02/2017 and 07/25/2017 Quarterly MDS assessments. EI #3's response was, Yes ma'am. EI #3 was asked what was the concern in not coding MDS assessments accurately for RI #9. EI #3's response was, The correct information is not being transmitted to the agencies that need the information. And it's not a true reflection of resident care. During an interview on 09/20/2017 at 5:22 p.m., EI #4, Director of Nursing, was asked how long had RI #9 been receiving oxygen therapy. EI #4's response was, since April 26, 2017. EI #4 was asked if oxygen therapy was coded on RI #9's 05/02/2017 and 07/25/2017 assessments. EI #4's response was, I don't see it coded for 5/2/17 or 7/25/17. EI #4 was asked if oxygen therapy should have been coded for the 05/02/2017 and 07/25/2017 assessments. EI #4's response was, Yes. It should have been on both. EI #4 was asked what was the concern for not coding MDS assessments for RI #9's oxygen use. EI #4's response was, The MDS should always reflect exactly what's going on with the patient at that time.

Based on observation, interviews, review of job descriptions of the Director of Food Services, Speech Therapist and Dietician, a review of a facility document titled, CARE PLAN FEEDING TUBE, and review of the medical record, the facility failed to ensure Resident Identifier (RI) #12's care plan was revised to reflect an alteration requested by RI #12's spouse to the ordered pureed diet. This affected RI #12, one of 21 sampled residents. Findings Include: Review of a facility document titled, CARE PLAN FEEDING TUBE dated, 9/13/17 documented the following: Problem . Receives Puree diet w/ (with) honey-liquids & (and) nosey cup . Approaches . B (breakfast), L (lunch), D (dinner) meals trays to be sent Review of the Dietitian job description, with no date, revealed the following: . Care Plan and Assessment Functions Develop preliminary and comprehensive assessments of the dietary needs of each resident .Ensure that all dietary personnel are aware of the care plan and that care plans are used in planning daily dietary services for the resident . Review and revise care plans and assessments as necessary, . Review of the Speech Therapist job description, with no date, documented: . Administrative and Surveillance Functions . Assist in developing, implementing and coordinating . resident care plans, . Care Plan Functions Ensure that speech therapy treatments are indicated on the care plan. Review of the Director of Food Services job description, with no date, revealed: . Care Plan and Assessment Functions Assist in developing preliminary and comprehensive assessments of the dietary needs of each resident. Assist in developing a written dietary plan of care (preliminary and comprehensive) that identifies the dietary problems/needs of the resident and the goals to be accomplished for each dietary problem/need identified . Ensure that all dietary personnel are aware of the care plan and that care plans are used in planning daily dietary services for the resident. Review nurses' notes to determine if the care plan is being followed. Discuss problem areas with the director of Nursing Services . RI #12 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of RI #12's Annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 07/18/2017, documented the resident as total dependence with one person physical assistance for eating. On 9/20/17 at 8:01 a.m., the surveyor observed RI #12's breakfast tray to contain scrambled eggs, oatmeal and a bowl of gravy with a whole biscuit on top of the gravy. After the biscuit was mashed into the gravy by a CNA, there were still visible pieces of biscuit observed in the bowl. On 9/20/17 at 5:01 p.m., an interview was conducted with Employee Identifier (EI) #9, Dietary Manager. The surveyor asked, if RI #12 was on a pureed diet with honey consistency liquids, should he/she have gotten biscuit and gravy if his/her diet did not have it written in it. EI #9 said, no ma'am, he/she should not receive it. On 9/21/17 at 11:05 a.m., an interview was conducted with EI #6, Speech Therapist. The surveyor asked, how did the process of treatment/approaches and recommendations for treatment get ordered for speech caseload. EI #6 said, they had standing orders to evaluate and treat. EI #6 said she did her evaluation and gave recommendations to the doctor and developed her plan of care. EI #6 said her recommendations were part of her plan of care. The surveyor asked, did RI #12 have a plan of care in place for the biscuit and gravy at the spouse's request prior to the added approach on 9/20/17. EI #6 replied, no. EI #6 was asked, were there any plans of care for biscuit and gravy for residents on pureed diets. EI #6 replied, as of last night and this morning there were. EI #6 was asked who wrote them. EI #6 answered, she did. On 9/21/17 at 1:59 p.m., an interview was conducted with EI #4, Director of Nursing. The surveyor asked, did all the residents on a pureed diet with an alteration to their diet have an order and a care plan regarding the alteration. EI #4 said, they were looking at that now and correcting everything that needed an order or care plan. EI #4 was asked, should they have had an order and care plan. EI #4 said, everybody had discussed it, but she guessed it just did not get on paper.

Based on observation, interviews, and medical record review, the facility failed to ensure a physician's order for Resident Identifier (RI) #12's diet was obtained and written to include an alteration to the pureed diet at spouse's request. The facility also failed to ensure an order for [REDACTED].>This affected RI #12, one of 13 sampled residents whose diet orders were reviewed. Findings Include: RI #12 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of RI #12's Annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 07/18/17, documented the resident as total dependence with two plus persons physical assistance for Activities of Daily Living (ADLs). Review of Physician's Orders for the month of September 2017 revealed the following: . PUREED DIET WITH HONEY THICK LIQUIDS VIA (BY WAY OF) NOSEY CUP AVOID STRAWS . On 9/20/17 at 8:01 a.m., the surveyor observed RI #12's breakfast tray to contain scrambled eggs, oatmeal, a bowl of gravy with a whole biscuit on top of the gravy, two containers of nectar thickened apple juice and two containers of nectar thickened water. Employee Identifier (EI) #7, a Certified Nursing Assistant (CNA), mashed the biscuit into the gravy with pieces of biscuit still visible in the bowl. On 9/20/17 at 8:25 a.m., an interview was conducted with EI #8, Registered Nurse (RN) Unit Manager (UM). EI #8 was asked, was RI #12 on a pureed diet with honey thick liquids. EI #8 reviewed the order and stated, RI #12 was on a pureed diet with honey thick liquids with a nosey cup. EI #8 was asked, did the kitchen send out a regular biscuit in a bowl of gravy for pureed diets. EI #8 said, yes ma'am, the nursing assistants mixed it up in the bowl with the gravy and it was pureed according to their policy. The surveyor asked EI #8, did RI #12's breakfast tray have honey thick liquids. EI #8 replied, no ma'am it did not. EI #8 was asked, what consistency did RI #12 have. EI #8 answered, nectar. The surveyor asked, what could happen with RI #12 receiving the wrong consistency liquids. EI #8 stated, he/she could aspirate. On 9/20/17 at 12:13 p.m., an interview was conducted with EI #7. The surveyor asked, did she know what consistency RI #12's liquids were supposed to be. EI #7 said, honey. EI #7 was asked, what kind was on RI #12's tray. EI #7 replied, nectar and she thought one honey. The surveyor asked, what could happen if he/she did not receive the correct consistency fluids. EI #7 answered, he/she would aspirate. On 9/21/17 at 11:05 a.m., an interview was conducted with EI #6, Speech Therapist. The surveyor asked, was there an order for [REDACTED].#6 said, not that she could find. On 9/21/17 at 1:59 p.m., an interview was conducted with EI #4, Director of Nursing. EI #4 was asked, did residents on a pureed diet with an alteration have an order for [REDACTED]. EI #4 said, everybody had discussed it, but she guessed it just did not get on paper.

Based on observations, interviews, review of facility policies titled, Incontinence Care Bowel, DRESSING CHANGES, and HANDWASHING, the facility failed to ensure: 1. a nurse did not remove tape and a permanent marker from her pocket after washing her hands, placed the tape to be used on Resident Identifier (RI) #5's dressings on an unclean night stand and then, apply gloves to begin wound care, 2. a nurse washed her hands and changed gloves after removing a soiled dressing and before applying a clean dressing for RI #5, 3. a nurse washed her hands and changed gloves when moving from a wound on RI #5's left heel and without washing her hands, removed the soiled dressing from RI #5's right heel, and 4. a Certified Nursing Assistant (CNA) did not transport RI #8 to the shower in a shower chair, without a waste receptacle in place, causing urine and fecal matter to be dropped in the hallway. Findings Include: Review of a facility policy titled, DRESSING CHANGES with no date revealed: Policy The purpose of this policy is to provide guidelines for clean technique and dressing changes to protect wounds from injury and to prevent the introduction of bacteria . Procedure . 13. Remove dirty dressing and discard in appropriate receptacle. 14. Wash hands. 16. Clean wound . 17. Wash hands. 18. put on clean gloves. 19. Apply the ordered medication/dressing. 20. Wash hands . Review of a facility policy titled, HANDWASHING with no date documented: . Policy Interpretation and Implementation Appropriate 10 to 15 second handwashing must be performed under the following conditions: .10. Before handling clean or soiled dressings, gauze pads. 11. After handling used dressing, contaminated equipment. . 15. After handling items potentially contaminated with blood, body fluids, excretions, or secretions . RI #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/20/17 at 8:48 a.m., the surveyor observed Employee Identifier (EI) #5, a Licensed Practical Nurse (LPN) wash her hands, take a roll of tape and a permanent marker from her pocket, tear off two pieces of tape, write the date on each piece of tape with the permanent marker, place the tape on an unclean night stand, and picked up a pair of gloves and put them on without washing her hands. EI #5 removed heel pillows from both of RI #5's heels and removed the soiled dressing from RI #5's left foot. Without washing her hands and changing her gloves, EI #5 cleansed a heel wound on RI #5's left foot and applied a clean dressing to RI #5's left foot. Without washing her hands and changing her gloves, EI #5 removed a removed a soiled dressing from RI #5's right foot and cleaned RI #5's right heel wound. On 9/20/17 at 9:49 a.m., an interview was conducted with EI #5. The surveyor asked, when should she wash her hands during wound care. EI #5 said, after she removed a dressing and any time she was visibly soiled, take off her gloves and wash her hands. EI #5 was asked, did she wash her hands after getting the tape and permanent marker out of her pocket and before applying her gloves. EI #5 answered no. The surveyor asked EI #5, did she place tape on the night stand for use on RI #5's dressings. EI #5 replied yes. EI #5 was asked, did she change her gloves and wash her hands after cleaning RI #5's left heel and before applying the clean dressing. EI #5 said no. The surveyor asked EI #5, did she change her gloves and wash her hands before removing RI #5's right heel dressing. EI #5 stated no. When asked, should she change her gloves and wash her hands between treatments, EI #5 replied yes. The surveyor asked, were these things infection control issues. EI #5 said, yes. On 9/20/17 at 4:15 p.m., an interview was conducted with EI #2, LPN/Infection Control Nurse. The surveyor asked, when should a nurse wash her hands during a treatment. EI #2 stated, before the treatment began, in between dirty and clean and after it was completed. EI #2 was asked, was it an infection control issue if a nurse washed her hands, removed a roll of tape and permanent marker from her pocket and put on gloves. EI #2 said, yes any time staff washed their hands they should be ready to do the procedure. EI #2 was asked, should tape be hung on a nightstand for use on a resident's dressings. EI #2 responded, no, nothing should touch any surface that had not been cleaned. The surveyor asked, when should gloves be changed. EI #2 answered, when dirty was removed, staff should take off their gloves and wash their hands before putting on a clean pair. A review of the facility's policy titled, Incontinence Care, Bowel revealed: . the purpose of this policy and procedure is to provide guidelines that will aid in preventing exposure to fecal matter. 12. Drop solid fecal matter into toilet or hopper and flush . RI #8 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #8's Quarterly Minimum (MDS) data set [DATE] revealed RI #8 was always incontinent of urine and feces. On 9/20/17 at 9:35 a.m., EI #1, CNA, transported RI #8 to the shower in a shower chair, without the waste receptacle in place, dropping feces and urine in the hallway. An interview was conducted on 9/20/17 at 4:15 p.m. with EI #2. EI #2 was asked if it was an infection control issue for a resident to be transported in a shower chair down the hall and have incontinence of feces and urine in the hallway. EI #2 replied, Yes ma'am. An interview was conducted on 9/21/2017 at 8:30 a.m. with EI #1. EI #1 was asked what happened yesterday when she was transporting RI #8 to the shower. EI #1 replied, I forgot to put the shower bucket under shower chair. EI #1 was asked if there were any concerns while transporting RI #8 to the shower. EI #1 replied, Infection . EI #1 was asked how she thought this affected RI #8 and the other residents. EI #1 replied, . They would feel that it was not very clean.

Based on observation, interviews and record review, the facility failed to provide evidence inservice education was provided to Certified Nursing Assistants (CNA) related to alterations in pureed diets. This affected Resident Identifier (RI) #12 and had the potential to affect all seven residents in the facility receiving altered pureed diets. Findings Include: RI #12 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/20/17 at 8:01 a.m., the surveyor observed RI #12's breakfast tray to contain scrambled eggs, oatmeal and a bowl of gravy with a whole biscuit on top of the gravy. After the biscuit was mashed into the gravy by a CNA, there were still visible pieces of biscuit observed in the bowl. On 9/20/17 at 4:15 p.m., an interview was conducted with Employee Identifier (EI) #2, Licensed Practical Nurse (LPN)/Staff Development. EI #2 was asked, had she trained or inserviced the CNAs on how to puree biscuit and gravy at the bedside. EI #2 said no. EI #2 was asked, to her knowledge had anyone else trained them to do that. EI #2 replied, not that she was aware of, unless Speech Therapy did it. On 9/21/17 at 11:05 a.m., an interview was conducted with EI #6, Speech Therapist. The surveyor asked, how did the CNAs know how to take the biscuit and mix it with the gravy to make it safe for a resident on a pureed diet. EI #6 said, she did the training. The surveyor asked EI #6, when was the last time she did the training. EI #6 replied, on 9/19/17, Tuesday. The surveyor asked EI #6, prior to that, when would have been the last time she provided training regarding the biscuit and gravy. EI #6 answered, 2016. The surveyor asked EI #6, who did she train on Tuesday to feed RI #12. EI #6 said, she did not have that information in her note. EI #6 said she usually did not put CNA's names in her notes. The surveyor asked, was there any documentation available for that training on Tuesday. EI #6 responded, no. EI #6 was asked, how did she know if a new CNA taking care of a resident getting biscuit and gravy on a pureed diet had been trained. EI #6 said she relied on the permanent CNAs on the hall and/or mentor to train them. EI #6 said she had a part in orientation, but she did not go over any specific resident. The surveyor asked EI #6, what follow-up education was provided to ensure the residents with altered diets remained safe with staff changes. EI #6 answered, that was the breakdown, she did not have a process in place for that outside the mentor training and referral from nursing. The surveyor asked EI #6, what happened if they ended up with a mentor that was never trained. EI #6 replied, she did not know. On 9/21/17 at 1:59 p.m., an interview was conducted with EI #4, Director of Nursing. The surveyor asked, what training had the CNAs had about pureed biscuit and gravy at bedside. EI #4 replied, Speech Therapy had a part in orientation where she talked about all the different diets and consistencies and she talked to the rehab CNAs and worked with the CNAs on the hall and watched them periodically and let them watch her feed to make sure the accuracy of what the diet was and how they should be feeding. The surveyor asked EI #4, did she have any documentation about the training. EI #4 said, no, she did not. We had where they were in orientation and inserviced in orientation, but not what she did on the hall. EI #4 was asked, had she been made aware that the last time education was provided regarding the biscuit and gravy was in 2016. EI #4 responded, no, they had orientation about every other weekend and the diets were gone over in orientation. The surveyor asked EI #4, was she aware that there was no written documentation of education being provided to the CNAs regarding the biscuit and gravy and the pureed diets. EI #4 said, no.

Based on interviews, record review and review of a facility policy titled: Physician's Orders, the facility failed to correctly transcribe Physician's Orders to administer Resident Identifier (RI) #1's medication, [MEDICATION NAME] (A medication used the treatment of [REDACTED]. According to hospital records, RI #1 had complained to the facility of swelling in the lower extremities, being mildly short of breath, and not receiving a medicine that was prescribed to treat [MEDICAL CONDITION] (weight gain). The medication, [MEDICATION NAME] was not administered, as ordered by the physician because the order was not transcribed to the resident's medical record or sent to the pharmacy to be filled. RI #1 was admitted to the local hospital's Cardiology service with severe volume overload. The Cardiologist stated RI #1 had approximately 14 plus liters of fluids, due to a fluid overload related to RI #1 not receiving the diuretic medications as ordered at the nursing home. The Cardiologist stated RI #1 gained 23 pounds of fluids within 10 days at the nursing home. This deficient practice affected RI #1, one of three resident sampled who received medications.Finding Included: A facility policy titled Physician's Orders (no date) documented: Policy Statement All residents medications must be ordered by a licensed physician or CRNP (Certified Registered Nurse Practioner) According to Potter & Perry, FUNDAMENTALS OF NURSING, Stocker-Hall, eighth edition, 2013, p. 305, documents: Health Care Providers' Orders. The health care provider (physician or advanced practice nurse) is responsible for directing medical treatment. Nurses follow health care providers' orders unless they believe the orders are in error or harm patients. Therefore you need to assess all orders; if you find one erroneous or harmful, further clarification from the health care provider is necessary . The health provider should write all orders. The nurse is responsible for transcribing written orders correctly . On 2/8/2016 at 2:20 p.m., the Division of Health Care Facility received a complaint alleging the family was not notified that medication [MEDICATION NAME] was not administered as ordered, and RI #1 had gained 23 pounds in 10 days. RI #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #1's Admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 01/25/2016, assessed RI #1 to score a 13 on the Brief Interview for Mental Status (BIMS) indicating no impairment in cognition. Section G - Functional Status assessed RI #1 needed extensive assistance with bed mobility, locomotion on and off the unit, Dressing and bathing. Section K - Swallowing / Nutritional Status assessed RI #1's weight at 162 pounds. Section N - Medications indicated RI #1 received diuretics for (1) one day during this assessment period. The facility's electronic system received a physician's orders from a local hospital on [DATE] 1:21 pm. New orders were sent to the facility on [DATE] at 3:10 PM. The new set of physician's orders, sent to the facility from the hospital, documented: [MEDICATION NAME] ([MEDICATION NAME] 100 milligram oral tablet) 100 mg = 1 tab(s) Oral - Daily . A review of RI #1's daily weights indicated RI #1 gained 10 pounds in five days. A review of the January 2016 Medication Administration Record [REDACTED] January 19 - 145 January 20 - 148 January 21 - 150 January 22 - 152 January 23 - 155 RI #1's medical record Departmental Notes - nurses notes were reviewed. There was no evidence in medical record from January 19, 2016 to January 23, 2016 to indicate the licensed staff contacted RI #1's attending physician concerning the weight gain. According to the daily weights, recorded on RI #1's January 2016 MAR, RI #1 gained 10 additional pounds. The weights were documented: January 24 - 159 January 25 - 162 January 26 - 164 January 27 - 165 Departmental Notes dated 1/29/2016 at 11:49 AM, documented, Late Entry for 01-28-16 @ 12 PM - This nurse recieved (received) phone call from patient's cardiologist nurse 'name of nurse.' (Name of nurse) states that she had recieved (received) a phone call from patients family related to patient weight gain . This nurse reviewed medications with (name of nurse) via (by) telephone. (Name of nurse) states that according to d/c (discharge) summary from UAB hospital that patient was supposed to be recieving (receiving) a daily regimen of [MEDICATION NAME] 100mg (milligram). This nurse explained to (Name of nurse) that patient did not have a (an) order from UAB hospital to administer [MEDICATION NAME] but (he/she) had recieved (received) [MEDICATION NAME] 40mg this am per (Name of doctor), MD orders. And that this nurse will follow-up with MD and nursing supervisor and will return call to Cardiologist ASAP (as soon as possible). On 1/28/2016, RI #1 was transported to a local hospital. The Hospital Record documented, Reason for visit: Fluid Retention History of Present Illness . [MEDICAL CONDITIONS] (EF (ejection fraction) severely reduced on echo 1/14), a-fib, CKD ([MEDICAL CONDITION]),[MEDICAL CONDITION](Hypertension), presents to ED (emergency department) with complain of swelling in (his/her) LE (lower extremities, Per (by) EMS her nursing home has not been giving (his/her) [MEDICATION NAME] as prescribed since her last discharge for [MEDICAL CONDITION] exacerbation. (He/She) has gained 23 lb in 10 days. (He/She) reports some mild SOB (shortness of breath) that began this morning as well. Denies an/and (nausea and vomiting) . Cardiovascular: . 3+ [MEDICAL CONDITION] bilaterally with [DIAGNOSES REDACTED] Labs . BUN 33 BNP 1,6661.8 pg/mL HI Troponin I 0.057ng/mL HI . Disposition: admit to Cardiology ward service for [MEDICAL CONDITION] with severe volume overload. Progress Notes (RI #1) . h/o (history of) [MEDICAL CONDITION] (LVEF 25 -30 %) who comes in with worsening [MEDICAL CONDITION] concerning for an acute HF (heart failure) exacerbation. admitted to Cardiology service for work up and management of this volume overload. Current presentation appears to be due to outpatient diuretic mis-management . Acute de-compensated systolic HF severe [MEDICAL CONDITION] + bibasilar crackles on lung auscultation 23# weight gain over the course of the past 10 days since discharge from hospital . inadequate diuresis at SNF (Skilled Nursing Facility) . cumulative diuresis since admission: negative 14.4L (Liters) . On 2/24/2016 at 12:50 p.m., the surveyor conducted an interview Employee Identifier (EI) #4, Admission Coordinator, responsible for taking the orders off the hospital discharge record and transcribing them to the facility records. EI #4 was asked what day was RI #1's admission's orders received from the hospital. EI #4 stated the facility received three pages of admission orders [REDACTED]. EI #4 stated she was not a nurse, but in addition to her looking over the orders, two nurses looked over the medication. EI #4 was asked if she looked at the orders to see if RI #1 was prescribed [MEDICATION NAME]. EI #4 said she did not. EI #4 was asked if there were additional orders sent to the nursing home from the hospital. EI #4 replied there were additional orders, but these orders were not viewed. On 2/25/2016 at 5:15 p.m., a follow-up interview was conducted with EI #4, Admission Coordinator. The facility's Administrator, EI #1, was present during this interview. The surveyor asked EI #4 about the facility's process for receiving physician's orders submitted electronically. EI #4 stated the hospital sends a notice with a code and she would go online and pull up the patient's information. EI #4 stated then the entire chart is printed with the attachments. EI #4 was asked if this included the medication orders written by the physician. EI #4, replied yes. EI #4 was asked to explain how updated information is brought to the facility's attention. EI #4 said the hospital would send her another code notification that will say new. Then she would print the whole package again, with the new stuff. The surveyor asked EI #4 if she opened RI #1's updated orders that were sent electronically from the hospital on [DATE]. EI #4 stated the orders were not viewed. EI #4 was asked if she was able to open these notifications today (2/25/2016) for the surveyor to view. EI #4 informed the surveyor that notifications are closed after the patient discharges from the hospital. EI #4 said it (the notification) would say record is closed. On 2/25/2016 at 1:35 p.m., the surveyor conducted a phone interview with RI #1's hospital Cardiologist. The surveyor asked the Cardiologist if RI #1's record had been reviewed. The Cardiologist said she was very familiar with RI #1's case. According to the Cardiologist, the patient came back to the hospital on [DATE], and she was shocked at the amount of weight (RI #1) had gained. The Cardiologist explained that there was an order for [REDACTED]. Someone should contact the doctor and give medications to decrease the swelling. The Cardiologist stated RI #1's legs were enormous. The Patient complained to the nursing home staff, but according the family members, staff ignored the patient's complaints. When asked if RI #1 was in a life threatening situation, the Cardiologist said no, but RI #1 needed a medical evaluation. The Cardiologist said RI #1 had approximately 14 plus liters of fluids, due to a fluid overload from the nursing home staff not providing the resident the diuretics that were ordered. The Cardiologist added that the nursing home staff failed to act upon RI #1's weight gained of 23 pounds of fluids within 10 days. When asked if the physician's orders sent to the facility on [DATE] were followed, the Cardiologist said no, they were not followed.

Based on interviews and record review, and review of a facility policy titled Change in a Resident's Condition or Status, the facility failed to notify the sponsor/family and physician of when RI #1 gained 10 punds in five days. On 1/19/2016, RI #1 weighed 145 lb and on 1/23/2016 weighed 155 pounds. This affected RI #1, one of three sampled residents. Findings include: A review of a facility policy titled, Change in a Resident's Condition or Status (no dated) documented: Policy Statement Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's condition and/or status . 1. The Nurse will notify the resident's attending physician when: . b. There is a significant change in the resident's physical, mental or psychosocial status; c. There is a need to alter the resident's treatment significantly . RI #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #1's medical record revealed a form titled Extended Care Facility Transfer dated 18 January 2016 documented . Outpatient Medications - chlorothiazide (chlorothiazide 500 mg (milligrams) oral tablet) 500 mg = 1 tab(s) (tablet) - Oral - Every AM (morning) PRN (as needed) (other (see comment) Please monitor daily weights and give dose if increase of 3 pounds in 24 hours, otherwise please hold chlorothiazide . A review of RI #1's January 2016 Medication Administration Administration Record (MAR) DAILY WEIGHTS: January 19 - 145 January 20 - 148 January 21 - 150 January 22 - 152 January 23 - 155 On 2/23/2016 at 7:25 p.m. the surveyor conducted an phone interview with the complainant. The surveyor asked the complainant if they wanted to be informed by the facility if there was a changed in RI #1's condition. The complainant said yes as well as RI #1's first contact (sponsor). They wanted to be notified if there were any changes in RI #1's condition, especially weight gained. On 2/24/2016 at 3:45 p.m., the surveyor conducted an interview with RI #1's sponsor. The surveyor asked RI #1's sponsor if she wanted to be notified if there were any changes in RI #1's condition. The sponsor said sure, especially if there was a weight gain. The sponsor said the doctors at the hospital had written in RI #1's orders, if there was a 2-3 pounds weight gained, the nursing needed to contact them. On 2/24/2016 at 6:00 p.m., an interview was conducted with EI #3, the RN (Registered Nurse) supervisor of the hall where RI #1 resided. The surveyor asked EI #3 if RI #1 ever asked her to call the physician or sponsor about the weight gained. EI #3 said no sir, the resident did not. The surveyor asked EI #3 if there was any documentation the family or physician was notified related to the weight gained. EI #3 said no, she did not see any documentation (after reviewing RI #1's nurses notes). On 2/25/2016 at 8:05 p.m., an interview was conducted with EI #2, the Director Of Nursing. The surveyor asked EI #2 if anyone contacted the physician or sponsor/family about (RI #1's) 10 pound weight gain from 1/19/16 - 1/23/16. The Administrator, EI #1, present during this interview, replied no. EI #1 further sated that from looking at the nurses notes it do not look like anyone was contacted. The surveyor asked EI #2 who would have been responsible for doing this. EI #2 said any of the nurses on duty.

Based on observation, interviews and review of a facility policy titled Oral Medications, the facility failed to ensure a Licensed Nurse, Employee Identifier (EI) #2, did not touch Resident Identifier (RI) #7's medications with bare hands while administering the morning medications on 9/2/15. This affected RI #7, one (1) of six (6) residents observed during the Medication Administration Observations. The facility further failed to ensure a CNA (Certified Nursing Assistant), EI #10 removed his contaminated gloves before touching a clean brief and a tube of Zinc Oxide ointment and before applying the ointment to RI #12's buttocks on 09/2/15. The facility failed to ensure a CNA, EI #5, changed contaminated gloves and washed their hands during and after the provision of incontinent care, and before handling RI #11's pillow and bed linens. This affected two (2) of two (2) residents observed during incontinence care. Findings Include: The facility's policy titled Oral Medications (no date) documented: . Purpose The purpose of this procedure is to provide guidelines for the administration of oral medications . Steps in the Procedure . 6. Do not touch the medicine with your hands . 1. RI #7 was originally admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of RI #7's medical record revealed Physician order [REDACTED]. . [MEDICATION NAME]-D 24 HOUR TABLET GIVE ONE TABLET (TAB) BY MOUTH EVERYDAY . [MEDICATION NAME] 50 MG (Milligrams) TABLET GIVE ONE BY MOUTH FOUR TIMES DAILY ., [MEDICATION NAME] 300 MG TAB GIVE ONE TABLET BY MOUTH TWICE DAILY . [MEDICATION NAME] 5 MG TABLET GIVE ONE TABLET BY MOUTH EVERY DAY . [MEDICATION NAME] XR (EXTENDED RELEASE) 28 MG CAPSULE GIVE ONE CAPSULE BY MOUTH EVERY DAY . [MEDICATION NAME] 1,000MG GIVE ONE TABLET BY MOUTH TWICE DAILY . ASPIRIN 81 MG CHEWABLE TABLET GIVE ONE TABLET BY MOUTH EVERY DAY . [MEDICATION NAME] POWDER GIVE 17 GM (GRAMS) MIXED WITH FOUR OUNCES OF FLUIDS BY MOUTH EVERY DAY . On 09/02/15 at 8:00 AM, during the Medication Administration Observation, RI #7 was observed out of bed sitting in a chair in the room. The surveyor observed EI #2, a Licensed Practical Nurse (LPN), administer the above medications to RI #7 by mouth. EI #2 administered the [MEDICATION NAME] XR 28 mg and [MEDICATION NAME] 1000 MG tablet with her bare hands, into RI #7's mouth. EI #2 administered RI #7's remaining medications in a clear plastic calibrated 30 cc (cubic centimeters) medication cup by mouth to the resident. On 09/02/15 at 10:35 AM, the surveyor conducted an interview with EI #2. The surveyor asked EI #2 when giving medications was she allowed to take the pill/capsule with her bare hands and put the medication into a resident's mouth. EI #2 stated, No, I should have put on gloves. The surveyor asked EI #2 when she gave the first two pills/capsules, if she used her bare hands. EI #2 stated Yes. The surveyor asked EI #2 what was the potential for harm when using your bare hands to administer medication to a resident. EI #2 stated, Contamination for bacteria. I washed my hands before I gave (RI #7) the medications with my bare hands. On 09/03/15 at 11:50 AM, the surveyor conducted an interview with EI #1, the Director Of Nursing (DON). The surveyor asked EI #1, are the medication nurses allowed to touch the pills/capsules with their bare hands and administer it to a resident. EI #1 stated, No, the pill/capsule should stay in the cup. The surveyor asked EI #1 what was the potential harm this could cause, to give medication with the bare hands. EI #1 stated, It's an infection control issue. 2. RI #12 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A Quarterly MDS (Minimum Data Set) Assessment, with a ARD (Assessment Reference Date) of 07/07/15, identified RI #12 as having short and long term memory problems and severely impaired cognitive skills for daily decision making. RI #12 was also assessed to be always incontinent of bowel and bladder. On 09/02/15 between 9:45 and 10:05 AM, the surveyor observed incontinent care being provided to RI #12. EI #10, the assigned CNA, removed RI #12's pajamas and adult brief. EI #11, a CNA assisting EI #10, dampened a washcloth (W/C), sprayed the W/C with periwash and handed the W/C to EI #10. EI #10 wiped in a downward motion RI #12's left, then right groin areas, using different areas on the W/C. EI #10 used a different W/C and wiped RI #12's private area. EI #10 next wiped RI #12's inner buttocks, then right and left buttocks using different W/Cs. With his contaminated gloves still on, EI #10 picked up a clean adult brief and handed it to EI #11. EI #10 then proceeded to pick up a tube of Zinc Ointment and applied the ointment to RI #12's buttocks. After applying the Zinc Ointment to RI #12's buttocks, EI #10 removed his contaminated gloves. On 09/02/15 at 2:25 PM, the surveyor conducted an interview with EI #10. The surveyor asked EI #10 what should he have done before touching the clean adult brief, picking up the tube of Zinc Ointment and applying the ointment to RI #12's buttocks. EI #10 said he should have changed his gloves. The surveyor asked EI #10 what would it be considered when gloves were not changed after touching dirty items and before touching clean items. EI #10 replied, Contamination. On 09/03/15 at 11:50 AM, the surveyor conducted an interview with EI #3, a LPN supervisor. The surveyor asked EI #3 what should the CNAs do with their gloves before touching a clean item. EI #3 replied, Take them off. Remove them. Wash their hands and put new gloves on if needed. The surveyor asked EI #3 when not done, what was that considered to be. EI #3 said, Contamination. 3. A facility policy titled: Using Gloves (no date) documented: . Purpose The purpose of this procedure is to provide guidelines for the use of gloves. Objectives 1. To prevent the spread of infection and disease to residents and employees . Miscellaneous . 5. Wash hands after removing gloves. (Note: Gloves do not replace handwashing.) . RI #11 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of RI #11's most recent Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 07/28/15 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 4, indicating the resident's cognition was severely impaired for daily decision making. The MDS also revealed the resident required extensive assistance with personal hygiene and toileting. The MDS further revealed the resident was always incontinent of bladder and bowel and had a history of [REDACTED]. On 09/01/15 at 10:55 AM, the surveyor observed EI #5 and EI #6 (two CNAs) perform perineal and incontinence care on RI #11. Both CNAs washed their hands and donned gloves. EI #1 placed a gait belt on RI #11 and with the assistance of EI #6, RI #11 was placed in bed, with EI #5 explaining to RI #11 what they were going to do. Both CNAs pulled off RI #11's sweat pants. With the same gloves on, EI #5 unfastened the left side of RI #11's brief as EI #6 unfastened the right side of the brief. EI #5 pulled the brief down and proceeded to fold, then tuck down the top of the brief. Urine was observed on the brief. EI #5 pulled a clean cloth out a packet and wiped down the right groin and left the cloth on top of the soiled brief. EI #5 used another cloth and wiped down the left groin, folded the corner of the cloth, and wiped down the middle of the perineal area, and left that cloth on top of the brief. EI #5 did not separate the labia and clean the labial folds from outer to inner before cleansing down the middle of the perineal area. EI #6 assisted the resident to turn to the right side. EI #5 folded the brief and placed it on the bed, obtained another wipe out of the pack, and wiped RI #11's right buttocks in an upward motion. EI #5 folded the cloth, and wiped the right buttocks in an upward motion again. EI #5 then obtained another cloth and wiped the left buttocks in an upward motion, folded the cloth, and wiped the left buttocks again in an upward motion. EI #5 took off her contaminated gloves, donned a clean pair, then applied some cream to RI #11's buttocks and coccyx area. EI #5 did not wash her hands after handling the urine-contaminated brief and before donning a clean pair of gloves. EI #6 took off her gloves and washed her hands, then placed a pillow between RI #11's legs. EI #5 took off her contaminated gloves, placed a pillow under RI #11's feet, and pulled the covers up on RI #11's shoulders. Then EI #5 washed her hands. On 09/01/15 at 2:30 PM, the Surveyor conducted an interview with EI #5. EI #5 was asked what should have been done after you and the other CNA (EI #6) transferred RI #11 to the bed, after pulling RI #11's clothes off and before EI #5 started incontinence care on RI #11. EI #5 stated she should have washed her hands and changed her gloves. EI #5 was asked after RI #11 was assisted to the right side and after she folded the urine-saturated brief what should she have done. EI #5 stated she should have placed the brief in the trash bag and changed her gloves. EI #5 was asked what she did. EI #5 stated she placed the soiled brief on the bed, got more wipes and continued to clean RI #11's bottom. EI #5 was asked what should have been done after finishing the incontinence care, taking off the contaminated gloves and before applying a clean pair of gloves. EI #5 stated, I should have went and washed my hands. EI #5 was asked after applying cream to RI #11's buttock/coccyx, taking off your gloves and before touching RI #11's pillow and linens, what should you have done? EI #5 stated, Washed my hands and put on another pair of gloves. EI #5 was asked what the potential harm was to the resident, when not washing or sanitizing the hands after changing gloves, before touching the resident's linen and pillow and going from dirty to clean. EI #5 stated, Infections. Carrying germs. On 09/03/15 at 12:12 PM, the Surveyor conducted an interview with EI #8, the RN (Registered Nurse) Supervisor of Station Two. EI #8 was asked after taking off a pair of gloves, before and after performing incontinence care involving urine, and before putting on a clean pair of gloves what should be done. EI #8 stated to wash the hands. EI #8 was asked after completing incontinence care and before touching the resident's linen and pillows what should have been done. EI #8 stated wash the hands. EI #8 was asked what the potential harm to the resident was during and after incontinence care involving urine and not washing the hands and touching the resident's linen and pillow. EI #8 stated, Infections, being susceptible to them.

Based on observations, interviews and review of a facility policy titled MEDICATIONS: [MEDICATION NAME] PATCHES, the facility failed to ensure a Licensed Nurse, Employee Identifier (EI) #2 provided privacy while applying an [MEDICATION NAME] to Resident Identifier (RI) #7's upper chest wall on 9/2/15. The facility further failed to ensure another Licensed Nurse, EI #4 locked the e-MAR (Electronic Medication Administration Record) screen of RI #12 before leaving the medication cart unattended, exposing the medications orders of RI #12. This affected RI #7 and RI #12, two (2) of six (6) residents observed during the Medication Administration Observations. Findings Include: 1) A facility's policy titled MEDICATIONS: [MEDICATION NAME] PATCHES, (no date) documented: . PROCEDURE: . 3. Explain procedure to the resident and provide privacy. RI #7 was originally admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of RI #7's medical record revealed: Physician order [REDACTED]. . [MEDICATION NAME] 9.5 MG/24HR (hour) PATCH APPLY ONE PATCH [MEDICATION NAME] EVERYDAY. On 9/2/15 at 8:00 a.m., during the Medication Administration Observation, RI #7 was observed out of bed, sitting in a chair in the room. RI #7 was eating breakfast and being assisted by a Certified Nursing Assistant (CNA). The surveyor observed EI #2, a Licensed Practical Nurse (LPN), administer the morning medications to RI #4. RI #7 took the scheduled medications by mouth. The [MEDICATION NAME] 9.5 MG patch was to be given at this time. EI #2 removed the old [MEDICATION NAME] from RI #7's right upper chest wall. The door to RI #7's room remained open. A staff member in the hallway passed by RI #7's room. Another staff member EI #9, the receptionist, entered RI #7's doorway and spoke to RI #7. EI #9 stood in the doorway while EI #2 applied the new [MEDICATION NAME] to RI #7's upper left chest wall. This allowed anyone passing by RI #7's room to observe this procedure. RI #7 was pleasantly confused. On 9/2/15 at 10:35 a.m., the surveyor conducted an interview with EI #2. The surveyor asked EI #2, after she gave RI #7 the oral medications, what medication was applied on the resident's body. EI #2 said an [MEDICATION NAME] to the upper left chest. The surveyor asked EI #2, while applying the [MEDICATION NAME] Patch ([MEDICATION NAME]) was privacy provided (to RI #7). EI #2 said it was not a treatment. Then EI #2 said no, she guessed not. EI #2 said she did not close the door. The surveyor asked EI #2 what did the (facility) policy say about applying an [MEDICATION NAME]. EI #2 said to give the resident privacy. On 9/3/15 at 11:50 a.m., the surveyor conducted an interview with EI #1, the Director Of Nursing (DON). The surveyor asked EI #1, when did she expect the staff (medication nurses) to provide privacy while applying a [MEDICATION NAME]. EI #1 said if the resident(s) were in a room, they (the nurse) closed the door. In a semi-private room (the nurse) pulled the curtains, and outside the room (the nurse) would take the resident to the room. The facility failed to maintain RI #7's privacy. EI #2 exposed RI #7's upper chest wall as she pulled the top/blouse back while applying the [MEDICATION NAME]. The door to the room remained open throughout, and staff (non nursing) stood in the doorway during the procedure of the patch removal and application. 2) A facility policy titled Protecting the Privacy of the Electronic Medical Record, (no date) documented: Policy: It is the policy of the facility to ensure that medical records are protected and safeguarded while using electronic medical records. Procedure: 1. While administering medication and treatments using e-MAR and e-TAR (electronic Treatment Administration Record), the nurse will touch the privacy screen button to protect the healthcare information before leaving the medication cart unattended. 3. It is the nurse's responsibility to maintain privacy and security of our resident's health information. RI #12 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A Quarterly MDS (Minimum Data Set) Assessment, with an Assessment Reference Date (ARD) of 07/07/15, identified RI #12 as having short and long term memory problems and severely impaired cognitive skills for daily decision making. RI #12's Physician order [REDACTED]. .ASPIRIN 81 MG (milligrams) CHEWABLE TABLET ONE TABLET PER (by) TUBE EVERY DAY. [MEDICATION NAME] 7.5-325 TABLET ONE TABLET PER TUBE TWICE DAILY .ELLIS TONIC 15ML (milliliters) PER TUBE TWICE DAILY. On 09/02/15 at 8:22 a.m., the surveyor observed EI #4, a LPN medication nurse, prepare the above medications for RI #12. EI #4 entered RI #12's room leaving the e-MAR screen open, revealing the names of RI #12's medications. EI #4 came out of RI #12's room and crushed RI #12's crushable medication. EI #4 again entered RI #12's room making no attempt to close the e-MAR screen before re-entering the room. Staff and visitors were observed walking in the hallway past the medication cart. A Did you lock the e-MAR reminder was observed by the surveyor to be blinking on the e-MAR screen. On 09/02/15 at 8:51 a.m., the surveyor observed EI #4 exit RI #12's room and walk back to the medication cart. A Did you lock cart reminder was observed by the surveyor to be blinking on the e-MAR screen. On 09/03/15 at 11:19 a.m., the surveyor conducted an interview with EI #4. The surveyor asked EI #4, before leaving the medication cart, what should he have done to the e-MAR screen. EI #4 said he should have pushed the privacy screen button on the computer. The surveyor asked EI #4 what would pushing the privacy screen button have ensured. EI #4 replied, It locks the screen, blanks the information off the screen. On 09/03/15 at 11:50 a.m., the surveyor conducted an interview with EI #3, a LPN supervisor. The surveyor asked EI #3 how would the nurses lock the e-MAR screen. EI #3 replied, There's a little button that says Privacy screen. When you leave the med cart you should lock that. That locks the screen.

Based on observation and interviews, the facility failed to ensure two CNAs (Certified Nursing Assistants) were not standing while feeding Resident Identifier (RI) #15 during the breakfast meal on 09/02/15. This deficient practice affected one of seven residents for whom feeding assistance was needed. Findings Include: RI #15 was admitted to the facility on [DATE] with Hospice, and [DIAGNOSES REDACTED]. An Admission MDS (Minimum Data Set) Assessment with an ARD (Assessment Reference Date) of 07/28/15 identified RI #15 as having short and long-term memory problems, and further indicated RI #15 was moderately impaired for cognition. RI #15 was also identified as totally dependent when eating, and having impairments on both sides of the upper extremities. On 09/02/15 at 9:40 AM, RI #15 was observed sitting up in a Geri-chair. RI #15 was being fed the breakfast meal by a CNA, Employee Identifier (EI) #7. EI #7 was observed by the Surveyor to be standing while feeding RI #15. On 09/02/15 at 9:50 AM EI #5, another CNA, entered RI #15's room and started feeding RI #15 the breakfast meal as the resident remained sitting up in the Geri chair. EI #5 was also observed by the Surveyor to be standing while feeding RI #15. EI #7 had exited the room once EI #5 took over feeding RI #15. On 09/02/15 at 9:43 AM, the Surveyor conducted an interview with EI #5. The surveyor asked EI #5 what her body position was when feeding RI #15. EI #5 stated she was standing. EI #5 was asked how she should have been positioned when feeding a resident. EI #5 stated she should have been seated at eye level. EI #5 was asked why she was standing. EI #5 stated, To me I could get (the resident) to eat better by me standing, and (the resident) can see me. EI #5 was asked what the potential harm was to the resident when standing above the resident and feeding them. EI #5 stated, that with them having to hold their head back, there was the possibility of them choking. On 09/02/15 at 12:03 PM, the Surveyor conducted an interview with EI #7. EI #7 was asked what was her body position when feeding RI #15. EI #7 stated she was standing up. RI #7 was asked how she should have been positioned when feeding a resident. EI #7 stated she should have been at eye level, sitting down. EI #7 was asked why was she not seated at the resident's eye level when feeding. EI #7 stated, The way (RI #15's) chair was positioned, I couldn't get eye level. EI #7 was asked how she was taught to be positioned when feeding a resident. EI #7 stated, At eye level. EI #7 was asked what issue could occur with a resident while she was standing up over the resident and feeding the resident. EI #7 stated, It could be a dignity issue or (RI #15) could feel like I was rushing (RI #15). On 09/02/15 at 3:01 PM, the Surveyor conducted an interview with EI #1, the DON (Director of Nursing). EI #1 was asked how a staff member should be positioned when feeding a resident. EI #1 stated, they should be facing them, sitting on the side of bed or sitting in a chair. EI #1 was asked should a staff member ever stand up over the resident and feed them a meal by mouth. EI #1 stated, No. EI #1 was asked what the facility policy was on positioning oneself when feeding a resident. EI #1 stated, They should be one- on-one with them, and sit on the bed or chair, and be able to see eye-to-eye when they are feeding them. EI #1 was asked what the potential harm to the resident was in standing up over the resident and feeding them. EI #1 stated, They may not eat. It is a dignity issue. It's more personal if you are sitting beside them and not towering over them.

Based on observations, record reviews, and interviews the facility failed to ensure a Certified Nursing Assistant (CNA) separated the labia and cleaned the vaginal area when performing incontinent care for Resident Identifier (RI) #11, a resident with a history of UTIs (Urinary Tract Infections), on 09/01/15. This affected RI #11, one of two residents observed during perineal and incontinence care. Findings Include: A review of a facility policy and procedure titled, PERINEAL CARE with no date, revealed: Policy: It is the policy of this facility to provide perineal care that reduces irritation and prevents infection. Procedure: .5. Position the resident for the procedure. 6. For females, separate the labia. 7. Wash the perineum well. RI #11 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of RI #11's most recent Quarter MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 07/28/15 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 4, indicating the resident's cognition was severely impaired for daily decision making. The MDS also revealed the resident required extensive assistance with personal hygiene and toileting. The MDS further revealed the resident was always incontinent of bladder and bowel, and had a history of [REDACTED]. A review of RI #11's Care Plan revealed: .Problem Need. Problem Onset: 01/31/2015. Risk for recurrent UTI. On 09/01/15 at 10:55 AM, the surveyor observed EI #5 and EI #6, (two CNAs), perform perineal and incontinence care on RI #11. Both CNAs washed their hands and donned gloves. EI #5 placed a gait belt on RI #11, and with the assistance of EI #6, RI #11 was placed in bed with EI #5 explaining to RI #11 what they were going to do. Both CNAs pulled off RI #11's sweat pants. With the same gloves on, EI #5 unfastened the left side of RI #11's brief as EI #6 unfastened the right side of the brief. EI #5 pulled the brief down and proceeded to fold, then tuck down the top of the brief that was saturated with urine. EI #5 pulled a clean wipe out a packet and wiped down the right groin. She left the soiled wipe on top of the resident's brief. Then EI #5, with another cloth, wiped down the left groin, folded a corner of the wipe, and wiped down the middle of the resident's perineal area. EI #5 left that wipe on top of the brief. EI #5 was observed wiping from front to back, but did not separate the labia and clean the labial folds from outer to inner before cleansing down the middle of the perineal area. On 09/01/15 at 2:30 PM, the Surveyor conducted an interview with EI #5. EI #5 was asked, during incontinence care how should the labia be cleansed. EI #5 stated, From the front to back, go down area of the groin; fold cloth, go to other groin area; fold the cloth, then go down middle; spread it apart and clean it. EI #5 was asked how she cleaned it (the labia). EI #5 stated, I cleaned one side, got another (wipe), clean(ed) the other side, fold(ed) it and went down the middle. EI #5 was asked if she separated the labia and cleaned the inner parts before cleaning down the middle. EI #5 stated she did not. EI #5 was asked why she did not. EI #5 stated she forgot; that she was nervous. EI #5 was asked what the potential harm to the resident was if the labia were not cleansed correctly. EI #5 stated, Bacteria, UTIs. On 09/03/15 at 12:12 PM, the Surveyor conducted an interview with EI #8, the RN (Registered Nurse Supervisor) of Station Two. EI #8 was asked, during incontinence care how should the labia be cleaned. EI #8 stated, Outer, outer, on each side of the inside, then straight down the middle. EI #8 was asked how the hands be positioned when cleaning the labia. EI #8 stated, One to hold it open and the one to wipe it with. EI #8 was asked what the potential harm to the resident was if the labia was not cleaned properly or correctly. EI #8 stated, UTI, susceptible to infections.

Based on observations, record review, interviews and review of a facility policy titled Controlled Medication Administration, the facility failed to ensure two LPNs (Licensed Practical Nurses) did not sign the Narcotic Inventory Log sheets before administering narcotic medications. This affected Resident Identifier (RI) #7 and #12, two (2) of five (5) residents receiving narcotic medications during the Medication Administration Observations on 09/02/15. Findings Include: 1) A facility policy titled: Controlled Medication Administration, (no date) documented: Policy: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility, in accordance with state/federal laws and regulations. Procedure: . · When a controlled medication is administered, the authorized personnel administering the medication must immediately complete the inventory log sheet . RI #12 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A Quarterly MDS (Minimum Data Set) Assessment, with a ARD (Assessment Reference Date) of 07/07/15, identified RI #12 as having short and long term memory problems and severely impaired cognitive skills for daily decision making. RI #12's Physician order [REDACTED]. . [MEDICATION NAME] 7.5-325 TABLET ONE TABLET PER TUBE TWICE DAILY . On 09/02/15 at 8:22 AM, the surveyor observed EI #4, a LPN (Licensed Practical Nurse) medication nurse open the narcotic book and sign RI #12's [MEDICATION NAME] 7.5-325 mg inventory log sheet. EI #4 next opened the narcotic box, pulled out the card of [MEDICATION NAME] 7.5-325 mg tablets, and punched one pill into a medication cup. On 09/03/15 at 11:19 AM, the surveyor conducted an interview with EI #4. The surveyor asked EI #4, when administering a narcotic medication, what should be done first. EI #4 said the label (on the medication) should be compared with the MAR (Medication Administration Record); you would pull the medication first, and then you would sign the medication off on the narcotic sheet (inventory log). On 09/03/15 at 11:50 AM, the surveyor conducted an interview with EI #3, a LPN supervisor. The surveyor asked EI #3 what procedure was used when administering or removing a narcotic medication. EI #3 replied, Unlock box, make sure count is right, pop pill out, and then sign it out. 2) RI #7 was originally admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of RI #4's medical record revealed: Physician order [REDACTED]. . [MEDICATION NAME] 50 MG (Milligrams) TABLET GIVE ONE BY MOUTH FOUR TIMES DAILY . On 09/02/15 at 8:00 AM, during the Medication Administration Observation, RI #7 was observed out of bed, sitting in a chair in the room. The surveyor observed EI #2, a Licensed Practical Nurse (LPN), medication nurse open the narcotic book and sign RI #7's [MEDICATION NAME] 50 MG inventory log sheet before she reviewed the medication to ensure the balance in the log book was correct. EI #2 opened the narcotic box, pulled out the card of [MEDICATION NAME] 50 MG tablets, and punched one pill into a medication cup for RI #7. On 09/02/15 at 10:35 AM, the surveyor conducted an interview with EI #2. The surveyor asked EI #2 if she was supposed to sign the narcotic book before she removed the drug from the locked compartment. EI #2 stated, No, you should review the drug, then sign the narcotic book. On 09/03/15 at 11:50 AM, the surveyor conducted an interview with EI #1, the Director Of Nursing (DON). The surveyor asked EI #1, when are the nurses supposed to sign the narcotic book. EI #1 said they should sign the narcotic book when looking at the card. EI #1 then said, after they gave the medication, the nurse would sign the e-MAR (electronic Medication Administration Record). The surveyor asked EI #1, should the nurse sign the narcotic book before she removed the narcotic from the locked compartment, and punched it out. EI #1 stated, No, they should (first) look at the medication and make sure the count is right. Then punch it out, sign the med(ication) out, put the pack back in the locked compartment; lock it, then administer the medication, then sign the e-MAR.

Based on observation, interview, and document review, the facility failed to ensure a licensed nurse closed the door and pulled the privacy curtain when administering eye drops to RI (Resident Identifier) #25 on 09/24/14 during the morning medication pass. This affected one of five residents observed during the medication pass observation. Findings include: A facility policy titled "Eye Drops", no date, documented: "... Steps in the Procedure ... 8. Close the door. 9. Pull the cubicle curtain around the bed for privacy ..." RI #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #25's physician's orders [REDACTED]. "... [MEDICATION NAME] 0.5% DROPS ... INSTILL 1 DROP IN BOTH EYES EVERY MORNING ..." On 09/24/14 at 7:30 a.m., the surveyor observed an LPN (Licensed Practical Nurse), Employer Identifier (EI) #2, knock on the door and enter RI #25's room. RI #25 was sitting in a Geri-chair on the right side of the room and the roommate was sitting on the left side of the room. EI #2 removed the top from the eye drops stating she was going to place a drop into the resident's eye. EI #2 administered an eye drop to RI #25's right then left eye. EI #2 failed to close the door and pull the privacy curtain between the two residents before administering the eye drops to RI #25. On 09/24/14 at 12:38 p.m., the surveyor conducted an interview with EI #2. The surveyor asked EI #2 how she would provide for privacy when administering eye drops. EI #2 said she would close the door. The surveyor asked EI #2 what did she not do when administering RI #25's eye drops. EI #2 replied she did not close the door and pull the privacy curtains. On 09/25/14 at 11:10 a.m., the surveyor conducted an interview with EI #1, the DON (Director of Nursing). The surveyor asked EI #1 how were the nurses expected to provide for privacy when administering eye drops. EI #1 said the nurses are suppose to pull the curtain or close the door. EI #1 said if the room was a semi-private room and someone was in the room, the nurse should pull the privacy curtain.