Every finding on record at Aliceville Manor Nursing Home

Based on observations, interviews, and record review, it was determined that the facility failed to ensure respiratory care, specifically the provision of oxygen therapy at prescribed rate, was provided in accordance with professional standards of practice for one (Resident #31) of one resident reviewed for respiratory care. Findings included: A review of a Face Sheet indicated the facility admitted Resident #31 on 12/27/2021 with diagnoses that included Anxiety and Chronic Obstructive Pulmonary Disease (COPD). A review of Resident #31's Care Plan(s), initiated on 12/27/2021, revealed the resident was at risk for shortness of breath related to a diagnosis of COPD. The care plan indicated the resident had oxygen therapy ordered as needed. Interventions directed staff to administer the resident's medications, respiratory treatments and oxygen as ordered. A review of Departmental Notes, dated 06/20/2023 at 2:47 AM and written by Registered Nurse (RN) #20, indicated RN #20 assessed Resident #31 and documented hearing rales (clicking, bubbling, or rattling sounds) in all lung fields. Per the note, a breathing treatment was administered without effect, the Nurse Practitioner (NP) was called, and orders were received. A review of a handwritten Physician Orders document revealed an order dated 06/20/2023 (no time indicated) for oxygen via a non-rebreather (face mask) at 5 (five) liters per minute (LPM). The order was signed by a Nurse Practitioner (NP). On 06/20/2023 at 9:40 AM, Resident #31 was observed lying flat on a bed with oxygen being delivered via a concentrator through a face mask at a rate of 2.5 (two and one-half) LPM. The resident was noted to have a wet-sounding cough at that time. On 06/20/2023 at 11:30 AM, Resident #31 was observed with oxygen being delivered at 2.5 (two and one-half) LPM via face mask. During an interview on 06/20/2023 at 12:00 PM with RN #17, she said that Resident #31 was supposed to be on oxygen at 5 (five) LPM. A Departmental Note, dated 06/20/2023 at 12:29 PM revealed RN #17 documented Resident #31 was on oxygen via face mask at 3 (three) LPM. The note indicated the resident's oxygen saturation measured 86% and the oxygen was increased to 5 (five) LPM via face mask. During an interview on 06/20/2023 at 12:58 PM, the NP indicated she then received a call around 6:45 AM on 06/20/2023 regarding the resident's oxygen saturation being in the low 80s, so an order was given to increase the oxygen to 5 (five) LPM. The NP noted a face mask or non-rebreather mask would be used at that rate of oxygen. The NP was unable to state why Resident #31's oxygen was not set at 5 (five) LPM earlier as that was her order at 6:45 AM that morning. The NP stated it was her expectation for orders to be followed by nursing staff. On 06/21/2023 at 10:10 AM, Resident #31 was observed lying on the bed with the head of the bed at approximately 30 degrees. A face mask was in place with oxygen delivery at 3 (three) LPM. On 06/23/2023 at 12:30 PM, the Director of Nursing (DON) stated nursing staff should have followed orders provided the morning of 06/20/2023.

Based on observations, interviews, a facility policies titled, Resource: Taking Accurate Temperatures, and Food Safety and Sanitation, the facility failed to ensure: 1. staff wore hair nets while in the kitchen and 2. staff took the temperatures of all foods on the tray line. This had the potential to affect 73 of 73 residents receiving meals from the kitchen. Findings include: A facility policy titled, Food Safety and Sanitation with no effective dated, revealed: Policy: All local, state and federal standards and regulations will be followed in order to assure a safe and sanitary food and nutrition services department. Procedure: . 2. Employees . c. Employees are required to have their hair styled so that it does not touch the collar, and to wear clean aprons, clothes and shoes. * Hair restraints are required and should cover all hair on the head. During the initial tour of the kitchen on 09/24/19 at 09:51 AM Employee Identifier (EI) #1 was observed in the kitchen fixing a cup of coffee, not wearing a hair net. On 09/26/19 at 10:59 AM, an interview was conducted with EI #3, Dietary Manager. EI #3 was asked what were employees supposed to do before they entered the kitchen. EI #3 replied, once they enter the kitchen they put on their hairnets and wash their hands. EI #3 was asked, was there an employee in the kitchen on 9/24/19 without a hair net on. EI #3 replied, yes, EI #1. EI #3 was asked, why was EI #1 in the kitchen without a hair net on. EI #3 replied, she was getting coffee for a resident. EI #3 was asked, what was the potential concern of an employee coming into the kitchen without a hair net on. EI #3 replied, they do not want to cause any cross contamination. On 09/26/19 at 11:14 AM, an interview was conducted with EI #1 Registered Nurse Supervisor. EI #1 was asked, what was she supposed to do before she entered the kitchen. EI #1 replied, put a hair net on. EI #1 was asked, did she have a hair net on when she was in the kitchen on 9/24/19. EI #1 replied, she did not. EI #1 was asked, what was the potential concern of being in the kitchen without a hair net on. EI #1 replied, contamination. A facility policy titled, Resource: Taking Accurate Temperatures, with no effective date revealed: 3-32 . Taking Accurate Temperatures using Metal Stem Thermometers . 2. To take hot food temperatures, insert the thermometer at a 45-degree angle to the middle of the food item, taking care not to touch the container or bone if applicable. Wait for the thermometer to rise to the maximum temperature, read and record the temperature and then remove the thermometer from the food item and immediately clean and sanitize. Repeat these guidelines until all hot food temperatures have been taken. 3. To take cold food temperatures, insert the thermometer at a 45-degree angle to the middle of the food item using care not to touch the container. Wait for the thermometer to drop to the minimum temperature, read and record the temperature and then remove the thermometer from the food item and immediately clean and sanitize. Repeat this guideline until all cold food temperatures have been taken. On 09/25/19 at 11:31 AM, during the tray line service an observation was made of the food temperatures being checked by EI #4, cook. An observation was made of 14 food items on the tray line. The temperature was not taken of the hamburger patties, mechanical turkey, or the tatter tots. Dishes of covered pears came out on a cart; the temperature was not taken. On 09/26/19 at 09:09 AM, an interview was conducted with EI #4, Cook. EI #4 was asked, when were the temperatures taken of the food. EI #4 replied, soon as you put it on the line. EI #4 was asked, what all on the line should be tempted. EI #4 replied, everything. EI #4 was asked, did she take the temperature of the hamburger patties on the line on 9/25/19. EI #4 replied, she took the temperature as soon as she put it on the line but EI #3 told her to stop because the surveyor wanted to see her tempt everything; the tatter tots were the same thing she had already done it but she forgot to do it in front of the surveyor. EI #4 was asked, did she take the temperature of the mechanical turkey on 9/25/19. EI #4 replied, she tempted it but she did not write it in because EI #3 stopped her. EI #4 was asked, was the temperature taken of the pears on 9/25/19. EI #4 replied, normally the aid tempted the desserts before the line starts. EI #4 was asked, did she know if that was done. EI #4 replied, she did not. EI #4 was asked, what was the potential concern of not taking the temperatures of all of the foods. EI #4 replied, it could be in the danger zone.

Based on record review, interview, and a facility policy titled, Nursing Comprehensive Care Plan (Developing) , the facility failed to ensure that Resident Identifier (RI) #58 had a baseline care plan within 48 hours. This affected 1 of 19 sampled residents. Findings include: A facility policy titled, Nursing Comprehensive Care Plan (Developing, last revised 10/17, revealed: Policy Plans of care are developed and implemented by the interdisciplinary team to coordinate and communicate care approaches and goals for the resident related to clinical [DIAGNOSES REDACTED]. Baseline Care Plans will be developed within 48 hours of a resident's admission and include the minimum healthcare information necessary to properly care for a resident including, but not limited to-Initial goals based on admission orders [REDACTED]. The facility will furnish each resident/resident representative with a summary of the Baseline Care Plan. RI #58 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A record review on 9/26/19 revealed, RI #58 was admitted on [DATE] and a Baseline Care Plan was not done until 7/29/19. On 09/26/19 at 11:19 AM an interview was conducted with Employee Identifier (EI) #5, Registered Nurse. EI #5 was asked, when should a base line care plan be done. EI #5 replied, it has to be done within 24 hours of their admitted . EI #5 was asked, when was RI #58's done. EI #5 replied, 7/29/19. EI #5 was asked, when was RI #58 admitted . EI #5 replied, 7/26/19. EI #5 was asked, what was the potential harm of not having a base line care plan for 3 days. EI #5 replied, when they first come in it is critical to do the base line care plan so you have an over all look of their base line health condition, and also the staff need to know how to take care of the resident. EI #5 was asked, what would be the concern of not having a base line care plan for 3 days. EI #5 replied they broke policy; they did not have an overall picture of him/her at all for those first 3 days. EI #5 was asked, how did the staff know how to take care of him/her those first few days. EI #5 replied, they had to learn on their own.

Based on observations and interviews, the facility failed to ensure: 1) crumbs and spots were not in the mixer bowl that was covered and stored for future use; 2) plates were not wet nesting in the plate warmer and; 3) the temperature of the milk at the lunch meal was taken. This had the potential to affect 77 of 77 residents who received meals from the kitchen. Findings Include: 1) On 8/21/2018 at 12:09 p.m., the mixer was wrapped for storage in plastic and four spots were noted in the bottom of the mixer bowl. There was food particle/crumbs on the top area of the mixer probe. On 8/23/18 at 9:34 a.m., an interview was conducted with EI #10, Certified Dietary Manager (CDM). EI #10 was asked what was covered and wrapped in plastic covering for future use. EI #10 replied, the floor mixer. EI #10 was asked what was in the mixer bowl and on the probe at the top of the mixer. EI #10 replied, just some particle debris. EI #10 was asked why was it important that kitchen equipment was free of food debris. EI #10 replied, they have to have equipment clean and sanitized for future use. EI #10 said they did not need any kind of bacteria growth. EI #10 was asked what did the facility policy say regarding wrapped dirty equipment. EI #10 replied, after use, equipment must be cleaned and sanitized and covered. EI #10 was asked when equipment was wrapped with food debris in it, was that an attraction for pest. EI #10 replied, yes. 2) On 8/22/2018 at 11:47 a.m., the surveyor observed the first plate in the plate warmer had water in it. The worker pulled the plate and put food in it. The surveyor observed seven wet plates with a large amount of water in the plates. The surveyor pointed the wet plates out to the Cook and CDM. The Cook pulled plates from the line and the CDM pulled ten plates from the line. A total of 17 plates were pulled. On 8/22/18 at 1:08 p.m.,the surveyor conducted an interview with EI #11, the Cook/ Dietary Aide. EI #11 was asked what was in plates that she was plating. EI #11 replied, water. EI #11 was asked did she put food in plates with water in the plates. EI #11 replied, she could not remember. EI #11 stated the plate warmer was not getting hot like it was supposed to. EI #11 was asked who was responsible for making sure plates were not wet. EI #11 replied, the morning puller. EI #11 was asked why should plates be free of water. EI #11 replied, it was not safe to serve food in wet plates. EI #11 was asked what did the facility policy say regarding putting food in wet plates. EI #11 replied it was not safe. EI #11 was asked how many plates did she pull from the tray line wet. EI #11 replied, about five or six. On 8/23/2018 at 9:30 a.m., the surveyor conducted an interview with EI #10. EI #10 was asked what did she observe in plates on the tray line. EI #10 replied, some condensation water. EI #10 was asked how many plates did she pull from the tray line to send back to the dish room. EI #10 replied, about eight. EI #10 was asked why should resident plates be free of water. EI #10 replied, it was contamination, bacteria, and as far as serving food in wet plates it was a dignity issue. EI #10 was asked were plates stacked on top of each other wet. EI #10 replied, yes. EI #10 was asked what was the facility policy on serving food in wet plates to the residents. EI #10 replied, they were not suppose to have any type of wet nesting. 3) On 8/22/2018 at 11:47 a.m., the surveyor observed milk on the food carts to go out to the residents. The surveyor observed no one taking the temperature of the milk. On 8/23/18 at 11:31 a.m., the surveyor conducted an interview with EI #10. EI #10 was asked who took the temperature of the milk on 8/22/18. EI #10 replied, she did not know. EI #10 was asked when should milk temperatures be taken. EI #10 replied, before meals. EI #10 was asked who recorded the milk temperature. EI #10 replied, she did not know. EI #10 was asked did milk leave the kitchen without the temperature being taken. EI #10 replied, she did not know. EI #10 was asked why should milk temperature be taken before giving milk to the residents. EI #10 replied, to make sure it was at the proper temperature. On 8/23/18 at 12:10 p.m., the surveyor conducted an interview with EI #14, dietary staff. EI #14 was asked did she take milk temperatures on 8/22/18. EI #14 replied, no. EI #14 was asked who took the milk temperature. EI # 14 replied, EI #16 would have been responsible for yesterday's lunch milk temperatures. EI #14 stated EI #16 would tell her what the temperature was and she would write it down. EI #14 was asked did EI #16 give her a temperature to write down on 8/22/2018. EI #14 replied, no she did not give her a temperature to write down.

Based on observations and interview, the facility failed to ensure the Dementia Unit dining area floor was free of brown stains. The facility further failed to ensure water did not drip from condensation collected at the air conditioner vent onto the hallway floor and ceiling tiles were also free from brown stains. This affected the Dementia Unit dining room and one of two hallways outside of two resident rooms. Findings include: On 08/23/18 at 08:56 AM, an observation was made of condensation from an air vent for an air conditioner dripping to the floor outside of rooms [ROOM NUMBERS]. Brown stains were also noted on the ceiling tiles around the vent. 08/23/18 09:09 AM, an observation was made in the Dementia Unit dining room of brown spots on the floor. On 08/23/18 at 12:15 PM, an interview was conducted with Employee Identifier( EI) #8, Maintenance Director. EI #8 was asked what did they observe with the ceiling air vents outside of room [ROOM NUMBER] and also in the hallway outside room [ROOM NUMBER]. EI #8 replied, condensation from the air conditioner with water dripping to the floor. EI #8 was asked, what did they observe on the dining area floor in the Dementia Unit. EI #8 replied, glue that had come up from under tiles causing brown spots. EI #8 reported this had been caused from chemicals used to clean the floors. EI #8 was asked, who was responsible for the upkeep to these areas. EI # 8 replied, maintenance. EI #8 was asked, what was the harm in the areas not being maintained properly. EI #8 replied, dripping on the floor could cause a slip by someone and the dining area in the Dementia Unit was unsightly.

Based on observation, interview, record review and review of a facility policy titled, Abuse, the facility failed to ensure Resident Identifiers (RI) #'s 27, 29, 49, 51, 83 and 334 were free of neglect, as reported by the facility to the State Agency on 8/10/18. This affected six of six residents reported as neglected by staff. This deficient practice was cited as a result of the investigation of complaint/report AL 830. Findings Include: A review of a facility policy ABUSE, with a last revised date of 03/17, revealed: Policy Residents have the right to be free from abuse, neglect, . A review of an Online Incident Report submitted by the facility on 8/10/2018 at 5:22 PM revealed: .Incident Type .Neglect .7) . Residents involved were RI #51, RI #334, RI #27, RI #83. The narrative summary of the incident revealed, the residents listed above were upset regarding the care they did not receive on the 11-7 shift. RI #51 stated that he/she did not get his/her bath or get up to get dressed. RI #334 stated that he/she was not turned all night. RI #27 was left soiled and was not cleaned. RI #83 stated that the Certified Nursing Assistant, (CNA) set his/her bath stuff up and told the resident to bath self and make own bed because she (CNA) did not have time because it was too close to 7:00 AM. The Administrator typed the following allegation: On the morning of (MONTH) 10, (YEAR), . ADON (Assistant Director of Nursing) reported to . DON (Director of Nursing) and myself that several residents (or their caregivers on 7-3 shift) reported that certain aspects of their care had not been provided on 11-7 shift. (name of CNA ) was the CNA assigned . Instructed . Social Service Director to interview other residents assigned to (name of CNA) on 11-7 shift . Statements were taken from RI #51, 334, 83 and 27. RI #29 and RI #49 were two residents added to the list after staff interviews revealed RI #29 was not cleaned up on 11-7 and RI #49 was in bed with stool and a wet sheet. RI #27 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #29 was readmitted to the facility 3/21/18 with a [DIAGNOSES REDACTED]. RI #49 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED].#49 reported the staff on the 11-7 shift did not provide care to the resident and the 7-3 shift found the resident soiled and the top sheet was wet. RI #51 was readmitted to the facility 7/7/15 with a [DIAGNOSES REDACTED].#51 and the son revealed RI #51 voiced to the son on 8/10/18 that he/she was not given a bath or gotten out of bed on the 11-7 shift, as was the usual routine. RI #83 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #334 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A brief interview with RI #334 on 8/21/18 at 2:12 PM revealed, the 7-3 shift came in and said bowel movement had been on resident to long and they needed to get it off. On 8/22/18 the surveyors made an unannounced entry to the facility at 4:00 AM to observe staff and care being provided. No negative observations were made at that time. On 8/22/18 at 4:15 AM, an interview was conducted with EI #5, CNA. EI #5 was asked if she worked with EI #15 and if she worked on 8/10/18. EI #5 replied, yes. EI #5 was asked to give a brief description of what did or did not occur. EI #5 replied later after she left work the DON called her and asked questions about EI #15 not giving care. EI #5 replied she was not aware as she was busy doing her assigned residents. On 8/22/18 at 4:45 PM, a phone interview was conducted with EI #3, the LPN coming on the 7-3 shift following EI #15. EI #3 was asked how she was made aware of residents not receiving care the night before. EI #3 replied, when she came in and was making her walking rounds she observed that residents that were usually up were not. EI #3 replied she tried to ask EI #15 about those residents and EI #15 would not respond and left the unit. EI #3 also reported that other CNAs on the 7-3 shift had reported to her of other residents found wet, soiled, not gotten up and not having been turned. EI #3 was asked what did she do to EI #15. EI #3 replied nothing, she tried to question her but she would not talk and left. EI #3 was asked what form of abuse was the incident. EI #3 replied, neglect. EI #3 was asked what was being done since the occurrence to assure it would not happen again. EI #3 replied, education and the nurses were to make pop in observations and observe staff giving care. EI #3 was asked if she was doing that. She replied yes, and the DON and ADON were making rounds as well. On 8/23/18 at 8:30 AM, an interview was conducted with EI #4, another CNA working the 11-7 shift on 8/10/18. EI #4 was asked if he worked the 11-7 shift with EI #15 on 8/10/18. He replied, yes. EI #4 was asked if he observed EI #15 giving care to her assigned residents. EI #4 replied, he knew she was up and in and out of resident rooms at times, but he was doing his own assignment and not sure what care she was performing. On 8/23/18 at 9:30 AM, an interview was conducted with EI #6, Social Service Director. EI #6 was asked what did or did not occur on 8/10/18. EI #6 replied when she arrived to work on 8/10/18 the Administrator (EI #1) told her residents complained of not getting care on the 11-7 shift. EI #6 replied the Administrator instructed her to go and interview other residents and get statements. The residents did not give a name, they only said she. EI #6 was asked how was it determined which staff it was. EI #6 replied by assignment sheets and a video. EI #6 was asked which residents were involved. EI #6 replied, resident names (RI #27,29, 49, 51, 83 and 334). EI #6 was asked what was it when staff did not check or change residents assigned to them. EI #6 replied, neglect. EI #6 was asked what had been done to assure it would not occur again. EI #6 replied, educated other staff, EI #15 had been terminated, and staff was being monitored. On 8/23/18 at 9:40 AM, an interview was conducted with EI #2, DON. EI #2 was asked what did or did not occur on the 11-7 shift on 8/10/18. EI #2 replied, when she arrived to work that morning residents had reported not getting up and not getting bathed or care. The 7-3 shift staff had reported finding residents wet, soiled and not up and given care. EI #2 continued saying she reported to the Administrator upon her arrival and an investigation was started. The staff on the 11-7 shift was called to return to the facility and interviewed. A video was reviewed and determined EI #15 had those assignments and did not give the care. Education was started and EI #15 was terminated. EI #2 was asked if care was given to the other residents. EI #2 replied, yes. EI #2 was asked when should care be given. EI #2 replied, every two hours and bathing and getting up started at 5:00 AM. EI #2 was asked what was it when staff did not check or change residents assigned to them. EI #2 replied, neglect. EI #2 was asked what had been done to assure it did not reoccur. EI #2 replied, education to be completed by 8/31/18 and compliance rounds. On 8/23/18 at 10:00 AM, an interview was conducted with EI #1, Administrator. EI #1 was asked to give a brief recap of what did or did not occur. EI #1 replied, it was reported to her upon arriving to the facility by the DON that care was not given on the 11-7 shift and an investigation was started. EI #1 was told by EI #2 that she assured care was given once she was made aware. EI #1 reported that after reviewing the video, watching the 11-7 staff, it was determined that EI #15 did not provide care. EI #15 was terminated. EI #1 was asked if she reviewed the video past to determine if that was EI #15's usual routine. EI #1 replied, no, there had never been any concerns before that one. EI #1 was asked how many residents were assigned to each staff and who was responsible for providing care. EI #1 replied she was not sure, as assignments were made by rooms and if it required two to assist they would help each other. EI #1 was asked about the performance of the other CNAs. EI #1 replied by reviewing the video it appeared care was performed by them. EI #1 was asked when should care have been performed. EI #1 relied, all during the night, every two hours and at 5 AM baths were started and residents that wish were assisted up. EI #1 was asked what was it when staff did not check or change residents assigned to them. EI #1 replied neglect. EI #1 was asked what was being done to assure it did not reoccur. EI #1 replied, education and nurse supervisors were observing care, and compliance rounds were being performed on varying shifts at varying times.

Based on observation, interview and record review, the facility failed to ensure Employee Identifier (EI) #7, Licensed Practical Nurse, did not place the cap from the eye drop medication bottle on Resident Identifier (RI) #48's over the bed table, then return the cap to the bottle after instilling the drops. This affected one of five nurses observed during medication pass. Findings Include: RI #48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #48's (MONTH) Physician order [REDACTED].[MEDICATION NAME] .CALCIUM .[MEDICATION NAME] OPHTH (Opthalmic) EYE GTTS (drops) 1 GTT OU (both eyes) BID (two times a day) . On 8/22/18 at 9:13 AM EI #7 was observed giving RI #48's scheduled medication. EI #7 prepared the medications and entered the room. EI #7 gave the by mouth medications then washed her hands and put on gloves. EI #7 removed the cap from the eye drop medication bottle and placed the cap on the over the bed table without a barrier between the table and bottle cap. EI #7 instilled a drop into each eye then picked up the bottle cap and placed it back on the eye drop medication bottle. On 8/22/18 at 9:20 AM an interview was conducted with EI #7. EI #7 was asked what was the policy on where to place the cap for an eye drop bottle while you are instilling the drops. EI #7 replied, hold it in her hand. EI #7 was asked where did she place the cap. EI #7 replied, on the over the bed table. EI #7 was asked what was the risk of placing the cap to the eye drop bottle on the over the bed table without a barrier. EI #7 replied, it could get bacteria or germs and they will go to the bottle and contaminate the drops, then to the resident. On 8/23/18 at 11:40 AM an interview was conducted with EI #9, Registered Nurse/ Infection Control. EI #9 was asked what was the policy on where to place the cap of an eye drop medication while the medication was being instilled in the resident eyes. EI #9 replied, on a barrier. EI #9 was asked when should staff place the cap on an over the bed table without a barrier. EI #9 replied, never. EI #9 was asked what were the risks of not placing the cap on a barrier. EI #9 replied, contamination.

Based on observation, interviews and a review of a facility policy titled, Dispose of Garbage and Refuse the facility failed to ensure the dumpster lid was closed, free of debris on top of the lid, around the dumpster and free of a foul odor. This had the potential to affect all 77 residents residing at the facility. Findings Include: A review of a facility policy titled, Dispose of Garbage and Refuse with a date of 8/2017 revealed: Policy Statement .Procedures 1. The Dining Services Director coordinates with the Director of Maintenance to ensure the area surrounding the exterior dumpster area is maintained in a manner free of rubbish or debris. On 8/21/18 at 11:52 a.m., the surveyor along with the CDM/ EI #10 toured the dumpster area. The surveyor observed trash hanging out of the dumpster. When facing the dumpster, one lid was opened all the way on the back side. On the top side the right lid was opened about a fourth of the way. The surveyor observed water around the dumpster, a glove on top of the lid and a trash bag on top with gloves in it. The surveyor also observed a bed pad on the ground on the right side of the dumpster. There was trash around the dumpster including glass, paper sticks and flies flying around the water with a foul odor noted. On 8/ 8 at 09:42 a.m., the surveyor conducted an interview with EI #10. EI #10 was asked what did she see on top of the dumpster. EI #10 replied, papertowel's, blue gloves, and a ripped bag. EI #10 was asked why was it there. EI #10 replied the trash was not properly disposed of. EI #10 was asked who was responsible for making sure the dumpster was free of debris and making sure it was closed. EI #10 replied, she was told maintenance because of the heavy lids on top of the dumpster. EI #10 was asked why was it important that the dumpster was closed and free of debris. EI #10 replied in her opinion for pest control. EI #10 was asked what could happen when the dumpster lid was left opened with water and other debris around the dumpster. EI #10 replied, attraction of different kind of pest, animals and critters could come closer to the building. EI #10 was asked was the lid on the back side opened. EI #10 replied, yes. EI #10 was asked was there a smell at the dumpster. EI #10 replied, yes, a soured smell. On 8/23/18 at 12:28 .p.m., the surveyor conducted an interview with EI #8, the Maintenance Director. EI #8 was asked who was responsible for keeping the dumpster lid closed. EI #8 replied, all staff, housekeeping, maintenance and dietary staff. EI #8 was asked when should the dumpster lid be closed. EI #8 replied, every time you dump trash in it, and every time the garbage truck came make sure it was closed. EI #8 was asked why should the lid be closed on the dumpster. EI #8 replied, to keep animals out so they will not drag the trash everywhere. EI #8 stated, biohazard. EI #8 was asked what was the potential harm to the residents when the dumpster lid was not closed, gloves, paper towel, and trash was on top of the lid and on the ground, and there was a foul smell around the dumpster. EI # replied, it would attract pest to the nursing home. EI #8 was asked when was the dumpster last cleaned. He replied, the previous Friday, 17th.

Based on observation, a review of facility handwashing and incontinence policies, medical record review, and staff interviews, the facility failed to ensure a Certified Nursing Assistant (CNA) washed her hands after providing continence care to Resident Identifier (RI) #5, who was wet with urine, and before putting a clean incontinent brief on the resident. This affected RI #5, one of two sampled residents observed for incontinent care. EI #1 stated handwashing was to be done before and after incontinent care. EI #1 stated she did not wash her hands when she put the clean brief on the resident, and affirmed it would contaminate the clean brief. Findings Include: A facility policy titled, Incontinence/Perineal Care with a revision date of 07/01/09 revealed: . 3) Wash hands thoroughly before, during, as needed, and after procedure: wear gloves. A facility policy related to Handwashing dated 07/01/09 revealed: Purpose: To provide guidelines to employees for proper and appropriate handwashing techniques that will aid in the prevention of the transmission of infections. .I. When to wash hands: . 6) After handling used dressing, .contaminated tissues . etc . 8) After handling items potentially contaminated with a resident's blood, body fluids, excretions . 9) After removing gloves. RI #5 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A nursing care plan related to the risk for infection, dated 02/29/16 revealed: (RI #5) has the potential for urinary tract infection r/t (related to) frequent incontinence of bladder and occasional incontinence of bowels and dx (diagnosis) of personal history of UTI's (Urinary Tract Infections). Approaches included: Incontinence care per facility protocol. On 07/12/17 at 4:10 PM, a Certified Nursing Assistant (CNA) Employee Identifier (EI) #1 provided incontinent care for RI #5. At the initiation of care, EI #1 washed her hands, donned gloves and opened the resident's brief. The brief was wet with urine. EI #1 wiped the resident's skin and changed her gloves throughout the provision of care, but with each change of soiled gloves, she failed to wash her hands. On 07/12/17 at 4:40 PM, an interview was conducted with EI #1. The CNA was asked to explain the facility policy regarding the washing of hands during incontinent care. EI #1 was asked if she washed her hands before putting the clean pad/incontinent brief underneath the resident. EI #1 stated she did not wash her hands when she put the clean brief on the resident, and affirmed it would contaminate the clean brief. On 7/12/2017 at 5:20 PM, an interview was conducted with the Nursing Supervisor (EI #2) who had also observed EI #1 provide the above incontinence care. When asked what potential harm could result from the lack of hand washing during incontinence care, EI #2 replied infection could spread to the resident, other residents and throughout the room and facility.

Based on observations, record reviews, and interviews, the facility failed to follow a Physician's order written on 03/16/2016 for a Magic Cup twice daily with lunch and supper for RI (Resident Identifier) #8, a resident who was admitted with a Stage III (three)pressure ulcer, had a low [MEDICATION NAME] level, and had the potential for altered nutrition. This affected one of thirteen sampled residents whose Physician orders were reviewed. Findings Include: A review of Fundamentals of Nursing, Eighth Edition, copyright 2013, Chapter 23 Legal Implications in Nursing Practice, page 305, revealed the following: . Health Care Providers' Orders. The health care provider . is responsible for directing medical treatment. Nurses follow health care providers' orders unless they believe the orders are in error or harm patients . RI #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #8's Quarterly MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 05/29/2016, revealed RI #8 had a BIMS (Brief Interview for Mental Status) of 14, which indicated the resident was cognitively intact for daily decision making. The MDS, under Skin and Ulcer Treatments, was checked for nutrition and hydration intervention to manage skin problems. A review of RI #8's Physician orders for the month of July 2016 revealed: . MAGIC CUP PO (by mouth) TWICE DAILY LUNCH & (and) SUPPER . A review of RI #8's Laboratory Results, with a Specimen Date of 03/14/16 and a result date of 03/14/2016, revealed RI #8 had a low [MEDICATION NAME] Level with a result value of 2.8. The reference range per the laboratory results should be 3.5 - 5.7. Documented under the Clinic Comments was add Magic Cup twice daily. A review of RI #8's dietary tray card for 07/27/2016 and 07/28/2016 revealed no Magic Cup as a supplement. On 07/27/2016 at 1:00 p.m., RI #8's lunch tray was observed with no Magic Cup. On 07/28/2016 at 12:30 p.m. RI #8 was asked if a Magic Cup was on the 07/27/16 lunch and dinner tray. RI #8 said, No. On 07/28/2016 at 12:40 p.m., RI #8's lunch tray was observed with no Magic Cup. On 07/28/2016 at 1:00 p.m., RI #8 was asked if a Magic Cup was on the lunch tray. RI #8 said, No. On 07/28/2016 at 1:10 p.m., an interview was conducted with EI (Employee Identifier) #2, Dietary Manager. EI #2 was asked what the Physician's order was for RI #8. EI #2 said Magic cup for lunch and supper. EI #2 was asked if the Physician's order was followed. EI #2 said no. EI #2 was asked why RI #8 should receive the Magic Cup. EI #2 said for low weight and a wound. EI #2 was asked who was responsible to ensure supplements were on the tray. EI #2 said dietary. EI #2 was asked what was the potential harm if RI #8 did not receive the supplement as ordered. EI #2 said the resident would not receive the added protein and calories. On 07/28/2016 at 1:30 p.m., an interview was conducted with EI #1, DON (Director of Nursing). EI #1 was asked if RI #8 received supplements. EI #1 said yes. EI #1 was asked what was the Physician's order. EI #1 said Magic cup for lunch and supper. EI #8 was asked why RI #8 should have received the supplement. EI #1 said because of a wound and a low [MEDICATION NAME]. EI #1 was asked who was responsible to ensure supplements were on the tray. EI #1 said dietary. EI #1 was asked if RI #8 received the Magic cup on 07/27/2016 and 07/28/2016. EI #1 said no.

Based on observations, record reviews, and interview, the facility failed to ensure RI (Resident Identifier) #8's care plan for altered nutrition and hydration was followed. RI #8 did not receive a Magic Cup for lunches served on Wednesday 07/27/2016 and Thursday 07/28/2016. This affected one of thirteen resident's whose care plans were reviewed. Findings include: A review of a facility policy titled, POLICY: RESIDENT ASSESSMENT CARE PLANNING, with a date of February 16,1999, revealed: . I. Formulation and implementation of an individualized, comprehensive plan of care for each resident based on thorough assessment will begin immediately upon admission . V. Nursing orders related to the daily basic needs of the resident will be formulated immediately upon admission; .C. Dietary requirements and assistance needed with eating . RI #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #8's Quarterly MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 05/29/2016, revealed RI #8 had a BIMS (Brief Interview for Mental Status) of 14, which indicated the resident was cognitively intact for daily decision making. The MDS, under Skin and Ulcer Treatments, was checked for nutrition and hydration intervention to manage skin problems. A review of RI #8's Physician orders [REDACTED]. A review of a document titled, Laboratory Results, with a Specimen Date of 03/14/16 and a Results Date of 03/14/16, revealed RI #8 had a low [MEDICATION NAME] level of 2.8 with a normal reference range between 3.5-5.7 Documented under Clinic Comments was add Magic Cup twice daily. A review of RI #8's Care Plan, with a problem onset date of 03/10/2016, revealed: Potential for altered nutrition/hydration . Approaches *Magic Cup po BID (twice daily) at Lunch and Supper . A review of RI #8's dietary tray cards for 07/27/2016 and 07/28/2016 revealed no Magic Cup. An observation was done on 07/27/2016 at 1:00 p.m. of RI #8's lunch and there was no Magic Cup. An observation was done on 07/28/2016 at 12:40 p.m. of RI #8's lunch and there was no Magic Cup. On 07/28/2016 at 1:30 p.m., an interview was conducted with EI (Employee Identifier) #1, DON (Director of Nursing). EI #1 was asked what was the physician's orders [REDACTED]. EI #1 was asked if the care plan was followed. EI #1 said no. EI #1 was asked if RI #8 was care planned to receive a supplement. EI #1 said yes, the Magic Cups. EI #1 was asked why RI #8 should have received the supplement. EI #1 said a wound and a low [MEDICATION NAME].

Based on observations, interviews and record review, the facility failed to ensure privacy was maintained for Resident Identifier (RI) #'s 10, 12 and 21 when the licensed nurses did not close the door, pull the privacy curtain or close the blinds at the window during the Medication Administration Observation Pass on 9/04/14. This affected 3 of 3 residents observed during the morning Medication Administration Observation. Findings Include: A facility policy titled "[MEDICATION NAME] Patch Administration", with an effective date of May 17, 2012, documented: "... PROCESS: ... 3. Provide privacy ..." Another facility policy titled "Eye Medication Administration", no date, documented: "... Procedure: ... 2) ... screen for privacy ..." 1. RI #12 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #12's September 2014 Physician order [REDACTED]. "... [MEDICATION NAME] 40 MG (milligrams) TAB (tablet) 1 PO (by mouth) QD (every day) ... [MEDICATION NAME] POWDER 1 17 GM (gram) WITH WATER/JUICE QD ... [MEDICATION NAME] 4.6 MG/24 HR (hour) PATCH QD ... PROMOD LIQUID PROTEIN 30 CC (centimeters) PO QD ... ARTIFICIAL TEARS 1 GTT (drop) OU (both eyes) BID (twice a day) ... [MEDICATION NAME] 3.125 MG TAB 1 PO BID ... [MEDICATION NAME] 10 MG TAB 1 PO BID ... B12 500 MCG (micrograms) TAB PO QD ... ICAR-C TAB 1 PO BID ... [MEDICATION NAME] 5 MG PO QD ... FOLIC ACID 1 MG TAB PO QD ... OMEGA 3 500 MG SOFTGEL PO QD ... RISPERADAL 1 MG TAB 1 PO BID ... [MEDICATION NAME] 200 MG CAPSULE BID ..." On 09/04/14 at 7:58 a.m., the surveyor observed a LPN (Licensed Practical Nurse) medication nurse, Employee Identifier (EI) #4, place the above medications into a medication cup and remove an [MEDICATION NAME] and a vial of Artificial Tears eye drops from the medication draw. EI #4 knocked on RI #12's door and entered the resident's room taking the medications with her. RI #12 was sitting in a wheelchair in the private room. EI #4 handed RI #12 the cup of medications which were taken with a cup of water. RI #12's door remained opened during this time. RI #4 put on a pair of gloves and pulled down the right side of RI #12's shirt exposing the resident left chest. EI #4 removed an [MEDICATION NAME] from RI #12's right chest wall then applied a new [MEDICATION NAME] to RI #12's right outer arm. The door remained opened and EI #5, a RN (Registered Nurse) observing EI #4 pass medications was observed standing near the medication cart looking into RI #12's room. At that time another staff member passed by the room. EI #4 then removed her gloves, washed her hands and administered an Artificial Tear eye drop to RI #12's left then right eye. The door also remained opened while the eye drops were being administered. The surveyor asked EI #4, when administering medications like eye drops and removing a patch (from a resident's body), how should privacy be provided. EI #4 replied she should have closed the door or pulled the privacy curtain. On 09/04/14 at 2:40 p.m., the surveyor conducted an interview with EI #5, the RN nurse observing EI #4 administer medications to RI #12. The surveyor asked EI #5, how do the nurses provide for privacy when administering medications. EI #5 replied the resident should be taken to the room, privacy curtains are in the room or the door could be closed. The surveyor asked EI #5 what should EI #4 have done that morning when she administered RI #12 the eye drops and placed the [MEDICATION NAME] on the resident. EI #5 replied, "She should have pulled the privacy curtain or closed the door." 2. RI #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #21's September 2014 Physician order [REDACTED]. "... CALCIUM 600 + VIT (vitamin) D TAB 1 PO QD ... [MEDICATION NAME] 75 MG TAB 1 PO QD ... ASPIRIN EC ([MEDICATION NAME] coated) 81 MG TAB 1 PO QD ... MULTIVITAMIN TABLET ONE PO Q DAY ... [MEDICATION NAME] 15 CC (1 TBSP (tablespoon)) PO QD ... [MEDICATION NAME] 300 MG TABLET PO QD ... [MEDICATION NAME] 5 MG TABLET 1 PO Q DAY ... [MEDICATION NAME] 20 MG TABLET ONE TAB PO QD ... [MEDICATION NAME] SOFTGEL ONE TAB PO QD ... [MEDICATION NAME] 2.5 MG TABLET PO QOD (every other day) ... [MEDICATION NAME] 9.5 MG/24 HR PATCH APPLY ONE PATCH DAILY ... REFRESH [MEDICATION NAME] EYE DROPS ONE GTT OU QID (four times a day) ... [MEDICATION NAME] 10 MG TAB 1 PO TID ... [MEDICATION NAME] ER (extended release) ... 400 MG TAB 1 PO BID ... KCL (Potassium Chloride) 40 MEQ (milliequivalents) TABLET PO BID ... [MEDICATION NAME] HCL ([MEDICATION NAME]) 500 MG PO BID ... [MEDICATION NAME] 24 MCG CAPSULES ONE CAP PO BID ... FISH OIL 1,000 MG BID ... [MEDICATION NAME] 10 MG PO BID ... [MEDICATION NAME] 12.5 MG 1 TAB PO BID ... [MEDICATION NAME] ([MEDICATION NAME]) 300 MG CAPSULE ONE CAP PO BID ..." On 09/04/14 at 8:08 a.m., the surveyor observed a second LPN medication nurse, EI #7, place the above medications into a medication cup, pour the [MEDICATION NAME] 15 cc's [MEDICATION NAME] into a cup and mixed with 240' cc of water and removed an [MEDICATION NAME] and a vial of Refresh [MEDICATION NAME] eye drops from the medication draw. EI #7 entered RI #21's room leaving the door open. RI #21 was sitting in a wheelchair. RI #21's roommate was lying in bed and the privacy curtain was not pulled between the residents. The door to the room remained opened and EI #8, a RN observing EI #7 administer medications, was observed standing in the doorway of the room next to the medication cart. EI #7 handed RI #21 the cup of medications which the resident took along with the cup of water mixed with the Sorbital. EI #7 then washed her hands and put on a pair of gloves. EI #7 pulled RI #21's blouse off of the resident's right shoulder exposing the area and removed an [MEDICATION NAME]. EI #7 then lifted RI #21's blouse from the left shoulder and applied a new [MEDICATION NAME]. EI #7 removed her gloves, washed her hands and put on a new pair of gloves. EI #7 proceeded to administer RI #21 her Refresh Octive eye drops. The door to the room remained opened and the privacy curtain between the residents was not pulled. The surveyor asked EI #7, when applying a patch to a resident's body and administering eye drops, how would she provide for privacy. EI #7 replied she should pull the privacy curtains. EI #7 admitted she had not pulled the privacy curtain or closed the door when she administered RI #21's medications. When asked what the facility's policy said to do when administering medications, EI #7 said to pull the privacy curtain. On 09/4/14 at 11:08 a.m., the surveyor conducted an interview with EI #8, the RN observing EI #7 administer RI #21's medications. The surveyor asked EI #8, what should EI #7 have done when she administered RI #21's medications on 09/04/14 at 8:08 a.m. EI #8 said EI #7 should have closed the door and pulled the privacy curtain in the room. 3. RI #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #10's September 2014 Physician order [REDACTED]. "... [MEDICATION NAME] ([MEDICATION NAME]) 500 MG TABLET, 1 PO BID ... [MEDICATION NAME] ([MEDICATION NAME]) 20 MG TABLET PO QD ... [MEDICATION NAME] 0.2% EYE DROPS ONE GTT OU Q (Every) AM ... TYLENOL 325 MG TABLET 2 TABS PO BID ... [MEDICATION NAME] 20 MG TABLET ONE TAB PO BID ... [MEDICATION NAME] ([MEDICATION NAME]) 20 MG TABLET ONE TAB PO TID ..." On 09/4/14 at 11:08 a.m., the surveyor conducted an interview with EI #8. The surveyor asked EI #8 if EI #7 closed the door or blinds for RI #10. EI #8 replied no she did not. The surveyor asked EI #8 what the facility's policy said nurses should do when giving medications. EI #8 said maintain their privacy.

Based on observation and interviews, the facility failed to ensure a schedule II controlled drug (Morphine Suppository 10 mg (milligrams)) was stored in a locked box in a permanently affixed compartment in the refrigerator on one of two medication rooms in the facility. Findings Included: On 09/4/14 at 2:41 p.m., during the inspection of the medication room, the surveyor, the Director Of Nursing, Employee Identifier (EI) #1 and EI #2, a charge nurse, observed a locked box attached to a rack in the refrigerator in a medication room. There was a Morphine 10 mg suppository, a schedule II narcotic in this lock box. However, the box was not permanently affixed and secured to the inside of the refrigerator. EI #2 lifted the box and it was easily removed from the refrigerator. There were also two Ativan 2 mg injectable vials, one bottle of Ativan 1 mg 30 cc (cubic centimeters) oral solution and two Ativan 2 mg vials that were used as a prn (as needed) medication for an unsampled resident. On 09/4/14 at 2:50 p.m., the surveyor conducted an interview with EI #2, the charge nurse. The surveyor asked EI #2 how long the Morphine 10 mg suppository had been in the locked box which was not permanently affixed to the refrigerator. EI #2 said she did not know. EI #2 said the maintenance man, EI #3, replaced the refrigerator and she did not know when this was done. EI #2 said EI #3 did not tighten the locked box down. EI #1 said this was her first time hearing about this. EI#1 said she did not know the locked box was not properly secured and this had not been reported to her. On 09/5/14 at 8:50 a.m., the surveyor conducted an interview with the maintenance staff member, EI #3 in the presence of EI #1. The surveyor asked EI #3 when he replaced the refrigerator. EI #3 said about two weeks ago. EI #3 did not remember the exact date. EI #3 said the old fridge went out and he replaced it with a new one. The surveyor asked EI #3 if the locked box used for storing narcotics' was secured and permanently affixed inside the new refrigerator. EI #3 said he guess not. EI #3 said he was told to come and do this (secure the locked box) yesterday (09/4/14) by EI #1. The surveyor EI #3 and EI #1 if the narcotic box had not been checked during the survey (09/3/14 - 09/5/14), when would the facility have found that the narcotic box was not permanently affixed to the inside of the refrigerator. EI #1 said the nurses check the narcotics box every shift and daily to make sure it is locked and they count the narcotic medications. The surveyor asked if counting the narcotics would ensure the narcotic box is permanently affixed inside the refrigerator. There was no response by the facility staff at this time. The surveyor requested a facility policy for storage of schedule II narcotics needing to be in a locked box permanently affixed in the refrigerator. The surveyor received a facility policy titled "MEDICATION ORDERING AND RECEIVING FROM PHARMACY" with the effective date of July 1, 2009. This policy failed to address how schedule II narcotics should be stored in a locked box permanently affixed box in the refrigerator.

Based on observations and interview, the facility failed to ensure residents' rooms and common areas on the South Wing were maintained neat and orderly. This affected six resident rooms and the bath and shower room on the South Wing, one of two units in the facility. Findings include: On 08/21/13 at 10:25 AM, the following environmental concerns were identified on the South Wing: Room Location (RL) #1 - The bathroom's metal door trim was rusty from the from up approximately two feet. The baseboard tiles in the bathroom were missing along two sides and paint was peeling around the light switch. RL #2 - The bathroom had a sagging ceiling tile and both entry doors into the bathroom had rusty areas to the bottom of the door frame. RL #3 - The wooden ledge under the window contained a large horizontal crack. Four large nail holes in the wall over the b-bed needed to be patched and painted. A large ceiling tile in the bathroom was sagging and the metal frame around the bathroom door needed to be sanded and repainted. RL #4 - Two ceiling tiles over the entry door were sagging. A drawer pull was missing from the vanity. RL #5 - A large ceiling tile was cracked next to the vent in the bathroom. The metal legs and frame of the adaptive toilet over the commode had rusty areas to the legs and frame. RL #6 - The wooden ledge under the window was splintered along the edge roughly 4 inches. The metal blinds were bent along the right hand side. The metal door frame of the shower room had 2 inches of rust from the ground up. The toilet room on the main hall next to the Beauty Shop had ceiling tiles that contained black rings. The metal frame holding the ceiling tiles in place were coated in a rust colored dried substance. The metal frame behind the commode had rust like substance. The metal switch plate cover and metal door frame had multiple rust colored spots. The paint on the walls was peeling. On 08/22/13 at 4:40 PM, a tour of the identified environmental concerns on the South Wing was conducted with Employee Identifier (EI) #1, the Administrator and EI #3, the Maintenance Director. When asked why it was was important to maintain the residents' environment in a neat and orderly fashion, EI #3 said for safety and appearance.

Based on interviews and record reviews, the facility failed to ensure the Activity Department was directed by a qualified activity professional. This had the potential to affect all residents that reside in the facility. Findings include: A review of the facility's key personnel list, indicated Employee Identifier (EI) #2 was responsible for activities. The facility's "Long Term Care Facility Application for Medicare and Medicaid (Form CMS-671) signed by EI #1, the Administrator, on 08/20/13 at 6:30 PM, indicated the facility provided onsite to residents, either by employees or contractors, a Qualified Activities Professional. In an interview on 08/22/13 at 3:15 PM, EI #1, the Administrator, was asked what was the Activity Director's qualifications. EI #1 replied that the Activity Director (EI #2) has been leading activities for the the past four or five years. When asked should EI #2 be qualified to provide activities, EI #1 stated it is not required. EI #1 further commented that he thought EI #2 (the Activity Director) was qualified. In an interview on 08/22/13 at 3:30 PM, EI #2, the Activity Director was asked if she was a qualified Activities Director. She stated, "I feel like I am." When asked about her training, EI #2 stated she had no formal training, that it was all on-the-job training. EI #2 was asked if she had any certifications (qualifications) to be an Activities Professional/Director. EI #2 said she did not.

Based on interview and record review, the facility failed to ensure Resident Identifier (RI) #17's sponsor was notified of wounds identified on RI #17's buttock on 06/02/11. This affected one of three residents sampled with wounds. Findings Included: A review of the facility's policy and procedure titled, "Situations Requiring Notification of Resident's Attending Physician and Sponsor," dated March 15, 1999, revealed the following: "I. Charge nurses are responsible for making notifications in the following situations: A. Attending Physician:... 2. Significant changes in the resident's status including, mental, physical and/or psychosocial changes. 3. A need to significantly alter treatment or obtain orders for treatment... B. Sponsor/Next-of-kin: ... 2. All situations specified under I-A above... III. Documentation: A. The responsible charge nurse will document a description of the situation and information provided to the physician and family in the Nurses Notes section of the resident's medical record..." RI #17 was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of RI #17's Annual Minimum Data Set ((MDS) dated [DATE], revealed RI #17's BIMS (Brief Interview for Mental Status) score was a 13, indicating cognitively intact skills for daily decision-making. The MDS documented RI #17 required extensive to total assistance with Activities of Daily Living except for eating, which he required supervision. The MDS also documented RI #17 was frequently incontinent of bowel and bladder. The MDS indicated the mobility device for RI #17 was a wheelchair. A review of the facility's "Body Audit Tool," revealed the following: "...Comments...6/2/11 Body Audit complete. Small denuded area to (left) buttocks...(signed by Employee Identifier (EI) #5 (Registered Nurse/RN/Treatment Nurse)." There was no documentation noted to indicate RI #17' s family or Physician was notified of the resident's denuded areas to the left buttock. A review of the facility's, "Departmental Notes," with an entry of 6/3/2011 at 12:56 PM revealed the following: "...MD (Medical Doctor) made aware per RN (Registered Nurse) supervisor of denuded are to (L) (left) buttock from his IBS (Irritable Bowel Syndrome) flaring up over weekend. Area is small. Covering with [MEDICATION NAME]. Prepared by: (EI #6(Licensed Practical Nurse/LPN))..." On 08/29/12 at 4:45 PM, during an interview with EI #6, the surveyor gave the Departmental Note dated 06/03/11, for review and asked when did she notice the areas to RI #17's buttock. EI #6 reviewed the note and stated she did not notice the area. The surveyor asked if she wrote the note with an entry time of 12:56 PM. EI #6 stated yes. The surveyor asked who actually noted the area. EI #6 stated she did not know. The surveyor asked why did she write the note regarding the areas to RI #17's left buttock if she was not aware of the denuded areas and never saw the area. EI #6 stated it was the facility's procedure that they follow when the nurses are given a communication sheet. The surveyor requested the communication sheet. EI #6 stated after a month the sheets are shredded. The surveyor asked who was the RN Supervisor. EI #6 stated (EI #7). The surveyor asked when did she notify the family. EI #6 stated anytime there is a skin concern the treatment nurse notifies the family. On 08/29/12 at 4:58 PM, during an interview with EI #5, the surveyor asked who was responsible for notifying the doctor and the family/sponsor when a resident has a change in skin condition. EI #5 stated she notifies the family and the RN Supervisor notifies the doctor. The surveyor asked who did she notify regarding RI #17's areas to his buttocks that were identified in June of 2011. EI #5 reviewed the Body Audit Tool and asked if the surveyor was asking about the denuded area. The surveyor responded yes. EI #5 stated she did not document anywhere regarding notification. She also stated she did not remember who or if she notified anyone about RI #17's denuded areas to his buttocks. The surveyor asked what should she have done. EI #5 stated she should have notified the doctor about the denuded area and what type of interventions were in place. EI #5 also stated that she should have notified the family regarding RI #17's denuded area and the treatment in place. The surveyor asked was that the policy and procedure for notification when a resident has a change in condition. EI #5 stated, "Yes ma'am." The surveyor asked was the policy and procedure followed for the denuded areas to RI #17's buttock. EI #5 stated, "No ma'am." On 08/29/12 at 5:30 PM, during an interview with EI #7 (RN/House Supervisor), the surveyor gave EI #7 the Departmental Note dated 06/03/11 for review and asked when was she made aware of RI #17's denuded areas to the buttock. EI #7 reviewed the Departmental Note and stated she was made aware on June 3rd of 2011. The surveyor asked by whom. EI #7 stated she could not be sure, either (EI #6) or (EI #5). The surveyor asked who did she notify of the denuded areas. EI #7 stated the doctor. The surveyor asked when did she notify the family. EI #7 stated she does not notify the family, either the LPN or the Treatment Nurse notifies the family.

Based on observation, interview and record review, the facility failed to ensure a Licensed Practical Nurse did not leave medications on top of the medication cart unattended. This affected one of seven nurses observed during medication pass observation. Finding Include: A review of the facility's policy and procedure titled, "Medication Administration," dated 5/16/12, revealed the following: "...12...Never leave the medication...on top of cart, ..." On 08/29/12 at 9:10 AM, a medication cart was positioned on the South Wing, short hall, with a packet of opened medication, Acidophilus, on top of the medication cart. The surveyor did not observed a nurse at the medication cart. The surveyor did observe a nurse in a room, across from the medication cart with her back facing the doorway of the room. On 08/29/12 at 9:15 AM, the nurse exited the room and the surveyor observed the packet of medication and asked what was the medication. Employee Identifier (EI) #4 (Licensed Practical Nurse/LPN) stated Acidophilus. The surveyor asked where should the medication be stored. EI #4 stated in the medication cart. The surveyor asked where was she when the medication was left unattended on top of the medication cart. EI #4 stated in a room. The surveyor asked was the medication cart in her visual sight at all times. EI #4 stated, "No." The surveyor asked what was the potential for harm when medications are left unattended and on top of the medication cart. EI #4 stated a resident could get the medication and overdose. The surveyor asked if there were residents who ambulate independently up and down the hall. EI #4 stated, "Yes."

Based on observations, record reviews and interviews the facility failed to ensure that the staff followed the accepted practice for the administration of narcotics for RI (Resident Identifier) #21. This affected 1 of 9 residents reviewed for correct narcotic counts. Findings Include: RI #21 was readmitted to the facility on [DATE] with current [DIAGNOSES REDACTED]. The review of the most recent annual MDS (minimum data set) with an assessment reference date of 12/12/10 revealed RI #21 had been on a scheduled pain medication regimen, received PRN (as needed) pain medication and received non-medication interventions for pain. A review of RI #21's care plan with a problem onset date of 3/22/07 revealed the following: Problem onset: "C/O (complains of) pain at times due to Dx (diagnoses) of [MEDICAL CONDITION] Disc Disease. Receives routine pain medications" Approaches: "...Administer meds as ordered. Monitor for effectiveness and any side effects..." An observation was made on 6/29/11 at 2:15 PM in the medication room on the south hall. A review of RI # 21's "Individual Residents Controlled Substance Record" for [MEDICATION NAME] 5-500 revealed: EI (employee identifier) # 2 documented on 6/29/11 at 12:00 PM that she administered one tablet of [MEDICATION NAME] to RI # 21. Further review revealed a documented "TOTAL ON HAND 100", "AMOUNT GIVEN (symbol for one)", "AMOUNT REMAINING 99". EI # 2, LPN (Licensed Practical Nurse) Charge Nurse signed her name indicating one tablet of [MEDICATION NAME] had been administered from that card. Observation of the card revealed 100 [MEDICATION NAME] tablets were left on the card, however the sign out sheet revealed the count should have been 99 tablets. During an interview on 6/29/11 at 2:20 PM with EI # 2, LPN Charge Nurse, the surveyor asked when do you count narcotics and EI # 2 replied "At the beginning of the shift and before we go off". The surveyor asked do you normally sign narcotics early EI # 2 said "For her I normally do. She usually takes these meds to [MEDICAL TREATMENT] clinic with her". The surveyor asked did you send the narcotics with her today and she responded "no". When asked why she did not send the narcotics with her today EI # 2 responded "I really forgot". The surveyor asked what time EI # 2 signed the narcotic out and she responded at 12:00 PM. EI # 2 further explained she planned to give the narcotic when RI # 21 returned from her appointment. The surveyor asked EI # 2 what is the facilty's policy regarding signing out narcotics. EI # 2 stated sign them out when you give them. EI # 2 was asked should you have waited to sign the narcotic out and EI # 2 responded "Yes, I should have waited". During an interview on 6/29/11 at 3:30 PM with EI # 1, DON (Director of Nursing), the surveyor asked what is the facility policy for administering medications that are scheduled for when the resident is out for [MEDICAL TREATMENT] and she responded we hold the medication and its given when they come back. A review of the physician orders [REDACTED]. A review of RI # 21's MAR (Medication Administration Record) for the month of June 2011 revealed an order for [REDACTED]. A review of the facility's policy titled "PREPARATION AND GENERAL GUIDELINES IIA7: CONTROLLED MEDICATIONS" with an effective date of July 1, 2009 revealed "...D. When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. 2) Amount administered. 3) Signature of the nurse administering the dose, completed after the medication is actually administered..." A review of Potter and Perry Fundamentals of Nursing, 7th Edition chapter 35 page 709 Medication Administration "...Nurses never document that they have given a medication until they have actually given it..."