Every finding on record at Arlington Rehabilitation & Healthcare Center

Based on interviews, record review, and the facility's policy titled Behavior Management Program the facility failed to ensure staff implemented Resident Identifier (RI) #3's behavioral care plan approaches. RI #3 had care planned behaviors of being combative and resisting care with an approach to leave the resident alone and return later when the resident resisted care. On 03/31/2023 staff continued to provide care to RI #3 after staff observed the resident was agitated and the resident asked to be left alone. This deficient practice affected RI #3, one of 12 sampled residents whose plan of care was reviewed. Findings include: The facility's policy titled Behavior Management Program with most recent date of 02/2013 documented: .PURPOSE: To provide facilities with a standardized process for identifying, assessing, and managing residents who display mental or psychosocial adjustment difficulties. PROCESS: . II. Behavior Management Programs a) The plan of care should be developed by the interdisciplinary team. e) Formal Behavior Intervention/Modification program: . if a resident is determined to require a formal (BIMP), an individualized plan of care will be developed to address the identified behavior . the effectiveness of approaches will be reflected in the Social Services notes. Approaches for the identified behavior(s) will remain on the plan of care while effective . f) Evaluation of the program - . A resident who exhibits behavior symptoms which are easily altered, i.e. (for example), yelling, cursing . will be maintained with the identified approaches outlined in the plan of care . RI #3 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include Cerebral Palsy, Mixed Receptive-Expressive Language Disorder, Major Depressive Disorder and Cognitive Communication Deficit. RI #3's care plan included Problem/Need . Problem Onset: 04/28/2022 . Resident has combative/aggressive behaviors, including but not limited to cursing at staff, exhibiting child like behaviors by calling staff names, physical aggression towards staff . throwing items at staff and on the floor . resisting care . This care plan included Approaches . When resident is combative, verbally or resisting care, leave resident alone and return later . The Quarterly Minimum Data Set (MDS) assessment for RI #3, with an Assessment Reference date of 02/10/2023, indicated RI #3's Brief Interview for Mental Status was 12 of 15, indicating moderately impaired cognition. According to this MDS, RI #3 was noted to need extensive assistance with hygiene and was totally dependent on staff for bathing. A review of Departmental Notes for RI #3 revealed a Social Services Note dated 02/15/2023 which documented Quarterly Note: .Patient has periods of when she is combative or verbally abusive towards staff. Not a new or worsening behavior . Will review/update care plans as needed and will continue to follow plan of care . On 03/31/2023 the facility submitted an allegation to the Alabama Department of Public Health (ADPH) via the Online Incident Reporting System. The initial report documented (Certified Nursing Assistant (CNA) #4) was assisting another CNA with providing care to (RI #3). (RI #3) was agitated and aggressive and kicked (CNA #4) in the chest. (CNA #4) stayed in the room while care was provided. Review of the facility's investigative file revealed a written statement by Certified Nursing Assistant (CNA) #3, with an incident date of 03/31/2023 at 12:50 PM, and a statement date of 03/31/2023, documented the following: . Name: (CNA #3) . I went into the room to do care for (RI #3) . When I first walked into the room I noticed (RI #3) had a attitude so I asked what was bothering (him/her), to which (he/she) replied leave (him/her) alone, I continued care and (RI #3) was still very bothered and upset (he/she) began throwing things and cursing . I continued care and (RI #3) threw the wet bed pad at (CNA #4) . I then went to get (CNA #5) to help me calm down (RI #3) . The Assistant of Director of Nursing (ADON) signed this form on 03/31/2023, as the interviewer. Review of the facility's investigative file revealed a written statement given by CNA #3, with an incident date of 03/31/2023 and a statement date of 04/03/2023, documented the following: . Name: (CNA #3) . I was in the room with (CNA #4) who was orienting with me. We were trying to provide care to (RI #3) . (RI #3) was agitated and aggressive . (he/she) just kept kicking the entire time .What made (RI #3) to become agitated? . when we first walked in (he/she) was already irritated. What all care did you provide to (RI #3)? . I gave a partial bed bath. I cleaned (his/her) upper body, (his/her) lower body, private area, changed (his/her) pad and clothes. I couldn't do a full bath because (he/she) was refusing and not being cooperative. (He/She) wouldn't follow commands . The former DON signed this form on 04/04/2023, as the Interviewer. Review of the facility's investigative file revealed a written statement given by CNA #4, with an incident date of 03/31/2023 and a statement date of 04/03/2023, documented the following: . Name: (CNA #4) . Why was (RI #3) so upset . when we were trying to get (him/her) cleaned up (he/she) kept fussing and calling us out of our names. When (CNA #3) was cleaning (him/her) (he/she) kept kicking . This was a telephone interview conducted by the former Director of Nursing (DON) on 04/03/2023. Review of the facility's investigative file revealed a written statement by CNA #5, with an incident date of 03/31/2023 and a statement date of 04/03/2023, documented the following: . Name: (CNA #5) . I was asked to come into the room by (CNA #3) to help calm (RI #3) down . (CNA #3) asked me to come in to help because (RI #3) was kicking and agitated . (He/She) was very irritated . When you went in (RI #3's) room to help calm (him/her) down was (name of RI #3) still having behaviors? . Yes, I am normally able to calm (him/her) down but (he/she) was throwing all of (his/her) teddy bears on the floor . they were trying to give (him/her) a bath . (CNA #3) was giving a bath . normally (he/she) would calm down and stop acting up, but this time (he/she) was acting worse than normal. (He/She) just wouldn't calm down . The former DON signed this form on 04/04/2023, as the Interviewer. On 02/21/2024 at 9:57 AM, an interview was conducted with CNA #5. The CNA said on 03/31/2023, CNA #3 asked her to assist with RI #3 and try to get RI #3 to calm down so she (CNA #3) could bathe RI #3. CNA #5 said when she walked into RI #3's room RI #3 was mad and yelling, cursing at staff and throwing his/her stuffed animals on the floor. CNA #5 said she asked RI #3 to let CNA #3 clean him/her up before his/her sponsor came to visit and left the room to assist another resident with bathing. On 02/22/2024 at 8:57 AM, the surveyor conducted a telephone interview with the former DON. The former DON said RI #3 had childlike behaviors and got frustrated easily. The former DON said RI #3's care plan directed staff to give RI #3 some time alone and to not try to provide care when RI #3 was agitated. The former DON said when RI #3 began to exhibit behaviors on 03/31/2023, staff should have allowed RI #3 to calm down then reapproached RI #3. On 02/22/2024 at 5:50 PM, the surveyor conducted an interview with the ADON. The ADON said CNA #3 and CNA #4 should not have provided care for RI #3 after RI #3 asked to be left alone. On 02/22/2024 at 5:56 PM, a telephone interview was conducted with RI #3's sponsor. RI #3's sponsor said he participated in RI #3's care plan meetings, and he agreed with the intervention to leave RI #3 alone when he/she was agitated. This deficiency was cited as a result of the investigation of complaint/report #AL00043773.

Based on interview, record review and review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to accurately code the resident's status on the completed Minimum Data Set (MDS) Assessment for three (3) residents (Resident #21, #25 and #94) out of 21 sampled residents. The findings include: Interview with the Director of Nursing (DON), on 4/1/21 at 3:00 p.m. revealed the facility did not have a policy to ensure MDS assessments were accurately coded. Review of the CMS RAI 3.0 User's Manual, Version 1.17.1, dated October 2019, Chapter 3, revealed under Section O Special Treatments, Procedures, and Programs, for item O0100C oxygen therapy code continuous or intermittent oxygen administered via mask, cannula, etc., delivered to a resident to relieve [MEDICAL CONDITION] in this item. For item O0100K Hospice care code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the palliation and management of terminal illness and related conditions. 1. Review of the medical record for Resident #21 revealed he/she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. An additional [DIAGNOSES REDACTED]. Review of the discontinued physician's orders [REDACTED]. Review of the current physician's orders [REDACTED]. Review of the Nurse's Progress Note for Resident #21, dated 12/28/2020, revealed Resident #21 had an oxygen saturation level of 94% on two (2) LPM of oxygen via nasal cannula. Review of the Nurse's Progress Note for Resident #21, dated 10/11/2020 as a late entry for 10/9/2020, noted use of oxygen per nasal cannula. Review of Resident #21's Quarterly MDS assessment dated [DATE] did not identify the use of oxygen therapy under Section O Special Treatment, Procedures, and Programs. Additionally, review of the Annual MDS assessment for Resident #21, dated 10/20/2020 did not identify the use of oxygen therapy under Section O Special Treatment, Procedures, and Programs. Interview with the MDS Coordinator, (Registered Nurse (RN) #3) on 4/1/21 at 1:30 p.m., revealed the documentation for the use of oxygen was overlooked and should have been coded on the MDS to reflect the use of oxygen by Resident #21. 2. Review of the medical record for Resident #25 revealed he/she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the current physician's orders [REDACTED]. Review of the Annual MDS assessment for Resident #25, dated 8/7/2020, did not identify the use of oxygen therapy under Section O Special Treatment, Procedures, and Programs. Additionally, review of Resident #25's Quarterly MDS assessment dated [DATE] did not identify the use of oxygen therapy under Section O Special Treatment, Procedures, and Programs. Review of the Medication Administration Record [REDACTED]. However, the MDS assessments completed on 8/7/2020 and 1/19/21 wasn't coded accurately for oxygen use. Interview with the MDS Coordinator (RN #3) on 4/1/21 at 1:30 p.m., revealed the documentation for the use of oxygen was overlooked and should have been coded on the MDS to reflect the use of oxygen by Resident #25. 3. Review of the medical record for Resident #94 revealed he/she was admitted to the facility on [DATE]. He/She was admitted to Hospice services on 3/4/21. [DIAGNOSES REDACTED]. Review of the medical record for Resident #94 revealed a written certification from the physician, for the period of 3/4/21 through 6/1/21, that he/she was terminally ill with a life expectancy of six (6) months or less if the terminal illness ran it's normal course. Review of the Significant Change MDS assessment, dated 3/10/21, revealed the assessment wasn't coded to reflect that Resident #94 had a condition that may result in a life expectancy of less than six (6) months. Interview with the MDS Coordinator (RN #3) on 4/1/21 at 1:30 p.m., confirmed the MDS did not reflect the life expectancy of less than six (6) months for Resident #94 as written by the physician on 3/4/21. He/She stated the statement of terminal illness from the physician was overlooked and should have been coded on the MDS.

Based on interview, record review and facility policy review, the facility failed to accurately document the code status of two (2) out of 24 sampled residents (Resident #17 and #94). The facility failed to properly transcribe the correct code status of Resident #17 and #94 to the Physician's Order. The findings include: Review of the facility's policy titled, Advance Directive and Refusal of Treatment, dated ,[DATE], revealed the policy did not address the use of the Physician's Order for Life Sustaining Treatment (POLST) as the POLST is not considered an Advance Directive by definition of an Advance Directive. 1. Review of the Face Sheet for Resident #17 revealed admission into the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment for Resident #17 dated [DATE] indicated admission from an acute hospital. The resident was admitted in a persistent vegetative state with no discernable consciousness. The resident was totally dependent on staff for all activities of daily living (ADLs). Review of the Physician's Orders dated [DATE] through [DATE] for Resident #17 revealed an order for [REDACTED]. Review of the Alabama Portable Physician Do Not Attempt Resuscitation Order No CPR/Allow Natural Death form dated [DATE] revealed that Resident #17 was not to be resuscitated. The form was signed by the Medical Doctor and surrogate. Observation on [DATE] at 12:15 p.m., revealed a small red round sticker located on outside of Resident #17's paper chart. Review of the Care Plan for Resident #17, dated [DATE], revealed Do Not Resuscitate (DNR) family and resident's wish for DNR will be honored and respected. Honor and respect family and resident's wishes for DNR, ensure DNR order is on the chart, provide spiritual support as needed, and Social Services to consult as needed. Interview with Registered Nurse (RN) #6 on [DATE] at 12:10 p.m. revealed that he/she was certain Resident #17 was not to be resuscitated as indicated by the red sticker on his/her chart. Interview with RN #5 on [DATE] at 12:15 p.m. revealed that there should be a red sticker on the front of the resident's chart to indicate that he/she is a do not resuscitate (DNR). RN #5 stated that he/she was certain Resident #17 was not to be resuscitated. Interview with the Director of Nursing (DON) on [DATE] at 12:25 p.m. revealed that Resident #17 is not to be resuscitated. The DON stated that there was a discrepancy between the Physician's Orders and the DNR choice of the resident's family. The DON stated that he/she would clarify the Physician's Order now. 2. Review of the medical record for Resident #94 revealed he/she was admitted to the facility on [DATE]. He/she was admitted to Hospice services on [DATE]. [DIAGNOSES REDACTED]. Review of the medical record for Resident #94 revealed a form titled, Resident's Rights and Advance Directive Acknowledgement was signed by Resident #94 on [DATE]. Review of the form titled, Appendix II, Alabama Portable Physician Do Not Attempt Resuscitation Order, No CPR (Cardiopulmonary Resuscitation)/Allow Natural Death revealed the form was signed by Resident #94's health care proxy on [DATE] when Resident #94 was admitted to Hospice services. This form was signed by the physician on [DATE]. Review of the Monthly Physician's Orders for the month of [DATE] were signed by the physician on [DATE]. These monthly physician's orders contained an order for [REDACTED]. Review of the Care Plan for Resident #94 revealed an identified problem of Do Not Resuscitate (DNR). A goal to honor wishes of the resident and family was documented. Interventions included: Honor and respect the family and resident's wishes for DNR; Ensure the DNR order is on chart; Provide spiritual support as needed; and Social Services to consult as needed. On [DATE] at 10:30 a.m. during an interview with Licensed Practical Nurse (LPN) #1, he/she stated Resident #94 had a code status of DNR. LPN #1 verified the statement by confirming the order was signed by the health care proxy on [DATE] and the physician on [DATE]. When questioned regarding the [DATE] monthly Physician's Orders, he/she stated this was in conflict with the DNR form and would need clarification. On [DATE] at 10:45 a.m. during an interview with the DON, he/she confirmed the DNR form and the March monthly Physician's Orders did not match. He/she stated clarification from the physician would need to be obtained and he/she would clarify the discrepancy immediately.

Based on observations, interviews, review of signage posted on room doors of Resident Identifier (RI) #1 though RI #5 and RI #7, review of the facility's policy titled, Novel Coronavirus Prevention and Response, and a Centers for Disease Control and Prevention (CDC) article titled Preparing for COVID-19 in Nursing Homes, the facility failed to ensure Employee Identifier (EI) #5, a Certified Nursing Assistant (CNA), wore gloves, a face shield and changed gowns between residents and upon re-entering residents' rooms while delivering meal trays to RI #1 through RI #5 on the first floor Quarantine Unit. The facility further failed to ensure EI #5, a CNA, wore a face shield while assisting RI #7 during mealtime on the COVID Isolation Unit. These failures affected RI #1 through RI #5, five of five residents observed during mealtime on the first floor Quarantine Unit and RI #7, one of nine residents on the first floor COVID Isolation Unit. Findings include: The facility's policy titled Novel Coronavirus Prevention and Response, effective 3/29/2020 and revised 8/2020, documented . 5. Procedure when COVID-19 is suspected . f. Implement standard, contact, and airborne precautions (droplet precautions if no airborne isolation room available). Wear gown, gloves, goggles/faceshield, and masks (respirators, including N95 masks) upon entering room and when caring for the resident . Review of the CDC's article titled Preparing for COVID-19 in Nursing Homes . , updated 6/25/2020, documented . Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown. Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP (Health Care Personnel) should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission . Residents with known or suspected COVID-19 should be cared for using all recommended PPE, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown. Cloth face coverings are not considered PPE and should not be worn when PPE is indicated . On 8/24/2020 beginning at 2:00 PM, a tour of the facility was conducted with EI #3, the Regional Corporate Nurse, also serving as the Interim Director of Nursing (DON) and Infection Preventionist. On the first floor was the facility's Quarantine Unit, that consisted of four rooms occupied by RI #1, RI #2, RI #3, RI #4 and RI #5. According to EI #3, residents are placed on the Quarantine Unit for 14 days following admission/readmission to the facility. There was signage posted on each door where RI #1 through RI #5 resided, that read: QUARANTINE ROOM PPE REQUIRED: Disposable Gown Gloves Disposable Surgical Mask over N95 Mask Face Shield (Sanitize Between Residents) CHANGE PPE BETWEEN RESIDENTS AND UPON REENTERING ROOMS On 8/24/2020 beginning at 5:03 PM, EI #5, a CNA, observed wearing a N95 mask and a gown, delivered a dinner meal tray to RI #3. EI #5 did not wear gloves or a face shield. EI #5 did not sanitize her hands or change her gown before she picked up the meal tray for RI #1. EI #5 delivered RI #1's meal tray. EI #5 did not sanitizer her hands or change her gown before she picked up the meal tray for RI #2. EI #5 delivered RI #2's meal tray. EI #5 did not sanitize her hand or change her gown when she delivered to the dinner meal tray to RI #4 and RI #5. There were isolation carts located at the doorway to each room stocked with gloves, blue disposable gowns, vinegar bags, trash bags and red biohazard bags. Hand sanitizer was located on top of each isolation cart, located at the doorway to each room. At 5:10 PM, EI #5 was asked if she was aware that changing gowns between residents was a requirement, per facility policy, for residents on the Quarantine Unit. EI #5 stated, I don't have to change gowns for these rooms. When the signage on each door was brought to EI #5's attention, EI #5 stated she was not sure and confused. On 8/24/2020 at 5:40 PM, the surveyor and EI #3, the Interim DON and Infection Preventionist, entered the facility's COVID Isolation Unit during dinner time. At 5:42 PM, EI #5, a CNA was observed in RI #7's room. EI #5 was seated at the resident's bedside assisting RI #7 with his/her meal. EI #5 was not wearing a face shield. As EI #3, was leaving the COVID Isolation Unit she was asked if the CNA, EI #5, was wearing the appropriate PPE while in RI #7's room. According to EI #3, EI #5 was not wearing a face shield and she should have been. The signage posted on RI #7's door read: ISOLATION ROOM DROPLET PRECAUTIONS PPE REQUIRED: Gown (Cloth or Disposable) Surgical Mask over N95 Mask Face Shield Gloves PPE (EXCEPT GLOVES) CAN BE WORN BETWEEN RESIDENTS In an interview on 8/25/2020 at 3:30 PM, EI #5, a CNA acknowledged she did not change gowns between residents, wear a face shield or gloves while delivering meal trays during dinner service. EI #5 also acknowledged that she didn't wear a face shield when she assisted RI #7's with his/her meal. According to EI #5, she had not read through the signs posted on the residents' room doors. During an interview on 8/26/2020 at 11:00 AM, EI #3, the Interim DON and Infection Preventionist, said if staff were not using the correct PPE for the COVID and Quarantine Units and not donning (putting on) and doffing (taking off) PPE properly, it could increase the spread of COVID.

Based on observation, interview, record review and review of a facility policy titled, Resident Privacy, the facility failed to ensure Resident Identifier (RI) #147's Foley catheter bag was in a privacy bag and not visible from the hallway on 03/21/19. This deficient practice affected RI #147, one of two residents sampled with a Foley catheter. Findings Include: A facility policy titled, Resident Privacy, dated 12/04, revealed the following: It is the policy of Ball HealthCare Services, Inc. (BHS) . that all residents have the right to personal privacy, including privacy in . medical treatment . RI #147 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 03/21/19 at 9:11 a.m., the surveyor observed RI #147's Foley catheter bag did not have a covering and could be seen from the hallway. RI #147's roommate was observed coming from the bathroom, passing the side of the bed where RI #147's Foley catheter could be observed. Staff was observed in the hallway walking past RI #147's room. On 03/21/19 at 9:26 a.m., the surveyor conducted an interview with Employee Identifier (EI) #3, the Licensed Practical Nurse (LPN) assigned to care for RI #147 on the 7 AM - 3 PM shift. The surveyor asked EI #3 could RI #147's Foley catheter bag be seen from the hallway. EI #3 said yes. The surveyor asked EI #3 how the Foley catheter bags were normally kept. EI #3 said the facility had Foley catheter bags with the built in covering. The surveyor asked EI #3 what type of concern/issue was it when a Foley catheter bag did not have a covering and could be seen from the hallway. EI #3 said dignity.

Based on observations, interview and record review, the facility failed to ensure Resident Identifier (RI) #146 had a Physician's order for the use of [REDACTED]. This deficient practice affected RI #146, one of 37 sampled residents whose Physician Orders were reviewed. Findings Include: RI #146 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. RI #146's Problem/Need care plan titled, (RI #1) is at risk for difficulty breathing related to HX (history) of Pneumonia and [DIAGNOSES REDACTED]. . * O2 (Oxygen) per NC (Nasal Cannula) as ordered *Suction as ordered . A review of RI #146's (MONTH) 2019 Physicians Orders revealed RI #146 did not have an order for [REDACTED].>A review of RI #146's Departmental Notes revealed the following: 3/7/2019 8:04 PM . 5:50 p.m. Resident requires suctioning, RT (Respiratory Therapy) in for setup . O2 at 2L (liters)/min (minute) via NC . 3/7/2019 8:28 PM . 8:00 p.m., RT called to set up suction in resident's room . Resident will need oral care along with suctioning prn (as needed) . 3/8/2019 3:21 PM . Suction provided . 3/11/2109 4:20 AM . O2 @ (at) 2L . On 03/19/19 at 2:27 p.m., the surveyor observed RI #146 utilizing O2 at 2 liters per minute via NC. A suction machine was observed on top of the dresser with a scant amount of secretions in the canister. On 03/20/19 at 9:23 a.m., the surveyor observed the suction machine to remain in RI #146's room and RI #146's O2 remained at 2 liters via NC. On 03/21/19 at 7:41 a.m., the suction machine was again observed in RI #146's room and RI #146 continued to utilize the O2 which was infusing at 2 liters per minute via NC. On 03/21/19 at 8:36 a.m., the surveyor conducted an interview with Employee Identifier (EI) #4, the Assistant Director of Nursing (ADON). EI #4 said RI #146 had been a resident at the facility since 3/07/19. EI #4 said she did not see where RI #146 was admitted on O2. The surveyor asked EI #4, looking at the Physicians Order, did she see an order for [REDACTED].#4 should there be an order for [REDACTED].#146 have an order for [REDACTED].#4 said yes.

Based on observations, interview and record review, the facility failed to ensure Resident Identifier (RI) #146's suction machine and [MEDICATION NAME] (oral suctioning tool) were covered while not in use on three of four days of the survey. This deficient practice affected RI #146, one of three residents sampled requiring suctioning. Findings Include: RI #146 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. On 03/19/19 at 2:27 p.m., the surveyor observed a suction machine on top of RI #146's dresser. A [MEDICATION NAME], which was connected to the suction machine was observed to be lying on the inside of the dresser drawer. Neither the suction machine nor [MEDICATION NAME] were in a covering. On 03/20/19 at 9:23 a.m., RI #146's suction machine and [MEDICATION NAME], which remained on the insider of the dresser drawer, remained uncovered. 03/20/19 at 3:42 p.m., RI #146's suction machine and [MEDICATION NAME] remained uncovered. On 03/21/19 at 7:41 a.m., RI #146's suction machine and [MEDICATION NAME], which remained on the inside of the dresser drawer, both remained uncovered. On 03/21/19 at 8:36 a.m., the surveyor conducted an interview with Employee Identifier (EI) #4, the Assistant Director of Nursing (ADON)/Infection Control Nurse. The surveyor asked EI #4 how should the suction machine be stored when not in use. EI #4 said they should be cleaned and a bag placed over them. The surveyor asked how should the [MEDICATION NAME] be stored. EI #4 said it should be in a bag also. When asked when not stored this way, what was that a potential for, EI #4 said infection.

Based on observation, interview, the 2013 Food Code, and the facility's policy on Waste Disposal, the facility failed to ensure the area around the outside oil refuse receptacle was free from food related garbage and trash, so as to discourage attracting vermin. This had the potential to affect all residents in the facility, 109 of 109 residents. Findings Include: 2013 Food Code by the United States Public Health Service and Food and Drug Administration documented the following: . 5-501.15 Outside Receptacles. (B) Receptacles and waste handling units for REFUSE . shall be installed so that accumulation of debris and insect and rodent attraction and harborage are minimized and effective cleaning is facilitated around and . under the unit. 5-501.115 Maintaining Refuse Areas and Enclosures. A storage area . for REFUSE . shall be maintained free of unnecessary items, as specified under . 6-501.114, and clean. 6-501.114 Maintaining Premises, Unnecessary Items and Litter. The PREMISES shall be free of: . (B) Litter. The facility's policy and procedure for Waste Disposal, last revised on 9/2014, included the following: . Policy: Garbage and trash are removed . to prevent . pests . Procedure: . 4. Outside storage areas are: . d. Kept clean of garbage and debris. On 3/13/18 at 2:31 PM, the outside dumpster area was observed with Employee Identifier (EI) #1, the Dietary Manager. At the base of the oil refuse receptacle the following debris was observed: one chicken bone, one plastic glove, one plastic spoon, one straw, one ice cream lid and six Q-tips. On 3/13/18 at 2:32 PM, EI #1 was asked what would be the problem with the items observed around the base of the oil refuse container. EI #1 replied it could attract rodents.

Based on observation, interview, medical record review and review of a facility policy titled, Resident Privacy, the facility failed to ensure licensed staff provided privacy during suctioning and [MEDICAL CONDITION] care for Resident Identifier (RI) #89. This deficient practice affected RI #89, one of one resident observed during [MEDICAL CONDITION] care. Findings Include: A review of a facility policy titled, Resident Privacy, revealed: It is the policy .that all residents have the right to personal privacy, including privacy in accommodations, medical treatment . RI #89 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 03/15/18 at 10:45 a.m., Employee Identifier (EI) #2, a Respiratory Therapist, was observed suctioning and providing [MEDICAL CONDITION] care for RI #89. The privacy curtain was not pulled and the door remained open during RI #89's medical treatment. On 03/15/18 at 2:11 p.m., an interview was conducted with EI #2. EI #2 was asked if the privacy curtain was pulled during RI #89's suctioning and [MEDICAL CONDITION] care. EI #2 said no. EI #2 was asked if RI #89's door was closed. EI #2 said no. EI #2 was asked should a resident be provided privacy during suctioning and [MEDICAL CONDITION] care. EI #2 answered yes, all the time. EI #2 was asked did he provide RI #89 privacy while he was suctioning and providing [MEDICAL CONDITION] care. EI #2 said no, he did not.

Based on interview, medical record review, and review of facility documents titled, ADMINISTRATIVE POLICY, the facility failed to ensure a care plan was developed for the use of a psychoactive medication for Resident Identifier (RI) #16. This deficient practice affected one of 28 residents reviewed for care plans. Findings Include: A review of a facility document titled, ADMINISTRATIVE POLICY with a revised date of 09/2009, revealed: SUBJECT: Care Plans PURPOSE: Plans of Care are developed . to coordinate and communicate the plan of care for the resident. A review of a facility document titled, ADMINISTRATIVE POLICY with a revised date of 02/2013, revealed: SUBJECT: Psychoactive Medications . PR[NAME]ESS: I. Unnecessary Drugs . (f)Nursing service, social service and other members of the interdisciplinary team will address behavior symptoms . in the plan of care . According to record review, RI #16 was readmitted on [DATE] with the [DIAGNOSES REDACTED]. On 3/15/2018 at 2:58 p.m., a review of the (MONTH) (YEAR) Physician order [REDACTED]. [MEDICATION NAME] 5 mg (MILLIGRAMS) TABLET GIVE ONE TABLET BY MOUTH AT BEDTIME (DX (DIAGNOSIS): DISTURBED BEHAVIORS) . On 3/15/2018 at 3:13 p.m., a review of RI #16's current care plan revealed no care plan addressing a psychoactive medication. On 3/15/2018 at 4:55 p.m., an interview was conducted with Employee Identifier (EI) #6, Minimum Data Set (MDS) Coordinator. EI #6 was asked, while RI #16 was a resident in the facility, was RI #16 on a [MEDICAL CONDITION] medication. EI #6 stated the care plan did not show the resident was on a [MEDICAL CONDITION] medication, but according to the Electronic Medication Administration Record [REDACTED]. EI #6 was asked what kind of drug [MEDICATION NAME] was. EI #6 replied it was a [MEDICAL CONDITION] medication. EI #6 was asked if RI #16 was care planned for the [MEDICAL CONDITION] medication. EI #6 stated no. EI #6 was asked why should RI #16 be care planned for the [MEDICAL CONDITION] medication. EI #6 answered to give better care. EI #6 was asked why RI #6 was not care planned for the [MEDICAL CONDITION] medication. EI #6 replied it was just overlooked.

Based on observation, interview, medical record review, review of a facility policy titled, Oral and Nasal Inhalation Administration and Fundamentals of Nursing the facility failed to ensure: 1.) a Licensed Nurse remained with Resident Identifier (RI) #53 during administration of a nebulizer treatment, and 2.) Licensed Nurses followed physician's orders [REDACTED].#3 and RI #25. These deficient practices affected RI #53, RI #3 and RI #25, three of eight residents and three of seven nurses observed during medication administration observation. Findings Include: A review of a facility policy titled, Oral and Nasal Inhalation Administration, dated 8-2007 revealed: PURPOSE: To administer oral, nasal and aerosol inhalation medications in a safe and accurate manner. .III. Aerosol/Hand Held/Mask Nebulizer Therapy .d. Monitor delivery of medication until completely delivered. A review of Fundamentals of Nursing Ninth Edition, (YEAR), by Potter Perry Stockert and Hall, Page 632 included, .Carefully monitor a patient's response to a medication . 1.) RI #53 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 03/14/18 at 9:36 a.m., Employee Identifier (EI) #4, Licensed Practical Nurse (LPN) was observed placing a nebulizer mask on RI #53's face and turning on RI #53's nebulizer machine. EI #4 was then observed going in the bathroom to wash her hands and return to the cart to sign out RI #53's medications. EI #4 was then observed preparing medications and going into another resident's room. On 03/15/18 at 2:59 p.m., an interview was conducted with EI #4. EI #4 was asked did she remain with RI #53 during his/her nebulizer treatment on 03/14/18. EI #4 said not directly in the room, but in the vicinity. EI #4 was asked what did she do while RI #53's nebulizer was infusing. EI #4 stated she gave his/her roommate's medications and medications to a resident in another room, but could still hear RI #53's machine going. EI #4 was asked could she tell if RI #53's mask slipped down just by listening. EI #4 said no. EI #4 was asked did RI #53 have an order to self administer his medications. EI #4 said no. EI #4 was asked should she have remained with RI #53 while his nebulizer treatment was administered. EI #4 said yes. EI #4 was asked what was the concern with not remaining with a resident during medication administration. EI #4 answered he/she could have aspirated or the mask could have come off and he/she would not have gotten the breathing treatment. On 03/15/18 at 4:02 p.m., an interview was conducted with EI #7, Registered Nurse/Staff Development Coordinator/Infection Control Coordinator. EI #7 was asked what would she expect a nurse to do while a nebulizer treatment is being administered. EI #7 said the nurse should have the resident in view while the treatment is administered. 2.) RI #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #3's medical record revealed the following: Physician order [REDACTED].> .FLUSH WITH 5 ML(milliliter) OF WATER BETWEEN EACH MEDICATION . On 03/14/18 at 5:25 p.m., Employee Identifier (EI) #5, Registered Nurse (RN), was observed administering medications by gastrostomy tube for RI #3. EI #5 was observed administering 30 cc's (cubic centimeters= milliliters) of water after administration of each medication. On 03/15/18 at 3:24 p.m., an interview was conducted with EI #5. EI #5 was asked, how much flush should be administered between each of RI #3's medications. EI #5 said at least 5 cc's. EI #5 was asked how much water did she administer after each of RI #3's medications on 03/14/18. EI #5 answered 30 cc's before and after each of his/her medications. When asked was the correct amount of water given between medications, EI #5 replied no. 3.) RI #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #25's medical record revealed the following Physician order [REDACTED].> .FLUSH 5 ML OF WATER BETWEEN MEDICATIONS . On 03/14/18 at 8:54 a.m., EI #3, Licensed Practical Nurse (LPN), was observed administering medications by gastrostomy tube for RI #25. EI #3 was observed administering 30 cc's of water after each medication. On 03/15/18 at 2:20 p.m., an interview was conducted with EI #3. EI #3 was asked how much were RI #25's flushes supposed to be before, during and after medication administration. EI #3 looked at RI #25's chart and said 30 cc's before and after medication administration and 5 cc's of water between medications. EI #3 was asked how much flush did she administer between each of RI #25's medications on 03/14/18. EI #3 answered 30 cc's. EI #3 was asked was that the correct amount. EI #3 replied no. EI #3 was asked what was the concern with administering too much water. EI #3 said fluid overload.

Based on observations, interviews, medical record reviews and review of a facility document titled, Standard Precautions, the facility failed to ensure licensed staff: 1. changed gloves after gastrostomy tube medication administration for Resident Identifier (RI) #3 before rinsing, drying and storing RI #3's syringe, 2. did not manipulate a paper towel dispenser lever while wearing gloves during RI #3's medication administration, and 3. rinsed and dried both pieces of RI #25's piston syringe before storing them in a plastic bag, These deficient practices affected RI #3 and RI #25, two of eight residents and two of seven nurses observed during medication pass observations. Findings Include: A review of a facility document titled, Standard Precautions revised 12/2009 revealed: Standard Precautions will be used in the care of all residents regardless of their [DIAGNOSES REDACTED].POLICY INTERPRETATION AND IMPLEMENTATION: 1. Hand Hygiene .b. Wash hands immediately after gloves are removed, between resident contacts, and when otherwise indicated to avoid transfer of microorganisms to other residents or environments. 2. Gloves .c. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, .and wash hands immediately after providing care to residents to avoid transfer of microorganisms to other residents or environments. 1.) RI #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 03/14/18 at 5:25 p.m., Employee Identifier (EI) #5, Registered Nurse (RN), was observed wearing gloves while administering RI #3's medications by gastrostomy tube. EI #5 was then observed entering RI #3's bathroom, manipulating the paper towel dispenser lever, rinsing and drying RI #3's piston syringe while wearing the same gloves she wore during medication administration. On 03/15/18 at 3:24 p.m., an interview was conducted with EI #5. EI #5 was asked, when you should wash hands. EI #5 said, before putting gloves on and after taking them off. EI #5 was asked, should she have worn the same gloves that she wore while administering RI #3's medications and to rinse and dry. EI #5 replied, no ma'am. EI #5 was asked, what was the concern with wearing the same gloves. EI #5 answered infection control. 2.) RI #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 03/14/18 at 8:54 a.m., EI #3, Licensed Practical Nurse (LPN), was observed administering medications by gastrostomy tube for RI #25. EI #3 then went into RI #25's bathroom and was observed rinsing and drying the barrel of the piston syringe without rinsing and drying the plunger and storing both pieces in a plastic bag. On 03/15/18 at 2:20 p.m., an interview was conducted with EI #3. EI #3 was asked, when she rinsed RI #25's syringe, did she rinse both pieces. EI #3 said no she just rinsed the barrel. EI #3 was asked what was the concern with not rinsing both the plunger and the barrel. EI #3 answered infection control. On 03/15/18 at 4:02 p.m., an interview was conducted with EI #7, Registered Nurse/Staff Development Coordinator/Infection Control Coordinator. EI #7 was asked how should a nurse rinse and dry the piston syringe after tube medication administration. EI #7 said both pieces should be rinsed and dried before returning them to the bag. EI #7 was asked should a nurse manipulate the paper towel dispenser lever while wearing gloves. EI #7 said no.

Based on observation and interview the facility failed to ensure Room Locators (RL) #1 was free of a fall mat which was torn and stained; they further failed to ensure RL #2 was free of cracked and broken tiles. This affected 1 of 1 fall mat observed and 1 of 2 halls with cracked and broken tiles. This was observed on 1/31/17, 2/1/17 and 2/2/17 and affected one of two units in the facility. Findings Include: On 1/31/17 at 11:00 a.m., during the initial tour, the fall mat at RL #1 was observed with stains and tears. Also the floor tiles at RL #2 were observed with multiple cracked and broken tiles. On 2/1/17 at 10:30 a.m. the fall mat at RL #1 was observed with stains and tears. The floor tiles at RL #2 were again observed with multiple cracked and broken tiles. On 2/2/17 at 8:15 a.m., the fall mat at RL #1 was observed with stains and tears; the floor tiles at RL #2 were observed with multiple cracked and broken tiles. On 2/2/17 at 8:45 a.m. a walk thru was conducted with Employee Identifier (EI) #3, Maintenance Director. EI #3 was asked to describe what he observed at RL #1. He replied as he was standing in the hall before entering RL #1,tears on the mat; upon entering RL #1 he replied and stains on the mat. EI #3 was asked who was responsible for the floor mats; he replied he was. EI #3 was asked what the concern was with the floor mat torn and stained; he replied it was torn and did not look nice. EI #3 was asked what he observed at RL #2; he replied cracked and broken tiles across the entire hall. EI #3 was asked who was responsible for repairing the floor tiles; he stated, I am. EI #3 was asked what was the concern with the floor tiles cracked and broken. EI #3 replied it looked bad and this was their home.

Based on observation, interview and a review of a facility policy titled Oral Medication Administration the facility failed to ensure a staff Registered Nurse did not touch the inside of Resident Identifier (RI) # 15's medication cup and Juven packet with her index and second fingers. This affected one of five residents observed during the medication pass. Findings Include: A facility policy titled: Oral Medication Administration with an effective date of June 1, 2004 documented . PURPOSE: To administer oral medications in an organized and safe manner. PROCESS: . 7. Do not touch any of the medication with fingers . RI #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Physician order [REDACTED]. On 01/31/17, at 5:00 p.m. Employee Identifier (EI) #1 Registered Nurse was observed preparing RI #15's medication. She touched the inside of RI # 15's medication cup with her index and second fingers and touched the inside of RI #15's Juven packet while preparing it with the same 2 fingers. An interview was conducted with EI #1 on 02/01/17, at 3:25 p.m. EI #1 was asked was asked how she should pick up a resident's medication cup. She stated, Pick it up on side and don't touch the inside. She was asked why she touched the inside of RI #15's medication cup and Juven pack with her index and second fingers. She stated, I don't recall doing that but I know I should not have if I did. EI #1 was asked what the potential for harm was for putting her ungloved fingers inside a resident's medication cup and pack of Juven. She stated, It could be contaminated and cause an infection. An interview was conducted with EI #2 Infection Control Registered Nurse on 02/02/17, at 9:26 a.m. EI #2 was asked how she would expect a medication nurse to pick up a resident's medication cup. She replied, from the side. EI #2 was asked what the potential for harm was if the staff nurse touched the inside of a resident's medication cup. EI #2 stated, Cross Contamination.

Based on record review and interview, the facility failed to monitor the bowel movements of (RI) # 1, RI #2, and RI #4 to ensure the residents did not go four or more days without a bowel movement. This affected three of three sampled residents reviewed. Findings Include: RI #1 was admitted to the facility 2/21/14 with a [DIAGNOSES REDACTED]. A review of a Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD)of 10/28/16 revealed RI #1 was totally dependant for toilet use and always incontinent of bowels. A review of a facility report titled Bowel Report Roster for RI #1 revealed the resident went four days without a bowel movement, from 11/11/16 to 11/14/16. On 12/7/16 at 3:00 p.m. an interview was conducted with Employee Identifier (EI) #3 Certified Nursing Assistant (CNA); she was asked when to notify the nurse if a resident does not have a bowel movement. EI #3 replied 2 or 3 days. EI #3 was asked where was it recorded if a resident had a bowel movement; she replied it was entered in the kiosk. On 12/8/16 at 8:30 a.m. an interview was conducted with EI #2, Registered Nurse, unit manager. EI #2 was asked who was responsible for documenting bowel movements. EI #2 replied CNA's were responsible for documentation on the bowel roster. EI #2 was asked to review the Bowel Roster Report for RI #1, she was then asked if RI #1 had a bowel movement logged for November 11, 12, 13 or 14, 2016. She replied no. EI #2 was asked how many days had RI #1 gone without a recorded bowel movement; she replied 4. EI #2 was asked how many days should a resident go without a bowel movement; she replied no more than three days. EI #2 was asked what was the potential for harm in a resident going more than three days without a bowel movement. EI #2 replied possible impaction and the resident not having proper motility. RI #2 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of a facility report titled Bowel Report Roster for RI #2 revealed 10/14/16 thru 10/18/16 no bowel movement recorded; 5 days without a bowel movement. A review of a 14 day MDS with an ARD date of 10/27/16 revealed RI #2 was totally dependant for toilet needs and always incontinent. On 12/8/16 at 9:30 a.m., an interview was conducted with EI #4, Registered Nurse. EI #4 was asked to review the Bowel Roster Report and then asked if RI #2 had a bowel movement recorded for October 14, 15, 16, 17 or 18, 2016. EI #4 replied not according to the documentation. EI #4 was asked how many days were there without a recorded bowel movement; she replied 5. EI #4 was asked what was the facility protocol related to bowel elimination. EI #4 replied if no bowel movement in 3 days initiate intervention. EI #4 was asked what was the intervention for RI #2. EI #4 replied she was not sure as no laxative was documented as given. EI #4 was asked if it would appear that RI #2 went 5 days without a bowel movement; she replied yes. RI #4 was readmitted to the facility 10/25/16 with a [DIAGNOSES REDACTED]. A review of a facility report titled Bowel Report Roster for RI #4 revealed 11/6/16 thru 11/9/16 no bowel movement recorded; 4 days without a bowel movement. A review of RI #4's 30 day MDS with an ARD date of 11/22/16 revealed RI #4 requiring extensive assistance with toileting needs. A brief interview with RI #4 revealed needing assistance to the bathroom for bladder and bowel elimination. On 12/8/16 at 11:00 a.m., an interview was conducted with EI #4, she was asked to review the bowel roster report for RI #4. EI #4 was then asked if RI #4 had a bowel movement recorded for November 6, 7, 8 or 9 and also November 18, 19, 20 and 21, 2016. EI #4 replied no. EI #4 was asked how many days each time without a bowel movement; she replied 4 days. EI #4 was asked what was the potential for harm in a resident going more than three days without a bowel movement. EI #4 replied it could be multiple things the resident should have one, they could have an impaction. On 12/8/16 at 11:30 a.m., during a phone interview with EI #5, Medical Director he was asked what was the protocol for bowel elimination. EI #5 replied 3 days without a bowel movement give stool softener and call the Physician. It was explained to him that according to records residents had went more than 3 days without a recorded bowel movement; he was then asked what the harm was. EI #5 replied sometimes they could have problems. EI #5 was asked if it would be acceptable for residents to go 4, 5 or 7 days without a recorded bowel movement. EI #5 replied no. This deficiency was cited as a result of the investigation of complaint/report number AL 781.

Based on record review and interview the facility failed to ensure the Bowel Roster Report for Resident Identifier (RI) #1 and RI #4 were completed. This affected two of three residents in which the Bowel Report Roster was reviewed. Findings Include: RI #1 was admitted to the facility 2/21/14 with a [DIAGNOSES REDACTED]. A review of a facility report titled Bowel Report Roster for RI #1 revealed no documentation from 11/1/16 thru 11/7/17 and no documentation from 11/25/16 thru 11/27/16. RI #4 was readmitted to the facility 10/25/16 with a [DIAGNOSES REDACTED]. A review of a facility report titled Bowel Report Roster for RI #4 revealed 11/12/16 thru 11/14/16 and 11/30/16 and 12/1/16 no documentation recorded. On 12/8/16 at 8:30 a.m. an interview was conducted with Employee Identifier (EI) #2, Registered Nurse, Unit manager. EI #2 was asked who was responsible for documenting bowel movements for residents. EI#2 replied the Certified Nursing Assistants (CNAs). EI #2 was asked what was the potential for harm in the bowel roster report not being completed. EI #2 replied residents could go without bowel movements and staff would not know it. EI #2 was asked after reviewing the bowel roster report with days missing would that report be accurate. EI #2 replied no. On 12/8/16 at 11:00 a.m. an interview was conducted with EI #1 Director of Nursing; she was asked to review the bowel roster reports for RI #1 and 4, she was then asked where was the documentation. EI #1 replied she was not sure. EI #1 was asked if there was to be something documented each shift; she replied yes. EI #1 was asked if bowel movements should be recorded and by whom. EI #1 replied yes by the CNAs. EI #1 was asked in reviewing the bowel roster report for RI #1 and 4 were the reports accurate in determining bowel elimination. EI #1 replied no, not for the dates referenced. EI #1 was asked what was the potential for harm in not having the bowel roster report accurate. EI #1 replied constipation. On 12/8/16 at 11:30 a.m. during a phone interview with EI #5, Medical Director; he was asked if a lack in bowel movement documentation would be a problem. EI #5 replied, if just not documented there could most definitely be a problem. This deficiency was cited as a result of the investigation of complaint/report number AL 781.

Based on observation, interview and record review, the facility failed to ensure Employee Identifier (EI) #2, a Certified Nursing Assistant (CNA) did not touch clean items and apply moisture barrier to Resident Identifier (RI) #3 with the same soiled gloves. This affected one of two residents sampled for incontinent care. Findings include: The facility's policy titled BALL HEALTHCARE SERVICES, INC. ADMINISTRATIVE POLICY dated February 2014 documented SUBJECT: Perineal Care . PROCESS - General: . f) Ensure that proper infection control practices are maintained. RI #3 was admitted to the facility 1/13/2016. RI #3's Minimum Data Set with an assessment reference date of 7/12/2016 identified the resident as requiring extensive assistance with toilet use and always incontinent of bowel and bladder. On 9/27/16 at 9:00 a.m. Employee Identifier (EI) #2, a CNA was observed providing incontinent care to RI #3. EI #2 cleaned the resident and removed the soiled brief and pad. Then with the same soiled gloves, EI #2 placed the clean pad and brief on RI #3. EI #2 then opened a jar of moisture barrier and with the same soiled gloves, she reached into the jar and applied moisture barrier to RI #3. On 9/27/16 at 2:30 p.m. an interview was conducted with EI #2, she was asked how was she trained as when to change gloves during pericare. EI #2 stated I had on two pair of gloves and I forgot to remove one pair after I cleaned and before I placed the clean pad and brief. EI #2 was then asked how was she trained to change gloves with incontinent care. EI #2 stated, Change gloves when you start clean stuff; I am not trained to double glove I just do it sometimes. EI #2 was asked if she changed her gloves before touching clean items. EI #2 replied no. EI #2 was asked if she was supposed to use the same soiled gloves to reach in a jar of moisture barrier then apply it to the resident. EI #2 replied no. EI #2 was asked what was the harm in touching clean items with soiled gloves. EI #2 replied cross contamination. During an interview on 9/27/2016 at 5:30 p.m., EI #1, the Assistant Director of Nursing/Infection Control Nurse was asked, was staff instructed to double glove during the provision of incontinent care. EI #1 replied never. EI #1 was asked, how was staff trained on when to change gloves during the provision of incontinent care. EI #1 replied, changed gloves when going from front to back, then when finishing the back side change gloves and apply the moisture barrier, then change before placing the clean pad and brief. EI #1 was asked, if it would be acceptable for a CNA to clean the resident then with the same soiled gloves place the clean pad and brief and apply moisture barrier. EI #1 replied no. EI #1 was asked, what was the harm in staff touching clean items with soiled gloves. EI #1 replied cross contamination and the risk for infection. This deficiency was cited as a result of the investigation of complaint/number AL 689.

Based on record reviews and interviews, the facility failed to ensure [MEDICATION NAME] breathing treatments were administered as prescribed by the physician. The medication was not administered for 6 days after the physician's orders [REDACTED].#1. This affected RI #1, one of four residents sampled for following medication orders. Findings include: RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1's Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/5/16, revealed RI #1 had long and short term memory problems. The resident had modified independence with some difficulty in new situations with cognitive skills for daily decision making. The assessment also revealed RI #1 required total assistance for all activities of daily living. RI #1 had an indwelling catheter and was always incontinent of bowel. A review of RI #1's medical record revealed an order dated 5/24/16, for [MEDICATION NAME] nebulizer breathing treatments twice a day for seven days. The physician wrote the order to begin on that day which was 5/24/16. A second order was written on 5/30/16 for RI #1, that was just below the above order. The following was revealed: Order Clarification: [MEDICATION NAME] 40 mg (milligram)/ml (milliliter)vial Give 300 mg (7.5 ml) via neb (nebulizer) Bid (twice a day) x (times) 7 days (Carbapenem Resistant Acinetobacter) Sputum Mix (sign for with) 3 ml NS (normal saline) A review of RI #1's Respiratory Therapist's MAR (Medication Administration Record) for May of 2016 revealed the resident had the above order for [MEDICATION NAME] on 5/24/16. An initial with a circle was documented on 5/24/16 and the remaining dates from 5/25/16 to 5/30/16, were blank. RI #1 did not receive the [MEDICATION NAME] for six days following the order to start the medication on 5/24/16. A review of RI #1's Respiratory Therapist's MAR for the month of June 2016 revealed the resident had the above order for [MEDICATION NAME] on 5/30/16. An initial was documented from 6/1/16 to 6/7/16 on the MAR indicating RI #1 received the [MEDICATION NAME]. An interview was conducted on 7/21/16 at 11:26 a.m., with EI #1, the facility's pharmacist. The surveyor asked EI #1 when did the pharmacy receive the order for RI #1's [MEDICATION NAME] nebulizer treatment. EI #1 stated, May 30, 2016. When asked when was the medication sent to the facility, EI #1 stated, Dispensed on 5/30/16. The surveyor asked EI #1 what documentation did she have to show the medication was filled and sent to the facility. EI #1 stated, The delivery receipt. The surveyor asked why was the [MEDICATION NAME] not filled on 5/24/16. EI #1 stated, If we did not receive it, or if it was an error in transmission, we would not have known to fill it 5/24/16. A review of the [MEDICATION NAME] order and delivery sheets from the facility's pharmacy revealed, the medication for RI #1 was delivered on 5/30/16. An interview was conducted on 7/21/16 at 2:20 p.m., with EI #2, an LPN (Licensed Practical Nurse). The surveyor asked EI #2 what was the process for transcribing physician's orders [REDACTED].#2 stated, When the doctor writes an order we fax it over to pharmacy. We put the yellow copy in the nurse manager's box. We then transcribe the order onto the MAR. The surveyor asked EI #2 when was the order for [MEDICATION NAME] sent to the pharmacy for RI #1. EI #2 looked at the orders and the MAR for RI #1 and stated, It looks like the 24 th of May, and they did a clarification on the 30th of May. The surveyor asked EI #2 what documentation did they have to show orders were sent, and medications were received from the pharmacy. EI #2 stated, When we fax it, we get the confirmation form. When the medication is delivered, we receive 2 sheets. One sheet is given to the delivery person, and the other form is put in the delivery log book. An interview was conducted on 7/21/16 at 3:17 p.m., with EI #3, an RT (Respiratory Therapist) who provided care for RI #1. The surveyor asked EI #3 who transcribed the orders for the [MEDICATION NAME] nebulizer treatment for [REDACTED]. EI #3 stated, I took the order off and faxed it to the pharmacy. The surveyor asked EI #3 when was the order sent to the pharmacy. EI #3 stated, It was sent on the 24 th between 7:30 and 8:00 p.m The surveyor asked EI #3 what documentation did she have to show orders were sent, and medications were received from the pharmacy. EI #2 said, it could be her fault. She explained that she rounded with the pulmonologist and there were several orders written for several residents. She said nursing was tied up and she decided to fax all of the orders. EI #3 stated she did not know why the pharmacy did not receive the orders. She said five other orders were sent, and only RI #1's orders did not go through. The surveyor asked EI #3 why was the medication not administered until 6/1/16. EI #3 stated, The pharmacy said they did not receive the order. On 7/21/16 at 3:45 p.m., an interview was conducted with EI #7, the Unit Manager where RI #1 resided in the facility. EI #7 was asked why the [MEDICATION NAME] was not administered until 6/1/16. EI #7 stated, I would not be able to give a reason why. If it is a nebulizer treatment or nebulizer medication, we write RT on our MAR. Unless they us tell they do not have the medication, we would not know. EI #7 looked at the RT MAR and stated, .This is a RT MAR, that is in their own RT book. On 7/21/16 at 6:35 p.m., an interview was conducted with EI #4, the Administrator of the facility. EI #4 was asked what proof did the facility have that the fax was received by the pharmacy, regarding RI #1's [MEDICATION NAME]. EI #4 stated, I don't have proof. I have a staff member who told me through the investigation, that she faxed it. I have pharmacy that said through the investigation, that they did not receive it. I don't have proof.

Based on observation, interview and record review the facility failed to ensure Employee Identifier (EI) #3, a Certified Nursing Assistant (CNA) did not stand at the bedside while feeding Resident Identifier (RI) #5 on 11/18/15. This affected one of ten residents observed during meals. Findings include: RI #5 was readmitted to the facility on [DATE]. RI #5 Quarterly Minimum Data Set with an assessment reference date of 10/22/15, indicated RI #5 required extensive assistance of one person with eating. On 11/18/15 at 7:56 AM, Employee Identifier (EI) #3, a Certified Nursing Assistant, was observed standing at RI #5's bedside while feeding the resident breakfast. On 11/19/15 at 8:06 AM, EI #3 was asked how was she trained on what position she should be while feeding a resident. EI #3 stated, in a comfortable position. EI #3 was asked why did she stand while feeding RI #5. EI #3 replied that's what she thought she was supposed to do and not to sit down. On 11/19/15 at 2:41 PM, EI #1, the Director of Nurses was asked how are CNAs trained on what position they should use to feed a resident who is in bed. EI #1 replied they should be sitting down at eye level so they can engage the resident.

Based on record review and interview, the facility failed to ensure discharge summaries/recapitulation of the residents's stay were completed at the time of discharge for two of three residents, whose closed records were reviewed. This affected Resident Identifier (RI) #22 and RI #23, two of three residents whose closed records were reviewed. Findings include: The facility's policy titled .Discharge Summary and Plan of Care with a revision date of 10/2013 revealed: . STANDARD: . Upon discharge of a resident (other than in emergency to hospital or death) a discharge summary is provided to the receiving care provider. (In case of discharge home or to another facility). The Discharge Summary should include: A recapitulation of the resident's stay. A review of records selected for purpose of closed record review, revealed the facility did not complete a recapitulation of each residents stay when discharge was anticipated. RI #22 was admitted to the facility on [DATE] and discharged on [DATE]. RI #23 was admitted to the facility on [DATE] and discharged on [DATE], A closed record review was conducted on 11/19/15 at 11:30 am. There were no discharge summaries/recapitulations of RI #22's and RI #23's stay in the medical record. On 11/19/15 at 4:30 PM, the surveyor conducted an interview with EI #1, the Director of Nursing (DON). EI #1 was asked to locate discharge summaries in the records for RI #22 and RI #23. EI #1 looked through the records of RI #22 and RI #23 but could not locate the discharge summaries. EI #1 was asked what was the facility's policy regarding completing discharge summaries. EI #1 replied, the nurse completes a discharge summary when a resident is discharged home or to another facility. EI #1 was asked why no discharge summaries were done on RI #22 and RI #23. EI #1 said, I don't know.

Based on observations, interviews, medical record reviews, facility's policies and product information, Employee Identifier (EI) #5, a Licensed Practical Nurse, failed to sanitize the glucometer (a portable instrument used to measure blood glucose levels) used on multiple diabetic residents for accucheck/fingerstick blood sugar testing between each resident use. In addition, EI #3, a LPN failed to clean a glucometer after use with an appropriate sanitizing agent as dictated by the facility's policy and product information sheet. During the medication pass observation on 04/17/12 beginning at 4:10 PM, EI #5 utilized one glucometer to test six residents (RI #16, RI #17, RI #18, RI #19, RI #23 and RI #24) without cleaning the device between resident use. Two residents (RI #23 and RI #24) were identified by the facility as having a communicable disease. A communicable disease is any disease transmitted from one person to another directly or indirectly. RI #23 was placed on contact isolation for the treatment of [REDACTED]. MRSA is a bacteria that is resistant to certain antibiotics. Factors that have been associated with the spread of MRSA skin infections include contaminated items and surfaces. Healthcare procedures can leave patients vulnerable to MRSA, which it typically spread in healthcare settings from patient to patient on unclean hands of healthcare personnel or through the improper use or reuse of equipment. RI #24 has a past medical history that included a [DIAGNOSES REDACTED]. It results from infection with the Hepatitis C virus (HCV), which is spread primarily through contact with the blood of an infected person. According to the product information for the glucometer used to test RI #1 and RI #26's blood sugar, the glucometer should be sanitized with any Environmental Protection Agency (EPA) approved disinfectant product that meets the 1:10 bleach solution. EI #3, a LPN, did not clean a glucometer with the appropriate sanitizing agent. During another medication pass observation 04/17/12 beginning at 5:00 PM, EI #3 used an alcohol prep pad to clean the glucometer between resident use (RI #1 and RI #26). The alcohol prep pad used by EI #3 during the medication pass on 04/17/12, indicated the alcohol prep pad is made up on 70% [MEDICATION NAME] alcohol and 30% water; not a bleach solution. These deficient practices placed the health and safety of RI #1, RI #16, RI #17, RI #18, RI #19, RI #23, RI #24, and RI #26, eight of 11 residents observed for medication pass, in immediate jeopardy as it was likely to cause serious harm, injury or death. On 04/18/12 at 5:40 PM, the facility's Administrator, Director of Nursing and Corporate Nurse were informed immediate jeopardy in the area of Infection Control, F 441 had been identified. Findings include: The facility's policy titled "Administrative Procedure Subject: Standard Precautions" revised 12/2009 documented " ... 5. Resident-Care Equipment ... b. Ensure that reusable equipment is not used for the care of another resident until it has been appropriately cleaned ... blood glucose monitoring machines and similar equipment should be sanitized after use and prior to use for each resident. The sanitizing agent should be based on manufacturer's recommendations ... ." The product information for the "EasyMax L Self-Monitoring Blood Glucose System" used to perform accuchecks/fingersticks documented, "Caring for your Blood Glucose Meter in a LTC (Long Term Care) setting In order to prevent the growth of microorganism, make sure you cover all the steps below ... 2. Put on a pair of protective gloves before you start the cleaning procedure 3. Sanitize the glucose meter with any EPA (Environmental Protection Agency) approved disinfectant product that meets the 1:10 bleach solution. 4. Wipe the surface of the glucose meter including the test strip port ... after each use ... the treated surface must remain visibly wet for a full 2 minutes to attain complete disinfection ... 6. Air dry the meter to sanitize completely before next use." The facility's policy titled "Administrative Procedure" revised 03/2010 documented "Subject: Glucose Monitoring Equipment - Care and Quality Control Testing ... Standard: ... Glucometers must be disinfected between resident use. Process: ... a) Clean glucose monitoring equipment using moist (not wet) bleach based, lint free product before and after each use. b) Store the meter in its case when not in use ... ." According to "Mosby's Medical Dictionary 7th Edition" page 426, documented "communicable disease, any disease transmitted from one person or animal to another directly... or indirectly ... ." Page 815, documented "Glucometer, trademark for a battery-powered instrument used to calculate blood glucose from ... blood ... ." During the medication pass observation on the MSU hall on 04/17/12 at 4:10 PM, the State Surveyor observed Employee Identifier (EI) #5, a Licensed Practical Nurse (LPN), put on gloves and prick the right ear of Resident Identifier (RI) #17, a diabetic resident, with a lancet to obtain blood for a pattern blood sugar. After the blood sugar was obtained, EI #5 removed her gloves, discarded the lancet, sanitized her hands and without cleaning the glucometer, placed it on top of the medication cart. RI #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #17's "New Admission physician's orders [REDACTED]. RI #17's April 2012 Medication Administration Record (MAR) indicated pattern blood sugar with regular sliding scale insulin at 6:30 AM, 11:00 AM, 4:00 PM and 9:00 PM. On 04/17/12 at 4:14 PM, EI #5 sanitized her hands, inserted a test strip into the same glucometer used for RI #17, put on gloves and pricked the right middle finger of RI #18, a diabetic resident, to obtain blood for a pattern blood sugar. After the blood sugar was obtained, EI #5 discarded the lancet, removed her gloves, sanitized her hands and placed the glucometer on top of the medication cart without cleaning it. RI #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #18's April 2012 "physician's orders [REDACTED]. Without cleaning the glucometer, on 04/17/12 at 4:21 PM, EI #5 again washed her hands, put on gloves, inserted a test strip into this same glucometer and pricked the left ring finger of RI #24, a diabetic resident with a history of Hepatitis C and past treatment of [REDACTED]. After the blood sugar was obtained, EI #5 discarded the lancet and removed her gloves. EI #5 was observed to not clean the glucometer. RI #24 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to RI #24's "History and Physical" from a local hospital dated 12/21/11, RI #24 has a past medical history of [REDACTED]. [REDACTED]. According to the Centers for Disease Control (CSC) Prevention, Hepatitis C is a contagious liver disease that ranges in severity from a mild illness [MEDICATION NAME] a few weeks to a serious, lifelong illness that attacks the liver. It results from infection with the Hepatitis C virus (HCV), which is spread primarily through contact with the blood of an infected person. Approximately 75%-85% of people who become infected with the Hepatitis C virus develop chronic infection. Chronic Hepatitis C is a serious disease that can result in long-term health problems, including liver damage, liver failure, [DIAGNOSES REDACTED], or even death. Without cleaning the glucometer, on 04/17/12 at 4:28 PM, EI #5 washed her hands, inserted a test strip into this same glucometer, put on gloves and pricked the right middle finger of RI #19, a diabetic resident, to obtain a blood sugar. After the blood sugar was obtained, EI #5 removed her gloves, discarded the lancet, sanitized her hands and without cleaning, placed the glucometer on top of the medication cart. RI #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #19's April 2012 "physician's orders [REDACTED]. On 04/17/12 at 4:33 PM, EI #5 put on gloves, inserted a test strip into this same glucometer and entered the room of RI #23, a diabetic resident with a sign on the outside of the door that read "Contact Isolation." Without placing a barrier between the glucometer and the over bed table, EI #5 placed the glucometer on RI #23's over bed table. After the pattern blood sugar was obtained, EI #5 removed her gloves, discarded the lancet, sanitized her hands and placed the glucometer on top of the medication cart without cleaning it. RI #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #23's "physician's orders [REDACTED]. (diagnosis) MRSA (Methicillin-resistant Staphylococcus Aureus) sputum ... ." RI #23's care plan with a problem onset date of 02/17/12, documented "... Resident requires isolation due to an infection (MRSA in sputum) ... ." RI #23's April 2012 "physician's orders [REDACTED]. RI #23 also has an order for [REDACTED]. The Annual Minimum Data Set (MDS) with an assessment reference date of 02/14/12, documented under Section O - Special Treatments, Procedures, and Programs that RI #23 receives tracheostomy care, suctioning and oxygen therapy. RI #23 was observed on 04/17/12 at 10:20 AM. An isolation cart with gowns, masks and red bags were observed sitting just inside the resident's room door. A contact isolation sign was observed on RI #23's door. On 04/18/12 at 11:08 AM, RI #23 was observed receiving oxygen via trach collar at 30%. RI #23's "Wound Care Specialist Evaluation" dated 03/30/12 documented " ... Trach collar with secretions ... ." RI #23's "Wound Care Specialist Evaluation" dated 04/06/12 documented " ... Trach coller (collar) with thick secretions ... ." According to the Centers for Disease Control (CDC) and Prevention, MRSA is a type of staph bacteria that is resistant to certain antibiotics. More severe or potentially life-threatening MRSA infections occur most frequently among patients in healthcare settings. MRSA infections are usually spread by having contact with someone's skin infection or personal items they have used that touched their infected skin. Factors that have been associated with the spread of MRSA skin infections include contaminated items and surfaces. Healthcare procedures can leave patients vulnerable to MRSA, which is typically spread in healthcare settings from patient to patient on unclean hands of healthcare personnel or through the improper use or reuse of equipment. Without cleaning the glucometer, on 04/17/12 at 4:43 PM, EI #5 inserted a test strip into this same glucometer, put on gloves and pricked the right middle finger of RI #16, a diabetic resident, to obtain a blood sugar. After the blood sugar was obtained, EI #5 removed her gloves, discarded the lancet, placed the glucometer on top of the medication cart without cleaning it and sanitized her hands. EI #5 (LPN) used one glucometer to test six residents' blood sugar, without cleaning the glucometer between resident use. RI #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #16's April 2012 "physician's orders [REDACTED]. On 04/17/12 at 4:47 PM, an interview was conducted with EI #5, the LPN who obtained blood sugars on RI #16, RI #17, RI #18, RI #19, RI #23 and RI #24, without cleaning or disinfecting the glucometer between use. EI #5 was asked, when did she clean the glucometer. EI #5 stated that the glucometer is cleaned on the 11:00 PM - 7:00 AM shift. When asked, what is the glucometer cleaned with, EI #5 replied that she would assume they (nursing staff) clean it with alcohol. EI #5 stated that each medication cart has its own glucometer that is shared between residents on the MSU hall. EI #5 was then asked, what is the facility's policy on cleaning the glucometer. The LPN (EI #5) replied that it is cleaned in between residents if blood gets on the glucometer or if it gets dirty. EI #5 then commented that she should read the policy. When asked if she cleaned the glucometer between resident use, EI #5 responded that she didn't and only cleaned it if the glucometer became visibly soiled. EI #5 was asked, if the glucometer became dirty what would she clean it with and she stated a dry towelette and an alcohol swab. When asked, why is it important to clean the glucometer between resident use, EI #5 stated because of infection control, it could be possible to transmit germs between residents. In a follow up interview on 04/17/12 at 4:54 PM, EI #5 was asked where did she set the glucometer at when she entered RI #23's room. EI #5 answered on the bedside table. EI #5 stated she brought the glucometer out of the room and used it next for RI #16. When asked did she clean the glucometer between use for RI #23 (a resident on contact isolation) and RI #16, EI #5 said no and that she should have cleaned it. In an interview with EI #1, the Director of Nursing (DON) on 04/17/12 at 4:50 PM, she was asked what are glucometers cleaned with. EI #1 replied a soft cloth that is slightly damp, but that alcohol was approved for use to clean the glucometer. During the medication pass observation on the 100 hall on 04/17/12 at 5:00 PM, the State Surveyor observed EI #3, a Licensed Practical Nurse (LPN), obtain a blood sugar from RI #26. After the blood sugar was obtained, EI #3 wiped the glucometer with an alcohol prep pad and proceeded to RI #1's room to obtain her blood sugar. After RI #1's blood sugar was obtained, EI #3 again wiped the glucometer with an alcohol prep pad. In an interview with EI #4, a RN, on 04/17/12 at 5:10 PM, she was asked how did she clean the glucometer. EI #4 demonstrated by wiping the outer area of the glucometer with an alcohol pad. The Material Safety Data Sheet (MSDS) for the alcohol prep pad used by EI #2 and EI #3 during the medication pass on 04/17/12, indicated the alcohol prep pad is a non-woven saturated pad made up on 70% [MEDICATION NAME] alcohol and 30% water. RI #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #26's "New Admission physician's orders [REDACTED]. RI #26's "physician's orders [REDACTED]." RI #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1's April 2012 "physician's orders [REDACTED]. ************************* On 04/19/12 at 2:50 PM, the facility submitted an acceptable allegation of compliance for F 441, which documented: " ... The facility will ensure that each resident is provided blood glucose monitoring in a manner that meets accepted infection control practices. 1. RI #1, 16, 17, 18, 19, 23, 24 and 26 - As of April 18, 2012 all have been provided blood glucose monitoring as prescribed by a physician and in accordance with the facility policy regarding sanitizing glucose monitoring machines. The Medical Director and each attending physician have been notified of the potential exposure to an infectious disease. Each resident with orders for finger sticks will be evaluated by a physician on Monday, April 23, 2012. Additional monitoring/testing will be performed as ordered by the physician. RI #23 and #24 have been assigned separate Glucose monitoring machines which will be kept in their rooms for single resident use. Any future residents with blood borne illnesses will have glucose monitoring machines kept at the bedside for single resident use. 2. All diabetic residents with physician orders [REDACTED]. 3. On April 17, 2012, beginning with the 3-11 shift, and continuing at the beginning of each subsequent shift, licensed nurses were provided inservice education by the DON, Staff Development Nurse and Unit Managers regarding the facility policy and procedure for sanitizing multi-use blood glucose monitoring machines. On April 18, 2012, beginning on the 3-11 shift and continuing for each licensed nurse, skills validations will be completed. On April 18, 2012, to begin the process of skills validations the Regional Director of Clinical Services completed an observation of the DON. The DON observed the Staff Development Nurse and Unit Managers. Each licensed nurse will be observed while performing the 19 step Glucometer Sanitizing Skills Validation Check. Any nurse who fails to complete the validation successfully will receive immediate retraining and a repeat skills validation check. A nurse will not be allowed to work until the validation is completed. The skills validation observations will be performed by the DON, Staff Developments Nurse and Unit Managers. Newly employed licensed nurses will receive inservice education during the initial classroom orientation and will complete a Glucose Sanitizing Validation Check before leaving the classroom orientation. 4. Initial skills validation for all licensed nurses will be completed by Monday, April 23, 2012 by the DON, Staff Development Nurse and Unit Managers. Beginning April 23, 2012, each nurse will be monitored once/shift for one week. Beginning on April 30, 2012 each day a different nurse will be monitored for a period of one month. Thereafter, each nurse will be monitored once monthly to ensure that finger sticks are performed appropriately. The skills validation tools will be maintained by the DON." ************************* On 04/19/12, the State Surveyor team reviewed the facility's information provided in their allegation of credible compliance, in-service records, conducted staff interviews and observations of glucometer cleaning completed as of 04/19/12, to determine if the facility had implemented their allegation of credible compliance. The immediate jeopardy was abated on 04/19/12 at 5:45 PM, with the scope and severity being lowered to a "E" level, to allow the facility time to monitor/revise their corrective actions to achieve compliance.

Based on observations, interviews and record reviews, the facility failed to ensure Certified Nursing Assistants changed gloves and washed/sanitized hands prior to touching objects in the residents' rooms, applying ointments and in between steps of incontinence and catheter care. This affected Resident Identifier (RI) #5 and RI #36, two of four residents observed during incontinence and catheter care. Findings include: 1) RI #5 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. On 05/29/12 at 3:50 PM, an observation was made of Employee Identifier (EI) #12, a CNA performing perineal care on RI #5. EI #12 removed the urine soaked incontinence brief from RI #5 with her gloved hands. EI #12 rolled up the brief and placed it into a trash bag. EI #12 then proceeded to touch the resident's socks and sheets with those same gloves. EI #12 then removed her gloves and washed her hands. At the end of the perineal care, EI #12 took the two wash basins that were used for bathing and rinsing water and dumped the left over water from each basin into the resident's toilet. EI #12 then placed each one under the sink faucet and used her gloved hand to clean the inside of each basin. EI #12 then used those same gloves to pick a bottle of peri wash and leftover dry incontinence wipes and placed them in RI #5's bedside table by opening the drawer with the contaminated gloves. An interview was conducted with EI #12 on 05/30/12 at 5:40 PM. In the interview, EI #12 acknowledged touching the items in the residents room with the contaminated gloves. When asked why it was important to change gloves and wash hands after touching a resident's private areas, EI #12 replied that you could spread bacteria and infection. 2) RI #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #36's care plan with a problem onset date of 05/22/12, documented a problem/need of "Resident used an indwelling catheter." An observation of RI #36's catheter care with incontinence care was observed on 05/30/12 at 8:58 AM. EI #16, a CNA, performed the catheter and incontinence care, while EI #17, a CNA, assisted with the care. RI #36 was observed with a dressing with paper tape to the sacrum and some stool was present on tape. Once the CNA put on new gloves and removed the old dressing, she did not change her gloves. The CNA was observed to touch the box on the bedside table, the dry Tena wipes, the resident's clean pad, RI #36's gown and the trash can liner. Once the CNA rolled RI #36 to the left to finish unrolling the clean pad, she removed her gloves and placed them in the trash. In an interview with EI #16 on 05/30/12 at 2:25 PM, she was asked why it was important to change gloves with cleaning stool before touching things in the room. EI #16 replied so they (residents) won't get an infection. Tracey Pittman, RT/QMRP Wendy Johnson, RN