Every finding on record at Altera Health and Rehabilitation Center

Based on interviews, resident record reviews, and review of the facility Resident Rights policy, the facility failed to honor the rights of Resident Identifier (RI) #1 and RI #2, to communicate with and have access to each other with privacy. This affected RI #1 and RI #2, 2 of 5 residents sampled for residents rights. Findings include: The facility policy titled Resident Rights dated 2001 documented 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: f. communicate with and access to people and services, both inside and outside the facility; . h. be supported by the facility in exercising his or her rights; dd. communicate in person . with privacy . RI #1 was readmitted to the facility on [DATE]. RI #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] coded RI #1 with a Brief Interview for Mental Status (BIMS) score of 15 which indicated RI #1 had intact cognition for daily decision-making skills. RI #2 was admitted to the facility on [DATE]. RI #2's quarterly MDS assessment dated [DATE] coded RI #2 with a BIMS score of 15 which indicated RI #2 had intact cognition for daily decision-making skills. RI #1's Progress Notes were reviewed and an entry dated 04/25/2023 documented the following: . Note Text: Care Plan meeting held today 04/25/23 @ (at) 10am with administrative staff. Meeting covered a plan of care for (name of RI #1) to only meet and socialize with (name of RI #2) in dining room only per request from (RI #2's) family. Staff has spoken with (RI #1) about situation and decided to call (name of local Ombudsman) to come and speak with RI #1) as well. A facility form used to document a Care Plan meeting for RI #1 dated 04/25/2023 was reviewed and revealed the following: . Resident Name: (name of RI #1) Plan of care regarding issue/concern of Resident. What do we do to make sure Resident only visits in dining room instead of room . Spoke with (RI #2's) Family & (and) family requests for the two to only visit in dining room and not to visit (in) room. (RI #1) says (he/she) has the right to visit. The following facility staff signed as having attended the meeting: Employee Identifier (EI) #1, the Administrator; EI #2, the Director of Nursing (DON); EI #3, the Social Service Director; EI #4, the Activities Director; and EI #5, a Unit Manager. On 06/07/2023 at 3:11 PM an interview was conducted with Employee Identifier (EI) #3, the Social Services Director. EI #3 was asked about the BIMS scores for RI #1 and RI #2. She said they were both 15. EI #3 was asked about the care plan meeting note dated 04/25/2023 for RI #1. EI #3 claimed the daughter said they could visit outside of RI #2's room and EI #1 had concluded for them to visit in the dining room. EI #3 was asked what was done to assess the right of RI #1 and RI #2 to visit where they pleased. EI #3 answered, they were given the Resident Rights handout and told they had the right to visit. EI #3 said, the plan was for RI #1 to meet and socialize with RI #2 in the dining room only, per request from RI #2's family. EI #3 was asked if residents with a BIMS score of 15 have the right to choose how and where they socialize, and EI #3 answered, yes. RI #1's Progress Notes were reviewed and revealed the following: An entry dated 04/26/2023 documented: . AD (Activity Director) found resident in (RI #2's) room, after administrator and nurses told resident that (he/she) was not to enter (his/her) room. Resident became angry and intimidating towards AD. Resident claimed that it is (his/her) right to be in anyone's room. AD agreed with resident but stated that (RI #2's) POA does not want (him/her) in the room with (him/her). An entry dated 05/18/2023 as follows: Note Text: . AD found resident had (another resident) in (his/her) room alone. They were sitting together on the bed listening to (his/her) radio. AD reminded the two residents that the (other) resident's POA does not want them to be in each other's rooms alone. (The) resident reacted with a lot of anger towards the AD. On 06/08/2023 at 8:11 AM an interview was conducted with EI #4 Activities Director. EI #4 was asked what she was aware of regarding a care plan for RI #1 to only socialize with RI #2 in the dining room per the request of family. EI #3 said, she was told RI #2's daughter did not want them alone together in each others room. EI #4 said, she thought it was because the daughter was Power of Attorney (POA) for RI #2 and she was told by a nurse they had to honor what the POA said. EI #4 was asked about 05/18/2023 when she found RI #1 sitting on the bed with RI #2 listening to the radio and why she intervened. EI #4 said, she thought the POA had the final say. EI #4 was asked why were they told not to socialize as they chose. She answered she was still under the impression that the POA's request had to be honored. On 06/08/2023 at 11:22 AM an interview was conducted with EI #5, a Unit Manager. EI #5 was asked about the residents with BIMS scores of 15 not being able to socialize. EI #5 said, they had rights to visit and socialize and that was not an appropriate intervention. On 06/08/2023 at 1:50 PM an interview was conducted with RI #2. RI #2 was asked what she could tell the surveyor about the POA/daughter saying who RI #2 could visit with and where. RI #2 said, he/she did not know the daughter could decide that, and the daughter could not tell RI #2 what to do and where to go. RI #2 said, he/she can make his/her own decisions. RI #2 was asked what facility staff had done or said to keep him/her and RI #1 from socializing as they both choose. RI #2 said he/she was in RI #1's room and sitting on the bed listening to television and somebody that worked there came in and said they were not supposed to do that. RI #2 was asked if he/she had spoken with his/her daughter about RI #1 visiting in their room. RI #2 said no, but guessed he/she should. On 06/08/2023 at 2:30 PM an interview was conducted with RI #1. RI #1 said the Administrator said they (RI #1 and RI #2) could watch television (TV) in his/her room because RI #2 had a small TV and they like to watch ball games and cheer them on. RI #1 said, they were treating him/her like a pervert. RI #1 stated he/she knew his/her rights and it was about companionship and that was all it was about. RI #1 said, the people at the facility did not respect his/her right to Communicate privately and freely with any person. RI #1 read the quote from the Resident Rights flyer with the Ombudsman's name on it. RI #1 said the Ombudsman had not called him/her back, adding he/she had been calling him/her for two weeks. RI #1 said, the Administrator had lied three times by saying they could watch TV in his/her room, then said they had to sit in a chair by the bed to watch TV, then said they could not be together at all in their rooms. RI #1 was asked what reason the Administrator had given. RI #1 said about a week ago, RI #2's daughter did not want them in rooms alone together. On 06/09/2023 at 3:31 PM an interview was conducted with EI #2, the DON. EI #2 was asked about RI #1 and #2. EI #2 said, RI #1 loved their friendship. EI #2 reported she spoke to the daughter of RI #2, the responsible party. She told the daughter that her family member and RI #1 had a great friendship and they cared about each other. She informed RI #2's daughter of this because she wanted her to know that RI #2 was happy. EI #2 told the daughter they ate in the dining room together, went to activities together, have great conversations, and laugh a lot. The daughter was thrilled and she thanked EI #2 for letting her know and giving her an update. EI #2 was asked what restrictions the daughter requested of RI #1 and RI #2. She said none, except she did not want them to move into a room together this early in the relationship. EI #2 was asked regarding about residents with a BIMS of 15 not going to each others rooms to socialize if they wanted. EI #2 responded, they have a right to have their own privacy. EI #2 said, she was not aware that RI #1 and RI #2 were being told that they could not socialize in private because that was not the daughter's wishes. EI #2 added, she knew people's rights, because all human beings have the same rights. She said she was unaware of the plan to keep them from visiting as they wished. On 06/08/2023 at 4:15 PM a call was placed to RI #2's daughter. She recalled being told by the DON that her parent and RI #1 went to things together and were great friends. She reported the DON called her first to inform her of the friendship and the social worker called her and said they had told RI #1 that he/she should not be going in RI #2's room and she agreed with them. It was not her suggestion that RI #1 not go in RI #2s' room. The daughter was told that it was documented that she was the one who asked for them not to be alone and she declared, that was not true. She said the social worker said they had suggested that they only hang out in the dining room/common area. The daughter understood the residents have the right to choose. She recalled telling the DON that she was happy that her parent had the friendship. On 6/9/23 at 4:37 PM a follow up interview with EI #3, the Social Services Director. EI #3 was asked who had the idea to do the care plan meeting to make RI #1 comply with their plan to keep RI #1 and RI #1 from socializing alone. She said she did not remember. On 06/09/2023 at 5:10 PM an interview was conducted with EI #1, the Administrator. EI #1 was asked about residents with a BIMS score of 15 socializing. EI #1 said, they can make decisions as to who can they visit. EI #1 said, the meeting had been about another subject regardless of what was documented. EI #1 believed the documentation was done after he had signed and the meeting concluded. EI #1 was asked why were restrictions put on RI #1 and RI #2 as to where they could socialize. He said it was staff not understanding their right to do that. EI #1 was asked who were the staff. He answered, the social service director and activities director. EI #1 was asked why he did not ensure the residents rights to communicate privately and freely with any person were honored. EI #1 said, he was told the POA requested it. EI #1 was asked why were the residents told that the POA suggested they not be in the room alone together. He said that came from the social service director. EI #1 was asked who's idea was it to do the care plan meeting to make RI #1 comply with their plan to keep them from socializing alone. He answered EI #3, the Social Services Director.

Based on observation, interview, the 2022 United States (U.S.) Public Health Service Food and Drug Administration (FDA) Food Code, and the facility's policies for FOOD STORAGE, and Handwashing/Hand Hygiene; the facility failed to ensure: 1. foods were properly stored in the reach-in freezer; 2. a dietary staff member washed her hands between going from the dirty side to the clean side of the dish machine during dishwashing and; 3. there was not heavy dust accumulation on a ceiling air vent and overhead pipes. This had the potential to affect 65 of 65 residents receiving meals from the facility kitchen. Findings Include: 1.) The facility's policy for Food Storage, undated, included the following: Policy Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. 17. Freezer Temperatures: a. Temperatures for freezer should be 0 degrees or below and must be recorded daily. c. Holding temperature for frozen foods is 0 degrees or below. f. Do not refreeze food which has been thawed. The 2022 U.S. Public Health Service FDA Food Code included the following: . 3-501.11 Frozen Food. Stored frozen FOODS shall be maintained frozen. and . Freezing prevents microbial growth in foods, but usually does not destroy all microorganisms. Improper thawing provides an opportunity for surviving bacteria to grow to harmful numbers and/or produce toxins. If the food is then refrozen, significant numbers of bacteria and/or all preformed toxins are preserved. Annex 3 - (page) 112 . During the initial tour of the kitchen on 03/07/2023 at 8:27 AM, the Reach-in Freezer temperature was 6 degrees Fahrenheit (F). Onion rings in clear bag were observed to be soft and not frozen when touched. Other items, specifically Field Peas and Sliced Okra, were semi-frozen. Employee Identifier (EI) #4, the Dietary Manager, said sometimes the night shift leaves a freezer door cracked open. EI #4 then checked with EI #5, the AM Cook. EI #5 said, when she came in that morning, one of the freezer doors was cracked open from last night. On 03/07/2023 at 8:44 AM, EI #3, the Maintenance/Plant Operations Director, was observed checking on the Reach-in Freezer. EI #3 said they needed some new door seals/gaskets for the freezer doors. On 03/08/2023 at 10:12 AM, the previously thawed bag of Onion Rings in the Reach-in Freezer was observed to have refrozen so that the contents were solid to touch. The Reach-in Freezer was observed to have three doors. EI #4, the Dietary Manager was interviewed on 03/09/2023 at 2:23 PM. EI #4 said the Reach-in Freezer doors had not been closing tightly for less than a month. EI #4 further said there were three doors on the Reach-in Freezer and the middle door was the problem. EI #4 said she had twice found one of the Reach-in Freezer doors left open all night. EI #4 said the problem with food not being solidly frozen due to a freezer door being left open was that it caused a loss of nutrition value from the product. 2.) The facility's policy for Handwashing/Hand Hygiene, revised August 2015, included the following: Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation . 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 6. Wash hands with soap (antimicrobial or non-antimicrobial) and water . 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. 9. The use of gloves does not replace hand washing/hand hygiene. The 2022 U.S. Public Health Service FDA Food Code included the following: . 2-301.11 Clean Condition. FOOD EMPLOYEES shall keep their hands and exposed portions of their arms clean. 2-301.12 Cleaning Procedure. (A) . FOOD EMPLOYEES shall clean their hands and exposed portions of their arms . using a cleaning compound in a HANDWASHING SINK . 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms . immediately before engaging in FOOD preparation including working with . clean EQUIPMENT and UTENSILS, and . (E) After handling soiled EQUIPMENT or UTENSILS; . (H) Before donning gloves to initiate a task that involves working with FOOD; . 2-301.16 Hand Antiseptics (A) A hand antiseptic used as a topical application . shall: . (3) Be applied only to hands that are cleaned as specified under . 2-301.12. On 03/07/23 at 9:42 AM, the dishwashing of the breakfast trays was observed. The Dietary Aide, EI #11 was loading the dirty dishes onto racks and sending them through the dish machine. EI #11 then took off her gloves, went to the clean side of the dish machine, and unloaded lids and silverware. EI #11 did not wash her hands prior to touching the clean lids and silverware. At 9:44 AM, EI #11 put on gloves and started reloading racks of dirty dishes to send through the dish machine. At 9:48 AM, EI #11 took off her gloves and went to the clean side of the dish machine. EI #11 did not wash her hands. EI #11 unloaded clean dishes from the racks. At 9:49 AM, EI #11 returned to the dirty side of the dish machine as she put on gloves. At 9:52 AM, the Dietary Manager, EI #4, was present when EI #11 went to the clean side of the dish machine after taking off her gloves. At 9:53 AM, EI #11 was asked if just removing her dirty gloves and going to unload the clean dishes was what she had been taught. EI #11 first pointed to the sanitizer wall pump saying it was out. When told that sanitizer alone was unacceptable, EI #11 said she was supposed to wash her hands. At 9:55 AM, EI #4, the Dietary Manager, was asked to identify the problem with working on the dirty side of the dish machine and then going to the clean side after only removing one's dirty gloves and not washing one's hands. EI #4 said the Dietary Aide's hands were dirty with germs. EI #4, the Dietary Manager was interviewed on 03/09/2023 at 2:23 PM. EI #4 said she expected staff to wash their hands when they went from working on the dirty side of the dish machine to perform tasks on the clean side of the dish machine. Upon being asked to identify the problem with staff not washing their hands when going from a dirty task to a clean task, EI #4 said cross-contamination. 3.) The 2022 U.S. Public Health Service FDA Food Code included the following: . 3-305 Preventing contamination from the premises 3-305.11 Food Storage. (A) . FOOD shall be protected from contamination by storing the FOOD: . (2) Where it is not exposed to . dust . 3-305.14 Food Preparation. During preparation, UNPACKAGED FOOD shall be protected from environmental sources of contamination. During the initial tour of the kitchen on 03/07/2023 at 8:20 AM, the ceiling air vent over the entryway to the Walk-in Cooler was observed to have a heavy build-up of dark dust. EI #4, the Dietary Manager agreed there was a dust build-up on the vent and said Maintenance usually cleaned it. On 03/07/2023 at 8:35 AM, EI #3, the Maintenance/Plant Operations Director, was asked how often the ceiling vents in the kitchen were cleaned. EI #3 said once or twice a year. EI #3 said he had seen the vent last week, when they were painting the ceiling, and had meant to get it down to clean it, but he forgot about it. On 03/08/2023 at 4:26 PM, dust build-up was observed on overhead pipes throughout the kitchen, specifically over the Dishwashing Area, the Cooks' Area, and the Preparation Area between the microwave and the coffee maker. EI #4, the Dietary Manager was interviewed on 03/09/2023 at 2:23 PM. EI #4 said dust particles from the ceiling air vent could blow into the Walk-in Cooler and bacteria attached to the dust could cause cross-contamination. EI #4 further said dust particles from the overhead pipes could fall into the food being prepared for the residents and that would also be cross-contamination.

Based on observations, interviews, and review of the facility's, Facility Information & (and) Reference Guide, the facility failed to ensure that a resident had a ceiling suspended curtain to provide total visual privacy, in combination with adjacent walls and curtains, in Room Locator (RL) #1. This deficient practice affected one of 58 residents residing in a semi-private room at the facility. Findings Include: A review of the facility's Facility Information & Reference Guide, undated, revealed, . The Resident's Rights *YOU have the right to be treated with dignity, privacy, respect, and to live in a safe, clean, comfortable and homelike environment. Resident Identifier (RI) #7 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis to include Post-Traumatic Hydrocephalus and Paraplegia. On 03/07/2023 at 9:27 AM, RL #1 observed, no privacy curtain for RI #7. On 03/08/2023 at 8:28 AM, RL #1 observed, no privacy curtain for RI #7. On 03/08/2023 at 3:48 PM, an interview was conducted with Employee Identifier (EI) #7, Director of Plant Operations. EI #7 stated the track for the privacy curtain was not broke and there should be a privacy curtain there. EI #7 did not know why there was not a privacy curtain on the track for RI #7. EI #7 stated the resident could not have proper privacy without a curtain. EI #7 did not know how long RI #7 had been without a curtain. On 03/08/2023 at 4:08 PM, an interview was conducted with EI #8 Licensed Practical Nurse (LPN) who has worked at the facility since October of 2022. EI #8 said there had not been a privacy curtain for RI #7 since she had worked at the facility. EI #8 stated there should be a privacy curtain and that it would be a dignity issue for RI #7.

Based on observations, interviews and review of the facility's policy titled, Posting Direct Care Daily Staffing Numbers, the facility failed to ensure the staff posting reflected the name of the facility and the actual hours staff were scheduled to work for the shifts on four of four days of the survey. This deficient practice had the potential to affect all 65 residents residing in the facility. Findings include: A review of the facility's policy titled, Posting Direct Care Daily Staffing Numbers, with a revised date of 07/2016, revealed the following: Policy Statement Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. Policy Interpretation and Implementation . 3. Shift staffing information shall be recorded on the Nursing Staff Directly Responsible for Resident Care form for each shift. The information recorded on the form shall include: a. The name of the facility. b. The date for which the information is posted. c. The resident census at the beginning of the shift for which information is posted. e. The shift for which the information is posted. f. Type (RN [Registered Nurse], LPN [Licensed Practical Nurse], LVN [Licensed Vocational Nurse], or CNA [Certified Nursing Assistant]) and category (licensed or non-licensed) of nursing staff working during that shift. g. The actual time worked during that shift for each category and type of nursing staff. A review of the RESIDENT CENSUS AND CONDITIONS OF RESIDENTS form dated 03/07/2023 revealed there were 65 residents residing in the facility during the survey. On 03/07/2023 at 7:56 AM, the surveyor observed the nurse staff posting at the nurses' station on the South wing. There was no facility name or total actual hours worked for the 6 AM - 2 PM staff on the form. On 03/07/2023 at 2:59 PM, the surveyor observed the nurse staff posting at the nurses' station on the South wing. There was no facility name or total actual hours worked for the 2 PM - 10 PM staff on the form. On 03/08/2023 at 8:08 AM, the surveyor observed the nurse staff posting at the nurses' station on the South wing. There was no facility name or total actual hours worked for the 6 AM - 2 PM staff on the form. On 03/08/2023 at 3:33 PM, the surveyor observed the nurse staff posting at the nurses' station on the South wing. There was no facility name or total actual hours worked for the 2 PM - 10 PM staff on the form. On 03/09/2023 at 8:15 AM, the surveyor observed the nurse staff posting at the nurses' station on the South wing. There was no facility name or total actual hours worked for the 6 AM - 2 PM staff on the form. On 03/09/2023 at 11:04 AM, the surveyor conducted an interview with Employee Identifier (EI) #6, the Staffing Coordinator. When asked what information was missing from the nurse staff postings for 03/07/2023, 03/08/2023 and 03/09/2023, EI #6 said the facility name and the hours that staff were working. On 03/09/2023 at 2:36 PM, the surveyor conducted an interview with EI #2, the DON (Director of Nursing). EI #2 said the name of the facility and the total hours staff worked should be on the daily nurse staff form. When asked why it would be important to ensure the correct information was on the form, EI #3 said the information would give a total picture of what was going on in the facility as far as staffing.

Based on an interview, review of the facility GRIEVANCE/COMPLAINT LOG, the accompanying CONCERN form and a facility policy titled, Abuse Investigation and Reporting, the facility failed to report an allegation of abuse. This affected Resident Identifier (RI) #111, one of four residents sampled for dignity. Findings include: A review of the facility policy with a revision date of April 2019, titled, Abuse Investigation and Reporting revealed, Policy Statement All reports of resident abuse, neglect, . shall be reported within two (2) hours to local, state, and federal agencies (as defined by current regulations) . A review of the facility form titled, GRIEVANCE/COMPLAINT QA (Quality Assurance) & A (Answer) LOG, dated June 2021, revealed, Date 6/4 . RI #111 Issue/Concern Neglect/hygiene . A review of the facility form titled, CONCERN FORM, dated 6/4/21, revealed, . Resident feels neglected. RI #111 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #111's Admission Minimum Data Set (MDS) assessment indicated RI #111 had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15. This score indicated RI #111 was cognitively intact for daily decision making skills. On 9/16/2021 at 6:09 p.m., an interview was conducted with Employee Identifier (EI) #1, the Administrator. EI #1 was asked according to the facility document titled, CONCERN FORM, what concerns had RI #111 voiced on 06/04/2021. He answered, according to the document, RI #111 had voiced the concern that he/she felt neglected. EI #1 was asked what actions should have been taken on 6/04/2021. He answered what he would have done, if he had been the Administrator at the time, was to investigate fully and report in the appropriate timeframe according to regulation. EI #1 was asked what the abuse policy indicated he was supposed to do when potential neglect has been alleged. He answered, it said to investigate and report timely. EI #1 was asked what was the time frame for reporting allegations of abuse. He answered two hours. EI #1 was asked if the 6/04/2021 allegation had been reported to the state. He answered the system did not allow him to go back and look. EI #1 was asked what was documented as the Issue/Concern on the June 2021 GRIEVANCE/COMPLAINT QA & A LOG form. EI #1 answered what was listed was neglect and hygiene. EI #1 was asked what the concern of not reporting and investigating allegations of abuse was. He answered it could continue.

Based on observation, interviews and review of a facility policy titled, Confidentiality of Information and Personal Privacy, the facility failed to ensure Employee Identifier (EI) #4 did not park her medication cart in front of Resident Identifier (RI) #3's room, walk away from her computer into RI #3's room, leaving RI #3's personal and private information open and exposed. This deficiency had the potential to affect one of five residents observed during medication administration. Findings Includes: A review of a facility policy titled, Confidentiality of Information and Personal Privacy with a revised date of 10/2017, revealed the following: . 1. The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records . RI #3 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/16/2021 at 9:05 a.m., the surveyor conducted an interview with EI #4, the Registered Nurse (RN) Unit Manager. The surveyor asked RI #4 how did she leave her computer. EI #4 stated she did not close the screen. The surveyor asked how should the computer have been left while in RI #3's room. EI #4 stated the screen should have been closed down. The surveyor asked EI #4 what are the concerns with not closing the computer screen while in the resident's room. EI #4 stated it was a HIPAA (Health Insurance Portability and Accountability Act) violation where someone could come along and read something about the patient that was their private business. On 9/16/2021 at 6:26 p.m., the surveyor conducted an interview with EI #2, the Director of Nursing (DON). The surveyor asked EI #2 should a nurse leave the computer open with resident's private information exposed when they leave the cart to give medications. EI #2 stated no ma'am. The surveyor asked EI #2 how should a nurse leave the computer when they go into a resident's room to give medications. EI #2 stated the computer should be closed or closed out. There should not be any resident's information showing. The surveyor asked EI #2 what are the concerns when a nurse leaves the computer screen open and exposing resident's private information. EI #2 stated we do not want to violate HIPAA and we want to protect the patient's privacy.

Based on observation, review of the facility's policy titled, Proper Hand Washing and Glove Use and interviews with staff, the facility failed to ensure staff routinely washed hands before putting on new gloves. This occurred during the preparation and service of food at the 04/17/19 supper tray line. This had the potential to affect all 62 residents for whom meals were prepared and served at the time of this survey. Findings Include: The facility's policy, Proper Hand Washing and Glove Use (2016), revealed: All employees will use proper hand washing procedures and glove usage in accordance with State and Federal Sanitation Guidelines Procedure: .3. All employees will wash hands . between all tasks. 4. Employees will wash hands before and after handling foods . 6. Hands are washed before donning gloves and after removing gloves. 9. When gloves must be changed, they are removed, hand washing procedure is followed, and a new pair of gloves is applied. Gloves are never placed on dirty hands; the procedure is always wash, glove, remove, rewash, and re-glove. On 04/17/19, the surveyor observed the supper tray line. The evening cook, Employee Identifier (EI) #2, received a resident request for soup at 5:19 PM. EI #2 removed her gloves, went to the pantry and came back with two small cans of soup. EI #2 put on a new pair of gloves without first washing her hands, and prepared two bowls of soup. At 5:20 PM, EI #2 threw the cans away, pushing them down into the full garbage can (through a lid with a circular hole). EI #2 removed one glove and reapplied a new glove, again without first washing her hand(s). At 5:35 PM, after the completion of the tray line, the surveyor described to EI #2 the above observation. EI #2 was asked what she should have done. EI #2 replied, Washed hands. The surveyor described EI #2's action of pushing the soup can down into the garbage can, removing her glove and reapplying a new glove (her second glove change) and failing to wash her hand again. The surveyor asked what was the potential problem. EI #2 did not know it was potential cross-contamination.

Based on observations, the (YEAR) Food Code, and interviews with staff, the facility failed to ensure the temperature gauge of the final rinse water of the dish machine was functioning properly to ensure dishes were effectively sanitized. This had the potential to affect 62 residents for whom meals were prepared and served. Findings Include: The (YEAR) Food & (and) Drug Administration Food Code revealed: .4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. (A) .in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than . (194 (degrees) (Fahrenheit) F), or less than: .(180 degrees F) . On 04/16/19 at 8:30 AM, a Dietary Aide, Employee Identifier (EI) #1, processed a rack of dishes through the dish machine. The minimum recommended rinse temperature of the machine was listed as 180 degrees F (with no maximum temperature listed). During three of four rinse cycles, the thermostat registered: 203, 200 and 204 degrees F. The surveyor asked EI #1 if the final rinse temperature went above 200 degrees very often. EI #1 responded, It does. On 04/17/19 at 5:40 PM, two staff members processed racks of assorted trays and utensils through the dish machine. The final rinse temperature of four cycles of dish washing displayed final rinse temperatures of : 198, 196, 194 and 210 degrees F. Three of these four cycles registered final rinse temperatures in excess of the Food Code recommendations (of no greater than 194 degrees F). Following this observation, the surveyor asked the Dietary Manager, EI #3, if the final rinse water could be too hot. EI #3 responded, I've never known of a problem if the temperature gets too high. Neither staff member were aware the rinse water temperatures could get too hot to effectively sanitize the dishes. On 04/18/19 at 10:53 AM, the surveyor interviewed the Ecolab Service Representative (EI #4). EI#4 serviced the dish machine on 04/17/19, after staff were made aware of the excessively hot rinse temperatures. EI #4 stated the final rinse temperature gauge was malfunctioning; it would not go below 190 to 195 degrees F. When asked how he verified the gauge was giving inaccurate readings, EI #4 explained he turned off the dish machine and waited awhile and the rinse water temperature would not go down. EI #4 installed another thermostat. When he changed the gauge, the new gauge read 178 degrees F with the first cycle, rather than 200 degrees F. When he called, it was 210 degrees F and the wash temperature was not greater than 150 degrees F. At a temperature of 200 degrees F or higher, the wash water gauge should have read about 170 degrees F. (The final rinse water is re-cycled through the machine to be used as the wash water in the next cycle). The surveyor asked EI #4 when he had last checked the rinse water gauge. EI #4 could not recall, but stated the gauge could go bad at any time. The surveyor commented the staff were unaware that the final rinse temperature could be too high, and asked what Ecolab's recommendations were regarding the maximum rinse temperatures and why had he not previously discussed this with the staff. EI #4 stated he recommends temperatures between 180 and 190 degrees F. He was not aware of a maximum temperature unless it was posted on the machine (none was posted on this dish machine). EI #4 had never heard of temperatures greater than 194 degrees F being a problem.

Based on observations, interviews and review of facility documents titled LABELING AND DATING, RECEIVING AND STORAGE OF FOOD, SERVICE LINE PR[NAME]EDURES, TIME AND TEMPERATURE CONTROL AND RECORDING, and Service Line Checklist, the facility failed to ensure: 1) food items in the dry storage area and in the freezer were sealed and labeled with an open and use by date; 2) temperatures of the milk was taken before being serving to the residents; and 3) the temperature of a second batch of chicken was taken and documented. This had the potential to affect 59 of 62 residents who received meals from the kitchen. Findings Include: 1) A review of a document provided by the facility titled LABELING AND DATING, with a date of (YEAR) revealed: . Guidelines for Labeling and Dating . Food labels must include: · The food item name · The date of preparation/receipt/removal from freezer · The use by date as outlined in the attached guidelines . A review of a document provided by the facility titled RECEIVING AND STORAGE OF FOOD, undated revealed: . Dry Storage · Store opened package in closed, labeled containers . Frozen Storage · Tightly wrap open bags and boxes to prevent freezer burns. On 03/06/2018 at 4:31 p.m., the surveyor observed a 16 ounce box of corn starch in dry storage that was opened at the top. The box had no open or use by date on it and the starch was not in a plastic bag. On 3/06/2018 at 4:36 p.m., the surveyor observed an opened bag of chicken quarters in the freezer. The bag was open at the top. There was no open or use by date on the bag. On 03/08/2018 at 11:14 a.m., the surveyor conducted an interview with EI (Employee Identifier) #2, the Kitchen Manager. EI #2 was asked what food item in the dry storage area was not labeled. EI #2 replied, the starch. EI #2 was asked why was the food item not labeled. EI #2 replied, they forgot to date it. EI #2 was asked who was responsible for labeling food items in dry storage area. EI #2 replied, everybody and the Kitchen Manager. EI #2 was asked what did the facility's policy say regarding labeling food items once they were opened. EI #2 replied, they had to date them. EI #2 was asked how should food items be labeled. EI #2 replied, date the item with the open date and the expiration date. EI #2 was asked what was the potential harm to the residents when food items are not labeled. EI #2 replied the resident could get sick. On 03/08/2018 at 11:16 a.m., the surveyor conducted an interview with EI #2. EI #2 was asked what food item was not labeled in the freezer. EI #2 replied, chicken quarters. EI #2 was asked why the food item was not labeled. EI #2 replied, the label fell out of the bag. EI #2 was asked who was responsible for labeling food items in the freezer. EI #2 replied, everybody. EI #2 was asked what was the facility's policy regarding labeling food items once they were opened. EI #2 replied, to date the food item the same day it was opened. EI #2 was asked what was the potential harm to the resident when food items were not labeled. EI #2 replied, the resident could get sick. 2) A review of a facility document titled SERVICE LINE PR[NAME]EDURES, undated revealed: . Guidelines for Service Line Procedures . · Cold Foods . ii. All cold foods .are checked . for the appropriate temperature. Temperatures are recorded in the Service Line Checklist immediately prior to service. On 03/07/2018 at 11:15 a.m., during the lunch meal the Surveryor observed four milk cartons in cart one and three milk cartons in cart two with no milk temperature taken. The surveyor looked at the service line checklist form. The cook was writing her temperatures down on a blank sheet of typing paper. All cooked food temperatures were taken and written down on the blank sheet of typing paper. The milk temperature was not taken or recorded on the blank sheet of typing paper. On 03/08/2018 at 11:43 a.m., the surveyor conducted an interview with EI #3, the AM cook. EI #3 was asked who took the temperature of the milk on 03/07/2018. EI #3 replied no one. EI #3 was asked why was the milk temperature not taken and recorded. EI #2 replied, she got behind. EI #3 was asked who was responsible for taking the milk temperatures. EI #3 replied, the cook. EI #3 was asked what did the facility's policy say regarding taking food temperatures and recording them on the temperature log. EI #3 replied, they have to do it every day. EI #3 was asked what was the potential harm to the residents when milk temperatures were not taken and the milk was served to the resident. EI #3 replied, the residents could get any kind of food borne pathogen and they could get sick. 3) A review of a facility policy titled TIME AND TEMPERATURE CONTROL AND RECORDING, undated revealed: . · Monitoring Cooking Temperatures . · Take at least two internal temperatures of each large food item . · Once cooking is complete, record final temperatures on the Cooking Temperature Log. On 03/07/2018 at 11:30 a.m., the fried chicken was taken from the fryer and placed on the steam table with no temperature taken. The fried chicken was taken out of the kitchen by dietary staff without the temperature being taken. On 03/08/2018 at 11:46 a.m., the surveyor conducted an interview with EI #3. EI #3 was asked what was the temperature of the second batch of chicken. EI #3 replied, she did not take the temperature of the chicken. EI #3 said she was trying to get the food out of the kitchen in an appropriate time. EI #3 was asked did she take the temperature of the second batch of chicken when she placed it in the container with the other chicken. EI #3 replied, no. EI #3 was asked what was the facility's policy on taking food temperatures on the tray line. EI #3 replied, she had to do it everyday. EI #3 was asked what was the potential harm to the residents when food temperatures on the tray line were not taken and recorded. EI #3 replied, they could get sick and food borne pathogens.

Based on review of a facility policy titled Resident Assessment Instrument (RAI) Process, observations and interviews, the facility failed to ensure RI (Resident Identifier) #9's Comprehensive MDS (Minimum Data Set) Assessment accurately reflected the resident's use of a walker for ambulation. This affected RI #9, one of 18 sampled residents whose Comprehensive Assessments were reviewed. Findings Include: A review of a facility policy titled Resident Assessment Instrument (RAI) Process with a revised date of (MONTH) (YEAR), revealed the following: POLICY . to provide the appropriate care and services for each resident . PR[NAME]EDURE 1. The facility conducts a comprehensive assessment . to identify the resident's needs, strengths . and preferences . RI #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #9's care plan revealed an Activity care plan with an initiated date of 12/12/2017, and a revised date of 12/13/2017, which stated the resident ambulated with a walker or propelled his/herself in a wheelchair to independent activities of interest. A review of RI #9's admission MDS assessment with an ARD (Assessment Reference Date) of 12/14/2017, revealed a BIMS (Brief Interview of Mental Status) score of 6, which indicated the resident had severely impaired cognition for daily decision making. Further review of RI #9's MDS revealed the resident used a wheelchair for mobility. The MDS did not reflect RI #9's use of a walker for mobility. Further review of RI #9's Physical Mobility care plan with an initiated date of 12/26/2017, and a revised date of 12/26/2017, revealed the resident required supervision with one staff for locomotion using a wheelchair. The Care Plan did not mention RI #9's use of a walker for ambulation. On 03/06/2018 and 03/08/2018, the resident was observed by the surveyor ambulating with a walker to the dining room and when attending resident council. On 03/08/2018 at 2:12 p.m., an interview was conducted with EI (Employee Identifier) #5, a CNA (Certified Nursing Assistant). EI #5 was asked how did RI #9 get around in the facility. EI #5 said, by walker and the resident used his/her wheelchair. EI #5 was asked how long had she cared for RI #9. EI #5 said since the resident was admitted . EI #5 was asked had RI #9 used a walker from the time the resident was admitted . EI #5 said yes. EI #5 was asked how often would she say the resident walked with his/her walker. EI #5 said, all day and sometimes the resident would forget to use the walker when walking. EI #5 said staff would have to remind RI #9 to use his/her walker. EI #5 was asked how often did RI #9 use his/her wheelchair to propel around the facility. EI #5 said none. On 03/08/2018 at 3:04 p.m., an interview was conducted with the MDS Coordinator EI #6, a RN (Registered Nurse). EI #6 was asked was she familiar with RI #9. EI #6 said yes. EI #6 was asked how did RI #9 get around in the facility. EI #6 reviewed the resident's care plan and stated the resident ambulated with supervision and propels his/herself. EI #6 was asked what did RI #9's care plan state regarding the resident's mobility. EI #6 said the care plan required the resident to have supervision with one staff to walk when necessary. EI #6 was asked when the resident's 12/14/2017 MDS was completed, why was the resident's use of a walker not checked as a device used to ambulate with. EI #6 said the resident had the walker when he/she was admitted but was using the wheelchair more. EI #6 was asked should the walker have been checked as a device used for the resident's ambulation. EI #6 said yes it should have. EI #6 was asked who was responsible for ensuring the MDS reflected the use of equipment RI #9 used for ambulation/ physical mobility. EI #6 said it was her responsibility.

Based on observation, record reviews, interviews, review of the facility's Matrix, and review of facility's policies titled, Documentation and Standards for Clinical Procedures, the facility failed to ensure documentation was recorded for removal of an IV (Intravenous) catheter. This affected RI (Resident Identifier) #25, one of eighteen sampled residents whose medical records were reviewed. Findings Include: A review of a facility policy titled, Standards for Clinical Procedures with a revision date of 12/05, revealed: . GUIDELINES . 3. Following the clinical procedure: . h. Document the procedure and the resident's response in the medical record. A review of a facility policy titled, Documentation with a revision date of 02/17, revealed: . POLICY Healthcare personnel will complete documentation as outlined below and will record in the medical record using accepted principles of documentation. Integrity Aspects of resident care such as observations and assessments, administration of medication, and services or treatments performed must be documented in the medical record according to policy. A review of the Resident Matrix provided on 3/6/18, was reviewed for identifying residents receiving Intravenous therapy for possible medication pass observation. RI #25 was identified on the Matrix as receiving IV (Intravenous) therapy. A review of the medical record revealed RI #25 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the medical record for RI #25 revealed a physician's orders [REDACTED]. Maxipeme 2 gm (grams) 50 ml (milliliters) IV Q (Every) 12 hrs (hours) X (times) 5 Days . A review of the medical record for RI #25 revealed a physician's orders [REDACTED]. Midline Drsg (Dressing) (symbol for change) Q 7 Days (and sign) PRN (As needed) . A review of a late entry physician's orders [REDACTED]. A review of the Progress Notes which includes Nurse's Notes dated 2/1/18 through 3/2/18 revealed no entry for documentation of removal of the Midline Intravenous catheter. An interview was conducted with EI #1, the Director of Nursing, on 3/08/18 at 4:43 p.m EI #1 was asked when the Midline catheter was removed from RI #25. EI #1 answered they (she and other management) thought a new nurse had done it. EI #1 was asked where was the order documented. EI #1 answered it was documented in the medical record. EI #1 was asked when the order was documented. EI #1 answered it had been entered the day before as a late entry for 3/1/18. EI #1 was asked where was the procedure documented and she answered it was not. EI #1 was asked what was the policy regarding complete documentation. EI #1 answered documentation should be accurate, complete, and in the EMR (Electronic Medical Record) or the hard chart. EI #1 was asked what was the concern of not completing documentation. EI #1 answered staff would not have an accurate record of the care the resident received or that orders were being carried out properly.

Based on review of a facility policy titled Comprehensive Care Plan and review of RI (Resident Identifier) #9's Care Plan for Mobility, observations and interviews, the facility failed to ensure RI #9's Care Plan for Mobility included the resident's use of a walker for ambulation. This affected RI #9, one of 18 sampled residents whose Care Plans were reviewed. Findings Include: A review of a facility policy titled Comprehensive Care Plan, with a revised date of (MONTH) (YEAR), revealed the following: FUNDAMENTAL INFORMATION Purpose To provide effective and person-centered care for each resident. Minimum Requirements of the Comprehensive Care Plan The comprehensive care plan must describe services that are provided to the resident to attain or maintain the resident's highest practicable physical . well-being. The plan must address the resident's individual . strengths . preferences . Procedure . 3. The Comprehensive Care Plan planning process includes: a. An assessment of the resident's strength . RI #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #9's admission MDS assessment, with an ARD (Assessment Reference Date) of 12/14/2017, revealed a BIMS (Brief Interview of Mental Status) score of 6, which indicated the resident was severely impaired cognitively for daily decision making. Further review of RI #9's Mobility care plan with a initiated date of 12/26/2017, and a revised date of 12/26/2017, revealed the resident required supervision with one staff for locomotion using a wheelchair. The Care Plan did not mention RI #9's use of a walker for ambulation. On 03/06/2018 and 03/08/2018, the resident was observed by the surveyor ambulating with a walker to the dining room and when attending resident council. On 03/08/2018 at 2:12 p.m., an interview was conducted with EI (Employee Identifier) #5, a CNA (Certified Nursing Assistant). EI #5 was asked how did RI #9 get around in the facility. EI #5 said by walker. EI #5 was asked how long had she cared for RI #9. EI #5 said since the resident was admitted . EI #5 was asked had RI #9 used a walker from the time the resident was admitted . EI #5 said yes. EI #5 was asked how often would she say the resident walked with his/her walker. EI #5 said, all day. On 03/08/2018 at 3:04 p.m., an interview was conducted with the MDS Coordinator EI #6, a RN (Registered Nurse). EI #6 was asked was she familiar with RI #9. EI #6 said yes. EI #6 was asked how did RI #9 get around in the facility. EI #6 reviewed the resident's Physical Mobility care plan and stated the resident ambulated with supervision and propelled him/herself. EI #6 was asked what did RI #9's care plan state regarding the resident's mobility. EI #6 said the care plan required the resident to have supervision with one staff to walk when necessary. EI #6 was asked did RI #9's Mobility care plan show if RI #9 used a devices such as a walker for ambulation and or mobility. EI #6 said the care plan did state RI #9's use of a wheelchair but did not reference to the use of a walker. EI #6 was asked should RI #9's Physical Mobility care plan show the resident's use of a walker as a device used for ambulation. EI #6 said yes. EI #6 was asked why should RI #9's Physical Mobility care plan reference the resident's use of a walker. EI #6 said so the person that is caring for the resident would know the type of devices RI #9 used for ambulation. EI #6 was asked why did RI #9's Physical Mobility care plan not reflect the resident's use of a walker. EI #6 said it was an oversight. EI #6 was asked who was responsible for ensuring the care plan reflected the status of equipment RI #9 used for ambulation/physical mobility. EI #9 said it fell on her but all disciplines were responsible for supplying information regarding the resident.

Based on a review of a facility policy titled Self Administration of Medication, observations and interviews with facility staff as well as the resident, the facility failed to ensure their Self Administration of Medication policy was followed. Resident Identifier (RI) #38, a resident with a [DIAGNOSES REDACTED]. This deficient practice affected one of one sampled residents observed for self administration of medications. Findings Include: A review of a facility policy titled Self Administration of Medication, with a revised date of (MONTH) 2011, revealed the following: . GUIDELINES . 2. If a resident desires to participate in self-administration, the interdisciplinary team will assess the competence of the resident to participate by completing a Self-administration of Medication Review, . 5. The nurse will obtain a physician's orders [REDACTED]. medications .D[NAME]UMENTATION . 2. Document the self-administration of medication on the resident's comprehensive plan of care. 3. Mark medication administration records to identify individual medicines that are self-administered by each resident. RI #38 was readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #38's most recent Quarterly MDS (Minimum Data Set) assessment, with an ARD (Assessment Reference Date) of 02/01/2018, revealed the resident was cognitively intact. A review of RI #38's medical record did not contain a completed Self Administration of Medication Review as stated in the Self Administration of Medication policy, when a resident was able to self administer his/her medications. The resident was not assessed to self administer medication nor was there a physician order [REDACTED]. A review of RI #38's (MONTH) (YEAR) physician's orders [REDACTED]. There was no documentation found on RI #38's physician's orders [REDACTED]. Review of RI #38's MAR (Medication Administration Record) revealed the nurse's initial beside the 4:00 PM administration time, indicating the resident received [MEDICATION NAME]-[MEDICATION NAME] treatments on 03/06/2018, and 03/07/2018, at the 4:00 PM administration time. There was no documentation found on RI #38's MAR indicated [REDACTED]. A review of one of RI #38's care plans revealed the following: . Focus . [MEDICAL CONDITION]/[MEDICAL CONDITIONS] r/t (related to) Smoking . Interventions . Give aerosol or [MEDICATION NAME][MEDICATION NAME] as ordered . There was also no documentation found on the care plan regarding RI #38 self administering the medication. On 03/06/2018 at 5:00 p.m., RI #38 was observed sitting on the side of his/her bed. RI #38's nebulizer treatment was ongoing and no nurse was present. RI #38 was asked about the breathing treatment. RI #38 explained the nurse mixed up the medication in the vial and he/she used the nebulizer on his/her own. On 03/07/2018 at 4:30 p.m., another observation was made of RI #38 sitting on the side of his/her bed in his/her room administering his/her breathing treatment. On 03/08/2018 at 2:39 p.m., an interview was conducted with LPN (Licensed Practical Nurse), EI (Employee Identifier) #4, the nurse who initialed RI #38's MAR for the nebulizer treatment for 03/06/2018 and 03/07/2018. EI #4 was asked to review the MAR. EI #4 was asked what was the facility's policy regarding residents self administering medications. EI #4 explained there must be a physician's orders [REDACTED]. EI #4 was asked did that include nebulizer treatments. EI #4 said yes. EI #4 was asked what type of assessment needed to be completed for residents to self administer their medications. EI #4 explained there was a form that would have to be completed to ensure the resident was alert and oriented enough to self administer the medication. EI #4 was asked why should residents be monitored when they received a nebulizer treatment. EI #4 said because it could affect their breathing status and could at times elevate their pulse and blood pressure. EI #4 was asked was RI #38 monitored in plain view for his/her nebulizer treatments on 03/06/2018 at 5:00 p.m. and 03/07/2018 at 4:30 p.m. EI #4 said no, the resident was not. EI #4 was asked why was RI #38 not monitored on those two days around those times. EI #4 said, I stepped out to give another medication to another resident. EI #4 was asked should RI #38 have been monitored in close proximity while he/she received the nebulizer treatments. EI #4 said yes. EI #4 was asked what was the potential harm of allowing RI #38 to administer his/her own nebulizer treatments. EI #4 explained RI #38 may turn the nebulizer off and save some of the medication for later. EI #4 also explained the resident may not get the benefits of the medication.

Based on medication pass observation, staff interviews and review of the facility's policy titled HAND HYGIENE, the facility failed to ensure Employee Identifier (EI) #2, a Licensed Practical Nurse (LPN) did not touch the paper towel dispenser with her wet hand to dispense paper towels. This deficient practice affected Resident Identifier (RI) #6, one of nine residents observed for medication pass. Findings include: The facility's policy titled HAND HYGIENE with a revised date of September 2015, documented PURPOSE: To decrease the risk of transmission of infection by appropriate hand hygiene . I. HANDWASHING . A. Turn on water to a comfortable warm temperature. B. Moisten hands with soap and water and make a heavy lather. C. Wash well under running water for a minimum of 15 seconds, using a rotary motion and friction. D. Rinse hands well under running water. E. Dry hands with a clean paper towel. Use the paper towel to turn off the faucet, then discard . After medication pass observation on 1/24/17 at 4:25 p.m., for RI #6, EI #2, a LPN washed her hands. EI #2 used her right hand, which was wet, and pressed the lever on the paper towel holder to dispense paper towels after washing her hands. EI #2 then dried her hands. On 1/25/17 at 6:13 p.m., an interview was conducted with EI #2. EI #2 was asked what the policy and procedure was regarding handwashing at the facility. EI #2 stated wash hands before medication pass, after medication pass, before going into a room, and after going into a room. EI #2 was asked how should paper towels be obtained during handwashing. EI #2 stated, Here we have some automatic and some that have the pull down lever. EI #2 was asked should the paper towel dispenser be touched to dispense towels after hands have been washed. EI #2 stated, No. EI #2 was asked why should the towel dispenser not be touched to dispense towels after hands have been washed. EI #2 stated, Cross Contamination. EI #2 was asked what the potential negative outcome was if a Nurse touched the towel dispenser after washing hands to dispense paper towels. EI #2 stated, Transfer germs somewhere else.

Based on wound care observation, interviews with staff, review of Resident Identifier (RI) #8's medical record, and the facility's policy and procedure titled WOUND CARE PROCEDURE FOR MAJOR WOUNDS, the facility failed to ensure Employee Identifier (EI) #1, a Licensed Practical Nurse cleaned Resident Identifier (RI) #8's left ischium (hip) wound from the inner wound bed to the outer wound bed. EI #1 was also observed to clean RI #8's right buttock wound with the same 4x4 used to clean RI #8's sacral area. Furthermore, EI #1 did not remove her gloves and wash her hands after removing the dressing from RI #8's right heel prior to cleansing the wound and dressing the wound on the right heel. These deficient practices affected RI #8, one of one residents observed for wound care. Findings include: The facility's policy and procedure titled WOUND CARE PROCEDURE FOR MAJOR WOUNDS with a revised date of September 2015 revealed, PURPOSE: To provide guidelines for good technique in doing wound care . II. PROCEDURE . I. Remove the soiled dressing and place in a bag at the bedside. Place the soiled scissors on one corner of your setup not touching supplies. J. Remove gloves and discard in the bag . L. WASH YOUR HANDS M. Put on clean gloves. N. Clean the wound according to the order. Clean from the center outward. RI #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During wound care observation on 1/25/17 beginning at 9:09 a.m., EI #1, a LPN, was observed performing wound care for RI #8. EI #1 was observed cleansing the wound to the left ischium by patting the wound with a 4 X 4 which was moistened with wound cleanser. EI #1 failed to cleanse the wound from the inner wound bed to the outer wound bed. EI #1 discarded the 4 X 4, obtained a second 4 X 4 which was moistened with wound cleanser and cleansed the wound which was located on the lower left buttock by patting the wound with the 4 X 4. EI #1 discarded the 4 X 4, obtained a clean 4 X 4, moistened with wound cleanser, and cleansed the wound located on the sacral area by patting the wound. EI #1 cleansed the wound located on the right buttock by patting the wound, using the same 4 X 4 which was used to cleanse the wound located on the sacral area. EI #1 failed to use a clean 4 X 4 to cleanse the wound on the right buttocks. Wound care was observed for RI #8 to the right heel. EI #1 removed the dressing from RI #8's right heel after moistening the old dressing with wound cleanser. EI #1 failed to remove her gloves and wash her hands. EI #1 then cleansed the wound with a 4 X 4 moistened with wound cleanser by patting the wound with the 4 X 4 moistened with wound cleanser. EI #1 measured the wound, covered the wound with a 4 X 4 moistened with Dakins solution, covered with a dry 4 X 4, wrapped with rolled gauze, and secured with tape. EI #1 performed the entire procedure with the gloves used to remove the old dressing. On 1/26/17 at 1:50 p.m., an interview was conducted with EI #1. EI #1 was asked what the proper way to cleanse a wound was to prevent the potential for cross contamination. EI #1 stated the proper way was to wash hands, set up supplies and to remove the old dressing after donning (put on) gloves. EI #1 stated to use the wound cleanse and to go from inside the wound to the outside of the wound. EI #1 stated to wash hands and then change gloves, pat the wound dry, change gloves after washing hands and place a dressing on the wound which was ordered. EI #1 stated the dressing should then be secured with tape. EI #1 was asked what the potential risk was of patting the wound while cleansing the wound. EI #1 stated, You could leave particles on the wound bed then not thoroughly clean it. EI #1 was asked should two wounds be cleansed with the same 4 X 4. EI #1 stated, No. EI #1 was asked, why two wounds should not be cleansed with the same 4 X 4. EI #1 stated, Cross contamination from one wound to the next. EI #1 was asked what the facility's Policy and Procedure was regarding handwashing when changing gloves. EI #1 stated, Wash your hands when you take off dirty gloves. Wash your hands and dry thoroughly before donning clean gloves. EI #1 was asked after wounds were measured and gloves were removed, prior to donning clean gloves, should hands have been washed. EI #1 stated, Yes. EI #1 was asked why she did not wash her hands prior to donning clean gloves. EI #1 stated, I just got nervous. EI #1 was asked, after removing the dressing from RI #8's right heel should gloves have been changed prior to cleansing the wound on the right heel and applying the dressing. E#1 stated, Yes, because I was putting on a clean dressing. EI #1 was asked why gloves were not changed prior to cleansing the wound and applying a clean dressing. EI #1 stated, I was just nervous. EI #1 was asked what was the potential negative outcome for the resident if handwashing was not performed and gloves were not changed during wound care. EI #1 stated, Increase in infection. On 1/26/17 at 2:39 p.m., an interview was conducted with EI #3, the DON (Director of Nursing). EI #3 was asked what the proper way to cleanse a wound was to prevent the potential for cross contamination. EI #3 stated, From the inside to the outside; a circular motion. EI #3 was asked what was the potential risk of patting a wound while cleansing the wound. EI #3 stated, If infected in one area you could contaminate the wound, contamination. EI #3 was asked should two wounds be cleansed with the same 4 X 4. EI #3 stated, No. EI #3 was asked why two wounds should not be cleansed with the same 4 X 4. EI #3 stated, Against Policy and Procedure, not good infection control. It will cause contamination. EI #3 was asked what the potential negative outcome for the resident was if handwashing was not performed and gloves were not changed during wound care. EI #3 stated, Contamination.

Based on an observation, record review, and interviews, the facility failed to ensure the Licensed Nurse flushed the [DEVICE] prior to administering the medication to RI (Resident Identifier) #10. This affected RI #10, one of eleven residents observed for Medication Pass. Findings include: A review of a facility document titled, Gastrostomy tube drug instillation, revealed: .*Release the clamp and instill 15 mL (millimeters) of water into the tube. * Give the medication, followed by a minimum of 15 mL of water. Repeat as necessary with additional medications. A review of RI #10's medical record revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #10's Quarterly MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 10/08/15, revealed RI #10 had severe impairment of cognitive skills for daily decision making. RI #10 was coded as requiring total assistance for all ADLs (Activities of Daily Living). RI #5 was coded as always incontinent of bowel and bladder function. A review of RI #10's Physician order [REDACTED].> .4 Flush tube (the symbol for with) 30 cc (cubic centimeters) before and after administration of meds (medications) . This order was dated 1/20/15. A medication pass observation was conducted with EI #10 on 12/01/15 at 4:45 PM. EI #10 checked RI #10's G (Gastrostomy-tube) for placement and attempted to administer a diluted medication via [DEVICE]. EI #10 did not flush the [DEVICE] prior to administering the medication. EI #10 massaged the [DEVICE] due to having difficulty with the flow of the medication. The medication and flush was pushed in. The second medication was then administered. An interview was conducted with EI #10 on 12/2/15 at 12:45 PM. The surveyor asked EI #10 when should a resident's [DEVICE] be flushed during medication administration. EI #10 stated, Before and after each medication. The surveyor asked EI #10 if she flushed RI #10's [DEVICE] prior to administering the resident's medications. EI #10 stated, I can't remember. I thought I did. I think I flushed it on the pump. I'm not sure. The surveyor asked EI #10 what was the concern when a [DEVICE] was not flushed prior to administering medications. EI #10 stated, The medications not clearing the tube. The tube can become clogged. An interview was conducted with EI #3, the facility's Director of Nursing, on 12/3/15 at 4:45 PM. The surveyor asked EI #3 should a nurse flush a [DEVICE] prior to administrating diluted medications via [DEVICE]. EI #3 stated, Yes. The surveyor asked what was the concern when a [DEVICE] was not flushed prior to administering medications. EI #3 stated, It may hinder the medication from going in. There may be a blockage.

Based on observation, record review, and interview, the facility failed to ensure a licensed nurse did not pick up an object from the floor with her gloved hands and then pack RI (Resident Identifier) #5's wound with a dressing with the contaminated gloves. This affected RI #5, one of two sampled residents with an observation of wound care. Findings Include: A review of Potter - Perry Fundamentals of Nursing 7th Edition, Chapter 34, page 655, Infection Prevention and Control, revealed, The CDC (Center for Disease Control) recommends the following: 1. Wash hands with a non-antimicrobial soap or antimicrobial soap and water when hands are visibly soiled. 2. If hands are not visibly soiled, use an alchol-based waterless antiseptic agent for routinely decontaminating hands in all other clinical situations: .e. After contact with inanimate objects (including medical equipment) in the immediate care of the client.h. After removing gloves. A review of Potter - Perry Fundamentals of Nursing 7th Edition, Chapter 48, page 1315, Skin Integrity and Wound Care, revealed: SKILL 48-3 Applying Dry and Moist Dressings . STEPS . 16. Apply dressing: A. Dry dressing (1) Apply sterile gloves.Rationale .Allows handling of sterile supplies without contamination. (2) Inspect wound . (3) Clean wound . (4) Dry area. (5) Apply sterile dry dressing covering wound. (6) Apply [MEDICATION NAME] dressing if indicated. A review of RI #5's medical record revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #5's Annual MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 09/14/15, revealed RI #5 had a BIMS (Brief Interview for Mental Status) score of 10 out of a possible 15. This score indicated RI #5 was moderately impaired of cognitive skills for daily decision making. RI #5 was coded as requiring extensive to total assistance for ADLs (Activities of Daily Living). RI #5 was coded as always incontinent of bowel function. RI #5 had an indwelling Foley Catheter. On 12/2/15 at 10:00 AM, EI (Employee Identifier) #9, an LPN (Licensed Practical Nurse), was observed performing wound care for RI #5. EI #9 washed her hands, changed her gloves, and wiped the outer area of the wound with a skin prep. EI #9 dropped an item on the floor, picked it up, and put the item in the garbage. EI #9 then packed RI #5's wound with a dry dressing and covered the wound with a border dressing. EI #9 did not wash her hands or change her gloves prior to packing the wound with the dressing. The surveyor asked EI #9 what item did she drop onto the floor. She answered, a piece of paper that she put in the trash. RI #5 had a stage IV (four) pressure to the sacrum. The wound measurements were 5 cm (centimeter) long, 6 cm wide, and 5.5 cm deep. The wound bed was beefy red. On 12/2/15 at 5:10 PM, EI #9 was interviewed. EI #9 was asked what she did when she dropped the item on the floor during wound care for RI #5. EI #9 stated, I think I picked it up and put it in the trash. It was a piece of paper. The surveyor asked EI #9 if she washed her hands and changed her gloves after picking the item up off of the floor, prior to putting the dressing in the wound bed. EI #9 stated, I don't think I did, I should have. The surveyor asked EI #9 what was the concern with not washing her hands or changing her gloves at that time. EI #9 stated, Contamination, cross contamination.

Based on interviews and record reviews, the facility failed to ensure a licensed staff member notified RI (Resident Identifier) #1's physician and transfered the resident to the hospital when the resident experienced a decline. RI #1's oxygen level dropped to 81% and the resident was unresponsive on 11/8/15. RI #1 was transferred to the hospital on [DATE]. This affected RI #1, one of four residents sampled for change in condition. Findings Include: A review of Potter - Perry Fundamentals of Nursing 7th Edition, with a Copyright date of 2009, Chapter 26, Documentation and Informatics, page 387 and 389, revealed, Guidelines for Quality Documentation and Reporting . Current . Activities or findings to communicate at the time of occurrence include the following: . · Vital Signs · Administration of medications and treatments . · Change in client's status and who was notified, (e.g., physician, manager, client's family) . · treatment for [REDACTED]. · Client's response to treatment or intervention . A review of a facility's document titled, Lippincott Procedures - Patient condition changes, recognizing and responding, revealed: Implementation . *Recognize that the patient is experiencing a change in condition; you may see an acute change or may simply have a feeling that someone isn't quite right with the patient or a family member may voice concerns. *Obtain the patient's vital signs and oxygen saturation level by pulse oximetry; compare them to the patient's baseline measurements to determine the severity of the condition change. *Assess the patient's neurologic status and compare your findings to baseline findings to determine whether the patient experienced an acute change in level of consciousness. *Calculate the patient's early warning score, if used in your facility, to help verify your clinical impression that the patient's condition is deteriorating and requires intervention. An early warning score can help you determine when to activate the rapid response team. Assign a score to each patient parameter. If your patient's total score is more than 3, notify the practioner . RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1 had a Pacemaker and was a [MEDICAL TREATMENT] patient. A review of RI #1's NURSING ADMISSION INTAKE FORM, dated 11/04/15 at 5:45 PM, revealed RI #1 was alert and oriented to time, place and person. According to the assessment, RI #1 was calm and cooperative, had adequate vision and hearing and RI #1's speech was clear. The assessment revealed RI #1's respirations were regular and had moderate Dyspnea (difficulty breathing) with exertion only. RI #1 was assessed as being able to ambulate with assistance of one or two staff members. The resident was assessed to have no difficulty with chewing or swallowing. The admission assessment revealed RI #1 was continent for elimination. RI #1's Interim Plan Of Care dated 11/04/15, identified the resident to require assistance with ADLs (activities of daily living) due to complaints of pain. A review of RI #1's NURSING DAILY SKILLED SUMMARY, dated 11/08/15 at 1000 (10:00 AM), revealed: Resident unresponsive. Unable to unable to eat breakfast. Unable to take meds (medications) put spoon in mouth - no response. O2 (oxygen) Sats (saturation) 81%. O2 (arrow sign for increased) from 2 L (liters) to 4 L. O2 Sats (arrow sign for increased) to 86%. BP (blood pressure) low, fingers and toes dark purple, legs and arms mottled. Noted to be a DNR (Do Not Resuscitate). Mouth breathing. No response to leg rolling to clean RI #1 up. Total assist X (times) 2. Will monitor. 1245 (12:45 PM) Resident continued all morning with O2 Sats in 80's. Put non rebreather mask on RI #1 d/t (due to) mouth breathing. Sats increased to 96%. Occasionally moves legs and arms now and has some color to her now. Lips fingers toes no longer purple. Will continue to monitor. Daughter @ bedside This note was signed by EI #4, an RN (Registered Nurse) at the facility. There was no documentation that the physician was notified of RI #1's decline. RI #1 was admitted to the hospital the next day, 11/9/15. The parameters listed for the Early warning score of the form for RI #1 were: Heart rate, Respiratory rate, Systolic blood pressure, Temperature, Level of consciousness, Hourly urine output, for 2 hours. Under Level of consciousness for RI #1, the Unresponsive score was 3 on 11/8/15. A review of the nursing note dated 11/8/15 for RI #1 revealed the resident was unresponsive. There was no documentation of RI #1's heart rate, respiratory rate, blood pressure, temperature, or urine output. The resident was unresponsive, which indicated the doctor should have been notified. A review of a Progress Note dictated by EI #6 revealed: .RI #1 is an .admitted to the facility last night, 11/4/15, after being discharged from the hospital . Advanced care directive: RI #1 is a full code. She was a DNR in the facility, and DNR orders are in progress. An interview was conducted with EI #4, an RN (Registered Nurse) at the facility, on 12/3/15 at 10:35 AM. The surveyor asked EI #4 if she remembered RI #1 and if she provided care for the resident on 11/8/15. EI #4 stated, .Oh yes her daughter was staying with her and said RI #1 was slowly getting worst. That is what the daughter said. The surveyor asked EI #4 what occurred on 11/8/15 regarding problems with RI #1's oxygen saturation levels. EI #4 stated, Yes, I remember we increased RI #1's oxygen and changed RI #1 from the nasal cannula to a non-rebreather mask. We gave RI #1 a breathing treatment. RI #1 stayed about the same. RI #1's Sats did increase. When I first went in the nasal cannula was on RI #1's forehead. I put the rebreather mask on because RI #1 was mouth breathing. RI #1's lips and finger tips were purple and RI #1's legs were mottled. RI #1 looked better after RI #1's Sats went up, but RI #1 was still unresponsive. The nurse stated the resident was not able to swallow due to no gag reflex. EI #4 stated, I stuck a spoon in her mouth, no gag reflex. She was unresponsive. I asked the daughter, who was there, if she wanted RI #1 sent to the hospital and she said no. The daughter said RI #1 was a DNR, and she wanted to monitor RI #1. EI #4 stated, There was another daughter on the phone. She was concerned, but felt better after the daughter and I, who spent the night told her RI #1's oxygen saturation (levels) were up. The surveyor asked EI #4 when did she notify the doctor. EI #4 stated, I don't think I did. They said she had been unresponsive the day before. Did I chart that I called the doctor? The surveyor said no. EI #4 stated she did not remember calling the doctor. The surveyor asked EI #4 what was the concern when a resident was in distress and was not transported to the hospital. EI #4 stated [MEDICAL CONDITION] and death, if not transferred. An interview was conducted with EI #3, the facility's DON (Director of Nursing), on 12/03/15 at 2:55 PM. EI #3 stated she did remember RI #1. The surveyor asked EI #3 about the incident regarding RI #1's problems with the oxygen saturation levels. EI #3 stated she was made aware on Monday, 11/9/15, when the nurse went in to assess RI #1 that morning. EI #3 said she was told RI #1 was lethargic and the nurse had some concerns. EI #1 stated the physician was called and the resident was sent to the hospital. The surveyor asked EI #3 was she aware RI #1 had a decline on 11/8/15 with respiratory distress, a decline in the oxygen saturation level, a change in color, no gag reflex, and was unresponsive. EI #3 stated, No ma'am. EI #3 stated, She should have called the doctor. As a nurse, if we have a problem, we have an obligation to the patient. I would have called the doctor. Even if the family said they wanted the resident to stay and be monitored. I would have still called the doctor and documented. The surveyor asked EI #3 what was the concern when a resident was in distress and was not transported to the hospital, especially after a family member/sponsor requested for the resident to be sent to the hospital. EI #3 stated, Harm could be brought to the resident. An interview was conducted on 12/3/15 at 3:35 PM, with EI #6, a Nurse Practitioner for the facility. The surveyor asked EI #6 if she was familiar with the resident RI #1. EI #6 stated, Yes, I remember RI #1 and her daughter, who was a nurse. The surveyor discussed the concern regarding RI #1 who was admitted on [DATE], and had a decline on 11/8/15. The surveyor shared that the resident was able to ambulate with assistance on admission, but on 11/8/15, RI #1 was unresponsive, had a drop in her oxygen saturation, a change in color, and had an overall decline. The surveyor asked EI #6 was she notified of RI #1's decline. EI #6 stated, No I was not on call that day. I did a note on her because of the issues with her daughter. The surveyor asked EI #6 if the staff should have called the physician when RI #1 became unresponsive, had difficulty breathing, and was in distress. The surveyor shared that RI #1's family members requested for RI #1 to be transported to the hospital. EI #1 stated, When RI #1 came here, she was not a DNR. Yes, any change in condition the physician should be called. When in doubt send them out. Use nursing judgment. I would have called. An interview was conducted on 12/4/15 at 8:00 AM, with EI #7, the Nurse Practitioner who was on call for the facility on 11/8/15. The surveyor shared the concern regarding RI #1's decline and respiratory distress. The surveyor asked EI #7 if the nurse should have called her. EI #7 stated most definitely. The nurse should have called her or whoever was on call. Unsuccessful attempts were made to contact EI #5, an RN that cared for RI #1, for an interview.

Based on record review and interviews, the facility failed to ensure the nursing staff notified the Physician when RI (Resident Identifier)#1 had a change in condition on 11/8/2015. This affected RI #1, one of four residents sampled for a change in condition. Findings include: A review of Potter - Perry Fundamentals of Nursing, 7th Edition, Chapter 26, page 387 and 389, revealed, Documentation and Informatics: Guidelines for Quality Documentation and Reporting . Current .Activities or findings to communicate at the time of occurrence include the following: . · Vital Signs · Administration of medications and treatments . · Change in client's status and who was notified, (e.g., physician, manager, client's family) . · treatment for [REDACTED]. · Client's response to treatment or intervention . A review of RI #1's medical records revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1 had a Pacemaker and was a [MEDICAL TREATMENT] patient. A review of RI #1's NURSING ADMISSION INTAKE FORM, dated 11/04/15 at 5:45 PM, revealed RI #1 was alert and oriented to to time, place and person. According to the assessment, RI #1 was calm and cooperative, had adequate vision and hearing. The document revealed RI #1's speech was clear. The assessment also revealed RI #1's respirations were regular and the resident had moderate dyspnea (difficulty breathing) with exertion only. RI #1 was assessed as being able to ambulate with assistance of one or two staff members. The resident was assessed to have no difficulty with chewing or swallowing. The admission assessment revealed RI #1 was continent for elimination. A review of RI #1's NURSING DAILY SKILLED SUMMARY, dated 11/08/15 at 1000 (10:00 AM), revealed: Resident unresponsive. Unable to eat breakfast. Unable to take meds (medications) put spoon in mouth - no response. O2 (oxygen) Sats (saturation) 81%. O2 (arrow sign for increased) from 2 L (liters) to 4 L. O2 Sats (arrow sign for increased) to 86%. BP (blood pressure) low, fingers and toes dark purple, legs and arms mottled. Noted to be a DNR (Do Not Resuscitate). Mouth breathing. No response to leg rolling to clean RI #1 up. Total assist X (times) 2. Will monitor. 1245 (12:45 PM) Resident continued all morning with O2 Sats in 80's. Put non-rebreather mask on RI #1 d/t (due to) mouth breathing. Sats increased to 96%. Occasionally moves legs and arms now and has some color to her now. Lips fingers toes no longer purple. Will continue to monitor. Daughter @ bedside This note was signed by EI #4, an RN (Registered Nurse) at the facility. There was no documentation the physician was notified of RI #1's decline. RI #1 was admitted to the hospital the next day, 11/9/15. An interview was conducted with EI #4, on 12/3/15 at 10:35 AM. The surveyor asked EI #4 if she remembered RI #1 and if she provided care for the resident on 11/8/15. EI #4 stated, .Oh yes, her daughter was staying with her and said RI #1 was slowly getting worst. That is what the daughter said. The surveyor asked EI #4 what occurred on 11/8/15 regarding problems with RI #1's oxygen saturation levels. EI #4 stated, Yes, I remember we increased RI #1's oxygen and changed RI #1 from the nasal cannula to a non-rebreather mask. We gave RI #1 a breathing treatment. RI #1 stayed about the same. RI #1's Sats did increase. When I first went in, the nasal cannula was on RI #1's forehead. I put the rebreather mask on because RI #1 was mouth breathing. RI #1's lips and finger tips were purple and RI #1's legs were mottled. RI #1 looked better after RI #1's Sats went up, but RI #1 was still unresponsive. The nurse stated the resident was not able to swallow due to no gag reflex. EI #4 stated, I stuck a spoon in her mouth, no gag reflex. She was unresponsive. I asked the daughter, who was there (with resident), if she wanted RI #1 sent to the hospital and she said no. The daughter said RI #1 was a DNR, and she wanted to monitor RI #1. EI #1 stated, There was another daughter on the phone. She was concerned, but felt better after the daughter and I who spent the night told her RI #1's oxygen saturation (levels) were up. The surveyor asked EI #4 when did she notify the doctor. EI #4 stated, I don't think I did. They said she had been unresponsive the day before. Did I chart that I called the doctor? The surveyor said no. EI #4 stated she did not remember calling the doctor. The surveyor asked EI #4 what was the concern when a resident was in distress and was not transported to the hospital. EI #4 stated, [MEDICAL CONDITION] and death, if not transferred. An interview was conducted with EI #3, the facility's DON (Director of Nursing), on 12/03/15 at 2:55 PM. EI #3 stated she did remember RI #1. The surveyor asked EI #3 about the incident regarding RI #1's problems with the oxygen saturation levels. EI #3 stated she was made aware on Monday 11/9/15, when the nurse went in to assess RI #1 that morning. EI #3 said she was told RI #1 was lethargic and the nurse had some concerns. EI #1 stated the physician was called and the resident was sent to the hospital. The surveyor asked EI #3 was she aware RI #1 had a decline on 11/8/15 with respiratory distress, a decline in the oxygen saturation level, a change in color, no gag reflex, and was unresponsive. EI #3 stated, No ma'am. EI #3 stated, She should have called the doctor. As a nurse, if we have a problem, we have an obligation to the patient. I would have called the doctor. Even if the family said they wanted the resident to stay and be monitored. I would have still called the doctor and documented. The surveyor asked EI #3 what was the concern when a resident was in distress and was not transported to the hospital, especially after a family member/sponsor requested for the resident to be sent to the hospital. EI #3 stated, Harm could be brought to the resident. An interview was conducted on 12/4/15 at 8:00 AM, with EI #7, the Nurse Practitioner who was on call for the facility on 11/8/15. The surveyor shared the concern regarding RI #1's decline and respiratory distress. The surveyor asked EI #7 if the nurse should have called her. EI #7 stated most definitely. EI #7 stated the nurse should have called her or whoever was on call. Unsuccessful attempts were made to call EI #5, an RN that cared for RI #1, for an interview.

Based on an observation, interviews, and record reviews, the facility failed to ensure a CNA (Certified Nursing Assistant) provided incontinence care for RI (Resident Identifier) #8 in a manner to prevent the potential for cross contamination. This affected RI #8, one of one residents observed for incontinence care. Findings include: A review of Potter - Perry Fundamentals of Nursing, 7th Edition, with a Copyright date of 2009, Chapter 34, pages 654 and 655, revealed, Asepsis . 1. Wash hands with a non-antimicrobial soap or antimicrobial soap and water when hands are visibly soiled. 2. If hands are not visibly soiled, use an alcohol-based waterless antiseptic agent for routinely decontaminating hands in all other clinical situations: . c. After contact with body fluids or excretions, mucous membranes, nonintact skin, or wound dressings as long as hands are not visibly soiled. d. When moving from a contaminated body site to a clean body site during client care . A review of RI #8's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of an Annual MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 10/6/15, revealed RI #8 had a BIMS (Brief Interview for Mental Status) score of 10 out of a possible 15. This score indicated the resident was moderately impaired of cognitive skills for daily decision making. RI #8 required extensive to total assistance with ADLs (Activities of Daily Living). RI #8 was coded as always incontinent of bladder and bowel function. On 12/3/15 at 9:20 AM, an observation was made of incontinence care performed for RI #8. EI (Employee Identifier) #1, a CNA, and EI #2, a CNA, performed incontinence care for RI #8. EI #2 positioned RI #8 on the right side, EI #1 cleansed the rectal area in an upward motion with a small amount of soft, brown stool noted on the disposable wipe. EI #1 disposed of the wipe, using a clean wipe, cleansed the rectal area in an upward motion and discarded the wipe. RI #8 was then repositioned onto (RI #8's) back. EI #1 failed to wash her hands and change gloves prior to cleansing the perineal area in a downward motion. There was a small amount of brown stool noted on the wipe when EI #1 cleansed the perineal area of RI #8. EI #1 repeated this process three times using a clean wipe each time the perineal area was cleansed. On 12/3/15 at 11:10 AM, an interview was conducted with EI #1. EI #1 was asked when should hands be washed during incontinence care. EI #1 stated hands should be washed before, during, and after incontinence care. EI #1 also stated during incontinence care, if the resident had a bowel movement, after cleaning the resident, gloves should be changed and hands washed before putting linen on the bed. EI #1 was asked what was the facility's Policy and Procedure regarding washing hands and changing gloves during incontinence care. EI #1 stated, Every time you enter (the) room, wash hands, put on gloves, wash hands and change gloves during care, tie bags up, remove gloves, wash hands, take trash out, (and) then wash hands again. EI #1 was asked if gloves should be removed and hands washed after cleaning stool, prior to cleaning the perineal area. EI #1 stated, Yes ma'am. EI #1 was asked had she removed her gloves, washed her hands, and donned clean gloves prior to cleaning RI #8's perineal area after removing stool from the rectal area. EI #1 stated she had, and then thought about the question. After the observation was shared with EI #1, she agreed she had forgotten a step regarding washing her hands. EI #1 was asked what was the potential negative outcome if hands were not washed and gloves changed after cleansing stool from a resident then cleaning the perineal area. EI #1 stated, They could have an infection, some type of discharge. On 12/3/15 at 5:40 PM, an interview was conducted with EI #3, the DON (Director of Nursing). EI #3 was asked if hands should be washed and gloves changed after cleaning stool from a resident's rectal area, prior to cleaning the perineal area. EI #3 stated, Yes. EI #3 was asked why gloves should be changed and hands washed. EI #3 stated to decrease the risk of infection.

Based on interviews, record review and review of a facility policy titled "Incident/Accident Reporting for Residents", the facility failed to ensure RI (Resident Identifier) #1, a resident with a history of falls, was transferred using the mechanical lift with the assist of two staff. On 07/18/13, on the 2:00 p.m. - 10:00 p.m. shift, RI #1 was transferred from the shower chair to the bed with a gait belt by a RCS (Resident Care Specialist), EI (Employee Identifier) #9. In an interview with EI #9, it was revealed EI #9 assisted RI #1 to stand using a gait belt. EI #9 said she pivoted (turning on her feet or taking small steps) RI #1 and sat the resident down on the side of the bed by herself. According to RI #1's Cardex, she was to be transferred with a full body mechanical lift with the assist of two staff. On 07/18/13, on the 10:00 p.m. - 6:00 a.m. shift, RI #1 was found to have a bruise to the right foot. A X-ray was obtained and RI #1 was found to have two fractures, to the right ankle. According to the facility's investigative file it was documented "... (name of Orthopedic doctor) and our Medical Director agreed that it was a twist to the ankle" that caused the injury ..." These deficient practices affected RI #1, one of three residents sampled for falls. Findings Include: RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A facility form titled "Lift and Transfer Training" dated 2009, documented: "EQUIPMENT DESCRIPTION Full Body Lift - Lifting/transfer device for residents evaluated to be totally dependent on staff for lifting and transfers ..." RI #1's Resident Care Cardex Worksheet with an admission date of [DATE], documented: "... 3. Mobility ... Transfer ... Lift ... full body lift 2 person ..." Review of a Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 05/30/13, identified RI #1 to score a 0 on the BIMS (Brief Interview for Mental Status), indicating severely impaired cognition. RI #1 was also assessed as needing assistance with bed mobility and being totally dependent on staff for transfers. Nurses Notes (NN) for RI #1 documented: "07/18/13 0300 (3:00 a.m.) Called to resident's room by RCS large dark purple bruising area noted to (R) (right) foot area warm to touch slight swelling note to area also resident flinches when area is slightly touched, will notify oncoming nurse. 07/18/13 6-2 resident lethargic this shift ... Flinches when (R) foot is touched very obvious bruising to outer ankle and lateral part of foot. PRN (as needed) tylenol given to help ease come discomfort. Little change noted upon touching foot. X-ray performed. Positive for fx (fracture) ..." A Mobilex Radiology Report for RI #1 dated 07/18/2013, documented: "... Exam: ANKLE COMP (complete), MIN 3V (view), RIGHT Results: There is an acute angulated fracture of the distal fibular metaphysis at and above the ankle mortise. There is a displaced fracture of the posterior malleolus of the distal tibia ... Conclusion: Bimalleolar fracture ..." Review of a report for RI #1 from the Orthopedics office documented: "... Date of Encounter: 07/19/2013 ... Chief Complaint Right Ankle HISTORY OF PRESENT ILLNESS ( RI #1's first name) presents today for evaluation of the right ankle ... she had lived at (name of nursing home) for several years. She has an ankle injury from 07/18/2013. The patient is not ambulatory and is a total care patient ... X rays were made by (name of nursing home) and it revealed a bimalleolar ankle fracture. She (RI #1) is here today for evaluation ... Physical Exam ANKLE EXAMINATION: INSPECTION: Ecchymosis present to ankle ... PALPATION: Tender to palpate about the lateral malleolus ... X-Ray Interpretation Three views demonstrate a long oblique fibular fracture ... Appears to have a posterior malleolus fracture. Diagnosis: [REDACTED]. IMPRESSION: Right bimalleolar ankle fracture. Plan: 1. ... The patient is non-ambulatory with significant contractures. 2. We elected to go ahead and put her (RI #1) in a clamshell cast to evaluate the soft tissue as needed. We put an ACE wrap around the outside of the cast to protect it from the other foot as well ..." A review of the facility's investigative file dated 07/23/2013, documented: "... (name of Orthopedic doctor) and our Medical Director agreed that it was a twist to the ankle" that caused the injury. (Name of Orthopedic doctor) placed her (RI #1) in a clamshell cast ... (Name of RI #1) is a [AGE] year old with severe dementia; she is non-ambulatory and total care ... Initiated education on 7/23/2013 on safe transfers and repositioning of residents with frail bones ..." (Entry signed by the facility's DON, EI #2) On 08/14/13 at 1:46 p.m., the surveyor conducted an interview with EI #9, the RCS caring for RI #1 on 07/17/13 on the 2 p.m. - 10 p.m. shift. The surveyor asked EI #9 how was RI #1 to be transferred in and out of bed. EI #9 stated RI #1 was a two person assist. The surveyor asked EI #9 if RI #1 required a lift. EI #9 replied, yes. The surveyor asked EI #9 was RI #1 gotten out of bed or put back to bed on the day she care for her (07/17/13). EI #9 stated when she came on (to work), RI #1 was in bed. EI #9 stated she got RI #1 up to shower her. The surveyor asked EI #9, who assisted her in getting RI #1 up. EI #9 replied, another RCS, (name of EI #6). The surveyor asked EI #9 did anyone assist her in getting RI #1 back to bed. EI #9 said yes, the same person (EI #6) who assisted her in getting RI #1 out of bed. On 08/14/13 at 6:30 p.m., the surveyor conducted an interview with EI #6, the RCS assisting EI #4 to get RI #1 out of bed. The surveyor asked EI #6 how did he and EI #4 transfer RI #1 out of bed. EI #6 stated manually, one on each side. The surveyor asked EI #6, did he help EI #4 to transfer RI #1 back to bed. EI #6 replied no. The surveyor asked EI #6 who helped EI #4 to transfer RI #1 back to bed. EI #6 stated he didn't. EI #6 stated RI #4 did not come back to get him. The surveyor asked EI #6 why did he think EI #4 would say he helped to put RI #1 back to bed. EI #6 stated he did not know. EI #6 said he knew he didn't help. On 08/15/13 at 10:12 a.m., the surveyor conducted a second interview with EI #9. The surveyor asked EI #9 did EI #6 help her to put RI #1 back to bed (on 07/17/13). EI #9 said, "I now remember, I used the gait way belt ... I used it by myself." The surveyor asked EI #9 to demonstrate how she transferred RI #1 back to bed by herself. EI #9 demonstrated how she placed the gait belt around RI #1's waist and assisted RI #1 to stand. EI #9 stated she pivoted RI #1 and sat her on the bed. The surveyor asked EI #9 was RI #1 care planned for a gait belt to be used when transferring her. EI #9 stated she was not sure, but she thought RI #1 was. RI #1's Care Plan - Transfers dated 06/13/13, with a "... Problem/Need ... Potential for injury. Impaired ability to self transfer related to: ... Ambulatory Status Gait/Balance ... Mechanical lift (2 person assist required at all times) ... sling type ... To/From chair To/From bed" documented under "Goal Mr/s (name of RI #1) will be transferred with identified transfer devices/assistance ... Approach ... Full body lift ...To/From chair To/From bed ..." On 08/15/13 at 1:35 p.m., the surveyor conducted a phone interview with the Orthopedic doctor evaluating RI #1's right foot. The surveyor asked the Orthopedic doctor did he recall any of RI #1's diagnoses. The Orthopedic doctor said RI #1 had a right malleolar fracture. The Orthopedic doctor stated this was a type fracture where there is a fracture on the outside and on the medial side of the ankle. The Orthopedic doctor stated the fracture was not displaced, meaning the bone wasn't moved. The Orthopedic doctor said the bone was cracked and the foot was placed in a cast. The surveyor asked the Orthopedic doctor, in his professional opinion, what were some of the reasons a fracture like this occurred. The Orthopedic doctor stated, with RI #1, she has immobility and doesn't put weight on her bones. The surveyor asked the Orthopedic doctor if someone attempted to stand RI #1, could this type fracture happen. The Orthopedic doctor said, "It could have. Any pressure on the bone or hit to the bone could have caused the fracture." On 08/15/13 at 2:16 p.m., the surveyor conducted an interview with EI #3, the facility's RN Unit Manager. The surveyor asked EI #3 how was RI #1 to be transferred in and out of bed. EI #3 stated prior to RI #1's injuries, she was a two person assist using the stand assist lift. The surveyor asked EI #3 was RI #1 care planned to use a gait belt. EI #3 stated not to her knowledge. The surveyor asked EI #3 was RI #1 able to stand and pivot. EI #3 said she couldn't say. The surveyor asked EI #3 was she aware that when EI #4 transferred RI #1 back to bed on 07/17/13, she transferred RI #1 by herself using a gait belt. EI #3 stated no. The surveyor asked EI #3 was she aware that on 07/17/13, when RI #1 was transferred out of bed to the shower, she was lifted manually. EI #3 stated no. The surveyor asked EI #3 was being lifted manually an improper transfer (for RI #1). EI #3 said yes. The surveyor asked EI #3 was using the gait belt an improper transfer. EI #3 stated, "Yes." On 08/15/13 at 4:35 p.m., the surveyor conducted an interview with EI #2, the facility's DON. The surveyor asked EI #2 when was she made aware that RI #1 had an injury to her right foot. EI #2 stated she was made aware the first thing that morning on the 18th (07/18/13). EI #2 stated EI #3 called her and said she needed to look at RI #1's ankle/foot when she (EI #2) got to work. The surveyor asked EI #2 what did she observe when she saw RI #1's foot. EI #2 stated the ankle was bruised with some slight swelling. EI #2 stated the facility could not find any source of how the injury occurred. The surveyor asked EI #2 how many staff did it take to transfer RI #1 in and out of bed. EI #2 replied two. The surveyor asked EI #2 was RI #1 to be transferred mechanically or manually. EI #2 stated RI #1 was to be transferred with the mechanical lift. The surveyor asked EI #2 was RI #1 care planned for a gait belt to be used when transferring her. EI #2 stated no. The surveyor asked EI #2 if she was aware that when EI #6 and EI #4 transferred RI #1 out of bed on 07/17/13 on the 2 p.m. - 10 p.m. shift, RI #1 was transferred manually and not with the lift. EI #2 stated she was not. The surveyor asked EI #2 if she was aware when RI #1 was transferred from the shower chair back to bed (on 07/17/13) EI #4 transferred her (RI #1) alone using a gait belt. EI #2 replied no. The surveyor asked EI #2, during the facility's investigation was EI #4 asked about transferring RI #1 on 07/17/13. EI #2 stated she asked EI #4 was RI #1's foot bumped going from the room to the shower room. EI #2 stated she never would have dreamed the (RCS's) would not have used a lift to transfer RI #1. The surveyor asked EI #2 what would she say contributed to RI#1's fracture. EI #2 stated she really didn't know. EI #2 said it could have been the transfer. EI #2 said according to the Medical Director and (Name of Orthopedic doctor), RI #1's foot would have gone inward. EI #2 stated the doctors said it was a twist fracture. The surveyor asked EI #2, would trying to assist RI #1 to pivot have caused the fracture. EI #2 replied, "Possibly. I would say for the last 3 months RI #1 would have not been able to pivot." This deficiency was written as a result of the investigation of complaint #AL 412.