Every finding on record at Allen Health and Rehabilitation

Based on an observation and interviews the facility failed to ensure that a locked narcotic box in one of the medication room refrigerators was affixed and permanently attached to prevent removal. This was observed on 2/20/20 and affected one of three medication rooms observed. Findings Include: On 2/20/20 at 4:34 PM, the surveyor made an observation, along with the unit nurse, of the locked narcotic medication box on the east unit. The surveyor observed in the locked medication room the locked narcotic medication box within the locked refrigerator. The narcotic box was attached to a shelf in the refrigerator that was not anchored or permanently affixed. The whole shelf containing the locked narcotic medications box could be removed from the refrigerator. The locked box contained 11 vials of 2 milligrams /1 milliliter [MEDICATION NAME]. On 02/20/20 at 4:41 PM, Employee Identifier (EI) # 9, LPN (Licensed Practical Nurse) was interviewed. EI #9 was asked, what did the locked narcotic box contain. EI #9 replied, 11 vials of 1 milligram [MEDICATION NAME] for a resident. EI #9 was asked, where was this refrigerator located. EI #9 replied, east med room. EI #9 was asked, how was the locked narcotic box anchored. EI #9 replied, it was anchored on a shelf with some bolts but the shelf was not anchored or permanently affixed. EI #9 was asked why was the shelf not bolted and permanently affixed. EI #9 replied, she did not know, maintenance missed it she guessed. EI #9 was asked, why was that a problem. EI #9 replied, the shelf could be removed from refrigerator and taken away with the locked narcotic box attached to the shelf. EI #9 was asked, who had access to the medication room. EI #9 replied, center east and east nurses. EI #9 was asked, when did nurses access that box. EI #9 replied, for as needed orders for the resident. EI #9 was asked, why would this be a problem to not be permanently attached within the refrigerator. EI #9 replied, someone if they wanted to could walk out with the shelf containing the locked narcotics. On 02/20/20 at 5:47 PM, an interview was conducted with EI #2, Director of Nursing, regarding the narcotic box in the refrigerator. EI #2 was asked, how was the locked narcotic box anchored. EI #2 replied, it was anchored to the shelf but the shelf was not permanently affixed to the refrigerator. EI #2 was asked, where was the refrigerator located. EI #2 replied, east medication room EI #2 was asked, what did the locked narcotic box contain. EI #2 replied, 11 vials of 2 mg per 1 milliliters of [MEDICATION NAME]; five in one bag, five in a second bag, and one in a third bag. EI #2 was asked, who had access to the medication room. EI # 2 replied, center east and east nurses. EI #2 was asked, when did nurses access that box. EI #2 replied, when nurses were counting or needed something. EI # 2 was asked, why was it not anchored. EI #2 replied, they replaced that box as it was cracked but when replaced it was not affixed to the shelf permanently. EI #2 was asked, what was the potential harm in having the locked narcotic box on a shelf that was not permanently affixed to the refrigerator. EI #2 replied, if someone had a key to the med room and key to refrigerator they could access.

Based on record review, interviews, a facility policy titled Care Plans, the facility failed to update the care plan with interventions for Resident Identifier (RI) #87's decline in food and fluid intake. This affected RI #87 one of one residents reviewed for decline in nutritional and fluid intake. Findings Include: A review of a facility policy titled Care Plans with an effective date of 5/2018 revealed: . PR[NAME]ESS: . b. Comprehensive Plan of Care - .The person centered care plan should be reviewed . with significant change of condition, or whenever a change is needed. RI #87 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a facility form titled Oral Intake monitor Roster dated 1/27/2020 thru 2/15/2020 revealed Oral Intake Measurement . Breakfast . Breakfast Fluid Intake . Oral Intake Measurement Lunch . Lunch Fluid Intake . Oral Intake Measurement Supper . Supper Fluid Intake . with daily fluid intake varying 120 cc to 1200 cc. A review of RI #87's Care Plan revealed Problem Onset: 1/27/2020 . has the potential for alteration in weight/nutrition/hydration . Approaches .Registered Dietitian to review as needed . The Care Plan did not reveal interventions after 1/27/20 related to resident's poor acceptance of, nor interventions to improve fluid and nutrition needs. On 2/20/20 at 5:47 PM, an interview was conducted with Employee Identifier (EI) #3, Registered Dietitian. EI #3 was asked what was RI #87's assessment needs for fluid and food. EI #3 replied, 1425 to 1710 milliliters a day. EI #3 was asked what time frame was RI #87's weight loss. EI #3 replied, loss from 1/28/20 to 2/11/20 was 5% (percent). EI #3 was asked, when was RI #87 reassessed again. EI #3 replied, RI #87 was not documented on, but the group did discuss RI #87. EI #3 was asked, because there was a weight loss of 5% what was done. EI #3 replied, she had not documented on RI #87, at that point, a FEES study was ordered which RI #87 had refused. EI #3 was asked, what date was the FEES study ordered. EI #3 replied, she thought it was ordered 1/30/20, not necessarily the date it would be done. EI #3 was asked, when was there a change in food and fluid acceptance. EI #3 replied, RI #87 had started pocketing food but she did not know exact date. EI #3 was asked, where in RI #87's record did it reflect a weight loss cause. EI #3 replied, it was not documented. EI #3 was asked if RI #87 should have had documentation. EI #3 replied, there was not time frame for documentation but interventions should have been placed. EI #3 and the surveyor reviewed the care plan then EI #3 was asked, what was the date of interventions. EI #3 replied, 1/27/20 on admission. EI #3 was asked, where were new interventions placed and tried. EI #3 replied, she did not see any. EI #3 was asked if the care plan reflected new interventions. EI #3 replied, as far as supplements or other interventions, no. EI #3 was asked, who was responsible for new interventions. EI #3 replied, anyone, typically she would do that for calories, proteins and fluids. EI #3 was asked, where in the record did it reflect weight change. EI #3 replied, the weight sheet and RI #87 was a significant loss. EI #3 was asked, where in the record would it reflect ongoing interventions due to poor food and fluid acceptance. EI #3 replied, the care plan. EI #3 was asked had there been ongoing interventions placed. EI #3 replied, no there was nothing, it did say offer snacks and she was not sure where they would be documented. EI #3 was asked, what was the harm in care plans not updated to reflect changes and interventions. EI #3 replied, for all to look at as a team and if the care plan was not updated the team would not know what to look for. On 2/21/20 at 10:31 AM, an interview was conducted with EI #2, Director of Nursing, (DON). EI #2 was asked, what type care RI #87 required. EI #2 replied, RI #87 was admitted for therapy, however, did not participate, EI #2 continued that RI #87 came on a regular diet and was helped by the staff to eat. EI #2 was asked, how long was it known of RI #87's poor acceptance of adequate fluids. EI #2 replied, she was not sure on the date; RI #87 was observed in the assist dining room pocketing food and was not swallowing. EI #2 was asked, in #87's record was it documented about further interventions to increase fluid intake. EI #2 replied, it was not captured in the care plan. EI #2 continued with a reply stating they did things but failed to add to care plan; however, other things were done. EI #2 said RI #87 was placed in assisted dining, snacks were offered, the family helped because they did not want to make a decision about tube placement. EI #2 said, lack of documenting it in the record seemed to be an issue. EI #2 was asked, how many times had the care plan been updated. EI #2 replied, once on 2/6/20, nectar thick liquids was added. EI #2 was asked, what was the harm of not updating RI #87's care plan and documenting. EI #2 replied, they failed to capture the care that was actually provided and if they do not update interventions staff may not know what to follow.

Based on observations, interview, and review of the (YEAR) U.S. (United States) Public Health Service Food Code, the facility failed to ensure: 1) the flour bin had a date of when the flour was placed in the bin and a date to be used by on. This was observed on [DATE], during the initial tour of the facility. 2) food particles were not left on the meat slicer, as observed on [DATE]. These deficient practices had the potential to affect 86 of 86 residents receiving meals from the kitchen. Findings Include: 1) On [DATE] at 5:33 p.m., during the initial tour of the kitchen, the surveyor observed the flour bin to not have a date or use by date on the bin. On [DATE] at 5:42 p.m., the surveyor asked the Dietary Manager (DM), Employee Identifier (EI) #4, when was the flour placed in the flour bin. EI #4 said on the 24 th of January, last Thursday. The surveyor asked EI #4 should there be a date when the flour was placed in the bin and a use by date on the bin. EI #4 said yes. On [DATE] at 09:49 a.m., the surveyor conducted an interview with EI #4. The surveyor asked EI #4 why should there be a date when the flour was placed in the bin and a date when it should be used by. EI #4 said so expired products would not be used. When asked what was there a potential for when expired products were used, EI #4 replied sickness. 2) A review of the (YEAR) U.S. Public Health Service Food Code revealed: . ,[DATE] CLEANING OF EQUIPMENT AND UTENSILS . ,[DATE].11 Equipment, Food-Contact Surfaces . (A) EQUIPMENT FOOD-CONTACT SURFACES . shall be clean to sight . On [DATE] at 10:33 a.m., the surveyor observed food looking particles on the base of the meat slicer. The surveyor asked EI #4 what did it look like was on the meat slicer. EI #4 said food looking particles. The surveyor asked EI #4 when was the meat slicer last used. EI #4 said on yesterday. The surveyor asked EI #4 how often was the meat slicer cleaned. EI #4 said every time it was used. When asked what she thought happened for food particles to still be on the meat slicer (after it had been cleaned), EI #4 replied who ever cleaned it probably just missed it. On [DATE] at 09:53 a.m., the surveyor conducted a second interview with EI #4. The surveyor asked EI #4 should there have been any food particles left on the meat slicer if it had been cleaned. EI #4 said no, there should have been none left on the slicer at all. When asked why there should be no food particles left on the meat slicer, EI #4 replied, because equipment should be stored clean.

Based on interview, record review and review of a facility policy titled Disposal of Medications Non-Controlled Medication Destruction, the facility failed to ensure the Non-Controlled Packet Medication Destruction forms contained the required signatures. This affected four of 11 months (January, February, May, and (MONTH) of (YEAR)) of the Non-Controlled Packet Medication Destruction forms reviewed. Finding Include: A facility policy titled Disposal of Medications Non-Controlled Medication Destruction, dated 03/11, revealed: . Procedures . 3. The registered nurse and/or pharmacist witnessing the destruction, or their preparation for environmental service pickup, ensures that the following information is entered on the Record of Medication Destruction form . : J. Signatures of witnesses, two witnesses required for non-controlled substances . On 01/31/19 at 2:02 p.m., the surveyor conducted an interview with Employee Identifier (EI) #1, the Director of Nursing (DON). The surveyor asked EI #1, according to the facility's policy, how many signatures should there be on the Non- Controlled Packet Medication Destruction forms. EI #1 said two. A review of the Non-Controlled Packet Medication Destruction forms was made with EI #1. She was asked how many forms for the months had only one signature. EI #1 replied, (MONTH) (YEAR), revealed 18 of 25 forms only had one signature, (MONTH) (YEAR), one of 33 Non-Controlled Packet Medication Destruction forms only had one signature, (MONTH) (YEAR), one of 13 of the Non-Controlled Packet Medication Destruction forms only had one signature, and (MONTH) (YEAR), seven of 21 Non-Controlled Packet Medication Destruction forms only had one signature.

Based on observations, interviews and record review, the facility failed to ensure: 1) Resident Identifier (RI) #9 was accurately assessed under Section M 0100 on RI #9's 11/06/18 Significant Change (SC) MDS (Minimum Data Set) assessment as having Pressure Ulcers (PU); and 2) RI# 77 was accurately assessed under Section M 0100 on RI #77's 01/11/19 Admission MDS assessment as having a PU. These deficient practices affected RI #9 and #77, two of 25 sampled residents whose MDS assessments were reviewed. Findings Include: 1) RI #9 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. RI #9's Admission body audit, dated 07/09/18, revealed RI #9 was admitted with PU's to the left and right scapula, back of the right arm and the sacrum area. A review of RI #9's SC MDS assessment, with an Assessment Reference Date (ARD) of 11/06/18, did not identify RI #9 as having a PU under Section M 0100 during this assessment period. On 01/30/19 at 2:47 p.m., the surveyor observed Employee Identifier (EI) #3, the treatment nurse, provide wound care to RI #9's right thumb, left and right scapula, sacrum and right ischium PU's. On 01/31/19 at 12:47 p.m., the surveyor conducted an interview with EI #2, the RN (Registered Nurse) MDS Manager. The surveyor asked EI #2 did RI #9 have any PU's. EI #2 said, according to RI #9's SC MDS dated [DATE], yes. The surveyor asked EI #2 should Section M 0100 on the MDS assessment be checked. EI #2 said yes. The surveyor asked EI #2 who was responsible for completing that section of the MDS. EI #2 said the treatment nurse. When asked would this be an accurate assessment, EI #2 replied no because it was not marked that RI #9 had a PU. 2) RI #77 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. RI #77's Admission body audit, dated 01/04/19, revealed RI #77 was admitted with a PU to sacrum area. A review of RI #77's Admission MDS assessment, with an ARD of 01/11/19, did not identify RI #77 as having a PU under Section M 0100 during this assessment period. On 01/30/19 at 9:33 a.m., the surveyor observed EI #3 provide wound care to RI #77's sacral wound PU. On 01/31/19 at 1:00 p.m., the surveyor conducted an interview with EI #2. The surveyor asked EI #2 was RI #77 admitted with the PU. EI #2 said yes. The surveyor asked EI #2, on RI #77's Admission MDS assessment dated [DATE], should RI #77 be coded as having the PU. EI #2 said yes. The surveyor asked EI #2, under Section M 0100, was RI #77 coded as having the PU. EI #2 said no. The surveyor asked EI #2 would this be an accurate assessment. EI #2 said no because it was not marked that RI #77 had a PU. On 01/31/19 at 1:21 p.m., the surveyor conducted an interview with EI #3, the treatment nurse. EI #3 said on RI #9's SC MDS assessment dated [DATE], and on RI #77's Admission MDS assessment dated [DATE], Section M 0100 should have been checked. When asked why the sections were not checked, EI #3 said it probably was an oversight on her part.

Based on observations, interview, and review of a facility policy titled, JOB DESCRIPTION, the facility failed to ensure the following were not observed during the survey: 1) uncapped rusted toilet bolts in RL (Room Locator) #s: 1, 2, 3, 4, 6, 7, 8, 9, 12, 13, 14, and East Unit resident bathroom, found on 2 of 3 Units; 2) dry green substance observed on pipes behind toilet in resident bathrooms in RL #s: 6, 8, and 1; 3) a loose faucet appliance in RL #14; 4) broken tiles in tubroom on East Unit; 5) a shower room on East Unit had black substance on the faucet plate; there was a black, green, and pink substance on the shower floor/wall; and pieces of white plastic bag was tied on the handrail in the shower; 6) an area of sheetrock was broken above the baseboard outside the East Unit shower; 7) the floor under the a/c (air conditioner) unit was missing tiles and there was a broken baseboard tile near the a/c unit of RL #10; 8) a thick yellow substance on a metal device attached to the wall was observed in resident bathroom, RL #7; 9) missing sheet rock in an open hall storage area of East Unit; 10) chipped and peeling paint on 2 windows near Nurses Station on East Unit; 11) a sharps container was full in a shower room of the East Unit; 12) a toilet chair seat was rusted in a East Unit resident bathroom; 13) a black strip of flooring on the East Unit near the Nurses Station and the Resident Dining Room was found dirty and had torn areas of flooring; and 14) the floors had a gray/black substance under the a/c unit of RL #5 and 9. This was observed in RL #s 1-14, on two of three units in the facility. Findings Include: A review of a facility's document titled, JOB DESCRIPTION, dated 11/11/13, revealed: Job Title Director of Maintenance . Summary of Duties Maintain the grounds, facilities, and equipment for the Community in a safe and efficient manner in accordance with established policies and procedures and applicable federal, state, and local standards, guidelines, and regulations . Essential Job Functions . 2. Maintain the grounds, facilities, and equipment in good repair, ensuring safe, clean, and orderly environment. 5. Schedule routine maintenance and repair on the facility and equipment. 6. Make inspections of all facility functions to assure that quality control measures are continually maintained. Report findings to appropriate individuals. The facility uses contract housekeeping services. A review of the Housekeeper Job Description, not dated, revealed: . Areas: (room numbers), locker room, shower rooms, whirlpool room, utility room, storage room, nourishment room, nurse manager office, nurses station area, med room, central . During the initial tour of the facility on 12/19/17, observations were made of resident rooms, bathrooms, shower rooms, and residential areas. On 12/19/17 at 3:37 p.m., a shower room on the Central East Unit, was observed with a strong smell of mildew. The white hand-held shower head was observed with a black slimy substance. There were 2 clear plastic cups observed in the recessed shelf area of the shower with an orange substance at the bottom of both cups. There were 3 wash cloths and a harness hanging on the towel rack. On the floor and wall of the shower, there was a black substance observed. There was a nearly empty bottle of Suave shampoo lying on top of the wash cloths that were on the towel rack. There was a padded shower chair in the shower room. In the East Unit resident bathroom, a toilet chair was over the toilet and had rusted areas on the metal frame of the toilet seat. There were 1 1/2 (inch) uncapped rusted toilet bolts on both sides of the toilet base. At 5:10 p.m. on 12/19/17, EI (Employee Identifier) #1, the Maintenance Director, and EI #5, the Administrator, spoke with the surveyor. EI #1 stated staff were not using the shower on the Central East Unit. EI #5 stated she had been at the facility for [AGE] years and during those years, staff did not use the shower on Central East Unit. At 4:30 p.m. on 12/19/17, RL #11 was observed with a dry green substance all over the top of the pipe and running down the sides of the pipe located behind the toilet. The metal hand rail bolted to the wall next to the toilet had a dry green substance and corrosion at the end of the hand rail. The surface was rough with raised corroded areas. The hose attached to the wall behind the toilet had a dry green substance on the handle and at the end of the spray nozzle. At 4:33 p.m. on 12/19/17, RL #13 had uncapped rusted toilet bolts 1/2 tall on both sides of the toilet base. The piping behind the toilet had a dry green substance on the top and sides of the pipe. At 4:42 p.m. on 12/19/17, RL #9 had uncapped 1/2 toilet bolts on both sides of the toilet base. There was a gray/brown substance on the floor under the a/c unit and rust stains were observed on the floor under the a/c unit. There was black strip flooring that runs along East Dining Room and near the Nurses Station and Soiled Utility room that was observed dirty and had broken/missing areas/patches along the black strip. At 4:48 p.m. on 12/19/17, the flooring under the a/c unit of RL #5 was observed. The flooring under the a/c unit was dirty with a brown/black substance on the floor. There was a missing tile piece on the wall to the side and below the a/c unit. On 12/21/17 at 8:20 a.m., the tub room on the East Unit had missing floor tiles around the edge of the whirlpool tub. The East Unit shower room was observed for the following: peeling paint on the door, floor dirty with black marks; black, green and pink substance on the floor of the shower; walls with black substance; a sharps container in the shower room was full; pieces of plastic bag was tied around a shower handle; and the shower faucet back plate had a black substance on it. In the doorway of the shower room, there were black anti-slip strips that were torn and jagged. Outside of the shower room, the wall between the floor molding and lower wall bumper pad had a 2 x (by) 12 to 14 long hole in the sheetrock. On 12/21/17 at 8:20 a.m., the following observations were made by another surveyor: RL #12 was observed with uncapped rusted toilet bolts on both sides of the toilet base; a glove was observed on the floor of the bathroom; the sink faucet appliance in RL #14 lifted up when the handle was turned; there were uncapped rusted toilet bolts on both sides of the toilet base; RL #8 had uncapped rusted toilet bolts on both sides of the toilet base. There was a dry green substance on the pipe behind the toilet; RL #6 had uncapped rusted toilet bolts on both sides of the toilet base. There was a dry green substance on the pipe behind the toilet. On 12/21/17 at 8:24 a.m., RL #7 was observed with water on the floor near the a/c unit. The water was seen coming from under the a/c unit onto the floor area. There was 3x 4 area of missing tiles under the a/c unit. Other observations made in RL #7 were: uncapped rusted toilet bolts on both sides of the toilet base; a dry green substance on the pipe behind the toilet; a metal piece on the wall near the toilet and under the soap dispenser had a very thick sticky yellow substance covering it. At 8:28 a.m. on 12/21/17, the area on the hall of the East Unit where geri-chairs and linen carts, were stored, a 4'10 high area of the outer corner wall was missing sheet rock. Across from the nurses station on the East Unit were 2 windows with chipped and peeling paint. On 12/21/17 at 8:40 a.m., the floor of RL #10 had missing tiles under the a/c unit. There was a broken tile baseboard located near the edge of the a/c unit. On 12/21/17 at 10:10 a.m., RL #s 1, 2, 3, and 4 were observed with 3/4 uncovered, rusted toilet bolts on both sides of the toilet base. On 12/21/17 at 1:40 p.m., EI #1 was interviewed and was asked who was responsible for the maintenance of resident rooms and residential areas. EI #1 stated he was, maintenance. When asked how often areas were checked for condition, EI #1 stated he was always looking and staff will let him know if something needs to be fixed. EI #1 was asked who was responsible for cleaning resident areas and EI #1 stated housekeeping. EI #1 further stated that if something needed to be repaired or replaced, maintenance does it. EI #1 was asked how often were residential areas cleaned and he stated daily. When asked what was the concern of resident rooms and residential areas not being clean, EI #1 stated the resident areas need to be clean for residents' health. EI #1 was asked what was the concern of residential areas not being in good repair. EI #1 stated the areas need to be safe and this was their home and the facility wanted it to look nice. EI #1 stated he didn't want anyone to get hurt, it's for their safety. At 1:55 p.m., the surveyor toured the areas of concern with EI #1 and he verbalized understanding of the areas of concern and indicated they would begin repairing and fixing the concerns immediately.

Based on record reviews, interviews, and review of a facility policy titled, Policy: Catheters, Urinary: Catheterization., the facility failed to obtain a physician's orders [REDACTED]. This affected RI (Resident Identifier) #66, one of twenty-one residents whose orders were reviewed. Findings Include: A review of a facility policy titled, Policy: Catheters, Urinary, with an effective date of 11/16, revealed: . Policy: Catheters, Urinary: Catheterization, . STANDARD: a physician's orders [REDACTED]. A review of RI #66's medical record revealed a re-admission date of [DATE] with [DIAGNOSES REDACTED]. A review of the Significant Change MDS (Minimum Data Set) assessment for RI #66, dated 11/21/17, revealed the resident was assessed as having a urinary catheter in use. A review of the December 2017 physician's orders [REDACTED]. During an interview on 12/21/17 at 3:43 p.m., with EI (Employee Identifier) #2, an LPN (Licensed Practical Nurse), the physician's orders [REDACTED]. EI #2 was asked what did the physician's orders [REDACTED].#66's catheter. EI #2 answered there was not an order. EI #2 was asked how long had RI #66 had a urinary catheter. EI #2 answered it had been since she (EI #2) had been working at the facility, which was three months and ten days. EI #2 was asked what was the facility policy regarding having a physician's orders [REDACTED]. EI #2 was asked what was the concern of not having a physician's orders [REDACTED]. EI #2 answered it (a physician's orders [REDACTED]. During an interview on 12/21/17 at 6:17 p.m., with EI #4, the RN (Registered Nurse)/Quality Assurance Coordinator, the physician's orders [REDACTED]. EI #4 was asked what did the physician's orders [REDACTED].#66's catheter. EI #4 answered she did not see a physician's orders [REDACTED].#66 had a urinary catheter and she answered since admission (7/11/17). EI #4 was asked what was the facility policy regarding having a physician's orders [REDACTED]. EI #4 answered providing care without an order.

Based on record reviews, interview, and review of the facility policy titled, Medication Monitoring Medication Management, the facility failed to provide evidence of monitoring of the efficacy and potential side effects of [MEDICAL CONDITION] drugs. This affected RI (Resident Identifier) #s 4, 50, and 83, three of six residents whose [MEDICAL CONDITION] medications were reviewed. Findings Include: A review of the facility policy titled, Medication Monitoring Medication Management, with a copyright date of 2007, revealed: . In order to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences, facility staff, the attending physician/prescriber, and the consultant pharmacist perform ongoing monitoring for appropriate, effective, and safe medication use. When selecting medications and non-pharmacological interventions, members of the interdisciplinary team participate in the care process to identify, assess, address, advocate for, monitor, and communicate the resident's needs and changes in condition. PR(NAME)EDURES The interdisciplinary team reviews the resident's medication regimen for efficacy and actual or potential medication-related problems on an ongoing basis. g. Monitoring of potential for adverse consequences: Tools are available for monitoring adverse medication consequences such as the Abnormal Involuntary Movement Scale (AIMS), Dyskinesia Identification System - Condensed User Scale (DISCUS), and other behavioral interventions monitoring tools and flow records. The nursing center assures that residents are being adequately monitored for adverse consequences . 1. A review of the medical record revealed RI #4 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Annual MDS (Minimum Data Set) assessment, dated 12/12/17, for RI #4 revealed a BIMS (Brief Interview for Mental Status) score of 15 out of a possible 15. This score indicated RI #4 was cognitively intact for daily decision making skills. RI #4 was assessed as needing limited to extensive assistance of one person for ADLs (Activities of Daily Living). A review of the December 2017 physician's orders for RI #4 revealed an order for [REDACTED]. A review of the December Medication Administration Record [REDACTED]. A review of the nurse's notes from 8/4/17 through 12/21/17 for RI #4 provided no documentation of the monitoring of efficacy or possible adverse consequences of antipsychotic medications. 2. A review of the medical record revealed RI #50 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Quarterly MDS assessment, dated 11/08/17, for RI #50 revealed a BIMS score of 15 out of a possible 15. This score indicated RI #50 was cognitively intact for daily decision making skills. RI #50 was assessed as needing limited to extensive assistance of one person for ADLs. A review of the December 2017 physician's orders for RI #50 revealed an order for [REDACTED]. A review of the December Medication Administration Record [REDACTED]. A review of the nurse's notes from 8/2/17 through 12/20/17 for RI #50 provided no documentation of the monitoring of efficacy or possible adverse consequences of antipsychotic medications. 3. A review of the medical record revealed RI #83 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Quarterly MDS assessment, dated 11/29/17, for RI #83 revealed a BIMS score of 10 out of a possible 15. This score indicated RI #83 was moderately impaired for daily decision making skills. RI #83 was assessed as needing only set-up for meals and was independent with ADLs. A review of the December 2017 physician's orders for RI #83 revealed an order for [REDACTED]. [MEDICATION NAME] 25 mg in the a.m. A review of the December 2017 Medication Administration Record [REDACTED]. A review of the nurse's notes from 8/1/17 through 12/6/17 for RI #83 provided no documentation of the monitoring of efficacy or possible adverse consequences of antipsychotic medications. During an interview on 12/21/17 at 6:01 p.m., with EI #4, the RN (Registered Nurse)/Quality Assurance Coordinator, the medical records were searched for documentation of the efficacy and potential side effects of [MEDICAL CONDITION] drugs for RI #s 4, 50, and 83. EI #4 was asked what documentation she could provide for the monitoring of the efficacy and potential side effects of [MEDICAL CONDITION] drugs for RI #s 4, 50, and 83. EI #4 answered charting by exception for adverse reactions, communicated to the physician. EI #4 was asked what about the efficacy and she answered it would be in the behavior logs and charting by exception. EI #4 was asked what did the pharmacy policy recommend to monitor and how. EI #4 answered [MEDICATION NAME] effects, Neurolypti[DIAGNOSES REDACTED], Cardiac Arrythmias, falls, and Akathisia and tools are available for monitoring adverse medication consequences. EI #4 was asked where that had been done and again she answered they charted to exception. EI #4 was asked how monitoring could be verified without documentation. EI #4 answered by following the plan of care and documenting adverse observations. EI #4 was asked what was the concern of no documentation of the monitoring of the efficacy and potential side effects of [MEDICAL CONDITION] drugs for RI #s 4, 50, and 83. EI #4 answered all staff were to observe for changes, but nurses assess. EI #4 was asked how were signs of involuntary movements addressed and she answered with the assessments by the nurse during observations.

Based on record reviews, interview, and review of a facility document titled, PHYSICIAN RECOMMENDATIONS, the facility failed to ensure a pharmacy recommendation of dose reduction form was completed by the medical doctor or designee. This affected RI (Resident Identifier) #4, one of six residents whose [MEDICAL CONDITION] meds were reviewed. Findings Include: A review of a facility document titled, PHYSICIAN RECOMMENDATIONS, revealed the following directions for completion: . Please evaluate the current dose and consider a gradual taper to ensure this resident is using the lowest possible effective/optimal dose. The comments below may assist you in the documentation process. Please check the appropriate response and add additional information as requested: . A review of the medical record revealed RI #4 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Annual MDS (Minimum Data Set) assessment for RI #4, dated 12/12/17, revealed a BIMS (Brief Interview for Mental Status) score of 15 out of a possible 15. This score indicated RI #4 was cognitively intact for daily decision making skills. RI #4 was assessed as needing moderate to extensive assistance of one person for ADLs (Activities of Daily Living). A review of the December 2017 physician's orders [REDACTED]. A review of RI #4's physician recommedations for dose reduction form with a print date of 9/17/17, revealed none of the pre-filled comments were checked, nor any other explanation for refusing to attempt a gradual dose reduction. The DISAGREE box was checked with no explanation/rationale. During an interview on 12/21/17 at 6:23 p.m., EI (Employee Identifier) #4, the RN (Registered Nurse)/Quality Assurance Coordinator, the Pharmacy initiated physician recommendation for RI #4 was reviewed with the surveyor. EI #4 was asked what rationale was given for declining the dose reduction of [MEDICATION NAME] for RI #4 on 9/17. EI #4 answered none was checked. EI #4 was asked if a rationale should have been provided and she answered yes. EI #4 was asked what was the facility policy for providing a rationale for declining a pharmacist recommended dose reduction. EI #4 answered documentation of the rationale on the pharmacy recommendation form.

Based on observations, interviews, and record reviews, the facility failed to ensure enough cabbage was prepared in advance during the lunch trayline on 10/4/16. This resulted in an interruption of the trayline and a delay of meals for 29 of 76 residents served regular and mechanical diets. Findings include: A review of a facility policy with an effective date of 7/16, revealed: . Policy: Food Preparation Principles . PURPOSE: To assure that the nutritive value of food is not compromised . STANDARD: According to federal regulations, food should be prepared by methods that conserve nutritive value, flavor, and appearance. Food should be prepared according to tested recipes; in sufficient quantity; . On 10/4/16 at 11:02 a.m., an observation was made of the trayline. At 11:30 a.m., the plating process began. At 12:23 p.m., the steamed cabbage was depleted on the trayline and no additional cabbage had been prepared. Plating was suspended while EI (Employee Identifier) #1, the Dietary Manager, cooked more cabbage. Plating resumed at 12:31 p.m., after the cabbage temperature was checked. Twenty-nine trays remained to be plated. At 12:58 p.m., the trayline stalled again while more cabbage was cooked. The third pan of cooked cabbage was checked for temperature and placed on the trayline at 1:07 p.m Fourteen resident trays had not been plated at that time. At 1:15 p.m., the plating of resident meals was completed. An interview was conducted with EI #4, the cook, at 8:24 a.m. on 10/5/16. EI #4 was asked how many times was the trayline stalled for more cabbage to be cooked during the trayline observation on 10/4/16. She answered, It seemed like 2 or 3 times. EI #4 was asked why was it stalled. She stated, It wasn't enough cooked. I'm used to doing it myself. I know how much I need. EI #4 was asked why should food be prepared in advance of trayline starting. She answered so everything starts on time, goes out on time, and it should be prepared prior. She said once the steam table was set up, the food temperatures were to be checked and the trayline should be started. On 10/5/16 at 8:50 a.m., an interview was conducted with EI #5, a dietary aide. EI #5 was asked how many times was the trayline stalled for more cabbage to be cooked, during the above observations. She answered, Twice. EI #5 was asked why was it stalled. She stated, She (EI #1) had to cook more. EI #5 was asked why should food be prepared in advance of starting the trayline. She answered to keep the food warm or not overcooked on the trayline. On 10/5/16 at 9:12 a.m., an interview was conducted with EI #3, the facility's Registered Dietician. EI #3 was asked why should food be prepared in advance of the trayline starting. She answered because the trayline runs efficiently and everything stays warm. An interview was conducted with EI #2, the Director of Nutritional Services/Registered Dietitian/Licensed Dietitian, at 3:44 p.m. on 10/5/16. EI #2 was asked why should food be prepared in advance of the trayline starting. He answered so it could be served on schedule. EI #2 was asked what was the concern of having to stop and wait for food to be cooked. He answered so staff could follow the schedule. On 10/5/16 at 4:07 p.m., EI #1 was asked how many times was the trayline stalled for more cabbage to be cooked. She said I think 3 times. EI #1 was asked why was it stalled. She answered she had gotten side tracked and the first batch cooked during the trayline burned. EI #1 was asked why should food be prepared in advance of starting the trayline. She stated, To make sure we are on time and we have everything ready and temps (temperatures checked). EI #1 was asked what was the concern of the trayline stalling twice while waiting for cabbage to be cooked. She answered, Some trays in the carts could be getting cold and the food being served late. EI #1 was asked what was the policy on food preparation timeliness. She answered, (To have) sufficient quantity cooked.

Based on an observation, interviews, and record reviews, the facility failed to ensure residents with pureed diets were served bread as indicated on the menu during the lunch trayline on 10/4/16. This affected all 23 residents served pureed diets from the kitchen. Findings include: A review of a facility policy titled: Menus, dated 7/16, revealed: . PURPOSE: Menus are designed to meet the daily food allowance requirements . for residents. STANDARD: The menu should be planned in advanced and followed whenever possible. When situations arise that prevent adherence to the menu, the Dietary Manager should select food replacements that are of similar nutritive value. An observation was made of the trayline beginning at 11:02 a.m. on 10/4/16. No pureed bread was observed on the steam table for distribution with meals. Throughout the plating of resident meals, no pureed bread was served to the residents receiving those meals. An interview was conducted with EI (Employee Identifier) #4, the cook, at 8:24 a.m. on 10/5/16. EI #4 was asked how many residents with a pureed diet received bread with their lunch meal on 10/4/16. She answered, None. EI #4 was asked if the pureed menu included bread. She answered, It does say bread. EI #4 was asked why the menu was not followed. She stated, Our procedure was giving the resident a double starch, like the peas we had yesterday, or say if we have mashed potatoes, we have to give 2 scoops. EI #4 was asked how many residents got 2 scoops of peas served to them. She answered they didn't get 2 scoops. An interview was conducted with EI #3, the Registered Dietitian, at 9:12 a.m. on 10/5/16. EI #3 was asked if the pureed menu included bread. She answered the latest one did. EI #3 was asked why the menu was not followed. She answered many of the residents complained about the pureed bread being cold and it's taste. EI #3 indicated they decided to give the residents 2 starches instead of a starch and bread. EI #3 was asked why does the menu not reflect that. She answered, The menu I signed did reflect that before (name of owner of facility) took over. An interview was conducted with EI #2, the Director of Nutritional Services/Registered Dietitian/Licensed Dietitian, at 3:44 p.m. on 10/5/16. EI #2 was asked if the current menu was signed off by him. He answered yes. EI #2 was asked if the current pureed menu included bread. He answered it does. EI #2 was asked if he would expect bread to be served if it was on the menu. He answered, I would expect it to be served, but with (name of facility) the residents had not accepted it well. EI #2 was asked if the menu should be updated to reflect double starches being served if that was the plan. He answered yes. EI #2 was asked what would be the concern of bread not being served to residents receiving pureed diets. He answered nutritionally, not a great concern. They may not get adequate calories. An interview was conducted on 10/5/16 at 4:07 p.m., with EI #1, the Dietary Manager. EI #1 was asked how many residents with a pureed diet received bread with their lunch meal on 10/4/16. She answered, They all should have . EI #1 was asked if the pureed menu included bread. She stated, Yes ma'am. EI #1 was asked if the menu should reflect what the residents were being served. She answered, Yes ma'am. EI #1 was asked why was the menu not followed during lunch the trayline on 10/4/16. She answered they had been given double starches. EI #1 was asked how many residents got 2 scoops of peas. She answered none. EI #1 was asked what was the concern of residents not receiving bread as the approved menu indicated. She stated, It could be the difference in weight loss. EI #1 was asked what was the facility's policy regarding following the menu. She stated, Follow the menu.

Based on observations, record reviews and interviews the facility failed to ensure dietary staff did not have on exposed jewelry while working in the kitchen. This had the potential to affect 89 residents receiving meals from the kitchen. Findings include: A review of a facility document titled Dietary Services - Dress Code with a review date of August, 25,2015, revealed, . Procedure . 4. Jewelry must be kept to a minimum. No facial jewelry is permitted. A review of the 2013 Food Code revealed, . Jewelry 2-303.11 Prohibition Except for a plain ring such as a wedding band, while preparing food, food employees may not wear jewelry including medical information on their arms and hands. An observation was made on 11/18/2015 at 10:45 AM of EI (Employee Identifier) #3, a dietary staff member. EI #3 was observed wearing silver colored earrings with a dark pink stone in the center, dime/quarter size in both ears. EI #3's hairnet was not covering the earrings. An observation was made on 11/18/2015 at 10:48 AM. EI #2, a dietary cook, was observed wearing silver colored, square shaped, stud earrings in both ears. Her hairnet was not covering her earrings. EI #2 also was observed wearing a gold colored necklace with a heart shaped pendant around her neck. EI #2 had a rope type chain around her neck with a plastic type box on the end. There was a writing pen that had been inserted into the bottom end of the box. EI #2 was observed to be wearing the earrings, the necklace and the pen holder during tray line while she was plating food. On 11/19/2015, at 8:50 AM, an interview was conducted with EI #2, a Dietary Cook. EI #2 was asked what the dress code was for working in the kitchen. EI #2 stated any type of scrub shirt and black or white scrub pants. EI #2 was asked if jewelry could be worn. EI #2 replied no rings and no hoop earrings. She stated when she worked at another facility she could wear stud earrings. EI #2 was asked if she knew the facility policy on wearing jewelry. EI #2 stated she did not. EI #2 was asked if she knew what the food code stated about the dietary dress code. EI #2 said no. The surveyor shared the two observations made on 11/18/2015 and asked what the potential negative effect could be of wearing jewelry, other than a plain ring, while working in the kitchen. She stated she usually tucked the pen holder in her shirt but didn't yesterday. EI #2 then stated that something could fall into the food. On 11/19/2015 at 08:55 AM EI #1, the Dietary Manager, attempted to call EI #3 on the phone for the surveyor. There was no answer. EI #1 left EI #3 a message to call him at the facility. EI #1 stated that she did not have to come in, he needed to ask her a question and it was important EI #3 had not called back to the facility by the end of the survey. On 11/19/2015, at 9:00 AM, an interview was conducted with EI #1. EI #1 was asked the facility policy regarding the dress code and wearing jewelry. EI #1 stated dietary employees could have earrings as long as they were covered by the hairnet, one ring and no fake fingernails. EI #1 was asked what the food manual stated about wearing jewelry. EI #1 replied, I'll have to look that up EI #1 was asked the potential negative effect of wearing jewelry, other than a plain ring,` while working in the kitchen. EI #1 responded, Them falling into the food.

Based on observations, interviews, and record reviews, the facility failed to ensure: 1) A kitchen staff member did not pick up a silverware bin from the floor, place it on a clean food preparation table, and wash their hands prior to returning to duties in the kitchen; and 2) A kitchen staff member did not pick up an oven mitt from the floor, place the mitt on clean plates, and wash their hands prior to returning to the tray line for serving. This had the potential to affect 102 residents receiving meals from the kitchen. Findings include: A review of the facility's undated Policy and Procedure titled, "DIETARY SERVICES - HANDWASHING," revealed, "Purpose: To prevent foodborne illness caused by contaminated hands. ... Instructions: ... 6. Wash hands: ? ... ? During food preparation ? ... ? After touching dirty dishes, equipment, or utensils ? ... ? After any time the hands may become contaminated." A review of the 2013 FDA (Food and Drug Administration) Food Code Chapter 2, Section 2-301.14 revealed, "When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: ... (E) After handling soiled EQUIPMENT or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; ... (I) After engaging in other activities that contaminate the hands." 1) On 10/16/2014 at 11:57 AM, EI (Employee Identifier) #6, a Dietary Staff member, picked up a silverware bin from the floor, placed the bin on a food preparation table, and continued to work around the freezer area in the kitchen. EI #6 failed to wash her hands after picking up the silverware bin from the floor prior to resuming duties in the kitchen. On 10/16/2014 at 3:05 PM, an interview was conducted with EI #6. EI #6 was asked when picking an item up that had fallen on the floor and hands were contaminated, what should be done. EI #6 stated, "Wash your hands." EI #6 was asked what should be done with the item which was picked up from the floor. EI #6 stated, "Throw it in the garbage." EI #6 was asked why the contaminated item should not be placed on a clean surface. EI #6 stated, "It would contaminate the food and get out to the residents and make them sick." EI #6 was asked what had been done with the silverware bin after it was picked up from the floor. EI #6 stated, "I should have thrown it away." EI #6 was asked what should have been done regarding her hands after picking up the bin from the floor. EI #6 stated, "Washed my hands." 2) On 10/16/2014 at 12:10 PM, the surveyor observed an oven mitt which had fallen on the floor in the kitchen. EI #7, a Dietary Staff member, had dropped the mitt on the floor, picked the mitt up, and threw the mitt under a table with plates which were used to serve food. EI #7 was serving food at the time of this observation. EI #7 failed to wash her hands, and obtained a plate, which the mitt had been placed on top of, from the dish table and plated food on the plate. On 10/17/2014 at 2:05 PM, an interview was conducted with EI #5, the Dietary Manager. EI #5 was asked when staff should wash their hands while in the kitchen. EI #5 stated, "Every time they come into the kitchen and change jobs. EI #5 also stated, "When going from prepping food to another job." EI #5 was asked when a food preparation item falls on the floor and becomes contaminated what should be done with that item. EI #5 stated, "... We would take the gloves back to be washed." EI #5 was asked what employees should do after picking up a contaminated item from the floor. EI #5 stated, "They should be washing their hands."

Based on observations, interviews, and document reviews, the facility failed to ensure licensed nurses administered medications as ordered by the physician, by the following: 1) Administering 5 mls (milliliters) water between medications for RI (Resident Identifier) #15 during med (medication) pass observation on 10/15/2014 at 4:10 PM; 2) Instructing RI #16 to rinse the mouth with water after the administration of [MEDICATION NAME] on 10/16/2014 at 8:22 AM; 3) Mixing 6 to 8 ounces of water or juice to liquid Potassium as ordered for RI #17, on 10/16/2014 at 8:40 AM; and, 4) Placing an [MEDICATION NAME] Patch on to RI #18's chest, instead of the back, on 10/16/2014 at 9:15 AM. These deficient practices resulted in a medication error rate of 16% (percent), and had the potential to affect RI #'s 15, 16, 17, and 18, four of eight residents observed for medication administration. Findings included: 1) A review of the facility's undated Policy and Procedure entitled, "I. PHARMACY SERVICES - ADMINISTERING MEDICATION," revealed, "Policy Medications are administered only by licensed nurses, ... in accordance with state and federal regulations and administering medication in a safe and effective manner ..." A review of medical records indicated RI #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 10/16/2014, revealed RI #15 had long and short term memory problems, and was severely impaired for decision making skills. This MDS also indicated RI #15 had a swallowing disorder, and was totally dependent on staff for all ADLs (Activities of Daily Living). A review of the Care Plan for RI #15, with a Problem Onset date of 07/01/2014, revealed, "I receives Nutrition Via [DEVICE] R/T (related to) dysphagia." Approaches revealed, "... *flush [DEVICE] with 30 cc (cubic centimeters) H2O (water) before and after meds with 5 cc given between each med (medication). ..." A review of the October 1, 2014 through October 31, 2014 physician's orders [REDACTED]. 9AM (AND) 5PM ... [MEDICATION NAME] 50MG TABLET [MEDICATION NAME] HCL 50 MG TABLET GIVE ONE (1) TABLET BY MOUTH TWICE DAILY. " A medication pass observation was made for RI #15 on 10/14/2014 at 4:10 PM, performed by EI (Employee Identifier) #2, a Licensed Practical Nurse. During this observation, EI #2 administered 5 mls of water into the [DEVICE] of RI #15 via syringe, by push method. EI #2 then administered the crushed [MEDICATION NAME] with 5 mls of water, again by push method to RI #15, followed by the crushed Tylenol with 5 mls water, again by push method. EI #2 then administered 30 mls of water by push method, and connected the tube feeding for RI #5. EI #2 failed to flush the [DEVICE] between administrations of medications. An interview with EI #2 was conducted on 10/17/2014 at 3:11 PM. EI #2 was asked if flushes should be done between medications, when administering medicines via [DEVICE]. EI #2 stated, "Yes." EI #2 was asked why, and she replied, "To make sure the medicines are out of the tube." EI #2 was asked what the potential harm was of not flushing between each medication. EI #2 stated, "The tube can become clogged, and the patient won't receive the full effect of the drugs." EI #2 was asked what she did wrong while being observed during this medication pass. EI #2 stated, "I didn't check for residual and I didn't flush after each med." On 10/17/2014 at 3:30 PM, an interview was conducted with EI #4, the Assistant Director of Nursing. EI #4 was asked if flushes should be done between medications, when administering via [DEVICE]. EI #4 stated, "Yes." EI #4 was asked why, and she replied, "It keeps the medicines from mixing." EI #4 was asked what the potential harm was of not flushing between each medication, and she replied, "Interaction of medications." 2) A review of "Mosby's 2013 NURSING DRUG REFERENCE 26TH EDITION," revealed on page 1156, "[MEDICATION NAME] HandiHaler ... Rinse mouth after use." A review of the medical records indicated RI #16 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Quarterly MDS for RI #16, with an ARD of 09/11/2014, revealed a BIMS (Brief Interview for Mental Status) score of 13 out of a possible score of 15. This indicated RI #16 was cognitively intact for decision making skills. This MDS also indicated RI #16 required extensive staff assistance with ADLs, but could feed self, after meals were set-up. A review of the October 2014 eMAR (electronic Medication Administration Record) revealed, "[MEDICATION NAME] 18 MCG (microgram) CP-HANDIHALER (capsule in handihaler), INHALE ONE CAP (capsule) VIA INHALER DAILY, RINSE MOUTH AFTER EACH USE ..." During the medication administration pass for RI #16 on 10/16/2014 at 8:22 AM, EI #3, a Licensed Practical Nurse, was observed to place the [MEDICATION NAME] capsule into the handihaler chamber, then charged it. The medication was then administered to RI #16. EI #3 then gave a cup of water to RI #16 who drank the water. EI #3 did not instruct RI #16 to rinse and spit. An interview was conducted with EI #3 on 10/17/2014 at 1:17 PM. EI #3 was asked how mouth rinsing should be done. EI #3 stated, "Put water or a liquid in your mouth and spit it out ..." EI #3 was asked if it was appropriate to allow a resident to drink or swallow water, if the order stated to rinse mouth after each use. EI #3 stated, "If the order doesn't say spit out. ..." EI #3 was asked what the potential harm was of not rinsing and spitting after [MEDICATION NAME] was administered. EI #3 did not have an answer at that time. An interview was conducted on 10/17/2014 at 1:45 PM, with EI #1, a Licensed Practical Nurse. EI #1 was asked how mouth rinsing should be done. EI #1 stated, "Put liquid in; swish it around and spit it out." EI #1 was asked if it was appropriate to allow a resident to drink or swallow water, if the order stated to rinse mouth after each use. EI #1 stated, "If they choose to, but they need to swish it around and spit it out. We encourage them to spit it out." EI #1 was asked what the potential harm was of not rinsing and spitting after [MEDICATION NAME] was administered. EI #1 stated, "Swallowing particles." During the interview with EI #4, ADON (Assistant Director of Nursing), on 10/17/2014 at 3:20 PM, EI #4 was asked how mouth rinsing should be done, and she replied, "Rinse and Spit." EI #4 was asked if it was appropriate to allow a resident to drink or swallow water, if the order stated to rinse mouth after each use. EI #4 stated, "With [MEDICATION NAME], I thought it was just to keep the mouth moist. ... Our policy is to rinse and spit with [MEDICATION NAME]." 3) A review of the facility's undated Policy and Procedure entitled, "I. PHARMACY SERVICES - ADMINISTERING MEDICATION," revealed, "Policy Medications are administered only by licensed nurses, ... in accordance with state and federal regulations and administering medication in a safe and effective manner. ...PROCEDURE FOR MED PASS TIPS ... 23. 4-6 oz.(ounces) of water or fruit juice with bulk laxatives, K+ (Potassium) supplements ... " A review of the medical records revealed RI #17 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of RI #17's Quarterly MDS with an ARD of 10/16/2014, revealed RI #17 was severely impaired for decision making skills, and had short and long term memory problems. This MDS also indicated RI #17 was totally dependent on staff for all ADLs. A review of RI #17's physician's orders [REDACTED]. During the medication pass observation for RI #17 on 10/16/2014 at 8:40 AM, EI #1, a Licensed Practical Nurse, was observed. EI #1 flushed the [DEVICE] for RI #17 with 30 mls water, followed by [MEDICATION NAME], followed by 10 mls water. This was followed by the Potassium supplement, followed by 10 mls of water. After all medications were administered, EI #1 then flushed RI #17's [DEVICE] with 30 mls of water. EI #1 did not mix the Potassium with 6 to 8 ounces of water or juice, as ordered. During the interview on 10/17/2014 at 1:45 PM, EI #1 was asked what should be done if there was an order to mix Potassium in 6 to 8 oz water or juice. EI #1 stated, "Mix it with the juice or water. It helps with absorption." EI #1 was asked what the potential harm was of not mixing Potassium as ordered. EI #1 stated, "Terrible taste, and could burn or irritate when swallowing, and for the stomach." EI #1 was asked why water or juice was not mixed with the Potassium given to RI #17 on 10/16/14 during the observation. EI #1 stated, "I didn't mix it with the full 6 to 8 ounces of water. I mixed it with 30 ccs." During the interview on 10/17/2014 at 3:30 PM, EI #4 was asked what should be done if there was an order to mix Potassium in 6 to 8 oz water or juice. EI #4 stated, "Mix Potassium with water or juice, 6 to 8 ounces." EI #4 was asked what the potential harm was of not mixing Potassium as ordered. EI #4 stated, "More concentrated and not diluted. You're dealing with the heart rate then. Potassium deals with the heart." 4) A review of the facility's Policy and Procedure with a revised date of April 24, 2014, and entitled, "QUALITY OF CARE - ADMINISTRATION OF medications: [REDACTED]. A structured system is initiated for the use in preparation and administration of resident's medications. Procedure The purpose is to provide instructions for the topical administration of medications in an effort to bring about: 1. Desired effects on skin tissue 2. Desired systemic effects ... SIGNIFICANT INFORMATION: ... 2. Assure the physician's orders [REDACTED]. ..." A review of medical records indicated RI #18 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #18's Quarterly MDS with an ARD of 10/07/2014, revealed RI #18 was severely impaired for decision making skills and had short and long term memory problems. This MDS also indicated RI #18 was totally dependent on staff for all ADLs. A review of RI #18's physician's orders [REDACTED]. During the medication pass observation on 10/16/2014 at 9:15 AM, EI #1 was observed to remove a patch from RI #18's right upper chest area. EI #1 then wiped the area with an alcohol swab, and flushed the old patch. EI #1 dated and initialed the new patch, then applied it to RI #18's left upper chest area. EI #1 then adjusted RI #18's clothing. EI #1 did not apply the patch to RI #18's back, as ordered. During a subsequent interview on 10/17/2014 at 4:05 PM, EI #4 was asked if it was appropriate to apply a patch to the chest, if orders stated to apply the patch to the back. EI #4 stated, "No. You have to follow the orders." EI #4 was asked what the potential harm was, and she replied, "... It had to be for a reason. Potential for resident to pull off; it could interfere with something ... The orders should have been followed."

Based on observation, interviews, and document reviews, the facility failed to ensure a licensed nurse assessed the [DEVICE] (Gastrostomy tube) for residual (gastric contents) prior to starting tube feeding, as care planned. This had the potential to affect RI (Resident Identifier) #15, one of five residents sampled with tube feedings. Findings include: A review of the medical records indicated RI #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 10/16/2014, revealed RI #15 had long and short term memory problems, and was severely impaired for decision making skills. This MDS also indicated RI #15 had a swallowing disorder, and was totally dependent on staff for all ADLs (Activities of Daily Living). A review of RI #15's physician's orders [REDACTED]. A review of the Care Plan for RI #15, with a Problem Onset date of 07/01/2014, revealed, "I receives Nutrition Via [DEVICE] R/T (related to) dysphagia." Approaches revealed, " ... *check residual prior to administering TF (tube feeding) if 60 cc or more hold for 2 hrs then recheck." A medication pass observation was made on 10/14/2014 at 4:10 PM, performed by EI (Employee Identifier) #2, a Licensed Practical Nurse. During this observation, using a stethoscope, EI #2 assessed placement of the [DEVICE] by auscultation, but did not assess for residual, prior to administering medications of Tylenol and [MEDICATION NAME] or starting the tube feeding of [MEDICATION NAME] 1.2 for RI #15. On 10/17/2014 at 3:11 PM, an interview was conducted with EI #2. EI #2 was asked if there was an order or care plan that stated to assess a resident for residual prior to starting tube feedings, what should be done. EI #2 stated, "You should get a syringe and pull back to see if there is any residual." EI #2 was asked what the potential harm was of not assessing for residual, and she replied, "They could be too full and this could cause them to aspirate." EI #2 was asked what had she done incorrectly during the medication pass observation, and she replied, "I didn't check for residual and I didn't flush after each med. I was nervous." An interview was conducted with EI #4, the Assistant Director of Nursing, on 10/17/2014 at 3:30 PM. EI #4 was asked what should be done if there was an order or care plan that stated to assess a resident for residual prior to starting tube feedings. EI #4 stated, "Check placement and assess for how much residual you do have." EI #4 went on to say that checking placement and residual was their policy. EI #4 was asked what the potential harm was of not assessing a resident for residual and starting tube feedings. EI #4 stated, "You don't know if the tube feedings been digested. High residual means it's not been taken in. You could have fluid overload."

Based on an observation, interviews, and document reviews, the facility failed to ensure a licensed nurse did not place a medication syringe into a multi-dose bottle of liquid medicine. This had the potential to affect RI (Resident Identifier) #18, one of eight residents observed for medication administration. Findings include: A review of the facility's Policy and Procedure titled,"QUALITY OF CARE- ADMINISTRATION OF MEDICATIONS: - ORAL MEDICATION," with a revision date of April 24, 2014, revealed, "Policy (Named Facility) administers medications only upon a physician's orders [REDACTED]. ... Procedure The purpose of administering oral medication is to assure the correct dosage of the prescribed medication at the scheduled time to the correct resident as ordered by the physician. ... PROCEDURE: ... 6. Prepare liquid medication for administration: a. Shake or prepare medication as instructed on label. b. Hold medicine cup at eye level. c. Pour the exact amount from side of bottle opposite the label. d. Wipe neck of bottle with damp paper towel. ..." A review of the medical records indicated RI #18 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #18's Quarterly MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 10/07/2014, revealed RI #18 was severely impaired for decision making skills and had short and long term memory problems. This MDS also indicated RI #18 was totally dependent on staff for all ADLs. A review of the 10/01/14 through 10/31/14 physician's orders [REDACTED]. 9AM." During the medication administration pass for RI #18 on 10/16/2014 at 9:43 AM, EI (Employee Identifier) #1, a Licensed Practical Nurse, was observed. EI #1 retrieved a bottle of [MEDICATION NAME], labeled for RI #18, from the medication cart. EI #1 removed the last brown medication syringe with ungloved hands from a plastic bag, and placed the syringe into the bottle of medication. EI #1 extracted 10mls from the bottle, using the syringe, then placed the medication into a plastic cup. An interview was conducted with EI #1 on 10/17/2014 at 1:45 PM. EI #1 was asked how medications should be removed from a multi-dose bottle of liquid medicines. EI #1 stated, "Pour it up in a cup and draw (it) up with a syringe. Discard any extras. Never pour back in." EI #1 was asked why the brown medication syringe was placed in the bottle of [MEDICATION NAME] for RI #18, during the medication pass observation. EI #1 stated, "I was aggravated with myself because I had forgotten to give it earlier. It's no excuse, but I was rushed." EI #1 was asked what the potential harm was of placing the syringe into the medication bottle and she replied, "Contamination." An interview was conducted with EI #4, the Assistant Director of Nursing, on 10/17/2014 at 3:30 PM. EI #4 was asked how medications should be removed from a multi-dose bottle of liquid medicines. EI #4 stated, "You should always measure at eye level. Make sure you've got the accurate dose. If you pour too much, discard the excess." EI #4 was asked what the potential harm was of placing the syringe into the medication bottle and she replied, "Infection." An interview was conducted with EI #8, the Director of Nursing / Infection Control Nurse, on 10/17/2014 at 4:23 PM. EI #8 was asked if it was appropriate for a nurse to stick a syringe in a medication bottle to obtain the liquid medication. EI #8 informed the surveyor, "For liquid medications, they are to pour it in a cup at eye level ..."

Based on observation, interviews, and document reviews, the facility failed to ensure a licensed nurse assessed the [DEVICE] (Gastrostomy tube) for residual (gastric contents) prior to administering a tube feeding and administering medications. This had the potential to affect RI (Resident Identifier) #15, one of five residents sampled with tube feedings. Findings include: A review of "Potter-Perry 7th Edition Fundamentals of Nursing," with a copyright date of 2009, revealed, "... Chapter 44 Nutrition Page 1119 ... ADMINISTERING ENTERAL FEEDINGS VIA [MEDICATION NAME], GASTROSTOMY, ... 12. Check for gastric residual. ... b. Pull back evenly to aspirate gastric contents c. Return aspirated contents to stomach unless volume exceeds 200 mL (milliliters) (check agency policy). RATIONALE Gastric residual volume indicates if gastric emptying is delayed. Delayed gastric emptying is a concern if 200 mL or more remains in the client's stomach. Return of aspirate prevents fluid and electrolyte imbalance. 13. Flush tubing with 30 ml (milliliters) water. RATIONALE Ensure tube is clear and patent. 14. Initiate feeding. ..." A review of "Nurses' Guide to Clinical Procedures, 5th Edition," revealed, "Chapter 7 Page 446 Managing a Gastrostomy/Jejunostomy Tube ...12. Check the residual volume (aspirating with a large-bore syringe). Clamp or crimp tube and place tip of syringe into end of appropriate port of tube; release clamp and withdraw GI (Gastrointestinal) fluid content... Rationale Determines if feeding solution being propelled through GI tract" A review of the medical records indicated RI #15 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 10/16/2014, revealed RI #15 had long and short term memory problems, and was severely impaired for decision making skills. This MDS also indicated RI #15 had a swallowing disorder, and was totally dependent on staff for all ADLs (Activities of Daily Living). A review of RI #15's physician's orders [REDACTED]. A review of the Care Plan for RI #15, with a Problem Onset date of 07/01/2014, revealed, "I receives Nutrition Via [DEVICE] R/T (related to) dysphagia." Approaches revealed, " ... *check residual prior to administering TF (tube feeding) if 60 cc or more hold for 2 hrs then recheck." A medication pass observation was made on 10/14/2014 at 4:10 PM, performed by EI (Employee Identifier) #2, a Licensed Practical Nurse. During this observation, using a stethoscope, EI #2 assessed placement of the [DEVICE] by auscultation, but did not assess for residual, prior to administering medications of Tylenol and [MEDICATION NAME] or starting the tube feeding of [MEDICATION NAME] 1.2 for RI #15. On 10/17/2014 at 3:11 PM, an interview was conducted with EI #2. EI #2 was asked if there was an order or care plan that stated to assess a resident for residual prior to starting tube feedings, what should be done. EI #2 stated, "You should get a syringe and pull back to see if there is any residual." EI #2 was asked what the potential harm was of not assessing for residual, and she replied, "They could be too full and this could cause them to aspirate." EI #2 was asked what had she done incorrectly during the medication pass observation, and she replied, "I didn't check for residual and I didn't flush after each med. I was nervous." An interview was conducted with EI #4, the Assistant Director of Nursing, on 10/17/2014 at 3:30 PM. EI #4 was asked what should be done if there was an order or care plan that stated to assess a resident for residual prior to starting tube feedings. EI #4 stated, "Check placement and assess for how much residual you do have." EI #4 went on to say that checking placement and residual was their policy. EI #4 was asked what the potential harm was of not assessing a resident for residual and starting tube feedings. EI #4 stated, "You don't know if the tube feedings been digested. High residual means it's not been taken in. You could have fluid overload."

Based on observations and record review, the facility failed to ensure: 1.) RI (Resident Identifier) #9's left lower extremity was elevated when out of bed as care planned on 1 of 3 survey days. 2.) That RI #9 was checked or changed for incontinence for a total of 5 hours and 55 minutes, instead of every 2 hours as care planned. This affected RI #9, 1 of 18 sampled residents whose care plans were reviewed. Findings include: A review of RI #9's medical records revealed RI #9 was originally admitted to the facility on [DATE] and re-admitted on [DATE], with [DIAGNOSES REDACTED]. (Escherichia) Coli Infection. A review of RI #9's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/16/2013 indicated RI #9 had a BIMS (Brief Interview for Mental Status) of 15, indicating RI #9 was cognitively intact. This assessment also indicated RI #9 was incontinent of bowel and bladder, and totally dependent on staff for transfer, dressing and toileting. RI #9 was also documented as having impairment on one side, upper and lower extremities. Based on the facility's document entitled, "Care Plan ...Problem Onset: 10/14/201 ... 6/7/13 Elevate Lt (left) foot and leg when OOB (Out of Bed) *Extensive assist for bathing, dressing,, total care for toileting ..." On 01/24/2014 at 7:39 AM, RI #9 was observed in her room, in her wheelchair, with her left leg not elevated. On 01/24/2014 at 8:15 AM, RI #9 was observed still in her room, in the wheelchair, with both feet on the foot rest, not elevated. On 01/24/2014 at 11:40 AM, RI #9 was observed eating while sitting in the wheelchair with her feet on the foot rest, not elevated. On 01/24/2014 at 1:22 PM, RI #9 was observed by the surveyor as still having both lower extremities down. 2. A review of the Care Plan dated 10/14/2010 for RI #9 revealed " ... incontinent of B&B (bowel and bladder) ... Check and dry when repositioning q (every) 2 (hours) and prn (as needed)." A review of the policy entitled, "NURSING SERVICES - INCONTINENCE CARE QA (Quality Assurance)/QI (Quality Improvement) Committee Approval/ Effective Date: May 25, 2010 Revised Date: February 22, 2013 " revealed, "Policy Residents who are incontinent of bowel and bladder will receive incontinent care to maintain hygiene, skin integrity, and to prevent urinary tract infections." A review of the documentation titled "Completed Care Tasks" Service Date of 01/24/2014 for RI #9, indicated "01/14/14 02:10 AM E (East) 1460 1 (room [ROOM NUMBER] Bed 1) Document Urine Output - Resident Incontinent of Urine." The last noted entry was timed at 10:47 AM. There were no other tasks addressed for RI #9's incontinence. During continuous observation of RI #9 on 1/24/14 from 7:37 AM until 1:32 PM, RI #9 was not assessed for incontinence. At 7:37 AM, EI (Employee Identifier) #3, a CNA (Certified Nursing Assistant) was in the room with the resident and exited the room at 7:46 AM. During this time, the resident was not checked for incontinence or asked if she was soiled. EI #3 re-entered the room at 7:48 AM, and during this time the resident was not checked for incontinence or asked if she was soiled. At 8:07, AM EI #3 entered RI #9's room and during this time the resident was not checked for incontinence or asked if she was soiled. At 8:34, AM EI #3 delivered RI #9's breakfast tray. During this time, the resident was not checked for incontinence or asked if she was soiled. At 8:52 AM, EI #3 entered RI #9's room to assist the roommate of RI #9 with breakfast. During this time, RI #9 was not checked for incontinence or asked if she was soiled. At 9:06 AM, EI#3 removed RI #9's breakfast tray then exited the room. At 9:08 AM, EI #3 re-entered RI #9's room and set up make up for RI #9 to put on. During this time, the resident was not checked for incontinence or asked if she was soiled. At 9:16 AM, a hospice aide entered the room to give care to RI #9's roommate. The surveyor remained in the room with RI #9 while the door was closed to maintain tracking/observation while the hospice aide cared for the roommate. At 9:29 AM, EI #2, a LPN (Licensed Practical Nurse) entered RI #9's room and gave medications to RI #9. During this time, the resident was not checked for incontinence or asked if she was soiled. At 9:43 AM, EI #2 knocked on RI #9's door and informed the resident that the CNA would be in soon to get her ready to go to activities. During this time, the resident was not checked for incontinence or asked if she was soiled. At 10:00 AM no CNA had approached RI #9 about getting her ready to go to activities, and the Pastoral Care staff member entered the room. He moved the bed table from in front of the resident, got a sweater and placed it over the shoulders of RI #9 and pushed her wheel chair to the chapel for mass. At 10:02 AM, RI #9 entered the chapel for mass. At 10:56 AM, RI #9 exited the chapel in her wheel chair and was taken to the East dining room at 10:58 AM. From 10:58 AM until 12:53 PM, the resident was in the East dining area in her wheel chair. During this time, RI #9 was not checked for incontinence or asked if she was soiled. At 12:53 PM, EI #2 informed RI #9 that she was going to take her down the hall to give her medications. At 12:56 PM, EI #2 pushed RI #9's wheelchair into her room and administered medications. EI #3 entered the room also and during this time, the resident was not checked for incontinence or asked if she was soiled. At 12:58 PM, EI #2 turned RI #9's wheelchair around and exited the room. EI #2 was asked, by the surveyor, where she was taking RI #9. EI #2 replied "Back to activities." At 1:01 PM, residents were still eating in the activity room and EI #2 took RI #9 back to East dining room at 1:03 PM. At 1:05 PM, a staff member approached RI #9 as she (RI #9) was requesting to go to PT (Physical Therapy). During this time, the resident was not checked for incontinence or asked if she was soiled. At 1:08 PM, EI #3 notified RI #9 that she needed to take her to the room to check if she for incontinence. At 1:09 PM, RI #9 arrived at her room. EI #3 gathered supplies and re-entered the room at 1:12 PM. At 1:15 PM, EI #3 exited RI #9's room to push another resident down the hallway. At 1:22 PM, EI #3 re-entered the room and was assisted by EI #4, a CNA, to use a hoyer lift to place RI #9 into the bed. At 1:31 PM, EI #3 exited the room to answer a call bell alarm. At 1:32 PM, EI #3 re-entered RI #9's room and incontinence care was started. The brief removed from the resident was soaked with urine and a small amount of semi-soft, brown stool was noted. Numerous wrinkled indentions were observed on bilateral buttocks and moderate amount of redness around the rectum where stool had been present. An interview was conducted with EI #3, on 01/24/2014 at 2:00 PM. EI #3 was asked how often were incontinent residents assessed for the need of perineal care. EI #3 answered, "Every 2 hours." EI #3 was asked what was the facility's policy regarding incontinent residents. EI #3 stated, "Make sure they are cleaned, turned and dried." EI #3 was asked who was the CNA responsible for the care of RI #9 for 01/24/2014. EI #3 stated, "I am." When EI #3 was asked when was incontinence care was provided for RI #9, EI #3 responded, "7 AM and just then when you watched me." EI #3 was asked who was responsible for checking residents for incontinence. EI #3 stated, "Everybody." An interview was conducted with EI #2, on 01/24/2014 at 2:15 PM. EI #2 was asked what was the facility's policy for monitoring residents for incontinence. EI #2 stated, "We are to check them every 2 hours." EI #2 was asked who was to perform this task. EI #2 stated, "CNAs and sometimes the nurses if the CNAs are on break and the resident has an incontinent episode. They are to be repositioned Q 2 hours and PRN." EI #2 was asked who was the CNA responsible for RI #9 on 01/24/2014. EI #2 named, EI #3. EI #2 was asked when incontinence care had been given to RI #9 during her shift. EI #2 stated, "When she got up for her bath this morning and this evening about 12:00-12:30 when she got through eating lunch." EI #2 was asked who was responsible for ensuring this task was completed. EI #2 stated, "Me." EI #2 was asked why RI #9 was not checked for incontinence between 7:37 AM and 1:32 PM. EI #2 stated, "While I was giving meds this morning, the aides were on the hall giving care. I assumed that because they were getting residents up it should have been done. She was to have been done at 10 and noon." EI #2 was asked what was the potential negative outcome if residents were not assessed for incontinence. EI #2 stated, "Breakdown, skin breakdown." An interview was conducted with EI #1, the Infection Control Nurse, on 01/24/2014 at 5:02 PM. EI #1 was asked how often residents were to be checked for incontinence. EI #1 stated, "They should be checked every 2-3 hours and prn." EI #1 was asked who was supposed to carry out the task. EI #1 stated, "CNAs, but they should be monitored also by the unit manager/charge nurses." EI #1 was asked who was responsible for monitoring that incontinence care was provided per policy. EI #1 stated, "The unit manager/charge nurses." EI #1 was asked what was the potential negative outcome if residents were not given routine incontinence care. EI #1 stated, "UTIs (Urinary Tract Infections), infection, rashes, breakdown of the skin, then you've got a dignity issue with that resident."

Based on observations, record reviews, and interviews, the facility failed to ensure a resident was not checked and changed for incontinence in a timely manner in order to prevent the potential for skin breakdown. This affected RI #9, 1 or 2 residents continuously monitored for incontinence care. Findings include: A review of the medical record for RI (Resident Identifier) #9 revealed she was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #9's MDS (Minimum Data Set), dated 12/16/13, revealed she had a BIMS (Brief Interview Memory Score) of 15, indicating RI #9 was cognitively intact and noted to have disorganized thinking. RI #9 was identified as always incontinent of bowel and bladder. A review of the Care Plan, dated 10/14/2010 for RI #9, revealed "...incontinent of B&B (bowel and bladder) ... Check and dry when repositioning q (every) 2 (hours)and prn (as needed)." A review of the facility's policy titled, "NURSING SERVICES - INCONTINENCE CARE QA(Quality Assurance/QI (Quality Improvement) Committee Approval/ Effective Date: May 25, 2010 Revised Date: February 22, 2013" revealed, "Policy Residents who are incontinent of bowel and bladder will receive incontinent care to maintain hygiene, skin integrity, and to prevent urinary tract infections." A review of the facility's documentation titled "Completed Care Tasks" Service Date of 01/24/2014 for RI #9, indicated "01/14/14 02:10 AM E (East) 1460 1 (room [ROOM NUMBER] Bed 1) Document Urine Output - Resident Incontinent of Urine." The last noted entry was timed at 10:47 AM. There were no other tasks addressed for RI #9's incontinence. During continuous observations of RI #9 on 1/24/14 from 7:37 AM until 1:32 PM, RI #9 was not assessed for incontinence. At 7:37 AM, EI (Employee Identifier) #3, a CNA (Certified Nursing Assistant) was in the room with the resident and exited the room at 7:46 AM. During this time, the resident was not checked for incontinence or asked if she was soiled. EI #3 re-entered the room at 7:48 AM, and during this time the resident was not checked for incontinence or asked if she was soiled. At 8:07 AM, EI #3 entered RI #9's room. RI #9 was not checked for incontinence or asked if she was soiled. At 8:34 AM, EI #3 delivered RI #9's breakfast tray, the resident was not checked for incontinence or asked if she was soiled. At 8:52 AM, EI #3 entered RI #9's room to assist RI #9's roommate with breakfast. RI #9 was not checked for incontinence or asked if she was soiled. At 9:06 AM, EI#3 removed RI #9's breakfast tray and exited the room. At 9:08 AM, EI #3 re-entered RI #9's room and set up make-up for RI #9 to put on. The resident was not checked for incontinence or asked if she was soiled. At 9:16 AM a hospice aide entered the room to give care to RI #9's roommate. The surveyor remained in the room with RI #9 while the door was closed to maintain continuous observation while the hospice aide cared for the roommate. At 9:29 AM, EI #2, the LPN (Licensed Practical Nurse),entered RI #9's room and administered medications to RI #9. RI #9 was not checked for incontinence or asked if she was soiled. At 9:43 AM, EI #2 knocked on RI #9's door and informed the resident that the CNA would be in soon to get her ready to go to activities. At this time,the resident was not checked for incontinence or asked if she was soiled. At 10:00 AM, no CNA had approached RI #9 about getting her ready to go to activities. The Pastoral Care staff member entered the room. He moved the bed table from in front of the resident, got a sweater and placed it over the shoulders of RI #9 and pushed her in the wheelchair to the chapel for mass. At 10:02 AM, RI #9 entered the chapel for mass. At 10:56 AM, RI #9 exited the chapel in her wheelchair and was taken to the East dining room at 10:58 AM. From 10:58 AM until 12:53 PM the resident was in the East dining area in her wheel chair. During this time, RI #9 was not checked for incontinence or asked if she was soiled. At 12:53 PM, EI #2 informed RI #9 that she was going to take her down the hall to administer her medications. At 12:56 PM, EI #2 pushed RI #9 in her wheelchair into her room and administered her medications. EI #3 entered the room also, and the resident was not checked for incontinence or asked if she was soiled. At 12:58 PM, EI #2 turned RI #9 in her wheelchair around and exited the room. EI #2 was asked, by the surveyor, where she was taking RI #9. EI #2 replied, "Back to activities." At 1:01 PM, residents were still eating in the activity room and EI #2 took RI #9 back to East dining room at 1:03 PM. At 1:05 PM, a staff member approached RI #9 as she (RI #9) was requesting to go to PT (Physical Therapy). The resident was not checked for incontinence or asked if she was soiled. At 1:08 PM, EI #3 notified RI #9 that she needed to take her to the room to check her for incontinence. At 1:09 PM, RI #9 arrived to her room. EI #3 gathered supplies and re-entered the room at 1:12 PM. At 1:15 PM, EI #3 exited RI #9's room to push another resident down the hallway. At 1:22 PM, EI #3 re-entered the room and was assisted by EI #4, a CNA, to use a hoyer lift to place RI #9 into the bed. At 1:31 PM, EI #3 exited the room to answer a call bell alarm. At 1:32 PM, EI #3 re-entered RI #9's room and incontinence care was started. The adult brief removed from the resident was soaked with urine and a small amount of semi-soft, brown stool was observed. Numerous wrinkled indentions were observed on RI #9's bilateral buttocks. There was a moderate amount of redness observed around the rectum where stool had been present. An interview was conducted with EI #3, on 01/24/2014 at 2:00 PM. EI #3 was asked how often were incontinent residents assessed for the need of perineal care. EI #3 answered, "Every 2 hours." EI #3 was asked what was the facility's policy regarding incontinent residents. EI #3 stated, "Make sure they are cleaned, turned and dried." EI #3 was asked who was the CNA responsible for the care of RI #9 for 01/24/2014. EI #3 stated, "I am." EI #3 was asked when was incontinence care given to RI #9, EI #3 responded, "7 AM and just then when you watched me." EI #3 was asked who was responsible for checking residents for incontinence. EI #3 stated, "Everybody." An interview was conducted with EI #2, on 01/24/2014 at 2:15 PM. EI #2 was asked what was the facility's policy of monitoring residents for incontinence. EI #2 stated, "We are to check them every 2 hours." EI #2 was asked who was to perform this task. EI #2 stated, "CNAs and sometimes the nurses if the CNAs are on break and the resident has an incontinent episode. They are to be repositioned Q (every) 2 hours and PRN (as needed)." EI #2 was asked who was the CNA responsible for RI #9 for 01/24/2014. EI #2 named EI #3. EI #2 was asked when incontinence care had been given to RI #9 during her shift. EI #2 stated, "When she got up for her bath this morning and this evening about 12:00-12:30 when she got through eating lunch." EI #2 was asked who was responsible for ensuring this task was completed. EI #2 stated, "Me." EI #2 was asked why RI #9 was not checked between 7:37 AM and 1:32 PM. EI #2 stated, "While I was giving meds this morning, the aides were on the hall giving care. I assumed that because they were getting residents up it should have been done. She was to have been done at 10 and noon." EI #2 was asked what was the potential negative outcome if residents were not assessed. EI #2 stated, "Breakdown, skin breakdown." An interview was conducted with EI #1, the Infection Control Nurse, on 01/24/2014 at 5:02 PM. EI #1 was asked how often were residents checked for incontinence. EI #1 stated, "They should be checked every 2-3 hours and prn."EI #1 was asked who is supposed to carry out the task. EI #1 stated, "CNAs, but they should be monitored also by the unit manager/charge nurses." EI #1 was asked who was responsible for monitoring that incontinence care was provided per policy. EI #1 stated, "The unit manager/charge nurses."EI #1 was asked what was the potential negative outcome if residents were not given routine incontinence care. EI #1 stated, "UTIs (Urinary Tract Infections), infection, rashes, breakdown of the skin, then you've got a dignity issue with that resident."

Based on observations, record reviews, and interviews, the facility failed to ensure a resident was not checked and changed for incontinence in a timely manner in order to prevent the potential for a Urinary Tract infection. This affected RI #9, 1 of 2 residents tracked for incontinence care. Findings include: A review of the medical record for RI (Resident Identifier) #9 revealed she was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #9's MDS (Minimum Data Set), dated 12/16/13, revealed she had a BIMS (Brief Interview Memory Score) of 15, indicating RI #9 was cognitively intact and noted to have disorganized thinking. RI #9 was identified as always incontinent of bowel and bladder. A review of the Care Plan, dated 10/14/2010 for RI #9, revealed "... incontinent of B&B (bowel and bladder) ... Check and dry when repositioning q (every) 2 (hours) and prn (as needed)." A review of the "NURSING SERVICES - INCONTINENCE CARE QA (Quality Assurance)/QI (Quality Improvement) Committee Approval/ Effective Date: May 25, 2010 Revised Date: February 22, 2013" revealed, "Policy Residents who are incontinent of bowel and bladder will receive incontinent care to maintain hygiene, skin integrity, and to prevent urinary tract infections." A review of the facility's documentation titled "Completed Care Tasks" Service Date of 01/24/2014 for RI #9, indicated "01/14/14 02:10 AM E (East) 1460 1 (room [ROOM NUMBER] Bed 1) Document Urine Output - Resident Incontinent of Urine." The last noted entry was timed at 10:47 AM. There were no other tasks addressed for RI #9's incontinence. During continuous observation of RI #9 on 1/24/14 from 7:37 AM until 1:32 PM, RI #9 was not assessed for incontinence. At 7:37 AM, EI (Employee Identifier) #3, a CNA (Certified Nursing Assistant) was in the room with the resident and exited the room at 7:46 AM. During this time, the resident was not checked for incontinence or asked if she was soiled. EI #3 re-entered the room at 7:48 AM, and during this time the resident was not checked for incontinence or asked if she was soiled. At 8:07 AM, EI #3 entered RI #9's room. RI #9 was not checked for incontinence or asked if she was soiled. At 8:34 AM, EI #3 delivered RI #9's breakfast tray, the resident was not checked for incontinence or asked if she was soiled. At 8:52 AM, EI #3 entered RI #9's room to assist RI #9's roommate with breakfast. RI #9 was not checked for incontinence or asked if she was soiled. At 9:06 AM, EI#3 removed RI #9's breakfast tray and exited the room. At 9:08 AM, EI #3 re-entered RI #9's room and set up make-up for RI #9 to put on. The resident was not checked for incontinence or asked if she was soiled. At 9:16 AM a hospice aide entered the room to give care to RI #9's roommate. The surveyor remained in the room with RI #9 while the door was closed to maintain continuous observation while the hospice aide cared for the roommate. At 9:29 AM, EI #2, the LPN (Licensed Practical Nurse),entered RI #9's room and administered medications to RI #9. RI #9 was not checked for incontinence or asked if she was soiled. At 9:43 AM, EI #2 knocked on RI #9's door and informed the resident that the CNA would be in soon to get her ready to go to activities. At this time,the resident was not checked for incontinence or asked if she was soiled. At 10:00 AM, no CNA had approached RI #9 about getting her ready to go to activities. The Pastoral Care staff member entered the room. He moved the bed table from in front of the resident, got a sweater and placed it over the shoulders of RI #9 and pushed her in the wheelchair to the chapel for mass. At 10:02 AM, RI #9 entered the chapel for mass. At 10:56 AM, RI #9 exited the chapel in her wheelchair and was taken to the East dining room at 10:58 AM. From 10:58 AM until 12:53 PM the resident was in the East dining area in her wheel chair. During this time, RI #9 was not checked for incontinence or asked if she was soiled. At 12:53 PM, EI #2 informed RI #9 that she was going to take her down the hall to administer her medications. At 12:56 PM, EI #2 pushed RI #9 in her wheelchair into her room and administered her medications. EI #3 entered the room also, and the resident was not checked for incontinence or asked if she was soiled. At 12:58 PM, EI #2 turned RI #9 in her wheelchair around and exited the room. EI #2 was asked, by the surveyor, where she was taking RI #9. EI #2 replied, "Back to activities." At 1:01 PM, residents were still eating in the activity room and EI #2 took RI #9 back to East dining room at 1:03 PM. At 1:05 PM, a staff member approached RI #9 as she (RI #9) was requesting to go to PT (Physical Therapy). The resident was not checked for incontinence or asked if she was soiled. At 1:08 PM, EI #3 notified RI #9 that she needed to take her to the room to check her for incontinence. At 1:09 PM, RI #9 arrived to her room. EI #3 gathered supplies and re-entered the room at 1:12 PM. At 1:15 PM, EI #3 exited RI #9's room to push another resident down the hallway. At 1:22 PM, EI #3 re-entered the room and was assisted by EI #4, a CNA, to use a hoyer lift to place RI #9 into the bed. At 1:31 PM, EI #3 exited the room to answer a call bell alarm. At 1:32 PM, EI #3 re-entered RI #9's room and incontinence care was started. The adult brief removed from the resident was soaked with urine and a small amount of semi-soft, brown stool was observed. Numerous wrinkled indentions were observed on RI #9's bilateral buttocks. There was a moderate amount of redness observed around the rectum where stool had been present. An interview was conducted with EI #3, on 01/24/2014 at 2:00 PM. EI #3 was asked how often were incontinent residents assessed for the need of perineal care. EI #3 answered, "Every 2 hours." EI #3 was asked what was the facility's policy regarding incontinent residents. EI #3 stated, "Make sure they are cleaned, turned and dried." EI #3 was asked who was the CNA responsible for the care of RI #9 for 01/24/2014. EI #3 stated, "I am." EI #3 was asked when was incontinence care given to RI #9. EI #3 responded, "7 AM and just then when you watched me." EI #3 was asked who was responsible for checking residents for incontinence. EI #3 stated, "Everybody." An interview was conducted with EI #2, on 01/24/2014 at 2:15 PM. EI #2 was asked what was the facility's policy of monitoring residents for incontinence. EI #2 stated, "We are to check them every 2 hours." EI #2 was asked who was to perform this task. EI #2 stated, "CNAs and sometimes the nurses if the CNAs are on break and the resident has an incontinent episode. They are to be repositioned Q (every) 2 hours and PRN (as needed)." EI #2 was asked who was the CNA responsible for RI #9 on 01/24/2014. EI #2 named EI #3. EI #2 was asked when incontinence care had been given to RI #9 during her shift. EI #2 stated, "When she got up for her bath this morning and this evening about 12:00-12:30 when she got through eating lunch." EI #2 was asked who was responsible for ensuring this task was completed. EI #2 stated, "Me." EI #2 was asked why RI #9 was not checked between 7:37 AM and 1:32 PM. EI #2 stated, "While I was giving meds this morning, the aides were on the hall giving care. I assumed that because they were getting residents up it should have been done. She was to have been done at 10 and noon." EI #2 was asked what was the potential negative outcome if residents were not assessed. EI #2 stated, "Breakdown, skin breakdown." An interview was conducted with EI #1, the Infection Control Nurse, on 01/24/2014 at 5:02 PM. EI #1 was asked how often were residents checked for incontinence. EI #1 stated, "They should be checked every 2-3 hours and prn." EI #1 was asked who was supposed to carry out the task. EI #1 stated, "CNAs, but they should be monitored also by the unit manager/charge nurses."EI #1 was asked who was responsible for monitoring that incontinence care was provided per policy. EI #1 stated, "The unit manager/charge nurses." EI #1 was asked what was the potential negative outcome if residents were not given routine incontinence care. EI #1 stated, "UTIs (Urinary Tract Infections), infection, rashes, breakdown of the skin, then you've got a dignity issue with that resident."