Every finding on record at Atmore Nursing Center

Based on observation, interview, and record reviews, including facility policies titled, PREPARATION FOR MEDICATION ADMINISTRATION and VIALS AND [MEDICATION NAME] (INJECTABLE MEDICATIONS), the facility failed to ensure outdated insulin vials were not on a medication cart. This was observed on one of four medication carts in the facility observed by the surveyors. Findings Include: A review of a facility policy titled, 6.1 Preparation For Medication Administration, dated ,[DATE], revealed: .6. Multi-dose medications, like injectables .should be dated when opened and discarded according to manufacturer's specifications. A review of a facility policy titled, 7.13 Vials and [MEDICATION NAME] (Injectable Medications), dated ,[DATE], revealed: . 2. The initials of the first person to use the vial and the date opened are recorded on multidose vials 3. A. When opened, most multidose vials of insulin may be used (refrigerated or at room temperature) for four weeks. See specific package labeling. A review of the manufacturer's prescribing information on page 32 of 43 revealed: . Do Not use [MEDICATION NAME] after the expiration date stamped on the label or 28 days after you first use it. A review of the manufacturer's prescribing information on Humalog 100 revealed, Throw away all insulin [MEDICATION NAME] in use after 28 days, even if there is insulin left. Also throw away all insulin products after the expiration date on the package. A review of the manufacturer's prescribing information on [MEDICATION NAME] 100 revealed, Throw away all insulin [MEDICATION NAME] in use after 28 days, even if there is insulin left. On [DATE] at 12:41 p.m., an inspection of a medication cart was conducted with EI (Employee Identifier) #4, an LPN (Licensed Practical Nurse). A vial of [MEDICATION NAME] with a resident's name on it was observed on the medication cart with an open date of ,[DATE]. The vial was also labeled with an expiration date of ,[DATE]. If opened on ,[DATE], the expiration date would be ,[DATE], 28 days per manufacturer's information. On [DATE] at 12:50 p.m., an empty vial of [MEDICATION NAME] ,[DATE] insulin labeled for a resident was observed on the medication cart with no date or initial on the vial or the box. On [DATE] at 12:53 p.m., a vial of HUMALOG 100 insulin labeled for a resident was observed on the medication cart with an opened date of [DATE] and an expiration date of [DATE]. On [DATE] at 1:00 p.m., a vial of [MEDICATION NAME]labeled for a resident was observed on the medication cart with an opened date of [DATE] and a written expiration date of [DATE]. On [DATE] at 3:31 p.m., EI #4, LPN, was interviewed and asked what was observed with the surveyor on the medication cart during the inspection on [DATE]. EI #4 stated expired insulin vials, two vials of opened insulin were both dated with an expiration date of 57 days. EI #4 stated one vial had no dates but was opened. EI #4 further stated one vial had an open date of ,[DATE] and an expiration date of ,[DATE], which was more than 28 days. EI #4 was asked how long after insulin was opened did it expire and EI #4 replied 28 days after it was opened. On [DATE] at 3:48 p.m., EI #5, a LPN, was interviewed. EI #5 was asked how long was an opened vial of insulin safe to use and EI #5 replied 28 days. EI #5 was asked if a vial of [MEDICATION NAME] was opened on ,[DATE] when would it expire. EI #5 responded, on ,[DATE]. EI #5 was asked again if this was correct and EI #5 stated, Well, you have 8 days in (MONTH) and 20 days in March. EI #5 was asked if the insulin was dated ,[DATE] how many days in (MONTH) was the insulin used. EI #5 responded 9 days and then it expired on ,[DATE]. EI #5 was asked if the vial of [MEDICATION NAME] was dated with an open date of ,[DATE] was it safe to administer to the resident on ,[DATE]. EI #5 said no, it expired on ,[DATE]. When asked what was the concern if a resident was administered expired insulin, EI #5 stated it may not work properly, inadequate control and the resident may not get the correct dose. EI #5 was asked if she checked opened and expired dates prior to administration of insulin and EI #5 responded yes. EI #5 was asked if there was an expiration date on the vial of insulin did she verify it was correct prior to administering to the resident and she responded yes. When asked why, EI #5 stated to make sure it was the correct date.

Based on observations, interviews, record reviews, a review of Fundamentals of Nursing, Ninth Edition, and a review of the manufacturer's information for [MEDICATION NAME], the facility failed to ensure Resident Identifier (RI) #39 was not administered expired insulin on 03/19/18 and 03/20/18. This affected one of one sampled resident reviewed for expired medication. Findings Include: A review of Fundamentals of Nursing, Ninth Edition, copyright (YEAR), page 654, revealed: .SAFETY GUIDELINES FOR NURSES .Verify expiration date of every medication during preparation. Do not administer expired medications . A review of the manufacturer's information for [MEDICATION NAME] revealed: Discard all containers in use after 28 days, even if there is insulin left. Also discard all insulin products after the expiration date on the package . RI #39 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #39's (MONTH) (YEAR) Physician order [REDACTED]. A review of RI #39's (MONTH) (YEAR) Medication Administration Record (MAR) revealed RI #39 was administered the [MEDICATION NAME] on 3/19 and 3/20/18, after its expiration. On 3/21/18 at 12:41 p.m., during an observation of a medication cart with Employee Identifier (EI) #4, a Licensed Practical Nurse (LPN), a vial of [MEDICATION NAME] for RI #39 was observed with an open date of 2/18. The vial was also labeled with a written expiration date of 3/20, exceeding the 28 day expiration date specified by the manufacturer. The expiration date of the insulin opened on 2/18 would be 3/18. On 3/22/18 at 3:31 p.m., EI #4, LPN, was interviewed and asked what was found on the medication cart during observations on 3/21/18. She replied one vial of insulin was labeled with an open date of 2/18 and expiration date of 3/20, which was more than 28 days. EI #4 was asked how long after insulin was opened did it expire. EI #4 replied 28 days after it was opened. EI #4 reviewed RI #39's (MONTH) (YEAR) MAR and stated the resident received two doses of expired [MEDICATION NAME]. EI #4 stated two medication errors were made. On 3/22/18 at 3:48 p.m., EI #5, the LPN that initialed administering RI #39's [MEDICATION NAME] on 3/20/18, was interviewed . When asked how long a vial of opened insulin was safe to use, EI #5 stated 28 days. EI #5 explained RI #39's insulin should not have been administered because it expired on 3/19/18. When asked what was the potential concern for a resident receiving expired insulin, EI #5 said it may not work properly, inadequate control, and the resident may not get the correct dose. EI #5 said expiration dates of insulin should be checked prior to administering the medication. After reviewing RI #39's (MONTH) MAR, EI #5 stated RI #39 had received expired insulin on 3/20/18. She further stated she got confused because (MONTH) had fewer days than other months.

Based on observations and interviews, the facility failed to provide a homelike environment as evidenced by: 1. thirty-eight residents were served lunch meals on trays on tables in the dining rooms and 2. thirty-two residents of thirty-eight residents were served milk, healthy shakes, and nutritional supplements out of cartons and plastic containers with their lunch meals. This was observed on two of three survey days and affected 38 of 79 residents served meals from the kitchen. Findings Include: On 3/20/18 at 12:28 p.m., an observation was made in the Main Dining Room of residents seated in chairs with meals/plates and drinks on trays on the table. Twenty-six meals were being served off of trays on the tables. Twenty-three milks and healthy shakes were served to the residents in cartons. On 3/20/18 at 12:39 p.m., an observation was made in the Activity/Magnolia Dining room. Residents were fed from plates, cups, and cartons on trays placed on the tables. Twelve meals were being served off of trays on the tables. Nine milks and shakes were served to the residents n the cartons. On 3/21/18 at 12:00 p.m., an observation was made of the Main Dining Room. Twenty-seven residents were eating from plates left on trays on the tables. Twenty-seven cartons were opened and served to residents. These cartons contained milk, health shakes, and nutritional supplements. On 3/21/18 at 12:24 p.m., an observation was made of the Activity/Magnolia Dining room. Eleven resident were being fed from dishes on trays on the tables. Ten cartons were opened and served to residents. These cartons contained milk and health shakes. One nutrional supplement was being served from its plastic container/bottle it came in. On 3/22/18 at 4:56 p.m., an interview was conducted with EI (Employee Identifier) #3, the Dietary Manager. EI #3 was asked why residents were served meals from trays in the dining rooms. EI #3 answered that was how they have always done it. EI #3 was asked if dinnerware including glasses, plates, bowls, and silverware were on trays in a home setting and she answered no. EI #3 was asked what the expectations of the facility were for providing a homelike atmosphere. EI #3 responded in the dining area, yes they should. EI #3 was asked what was the concern of residents being served meals on trays rather than on the table. EI #3 answered the residents would probably feel like they were not having a homelike environment. EI #3 was asked if residents had always been served meals on trays in the dining rooms and she answered yes. EI #3 was asked why were residents served milk, healthy shakes, and nutritional supplements in cartons. EI #3 answered it was already being done when she came to the facility in December. EI #3 was asked if drinking from cartons rather than glasses would be homelike and she answered no. EI #3 was asked what was the policy for providing a homelike environment during the dining experience and she answered there was none. On 3/22/18 at 5:10 p.m., an interview was conducted with EI #1, the Administrator. EI #1 was asked why residents were served meals on trays rather than on tables in the dining rooms. EI #1 answered they had a concern with infection control and they felt like serving meals on trays would prevent the possibility of cross contamination. EI #1 was asked had residents always been served their meals on trays in the dining rooms and she answered yes. EI #1 was asked if serving meals on trays was consistently used in home settings and she answered not on her table. EI #1 was asked if that meant the trays were not homelike and she answered yes. EI #1 was asked if serving milk and healthy shakes in cartons rather than glasses would be considered homelike and she answered no.

Based on a review of Resident Identifier (RI) #1's medical record, the facility's policy and procedure for elopement and missing residents, the facility's Resident Incident Report, the Almanac for ATMORE, AL March 27, 2017, www.mapquest.com, an email from the local hospital's security guard, the ALABAMA UNIFORM INCIDENT/OFFENSE REPORT nursing home and hospital staff interviews, and the facility's corrective action plan, the facility failed to ensure RI #1, a cognitively impaired resident who wore a secure care alarm anklet, did not exit the facility without staff knowledge on 3/27/17. On 3/27/17 around 7:30 PM, the facility's secure care alarm sounded. Employee Identifier (EI) #3, a Licensed Practical Nurse (LPN) responded, along with EI #5, a Certified Nursing Assistant (CNA). EI #5 held the door while EI #3 looked in the facility's parking lot. After nothing was seen outside, EI #3 came back inside, reset the alarm and continued with medication pass. The staff failed to implement their policy to ensure all residents with a Secure Care bracelet was accounted for. Then around 8:15 PM, after the resident had to be identified a police officer, a local hospital staff member called the nursing home to inform them that RI #1 had been found wandering around the parking lot of the local hospital, 0.10 miles away from the facility. According to the hospital's security guard, the resident was found about five to six feet from a big ditch about to fall. The security guard stated that if the resident would have fell in the ditch, it would have been days before someone would have found him/her. The LPN, EI #3, sent EI #4, a CNA to the local hospital to get RI #1. RI #1 was returned to the facility without injury. This deficient practice placed RI #1, one of three sampled residents, in immediate jeopardy of serious injury, harm or death. On 4/1/17 at 6:10 PM, Employee Identifier (EI) #1, the Administrator and EI #2, the Director of Nursing were notified of findings of substandard Quality of Care at the Immediate Jeopardy level in the area of Quality of Care, F 323. Findings include: On 3/28/17, the State Agency received a complaint which alleged, RI #1 had gotten out of the facility on 3/27/17 without staff knowledge. The complaint further alleged, the resident was found by a ditch of the local hospital and returned to the facility by a police officer. The facility's POLICY/PROCEDURE FOR PREVENTION OF ELOPEMENT dated 6/1/07, documented Policy: Residents who wander will be monitored in an effort to prevent the resident from leaving the facility without consent . Procedure: . If a door alarm is activated and a resident with a Secure Care alarm bracelet cannot be located, staff shall immediately refer to and follow the Missing Resident Policy . The facility's POLICY/PROCEDURE Missing Resident revised 6/15/04, documented Policy: A resident leaving the building unaccompanied and without the consent of facility staff will be considered a missing resident. Purpose: To ensure that any missing resident is located and returned to the facility as soon as is reasonably possible. Procedure: In the event that a staff member cannot locate a resident who is in his or her care, the staff member shall contact all other nursing units and departments in an effort to locate the resident . If the resident is not then located: (1) the Nursing Supervisor shall be notified immediately and a head count of all facility residents will be conducted; . RI #1 was admitted to the facility on [DATE] with an admit [DIAGNOSES REDACTED]. RI #1's Elopement Risk Assessment dated 6/10/16, 12/16/16 and 3/17/17 indicated the resident was at risk for elopement due to independent means of locomotion and symptoms of confusion. According to the assessments, a secure care alarm was placed on RI #1's ankle. RI #1's Quarterly Minimum Data Set with an assessment reference date of 3/17/17, revealed RI #1 was severely impaired in cognitive skills for daily decision making, with a Brief Interview for Mental Status (BIMS) score of three. RI #1 was assessed as requiring supervision with walking in room and corridor and locomotion on and off the unit. The Resident Incident Report prepared by EI #3, a LPN indicated on 3/27/17 RI #1 eloped from the facility without staff knowledge. The report documented . Shortly prior to episode of elopement this nurse heard secure care alarm on west wing front door. I went to check alarm and met cna (Certified Nursing Assistant) on way. We opened door and cna held door while went into parking area and checked for eloping residents. Nothing was seen. We returned to building, closed door and reset alarm. Approximately 8:15pm a hospital employee called and said they found one of our res wandering in their parking lot. I dispatched care nurse to get res. Res returned to the facility with care nurse and 2 poli (police) No injury noted to resident . RI #1's Departmental Notes dated 3/27/17 10:39 PM written by EI #3, a LPN documented Received call from hospital staff that one of our res (resident) were there. Res was returned to facility without injury. Full body audit was performed and no obvious injury noted. Res denies pain. Res confused and unable to make coherent statements r/t (related to) dementia. Res comforted and reassured. Res assisted into bed . In an interview on 3/30/17 at 4:25 PM, with EI #3, the LPN assigned to care for RI #1 on 3/27/17, she was asked about RI #1's elopements from the facility on 3/27/17. EI #3 stated the last time she saw RI #1, it was around 6:30 PM and the resident was in his/her room. Then about 7:30 PM, EI #3 was on the short hall and heard the secure care alarm sound. EI #3 stated she went to the nurses' station to see which door had activated the alarm; the panel indicated the West front door. EI #3 stated as she was walking towards the West front door, she saw a resident who was identified as someone who wanders walking down the hall. As EI #3 approached the door, EI #5, a CNA came out of a resident's room and asked her what was going on. According to EI #3, she told EI #5 that she was checking the alarm. Both EI #3 and EI #5 went to the West front door. EI #5 held the door while EI #3 looked in the parking lot toward the street to see if there was a resident. When asked what she saw, EI #3 said she saw nothing. EI #3 stated she then came back inside, turned the alarm off and resumed medication pass. Then around 8:00/8:05 PM, EI #3 stated she received a phone call from a hospital employee that RI #1 was there. EI #3 stated the hospital staff had called the police. The police officer who responded identified RI #1 as he was related to the resident. EI #3 stated she informed the hospital staff that she would send someone to pick up the resident. According to EI #3, she sent EI #4, a CNA, to pick up RI #1. Upon return to the facility, the resident was assessed and found to have no injuries. When asked, how was RI #1 dressed when the resident returned to the facility, EI #3 stated the resident had on dark pants, a sleep duster with a house coat over it, a three-fourth sleeve sweater, knee high stocking and a pair of socks. EI #3 stated she then notified the Director of Nursing (DON) and Administrator; the police officer had already contacted the resident's responsible party. During an interview on 3/31/17 at 5:20 PM, EI #5, a CNA stated she last saw RI #1 before supper. EI #5 stated she was in a resident's room when she heard the secure care alarm sound. EI #5 stated as she exited the resident's room, she saw EI #3 (LPN) coming up the hall towards the West front door. EI #5 acknowledged she held the door while EI #3 looked in the parking lot. When nothing was seen, EI #3 came back in the facility and reset the alarm. Both staff (EI #3 and EI #5) then continued in their routine. During a telephone interview on 3/31/17 at 5:31 PM, EI #4, a CNA stated she last saw RI #1 around 7:30 PM; the resident was in his/her room. EI #4 explained after seeing RI #1 about 7:30 PM, she went on break. According to EI #4, a little after 8:00 PM, the Charge Nurse (EI #3) came into the break room and told her that RI #1 had gotten out of the facility. The hospital staff said the resident was found wandering around in their parking lot. EI #4 stated she then drove over to the hospital, got RI #1 and returned the resident to the facility. When asked if RI #1 said anything to her, EI #4 said the resident said I was just walking and I don't know where I am. I was just walking and praying. According to www.mapquest.com, the distance from the nursing facility to the local hospital where RI #1 was found was 0.10 miles. In a follow-up interview with EI #3, a LPN, on 3/31/17 at 5:00 PM, she was asked if it was dark outside. EI #3 said yes because it was around 7:30 PM. When asked if she went to check to see if all residents were accounted for after the secure care alarm sounded, EI #3 stated no she didn't think anyone was missing because she didn't see anyone outside and didn't think that someone could be missing. EI #3 was asked what else could have been done. EI #3 replied, In hindsight, I could have done a head count to make sure all the residents were accounted for. When asked if she ever looked for RI #1 after the secure alarm sounded, EI #3 said no. EI #3 stated it was not until the hospital employee called, that she went to look in RI #1's room and found the resident was not in the facility. According to the Almanac for ATMORE, AL March 27, 2017 revealed on 3/27/17, the minimum temperature was 64 degrees Fahrenheit and the maximum temperature was 83 degrees Fahrenheit. The local hospital's security guard sent an email to a staff member at the local hospital on [DATE] at 8:44 PM, the email read (name), just to let you know, at about 2025hrs (8:25 PM) tonight, (hospital staff name) and (hospital staff name) alerted me that a old (man/lady) was walking around out back by the warehouse. So I ran out back to check it out and found out that this (man/lady) didn't know where (he/she) was, how (he/she) got here or anything. All (he/she) knew, was (he/she) was tired of walking. When I caught up to here (he/she) was by the big ditch out back about to fall. (He/She) had gotten away from the nursing home and they did not know anything about it. So I wanted you to know that thanks to your crew members we might have save a situation from turning out BAD! A telephone interview was conducted with the local hospital's security guard on 3/31/17 at 10:45 AM. According to the security guard, around 7:40 PM, he received a call from two housekeeping employees that there was an old man/lady around the hospital's warehouse and it appeared that he/she was drunk because he/she staggering. The security guard stated he rushed out and found the individual about five to six feet from the ditch. The security guard stated he grabbed the individual and asked his/her name. The security guard stated the individual didn't know where he/she was or where he/she was going. The individual only stated that he/she was tired and legs were hurting. The security guard stated he then flagged down a police officer who was coming down the road. According to the security guard, he told the police officer that he had found this individual at the back of the warehouse. When the police officer called in the report, the police officer's supervisor responded and he then identified the individual as RI #1, a resident of the nursing home. The security guard stated before the police was called, the hospital's nursing supervisor called the nursing home to ask if they were missing a resident. The nursing supervisor was told no. The security guard stated he was thankful he was there because it could have been a real bad situation. According to the security guard, if the individual would have fallen in the ditch, he/she could have been there for days and nobody would have known. The ALABAMA UNIFORM INCIDENT/OFFENSE REPORT dated 3/27/17 8:03 PM, documented . ON 03/27/2017 20:03 (8:03 PM) I (NAME OF OFFICER) WAS WAVED DOWN BY (local hospital) BY THERE (their) SECURITY GUARD. I (name of officer) ARRIVED ON SCENE AND CAME IN CONTACT WITH (RI #1) . THE SECURITY GUARD ADVISED ME ANOTHER SUBJECT FROM OF (local hospital) EMPLOYEES CAME AND GOT HIM FROM INSIDE THE emergency room AND STATED TO HIM THERE WAS A ELDERLY (male/female) IN THE BACK PARKING LOT OF THE HOSPITAL. I (name of officer) ASKED THE (male/female) NAME WHICH I COULDN'T MAKE OUT CLEARLY THE FIRST NAME BUT THE LAST NAME WAS (RI #1's last name). THE SECURITY OFFICER ADVISED ME THE ELDERLY (male/female) STATED (he/she) WAS LOST AND WAS TIRED AND THAT THEY SAW A WHITE VAN LEAVING THE PARKING LOT. THEY BELIEVED DROPPED THE ELDERLY (male/female) OFF. I (name of officer) THEN ASKED MY SERGEANT (name) COULD HE MEET ME AT (local hospital) TO SEE IF HE WAS RELATED OR IF HE KNEW THE (male/female) SUBJECT . I (name of officer) THEN NOTICED THE ATMORE NURSING CENTER BRACELET ON (his/her) LEFT ANKLE. ATMORE NURSING CENTER WAS CALLED AND A FEMALE EMPLOYEE FROM ATMORE NURSING ARRIVED ON SCENE AND TRANSPORTED THE (male/female) BACK TO ATMORE NURSING CENTER AND RETURNED (him/her) BACK TO (his/her) ROOM . ************************* On 5/1/17 at 11:37 AM, the facility submitted an acceptable Allegation of Credible Compliance, which documented: This is Atmore Nursing Center's allegation of credible compliance . 3/27/2017 8:28 p.m. (EI #3) LPN called and reported to the DON that the hospital had called her and told her that one of our residents was wandering around in their parking lot. (EI #3) sent a CNA to the hospital to get our resident and when the CNA got there the police was there and they brought the CNA and the resident back to the facility. (EI #3) told the DON that she was in a resident's room and that she heard the door alarm going off. (EI #3) walked to the door and saw a resident with a secure anklet on standing at the door. (EI #3) and a CNA walked outside and looked around the parking lot and did not see anyone in the parking lot. (EI #3) assumed that the resident standing by the door set the alarm off. After the resident was returned to the facility (EI #3) completed a head to toe assessment and found no injuries, resident denied pain. (EI #3) completed an incident report and notified the MD (Medical Doctor) and was fixing to call the sponsor and the sponsor came in the facility. The sponsor told (EI #3) that the policeman that picked up RI #1 was (his/her) nephew and he came to her house and told her that RI #1 was found wandering in the hospital parking lot and that is why she was at the nursing home to check on the resident. (EI #3) stated she heard the alarm going off around 7:30pm and the hospital called her at 8:00pm. On 3/27/17, RI #1 was safely returned to the facility. A body audit was completed and no injuries were noted. RI #1 was placed on Q (every) 30 minutes rounds. RI #1's Elopement Risk assessment was updated and Behavior tracking was started for the identified behavior of exiting the facility. On 3/27/17, the facility began an investigation into the elopement of RI #1 from the facility without staff knowledge. On 3/28/17, (manufacturer of secure care system) came to the facility to inspect the secure care system to ensure the egress locking system was working properly and to assess the exit doors for a lock on demand system. No concerns were found with the doors. On 3/27/17, the facility conducted an audit for all residents that have a secure care anklet and have been determined to be at risk for elopement to ensure all residents were in the facility and then a 100% audit was completed to ensure all residents were in the building. On 3/27/17, all staff re-inservice began on the policy and procedure for prevention of elopement and the policy and procedure for a missing resident to include that if the secure care door alarms goes off the staff will complete a head count beginning with residents listed on the secure care list to ensure all residents are in the facility and if any resident is found missing to implement the policy and procedure for a missing resident. Staff members that were at the facility at the time of RI #1's return were trained beginning 3/27/17 and this education continued as staff came into the facility for their assigned shift to work prior to being allowed to go onto the halls until all staff were trained. 19 staff members were educated on 3/27/17; 52 staff members were educated on 3/28/17; 25 staff members were educated on 3/29/17; and 13 staff members were educated on 3/30/17. All staff members were educated by 3/30/17. On 3/28/17, the facility's policy and procedure for the Prevention of Elopement was revised to reflect the implementation of 100% head count after the secure care door alarm sounds. On 3/28/17, the facility held a quality assurance committee meeting related to RI #1's elopement. The DON or designee will begin drills by setting off the secure care door alarm each day on alternating shifts beginning 3/29/2017 for 5 days x 1 week then weekly x 4 weeks then monthly for 4 months then quarterly ongoing to monitor the response times of the staff and to make sure the policy and procedure for prevention of elopement and the Policy and procedure for a missing resident is followed. The facility alleges the Immediate Jeopardy is removed as of 3/30/17. ************************* After reviewing the facility's information provided in their acceptable Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F 323 was lowered to a D level to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficient practice was cited as a result of the investigation of complaint/report AL 087.

Based on a review of the Administrator's and Director of Nursing's job description and the facility corrective action plan, the administrative staff, who is responsible for the overall operation of the facility, failed to ensure the facility's policy and procedure for elopement and missing resident directed the staff to perform a head count of the residents when the secure care alarm sounded. The facility's policy did not specify to the staff to perform a head count to ensure all residents were in the facility. This failure allowed RI #1 to elope from the facility without staff knowledge on 3/27/17. On 3/27/17 around 7:30 PM, the facility's secure care alarm sounded. Employee Identifier (EI) #3, a Licensed Practical Nurse (LPN) responded, along with EI #5, a Certified Nursing Assistant (CNA). EI #5 held the door while EI #3 looked in the facility's parking lot. After nothing was seen outside, EI #3 came back inside, reset the alarm and continued with medication pass. The facility failed to implement measure to ensure all residents were in the facility. Then around 8:15 PM, after Resident Identifier (RI #1 had to be identified a police officer, a local hospital staff member called the nursing home to inform them that RI #1 had been found wandering around the parking lot of the local hospital, 0.10 miles away from the facility. EI #3 sent EI #4, a CNA to the local hospital to get RI #1. RI #1 was returned to the facility without injury. This deficient practice placed RI #1, one of three sampled residents, in immediate jeopardy of serious injury, harm or death. On 4/1/17 at 6:10 PM, Employee Identifier (EI) #1, the Administrator and EI #2, the Director of Nursing were notified of findings of Immediate Jeopardy in the area of Administration, F 490. Findings include: The undated ADMINISTRATOR JOB DESCRIPTION documented . General Purpose: To direct the day-to-day functions of the facility in accordance with current federal, state and local standards governing long-term care facilities to ensure that the highest degree of quality care can be provided to the residents at all times . The undated DIRECTOR OF NURSING SERVICES JOB DESCRIPTION documented General Purpose: To plan, organize, develop and direct the overall operation of the Nursing Services Department in accordance with current federal, state and local standards governing the facility, and as may be directed by the Administrator, to ensure that the highest degree of quality of care is maintained at all times . Refer to F 323 During an interview on 4/1/17 at 9:51 AM, EI #2, the DON acknowledged the facility's policy and procedure did not direct the staff specifically to perform a head sound when the secure care alarm sounded. When asked why, EI #2 stated because if the staff knew who triggered the alarm there would not be a reason to do a head count. When asked, should the facility's policy and procedure specify to the staff to do a head count, EI #2 replied, now the policy did. EI #2 acknowledged the facility had updated the policy and procedure to specify to the staff to do a head count. During an interview on 4/1/17 at 3:19 PM, EI #1, the Administrator acknowledged the facility had updated their policy and procedure to instruct the staff to perform a head count when the secure care alarm sounded and the staff did not know who had exited the door. ************************* On 5/1/17 at 11:37 AM, the facility submitted an acceptable Allegation of Credible Compliance, which documented: This is Atmore Nursing Center's allegation of credible compliance . 3/27/2017 8:28 p.m. (EI #3) LPN called and reported to the DON that the hospital had called her and told her that one of our residents was wandering around in their parking lot. (EI #3) sent a CNA to the hospital to get our resident and when the CNA got there the police was there and they brought the CNA and the resident back to the facility. (EI #3) told the DON that she was in a resident's room and that she heard the door alarm going off. (EI #3) walked to the door and saw a resident with a secure anklet on standing at the door. (EI #3) and a CNA walked outside and looked around the parking lot and did not see anyone in the parking lot. (EI #3) assumed that the resident standing by the door set the alarm off. After the resident was returned to the facility (EI #3) completed a head to toe assessment and found no injuries, resident denied pain. (EI #3) completed an incident report and notified the MD (Medical Doctor) and was fixing to call the sponsor and the sponsor came in the facility. The sponsor told (EI #3) that the policeman that picked up RI #1 was (his/her) nephew and he came to her house and told her that RI #1 was found wandering in the hospital parking lot and that is why she was at the nursing home to check on the resident. (EI #3) stated she heard the alarm going off around 7:30pm and the hospital called her at 8:00pm. On 3/27/17, RI #1 was safely returned to the facility. A body audit was completed and no injuries were noted. RI #1 was placed on Q (every) 30 minutes rounds. RI #1's Elopement Risk assessment was updated and Behavior tracking was started for the identified behavior of exiting the facility. On 3/27/17, the facility began an investigation into the elopement of RI #1 from the facility without staff knowledge. On 3/28/17, (manufacturer of secure care system) came to the facility to inspect the secure care system to ensure the egress locking system was working properly and to assess the exit doors for a lock on demand system. No concerns were found with the doors. On 3/27/17, the facility conducted an audit for all residents that have a secure care anklet and have been determined to be at risk for elopement to ensure all residents were in the facility and then a 100% audit was completed to ensure all residents were in the building. On 3/27/17, all staff re-inservice began on the policy and procedure for prevention of elopement and the policy and procedure for a missing resident to include that if the secure care door alarms goes off the staff will complete a head count beginning with residents listed on the secure care list to ensure all residents are in the facility and if any resident is found missing to implement the policy and procedure for a missing resident. Staff members that were at the facility at the time of RI #1's return were trained beginning 3/27/17 and this education continued as staff came into the facility for their assigned shift to work prior to being allowed to go onto the halls until all staff were trained. 19 staff members were educated on 3/27/17; 52 staff members were educated on 3/28/17; 25 staff members were educated on 3/29/17; and 13 staff members were educated on 3/30/17. All staff members were educated by 3/30/17. On 3/28/17, the facility's policy and procedure for the Prevention of Elopement was revised to reflect the implementation of 100% head count after the secure care door alarm sounds. On 3/28/17, the facility held a quality assurance committee meeting related to RI #1's elopement. The DON or designee will begin drills by setting off the secure care door alarm each day on alternating shifts beginning 3/29/2017 for 5 days x 1 week then weekly x 4 weeks then monthly for 4 months then quarterly ongoing to monitor the response times of the staff and to make sure the policy and procedure for prevention of elopement and the Policy and procedure for a missing resident is followed. The facility alleges the Immediate Jeopardy is removed as of 3/30/17. ************************* After reviewing the facility's information provided in their acceptable Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F 323 was lowered to a D level to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficient practice was cited as a result of the investigation of complaint/report AL 087.

Based on observations, interviews, and review of the medical record, facility policy regarding IV (Intravenous) Piggyback and Potter and Perry's Fundamentals of Nursing for IV therapy, the facility failed to ensure the Licensed Nurse labeled the IV (Intravenous) access site for RI (Resident Identifier) #9. This was observed on 3 of 3 survey days. This affected RI #9, one of one sampled residents with an IV access. Findings include: A review of the Facility's Policy and Procedure titled IV Policies and Procedures IV Piggyback with a date of 03/13 revealed . Guidelines 1. Peripheral IV site is to be rotated every 96 hours or per (according to) physician's orders [REDACTED]. A review of Potter - Perry Fundamentals of Nursing, Ninth Edition with a Copyright date of 2017, Chapter 42, page 976 revealed, INITIATING INTRAVENOUS THERAPY-cont'd (continued) . 24. Label dressing per agency policy. Include date and time of IV insertion, VAD (Vascular Access Device) gauge and length, and your initials . A review of RI #9's current medical record revealed RI #9 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #9's Admission MDS (Minimum Data Set) with an Assessment Reference Date) of 12/16/16 revealed, RI #9 had a BIMS (Brief Interview for Mental Status) score of 9. This score indicated RI #9 was moderately impaired for cognitive skills for daily decision making. RI #9 required extensive to total assistance from staff for all ADLs (Activities of Daily Living). A review of a Nurse's Note dated 2/5/2017 by EI (Employee Identifier) #1, a RN (Registered Nurse), revealed EXISTING IV INFILTRATED, RN RESTARTED IV SUCCESSFUL ON 3RD STICK TO RIGHT HAND USING A 24 GAUGE WITH BLOOD RETURN NOTED AND FLUSHED WELL. The following observations were made of RI #9's IV site in the resident's right hand: During the initial tour of the facility on 2/7/17 at 3:30 p.m. there was no label noted at the site. An observation was made of the resident's IV site on 2/7/17 at 5:55 p.m. with no date on the dressing of the IV site in RI #9's right hand. On 2/8/17 at 7:55 a.m. an observation was made of the IV site to RI #9's right hand. The dressing had no date noted on the dressing. An observation was made on 2/8/17 at 4:55 p.m. of RI #9's IV site to the right hand. There was no date on the dressing of the IV site. On 2/9/17 at 7:35 a.m., RI #9 was observed in bed with IV site to right hand. There was no date on dressing at IV site. On 2/9/17 at 1:35 p.m., an interview was conducted with EI #2, a RN. EI #2 was asked what the facility's Policy and Procedure was when an IV line was inserted. EI #2 stated that kits were used, first inform the resident what would be done, clean the site, insert the line, make sure to get a blood return, place clear biocclusive dressing on the site, and date the dressing. EI #2 was asked how IV site dressings should be labeled. EI #2 stated, With the date. EI #2 was asked what the purpose of labeling a dressing on the IV site was. EI #2 stated, So you know when it was done. EI #2 was asked when was RI #9's IV line inserted into the right hand. EI #2 stated, He/she came back with one on the 1st of February, I think and it was changed on 2/5 by (EI #1). (EI #1) is the evening RN. EI #2 was asked if EI #1 was responsible for labeling the IV. EI #2 stated, Yes ma'am. EI #2 was asked if she knew why the IV was not labeled. EI #2 stated, No, I do not know why. EI #2 was asked when should the site be changed. EI #2 stated, Today. On 2/9/17 at 1:50 p.m., a phone interview was conducted with EI #1. EI #1 was asked what the facility's Policy and Procedure was when an IV line was inserted regarding dressing the site. EI #1 stated to place a clear [MEDICATION NAME] on top of the site and stabilize with tape. EI #1 stated to label the site with the date, the gauge used and the Nurse's initials. EI #1 was asked what was the Policy and Procedure regarding changing IV sites. EI #1 stated, every 72 hours, I believe, maybe 96 hours. EI #1 was asked what the Standard of Practice was for changing IV sites. EI #1 stated, Every 96 hours. EI #1 was asked how an IV site dressing should be labeled. EI #1 stated with the date, gauge, and initials. EI #1 was asked what the purpose of labeling a dressing on an IV site was. EI #1 stated, So you know when it was done and when needs to be changed. EI #1 was asked when was RI #9's IV line inserted into the right hand. EI #1 stated, Can't remember if it was a Saturday or Monday night. I was going to start antibiotics and IV was bad. I removed it and started another one. EI #1 was asked who was responsible for labeling the site. EI #1 stated, I am, I did label it, it came off. EI #1 was asked why the site was not labeled. EI #1 stated, It must have come off, I did label it. On 2/9/17 at 2:03 p.m., an interview was conducted with EI #3, the DON (Director of Nursing). EI #3 was asked what the facility's Policy and Procedure was when an IV line was inserted regarding dressing the site. EI #3 stated to apply dressing and date and initial the dressing. EI #3 was asked what the policy and procedure was regarding changing the IV site. EI #3 stated, Our policy allows us to keep it 96 hours unless red, infiltrated. EI #3 was asked what the Standard of Practice was regarding changing IV sites. EI #3 stated, Every 72 hours. EI #3 was asked how IV site dressings should be labeled. EI #3 stated, I initial and date mine. EI #3 was asked what the purpose was of labeling a dressing on an IV site. EI #3 stated, Helps you keep up with when it is due to be changed. EI #3 was asked when was RI #9's IV line inserted into the right hand. EI #3 stated on the 5th of February. EI #3 was asked who was responsible for labeling the site. EI #3 stated (EI #1). EI #3 was asked why the IV site was not labeled. EI #3 stated, I did not know it wasn't labeled. EI #3 was asked when the IV site should be changed. EI #3 stated, Today.

Based on observations, records reviewed, interviews, review of the facility's Policy and Procedures on Medication Administration Procedures Enteral Tube Administration and Medication Administration - General Guidelinesregarding following physician's orders [REDACTED].#11. This affected RI #11 one of one residents observed for medication administration through the gastrostomy (G) tube. Findings Include: A review of a facility policy titled, Medication Administration Procedures Enteral Tube Administration with a copyright date of 2011, revealed, . Policy Medications are administered via (by way of) feeding tube in a safe and accurate manner when the resident is unable to take mediation by mouth. Medications should be provided through a feeding tube under the order of a physician. 6. Administer medications separately using a syringe. Medication can be diluted with water and flushed with approximately 5-10 mils (milliliter) of water. A review of a facility policy titled, Medication Administration - General Guidelines with a copyright date of 2011, revealed, . Policy The facility maintains equipment and supplies necessary for the preparation and administration of medications to residents. 2. Medications are administered in accordance with written orders of the attending physician. A review of Fundamentals of Nursing, Potter/Perry, Ninth Edition, revealed, Chapter 23 Legal Implementations in Nursing Practice, page 311, Abandonment and Assignment Issues . Health Care Providers' Orders. The health care provider, (physician, or advanced practice nurse) is responsible for directing medical treatment. Nurses follow health care providers' orders . A review of the medical record indicated RI #11 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a Quarterly MDS (Minimum Data Set) with an Assessment Reference Date of 09/12/2016, indicated RI #11 had a BIMS (Brief Interview of Mental Status) score of 3 out of a possible score of 15, indicating RI #11 was severely impaired for cognitive skills of daily decision making. This MDS also indicated RI #11 was totally dependent on staff for all activities of daily living. A review of the medical record for RI #11 revealed, Physicians Orders For the month of : February 2017 with an order Date of 7/29/16 . FLUSH W (with)/30CC'S (cubic centimeters) BEFORE & AFTER MEDICATION ADMINISTRATION & 5 CC'S BETWEEN EACH MED. (In addition to routine flush) . On 02/08/2017 at 5:01 p.m., EI (Employee Identifier) #4, a LPN, was observed preparing medications to administer to RI #11 by gastrostomy tube. Each medication was crushed and placed in separate medication cups. EI #4 took all cups of medications and a empty medication cup into RI #11's room. EI #4 added 5 ml's of water to each medication cup and 30 ml's to the empty medication cup. EI #4 checked the gastrostomy tube for placement, washed her hands and placed gloves on. EI #4 then administered 30 ml's of water through the [DEVICE]. EI #1 failed to provide water between each medication as ordered. An interview was conducted on 02/09/2017 at 12:11 p.m., with EI #4. EI #4 was asked to describe to this surveyor how she administered the medications by [DEVICE] to RI #11 on 02/08/2017 at 5:11 p.m EI #4 replied she diluted the medications and thought that was the 5 ml flush. She administered through the G tube 30 ml of water, after checking for placement. EI #4 stated that the medication was administered one after the other. EI #4 then said the [DEVICE] was flushed with 30 ml's of water and then 250 ml's of water was given. EI #4 was asked if the physician's orders [REDACTED].#11. EI #4 replied yes. The surveyor read the physician's orders [REDACTED]. EI #4 was asked again if the physician's orders [REDACTED].#11 medications by [DEVICE]. EI #4 replied no the order was not followed. EI #4 stated each medication was given one behind the other. EI #4 was asked what did the 5 ml flush between medications assure or prevent. EI #4 replied she didn't know. An interview was conducted on 02/09/2017 at 12:26 p.m., with EI #3 the Director of Nursing and Staff Development Educator. EI #3 was asked what the facility policy and procedure was on administration of medications by [DEVICE] and following Physican's orders. EI #3 looked at the facility policy and stated, to check placement, crush medications individually, mix a small amount of water, flush the [DEVICE] with 30 ml's of water and flush the [DEVICE] with 5 ml's of water between each medication administered. EI #3 was asked if the physician's orders [REDACTED]. EI #3 replied no. EI #3 was asked what the potential concern was regarding not following the physician's orders [REDACTED].

Based on observations, interviews, and record reviews, the facility failed to ensure air conditioners were not observed with debris on and under the vents. Also, the air conditioner vents were not found dented, loose and dislodged, rusted or missing. This affected 19 rooms on 3 halls and was observed on 3 of 3 survey days. Findings include: A review of an undated facility document titled, DIRECTOR OF MAINTENANCE JOB DESCRIPTION revealed, . General Purpose: To plan, organize and direct the overall operation of the department in accordance with current federal, state and local standards, ensuring that the facility is maintained in a safe, comfortable condition. Essential Job Functions . Duties . assist in establishing and maintaining a preventive maintenance program; . ensure proper maintenance of the facility including carpentry work, groundskeeping, painting, equipment . A review of a facility document with a revision date of 1/2/2014, titled Preventative Maintenance Checklist revealed, . Area to Check . Front Hall; Center Hall; East Wing; West Wing . Vents clean/secure . The following observations were made on 1/26/15, at the following times: At 10:58 AM - RL (Room Locator) #8 - 2 air conditioner vents were observed loose and dislodged. At 11:05 AM - RL #10 - 3 air conditioner vents were found loose, dented and dislodged. At 11:16 AM - RL #13 - 2 air conditioner vents were observed dented and dislodged. At 11:19 AM - RL #14 - 4 air conditioner vents were observed dented. At 11:24 AM - RL #16 - 3 air conditioner vents were observed dented and dislodged. At 11:29 AM - RL #17 - 2 air conditioner vents were dislodged and another was missing. At 11:32 AM - RL #18 - 2 air conditioner vents were dented. At 11:58 AM - RL #3 - the air conditioner vents were found with an accumulation of debris and rust on and under the vents. At 12:00 PM - RL #5 - 2 air conditioner vents were found with a heavy accumulation of debris and rust the vents. 2 vents were found dented. At 3:15 PM - RL #9 - the air conditioner vents were found dented and with peeling paint. Debris and rust was observed on and under the vents. At 3:19 PM - RL #11 - the air conditioner vents were found dented with a small amount of debris in the 2 right vents. At 3:22 PM - RL #15 - the air conditioner vents were found dented, loose, and dislodged. Debris was noted on and under the vents. On 1/26/16 at 5:00 PM, RL #1's air conditioner vent was observed to have a small amount of dust on the vent and a large accumulation of dust and a white substance was observed inside the air conditioner unit. On 1/26/16 at 5:05 PM, RL #4's air conditioner had a large accumulation of dust around the control panel, and dust was observed on the vent and inside the air conditioner unit. The vent was also bent. On 1/26/16 at 5:07 PM, RL #2's air conditioner had an accumulation of dust around the control panel and dust was observed on the vent and inside the air conditioner unit. The following observations were made on 1/27/15, at the following times: On 1/27/16 at 10:55 AM, RL #4's air conditioner had a large accumulation of dust around the control panel and dust was observed on the vent. Debris was observed inside the air conditioner unit. The vent remained bent. On 1/27/16 at 5:10 PM, RL #1's air conditioner vent was observed to have an accumulation of dust. Debris was inside the air conditioner unit. On 1/27/16 at 5:11 PM, RL #2's air conditioner had an accumulation of dust around the control panel, and dust was observed on the vent and inside the air conditioner unit. At 5:41 PM - RL #8 - the air conditioner vents were found with no changes. At 5:43 PM - RL #9 - the air conditioner vents were found with no changes. At 5:44 PM - RL #10 - the air conditioner vents were found with no changes. At 5:46 PM - RL #11 - the air conditioner vents were found with no changes. At 5:47 PM - RL #13 - the air conditioner vents were found with no changes. At 5:49 PM - RL #14 - the air conditioner vents were found with no changes. At 5:50 PM - RL #15 - the air conditioner vents were found with no changes. At 5:52 PM - RL #16 - the air conditioner vents were found with no changes. At 5:54 PM - RL #17 - the air conditioner vents were found with no changes. At 5:56 PM - RL #18 - the air conditioner vents were found with no changes. At 6:01 PM - RL #3 - the air conditioner vents were found with no changes. At 6:04 PM - RL #5 - the air conditioner vents were found with no changes. Observations were made during a tour with EI (Employee Identifier) #2, the Maintenance Director. The tour began on 1/28/16 at 8:42 AM and ended at 9:07 AM. EI #2 was asked to describe was he saw as he viewed the air conditioners in the specific Room Locators. The following includes a list of the Room Locators and EI #2's quotes of what he observed. RL #1 Looks like some debris and possible debris, food falls in there, control possibly dust. RL #2 Debris inside the unit, vents bent in. RL #3 Dust and some dented vents. RL #4 Dusty inside and some dented vents. RL #5 Loose and dented vents. RL #6 Debris in unit, vents are dented. RL #7 Dented vents. RL #8 They, the vents are dented, loose, and 1 missing. RL #9 They (the vents) dented, rusting, and paint flaking. RL #10 Loose, 2 missing and rest are bent and loose. RL #11 Dust, some vents are bent up. RL #13 Some rusty, dented/bent, and loose. RL #14 2 missing vents, dented and loose. RL #15 Vents are dented and 1 loose. RL #16 The vents are dented and 1 is loose. Debris in the unit. RL #17 2 missing vents, all loose and dented. RL #18 Same, rust, loose and dented. RL #19 Vents bent, rusty, and loose. An interview was conducted with EI #2 on 1/28/16 at 9:10 AM. EI #2 was asked who was responsible for maintenance and/or upkeep of air conditioner vents. EI #2 responded, I would say maintenance. EI #2 was asked how air conditioner vents should be maintained. He answered, Free of rust and dents. Securely mounted. EI #2 was asked what would be the concern of air conditioner vents that were dented, dislodged, rusted or found with an accumulation of dust and debris on them and inside the unit. He answered, Potential skin tear. EI #2 was asked what the facility's policy regarding maintaining equipment such as air conditioner vents was. He answered, We try to go around monthly, we vacuum them. We want preventative maintenance. EI #2 was asked how often were rounds made to assess air conditioner vents. He responded, Sometimes weekly, monthly, and when we get a report that something is needed. An interview was conducted with EI #1, the Administrator, on 1/28/16 at 10:47 AM. EI #1 was asked who was responsible for maintenance and/or upkeep of air conditioner vents. EI #1 responded, The Maintenance Director. EI #1 was asked how air conditioner vents should be maintained. She answered proper working order. EI #1 was asked what would be the concern of air conditioner vents that were dented, dislodged, rusted or found with an accumulation of dust and debris on them and inside the unit. She answered, If the air condition is functioning properly, those areas would be something to look at for appearance and function. EI #1 was asked what the facility's policy regarding maintaining equipment such as air conditioner vents was. She responded, We have a preventative maintenance guide that address that the unit is working, the filter is clean, and secure to the wall. EI #1 was asked if debris should be inside the units. She answered, No.

Based on observations, interviews, and record reviews the facility failed to ensure: 1. An LPN (Licensed Practical Nurse) washed her hands in a manner to prevent the potential for cross contamination during a medication pass on 1/26/16. 2. An LPN cleaned and dried a feeding tube syringe and a medication syringe in a manner to prevent the potential for cross contamination on 1/26/16. These deficiencies affected RI (Resident Identifier) #11, one of one residents observed for medication administration via G (Gastrostomy) tube. Findings include: A review of a facility policy titled, Handwashing Policy and Procedure with a revision date of 2/10 revealed: Purpose: The use of appropriate handwashing and hand antisepsis are recommended to promote improved hand-hygiene practices and reduce the transmission of microorganisms to patient and personnel in the health-care setting. Procedure: 1. Wash hands after touching blood, body fluids, secretions, excretions, mucous membranes, non-intact skin and contaminated items, regardless of whether gloves are worn. 3. Wash hands before and after performing invasive procedures, .when feeding residents, .when handling invasive devices, . when handling soiled linens and equipment, immediately after gloves are removed, .and when otherwise indicated, such as performing personal hygiene, to avoid transfer of microorganisms to other residents or environments. 5. It may be necessary to wash hands between tasks and procedures on the same resident to prevent cross contamination of different body sites. 6. You may use a plain (Non-antimicrobial) soap for routine handwashing, .When washing hands first with water, apply an amount of product recommended by the manufacturer to hands, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. HCW (Health Care Worker) may sing Happy Birthday To You to help determine the approximate time to apply friction. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet. A review of RI #11's medical record revealed RI #11 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #11's Annual MDS (Minimum Data Set) with an (ARD) Assessment Reference Date of 11/21/15 revealed RI #11 had a BIMS (Brief Interview for Mental Status) score of 4 out of a possible 15 points. This score indicated RI #11 was severely impaired for cognition and daily decision making. The assessment also revealed RI #11 required limited to extensive assistance for all activities of daily living. A medication pass observation was done on 1/26/14 at 5:15 PM. An LPN, EI (Employee Identifier) #3, set up medications to be administered to RI #11 on a paper towel placed on a bedside table. EI #3 washed her hands and obtained a paper towel by pressing the release bar of the towel dispenser with her wet bare hands. EI #3 checked the placement of the G tube with her bare hands. EI #3 rinsed the feeding syringe with water and rinsed her hands and obtained a paper towel by pushing the release bar of the paper towel dispenser with her wet bare hands and turned off the faucet with the contaminated paper towel. EI #3 applied gloves and administered medications to RI #11 via G tube. EI #3 rinsed out the feeding tube syringe with water and turned off the faucet with gloved hands. EI #3 obtained paper towels with her gloved hands, and dried the feeding syringe with the contaminated paper towels and gloves. EI #3 put the feeding syringe in a plastic bag. On 1/26/16 at 5:55 PM, EI #3 took the medication syringe out of a medication cart. The syringe was used to draw up a liquid medication during the above medication pass for RI #11. EI #3 used the pad lock on the door and entered a supply room on a unit in the facility. EI #3 turned on the water faucet with bare hands, rinsed the syringe, and turned off the faucet with her wet bare hands. EI #3 dried the syringe with a paper towel obtained by pushing the release lever with her wet hands. An interview was conducted with EI #3 on 1/27/16 at 5:20 PM. EI #3 was asked how she was taught to wash her hands. EI #3 stated, Turn on water with hands, wash real good then dry them. The surveyor asked when was her last in-service on hand washing. EI #3 stated, Well not too long ago, (the name of the Infection Control Coordinator, EI #4), will line us up at least once a month and do hand washing. EI #3 was asked how she washed her hands during the medication administration via G tube for RI #11 on 1/26/16. EI #3 stated, I set my stuff out and washed my hands. I made such a mess, I washed them twice. I washed when I went in and when I went out. I made a mess so I washed in the middle too. The surveyor asked EI #3 how she obtained the paper towels during hand washing, while administering medications to RI #11. EI #3 stated, I don't know. I think I punched it first, then washed my hands. I can't remember. The surveyor asked EI #3 how she cleaned the feeding syringe and medication syringe on 1/26/16, used for RI #11. EI #3 stated, I washed them out in the sink and dried them with a paper towel. EI #3 was asked how she turned off the faucet during hand washing. EI #3 stated, I reached with my hand and turned it off. The above observations were discussed with EI #3 and the surveyor asked EI #3 what was the concern. EI #3 stated, I contaminated the syringe for the medication.The concern with the hand washing was cross contamination. An interview was conducted with EI #4 on 1/28/16 at 10:30 AM. The surveyor asked EI #4 how were staff members taught to wash their hands. EI #4 stated, We do in-services on infection control, mini-in-services, and we have annual skills check off on infection control and hand washing. The surveyor asked EI #4 when was the last in-service on handwashing. EI #4 provided an in-service dated 10/13/15 and 10/14/15. EI #3's name and signature were on the Skills Fair sign in form. The surveyor shared the above observations for medication administration for RI #11 on 1/26/16, and asked EI #4 what was the concern. EI #4 stated, Potential for causing infection. Proper hand washing is the first line of defense. The nurse was administering through a G tube. That is a concern for potential for infection. EI #4 was asked how EI #3 should have washed her hands. EI #4 stated, Set up the items, release the paper towels down by pressing the bar. Use a sufficient amount of soap. Wash your hands singing the happy birthday song. Clean nails, rinse down, hanging down in the sink. You then take the paper towel and dry from fingers to wrist, clean to dirty. You then obtain a dry paper towel and turn off the faucet.

Based on observations and interviews, and medical record review, the facility failed to ensure Resident Identifier (RI) #15, a tube fed resident was not in view of the roommate by pulling the privacy curtain after the roommate was served a tray and eating. Observations of this occurring were made on 2 of 3 survey days, and affected RI (Resident Identifier) #15, one of two sampled resident receiving a tube feeding. Findings include: A review of the medical records indicated RI (Resident Identifier) #15 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a 5-Day MDS (Minimum Data Set) with an Assessment reference date of 09/02/2014, indicated RI #15 had long and short term memory problems, and was severely impaired for cognitive skills of daily decision making. This MDS also indicated RI #15 was totally dependent on staff for all activities of daily living. On 12/09/2014 at 4:55 PM, EI (Employee Identifier) #4, a CNA (Certified Nursing Assistant) served RI #15's roommate a tray. RI #15 was observed in bed, awake, and tube feeding was infusing at this time. EI #4 did not pull the privacy curtain between the residents. On 12/09/2014 at 5:12 PM, RI #15's roommate was observed sitting on the side of the bed and eating. The privacy curtain was not pulled. RI #15 was awake. On 12/10/2014 at 7:37 AM, EI #15 was awake in bed and lying on the left side with eyes open. RI #15's roommate was eating breakfast, and the privacy curtain was not pulled between the residents. On 12/10/2014 at 5:45 PM, RI #15 was in bed with eyes closed. RI #15's roommate was served supper at this time, and the privacy curtain was not pulled between the residents. An interview was conducted on 12/11/2014 at 10:06 AM with EI #4. EI #4 was asked what the facility's policy was on serving meals to residents with roommates that were tube feeders. EI #4 replied, "I would pull the curtain while they are eating. ..." EI #4 was asked why the privacy curtain should be pulled between residents when one resident was eating and the other was a tube fed. EI #4 stated, "Because tube feeders can't have anything by mouth. (RI #15) gets therapeutic trays at lunchtime so she eats herself." EI #4 was asked why the privacy curtain was not pulled between the residents on 12/09/2014 at 4:55 PM, or 12/10/2014, and 12/10/2014 at 7:37 AM, when the meals were served to RI #15's roommate. EI #4 replied, "I think I forgot to pull it." EI #4 was asked how it could affect the resident with tube feedings, by not pulling the curtain between residents. EI #4 stated, "They could be wondering why they can't have any. Wondering why the other resident is eating and they are not." On 12/11/2014 at 10:20 AM, an interview was conducted with EI #5, a CNA. EI #5 was asked what the facility's policy was on serving meals to residents with roommates that were tube feeders. EI #5 replied, "Serve resident tray and ask resident with tube feeding if they are ok." EI #5 was asked why the privacy curtain should be pulled between residents when one resident was eating and the other was tube fed. EI #5 stated, "The one not eating will probably feel they want something to eat because they see the other one eating." EI #5 was asked why the privacy curtain was not pulled between the residents on 12/09/2014 at 4:55 PM, or 12/10/2014 at 7:37 AM, when the meals were served to RI #15's roommate. EI #5 responded, "It should have been pulled because (RI #15's roommate) was eating ... breakfast. I don't know why it was not." EI #5 was asked how it could affect the resident with tube feedings, by not pulling the curtain between residents. EI #5 replied, "Resident may feel (RI #15) is being neglected because (RI #15) is not eating and (RI #15) is looking at the roommate's food." EI #6, the Director of Nursing was interviewed on 12/11/2014 at 1:40 PM. EI #6 was asked what the facility's policy was on serving meals to residents with roommates that were tube feeders. EI #6 replied, "There's not a specific policy, but the curtain should be pulled ..." EI #6 was asked why the privacy curtain should be pulled between residents when one resident was eating and the other was a tube fed. EI #6 responded, "You want to avoid eating in front of someone if they are not eating." EI #6 was asked if they trained or encouraged CNAs to pull the privacy curtains when one resident was tub fed and the other was eating. EI #6 stated, "We train the staff to provide privacy. That's just what we do for privacy."

Based on observations, interviews, and record reviews, the facility failed to ensure two CNAs (Certified Nursing Assistants) provided incontinence care in a manner to prevent the potential for cross contamination. This had the potential to affect RI (Resident Identifier) #8 and #9, two of two residents observed for incontinence care. Findings include: A review of Potter - Perry Fundamentals of Nursing, 6th Edition, with a Copyright date of 2005, Chapter 38, page 1033 revealed: "B. Male perineal care... (3) Gently raise penis, and place bath towel underneath. Gently grasp shaft of penis. If client is uncircumcised, retract foreskin. ... (4) Wash tip of penis at urethral meatus first. Using circular motion, cleanse from meatus outward... Discard washcloth, and repeat with clean cloth until penis is clean. Rinse and dry gently. (5) Return foreskin to its natural position. (6) Wash shaft of penis with gentle but firm downward [MEDICAL CONDITION]. Pay special attention to underlying surface of penis. Rinse and dry penis thoroughly. Instruct client to spread legs apart slightly. (7) Gently cleanse scrotum. Lift it carefully, and wash underlying skinfolds. Rinse and dry. ..." A review of the facility's policy with a revised date of 08/14, and entitled, "Giving a bEd Bath," revealed, "PURPOSE: 1. To cleanse, refresh, and soothe the resident 2. To stimulate the circulation ... PROCEDURE: ... 4. Obtain water in both basins and check that it is not too warm. ... 6. Wash face and ears. Rinse and dry. 7. Use separate washcloth to wash areas of the body and separate washcloth to rinse. ... 9. Wash neck, arms, hands ... Rinse and dry. 10. Wash thighs, legs and feet (between toes). Rinse and dry. 11. Wash back, back of legs and buttocks. Rinse and dry. Place used washcloths in bag for soiled linen. Remove gloves. Wash your hands. 12. Change water in both basins. Wash hands and apply golves. 13. Use clean washcloth to wash genitalia in the same manner as directed ... Rinse with clean washcloth and dry. Place used washcloths in bag for soiled linen. Remove gloves and wash hands. ... " 1) A review of RI #8's medical record revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a Significant Change MDS (Minimum Data Set) for RI #8 with an ARD (Assessment Reference Date) of 10/17/14 revealed, RI #8 was coded as requiring extensive assistance from staff for transfers, mobility, dressing, toileting, and bathing. RI #8 was coded as always incontinent of bladder and bowel functions. A review of RI #8's care plans revealed a care plan for the resident being totally incontinent of bowel and bladder functions. The resident was also care planned for a risk for [MEDICAL CONDITION] related to [MEDICAL CONDITION]. On 12/10/14 at 9:14 AM, an observation of incontinence care for RI #8 was observed by the surveyor. EI (Employee Identifier) #1, CNA, filled two basins with water and placed towels in each basin. EI #1 was observed performing AM care to the upper portion of RI #8's torso region. EI #1 then cleansed the right thigh, rinsed, and dried the area. EI #1 cleansed the left thigh, rinsed, and dried the area. EI #1 then emptied the bath water and placed a new towel in the basin. EI #1 did not change the rinse water or towel. EI #1 cleansed the pubic area and penis of RI #8 without changing the position of the towel. EI #1 used the rinse towel, rinsed the pubic area and penis, and dried the areas. RI #8 was positioned on the right side and EI #1 cleansed the upper back and buttocks, rinsed and dried these areas. EI #1 placed peri wash into the rectal area and used the rinse towel and cleansed the area. The surveyor observed yellow stool on the towel. EI #1 placed the towel into the rinse water then removed it and placed the towel in a plastic bag. EI #1 dried the rectal area, placed a brief on the resident and the resident was positioned on the left side. EI #1 using the soapy towel, washed right upper back, placed towel in rinse water, rinsed area, and dried area. RI #8 was then positioned on the back and the brief was secured. On 12/11/14 at 8:44 AM, an interview was conducted with EI #1. EI #1 was asked when performing hygiene care for residents and using basins with wash and rinse water, when the water should be changed. EI #1 stated before the care was done. EI #1 was asked when the wash towels should be changed. EI #1 stated the residents face, chest, and arms should be cleaned and then change towel/cloth. EI #1 further stated to clean the perineal area then change the towel/cloth before cleaning the back. EI #1 was asked when had she changed the bath water while performing care for RI #8. EI #1 stated, "Before cleaning perineal area." EI #1 was asked when she had changed the rinse water. EI #1 stated, "At the same time." EI #1 was asked how the perineal area and penis should be cleaned. EI #1 stated, "Wipe pubic area first, go down left groin then go down right groin, then fold rag and wash the penis (the shaft) in a circular motion. " EI #1 stated to continue by, "Pulling the foreskin down, fold the rag, and wipe the inside in a circular motion." EI #1 was asked was it appropriate to change the position of the towel when cleaning the perineal and penile areas. EI #1 stated, "Yes ma'am." EI #1 was asked why was changing the position of the towel appropriate. EI #1 stated, "So you don't wipe with the same part of the rag." EI #1 was asked if stool was noted on the wash cloth while providing care, what should be done. EI #1 stated, "Put it in a bag where you put dirty linens and get another one (clean cloth)." EI #1 was asked was it appropriate to clean the buttocks and perineal area then wash and rinse the upper back of a resident using the same towels and water. EI #1 stated, "No ma'am. You should always change the wash cloth before and after doing the perineal area." EI #1 was asked what the potential harm was to the resident if the wash and rinse water was not changed after washing the upper torso and before cleaning the perineal area and penis. EI #1 stated, "Can cause rash, bacteria, (and) infection" EI #1 was asked what the potential harm was to the resident for not changing the position of the towel with each stroke while cleaning the perineal area. EI #1 stated, "Same thing, rash, bacteria, (and) infection." EI #1 was asked what the potential harm was to the resident of washing and rinsing the upper back after washing and rinsing the buttocks and not changing the towels. EI #1 stated, "Same thing, cross contamination. You should always change first." 2) A review of RI #9's medical record revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #9's Quarterly MDS with an ARD of 11/27/14 revealed RI #9 was coded as requiring extensive assistance from staff for transfers, mobility, dressing, toileting, personal hygiene, and bathing. RI #9 was coded as always incontinent of bowel and bladder function. A review of RI #9's care plans revealed a care plan for the resident being totally incontinent of bladder and bowel function. On 12/10/14 at 10:19 AM, an observation was made of incontinence care performed for RI #9 by EI #3, CNA. EI #3 was observed to cleanse the groin areas, then using a clean disposable wipe EI #3 cleansed the scrotal area in an upward motion (from the rectal area forward). There was a small amount of brown stain on the wipe after EI #3 cleansed in an upward motion. EI #3 obtained a clean wipe, and cleansed the scrotal area in an upward motion with a small amount of brown stain on the wipe. EI #3 was observed rotating the disposable wipe and cleansed the scrotal area again in an upward motion. On 12/11/14 at 9:20 AM, an interview was conducted with EI #3. EI #3 was asked when providing incontinence care for a male resident how should the scrotal area be cleaned. EI #3 stated, "...clean sac, hold up and clean down when cleaning." EI #3 was asked why the scrotal area should be cleansed in a downward motion. EI #3 stated, "If I wipe up I will be putting urine right back on them. I usually clean down." EI #3 was asked what the potential concern for the resident was if the scrotal area was cleansed from back to front, and there was stool on the wipe. EI #3 stated, "It could get on them and cause rash or anything. Could have bad odor, germs, (and) cross contamination." On 12/11/14 at 12:45 PM, an interview was conducted with EI #8, Infection Control Nurse. EI #8 was asked when performing hygiene care for residents and using basins with wash and rinse water, when the water should be changed. EI #8 stated, "The water needs to be changed whenever it gets dirty and before doing perineal care." EI #8 also stated, "When washing, wash face, arms, hands, and upper torso. Then wash their back, each leg, feet and toes. Then change the water, both wash and rinse." Then perform perineal care, start with the front." EI #8 was asked when the wash towels should be changed. EI #8 stated, "Change cloths as often as needed, especially when they get dirty." "Change them prior to the perineal care when you change the water." EI #8 stated, "If doing pericare, if heavily soiled change it then also." EI #8 was asked how the perineal area and penis should be cleaned. EI #8 stated, "You retract the foreskin if uncircumcised, start at the meatus and wipe downward. We make sure we get the groin area. When we clean the scrotum, wipe downward, when we get ready to do the anal area, we wipe the buttocks upward. Wipe the anal area upward, 1 time each stroke." EI #8 was asked was it appropriate to change the position of the towel when cleaning the perineal and penile areas. EI #8 stated, "Wipe once and change the position. You should even change the position when you are patting dry." EI #8 was asked if stool was noted on the wash cloth while providing care, what should be done. EI #8 stated, "Put the cloth in the bag with other dirty linen or cloths, and get a clean wash cloth." EI #8 was asked was it appropriate to clean the buttocks and perineal area and then wash and rinse the upper back on a resident using the same towels and water. EI #8 stated, "No, because that's cross contamination. You will have cleaned one of the dirtiest areas of the body and then went to another area that's not as dirty." EI #8 was asked what the potential harm was to the resident of not changing the wash and rinse water after washing the upper torso and before cleansing the perineal area and penis. EI #8 stated, "Cross contamination because the wash and rinse water is dirty. You could possibly cause a UTI (Urinary Tract Infection) because the water is dirty." EI #8 was asked what the potential harm to the resident was of not changing position of the towel with each stroke while cleaning the perineal area. EI #8 stated, "Cross Contamination." EI #8 was asked what the potential harm to the resident was of washing and rinsing the upper back after washing and rinsing the buttocks and not changing towels. EI #8 stated, "Cross Contamination. After cleaning the peri area that's dirty, so therefore the resident's body wouldn't be clean." EI #8 was asked when cleaning the scrotal area in an upward motion and brown stain was noted on the wipe, what was the potential harm. EI #8 stated, "That would indicate feces and therefore the resident wouldn't be clean."

Based on observation, interviews and document reviews, the facility failed to ensure one of 5 licensed nurses administered medications to a resident as ordered by the physician. This was observed during medication pass during which there were 2 errors with 26 opportunities; resulting in a 7.69% (percent) medication error rate. This deficient practice occurred during the medication pass for one of 8 residents given medications, affecting RI (Resident Identifier) #14. Findings include: A review of medical records revealed RI #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #14's Admission MDS (Minimum Data Set) with an Assessment Reference Date of 09/02/2014, revealed a BIMS (Brief Interview for Mental Status) score of 7 out of a possible 15 points. This indicated RI #14 was severely impaired for cognitive daily decision making skills. This MDS also indicated RI #14 required extensive staff assistance, or was totally dependent on staff for all activities of daily living. A review of the December 2014 Physician order [REDACTED]. PROAIR HFA 90 MCG (Micrograms) 1 PUFF BID R/T [MEDICAL CONDITION] ..." On 12/09/2014 at 3:50 PM, RI #14 was observed to have medications administered by EI (Employee Identifier) #11, a Licensed Practical Nurse. EI #11 administered 1 puff of the Atrovent to RI #14, and dropped the uncapped inhaler onto RI #14's stomach/shirt. EI #11 retrieved the inhaler and gave RI #14 a second puff. EI #11 then administered some pills to RI #14. EI #11 then administered 2 puffs of ProAir to RI #14. An interview was conducted with EI #11 on 12/11/2014 at 9:55 AM. EI #11 was asked how she had administered the Atrovent and ProAir to RI #14, during the observation on 12/9/2014. EI #11 replied, "I gave (RI #14's) puffs. I think I gave 1. I may be wrong." EI #11 was asked how many puffs of the Atrovent had she given to RI #14 during the observation, and she replied, "I think I gave (RI #14) 1." The surveyor shared the observations of the Atrovent and ProAir being given, to include the inhaler being dropped twice, and the pills being given. EI #11 stated, "I gave (RI #14) 2, then." EI #11 was asked how many puffs of the ProAir she had administered to RI #14. EI #11 replied, "... I didn't realize I had given (RI #14) 2 puffs." EI #11 was asked if it was appropriate to give 2 puffs of the Atrovent and ProAir, when 1 puff was ordered, and she replied, "No." EI #11 was asked why not. EI #11 stated, "Cause that's not what's ordered." EI #11 was asked what the potential harm was of administering more than 1 puff as ordered. EI #11 replied, "(RI #14) could have a reaction or some problems from it, because it is steroids." An interview was conducted with EI #6, the Director of Nursing on 12/11/2014 at 1:46 PM. EI #6 was asked if it was appropriate to give 2 puffs of Atrovent and ProAir, when 1 puff was ordered, and she replied, "You should just give 1 puff." EI #6 was asked why, and she replied, "That would be the order." EI #6 was asked what the potential harm was of administering more than 1 puff as ordered. EI #6 stated, "It would depend on the resident and their condition. ..."

Based on observation, interviews and document reviews the facility failed to ensure an expired container of Pinto Beans was discarded by the use by date. This was observed on 1 of 3 survey days, and had the potential to affect 85 residents whose meals were prepared in the kitchen. Findings include: A review of the facility's document titled "FOOD STORAGE," and dated 2013 revealed, "... f. All foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded." During the initial tour of the kitchen on 12/9/14 at 1:00 PM a container of Pinto Beans, with a use by date of 12/8/14 was found in the cooler. An interview was conducted on 12/11/14 at 8:30 AM with EI (Employer Identifier) #7, the Dietary Manager. EI #7 was asked how leftover foods were dated. EI #7 stated, "When we have leftovers they are to be covered and dated from that date to up to three days." EI #7 was asked when were dates on leftover food checked. EI #7 stated, "Every night our night cook is to check dates in the coolers (and) freezers." EI #7 was asked who was responsible for checking the expiration dates on leftover food. EI #7 stated, "The night cook and once a week I come behind them to check and make sure they are doing what they are supposed to do." EI #7 was asked what was the potential harm to residents if they were served foods that were past their expiration dates. EI #7 stated, "They can cause illness if it's over (the use by) date. Any foods that are potentially a hazardous food could cause them to get sick." EI #7 was asked on the initial tour of the kitchen, what use by date was on the Pinto Beans. EI #7 stated, "12/8/14." EI #7 was asked what date was on the Pinto Beans when they were found. EI #7 stated, "12/9/14." EI #7 was asked what did the policy state concerning the length of time leftover foods were to be kept before discarding them. EI #7 stated, "Our policy says that (leftover) foods should be kept seventy-two hours or three days and then discarded."

Based on observations, interviews, and record reviews, the facility failed to ensure: 1. A Registered Nurse (RN) did not open a capsule with her bare hands during a medication pass for RI (Resident Identifier) #1. 2. A licensed nurse cleaned an Atrovent Inhaler in an appropriate manner after dropping it on the floor, and before returning it into the medication cart. This same nurse did not perform hand hygiene after leaving one resident's room, and before entering another resident's room. This had the potential to affect RI #1 and RI #14, two of eight residents observed for medication pass. Findings include: A review of the facility's Policy entitled, "Handwashing Policy and Procedure" with a revision date of, "2/10" revealed: "Purpose: The use of appropriate handwashing and hand antisepsis practices are recommended to promote improved hand-hygiene practices and reduce the transmission of microorganisms to patient and personnel in the health care setting. Procedure: "...3. Wash hands...when handling soiled linen and equipment, ...between resident contacts, and when otherwise indicated, such as performing personal hygiene, to avoid transfer of microorganisms to other residents or environments. ...5. It may be necessary to wash hands between tasks and procedures on the same resident to prevent cross contamination of different body sites. ..." A review of RI #1's medical record revealed RI #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's Quarterly MDS (Minimum Data Set) with an (ARD) Assessment Reference Date of 7/6/14, revealed RI #1 had a BIMS (Brief Interview for Mental Status), score of 8 out of a possible 15 points. This score indicated RI #1 was moderately impaired for cognition. RI #1 required extensive assistance for all activities of daily living. A review of RI #1's Care Plan with the onset date of 09/2014 revealed: "...RI #1 has a dx (diagnoses) of anemia. May be at risk for infections..." During a medication observation on 12/10/14 at 4:10 PM, the RN, EI (Employee Identifier) #10, set up medications to be administered to RI #1. EI #10 put two pills and a capsule in separate medication cups. EI #10 crushed the 2 pills in crush bags and added them to pudding in separate medication cups. EI #10 opened the capsule with her bare hands and mixed the contents with pudding. EI #10 then entered the room, set up the medications on the bedside table, washed her hands and applied gloves. During an interview with EI #10, on 12/10/14 at 4:00 PM, the surveyor asked how should a licensed nurse open a capsule during a medication pass. EI #10 stated, "With gloves." The surveyor asked EI #10 how did she open RI #1's capsule during the above medication pass observation. EI #10 stated, "I'm assuming without gloves, since you are asking me about that." The surveyor asked EI #10 what was the concern when a capsule was opened with bare hands during a medication pass. EI #10 stated, "I don't know. I'm assuming the medication could get on me. I was not touching the medication. My understanding is the capsule is the barrier. Well, it still should have been with gloves." An interview was conducted on 12/11/14 at 12:42 PM, with EI #8, the Infection Control Nurse. EI #8 was asked how should a licensed nurse open a capsule during a medication pass. EI #8 stated, "Wash her hands, put on gloves, then open the capsule. ..." The surveyor asked EI #8 what the concern was, when a skilled nurse opened a capsule with their bare hands. EI #8 stated, "Infection control, You don't need to touch the residents' medicine..." 2) A review of the medical records revealed RI #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Admission MDS with an Assessment Reference Date of 09/02/2014 for RI #14 revealed a BIMS score of 7 out of a possible 15 points. This indicated RI #14 was severely impaired for cognitive daily decision making skills. This MDS also indicated RI #14 required extensive staff assistance, or was totally dependent on staff for all activities of daily living. A review of the December 2014 Physician order [REDACTED]. PROAIR HFA 90 MCG (Micrograms) 1 PUFF BID R/T BRONCHITIS ..." On 12/09/2014 at 3:50 PM, RI #14 was observed to have medications administered by EI #11, a Licensed Practical Nurse. EI #11 administered 1 puff of the Atrovent to RI #14, and dropped the inhaler. EI #11 dropped the uncapped inhaler onto RI #14's stomach/shirt, then retrieved it and gave RI #14 a second puff. EI #11 dropped the inhaler on the floor, picked it up and wiped it off with a dry paper towel. EI #11 then recapped the inhaler. EI #11 then administered 2 puffs of ProAir to RI #14. EI #11 returned the inhalers to the medication cart, and placed them in their plastic bags. EI #11 did not wash her hands, or use hand sanitizer before leaving this resident's room. On 12/11/2014 at 9:55 AM, an interview was conducted with EI #11. EI #11 was asked what should be done with a resident's inhaler, if it was dropped on the floor. EI #11 replied, "Cleaned off." EI #11 was asked how she had cleaned the inhaler on 12/09/14 during the observation, when the inhaler had dropped on the floor. EI #11 stated, "A napkin from the dispenser. I should have used alcohol." EI #11 was asked what the potential harm was of only wiping the inhaler with a dry paper towel. EI #11 replied, "You're not cleaning it really. So, infection." EI #11 was asked when had she performed hand hygiene during the observation, after medicating RI #14, and before going into another resident's room. EI #11 stated, "I didn't. I did it when I came out of (RI #14's) room. I used the sink in (an unsampled resident's) room, after I helped (the unsampled resident) to the bathroom." EI #11 was asked what the potential harm was of not washing her hands after leaving RI #14's room, and before going in to another resident's room. EI #11 stated, "If I had done patient care and gave any medicines, infection. I washed my hands when I went into the (unsampled resident's) room. If I had not (washed my hands), it would have been the potential for infection." On 12/11/2014 at 1:06 PM, an interview was conducted with EI #8, the Infection Control Nurse. EI #8 was asked what should be done with a resident's inhaler, if it dropped on the floor. EI #8 stated, "We have to clean it. The parts I could wash, I'd use soap and water. It has to be cleaned before being given to the resident." EI #8 was asked what the potential harm was of only wiping the inhaler with a dry paper towel. EI #8 replied, "It has the potential of causing harm to the resident. There could have been particles of dirt left on there. It was contaminated when it hit the floor." An interview was conducted with EI #6, the Director of Nursing, on 12/11/2014 at 1:46 PM. EI #6 was asked what should be done with a resident's inhaler, if it drops on the floor. EI # replied, "Picked up immediately and cleaned. It should be wiped off with soap and water, unless it fell into something gross." EI #6 was asked if it was appropriate to clean hands between residents. EI #6 responded, "Yes. Because you are going to enter another patient's area."

Based on observations, interview and record review, the facility failed to ensure that food past the "use by" date was used or discarded from the refrigerator timely. This had the potential to affect 82 of 82 residents who receive meals from the kitchen. Findings include: A review of the facility's Policy and Procedure states, "Excessive leftovers should be avoided. Leftovers will be properly handled and used or discarded as appropriate. Leftover foods are not used for pureed diets. ... Any food that is left over will be handled as noted above and may be used as follows. ... Leftovers can be used if used within 72 hours (3 days) and if reheated to 165 degrees for a minimum of 15 seconds for hot food. ... Use leftovers within 3 days or discard. ..." During the initial tour on 12/17/2013 at 10:35 AM of the Dietary Department several containers of leftovers were found in the reach in refrigerator that was past the "use by" date. 1) "Lasagna 12/10/2013," "Cabbage 12/14/2013," "Chicken and Rice 12/16/2013," "Vegetable Soup 12/12/2013," "Tomato Soup 12/14/2013," "Pinto Beans 12/14/2013," "Roast Beef 12/15/2013," "Pinto Beans 12/11/2013" and pureed Bread 12/13/2013." On 12/19/2013 at 3:25 PM, an interview was conducted with EI (Employee Identifier) #7 Dietary Manager (DM). EI #7 was asked: 1) What is your policy and procedure on dating leftover foods in the refrigerator. "Any items that are considered leftovers, that have been prepared needs to be dated to discard in three days." 2) What is the policy and procedure for discarding food once it had reached its "use by" date, "they were to be discarded." 3) Who was responsible for removing the expired food products from the refrigerator. "We have a cleaning schedule with the refrigerator scheduled for a deep clean every Sunday." 4) What was the potential negative outcome for not discarding food by its "use by" date. "Depending on the type of food it could make someone sick."

Based on observations, interviews, and record review, the facility failed to ensure staff knocked prior to entering residents' rooms, observed on 2 of 3 survey days. Findings include: Based on the document provided by EI (Employee Identifier) #8, Administrator, entitled "RESIDENT RIGHTS 1. Residents have the right to be treated with dignity, privacy, respect, and to live in a clean, comfortable and homelike environment...." Per EI #8, the facility does not have a policy on knocking prior to entering a room, however, Item 1 of Residents Rights includes this. She further stated this was discussed with the staff. The following observations were made: During the tour on 12/17/2013 at 10:58 AM, EI #1, an LPN (Licensed Practical Nurse) entered AL (Area Locator) #10, without knocking. She left the room, then re-entered a second time without knocking, at 10:59 AM. There was a resident present in the room in Bed #1. On 12/17/2013 at 4:10 PM, EI #2, a RN (Registered Nurse) entered AL #11, without knocking. The resident for Bed #1 was in the room at that time. On 12/19/2013 at 2:09 PM, EI #3, a CNA (Certified Nursing Assistant) entered AL #11, without knocking. The resident in Bed #1 was in bed. On 12/19/2013 at 2:11 PM, EI #4, a CNA entered AL #12, without knocking. The resident in Bed #2 was in the room. On 12/19/2013 at 2:12 PM, EI #4, followed by EI #3, entered AL #13, without knocking. On 12/19/2013 at 3:29 PM, an interview was conducted with EI #2. EI #2 was asked what was the facility's policy on knocking before entering a resident's room. EI #2 stated, "You knock on door. If door is open, still knock letting them know you are there." EI #2 was asked about the possible negative outcome of not knocking prior to entering. EI #2 stated, "They can get upset or embarrassed if they didn't know you were coming in. They only have a small area to get privacy in." On 12/19/2013 at 5:30 PM, an interview was conducted with EI #6, DON (Director of Nursing). EI #6 was asked about the facility's policy on knocking prior to entering a resident's room. EI #6 stated, "They are to knock." EI #6 was asked about the potential negative outcome of not knocking prior to entering a resident's room. EI #6 stated, "It depends on the resident."

Based on record reviews and interview the facility failed to ensure labs were drawn as ordered by the physician. This affected RI #18, one of twenty residents sampled. Findings include: RI #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Nursing Admission Assessment for RI #18 indicated the resident was totally dependent for mobility and bathing, partially dependent with dressing/grooming and eating, and no behavior problems. The resident was identified as being oriented to self and date of birth with confusion. A review of the physician's orders [REDACTED]. A review of a facility form titled, "LAB/X-RAY/OP/APOINTMENT FOLLOW-UP MANUAL LOG, WING West, MONTH [DATE]" indicated RI #18 was scheduled to have a PT & INR lab specimen drawn on dates listed as follows "[DATE]" and "[DATE]" with a space that was left blank, that was intended to indicate the date the lab specimen was drawn. "[DATE]" the lab specimen was identified as drawn on "[DATE]." "[DATE]" with a notation of "unable to draw, attempted X (times) 3, notified MD (Medical Doctor)" in the space intended to indicate the date the lab specimen was drawn. On the line dated "[DATE]" a line was drawn through the date, lab specimen name, and "deceased " was written in the space intended to indicate the date the lab specimen was drawn. Further review of the clinical record found Lab results dated [DATE] with a hand-written note "Notify MD [DATE]" and initialed. Further review of the clinical record found Lab results dated [DATE] with a hand-written note "Notify MD [DATE]" and initialed. A review of the physician's orders [REDACTED]. During an interview with EI (Employee Indentifier) #6, the DON (Director of Nursing), on [DATE] at 5:12 PM, she was asked who was responsible for ensuring ordered labs were drawn. EI #6 stated, "the RN (Registered Nurse) Supervisor." When asked why were the ordered PT/INR labs for RI #18 not drawn on [DATE] and [DATE]. EI #6 stated, "I do not know. I spoke with the RN that worked that week and she just doesn't remember, she doesn't know." When asked what follow up was done and where it was documented, EI #6 stated, "the Doctor was notified that we tried Xs 3 to draw the PT and INR and were unable, on the lab log. That was for the 22nd, none on 19 and 20." When asked what was the Physician's guidance or instruction when he was notified. EI #6 responded, "There were no further orders given." When asked where the "no further orders" was documented, EI #6 stated, "Nothing in the chart documented." When asked why were the PT/INR labs ordered to be drawn. EI #6 stated, "[MEDICAL CONDITION] of lower extremity." When asked what was the potential negative outcome when a resident does not have PT/INR labs drawn as ordered, when they have a [DIAGNOSES REDACTED]. EI #6 stated, "I would like to refer you to the physician. That would depend on the acuity level and other diagnosis."

Based on record reviews and interview, the facility failed to ensure labs were drawn as ordered by the physician. This affected RI #18, one of twenty residents sampled. Findings include: RI #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Admission Nursing Assessment the resident was identified as totally dependent for mobility and bathing, partially dependent with dressing/grooming and eating, and no behavior problems. The resident was identified as being oriented to self and date of birth with confusion. A review of the physician's orders [REDACTED]. A reiview of a facility form titled, "LAB/X-RAY/OP/APOINTMENT FOLLOW-UP MANUAL LOG, WING West, MONTH October 2013," indicated RI #18 was scheduled to have a PT & INR lab specimen drawn on dates listed as follows "10-19-13" and "10-20-13" with a space that was left blank, that was intended to indicate the date the lab specimen was drawn. "10-21-13" the lab specimen was identified as drawn on "10-21-13." "10-22-13" with a notation of "unable to draw, attempted X (times) 3, notified MD (Medical Doctor)" in the space intended to indicate the date the lab specimen was drawn. During an interview with EI (Employee Identifier) #6, the DON (Director of Nursing), on 12/19/2013 at 5:12 PM, she was asked who was responsible for ensuring ordered labs were drawn. EI #6 stated, "the RN (Registered Nurse) Supervisor." When asked why were the ordered PT/INR labs for RI #18 not drawn on 10/19/13 and 10/20/13. EI #6 stated, "I do not know. I spoke with the RN that worked that week and she just doesn't remember, she doesn't know." When asked what follow up was done and where it was documented, EI #6 stated, "the Doctor was notified that we tried X's 3 to draw the PT and INR and were unable, on the lab log. That was for the 22nd, none on 19 and 20." When asked why were the PT/INR labs ordered to be drawn. EI #6 stated, "[MEDICAL CONDITION] of lower extremity." When asked what was the potential negative outcome when a resident does not have PT/INR labs drawn as ordered, when they have a [DIAGNOSES REDACTED]. EI #6 stated, "I would like to refer you to the physician. That would depend on the acuity level and other diagnosis."

Based on observations, interviews and record reviews, the facility failed to ensure that medications were administered as ordered by the physician. This resulted in a medication error rate of 7.4%. This affected RI (Resident Identifier) #12 and RI #19, two of seven residents observed on medication pass. Findings include: A review of the facility's policy entitled, "Medication Administration Procedures Oral Medications," dated "01/12" revealed "... 1. Refer to crushing guidelines (See Exhibit 19 - Do Not Crush List) prior to crushing any medication for assurance that it can be pulverized. ... Do Not Crush List ... Potassium Chloride (K-10, K-Dur)." RI #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #19 was on a Mechanical Soft Diet with Ground Meat, due to chewing problems. RI #19 was noted to have a BIMS (Brief Interview Memory Score) of 8 out of 15, this indicated the resident was moderately cognitively impaired. A review of RI #19's Physician order [REDACTED]. On 12/17/2013 at 4:15 PM, EI (Employee Identifier) #2, an RN (Registered Nurse) was observed to crush a KCL 20 meq (Millequivalents) tablet for RI #19. On 12/19/2013 at 3:29 PM, an interview was conducted with EI #2. EI #2 was asked what was the facility's policy on crushing medications. EI #2 stated, "Crush meds separately and give sips of water between each. Potassium can't be crushed." EI #2 was asked if an order read "May crumble Potassium," how was this done. EI #2 stated, "In water." EI #2 was asked if crumbling and crushing a medication using the pill crusher, was the same. EI #2 stated, "Crushing becomes powdery." EI #2 was asked about the potential negative outcome of crushing potassium. EI #2 stated, it "Alters the dosage." On 12/19/2013 at 5:30 PM, an interview was conducted with EI #6, DON (Director of Nursing). EI #6 was asked what was the facility's policy on crushing medications. EI #6 stated, "There is a list in front of the MARS (Medication Administration Record). If we have a med that is not to be crushed, the doctor would have to give an OK to crush the med; then we could crush it." EI #6 was asked if an order read "May crumble Potassium," how was this done. EI #6 stated, "I have not seen that order." EI #6 was asked if crumbling and crushing medications using the pill crusher was the same. EI #6 stated, "When we use the Silent Knight (pill crusher), that's crushing. I guess it would be at the nurses discretion for crumbling." EI #6 was then asked about the potential negative outcome of crushing potassium. EI #6 stated, "It may alter the dose." RI #12 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. On 11/12/2013, RI #12 was assessed to have a BIMS score of 15 out of a possible 15, which indicated the resident was cognitively impaired. A review of the December 2013 Physician orders [REDACTED]." On 12/18/2013 at 8:10 AM, EI #10, an LPN (Licensed Practical Nurse) was observed to administer medications to RI #12. EI #10 assessed the B/P for RI #12 and it was noted to be 110/55. EI #10 did not administer [MEDICATION NAME] as ordered. On 12/19/2013 at 2:30 PM, in an interview conducted with EI #10, she was asked if there were written facility policies for withholding B/P medications. EI #10 replied, "Like if SBP (systolic blood pressure) is less than 100 or DBP (diastolic blood pressure) is less than 60 hold blood pressure meds. There should be a written policy." EI #10 recalled the resident and medication observed and stated, "Not for that particular resident." EI #10 was asked what was the potential negative outcome of withholding B/P medications and she replied, "Their B/P could shoot up and have a [MEDICAL CONDITION]." EI #10 was asked if the doctor should be notified. EI #10 stated, "We usually don't; we just monitor the B/P's. If it's a continuous thing, we notify the MD (Medical doctor)." On 12/19/2013 at 5:30 PM, an interview was conducted with EI #6. EI #6 was asked if the facility had a written policy on withholding B/P meds (medications). EI #6 stated, "If a physician has given us a parameter, we are to go by that. If no parameter given we give the med. If the nurse enters room and made an assessment about administering the B/P med, that would be in her scope of practice to do that; then she would notify the doctor." EI #6 further stated that there was not a written policy available on withholding B/P meds. EI #6 was asked about the possible negative outcomes of not giving B/P meds. EI #6 stated, "If a nurse chose to hold it, it may indicate there is a problem and the doctor may need to be notified for further instructions." EI #6 was asked if the physician should be notified and she replied, "Yes."

Based on observation, interviews, and record review, the facility facility failed to ensure that medications were removed from the medication room refrigerator by the discard date. This had the potential to affect any resident receiving TB (Tuberculin) skin tests. Findings include: A review of the manufacturers insert titled, "Aplisol (Tuberculin Purified Protein Derivative, Diluted (Stabilized Solution))" revealed "... Aplisol vials should be inspected visually for both particulate matter and discoloration prior to administration and discarded if either is seen. Vials in use for more than 30 days should be discarded". Observations of med (medication) rooms on West and East Units were made on 12/19/2013 between 8:15 AM and 9:10 AM. A multi-dose vial of Aplisol (Tuberculin PPD) was observed in the refrigerator of the East Unit Nurses Station. This vial had "Opened 11/12/13" written on it. On 12/19/2013 at 9:10 AM, EI (Employee Identifier) #11, an RN (Registered Nurse) was asked how long the medication could be kept, and she stated, "It's good for one month". EI # 11 then placed the vial into a Sharps container at that time. An interview was conducted with EI #6, DON (Director of Nursing) on 12/19/2013 at 5:30 PM. EI #6 was asked how often were medication room refrigerators checked for expired medications and by whom. EI #6 stated, "Daily by the Charge Nurse on Duty". EI #6 was asked what was the possible negative outcome of expired medications not being removed from the medication rooms. EI #6 stated, "They were not disposed of properly. They could be administered".