Every finding on record at Arbor Springs Health and Rehab Center, Ltd

Based on observations, interviews, and review of the facility's food contract company's policy, Bulk Food - Delivery and Usage, the facility failed to ensure food with an expired use by date was discarded, placing 114 of 117 residents in the facility at risk for foodborne illness if served. Findings include: The facility's contract food service company's undated policy Bulk Food - Delivery and Usage, revealed, .The bulk meals should be held at the proper temperature in the refrigerator and served to residents within 3 days of preparation. During an observation on [DATE] from 9:45 AM to 9:58 AM, the following items prepared in another town by the food service contract company's central kitchen and stored on shelving in the walk-in cooler were observed: - Three large aluminum pans (full size steam table pans) containing chicken pot pie and labeled with a prepared date of [DATE] and a use by date of [DATE] - One small aluminum pan (,d+[DATE] size steam table pan) containing pureed chicken pot pie and labeled with a prepared date of [DATE] and a use by date of [DATE] - One small aluminum pan containing corn and labeled with a prepared date of [DATE] with a use by date of [DATE] - One small aluminum pan containing pureed green beans and labeled with a prepared date of [DATE] with a use by date of [DATE] - Two large pans containing green beans and labeled with a prepared date of [DATE] and a use by date of [DATE] - One large pan containing corn and labeled with a prepared date of [DATE] and a use by date of [DATE] - One large pan containing chicken fettuccini alfredo and labeled with a prepared date of [DATE] and a use by date of [DATE] - One small pan containing pureed baked beans and labeled with a prepared date of [DATE] and a use by date of [DATE] - Two large pans containing barbequed pork and labeled with a prepared date of [DATE] and a use by date of [DATE] - Two large pans containing baked beans and labeled with a prepared date of [DATE] and a use by date of [DATE] - Two large pans containing corn and labeled with a prepared date of [DATE] and a use by date of [DATE] - One small pan containing pureed corn and labeled with a prepared date of [DATE] and a use by date of [DATE] - One small pan containing pureed barbequed pork and labeled with a prepared date of [DATE] and a use by date of [DATE] During an observation on [DATE] at 10:00 AM, the following food items from the walk-in cooler, noted to be expired per the use by dates, were in the oven: - Two large pans (full size steam table pans) containing barbequed pork and labeled with a prepared date of [DATE] and a use by date of [DATE] - Two large pans containing baked beans and labeled with a prepared date of [DATE] and a use by date of [DATE] - Two large pans containing corn and labeled with a prepared date of [DATE] and a use by date of [DATE] - One small pan (,d+[DATE] size steam table pan) containing pureed corn and labeled with a prepared date of [DATE] and a use by date of [DATE] - One small pan containing pureed barbequed pork and labeled with a prepared date of [DATE] and a use by date of [DATE] - One small pan containing pureed baked beans and labeled with a prepared date of [DATE] and a use by date of [DATE] - One small pan containing pureed barbequed pork and labeled with a prepared date of [DATE] and a use by date of [DATE]. During an interview on [DATE] at 10:00 AM, Employee Identifier (EI) #6, Dietary Manager, indicated he was confused why the listed food items were in the oven because the facility usually cooked meals on Mondays, and the food in the oven was not listed on the menu. EI #6 further indicated that catered food was prepared and delivered to the facility by the facility's contracted food service company on Tuesday nights, Thursday nights, and Saturday nights. EI #6 stated the food in the oven should not have been heated up for residents but, instead, should have been discarded. During an observation on [DATE] at 10:46 AM, EI #8 was observed pulling the following expired food items from the oven and discarding them: - Two large pans (full size steam table pans) containing barbequed pork and labeled with a prepared date of [DATE] and a use by date of [DATE] - Two large pans containing baked beans and labeled with a prepared date of [DATE] and a use by date of [DATE] - Two large pans containing corn and labeled with a prepared date of [DATE] and a use by date of [DATE] - One small pan (,d+[DATE] size steam table pan) containing pureed corn and labeled with a prepared date of [DATE] and a use by date of [DATE] - One small pan containing pureed barbequed pork and labeled with a prepared date of [DATE] and a use by date of [DATE] - One small pan containing pureed baked beans and labeled with a prepared date of [DATE] and a use by date of [DATE] - One small pan containing pureed barbequed pork and labeled with a prepared date of [DATE] and a use by date of [DATE] During an interview on [DATE] at 10:47 AM, EI #8 indicated she was instructed by EI #6 to discard the food in the oven due to the use by date on the food having passed. EI #8 indicated dietary staff would be preparing lunch as per the menu for the residents. During an interview on [DATE] at 2:45 PM, EI #6 indicated it was his expectation for staff to dispose of food with an expired use by date. During an interview on [DATE] at 4:45 PM, EI #1, Administrator, revealed it was her expectation that dietary served food within its use by date.

Based on record review, observation, interviews, and review of a facility policy titled, Catheter Care, the facility failed to ensure thorough cleaning of the penis during indwelling urinary catheter care for Resident Identifier (RI) #86, increasing the resident's risk for a urinary tract infection ([CONDITION(S)]). The deficient practice affected RI #86, one of two residents sampled with an indwelling urinary catheter. Findings include: Review of a facility policy titled, Catheter Care, dated 06/01/2021, revealed: . Male: .15. Using circular motion, cleanse the meatus with a clean cloth moistened with water and perineal cleaner (soap). 16. With a new moistened cloth, starting at the urinary meatus moving down, cleanse the shaft of the penis . RI #86 was most recently admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #86's February 2022 Physician Orders, revealed an order dated 06/08/2021 directing staff to provide indwelling catheter care every shift per facility protocol. A review of RI #86's Care Plan revealed a problem onset date of 06/08/2021 regarding a potential for injury related to the presence of an indwelling catheter due to urinary retention. Further review of RI #86's Care Plan also revealed a problem onset date of 06/29/2018 regarding [CONDITION(S)] resulting in impaired urinary elimination (retention and overflow incontinence). According to the Care Plan, .[CONDITION(S)] increases the risk of urinary tract infections, urinary bladder stones, and [CONDITION(S)] . A review of RI #86's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 01/18/2022, identified the resident had intact cognition as evidenced by a Brief Interview for Mental Status score of 13 out of 15. According to the MDS, RI #86 required one-person limited assistance with personal hygiene and had an indwelling catheter. On 02/23/2022 at 3:47 PM, EI #19, Certified Nursing Assistant, provided indwelling urinary catheter care for RI #86. During the observation of catheter care, EI #19 failed to cleanse the shaft of the penis. EI #19 requested to start over and again failed to cleanse the shaft of the penis when the catheter care was provided the second time. Upon exiting the resident's room, during an interview, EI #19 was asked if she cleansed the shaft of the penis. EI #19 said, no, she forgot. During an interview on 02/24/2022 at 1:40 PM, EI #1, the Administrator, reviewed the Catheter Care policy and stated it should be followed.

Based on observations, record review, and interviews,the facility failed to ensure: 1) Resident Identifier (RI) #223's oxygen was administered in accordance with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2) RI #220's nebulizer mask and tubing was stored in a manner to prevent potential contamination when not in use. This deficient practice affected RI #223 and RI #220, two of four residents sampled for respiratory care. Findings include: 1) RI #223 was most recently admitted to the facility on [DATE]. RI #223's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #223's admission Minimum Data Set (MDS) dated [DATE] indicated RI #223 had no cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The resident required extensive assistance of one person for their activities of daily living (ADLs). The MDS indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #223's comprehensive care plans revealed a care plan dated 12/13/2021 related to RI #223's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This care plan included an intervention to administer oxygen therapy as ordered by the physician. A review of RI #223's February 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 02/23/2022 at 3:10 PM, RI #223 was wearing oxygen and the concentrator was set at three liters per minute. The resident, as well as a family member present at the time, both confirmed the resident's oxygen should be set at two liters per minute. On 02/24/2022 at 10:36 AM, RI #223 was sitting in his/her room receiving oxygen at a rate of three liters per minute. During an interview with Employee Identifier (EI) #25, Registered Nurse (RN), on 02/24/2022 at 10:49 AM, EI #25 stated they would look at the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . After reviewing RI #223's record, RI #25 stated the resident should be on two liters of oxygen and did not know why the concentrator was set to three liters per minute. During an interview with EI #28, Clinical Care Coordinator, on 02/24/2022 at 11:23 AM, EI #28 stated only the nurse could take care of an oxygen concentrator, and the nurse should refer to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with EI #2, Director of Nursing, on 02/24/2022 at 3:40 PM, with EI #1, Administrator, present, she indicated the nurse should look at the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2) RI #220 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #220's February 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 02/21/2022 at 10:06 AM and 11:15 AM revealed RI #220's nebulizer mask, canister and tubing were connected to the nebulizer machine and laying on top of the nightstand. According to the MAR, the last time the resident received a nebulizer treatment was on 02/20/2022 at 5:43 AM. Observations on 02/22/2022 at 10:47 AM revealed RI #220's nebulizer mask, canister and tubing were connected to the nebulizer machine. They were dated 02/20/2022. According to the MAR, the last time the resident received a nebulizer treatment was on 02/22/2022 at 6:00 AM. Observation on 02/23/2022 at 8:33 AM revealed RI #220's nebulizer equipment was connected to the machine; the canister had a small amount of fluid in it and the mask was connected to it and had not been rinsed out. According to the MAR, the last time the resident received a nebulizer treatment was on 02/22/2022 at 10:53 PM. During an interview with RI #220 on 02/23/2022 at 8:33 AM, RI #220 stated the staff had only rinsed out his/her nebulizer canister/tubing once since admission to the facility. The resident stated it should be rinsed out every day at least, otherwise it gets sediment built up in it. RI #220 stated the staff lay it on top of the machine when they are done using it. The resident stated he/she had mentioned rinsing it out before, but the staff did not listen. Observations on 02/24/2022 at 8:49 AM revealed the nebulizer equipment was connected to the machine and the canister had a small amount of fluid in it. The mask and the canister had not been rinsed out and stored properly. During an interview with EI #23, Registered Nurse (RN), on 02/24/2022 at 10:59 AM, EI #23 stated the nurses were responsible for cleaning the nebulizer machines daily. EI #23 stated there were no order to clean the nebulizers, but said the canister on the nebulizer should be rinsed out daily and stored in a bag when not in use. During an interview with EI #28, Clinical Care Coordinator, on 02/24/2022 at 11:23 AM, EI #28 stated the nebulizer canister should be rinsed before and after use and should be stored in a bag. During an interview with EI #2, Director of Nursing, on 02/24/2022 at 3:40 PM with EI #1, Administrator, present, she stated the nebulizer canister should be rinsed out daily and stored in a bag.

Based on observation, interviews, review of Resident Identifier (RI) #1's medical record and the facility's policy titled, Perineal Care, the facility failed to ensure Employee Identifier (EI) #1 and EI #2, both Certified Nursing Assistants (CNAs) removed gloves and washed their hands while performing perineal care for RI #1, prior to touching clean items in the resident's room. This affected RI #1, one of one resident observed for incontinence care. Findings include: The facility's policy titled Perineal Care, revised February 2018, documented Perineal Care Purpose The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition . Steps in the Procedure . 2. Wash and dry your hands thoroughly . 7. Put on gloves . When using disposable cleansing cloth: a. Wipe perineal area . 9. Discard disposable items into designated containers. 10. Remove gloves and discard into designated container. 11. Wash and dry your hands thoroughly. 12. Reposition the bed covers. Make the resident comfortable. 13. Place the call light within easy reach of the resident . RI #1 was admitted to the facility on [DATE]. On 12/30/2020 at 2:18 PM, EI #1 and EI #2, both CNAs, were observed performing incontinence care for RI #1. After applying gloves, EI #1 wiped RI #1's perineal area, then rolled the resident onto his/her side and wiped the right buttocks area. A small amount of brown stool was noted. EI #2 removed the dirty (soiled) brief and linen saver from under the resident, and EI #1 fastened a clean brief, while wearing the same soiled gloves. EI #1 adjusted RI #1's clothing. Without washing hands or changing gloves, both CNAs, positioned RI #1 in the bed and adjusted the bed linens. The call light was placed on the bed within the resident's reach, the head of the bed was raised, and the wipes were placed in the bedside table, all while wearing the same soiled gloves. An interview was conducted with EI #1, a CNA, on 12/30/2020 at 2:30 PM. EI #1 was asked what should be done after wiping the buttocks and removing stool. EI #1 stated, wash hands and change gloves. When asked if she had done that, EI #1 stated, No. EI #1 was asked, after cleaning the buttocks and removing stool, what should be done before touching clean items in the resident's room such as the bed controls, call light and the resident. EI #1 stated, one should wash their hands and change gloves. When asked what the potential for harm was, EI #1 said cross contamination and infection control. An interview was conducted with EI #2, a CNA, on 12/30/2020 at 2:35 PM. EI #2 was asked, after removing the dirty brief and linen saver, what should be done. EI #2 stated, she should have washed her hands and changed gloves. When asked if she had done that, EI #2 said, No. EI #2 was asked, what the potential for harm was and she replied, cross contamination and infection control. An interview was conducted on 12/31/2020 at 8:00 AM with EI #3, the Infection Control Preventionist. EI #3 was asked, what should be done during incontinence care after wiping stool from the buttocks. EI #3 replied, remove gloves, wash hands and re-glove. EI #3 was asked, what should be done before touching clean items and other items in the resident's room. EI #3 explained if the pad underneath is dirty it must be removed and discarded. Staff should then discard gloves, wash hands, and apply new gloves. When asked what the potential for harm was, EI #3 stated, urinary tract infections or other infections.

Based on observation, interviews and a review of the (YEAR) Food Code, the facility failed to ensure the Hot Box consistently maintained temperatures above 135 degrees Fahrenheit (F) for the storage of foods to be served from the 06/05/19 supper meal. This had the potential to affect all 153 residents who received special food requests (such as sweet potato fries, fried fish, grilled cheese sandwiches) or planned (replacement) food added to the line as needed. Findings Included: The (YEAR) Food and Drug Administration Food Code, regulation #3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding specifies under (A) Except during preparation, cooking, or cooling . TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 135 degrees F or above . During the 06/05/19 supper tray line at 5:05 PM, the heated reach in Hot Box at the start of the tray line displayed a temperature of 98 degrees, which soon thereafter, dropped to 95 degrees. The Surveyor asked the Certified Dietary Manager (Employee Identifier/EI) #2 what food items were stored inside. EI #2 explained the heated storage box contained Sweet Potato Fries, Fried Fish, Baked Potatoes, Carrots and Grilled Cheese Sandwiches. When asked to check the temperature of the fried fish (which had been served on the previous lunch tray line that day), EI #2 picked up a piece of fish, and without checking the actual temperature, immediately removed the entire pan of fish and discarded it. On 06/06/19 at 08:51 AM, the Surveyor questioned the Certified Dietary Manager (EI #2) about the low temperatures observed on the Hot Box. EI #2 confirmed the low temperatures were not holding the food at a level to prevent bacterial growth. EI #2 stated he had not previously noticed temperatures that low, and said they were going to look at repairing or replacing it. When asked why the temperatures were not set at a higher level, EI #2 responded that he did set it higher, and the temperature had gotten up to 155 or 160 degrees. EI #2 stated he had not seen any paper work on this piece of equipment. On 06/06/19 at 3:33 PM, the facility Administrator (EI #1) was asked about the status of the Hot Box. EI #1 commented he was going to get rid of the Hot Box, stating: We tried to repair the Hot Box several months ago and couldn't get the replacement parts, so I'm going to get rid of it.

Based on observation, interviews and a review of the (YEAR) Food and Drug Administration Food Code, and facility policies related to Food Storage, the facility failed to: 1) completely air dry utensils, dishes and trays prior to storage and use; 2) consistently label food with preparation and use-by date (UBD) and discard food in a timely manner; 3) completely cover refrigerated food prior to storage; 4) ensure milk was stored in a manner to retain a recommended safe temperature of 41 degrees or less on the [DATE] lunch tray line; and hot food was maintained above 135 degrees F on the [DATE] tray line; 5) wash hands between dirty and clean tasks; and 6) maintain frozen food in a solid state during storage. These infractions had the potential to affect all 153 residents for whom meals were prepared and served at the time of this survey. Findings Included: 1) AIR DRYING The (YEAR) Food Code mandates under ,[DATE].11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT AND UTENSILS: (A) Shall be air-dried . (B) (MONTH) not be cloth dried . On [DATE] at 11:30 AM, the surveyor observed two of two half-size steam table pans stacked and stored on a wire rack, wet-nested. Throughout the [DATE] supper tray line at 4:30 PM, the Cook, Employee Identifier (EI) #3, wiped no less than three (damp) dinner plates with a previously used terry cloth rag (including red plates used for the nutritionally at risk residents), prior to plating the food on each. The Diet Aide (EI #4) on the opposite side of the tray line (at the start of the line), wiped no less than eight wet trays prior to setting each up for the staff. The stacked trays were wet-nested. On [DATE] at 4:40 PM, the Surveyor asked the Certified Dietary Manager/CDM (EI #2) if he was aware of the Diet Aide routinely wiping wet trays at the start of the tray line. EI #2 stated he had not noticed this, and stated the staff should not do this. When asked why air drying was important, EI #2 explained the towel could have something on it; it would be the same problem with the plates. On [DATE] at 09:14 AM, the Surveyor questioned the Assistant Dietary Manager (EI #5) about the concern with air drying. EI #5 explained the department did not have a drying rack for the trays. 2) DATE MARKING AND TIMELY DISCARD The facility policy (unlabeled) related to leftovers (dated 2013) specifies: Excess leftovers should be avoided. Leftovers will be properly handled and used or discarded as appropriate . Procedure: .2, Leftovers will be covered, labeled, and dated; then stored appropriately . On [DATE] at 11:30 AM, the Surveyor observed the following undated or out-dated items in the reach-in refrigerator: a) one small container of hard cooked eggs with no dated label; b) one small steam table pan of ham slices (Canadian Bacon) in liquid with no dated label c) a small steam table pan of expired coleslaw, with a use by date of [DATE]; d) a small container of Chicken Pot Pie, with a preparation date of [DATE] and a UBD of [DATE]; e) a container of baked cornbread squares, with a UBD of [DATE]; f) a container identified by the CDM, as pepper gravy, with no dated label; and g) a container of mashed potatoes with no dated label. When questioned, the CDM explained the potatoes were fortified; and both (mashed potatoes and pepper gravy) were prepared the day before. The CDM confirmed these items should have a dated label. On [DATE] @ 11:50 AM, the surveyor asked EI #2 (the CDM) how the stored food items should be dated. EI #2 replied, they should have a preparation and a UBD. During the observation of the supper tray line on [DATE] at 4:05 PM, a plate of chef's salad was stored on the rack adjacent to the line for use. The plate was labeled with a preparation date of [DATE] and a UBD of [DATE]. At 4:55 PM, the Surveyor mentioned the chef's salad to the CDM. EI #2 looked at the label and said it It definitely doesn't need to be there. 3) PACKAGE INTEGRITY Regulation ,[DATE].15 of the (YEAR) Food Code, Package Integrity specifies: Food packages shall be in good condition and protect the integrity of the contents so that the FOOD is not exposed to ADULTERATION or potential contaminants. On [DATE] at 11:50 AM, the Surveyor showed EI #2 in the reach-in refrigerator, a cardboard case of previously frozen raw biscuits. The thawed, raw biscuit dough was exposed to the surrounding environment, in open plastic bags inside the cardboard case. 4) FOOD STORAGE AND SERVICE Regulation ,[DATE].16 Time/Temperature Control for Safety Food, Hot and Cold Holding of the (YEAR) Food Code specifies: .(A) Except during preparation, cooking, or cooling . TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 135 degrees F (Fahrenheit) or above . (2) At 41 degrees F or less. During the [DATE] lunch tray line at 11:59 AM, trays of 8-oz cartons of milk were stored on a tray atop a rack near the tray line. Sheets of plastic ice packs were draped over the tops of the milk, but most of which bubble cells (which were to be filled with frozen water) were empty--with no ice/coolant. The Surveyor felt a carton of milk. The carton was not cool to the touch. The Surveyor informed EI #2 of this observation at 12:15 PM. The CDM explained that new ice sheets had been ordered, and when the coolers arrive, a new procedure will be implemented to keep the milk cool on the line. At the Surveyor's request, EI #2 checked the temperature of a carton of 2% milk; it was 50 degrees F. On [DATE] at 12:25 PM, the Surveyor asked EI #2 at what temperature should milk be served. The CDM responded, 41 degrees (F) or less. On [DATE] at 5:05 PM, a reach-in heated oven, or Hot Box was positioned at the start of the tray line. The digital thermostat of the Hot Box registered 98 degrees F, which then dropped to 95 degrees F. The Surveyor asked EI #2 (CDM) what food items were stored inside, besides the planned replacement food. EI #2 stated the box included breaded fried fish (a heaping pan), left over from the lunch meal, special orders of grilled cheese sandwiches and sweet potato fries. The Surveyor requested a temperature check of the fried fish. EI #2 pulled out several pieces of fried fish, then pulled out the entire pan of fish, discarding it all. EI #2 stated he would rather not check the temperature. EI #2 admitted the fried fish was left over from lunch line--which was why he immediately threw it away. At 5:12 PM ([DATE]), the Surveyor asked the Cook (EI #3) how many plates of fried fish she had served thus far. She stated she had served two plates of fish. At 5:21 PM ([DATE]) and again at 5:24 PM, the digital thermostat of the Hot Box registered 100 degrees F. On [DATE] at 08:51 AM, EI #2 was informed of the Surveyors observations made of substandard holding temperature in the Hot Box (being less than 135 degrees F), and asked what problems he might foresee with the low temperatures. EI #2 explained that temperature was not holding the food at level to prevent bacterial growth. 5) HANDWASHING The (YEAR) Food Code mandates under ,[DATE].14 When to Wash the following: FOOD EMPLOYEES shall clean their hands and exposed portions of their arms . immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS . On [DATE] at 4:45 PM, the Assistant Manager Manager (EI #5) began processing utensils through the dish machine. EI #5 was working alone, placing soiled items in the dish racks and sending each through the machine. After several racks had been processed, he then immediately removed the clean items from the racks (including trays), without first washing his hands. On [DATE] at 08:51 AM, the Surveyor questioned the CDM (EI #2) about the observed lack of handwashing in the dish room. EI #2 explained there was only one handwashing sink in the kitchen. EI #2 stated usually there was a staff member who only handled the clean dishes, and two people on the dirty side of the dish washing process. On [DATE] at 09:14 AM, the Surveyor questioned the Assistant Dietary Manager (EI #5) about his lack of handwashing between the handling of dirty then clean dishes. EI #5 agreed he had failed to wash his hands and apologized. 6) FROZEN FOOD The (YEAR) Food Code regulation ,[DATE].11 Frozen Food mandates Stored frozen FOODS shall be maintained frozen. On [DATE] at 5:45 PM, the Surveyor observed four of five individual size portions of ice cream in the chest freezer were semi-soft to applied pressure, rather than solidly frozen. On [DATE] at 6:05 PM, the Surveyor discussed the semi-soft condition of ice cream in the chest freezer at the front of the Dietary Department with the Administrator, EI #1. EI #1 explained the chest freezer was given to the facility by an outside source; he would get their refrigeration people to reset the temperature.

Based on observation, interviews, record review and review of a facility policy titled, Enteral Tube Feeding via Continuous Pump, with a revised date on (MONTH) (YEAR), the facility failed to ensure licensed staff applied a label, with required information, onto Resident Identifier (RI) #110 and RI #351's tube feeding bottles. This affected two of three residents observed for tube feedings on one of three days of the survey. Findings include: Review of a facility policy titled Enteral Tube Feeding via Continuous Pump, revised 3/2015, revealed the following: . Initiate Feeding . 5. On the formula label document initials, date, time the formula was hung/administered, and initial that the label was checked against the order . 1. RI #110 was admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. On 6/4/19 at 4:20 PM, the surveyor observered a Glucerna 1.2 Cal bottle hanging and connected to RI #110. There was no label noted on the bottle. 2. RI #351 was admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. On 6/4/19 at 4:25 PM, an observation was made of RI #351's tube feeding [MEDICATION NAME] 1.2 Cal running at 60 ml/flush 35 ml/hr. There was no label applied to tube feeding. On 06/05/19 at 5:30 PM, an interview was conducted with the Registered Nurse / Infection Control Nurse, Employee Identifier (EI) #6. The Surveyor informed EI #6 of the observations made of RI #351 and RI #110's tube feeding on 6/4/19 without a label on the bottles. The Surveyor asked EI #6 who was responsible for placing a label on a nutritional tube feeding. EI #6 replied the Charge Nurse. The Surveyor asked what could be the potential harm in hanging a gastric tube feeding and not labeling the proper information on the tube feedings. EI #6 said it served as another check for proper medication administration. 06/06/19 at 4:35 PM, a phone interview was conducted with Licensed Practical Nurse, EI #8. The Surveyor informed EI #8 of her observations made of formula bottles hung, without a label, for RI #110 and RI #351 on 6/4/19. The Surveyor asked EI #8 asked did she hang the feedings on EI #351 and EI #110 and not label the feedings. EI #8 said yes. She was asked why she did not write the resident information on the labels. EI #8 answered she did not have a marker on her and she had intended on going back to do it and did not. EI #8 was asked what was the potential harm in not labeling a feeding bottle. EI #8 said you should always do it, make sure it was the right resident. EI #8 was asked what was the facility policy on labeling tube feedings. EI # 8 said every time you change the feeding you should fill in the label with resident's name and information.

Based on observation and interview, the facility failed to ensure RL(Room Locator) #'s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12, did not have a toilet with exposed rusty bolts. This affected resident bathrooms on 4 of 9 halls of the facility. Findings include: On 06/04/2019, during the initial tour of the facility, the following was observed in resident bathrooms. RL 1 had a missing bolt cover on the left side rusted appearance uncapped. RL 2 had a missing bolt cover on the left and right side with rusted appearance uncapped. RL 3 had a rusted toilet bowl bolt with no caps on the right and left side. RL 4 had no toilet bowl bolt cover on right and left side. RL 5 had rusted toilet bowl bolts uncapped on the right and left side. RL 6 had rusted toilet bowl bolts with uncapped on the right and left side RL 7 had rusted toilet bowl bolts uncapped. RL 8 had rusted toilet bowl bolts that were uncapped. RL 9 had missing cover on right side and the bolt was rusty in appearance on the toilet. RL 10 had a missing cover on the right side of the toilet bolt that was rusty. RL 11 had a missing toilet bolt cover on left side which was rusty. RL 12 had a missing cover on the right side with a rusty appearance. On 06/06/19 04:09 PM, a tour and interview was conducted with EI (Employee Identifier) # 9, Maintenance Director. EI #9 was asked why were toilet bolts uncapped, rusty and exposed. EI #9 state that the reason was the cleaning crew knocks them off or somebody was knocking them off. EI #9 stated that maintenance replaces them a lot of times but they will not fit and they will come back off. EI #9 said that maintenance had a problem in getting the right size cover without buying a new toilet. EI #9 was asked what was the concern with uncapped rusty exposed toilet bolts. EI #9 stated they do not look good. EI #9 stated they could be a hazard, anything could be a potential hazard but he would not say it was a high hazard, it would be a low chance of being a hazard. EI #9 was asked what was the concern of exposed uncapped rusted toilet bolts. EI #9 stated that a scratch or cut might occur. Any toilet bolt will rust. Toilets sit on a wax ring and it pretty much will rust a bolt. EI #9 was asked why did he believe so many toilet bolts are uncapped. EI #9 stated they get knocked loose cleaning a lot of times but when they notice the will try to replace them. EI #9 was asked what was maintenance doing on a routine basis to ensure that the toilet bowl bolts are covered. EI #9 said they make rounds, it is not on their checklist, but he was going to add it.

Based on observation, interviews, medical record review, and a review of the facility's policies titled, Personal Protective Equipment - Gloves and Handwashing / Hand Hygiene, the facility failed to ensure nursing staff wash their hands: 1. after removing gloves; 2. before leaving the resident's room; 3. after cleaning stool from a resident's buttocks, and 4. touching clean items, such as a new container of perineal wipes and a clean brief, while providing incontinence care to Resident Identifier #137. This affect one of three observations of incontinence care. Findings Include: A review of the facility's policy titled, Personal Protective Equipment - Gloves, with a revised date of (MONTH) 2009, revealed: Policy Statement Gloves must be worn when handling blood, body fluids, secretions, excretions, mucous membranes and/or non-intact skin. Policy Interpretation and Implementation . 8. Wash your hands after removing gloves. A review of the facility's policy titled, Handwashing/Hand Hygiene, with a revised date of (MONTH) (YEAR) revealed: Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation . 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: . b. Before and after direct contact with residents; . g. Before handling clean or soiled soiled dressings, gauze pads, etc; h. Before moving from a contaminated body site to a clean body site during resident care; . m. After removing gloves; . RI #137 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 6/6/19 at 9:50 a.m. Employee Identifier EI #12, Certified Nursing Assistant (CNA) took her gloves off after touching the resident and left the room without washing her hands during incontinence care of RI #137. On 6/6/19 at 9:50 a.m. Employee #13, CNA, also removed her gloves and replaced them without washing her hands during incontinence care. EI #13 opened a new container of perineal wipes and touched the clean brief wearing the same gloves used to wipe stool from RI #137's buttocks. An interview was conducted on 6/6/19 11:03 a.m. with EI #12. She asked, what should have been done after removing her gloves and before leaving the room while doing incontinence care. EI #12 stated, Wash my hands. EI #12 asked did she do that. EI #12 stated, No ma'am. She was asked what was the potential for harm. EI #12 stated, Can cause a lot of bacteria and a lot of germs. An Interview was conducted on 6/6/19 11:07 a.m. with EI #13. EI #13 was asked, what should be done after removing your gloves. EI #13 stated, Wash my hands. EI #13 was asked, did she do that every time. EI #13 stated, No ma'am, I was extremely nervous. EI #13 was asked, what should be done after cleaning the buttocks and before touching clean items such as the brief, and before opening a clean container of perineal wipes. EI #13 stated, Wash my hands. EI #13 was asked, what was the potential for harm. EI #13 stated, Cross contamination.

Based on observation, interviews, and review of a facility policy titled Main Dining Room Meal Service Assistance, the facility failed to ensure Resident Identifier (RI) #84 did not have to wait for his/her supper meal on 6/19/18 while other residents at the tables were already dining. This affected one resident, seated at one of 12 tables, in the main dining room for the supper meal on 6/19/18. Findings include: A review of the facility policy titled Main Dining Room Meal Service Assistance, implemented 4/3/2017, revealed: . 4. Meal observation will reflect: 1. Meals provided to all residents at a table at the same time. On 6/19/18 at 5:00 PM, RI # 84 was observed sitting at a table with four other residents in the main dining room. RI # 84 received his/her supper tray 25 minutes after the other residents at the table had received their trays. RI #84 was observed to ask the dietitian about his/her tray. RI #84's tray was pulled from the food cart 25 minutes after the other residents at the table had received their trays and were almost finished eating their meals. On 6/19/18 at 6:15 PM, RI # 84 was asked how he/she felt when the other residents at the dining room table received their trays and he/she had to wait. RI # 84 stated it made him/her feel bad because everyone else was eating; RI #84 also said it made him/her mad. On 6/21/18 at 9:15 AM, the Dietitian, Employee Identifier (EI) #2, was interviewed. EI #2 said all residents seated at a table should be served before serving other residents (at other tables) and the residents should not have to wait. EI #2 was told about RI #84 having to wait 25 minutes to receive his/her tray and was asked if that was acceptable. EI#2 stated that it was not . On 6/21/18 at 9:25 AM, the District Manager Chef, EI #3, was interviewed. When asked why it was important for all residents at a table receive their trays around the same time, EI #3 stated the residents did not need to feel left out or have to watch other residents eat. EI #3 was told RI #84 had to wait 25 minutes for his/her tray after the other residents at the table had received their trays. EI #3 stated it was not acceptable.

Based on interview, record review, and review of the facility policy titled Use of Side Rails, the facility failed to ensure an individualized plan of care that addressed the use of top 1/4 (quarter) side rails was developed for Resident Identifier (RI) #66. The facility further failed to ensure a urinary catheter care plan was developed for RI #89. This affected two of 32 sampled residents whose care plans were reviewed. Findings include: 1) Review of an undated policy titled Use of Side Rails revealed the following: Policy: The facility must ensure that residents receive treatment and care in accordance with . the comprehensive person-centered care plan . Policy statement: .5. The resident's specific use of side rails will be addressed in the residents' care plan. RI #66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of RI #66's care plan for ADL (Activity of Daily Living) assistance/self care deficit related to dementia with a problem onset of 4/13/18 and a revision date of 6/18/18, revealed an approach for . SIDE RAIL . There was not any further description of, or instruction for use of the side rail. Review of RI #66's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date of 4/20/18 revealed moderately impaired cognitive skills for daily decision making and long and short term memory problems. RI #66's SIDE RAIL ASSESSMENT, completed 5/11/18, indicated RI #66 required both upper 1/4 (quarter) side rails on the bed due to weakness, balance deficit, and safety. The Director of Nursing (DON), Employee Identifier (EI) #1 was interviewed on 6/21/18 at 5:02 PM. EI #1 said RI #66 had 3/4 (three quarter) length side rails on his/her bed, but the care plan did not specify that. EI #1 said RI #66 should have had the top 1/4 rails on the bed. EI #12, Registered Nurse/Care Plan Coordinator, was interviewed on 6/21/18 at 6:52 PM. EI #12 was asked why RI #66's careplan should have been individualized for the use of side rails. EI #12 said it was important so that whoever read the plan of care would know what type of side rail was needed. 2) RI #89 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of RI #89's (MONTH) (YEAR) Treatment Administration Record (TAR) revealed an order dated 6/15/18 for an indwelling catheter for three days to monitor output. However, review of RI #89's comprehensive care plans revealed no care plan approaches addressing the order for the indwelling catheter. On 6/21/18 at 2:50 PM, EI #9, Licensed Practical Nurse (LPN), stated RI #89's order for the catheter was written on 06/15/2018. During a follow-up interview with EI #9 on 6/21/18 at 3:44 PM, EI #9 said she did not see a care plan addressing RI #89's catheter, but there should have been one.

Based on observations, record review, interviews, and review of the facility's policies titled . Infection Control and Standard Precautions, the facility failed to ensure Resident Identifier (RI) #31's catheter tubing and bag were not directly on the floor. Further, the facility failed to ensure Certified Nursing Assistants (CNAs) removed their gloves and washed their hands after providing catheter care to RI #76, before touching the tube feeding pump, placing a clean pad under the resident, and touching the resident's body. This affected two of four residents sampled for catheters. Findings include: A review of a facility policy titled . Infection Control, with a revised date of (MONTH) 2007, revealed: . Policy Statement This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary . environment . to help prevent and manage transmission of diseases and infections. 1) RI #31 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #31's most recent comprehensive Minimum Data Set (MDS) assessment, an annual assessment, with an Assessment Reference Date (ARD) of 12/22/17, documented RI #31 had severe cognitive impairment and had an indwelling catheter. On 6/18/18 at 4:29 PM, RI #31's catheter bag and catheter tubing were observed lying on the floor. On 6/20/18 at 11:45 AM, the surveyor and Employee Identifier (EI) #8, Certified Nursing Assistant (CNA), entered RI #31's room. RI #31's catheter bag was observed lying on the floor. The surveyor asked EI #8 if she was RI #31's CNA. EI #8 said yes. When asked why the catheter bag should not be lying on the floor, EI #8 said it could cause infection. The surveyor asked EI #8 who was responsible for ensuring the catheter bag was not on the floor. EI #8 said the CNAs and the nurses. On 6/21/18 at 10:55 AM, an interview was conducted with EI #5, Registered Nurse (RN)/Infection Control. The surveyor asked EI #5 what the CNAs were taught about the care of catheter bags and the tubing. EI #5 said they are taught the bag and tubing are never to be on the floor, and even if the catheter bags are in a privacy bag it is not to be on the floor. EI #5 said the catheter bag and tubing should not be on the floor because of the potential for contamination of the bag and tubing. 2) A review of the facility's policy titled Standard Precautions, revised (MONTH) 2007, revealed the following: Policy Statement Standard Precautions will be used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status. Standard Precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. . Standard precaution include the following the following practices: 1. Hand hygiene a. Hand hygiene refers to handwashing with soap . OR using alcohol-based hand rubs . b. Hands shall be washed with soap and water whenever visibly soiled with dirt, blood, or body fluids, or after direct or indirect contact with such . d. Wash hands after removing gloves (see below). 2. Gloves . g. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces . RI #76 was readmitted to the facility on [DATE]. A review of RI #76's Significant Change in Status Minimum Data Set (MDS) assessment, with an Assessment Reference Date of 4/27/18, documented RI #76 had severe cognitive impairment and had an indwelling catheter. On 6/19/18 at 3:30 PM Certified Nursing Assistants (CNAs). EI #s 6 and 7 were observed providing catheter care to RI #76. After providing the care, EI #6 placed a clean blue pad under the resident and touched the resident's hand, arm, and leg. EI #6 then removed her gloves, and without washing her hands, pulled the covers on the bed up over the resident, touched the feeding pump, and lowered the bed . On 6/21/18 at 3:38 PM, EI #1, the Director of Nursing (DON), was interviewed. When asked when CNAs should wash their hands when providing catheter care, EI #1 said when they enter the room and when gloves are removed. EI #1 said gloves should be changed as many times as needed, such as after completing an unclean task. EI #1 said if a CNA did not wash hands before placing a clean pad under a resident or touching the resident's body or covers, it could result in contamination.

Based on records reviewed, interviews and review of a facility policy and procedure titled Care Plans-Comprehensive, the facility failed to ensure that all care plans were reviewed/revised at least every quarter for RI (Resident Identifier) #s 2, 3, 7, 8 and 9. This affected five of twenty-two sampled residents whose care plans were reviewed. Findings include: A review of a facility Policy and Procedure, titled, Care Plans - Comprehensive with a revised date of 1/1/2017, revealed: Highlights Policy Statement An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Policy Interpretation and Implementation . Reviewing and Updating 9. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met; c. When the resident has been readmitted to the facility from a hospital stay; and d. At least quarterly. A review of RI (Resident Identifier) #2's medical record revealed, RI #2 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #2's most recent Significant Change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 5/27/2016 revealed the resident was severely cognitively impaired for daily decision making and required extensive to total assistance from staff for all ADLs (Activities of Daily Living). A review of RI #2's medical record revealed, a facility document, titled Care Plan. The care plan had twenty nine Problem/Need areas developed by the facility for RI #2. Twenty seven of the Problem/Need areas identify had not been reviewed/revised by the facility within the last quarter. A review of RI (Resident Identifier) #3's medical record revealed, RI #3 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #3's Annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 9/28/2016 revealed intact cognition with a BIMS (Brief Interview for Mental Status) score of 15. RI #3 required limited assistance with most ADLs (Activities of Daily Living). A review of RI #3's medical record revealed, a facility document, titled Care Plan. The care plan had 32 Problem/Need areas developed by the facility for RI #3. 24 of the Problem/Need areas identified had not been reviewed/revised by the facility within the last year. A review of RI (Resident Identifier) #7's medical record revealed, RI #7 was admitted to the facility on [DATE] and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #7's Annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/17/2016 revealed intact cognition with a BIMS (Brief Interview for Mental Status) score of 14. RI #7 required extensive assistance with most ADLs (Activities of Daily Living). A review of RI #7's medical record revealed, a facility document, titled Care Plan. The care plan had 31 Problem/Need areas developed by the facility for RI #7. 19 of the Problem/Need areas identified had not been reviewed/revised by the facility within the last quarter. A review of RI (Resident Identifier) #8's medical record revealed, RI #8 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #8's Annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 9/11/2016 revealed severely impaired cognition. RI #8 required total assistance with most ADLs (Activities of Daily Living). A review of RI #8's medical record revealed, a facility document, titled Care Plan. The care plan had 27 Problem/Need areas developed by the facility for RI #8. 16 of the Problem/Need areas identified had not been reviewed/revised by the facility within the last year and 17 within the last quarter. A review of RI #9's medical record revealed, RI #9 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #9's most recent Annual MDS with an ARD of 12/29/2016 revealed the resident was severely cognitively impaired for daily decision making. RI #9 required total assistance from staff for all ADL's. A review of RI #9's medical record revealed, a facility document, titled Care Plan. The facility had developed a care plan care plan for thirty nine Problem/Need areas for RI #9. Thirty five of the Problem/Need areas identified had not been reviewed/revised by the facility within the last quarter. An interview was conducted on 4/20/2017 at 1:50 p.m., with EI #1, the MDS Coordinator. EI #1 was asked to review the care plans for RI #'s 2, 3, 7, 8 and 9. EI #1 was asked what was documented on the care plans for these residents as the last review/revise date for the problem/need which was developed for each of the above residents. EI #1 replied not all were consistently updated every quarter. EI #1 also replied some go back five months and others go back further. EI #1 was asked how often care plans should be reviewed/revised. EI #1 replied every 90 days. EI #1 was asked why care plans should be reviewed and revised on an ongoing regular basis. EI #1 replied because any changes would be addressed in the care plan. EI #1 was asked why that was important. EI #1 replied it helps to identify any significant change and meet the specific needs of the residents. The minimum expectation is at least every 90 days. EI #1 was asked what the potential negative outcome can be for the resident by not reviewing/revising the care plans every 90 days. EI #1 replied they may not be meeting the needs of the resident. An interview was conducted on 4/20/2017 at 2:16 p.m., with EI #2, the Director of Nursing. EI #2 was asked to look at the care plans for RI #'s 2, 3, 7, 8 and 9. EI #2 was asked were all care plans for the above residents reviewed and revised at least quarterly. EI #2 replied no. EI #2 was asked what was the potential negative outcome for the resident by not reviewing/revising care plans at least quarterly. EI #2 replied the facility could overlook an unmet need of the resident.

Based on observation, interview and record review the facility failed to ensure EI (Employee Identifier) #5, a Certified Nursing Assistant (CNA), did not use soiled gloves while providing perineal care to Resident Identifier (RI) #17. EI #5 failed to washed her hands or use hand sanitizer after soiling her gloves and before putting on clean gloves during perineal care on 4/13/16. This affected one of three residents observed for perineal care. Findings Include: A review of an undated facility form titled Perineal Care with use of Perineal Wipes revealed .turn over to side and wipe anal area .Remove soiled brief or underpad . Remove gloves and perform hand hygiene . Apply clean gloves . RI #17 was readmitted to the facility 11/3/15 with [DIAGNOSES REDACTED]. RI #17's Care plan for History of Urinary Tract Infection dated, Problem Onset: 5/3/2013, listed the following approach, . Use good handwashing technique and universal precautions. On 4/13/16 at 4:25 PM Employee Identifier (EI) #5, was observed performing perineal care to RI # 17. EI #5 wiped the anal area with wipes and applied clean gloves without washing hands or using sanitizer before applying clean gloves. During an interview on 4/13/16 at 4:45 PM, EI #5, CNA, was asked if the facility's Perineal Care policy included washing your hands after removing soiled gloves during peri care and before changing gloves. EI #5 stated, Yes. EI #5 was asked if she washed her hands when she changed gloves. EI #5 stated, No. On 4/14/16 at 8:20 AM an interview was conducted with EI #1, Registered Nurse, Infection Control. EI #1 was asked what infections were currently being monitored. EI #1 replied Urinary Tract Infections. EI #1 was asked what was the procedure for providing perineal care. EI #1 replied, apply gloves, do the dirty, then change gloves, wash hands, apply new gloves then do the clean. EI #1 was asked when should gloves be changed when providing perineal care. EI #1 replied after performing the dirty, before you do the clean. EI #1 was asked if it would be an acceptable practice for the staff to touch clean items after cleaning bowel movement on the resident with the same gloves. EI #1 replied no. EI #1 was asked what the potential for harm was in touching clean items with soiled gloves. EI #1 replied the potential to spread or cause an infection.

Based on observation, interview and record review the facility failed to ensure a Certified Nursing Assistant (CNA) did not touch clean items with soiled gloves while providing perineal care for Resident Identifier (RI) #16. This was observed on 4/13/16 and affected one of three residents observed for perineal care. Findings Include: A review of an undated facility form titled Perineal Care with use of Perineal Wipes revealed .turn over to side and wipe anal area .Remove soiled brief or underpad .Remove gloves .Apply clean gloves Apply clean brief and/or underpad Perform hand hygiene Assist patient back into a comfortable position Perform safety measures .place call light . RI #16 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 4/13/16 at 9:00 AM Employee Identifier (EI) #2, a CNA was observed performing perineal care to RI #16. EI #2 cleaned bowel movement from RI #16 then touched the draw sheet to position the resident. EI #2 then touched RI #16 ' s top covers and pillow, EI #2 then placed RI #16 ' s call light within reach with the same gloves she provided perineal care. On 4/13/16 at 4:30 PM an interview was conducted with EI #2. EI #2 was asked how she was trained to do perineal care. EI #2 replied, wash hands, apply gloves then do the care, then when finished clean up and wash hands. EI #2 was asked when should she change gloves during the procedure. EI #2 replied all during it. EI #2 was asked if she changed gloves prior to touching clean items; she replied no. EI #2 was asked what the potential for harm was in touching clean items with soiled gloves. EI #2 replied it was contaminating. On 4/14/16 at 8:20 AM an interview was conducted with EI #1, a Registered Nurse, Infection Control. EI #1 was asked what infections were currently being monitored. EI #1 replied Urinary Tract Infections. EI #1 was asked what was the procedure for providing perineal care. EI #1 replied apply gloves, do the dirty, then change gloves, wash hands, apply new gloves then do the clean. EI #1 was asked when should gloves be changed when providing perineal care. EI #1 replied after performing the dirty, before you do the clean. EI #1 was asked if it would be an acceptable practice for the staff to touch clean items after cleaning bowel movement on the resident with the same gloves. EI #1 replied no. EI #1 was asked what the potential for harm was in touching clean items with soiled gloves. EI #1 replied the potential to spread or cause an infection.

Based on record review, interview and observation, the facility failed to ensure: 1. meatballs stored in the walk in freezer were properly stored and had a use by date. 2. the milk cooler did not have spilled milk pooled in the bottom and a foul order. 3. water was not pooling underneath and around the ice machine. This had the potential to effect 150 of 165 residents who receive meals from the kitchen. 4. the orange sherbert located in the ice cream freezer was not formed in a hard, formed consistency. Findings include: A review of the facility's policy titled: "Food Storage" with no date revealed: "...15. Frozen Foods: ...c. All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded..." 1. On 3/3/2015 at 1:40 PM, the surveyor observed meatballs not stored properly with no use by date. On 3/5/15 at 1:40 PM, an interview was conducted with (Employee Identifier) EI #12, Dietary Manager. EI #12 was asked what did she observe in the walk-in freezer on 3/3/2015 at 1:40 PM. EI #12 said meatballs were not labeled or wrapped properly. EI #12 was asked what was the policy on labeling and storage of frozen foods. EI #12 said foods should be labeled when they come in, when they are opened and when they should be thrown out. EI #12 was asked how often do you check frozen foods for proper storage and labeling and who is responsible for doing this. EI #12 said everyday and everyone. EI #12 was asked if it was an acceptable practice for this facility to have meatballs improperly stored and no discard date on the wrapping. EI #12 replied no. EI #12 was asked what was the potential harm for frozen foods not stored properly and not having a discard date. EI #12 said freezer burn and it could make residents sick. 2. On 3/3/2015 at 1:35 PM the surveyor observed spilled milk on the bottom of the milk cooler with a very strong odor. A review of the facility's policy titled, "CLEANING INSTRUCTIONS MILK COOLER" dated 9/04 revealed: "POLICY: Equipment shall be maintained in a clean and sanitary condition. PROCEDURE: Daily or as needed: Wipe away any milk from the inside of the dispenser with a cloth wet with sanitizing solution...." On 3/5/2015 at 4:10 PM, an interview was conducted with EI #12. EI #12 was asked on 3/3/2015 at 1:35 PM, what she saw and smelled regarding the milk cooler. EI #12 said soured milk, it smelled very loud. EI #12 was asked when was the last time the milk cooler had been cleaned. EI #12 answered she was not sure. EI #12 was asked who was responsible for cleaning the milk cooler. EI #12 said everyone. EI #12 was asked how often should the milk cooler be cleaned. EI #12 said once a week. EI #12 was asked if it was an acceptable practice for a substance to be pooled on the bottom of the milk cooler and have an odor. EI #12 replied no. EI #12 was asked what was the potential harm in the milk cooler not being free of spilled substances and having an odor. EI #12 replied everyone could get very sick. 3. On 3/3/2015 at 2:16 PM, the surveyor observed leaking water pooled underneath and around the ice machine this was also observed again on 3/4/2015 at 10:35 AM. A review of the facility's policy titled, "MAINTENANCE DEPARTMENT POLICIES" without a date revealed the following:"...4. Services to be Performed: Routine repair and maintenance services are to be performed in the following categories: ...Plumbing, drainage and sewage disposal...." On 3/5/2015 at 4:10 PM, an interview was conducted with the maintenance director EI #15. EI #15 was asked was he aware of a problem with the ice machine. EI #15 replied no. EI #15 was asked what did he observe underneath and around the ice machine. EI #15 said water. EI #15 was asked who was responsible for water pooling under the ice maker. EI #15 said it was the kitchen's responsibility to make maintenance aware of it, then it was maintenance's responsibility to fix it or call the ice machine company. EI #15 was asked if anyone made him aware of the pooling water. EI #15 replied no. EI #15 was asked was it an acceptable practice for this facility to have water pooling underneath and around the ice machine. EI #15 replied no. EI #15 was asked what was the potential harm in water pooling underneath and around the ice machine . EI #15 replied a slip hazard for the employees. 4. On 3/3/2015 at 1:25 PM, the surveyor observed orange sherbet in the ice cream freezer not formed in a hard frozen consistency. A review of the facility's policy titled, "Food Storage" with no date revealed: "...15...Frozen Foods...b...Periodically, check the firmness of foods in the freezer to assure temperatures are maintained to keep food frozen solid...." On 3/3/2015 at 4:10 PM, an interview was conducted with EI #12. EI #12 was asked what did she observe on 3/3/2015 at 1:25 PM, regarding the ice cream freezer. EI #12 said the sherbet was thawed out. EI #12 was asked what consistency should the orange sherbet have been. EI #12 replied a frozen hard consistency. EI #12 was asked who was responsible for making sure there was not any thawed sherbet in the ice cream freezer. EI #12 replied everyone. EI #12 was asked if it was an acceptable practice for this facility to have thawed sherbet in the ice cream freezer. EI #12 replied no. EI #12 was asked what was the potential harm in having thawed sherbet in the ice cream freezer. EI #12 replied the residents could become sick.

Based on observation and interview the facility failed to ensure the dumpster was not open on one side and was free of cardboard boxes overflowing from the top and a broken dumpster lid was not lying on the ground. The facility further failed to ensure debris was not on the ground surrounding the dumpster and two garbage cans were without lids, one with kitchen garbage in it and one filled with water and cigarette butts. This had the potential to effect all 165 residents who reside in the facility. Findings include: On 3/3/2015 2:00 PM, the surveyor observed the area surrounding the dumpster littered with empty milk cartons, empty ceramic cups, used latex gloves, drink tops, straws, egg shells, a used band-aid and aluminum foil. The surveyor observed an open dumpster with empty boxes over flowing from the top and a broken dumpster lid lying on the ground. Also, the surveyor observed two garbage cans without lids, one filled with water and cigarette butts and one filled with kitchen garbage. An interview was conducted with (Employee Identifier) EI #12, Dietary Manager on 3/5/2015 at 4:50 PM. EI #12 was asked who was responsible for making sure the dumpster is properly maintained and the padded area around it was clean. EI #12 replied all departments are responsible for letting maintenance know. EI #12 was asked what she observed on 3/3/2015 at 2:00 PM. EI #12 said band-aids, egg shells, there were cardboard boxes overflowing and the lid was broken and lying on the ground. There was also a garbage can filled with trash and uncovered. EI # 12 was asked was it an acceptable practice for the facility's dumpster area to be littered with debris, kitchen garbage, a broken dumpster lid and the dumpster overflowing. EI #12 replied no ma'am. EI #12 was asked what was the potential harm to have a broken dumpster lid laying on the ground, overflowing with trash and debris all over the padded and surrounding area. EI #12 replied resident's could get sick with diseases such as salmonella. EI #12 also said it looks bad, maggots, rats, raccoons and cats can also get in it. An interview was conducted with EI #15 Maintenance Director on 3/5/2015 at 5:00 PM. EI #15 was asked who was responsible for making sure the dumpster was properly maintained and the padded area around it. EI #15 replied he was not really clear on that. EI #15 was asked if he was aware of the dumpster lid being broken and the dumpster overflowing with card board boxes. EI #15 replied no ma'am. EI #15 was asked have any other departments called you about the dumpster needing to be emptied and area needing to be cleaned. EI #15 replied no.

Based on record review, observations and interviews, the facility failed to ensure: 1) a CNA (certified nursing assistant) washed her hands or changed her gloves after touching the soiled chux and brief and before touching the clean brief and chux during incontinent care of RI (resident identifier) #9 on 03/04/2015. 2) a CNA washed her hands or changed her gloves after cleaning bowel movement from RI #11 and before touching a clean pad and placing it between a resident's legs during incontinent care on 03/04/2015. 3) a CNA washed her hands or changed her gloves after cleaning urine from RI #1 and before touching a clean pad and placing it between the residents legs during incontinent care on 03/04/2015. 4) a licensed staff member washed her hands or changed her gloves after wiping saliva from RI #11's mouth, touching the area underneath the resident's bottom lip and before touching the resident's eyelid to administer an eye drop on 03/04/2015. The facility further failed to ensure this licensed staff member did not place an ungloved finger inside of a plastic crush packet, crush the medication and administer the medication to RI #19 on 03/04/2015. 5) a licensed staff member washed her hands before, in between or after the medication administration of UR (unsampled resident) #1 and UR #5 on 03/04/2015. The facility further failed to ensure this staff member did not wipe her hands with Sani-Wipe/Germicidal wipe and then administer medications to UR #1 and UR #5 on 03/04/2015. This effected 5 of 7 staff members observed during resident care. Findings Include: 1. RI #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #9's most recent Significant Change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/17/2014 revealed that RI #9 had a BIMS (Brief Interview for Mental Status) score of 4 which indicated the resident was severely impaired for daily decision making. The MDS also indicated RI #9 was always incontinent of bladder and bowel. The MDS also indicated RI #9 needed extensive assistance with all ADL'S (activities of daily living). A review of RI #9's care plan with a problem onset date of 07/22/2013 revealed: "Problem/Need RI #9 HAS A history of Urinary Tract Infections...Approaches ...*Use good handwashing technique and universal precautions..." A review of a facility policy titled, "Handwashing/Hand Hygiene" with a revised date of June 2010 revealed: "...Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections....r. After handling soiled or used linens, dressings, bedpans... u. After removing gloves... 8. The use of gloves does not replace handwashing/hand hygiene..." A review of a facility policy titled, "Standard Precautions" with a revised date of 08/2007 revealed:"...e. Change gloves, as necessary, during the care of a resident to prevent cross-contamination from one body site to another (when moving from a "dirty" site to a "clean"one)... g. Remove gloves promptly after use,before touching non-contaminated items and environmental surfaces, and before going to another resident and wash hands immediately to avoid transfer of microorganisms to other residents or environments..." On 03/04/2015 at 4:05 PM, EI (Employee Identifier) #9, CNA (Certified Nursing Assistant) was observed providing incontinent care for RI #9. EI #9 donned gloves and unfastened the brief. A large amount of stool was on the brief and the chux. Using a wipe EI #9 went from front to back down right and left side of labia and down the middle obtaining a clean wipe with each section. EI #9 changed her gloves and did not wash or sanitize her hands before donning clean gloves. EI #9 turned RI #9 to the right side and cleaned the buttock area wiping from front to back and obtained a new wipe with each wipe. EI #9 changed her gloves and did not wash or sanitize before donning clean gloves. EI #9 then turned RI #9 to the left and wiped front to back and obtained a new wipe with each wipe. EI #9 rolled the soiled brief and chux under the buttock area and placed the clean chux and brief under the soiled chux and brief. EI #9 removed the soiled items and removed her gloves. EI #9 did not wash or sanitize her hands and fastened clean brief. EI #9 donned clean gloves and placed soiled items into the bag. EI #9 removed her gloves and performed handwashing. On 03/04/2015 at 5:10 PM, an interview was conducted with EI #9. EI #9 was asked when going from a dirty area to a clean area what was supposed to be done. EI #9 said do not put a clean chux under a dirty chux and she did not wash her hands after changing her gloves. EI #9 was asked did she wash/sanitize her hands after changing her gloves after cleaning stool and before touching the clean brief and pad. EI #9 said no. EI #9 was asked what was the potential harm in not washing/sanitizing her hands after changing her gloves and when there was feces. EI #9 said spreading bacteria. On 03/05/2015 at 10:15 AM, an interview was conducted with EI #10, LPN Unit Manager. EI #10 was asked what was the policy and procedure for this facility on handwashing/gloving. EI #10 said after removing gloves, hands should be washed. EI #10 was asked what were staff taught to do after doing incontinent care where feces was present. EI #10 said remove gloves and wash their hands after removing their gloves. EI #10 was asked when going from a dirty area to a clean area what was supposed to be done. EI #10 said remove gloves and wash hands. EI #10 was asked what was the potential harm in not washing/sanitizing hands after changing gloves during incontinent care and when feces was present. EI #10 said contamination. 2. RI #11 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #11's most recent Quarterly MDS with an ARD of 02/20/2015 revealed the resident was severely cognitively impaired for daily decision making. The MDS also revealed the resident was totally dependent on staff for all ADLs. The MDS further revealed the resident was always incontinent of bowel and bladder. On 3/4/15 at 12:05 PM, EI #2, CNA was observed performing incontinent care for RI #11. RI #11 had a small incontinent (bm) bowel movement. EI #2 cleaned RI #11's buttocks, touched the clean pad, placed the pad underneath the resident and placed the pad between the resident's legs. EI #2 did not change her gloves or wash her hands before touching the clean pad. On 3/4/15 at 12:14 PM, an interview was conducted with EI #2. EI #2 was asked at what point during incontinent care should her hands be washed or her gloves be changed. EI #2 said after she finished the procedure. EI #2 was asked if she had washed her hands or changed her gloves after cleaning bm from RI #11 and before she touched the clean pad and placed it between the resident's legs. EI #2 said no. EI #2 was asked if she should have washed her hands or changed her gloves after she cleaned bm from RI #11 and before she touched the clean pad and placed it between the resident's legs. EI #2 said yes. EI #2 was asked what was the potential harm in not washing her hands or changing her gloves after she cleaned bm from RI #11 and before she touched the clean pad and placed it between the resident's legs. EI #2 said contamination. 3. RI #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's 14 day MDS with an ARD of 02/18/2015 revealed the resident had a BIMS score of 13, which indicated the resident was cognitively intact for daily decision making. The MDS also revealed the resident was totally dependent on staff for toilet use and personal hygiene. The MDS further revealed the resident was frequently incontinent of bowel and bladder. On 3/4/14 at 4:02 PM, EI #3, CNA was observed performing incontinent care for RI #1. RI #1 was incontinent of urine. EI #3 cleaned the resident's perineal area and buttocks. EI #3 touched the clean pad, placed it underneath the resident and pulled the pad up between the resident's legs. EI #3 did not wash her hands or change her gloves before touching the clean pad. On 3/4/15 at 4:14 PM, an interview was conducted with EI #3. EI #3 was asked when were her hands supposed to be washed or her gloves changed during incontinent care. EI #3 said before and after care. EI #3 was asked if she was supposed to wash her hands or change gloves after cleaning urine and then touching the clean pad and applying it to the resident. EI #3 said, " Yes I should have, but I didn't ." EI #3 was asked why she did not wash her hands or change her gloves after cleaning urine and before she touched the clean pad and applied it to the resident. EI #3 said, " Probably because ya'll were there and I was hot." EI #3 was asked what was the potential harm if she did not wash her hands or change her gloves after cleaning urine and touching a clean pad and placing it between the resident's legs. EI #3 said germs. 4. RI #11 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #11's most recent Quarterly MDS with an ARD of 02/20/2015 revealed the resident was severely cognitively impaired for daily decision making. The MDS also revealed the resident was totally dependent on staff for all ADLs. The MDS further revealed the resident was always incontinent of bowel and bladder. On 3/4/15 at 11:14 AM, EI #4, RN (Registered Nurse), was observed administering medication to RI #11. EI #4 donned gloves, wiped saliva from the resident's mouth, touched the resident' s face underneath the bottom lip and then touched the resident's right bottom eyelid without washing her hands or changing gloves in between each action. On 3/5/15 at 12:43 PM, an interview was conducted with EI #4. EI #4 was asked should she have washed her hands or changed her gloves when she wiped saliva from RI #11's mouth, touched the resident's face underneath the bottom lip and pulled the resident's bottom eyelid down and administered an eye drop. EI #4 said, "Yes, I should have. " EI #4 was asked if she washed her hands or changed her gloves when going from wiping saliva from the resident's mouth to touching the resident's face underneath the bottom lip to pulling the resident's bottom eyelid down to administer an eye drop. EI #4 said, " No, I don't believe I did. " EI #4 was asked why she did not wash her hands or change gloves after wiping saliva from RI #11's mouth then touching below the resident's bottom lip then administering an eye drop where the bottom eyelid was pulled down. EI #4 said, "Just a mistake; don't know if it was me being watched. It slipped my mind." EI #4 was asked what was the potential harm in not washing her hands or changing her gloves when going from wiping saliva from RI #11's mouth, touching below the resident's bottom lip then administering an eye drop where the bottom eyelid was pulled down. EI #4 said the spread of infections and germs basically. On 3/5/15 at 4:25 PM, an interview was conducted with EI #1, DON (Director of Nursing). EI #1 was asked if it was an acceptable practice of that facility for a nurse to wipe saliva from a resident's mouth, then touch the resident's face to pull the bottom lip down then pull the resident's bottom right eyelid down to administer an eye drop without changing gloves or washing hands. EI #1 said no. EI #1 was asked what was the potential harm if a nurse wiped saliva from a resident's mouth, touched the resident's face to pull the bottom lip down then pulled the resident's bottom right eyelid down to administer an eye drop without changing gloves or washing hands. EI #1 said cross contamination. RI #19 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #19's most recent Quarterly MDS with an ARD of 12/09/14 revealed the resident was severely cognitively impaired for daily decision making. The MDS also revealed the resident had a feeding tube. On 3/4/15 at 11:39 AM, EI #4 was observed preparing medications for RI #19. EI #4 placed her ungloved index finger inside of all five plastic crush packets, crushed the medication and administered the medication to the resident. On 3/5/15 at 12:46 PM, an interview was conducted with EI #4. EI #4 was asked how were the plastic packets that were used for crushing medication supposed to be opened. EI #4 said, "Without putting your finger inside." EI #4 was asked how she had opened the packets when preparing medications for RI #19. EI #4 said "With my finger inside." EI #4 was asked if it was an acceptable practice of that facility for her to place her ungloved finger inside of the plastic crush packet, crush the medication and then administer it to the resident. EI #4 said, "No, I should have used a spoon or something." EI #4 was asked what the potential harm was of placing her ungloved index finger inside of the plastic crush packet, crush the medication and then administer the medications to the resident. EI #4 said, "Spreading germs." On 3/5/15 at 4:26 PM, an interview was conducted with EI #1. EI #1 was asked if it was an acceptable practice of that facility for a nurse to place an ungloved finger inside of the plastic crush packet, crush the medications and then administer the medications to the resident. EI #1 said no. EI #1 was asked what was the potential harm if a nurse placed an ungloved finger inside of the plastic crush packet, crush the medications and then administer the medications to the resident. EI #1 said cross contamination. 5. UR #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of UR #1's most recent Quarterly MDS with an ARD of 12/08/14 revealed the resident was cognitively modified independent for daily decision making. The MDS also revealed the resident was totally dependent on staff for all ADLs . UR #5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of UR #5's most recent Quarterly MDS with an ARD of 01/16/2015 revealed the resident had a BIMS of 15, which indicated the resident was cognitively intact. A review of a facility document titled, " SUPER SANI-CLOTH GERMICIDAL DISPOSABLE WIPE " with no date revealed: " ...Use on hard, non-porous environmental surfaces ....GENERAL GUIDELINES FOR USE: ...1. ...Wear gloves when dispensing and using this product ....NOT FOR USE ON SKIN! ... " On 03/4/15 at 5:20 PM, EI #14 was observed preparing medication for UR #1 and UR #5. EI #14 prepared UR #1's medications first. She did not wash her hands before or after UR #1's medication administration. EI #14 then prepared UR #5's medication and did not wash her hands before or after UR #5's medication administration. EI #14 did wipe her hands with the Sani-Cloth germicidal disposable wipes after UR #1's medication administration and before UR #5's medication administration. On 3/5/15 at 1:20 PM, an interview was conducted with EI #14. EI #14 was asked if she washed her hands before, in between or after the administration of medication to UR #1 and UR #5. EI # 14 said, "No, I did not." EI #14 was asked why she did not wash her hands before, during or after the medication administration of UR #1 and UR #5. EI #14 said, "I thought that we could use sani-wipes. " EI #14 was asked if she wiped her hands with the sani-cloth germicidal wipe on 3/04/15 during the medication administration of UR #1 and UR #5. EI #14 said yes. EI #14 was asked why she wiped her hands with the sani-wipe. EI #14 said, " They (co-workers) say it's like alcohol wipes." EI #14 was asked what was the potential harm if she did not wash her hands before, in between or after medication administration. EI #14 said the spread of infection. EI #14 was asked what was the potential harm if she wiped her hands with the sani-wipe and then administered medications to a resident. EI #14 said, " The chemicals in that can be transferred to the patient. " On 3/5/15 at 4:15 PM, an interview was conducted with EI #1. EI #1 was asked if it was an acceptable practice of that facility for a nurse to give medication to two residents and not wash or sanitize her hands before, in between or after the medication administration. EI #1 said no. EI #1 was asked if it was an acceptable practice of that facility for a nurse to wipe her hands with the germicidal sani-wipes and then administer medications to residents. EI #1 said no. EI #1 was asked why was it not acceptable. EI #1 said, " That's not the intent of the germicidal sani-wipe. The purpose is for glucometer cleaning and sanitizing the work surface itself. We teach our nurses to use the hand sanitizer and wash their hands with soap and water." EI #1 was asked what was the potential harm if a nurse did not wash or sanitize her hands before, during or after medication pass. EI #1 said cross contamination. EI #1 was asked what was the potential harm if a nurse wiped her hands with germicidal sani-wipes and then administered medications to residents. EI #1 said possible cross contamination. On 3/5/15 at 4:30 PM, an interview was conducted with EI #11, Infection Control Nurse. EI #11 was asked how infections were prevented in the facility. EI #11 said by monitoring, training, hand washing and education. EI #11 was asked how infections were controlled in the facility. EI #11 said isolation precautions. EI #11 was asked if direct care staff were washing their hands and changing gloves according to facility protocol. EI #11 said yes. EI #11 was asked how direct care staff were monitored to ensure they were washing their hands and changing gloves according to facility protocol. EI #11 said by observation. EI #11 was asked if it was an acceptable practice of that facility for a CNA to clean bm or urine from a resident and then touch a clean pad before washing their hands and changing gloves. EI #11 said no. EI #11 was asked if it was an acceptable practice of that facility for a nurse not to wash her hands before, in between or after administering medication to residents. EI #11 said no. EI #11 was asked if it was an acceptable practice of that facility for a nurse to wipe saliva from a resident's mouth, touch the resident's face and administer eye drops without washing her hands or changing gloves. EI #11 said no. EI #11 was asked if it was an acceptable practice of that facility for a nurse to place an ungloved finger inside of a plastic medication packet, crush the medication and then administer it to the resident. EI #11 said no. EI #11 was asked what was the potential harm in each of the before mentioned situations. EI #11 said the spread of infection in each case.

Based on record review and interview, the facility failed to ensure residents received a receipt when requesting funds from petty cash. This affected 5 of 128 residents whose funds are managed by the facility. Findings include: On 3/4/2015 at 3:00 PM, a resident council meeting was held. There were sixteen residents present at the meeting. It was discovered during the resident council meeting that five residents did not receive a receipt when requesting funds from petty cash. All five residents stated that they signed for funds but did not get a receipt. EI #13 (employee identifier), Social Service Designee showed the surveyor two receipts in a receipt book that belonged to two residents. These two receipts were the original and carbon copies and were not given to the residents after requesting funds from petty cash. There were three residents whose original and carbon copy receipts were attached to their accounting sheet. On 3/5/2015 at 5:25 PM, an interview was conducted with EI #13. EI #13 was asked who was responsible for giving residents a receipt when requesting funds from petty cash. EI #13 replied myself. EI #13 was asked why residents were not given a receipt. EI #13 replied residents have not requested a receipt. EI #13 was asked when should residents be given a receipt. EI #13 replied when requested. EI #13 was asked if she gave residents a receipt. EI #13 replied no, not when they receive petty cash. EI #13 was asked what was the potential harm when residents were not given a receipt. EI #13 replied residents will not have a record of money received. EI #13 was asked should residents be given a receipt when requesting funds from petty cash. EI #13 said no. EI #13 was asked what was the facility's policy on giving residents a receipt when requesting funds from petty cash. EI #13 replied give the residents a receipt if they request one.

Based on record review, observation and interview, the facility failed to ensure a licensed staff member placed the privacy screen on the electronic MAR (Medication Administration Record) before leaving the medication cart and entering a resident's room and closing the door on 3/4/15. The facility further failed to ensure a licensed staff member closed the door or pulled the privacy curtain when administering eye drops to UR (Un-sampled Resident) #1 on 3/4/15 with the roommate present in the room. This affected 1 of 4 nurses observed during medication administration. Findings Include: A review of a facility document titled, "(NAME OF FACILITY) RESIDENT HANDBOOK" with an effective date of January 1, 2015 revealed: "Privacy You have the right to personal privacy in accommodations, medical treatment, ...personal care..." A review of a facility policy titled, "Instillation of Eye Drops" with a revised date of October 2010 revealed: "...General Guidelines 1. Allow the resident as much privacy as possible." UR #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of UR #1's most recent Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/08/14 revealed the resident was cognitively modified independent for daily decision making. The MDS also revealed the resident was totally dependent on staff for all ADLs (Activities of Daily Living). On 3/4/15 at 5:10 PM, EI (Employee Identifier) #14, LPN (Licensed Practical Nurse) was observed walking away from the medication cart and into a resident's room while leaving the electronic MAR indicated [REDACTED] On 3/5/15 at 12:55 PM, an interview was conducted with EI #14. EI #14 was asked during medication administration, what was she supposed to do before entering a resident's room. EI #14 said, "Knock on door, make sure cart is locked, protect resident's privacy by putting up privacy screen on computer, if any paperwork, I would turn it over." EI #14 was asked should she walk away from a medication cart and leave the electronic MAR indicated [REDACTED]. EI #1 said no. EI #14 was asked if she walked away from the cart to enter a resident's room and leave the electronic MAR indicated [REDACTED]. The surveyor advised EI #14 that the MAR indicated [REDACTED]. EI #14 was asked if it was an acceptable practice of that facility for a nurse to walk away from the medication cart and leave the electronic MAR indicated [REDACTED]. EI #14 was asked what was the potential harm if she walked away from the medication cart and left the electronic MAR indicated [REDACTED]." On 3/5/15 at 4:10 PM, an interview was conducted with EI #1, DON (Director of Nursing). EI #1 was asked if it was an acceptable practice of that facility for a nurse to walk away from the medication cart and leave the electronic MAR indicated [REDACTED]. EI #1 said no. EI #1 was asked what was the potential harm if a nurse walked away from the medication cart and left the electronic MAR indicated [REDACTED]. EI #1 said, "Privacy violation, secured healthcare information could be viewed by someone else." On 3/4/15 at 5:20 PM, EI #14 was observed during medication administration. EI #14 entered UR #1's room and administered eye drops to the resident with the door open, privacy curtain not pulled and the roommate was awake and present in the next bed. On 3/5/15 at 1:10 PM, an interview was conducted with EI #14. EI #14 was asked what she should do when administering medications in a semi-private room with the roommate present. EI #14 said pull the curtain. EI #14 was asked if she closed the door or pulled the privacy curtain when she administered eye drops to UR #1 on 3/4/15 with the roommate present in the room. EI #14 said no. EI #14 was asked should she have closed the door or pulled the privacy curtain when she administered eye drops to UR #1 on 3/4/15 with the roommate present in the room. EI #14 said yes. EI #14 was asked why she did not close the door or pull the privacy curtain when she administered eye drops to UR #1 on 3/4/15 with the roommate present in the room. EI #14 said, "I don't know, I just forgot." EI #14 was asked what was the potential harm in not closing the door or pulling the privacy curtain when she administered eye drops to UR #1 on 3/4/15 with the roommate present in the room. EI #14 said, "Violation of privacy." On 3/5/15 at 4:10 PM, an interview was conducted with EI #1. EI #1 was asked if it was an acceptable practice for that facility for a nurse to administer eye drops to a resident with the roommate present and not close the door or pull the privacy curtain. EI #1 said, "If the resident does not concur, it is not acceptable. The resident should be offered privacy." EI #1 was asked if the resident's privacy was violated. EI #1 said, "Technically, yes."