Every finding on record at Barfield Health Care

Based on interviews, review of the facility's policy titled, Abuse Prevention, the facility's investigation file, and Resident Identifier (RI) #48 and RI #56's medical record, the facility failed to ensure Employee Identifier (EI) #4, a Registered Nurse (RN) did not take for personal use and without the residents' permission narcotic pain medication which belonged to RI #48 and RI #56, two of four residents reviewed for narcotic pain medication. Findings include: The facility's policy titled, ABUSE PREVENTION, dated 11/28/2016, documented . IV. IDENTIFICATION . 3. Staff are trained on actual activities that would constitute abuse and they are but not limited to: . b. Misappropriation of resident property- The deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without their consent . On 3/2/2021, the facility's Administrator reported to the State Agency an incident of misappropriation of resident property. According to the report, EI #4, a Registered Nurse (RN) took prescription medication that belonged to RI #48 and RI #56. The facility's INVESTIGATIVE SUMMARY, dated 3/1/2021, documented . CONCLUSION: Because (EI #4) failed her drug test through the Alabama Board of Nursing. Because (EI #4) admitted that since January 2021, she has been taking [MEDICATION(S)] and [MEDICATION(S)] prescribed to residents (RI #56) and (RI #48) whom both reside at [NAME] Health Care, the allegation of Misappropriation of Resident Property is substantiated . RI #48 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #48's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #56 was readmitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #56's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 4/15/2021 at 11:36 AM, EI #1, the Director of Nursing (DON), was asked how she became aware of this incident. EI #1 stated that she received a text from EI #4, a RN. EI #1 said she called EI #4 back and EI #4 told her that she (EI #4) had failed her drug screen done by the Alabama Board of Nursing. According to EI #1, EI #4 was instructed by the Alabama Board of Nursing to call the facility to make them aware. EI #1 stated she called EI #4's probation officer at the Alabama Board of Nursing and was told the drugs EI #4 took came from the facility. According to EI #1, she and the Administrator, called EI #4 back and asked who she took the drugs from and EI #4 replied it was RI #48 and RI #56. During a telephone interview on 4/16/2021 at 12:24 PM, EI #4 stated she had worked in the facility since December 2020 during the 11:00 PM to 7:00 AM shift. EI #4 stated she resigned her position with the facility on 3/1/2021. When asked did she take narcotics belonging to any residents while employed at this facility, EI #4 said she did. When asked what medications she took from the residents, EI #4 stated she took RI #56's [MEDICATION(S)] and RI #48's [MEDICATION(S)]. EI #4 was asked when she took these residents narcotic medications. EI #4 stated it started in January 2021. EI #4 was asked what it was considered when she took narcotics belonging to the residents. EI #4 answered, diverting drugs. When asked what it was considered if she took narcotics or anything else belonging to a resident, EI #4 replied, stealing and misappropriation of property. ************************* Once the facility became aware that EI #4, a RN, had admitted she took prescription medication that belonged to RI #48 and RI #56, the facility implemented the following corrective actions: * EI #4 was suspended and not allowed back to work pending the investigation findings. EI #4 last worked in the facility on 2/26/2021. EI #4's employment with the facility was terminated on 3/5/2021. * The facility timely reported the allegation and the subsequent findings to the Alabama Department of Public Health, the Alabama Board of Nursing, the local Police Department, the facility's Medical Director and the representatives of the residents involved. * The facility's licensed staff assessed the residents involved on 3/1/2021, for signs and symptoms of pain and none were voiced and/or observed. All other residents were assessed and interviewed with no concerns noted. * On 3/1/2021, the Director of Nursing reconciled all narcotic and all medications were accounted for. * The facility conducted staff in-service regarding Abuse Prevention, specific to Misappropriation of Resident Property. * The facility's Quality Assessment and Assurance Committee was made aware of the incident and will monitor the process of administering narcotics. ************************* After review of the facility's investigation file, in-service/education records, staff and resident interviews, and observation of the facility's acquisition, disposition and reconciliation of controlled and non-controlled medications, the facility implemented corrective actions from 3/1/2021 to 3/5/2021. This deficiency was cited as a result of the investigation of complaint/report number AL 308.

Based on observation, interviews, medical record review, and review of facility policy titled, CAPILLARY BLOOD SAMPLING, the facility failed to ensure Employee Identifier (EI) #3, a Licensed Practical Nurse (LPN), wore gloves when she performed a fingerstick blood sugar (FSBS) on Resident Identifier (RI) #62, one of two residents observed for medication administration. Findings include: The facility's undated policy titled, CAPILLARY BLOOD SAMPLING, documented: . Procedure 1. Perform hand hygiene. 2. Wear gloves . RI #62 was admitted to the facility on [DATE]. RI #62 has a medical history to include a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During medication administration observation on 4/14/2021 at 5:17 PM, EI #3, a LPN, was to obtain RI #62's FSBS with her bare hands. EI #3 pricked the resident's forefinger with a lancet, wiped blood from resident's finger with a tissue, squeezed blood from RI #62's finger and then wiped it with an alcohol wipe, and removed the strip from the glucometer. EI #3 was then observed to wipe RI #62's abdomen with an alcohol wipe and inject Insulin into RI #62's abdomen without wearing gloves. On 4/14/2021 at 5:59 PM, an interview was conducted with EI #3, a LPN. When asked when she should wear gloves during medication pass, EI #3 stated she had been working with the residents for a long time and felt comfortable with them. EI #3 was asked how many residents she felt comfortable enough with not to wear gloves. EI #3 replied she did sometimes, but she just messed up. When asked what she was taught about wearing gloves during med pass, EI #3 stated she should put them on before she gave the medications, before she touched any medication, before any injection or FSBS or before touching the resident. EI #3 was asked did she apply gloves before giving RI #62 an insulin injection. EI #3 replied she did not. EI #3 was asked did she apply gloves before obtaining RI #62's FSBS. EI #3 responded no. EI #3 was asked what the concern was with not applying gloves when giving injections and obtaining FSBS. EI #3 said possible contamination and transmission of pathogens. In an interview on 4/15/2021 at 4:12 PM, EI #2, the Infection Preventionist acknowledged the nurse should wear gloves during a FSBS check. When asked what it would be considered when gloves were not worn, EI #2 responded infection control.

Based on observation, interviews, medical record review, and a review of the facility's policy titled, Incontinence Care - ., the facility failed to ensure staff separated and thoroughly cleaned Resident Identifier (RI) #19's perineal area. This affected RI #19, one of one resident observed during incontinent care. RI #19 is a resident identified by the facility as having a history of Urinary Tract Infections ( UTIs). Findings Include: A review of the facility's policy titled, Incontinence Care - . dated 8/1/17, revealed the following: .PURPOSE: Good incontinence care helps prevent infection, irritation, and skin breakdown . RI #19 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #19's Significant Change Minimum Data Set ((MDS) dated [DATE], revealed RI #19's Brief Interview for Mental Status (BIMS) score of 3, indicating cognition was severely impaired. The MDS also revealed RI #19 was totally dependent on staff for toilet use and personal hygiene and had a history of [REDACTED]. On 9/06/18 at 11:20 AM, (EI) Employee Identifier #1, Certified Nursing Assistant (CNA) and EI #2, CNA were observed performing incontinent care for RI #19. EI #1 performed the incontinent care for RI #19, while EI #2 assisted with positioning the resident. RI #19 had an incontinent bowel movement. EI #1 performed incontinent care for RI #19, but did not open the perineal area and clean. On 9/06/18 at 11:35 AM, the surveyor asked EI #1 if she was finished with the incontinent care for RI #19 and EI #1 said yes. The surveyor asked EI #1 if RI #19 was clean and she said, Yes. EI #1 was asked if she visualized RI #19's perineal opening and she said she did. The surveyor asked EI #2 if EI #1 visualized RI #19's perineal opening. EI #2 said, She (EI #1) did not separate as much as she should have to see it. EI #1 was asked what should be done since RI #19 had an incontinent bowel movement and she did not separate the perineal area and wipe. EI #1 said, Redo the incontinent care. EI #1 separated RI #19's perineal area and wiped with a wash cloth. The surveyor observed a discoloration was present to the wash cloth after EI #1 wiped RI #19's perineal area. The surveyor asked EI #1 what the discoloration was and she said, A little bowel movement. On 09/07/18 at 10:01 AM, EI #3, Director of Nursing (DON), and the surveyor reviewed the perineal care/incontinence care check-off sheet and the policy for incontinence care. The surveyor asked where in the policy did it instruct staff to wipe or observe the perineal opening. EI #3 stated, It just says to wipe downward stroke on the right and left (perineal area) and the meatus, if the right and left (perineal area) is spread to see the meatus, then the perineal opening would be visible. The surveyor informed EI #3 that the CNA did not have RI #19's legs separated to visualize the meatus or the perineal opening. The surveyor asked where on the skills check-off sheet did it indicate for staff to wipe the perineal opening or what should should be done in order to view it. EI # stated, It does not.

Based on observations, interviews and record reviews of the 2013 Food Code, facility policy and Department of Food & Nutrition work schedule, the facility failed to prevent: I. Poor Cleaning and Sanitizing of Equipment a. Sectional plates. The facility failed to assure that food contact surfaces for three of six sectional plates observed on the tray line for plating, were clean to sight and touch. 2013 Food Code subpart 4-6011.11(A). b. Spoons were nested in a cylinder and on the tray line for distribution. When fanned out, four of four were observed to contain water droplets and two of the four contained food debris. 2013 Food Code subpart 4- 4-601.11(A) and 4-901.11(A). II. Staff failed to prevent potential cross-contamination a. Staff failed to use a light bulb with protective shielding (covered, coated or otherwise shatter resistant) in a refrigerator used to store food items and nourishments. 2013 Food Code, subpart 6-202.11 (A). III. Poor Personal Hygiene practiced by staff as evidenced by two of six females observed and who failed to effectively restrain their hair to prevent potential physical contamination of food, equipment and utensils. 2013 Food Code subpart 2-402.11(A). The above practices posed the potential for food contamination and compromised food safety. This had the potential to affect all 110 residents receiving meal trays from dining services as evidenced by a review of the facility's Diet list. Findings include: 1. Poor Cleaning and Sanitizing of Equipment a. Sectional plates. The facility failed to assure that food contact surfaces for three of six sectional plates observed on the tray line for plating, were clean to sight and touch. (2013 Food Code subpart .11(A). A record review of the 2013 Food Code by the United States Public Health (USPHS) and the Food and Drug Administration (FDA) included the following: 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch . An observation on 7/26/2017 at 11:30 AM of the storage of cleaned/sanitized items on the trayline revealed three of six sectional plates contained debris adhering to the surface. The CDM (Certified Dietary Manager), Employee Identifier (EI) #1 verbalized that crumbs had fallen into the plates. During an interview with EI #1 on 7/28/2017 at 10:00 AM, she was asked why the sectional plates were found soiled on the tray line. EI #1 responded, I don't know, I can't answer that. I know it's a problem because food particles were there. EI #1 was asked what would be the potential negative outcome. EI #1 said potential for bacterial growth. b. Spoons were observed nested in a cylinder and on the tray line for distribution. When fanned out, four of four were observed to contain water droplets and two of the four contained food debris. 2013 Food Code subpart 4- 4-601.11(A) and 4-901.11(A). A record review of the 2013 Food Code by the United States Public Health (USPHS) and the Food and Drug Administration (FDA) included the following: 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried . and 4-601.11 Equipment, Food Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD CONTACT SURFACES AND UTENSILS shall be clean to sight and touch. An observation on 07/27/17 at 4:35 PM, revealed silverware on the trayline in cylinders nested were wet and with food debris. On 7/28/2017 at 10:00 AM, during an interview with EI #1, she was asked if the spoons were air dried. EI #1 replied they were not dry because they were in the process of drying, they were nested and will not dry. EI #1 further she would work on that. II. Staff failed to prevent potential cross-contamination a. Staff failed to use a light bulb with protective shielding (covered, coated or otherwise shatter resistant) in a refrigerator used to store food items and nourishments. (2013 Food Code, subpart 6-202.11 (A). A record review of the 2013 Food Code by the United States Public Health (USPHS) and the Food and Drug Administration (FDA) included the following: 6-202.11 Light Bulbs, Protective Shielding. (A) Except as specified in (B) of this section, light bulbs shall be shielded, coated, or otherwise shatter-resistant in areas where there is exposed FOOD; clean EQUIPMENT, UTENSILS, . On 7/26/2017 at 11:30 AM, an observation of a double door refrigerator in the kitchen area revealed an elongated light bulb which was neither shielded, covered nor coated. Stored inside the refrigerator was food and nourishments. On 7/28/2017 at 10:00 AM, during an interview conducted with EI #1, the surveyor asked what was the potential problem if light bulb is not shielded. EI #1 replied physical contamination and harm to the digestive system. III. Poor Personal Hygiene practiced by staff as evidenced by two of six females observed and who failed to effectively restrain their hair to prevent potential physical contamination of food, equipment and utensils. 2013 Food Code subpart 2-402.11(A). A record review of the 2013 Food Code by the United States Public Health (USPHS) and the Food and Drug Administration (FDA) included the following: Hair Restraints 2-402.11 Effectiveness. (A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, . that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; On 7/26/2016 at 11:18 AM, an observation was made of EI #2 on the noon meal trayline. EI #2's hair at the nape of the neck was not restrained. On 7/27/17 at 11:50 AM, EI #3 was observed walking toward the Dishroom from the trayline. A large amount of hair was observed to be loose and not restrained to the back of EI #3's neck. An interview on 7/28/2017 at 10:00 AM, with the EI #1 stated that hair is restrained so it does not fall into the food with a potential harm of physical contamination.

Based on observation, interview and record review the facility failed to ensure Resident Identifier (RI) #24's Electronic Medication Administration Record [REDACTED]. Findings Include: RI #24 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #24's EMAR print out revealed the following resident's information: medications, diagnoses, name, room number, physician's name, and allergies [REDACTED].>On 07/26/2017 at 3:22 p.m., during observation of medication pass, the following was observed: Employee Identifier (EI) #4, Licensed Practical Nurse/LPN, walked away from her medication cart, leaving RI #24's EMAR open for public view. The EMAR screen was not within EI #4's view. Staff and residents, on the hallway walked past the medication cart. On 07/26/17 at 3:23 p.m., during an interview with EI #4, the surveyor asked when she left to go and check on RI #24, what was left open for public view. EI #4 replied RI #24's EMAR screen, which listed the resident's medications, name, room number, physician and the resident's diagnoses. The surveyor asked what type of issue would that be. EI #4 replied a HIPAA concern. EI #4 also stated the EMAR screen was not in her view after she left the medication cart.

Based on record review, observation, interview and a review of the facility's policy titled, Wound Care/Treatment, the facility failed to ensure Resident Identifier (RI) #7 was provided privacy during the provision of wound care. This affected one of two residents observed during wound care. Findings Include: A review of the facility's policy titled, Wound Care/Treatment, dated 03/16/2011 revealed the following: . 2. Provide privacy . RI #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #7's Admission Minimum Data Set assessment dated [DATE] revealed RI #7's Brief Interview for Mental Status score of 7, indicating severe impairment in cognition. The MDS assessed RI #7 as at risk for pressure sore development. On 07/27/17 at 9:07 a.m., during wound care, Employee Identifier (EI) #17, Licensed Practical Nurse/LPN, left RI #7's buttocks exposed during the treatment. EI #17 did not not close the door to the adjoining bathroom. Other staff was observed going in and out of the bathroom. On 07/27/17 at 9:55 a.m., during an interview with EI #17, the surveyor asked was the resident's bathroom door closed at all times during the provision of care. EI #17 stated no. EI #17 also stated other CNAs were in and out of the bathroom while the resident care was provided. EI #17 further stated that was a privacy issue.

Based on record review, observation, interview and review of FUNDAMENTALS OF NURSING, the facility failed to ensure a licensed nurse, Employee Identifier (EI) #8, a Licensed Practical Nurse (LPN), properly secured Resident Identifier (RI) #25's medication. On 07/27/17, EI #8 was observed during the Medication Administration Observation to leave RI #25's medication (Symbicort), an inhaler, unattended on top of the bed side table and out of her line of sight. This deficient practice affected RI #25, one of five residents observed during the Medication Administration Observation and one of five medication nurses, (EI) #8. Findings Include: RI #25 was originally admitted to the facility on [DATE], and readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. RI #25's Physician order [REDACTED]. (Symbicort) Budesonide-Formoterol Fumarate 160 MCG (Micrograms)/ACT (Active) -4.5 MCG/ ACT Aerosol Dose: (2 puffs) inhalation Q12H (every 12 hours) . For Asthma . A review of Potter and Perry's FUNDAMENTALS OF NURSING, Ninth edition, Chapter 32, Medication Administration, Page 657 revealed: . (4) . l. Do not leave medications unattended. Nurse is responsible for safe keeping of drugs . On 07/27/17 at 8:55 a.m., the surveyor observed EI #8 during the morning Medication Administration Observation to administer medications to RI #25. EI #8 applied gloves, and placed a paper towel on the bedside table with the medication. EI #8 removed her gloves, and touched the drawers in the bathroom. EI #8 left the medication Symbicort inhaler on top of RI #25's bed side table, then exited the room to go to the medication cart and return to RI #25's room. The Symbicort inhaler was left unattended and out of EI #8's view. On 07/27/17 at 9:00 a.m., the surveyor conducted an interview with EI #8. The surveyor asked EI #8 when should medication be left unattended and out of view. EI #8 said never. The surveyor asked EI #8 if the medications were in her view at all times. EI #8 said not within direct view. The surveyor asked EI #8 what was the potential for medications being left out of her view and unattended. EI #8 said the risk for residents or someone else getting the medications.

Based on record review, observation, interview and review of a facility's policy titled, Wound Care /Treatment and Gloves, the facility failed to ensure a Licensed staff member, Employee Indentifer (EI) #17 washed her hands after the removing soiled contaminated gloves during the provision of wound care and before applying clean gloves. This deficient practice affected Resident Identifier (RI) #7, one of two resident observed for wound care and one of one nurse observed to perform wound care. Finding Include: A facility's policy titled, Wound Care/Treatment dated 03/16/2011, documented the following: Policy: To provide wound care / treatments in accordance with current standards of practice . 4. Wash hands. Dry them. Then apply clean gloves. 5. Remove dirty dressing and put in waste bag at foot of bed. Remove gloves and put them in bag. 6. Wash hands. Dry them. Put on cleans gloves . A facility' policy titled, Gloves dated 11/17/2009, documented the following: . PROCESS 1. Before donning gloves: Wash hands. 2. To remove gloves: . 3. Discard the gloves . 4. Wash hands. RI #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 07/27/17 at 9:07 a.m., the following was observed during wound care. Employee Identifier (EI) #17/Licensed Practical Nurse/LPN, applied gloves and dispensed medication in a medication cup. EI #17 removed her gloves, opened the wound cart drawer, removed sterile q-tips and then pushed the wound cart down the hall across from the RI #7's room. Wound care was provided to the sacral wound and to the right buttock. Duoderm was placed to the sacral wound and [MEDICATION NAME] was placed to the right buttock wound. After EI #17 applied [MEDICATION NAME] to the wound, EI #17 removed her gloves, obtained two pieces of tape and placed one piece on the [MEDICATION NAME] and one piece on the Duoderm. EI #17 did not wash her hands after removing her gloves and before obtaining tape. EI #17 then initialed and dated each piece of tape. EI #17 applied clean gloves and assisted staff with placing RI #7's pants on and repositioning the resident. EI #17 did not wash her hands before she applied clean gloves. On 07/27/17 at 9:55 a.m., the surveyor asked what should be done after gloves are removed. EI #17 stated to wash hands, but that was not what she had done every time. EI #17 was asked what was the potential for harm, and EI #17 replied potential for infection.

Based on interviews and record review, the facility failed to ensure all residents were offered HS (hour of sleep) snacks. This affected 12 of 12 residents present for the 06/08/2016 Group Meeting and Resident Identifier (RI) #s: 16, 18, 19, and 23. Findings include: A review of the facility's policy titled, Snack Cart, effective 10/01/2010, revealed the following: PURPOSE: To ensure that the resident is provided opportunities for nourishing snacks between meals. STANDARD: The facility must offer snacks at bedtime daily. PROCESS: 1. All residents . are offered a snack in accordance with their diet . A Group Meeting was conducted on 06/08/2016 at 2:00 PM, with twelve alert and oriented residents in attendance. A review of the most recent Minimum Data Set (MDS) Assessment for each resident present confirmed all in attendance were cognitively intact. When asked if the facility offered HS snacks, all twelve residents agreed the facility did not offer them anymore. The residents further explained the facility used to pass out the snacks but stopped. They said the snacks were no longer offered to everyone, but available upon request. The members present represented both halls in the facility. Of the twelve residents who stated snacks were no longer offered at night, five of them stated they would definitely like to have a snack offered every night. 1.) RI #16 was admitted to the facility on [DATE]. Upon interview, RI #16 was alert and oriented and assessed as cognitively intact. On 06/09/2016 at 09:35 AM, the surveyor interviewed RI #16 about HS Snacks. RI #16 stated that he/she had received a bedtime snack the previous night but said during the week since admission, HS snacks were only offered one or two times. 2) RI #18 has resided in the facility since 02/02/16. The current Minimum Data Set (MDS) assessment, dated 03/29/16, determined RI #18 was cognitively intact. On 06/09/16 at 12:15 PM, the surveyor asked RI #18 whether an HS snack was ever offered after the supper meal. RI #18 stated no. 3) RI #19 was admitted to the facility on [DATE]. The resident was assessed via the 03/29/16 MDS to be cognitively intact. On 06/09/16 at 12:30 PM, the surveyor questioned RI #19 if a snack was ever offered after the supper meal. RI #19 stated no. 4) RI #23 has resided in the facility since 12/22/14. The 03/29/16 MDS identified RI #23 as moderately impaired in cognition. On 06/09/16 at 10:05 AM, the surveyor asked RI #23 if staff ever offered a bedtime snack. RI #23 responded, Not often. RI #23 stated no snack had been offered the previous evening. Certified Nursing Assistants (CNAs) from both halls of the facility were interviewed on 06/08/2016 at 6:00 PM and 6:08 PM, respectively. Employee Identifier (EI) #1, the first CNA interviewed, was unsure which residents received HS snacks. EI #2, another CNA, stated residents should receive an HS snack. She further explained the residents let them know if they wanted a snack, and said staff sometimes went around to offer them. On 06/09/2016 at 10:45 AM, EI #3, the Director of Nursing, was interviewed regarding HS snacks. She said snacks should be offered at 8:00 PM, if residents were awake. When asked why twelve of the twelve residents present in the group meeting agreed HS snacks were no longer offered, she said she did not know what to think of that.

Based on observation, record review, and interviews, the facility failed to ensure Resident Identifier (RI) #11 received a nutritional supplement with the 06/08/2016 lunch meal as ordered by the physician. This was observed during one of two meal observations for RI #11 and affected one of 19 residents for whom physician's orders [REDACTED]. Findings include: A review of Potter and Perry, Fundamentals of Nursing, Eighth Edition, copyright 2013, Chapter 23 Legal Implications in Nursing Practice, page 305, revealed the following: .Health Care Providers' Orders . Nurses follow health care providers' orders unless they believe the orders are in error or harm patients . RI #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #11's Admission Minimum Data Set Assessment, dated 04/22/2016, revealed RI #11 was cognitively intact and required one person physical assist with meals. RI #11's current physician's orders [REDACTED]. RI #11's lunch meal was observed on 06/08/2016 at 11:20 AM. RI #11 received two 8 ounce cups of tea, 8 ounces of water, and coffee with the lunch meal. No nutritional supplements were provided. RI #11's Meal Tray Card indicated a nutritional supplement should have been provided. Employee Identifier (EI) #4, a Certified Nursing Assistant, was interviewed on 06/08/2016 at 11:45 AM. EI #4 said RI #11 should have received two sweet teas, water, and a nutritional supplement with the meal, but said a nutritional supplement was not provided. When asked why the nutritional supplement was not provided, EI #4 said they must have forgotten to give it to the resident. EI #4 said the resident needed the supplement to maintain weight, and should have been given a Mighty Shake (nutritional Supplement). EI #3, the Director of Nursing, was interviewed on 06/09/2016 at 10:45 AM. EI #3 said RI #11 had a physician's orders [REDACTED]. EI #3 explained it was important to follow physician's orders [REDACTED].

Based on record review and interviews, the facility failed to ensure Resident Identifier (RI) #13 was re-evaluated and the rationale for continued use of a catheter was documented. This affected RI #13, one of three sampled residents with indwelling catheters. Findings include: A review of the facility's policy titled, Appropriate Use of Catheters ., effective 04/01/2014, revealed the following: PURPOSE: Use of urinary catheters . affects the resident's sense of dignity, psychosocial well-being and could lead to other medical problems. STANDARD: A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary . PROCESS: I. Urinary Catheters . d) Documentation in the medical record should reveal the need for use of the catheter . A review of the facility's policy titled, SKIN ASSESSMENT & PRESSURE ULCER PREVENTION, dated 08/01/2010, revealed the following: . III. PROCEDURE . 4. A licensed nurse will perform a body audit . a minimum of weekly, on each resident. The weekly body audits will be documented on the treatment record. If a skin concern is identified . document in the Nurses' Notes. 5. All wounds . including pressure and non-pressure skin concerns . should be documented on daily and weekly until they are resolved . RI #13 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #13's physician's orders [REDACTED]. RI #13's Nurses' Notes for 04/21/2016 at 9:58 AM revealed the following entry by Employee Identifier (EI) #5, the Wound Care Nurse: . Resident noted with bright red intact fungal areas on periarea, resident states [MEDICAL CONDITION] (RI #13) urinates (resident incontinent) Physician . notified . new orders for treatment(s), for order for foley catheter placement . However, a further review of RI #13's Nurses' Notes revealed no documentation related to RI #13's skin condition or evidence of the continued need for catheter use. On 05/10/2016, a Braden Scale was completed. This assessment indicated RI #13 was constantly moist related to perspiration and urine. However, this assessment made no note of an existing or ongoing skin problem warranting the continued use of a catheter. A 06/08/2016 Nurses' Note entry, timed 1:40 PM, indicated RI #13's area to the abdominal fold was intact, pink, and healed. At this time, the physician was notified and orders were obtained to discontinue treatments and the foley catheter. RI #13's daily Certified Nursing Assistant (CNA) skin charting was reviewed. From 04/21/2016, when the foley catheter was inserted, until 06/08/2016, when the order was discontinued, it was documented RI #13's skin was intact with no new areas of concern. On 06/09/2016 at 9:48 AM, EI #5, the Wound Care Nurse was interviewed. She explained RI #13 had ongoing sensitive skin they had to treat with [MEDICATION NAME] (anti-fungal cream). She said the area extended under the resident's abdominal fold and down the front. EI #5 said the catheter was used to enable the area to heal and to prevent pain. When asked where there was documentation to show the need for the catheter, EI #5 said it would not show up. She said they do not normally document on rashes and just make sure there is a treatment in place. EI #3, the Director of Nursing, was interviewed on 06/09/2016 at 10:45 AM. EI #3 indicated RI #13 had a catheter due to skin irritation to the abdomen. She further explained because the resident was obese, urine would puddle and cause skin irritation. When asked if there was any documentation to support the continued use of a catheter for RI #13 (from 04/21/2016 through 06/08/2016), EI #3 said a Braden Scale was done on 05/10/2016 indicating RI #13 was consistently moist. She further explained in the case of RI #13's skin, there would not be any documentation since it was not an open wound. EI #6, the Restorative Nurse, was interviewed on 06/09/2016 at 12:00 PM. When asked how often residents should be re-evaluated for the continued use of a catheter, EI #6 said body audits should be done at least weekly, and any skin irritation assessed weekly.

Based on observations, interviews, and review of facility policy, the facility failed to ensure: 1) thawed Mighty Shakes were not strored in the refrigerator beyond their use by date; 2) frozen items in the walk-in freezer were labeled and dated; 3) pureed corndogs were not served prior to verifying the temperature was 135 degrees Fahrenheit (F) or above; and 4) staff sanitized the probe of the thermometer between each food item while taking trayline temperatures. This had the potential to affect all 103 residents receiving meals from the Dietary Department. Findings Include: 1) The initial tour of the kitchen was conducted on 06/24/2014 beginning at 12:50 PM. At 1:10 PM, the surveyor noted 21 Mighty Shakes in the reach-in cooler dated "6/19" and one dated "6/20". When asked what the dates on the cartons meant, EI #5, the Certified Dietary Manager (CDM), stated it was the use by date. EI #5 was interviewed on 06/26/2014 at 9:10 AM. When asked how long Mighty Shakes were good, she stated 14 days after they are thawed. The surveyor then asked when staff go through and dispose of items exceeding their use by dates. EI #5 stated staff should go through daily to discard items. When asked what potential harm could occur if Mighty Shakes were stored past their use by dates, EI #5 stated they could spoil. 2) Review of the facility's undated policy titled "FOOD STORAGE" revealed the following: "... Frozen Meat/Poultry and Foods... Storage: ... Label and date all food items..." The initial tour of the kitchen was conducted on 06/24/2014 beginning at 12:50 PM. A bag of product labeled "Steak Fries" dated "3-9-14" was observed in the walk-in freezer. The CDM stated the date on the bag was the open date. She was unable to locate a use by date on the packaging. An unlabeled plastic bag of frozen meat was also observed. EI #5, the CDM, stated it was chicken fingers. When asked if she could locate any labeling on the item, EI #5 stated she could not. EI #5 was interviewed on 06/26/2014 at 9:10 AM. When asked how items stored in the freezer should be labeled, EI #5 explained items should be labeled with the open date, the use by date, and what the item is. When asked how staff would know whether an item is still in date if not labeled with all required information, EI #5 stated they would not know, and the items should be discarded. EI #7, the Registered Dietitian, was interviewed on 06/26/2014 at 11:04 AM. When asked how items stored in the freezer should be labeled, EI #7 stated every item should have a use by date. 3) On 06/25/2014 at 4:00 PM, the surveyor entered the kitchen to observe trayline proceedings. At 4:42 PM EI #5, the CDM, was observed to place a serving of pureed corndogs on a resident's tray then place the remainder of the pureed corndogs in the oven until placed on the trayline. The tray was delivered to the Dining Room without checking the temperature. When asked if she had obtained a temperature of the pureed corndogs prior to serving to a resident, EI #5 stated she had not because they had been made with the corndogs staff had just pulled from the oven. EI #5 was interviewed on 06/26/2014 at 9:10 AM. When asked why she had not obtained a temperature on the pureed corndogs prior to serving a resident, EI #5 stated they had verified the temperature of the corndogs just prior to pureeing them. EI #7, the Registered Dietitian, was interviewed on 06/26/2014 at 11:04 AM. During the interview EI #7 stated staff should have obtained a temperature on the pureed corndogs prior to serving them. She also stated there would be no way to know if the temperature was acceptable without obtaining a temperature. 4) When asked to provide a copy of the facility's policy addressing their procedure for taking trayline temperatures, EI #7, the Registered Dietitian, provided a policy with an effective date of 06/26/2014. When asked if the facility had a policy prior to the new policy, she stated they did not. On 06/25/2014 at 4:00 PM, the surveyor entered the kitchen to observe trayline proceedings. At 4:12 PM, staff were observed taking temperatures of foods on the buffet-style steam table in the Dining Room. Dietary Staff were observed to take temperatures on the following items in the order listed: corndogs, soup, pinto beans, and cabbage. The staff member did not sterilize the probe of the thermometer between each food item. Instead, she wiped the probe with a towel and dipped it in water. At 5:07 PM, staff began taking temperatures of the foods on the trayline in the kitchen. The staff member taking the temperatures had an alcohol prep ready to use on the thermometer probe. EI #5, the CDM, stated she did not have to use the alcohol prep pad unless the foods were out of range. Staff began by first wiping the probe of the thermometer with the alcohol prep. The CDM then handed her a towel to use. The staff member then alternated between the alcohol prep and the paper towel for the remainder of the trayline temperatures. EI #7, the Registered Dietitian, was interviewed on 06/26/2014 at 11:04 AM. When asked to describe their procedure for obtaining trayline temperatures, EI #7 explained the probe of the thermometer should be sanitized with an alcohol prep pad between each food item.

Based on observations, record review and interviews the facility failed to ensure the swallowing precaution of "no straws" was implemented for RI (Resident Identifier) #2, a resident at risk for aspiration. This affected 1 of 8 residents sampled with swallowing concerns. Findings Include: RI #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #2's most recent quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 06/17/2014 indicated RI #2 had severe cognitive impairment and required extensive assistance with eating. Review of RI #2's nutritional care plan dated 06/05/2014 as well as her "CNA (Certified Nursing Assistant) Care Plan" revealed the intervention of "No Straws". During RI #2's breakfast and lunch meals on 06/25/2014, staff provided RI #2 straws in her beverages. EI #3, the Director of Nursing, was interviewed on 06/26/2014 at 8:32 AM. When asked what swallowing interventions should be in place for RI #2, EI #3 explained there was an intervention of no straws recommended by the Speech Therapist in February 2013 to control or limit the amount of fluids consumed at one time. The surveyor then asked how staff were made aware of interventions in place for residents. EI #3 stated anytime there is a change in the plan of care they provide inservices, and in the case of an intervention of no straws, a dietary report would be sent to the Dietary Department so the tray card could be updated. EI #6, the Care Plan Coordinator was interviewed on 06/26/2014 at 3:16 PM. When asked what swallowing interventions were in place for RI #2, EI #6 stated no straws. She then stated if staff were observed providing RI #2 beverages through straws, they would not have been following her care plan.

Based on observations, record review and interviews the facility failed to ensure the swallowing precaution of "no straws" was implemented for RI (Resident Identifier) #2, a resident at risk for aspiration. This affected 1 of 8 residents sampled with swallowing concerns. Findings Include: RI #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #2 was discharged from Speech Therapy on 02/28/2013. Her discharge summary documented the following: "... Swallow Precautions... Current Level of Function... The patient utilizes swallow strategies/precautions exhibiting Minimum Assistance (Requires 1% to 25% assistance to monitor speed and amount of food intake, minimal aspiration risk on thin liquids...)... " RI #2's Functional Maintenance Plan initiated on 02/28/2013 after her discharge from Speech Therapy indicated "NO STRAWS". RI #2's most recent quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 06/17/2014 indicated RI #2 had severe cognitive impairment and required extensive assistance with eating. Review of RI #2's nutritional care plan dated 06/05/2014 as well as her "CNA (Certified Nursing Assistant) Care Plan" revealed the intervention of "No Straws". During RI #2's breakfast meal on 06/25/2014 at 7:50 AM, she received whole milk, water, coffee, and a Mighty Shake. Staff poured all of RI #2's beverages into cups with lids and placed a straw into each. RI #2 received her lunch on 06/25/2014 at 12:20 PM. The surveyor observed staff pour her beverages into cups and place straws into her Mighty Shake, water, and coffee. Throughout the meal two different staff members were observed to hold up RI #2's beverages and encourage her to drink through the straws. EI (Employee Identifier) #1, the CNA observed to set up RI #2's lunch tray, was interviewed on 06/25/2014 at 12:57 PM. When asked how staff would become aware if a resident was not supposed to have straws, EI #1 stated it would be listed on the tray card. The surveyor and EI #1 referred to RI #2's traycard, and it did not reflect the swallowing precaution of "no straws". When asked why some residents do not receive straws, EI #1 stated it was to prevent choking on fluids. The surveyor then asked EI #1 if the intervention of "no straws" was not listed on the tray card how staff would know not to give RI #2 straws. EI #1 explained it would be on the care plan. EI #2, a CNA observed assisting RI #2 during her lunch meal on 06/25/2014, was interviewed on 06/25/2014 at 1:13 PM. When asked how she would know when feeding a resident if they should have a straw or not, EI #2 explained it would be listed on the tray card under adaptive equipment. The surveyor then asked if there was anywhere else caregivers could find information on interventions if it was not listed on the tray card. EI #2 stated interventions would be listed on the care plans. EI #3, the Director of Nursing, was interviewed on 06/26/2014 at 8:32 AM. When asked what swallowing interventions should be in place for RI #2, EI #3 explained there was an intervention of no straws recommended by the Speech Therapist in February 2013 to control or limit the amount of fluids consumed at one time. The surveyor then asked how staff were made aware of interventions in place for residents. EI #3 stated anytime there is a change in the plan of care they provide inservices, and in the case of an intervention of no straws, a dietary report would be sent to the Dietary Department so the tray card could be updated. EI #4, the Speech Therapist, was interviewed on 06/26/2014 at 1:48 PM. When asked to explain RI #2's intervention of no straws, EI #4 explained her recommendation was based on a combination of the FEES (Fiberoptic Endoscopic Evaluation for Swallowing) and continuing evaluation of the resident throughout the time she was on her caseload. EI #4 further explained that usually when she recommends no straws it is to prevent aspiration. She then stated she felt that drinking from the rim of a cup was more beneficial to RI #2 verses drinking from a straw, in order to prevent aspiration. When asked what potential harm could occur if RI #2 was provided fluids through a straw, EI #4 stated possible aspiration if the fluids came up too fast or she took too many sips at once.

Based on observation, interview and record review, the facility failed to ensure planned interventions were in place for Resident Identifier (RI) #10, a resident with a history of falls on 04/25/2013 and 06/03/2013. The facility further failed to ensure a tabs alarm was in place for RI #10 as planned on 1 of 4 days of the survey. This affected 1 of 5 residents sampled for falls. Findings include: The facility's policy with an effective date of February 1, 2009 titled "Incidents and Accidents" revealed; "...PROCESS: The facility should: ... Implement interventions, including adequate supervision and assistive devices consistent with a resident's needs, goals, plan of care, and current standards of practice in order to reduce the risk of an accident; ..." RI # 10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Assessment with an Assessment Reference Date of 03/04/2013 documented RI #10 had a fall prior to admission. A review of RI #10's "CARE PLAN CONFERENCE SUMMARY" documented "... Admission assessment completed (after) interviews (with) resident/family/staff ... Several falls noted in past 6 months. ...Care plan reviewed (and) revised. ..." A review of RI #10's Care Plan number 6 documented RI #10 "...RISK FOR FALLS & (and)/OR FALL-RELATED INJURY R/T (related to) (L) (left) SIDED WEAKNESS, ...HX (history) FALLS &/OR FALL-RELATED INJURY. ..." Approaches listed for this Care Plan included "...(07) 02/22/2013 ... TABS ALARM TO W/C (wheelchair) AND BED, TRANSFER BACK AND FORTH ... (15) 4/25/13... While Resident is OOB (Out Of Bed) pull side rails (up) to prevent Resident from trying to place self back to bed. ..." A review of a facility document titled "RESIDENT INCIDENT REPORT ANALYSIS & QA (Quality Assurance)" dated 4-25-13 documented RI #10 was found on the floor in her room at 4:40 PM. It also documented "...Tabs alarm on W/C but not attached. ..." This report included a statement from Employee Identifier (EI) # 1, Certified Nursing Assistant (CNA). This statement documented "(Name) EI #2 and I went to get (name) RI #10 up...Tabs alarm was on the back of her (RI #10) wheelchair, but we forgot to attach it to her. A statement for EI #2, CNA was also included in the Report. The statement documented "(Name) EI #1 and I went to get (Name) RI #10 up ...Tabs alarm was on wheelchair but we forgot to attach it to her. ..." During an interview with EI # 3, Unit Manager/Licensed Practical Nurse on 6/6/2013 at 4:05 PM, EI #3 was asked if she completed the Resident Incident Report dated 4/25/2013. EI #3 stated,"Yes". The surveyor asked what interventions were in place at the time of the fall on 4/25/2013. EI #3 stated all interventions dated 2/22/2013. The surveyor asked EI #3 to explain the intervention "TABS ALARM TO W/C AND BED, TRANSFER BACK AND FORTH". EI #3 explained the tab alarm was to be used for RI #10 when she was in the wheelchair and in the bed. The surveyor asked EI #3 if they were in place when EI #10 fell on [DATE]. EI #3 stated, "No". The surveyor asked EI #3 what is the potential harm when interventions are not followed. EI #3 explained the resident could have fallen on the floor, had a head injury or a broken bone. A review of a facility document titled "RESIDENT INCIDENT REPORT ANALYSIS & QA" dated 06/03/2013 revealed RI #10 was found on the floor on 6/3/2013 at 5 PM. It also revealed a statement from a staff member who assisted RI #10 on 6/3/2013. The statement documented RI #10's bed's side rails were not pulled up to prevent her from putting herself to bed. During an interview with EI # 3, Unit Manager/Licensed Practical Nurse on 6/7/2013 at 10:10 AM, EI #3 was asked if she completed the Resident Incident Report dated 6/3/2013. EI #3 stated, "Yes". EI #3 was asked what fall interventions were in place before the fall on 6/3/2013. EI #3 explained on 4/25/2013 the intervention to pull up side rails was added to prevent the resident from trying to place herself back to bed. She further explained the interventions added on 2/22/2013 were also in place for RI #10. The surveyor asked EI #3 if during her investigation of the fall did she discover that the side rails had not been pulled up when the resident was out of bed. EI #3 stated, "Yes". On 06/06/2013 at 3:35 PM, the surveyor observed RI #10 in her bed without the tab alarm attached, The tab alarm was observed on her wheelchair in the corner of the room. On 06/06/2013 at 3:50 PM, the surveyor asked EI # 4, Unit Manager what are the fall interventions for RI #10. EI #4 explained RI #10 was supposed to be brought to the Nursing Station when she was in her wheelchair. She further explained RI #10's tab alarm should be in place when RI #10 was in the bed or in the wheelchair. The surveyor and EI #4 observed RI #10 in the bed. When asked if the tab alarm was in place, EI #4 stated, "No, It's not." EI #4 left the room without attaching the tab alarm. On 6/06/2013 at 4:10 PM, the surveyor and EI #3 entered RI #10's room. RI #10 was in her bed and EI #4 was in the room. The surveyor asked EI #4 when the tab was attached to the bed. EI #4 stated, "I just did it".

Based on observations, record review and interview: 1) The facility failed to assure hot foods were maintained at 135 degrees F (Fahrenheit) or above when served from the trayline. 2) The facility failed to assure the dinnerware was clean and in good condition. 3) The facility failed to assure light bulbs were shielded, coated or otherwise shatter-resistant in areas exposed to food, clean equipment, utensils, or unwrapped single-service articles. (Food Code) 6 -202.11 4) The facility failed to prevent potential cross-contamination by leaving a blue plastic measuring device stored in a can of powdered thickener. The above practices posed the potential for food contamination and compromised food safety. This had the potential to affect 106 residents receiving meal trays from dining services. Findings include: FOOD TEMPERATURES 1) The facility failed to assure hot foods were maintained at 135 degrees F or above when served from the trayline. On 4/17/12 at 12:00 noon, while at the tray line, the temperature of chicken was measured by dietary staff. It indicated 115 degree F. The CDM (Certified Dietary Manager) Employee Identifier (EI) # 1 indicated tray line service began at 11:20 AM. At this time, the Cook, EI # 2 was asked how many pieces of chicken had been prepared. Her response was 10-12 pieces. EI # 2 was then asked, where was the temperature of the baked chicken documented. Her response was: "It's (it is) not". On 4/18/12 at 11:12 AM, the mobile steam table in the dining room was observed. The CDM was requested to measure the temperature of the chopped meat on the tray line. Her finding was that the chopped meat was 115 degrees F. The CDM indicated: "She (the employee server) documented the temperature at 10:30 AM, because we served at a quarter to eleven". The temperature of the chopped meat was recorded as 150 degrees. 2) The facility failed to assure the dinnerware was clean and in good condition. On 4/17/12 at 12:00 AM, plastic sectional plates were observed at the tray line. Three of the five were badly stained. 3) LIGHTING The facility failed to assure light bulbs were shielded, coated or otherwise shatter-resistant in areas exposed to food, clean equipment, utensils, or unwrapped single-service articles. (Food Code) 6 -202.11. On 4/17/12 at 11:57 AM, the lighting in a double door refrigerator was observed to not be shielded. This observation was pointed out to the CDM. 4) PREVENT POTENTIAL CROSS-CONTAMINATION The facility failed to prevent potential cross-contamination by leaving a blue plastic measuring device stored in a can of powdered thickener. On 4/17/12 at 12:05 PM, facility posted documentation revealed 11 residents were receiving liquids which were thickened. At this time, the surveyor opened a can containing powder thickener and found the blue measuring device handle lying on top of the powder.

Based on observation, interview, and record review, the facility failed to: 1) Date and label perishable foods such that the prepared, and/or use by dates were evident. 2) Store perishable foods in the refrigerator such that they were covered, preventing exposure to air and preventing the potential for contamination. This had the potential to affect 107 residents who receive meals from the kitchen. Findings include: During the initial tour of the kitchen on 3/15/11 at 11:35 AM the following was observed: a. A open bag of grated cheese with no dates to indicate the day the cheese was opened or to indicate it's use by date. b. A pan of cooked sausage patties was stored in the reach in cooler. There was no label or date to indicate when the sausage had been prepared or when the sausage should be discarded. During an interview with EI #1, Dietary Manager (DM), on 3/16/11 at 5:15 PM, the surveyor ask if the cooked sausage patties stored in the reach in cooler observed on 3/15/11 at 11:35 AM were labeled or dated. EI #1 responded by saying, "It was stored in the reach in, stored after breakfast and it did not have a label or dated." The surveyor ask who was responsible for monitoring the labeling and dating of stored foods. EI #1 responded by saying, "Me". EI #1 also stated the zip lock bag of grated cheese stored in the walk in cooler was open. During an interview with EI #2 Registered Dietitian (RD), on 3/16/11at 5:25 PM, the surveyor ask who is responsible for monitoring compliance with food storage policies. EI #2 responded by saying that she does random checks as well as the DM and her assistant. During a phone interview with EI #3, Cook, on 3/17/11 at 9:30 AM, the surveyor ask if she had stored the sausage patties that were observed by the surveyor in the reach in cooler on 3/15/11. EI #3 stated, "yes, I did and had the intention to take back out and chop them up, they were not labeled or dated." Review of the facility's policy entitled "Use of Leftovers" with a date of "2010" "Procedure:..2. Leftovers will be covered, labeled, and dated; then stored appropriately (refrigerate or frozen if necessary) immediately after the end of the meal service...4. Leftovers that had not been properly stored will be discarded..."

Based on observation, record review and interview, the facility failed to ensure that Resident Identifier (RI) #3 a resident with a history of pressure ulcers received incontinent care and position change every two hours for the prevention of skin break down. The facility further failed to ensure that RI #10 RI #12 and RI #15, residents at high risk for pressure ulcers, received incontinent care and position change every two hours. This affected four of eleven residents sampled with incontinence and at high risk for skin breakdown. The findings include: A review of the facility policy titled "Perineal Care - Female" provided the following information: "...Residents who are unable to turn themselves in bed, or reposition themselves in chairs, benefit from the staff performing this function. Proper positioning, and regular repositioning, helps to prevent pressure sores..." During an interview on 03/17/2011 at 12:15 PM with Employee Identifier (EI) #5 a certified nurse assistant was asked how you know what care is to be provided for the residents. EI #5 answered, the care plan. EI #5 was then asked if it was important to keep incontinent residents dry and why and she replied yes, if they are wet or soiled it can lead to sores. On 3/17/2011 at 12:35 PM the surveyor asked EI #6 Registered Nurse (RN) Supervisor how the staff know what care is to be provided for the residents? EI #6 stated that the main way is the care plans. The surveyor asked EI #6 how often should dependent residents be checked and changed for incontinence and positioning? EI #6 responded every two hours and PRN. EI #6 was asked what does your policy and procedure state regarding repositioning and incontinence check and change? EI #6 replied every two hours and PRN. EI # 6 was then asked to review the care plans for RI #3, RI #10, RI #12 and RI #15 and identify the care to be provided for incontinence and positioning. EI #6 stated every two hours and PRN. The surveyor stated on 3/16/2011 RI #3, RI #10, RI #12 and RI #15 were observed from 7:45 AM to 1:55 PM. These residents did not receive incontinence care and positioning every two hours. Should this have happened? EI #6 replied no, that should not have happened. On 03/17/2011 at 1:00 PM the surveyor asked EI #7 RN Director of Nursing how the staff know what care is to be provided for the residents? EI # 7 responded, the Care Plan. EI #7 was asked how often should dependent residents be checked and changed for incontinence and positioning? EI #7 replied typically every two hours. Some residents are every hour. EI #7 was asked what the facilities policy and procedure states regarding repositioning and incontinence check and change? EI #7 states the resident's plan of care specifies the intervals. On 3/17/2011 at 1:40 PM during an interview with EI #4 a Licensed Practical Nurse the surveyor asked where would you identify the care you need to provide the residents? EI #4 stated the Care Plan. 1.) RI #3 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. An Annual Minimum Data Set (MDS) with a reference date of 01/13/2011, assessed RI #3 had long and short term memory problems and was severely impaired for cognitive skills for daily decision-making. The MDS indicated RI #3 was totally dependent on staff for all activities of daily living (ADL's) and was always incontinent of bowel and bladder. RI #3's "Physician Orders" dated 03/01/2011 thru 03/31/2011 documents: "Braden Scale Score: 10 ... " A Braden Scale is used for predicting pressure sore risk. According to the form a score of 10-12 indicates a high risk. A review of RI #3's "Comprehensive Care Plan" documents the following: A review date of 01/19/2011 titled "Problem" "... Resident is incont' (incontinent) of Bowel and Bladder. Does not realize need to toilet." "Approach" "... Check and Change Q (every) 2 HRS (hours) and PRN (as needed)." A further review of RI #3's "Comprehensive Care Plan" with the problem"...Risk for skin breakdown..." with a review date of 1/19/2011 revealed the following approach: "...Turn and position Q 2 hours..." A document titled "Nurse's Notes" dated 02/08/2011 revealed RI #3's "...area to left buttock has closed. Skin still very fragile ... will continue care plan as written ..." During continuous observation on 03/16/2011 at 7:45 AM the surveyor observed RI #3 sitting in her room in a Geri-chair with her feet elevated wearing heel boots. From 7:45 AM to 1:55 PM RI #3's position was not changed and she was not checked for incontinence. 2.) RI #10 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) with a reference date of 03/10/2011, assessed RI #10 had long and short term memory problems and was severely impaired for cognitive skills for daily decision-making. The MDS indicated RI #10 was totally dependent on staff for all activities of daily living (ADL's) and was always incontinent of bowel and bladder. The RAP for Pressure Ulcers dated 06/23/2010 included "Narrative Note" "... resident is incontinent of Bowel and Bladder that increase risk for skin breakdown. She also has diabetes that affects skin integrity ..." RI #10's "Physician Orders" dated 03/01/2011 thru 03/31/2011 documents: "Braden Scale Score: 12 ..." According to the form a score of 10-12 indicates a high risk. A review of RI 10#'s "Comprehensive Care Plan" documents the following: A review date of 03/16/2011 titled "Problem" "... Resident is incont' (incontinent) of Bowel and Bladder... " "Approach" "... Check and Change Q (every) 2 HRS (hours) and PRN (as needed)." "Problem", "... Risk for skin breakdown r/t (related to) incont'(incontinence), impaired mobility: hx (history) skin breakdown" "Approach" "...Turn and position Q 2 hours and PRN..." On 03/16/2011 at 8:00 AM the surveyor observed RI #10 From 8:00 AM to 2:15 PM sitting in wheelchair with lap buddy in place. RI #10's position was not changed and she was not checked for incontinence until 2:15 PM. RI #10 was identified as wet with a moderate amount of urine when staff checked the resident and performed incontinence care. 3.) RI #12 was re-admitted to the facility on [DATE] with an original admission date of [DATE] with a [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) with a reference date of 02/10/2011, assessed RI #12 had a Brief Interview for Mental Status (BIMS) score of 8. The MDS indicated RI #12 required extensive assistance from staff for all activities of daily living (ADL's) and was always incontinent of bowel and bladder. The Care Area Assessment (CAA) for Pressure Ulcers for 11/11/2010 included "Complications and Risk Factors: " "Resident is at risk for development of pressure sores due to mobility problems and being incontinent of bowel and bladder ..." RI #12's "Physician Orders" dated 03/01/2011 thru 03/31/2011 documents: "Braden Scale Score: 13 ..." According to the form a score of 13-14 indicates a moderate risk. A review of RI 12#'s "Comprehensive Care Plan" documents the following: A review date of 02/16/2011 titled "Problem" "... Resident is incont' of Bowel and Bladder... " "Approach" "... Check and Change Q (every) 2 HRS (hours) and PRN (as needed)." "Problem", "... Risk for skin breakdown ..." "Approach" "...Turn and position Q 2 hours and PRN..." On 03/16/2011 the surveyor observed RI #12 from 10:45 AM to 2:05 PM sitting in a Geri-chair. RI #12's position was not changed and she was not checked for incontinence until 2:05 PM. When staff provided incontinent care at 2:05 PM, the resident's incontinent brief was found saturated with urine. The resident's upper thigh was red with an imprint/creases from the hoyer lift pad. 4.) RI #15 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) with a reference date of 12/30/2010, assessed RI #15 had long and short term memory problems and was severely impaired for cognitive skills for daily decision-making. The MDS indicated RI # 15 was totally dependent on staff for all activities of daily living (ADL's) and was always incontinent of bowel and bladder. The RAP for Pressure Ulcers for 07/14/2010 included "Complications and Risk Factors: " "At risk for developing pressure sores due to incontinence and problems with mobility..." RI #15's "Physician Orders" dated 03/01/2011 thru 03/31/2011 documents: "Braden Scale Score: 10 ... " According to the form a score of 10-12 indicates a high risk. A review of RI #15's "Comprehensive Care Plan" documents the following: A review date of 01/05/2011 titled "Problem" "... Incont' (incontinent) of Bowel and Bladder... " "Approach" "... Check and Change Q (every) 2 HRS (hours) and PRN (as needed)." "Problem", with no review date, "... Risk for skin breakdown ..." revealed the following: "Approach" "...Turn and position ... Q 2 hours and PRN..." On 03/16/2011 the surveyor observed RI #15 from 10:45 AM to 1:55 PM sitting in a Geri-chair. RI #15's position was not changed and she was not checked for incontinence until 1:55 PM. At that time, facility staff removed from the resident an adult brief saturated with urine and a small amount of stool.

Based on observation, record review and interview, the facility failed to ensure that Resident Identifier (RI) #3 a resident with a history of pressure ulcers received incontinent care and position change every two hours for the prevention of skin break down as care planned. The facility further failed to ensure that RI #10, RI #12 and RI #15, residents at high risk for pressure ulcers, received incontinent care and position change every two hours as care planned. This affected four of eleven residents sampled with incontinence and at high risk for skin breakdown. The findings include: During an interview on 03/17/2011 at 12:15 PM with Employee Identifier (EI) #5, a Certified Nurse Assistant, was asked how you know what care is to be provided for the residents. EI #5 answered, the care plan. On 3/17/201 at 12:35 PM the surveyor asked EI #6 ( Registered Nurse (R.N.) Supervisor), how does the staff know what care is to be provided for the residents? EI #6 stated that the main way is the care plans. The surveyor asked EI #6 how often should dependent residents be checked and changed for incontinence and positioning? EI #6 responded every two hours and (as needed) PRN. EI #6 was asked what does your policy and procedure state regarding repositioning and incontinence check and change? EI #6 replied every two hours and PRN. EI # 6 was then asked to review the care plans for RI #3, RI #10, RI #12 and RI #15 and identify the care to be provided for incontinence and positioning. EI #6 stated every two hours and PRN. The surveyor stated on 3/16/2011 RI #3, RI #10, RI #12 and RI #15 were observed from 7:45 AM to 1:55 PM. These residents did not receive incontinence care and repositioning every two hours as care planned. Should this have happened? EI #6 replied no, that should not have happened. On 03/17/2011 1:00 PM the surveyor asked EI #7( R.N., Director of Nursing), how the staff know what care is to be provided for the residents? EI #7 responded, the Care Plan. EI #7 was asked how often should dependent residents be checked and changed for incontinence and positioning? EI #7 replied typically every two hours. Some residents are every hour. EI #7 was asked what the facility policy and procedure states regarding repositioning and incontinence check and change? EI #7 stated the resident's plan of care specifies the intervals. On 3/17/2011 at 1:40 PM during an interview with EI #4, a Licensed Practical Nurse, the surveyor asked where would you identify the care you need to provide for the residents? EI #4 stated the Care Plan. 1.) RI #3 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. An Annual Minimum Data Set (MDS) with an assessment reference date of 01/13/2011, assessed RI #3 had long and short term memory problems and was severely impaired for cognitive skills for daily decision-making. The MDS indicated RI #3 was totally dependent on staff for all activities of daily living (ADL's) and was always incontinent of bowel and bladder. RI #3's "Physician Orders" dated 03/01/2011 thru 03/31/2011 documents: "Braden Scale Score: 10 ... " A Braden Scale is used for predicting pressure sore risk. According to the form a score of 10-12 indicates a high risk. A review of RI #3's "Comprehensive Care Plan" with the problem "... Resident is incont' (incontinent) of Bowel and Bladder. Does not realize need to toilet ..." with a review date of 01/19/2011 revealed the following approach": "... Check and Change Q (every) 2 HRS (hours) and PRN (as needed)." A further review of RI #3's "Comprehensive Care Plan" with the problem "... Risk for skin breakdown ..." with a review date of 1/19/2011 revealed the following approach: "...Turn and position Q 2 hours ..." A document titled "Nurse's Notes" dated 02/08/2011 revealed RI #3's "...area to left buttock has closed. Skin still very fragile ... will continue care plan as written ..." During continuous observation on 03/16/2011 at 7:45 AM the surveyor observed RI #3 sitting in her room in a Geri-chair with her feet elevated wearing heel boots. From 7:45 AM to 1:55 PM RI #3's position was not changed and she was not checked for incontinence as care planned. 2.) RI #10 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) with a reference date of 03/10/2011, assessed RI #10 had long and short term memory problems and was severely impaired for cognitive skills for daily decision-making. The MDS indicated RI # 3 was totally dependent on staff for all activities of daily living (ADL's) and was always incontinent of bowel and bladder. The RAP for Pressure Ulcers dated 06/23/2010 included "Narrative Note" "... resident is incontinent of Bowel and Bladder that increase risk for skin breakdown. She also has diabetes that affects skin integrity ..." RI #10's "Physician Orders" dated 03/01/2011 thru 03/31/2011 documents: "Braden Scale Score: 12 ... " According to the form a score of 10-12 indicates a high risk. A review of RI #10's "Comprehensive Care Plan" with the problem "... Resident is incont' (incontinent) of Bowel and Bladder. Does not realize need to toilet ..." with a review date of 03/16/2011 revealed the following approach: "... Check and Change Q (every) 2 HRS (hours) and PRN (as needed)." Upon further review of RI #10's "Comprehensive Care Plan" with the problem "... Risk for skin breakdown ..." with a review date of 1/19/2011 revealed the following approach: "... Turn and position Q 2 hours ... and PRN..." During continuous observation on 03/16/2011, the surveyor observed RI #10 from 8:00 AM to 2:15 PM sitting in a wheelchair with a lap buddy in place. RI #10's position was not changed and she was not checked for incontinence Q 2 hours as care planned. 3.) RI #12 was re-admitted to the facility on [DATE] with an original admission date of [DATE] with a [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) with a reference date of 02/10/2011, assessed RI #12 had a Brief Interview for Mental Status (BIMS) score of 8. The MDS indicated RI #12 required extensive assistance from staff for all activities of daily living (ADL's) and was always incontinent of bowel and bladder. The Care Area Assessment (CAA) for Pressure Ulcers for 11/11/2010 included "Complications and Risk Factors: " "Resident is at risk for development of pressure sores due to mobility problems and being incontinent of bowel and bladder ..." RI #12's "Physician Orders" dated 03/01/2011 thru 03/31/2011 documents: "Braden Scale Score: 13 ..." According to the form a score of 13-14 indicates a moderate risk. A review of RI #12's "Comprehensive Care Plan" with the problem "... Resident is incont'(incontinent) of Bowel and Bladder. Does not realize need to toilet ..." with a review date of 02/16/2011 revealed the following approach": "... Check and Change Q (every) 2 HRS (hours) and PRN (as needed)." Upon further review of RI #12's "Comprehensive Care Plan" with the problem "... Risk for skin breakdown ..." with a review date of 2/16/2011 revealed the following approach: "... Turn and position Q 2 hours ... and PRN". On 03/16/2011 the surveyor observed RI #12 from 10:45 AM to 2:05 PM sitting in a Geri-chair. RI #12's position was not changed and she was not checked for incontinence every 2 hours as care planned. 4.) RI #15 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) with a reference date of 12/30/2010, assessed RI #15 had long and short term memory problems and was severely impaired for cognitive skills for daily decision-making. The MDS indicated RI #15 was totally dependent on staff for all activities of daily living (ADL's) and was always incontinent of bowel and bladder. The RAP for Pressure Ulcers for 07/14/2010 included "Complications and Risk Factors: " "At risk for developing pressure sores due to incontinence and problems with mobility..." RI #15's "Physician Orders" dated 03/01/2011 thru 03/31/2011 documents: "Braden Scale Score: 10 ..." According to the form a score of 10-12 indicates a high risk. A review of RI #15's "Comprehensive Care Plan" with the problem "... Resident is incont' (incontinent) of Bowel and Bladder. Does not realize need to toilet ..." with a review date of 01/05/2011 revealed the following approach "... Check and Change Q (every) 2 HRS (hours) and PRN (as needed)." Upon further review of RI #15's "Comprehensive Care Plan" with the problem "... Risk for skin breakdown ..." with a review date of revealed the following approach: "... Turn and position Q 2 hours ...and PRN..." During continuous observation of RI #15 from 10:45 AM to 1:55 PM on 03/16/2011, RI #15 was sitting in a Geri-chair. RI #15's position was not changed and she was not checked for incontinence every 2 hours as care planned.