Every finding on record at Bridgeway Health and Rehabilitation Center

Based on observations, interviews, review of a facility document titled Manual Washing and Sanitizing, and the Food and Drug Administration (FDA) Food Code, the facility failed to ensure: 1. the 3-compartment sink's drain pipe did not extend into the floor drain and 2. food service pans were sanitized properly by immersion in hot water for 30 seconds in the sanitizer sink. This has the potential to affect 75 of 75 residents receiving meals from the kitchen. Findings Include: 1) A review of the FDA (YEAR) Food Code revealed: 1. . 5-402.11 Backflow Prevention. (A) . a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. On 1/06/20 at 1:20 PM, during the initial tour of the kitchen an observation was made of the 3 compartment sink's drain pipe. The drain pipe extended three to four inches below floor grade and into the floor drain. On 1/07/20 at 2:25 PM, an interview was conducted with Employee Identifier (EI) #6, Maintenance Supervisor in the kitchen. EI #6 was asked, did the drain pipe from the 3-compartment sink extend into the floor drain. EI #6 replied, yes. On 1/08/20 at 8:35 AM, during a kitchen observation, the surveyor noted the drain pipe from the 3 compartment sink extended greater than four inches below floor grade and into the floor drain. On 1/08/20 at 11:59 AM, an interview was conducted with a Certified Plumber hired by the facility. The plumber was asked, did the 3 compartment sink's drain pipe extend into the floor drain. He replied, yes. The plumber was asked, what was the potential harm caused by the drain extending into the floor drain below the flood grade. He replied, there was a potential for backflow of sewage into the sink. 2. A review of the FDA (YEAR) Food Code revealed: .4-703.11 Hot Water and Chemical. After being cleaned . UTENSILS shall be SANITIZED in: (A) Hot water manual operations by immersion for at least 30 seconds . An undated facility document titled Manual Washing and Sanitizing revealed . After washing and rinsing, dishes and utensils are sanitized by immersion in either: Hot water (at least 170 degrees Fahrenheit (F) ) for 30 seconds . On 1/09/20 at 8:11 AM, an observation was made of EI #7, Shift Supervisor in the dietary department as she washed pans in the 3 compartment sink. EI #7 washed, rinsed, and failed to completely immerse four of 11 pans in hot water for at least 30 seconds. The four pans not immersed, floating on top of the water, were rinsed with hot water for less than 5 seconds, and placed on a rack to dry. On 1/09/20 at 8:27 AM, an interview was conducted with EI #7. EI #7 was asked, what was the process for sanitizing pans. EI #7 replied, dishes stayed in the hot water with temperature of at least 170 degrees F and for at least 30 seconds. EI #7 was asked, should the pans float in the water during the 30 seconds. EI #7 replied, when the pans were put in the water, they floated. On 1/09/20 at 8:35 AM, an interview was conducted with EI #3, Certified Dietary Manager. EI #3 was asked, what was the policy or procedure for sanitizing pans in the 3 compartment sink. EI #3 replied, dishes were washed, rinsed , and sanitized in hot water for 30 seconds or more. EI #3 was asked, how were pans sanitized in the 3-compartment sink. EI #3 replied, during the final rinse the pans should be immersed in hot water of 171 degrees Fahrenheit for at least 30 seconds. EI #3 was asked, when should the pans be completely immersed in hot water for at least 30 seconds. EI #3 replied, at the final rinse in the third sink. EI #3 was asked, when should dishes to be sanitized in hot water float in the hot water and not be immersed for 30 seconds. EI #3 replied, never. EI #3 was asked, what was potential harm to residents when pans used for food preparation and service were not sanitized in hot water by complete immersion for at least 30 seconds before air drying. EI #3 replied, without 30 seconds of immersion in hot water, there was a possibility bacteria was not completely killed, and then someone could get sick On 1/09/20 at 10:18 AM, an interview was conducted with EI #1, Administrator. EI #1 was asked, when did the drain pipe from the 3 compartment sink extend into the floor drain. EI #1 replied, from 1999 until 1/8/2020. EI #1 was asked was there any harm in not sanitizing pans and utensils in the kitchen per policy and FDA food code. EI #1 replied, obviously there was because there was regulations governing that.

Based on observation, interviews, record review and a facility policy titled, Oxygen Therapy-Mask, Nasal Cannla & Nebulizers, the facility failed to ensure a nebulizer treatment mask was not out of the ZIPL[NAME]K bag and a hair brush resting on top of the nebulizer for Resident Identifier (RI) #48. This was observed on 1/6/20 and affected one of one sampled residents' observed for breathing treatments. Findings Include: A review of a facilitypolicy titled, Oxygen Therapy -Mask, Nasal Cannula & Nebulizer with no date revealed . nebulizer masks and/or pipes should be stored in a plastic bag . RI #48 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A review of RI #48's Physician orders [REDACTED]. On 1/06/20 at 2:07 PM, during the initial tour of the facility RI #48 was observed in bed resting with eyes closed. RI #48 was receiving oxygen by nasal cannula. The surveyor observed the breathing treatment machine with the treatment mask attached to the machine. The mask was uncovered and a hair brush was lying on top of the nebulizer mask attached to machine but uncovered. On 01/06/20 at 02:31 PM, an interview was conducted with Employee Identifier (EI) #4, Licensed Practical Nurse. EI #4 was asked, if RI # 48 received breathing treatments. EI #4 replied, yes, she was fixing to give one then. EI #4 was asked, how long had RI #48 been receiving breathing treatments. EI #4 replied, it had been since RI #48 was admitted to the facility. EI #4 was asked, what was the order for breathing treatment. EI #4 replied, [MEDICATION NAME] 0.63 mg per 3 milliliters. EI #4 was asked, to tell the surveyor where the breathing treatment mask was. EI #4, replied, on the bedside table attached to nebulizer with the plastic bag lying on the table beside the machine. EI #4 was asked, what was the protocol on storing the breathing treatment masks between treatments. EI #4 replied, it should be covered. EI #4 was asked if the breathing treatment mask was covered. EI #4 replied, no. EI #4 was asked what was the potential harm in not covering the mask between treatments. EI #4 replied, it could get germs and hair in mask. On 1/09/20 at 10:20 AM, an interview was conducted with EI #2, Director of Nursing. EI #2 was asked, what was the policy on storing the breathing treatment masks between treatments. EI #2 replied, inside a ziplock bag. EI #2 was asked, what was the potential harm in not covering the mask and having a resident's hair brush on the nebulizer between treatments. EI #2 replied, it could get contaminated by germs.

Based on observation, interview and review of facility policies titled: Handling Ice, Storing Dry Food and HYGIENE OF DIETARY STAFF, the facility failed to ensure: 1. two stored loaves of bread did not have a use by date of [DATE] and [DATE], 2. the ice scoop was not stored inside the ice machine on top of the ice, and 3. 2 dietary staff had exposed hair contained in hair restraints. This was observed on [DATE] and [DATE] and had the potential to affect 69 residents receiving meals from the kitchen. Findings Include: 1. A review of a facility policy titled: Storing Dry Food, no date, revealed . Rotate stock on first in/first out (FIFO) system. Date items if required . Opened items . If an item has a use by date, this date must be part of the labeling. On [DATE] at 3:14 PM, during the kitchen tour with Employee Identifier (EI) #2, Dietary Manager, the surveyor observed the bread rack. On the bread tray two loaves of bread were observed with expired dates. One loaf was dated [DATE], the other [DATE]. The surveyor asked EI #2 what was the use by date on each loaf. EI #2 replied, ,[DATE] and ,[DATE]. The surveyor asked what was that day's date. EI #2 replied, (MONTH) 26. 2. A review of a facility policy titled: Handling Ice, no date, revealed . Protecting ice during storage and service Ice must be protected from splash, drip and hand contamination during storage and service. On [DATE] at 3:18 PM, the surveyor observed inside the ice machine. The scoop was observed stored inside; the handle of the scoop was resting on the ice. The surveyor asked EI #2 where was the scoop to be stored. EI #2 replied, inside like this and placed the scoop inside the ice machine against the right side of the machine on the ice. 3. A review of a facility policy titled: HYGIENE OF DIETARY STAFF, no date, revealed All food service personnel are required to wear . and hair nets. On [DATE] at 11:15 AM the surveyor observed EI #3, dietary aide on the food line next to staff taking temperatures and later making a tomato sandwich. EI #3 had a mustache and beard and no beard cover. EI #3 was asked what was the policy on covering hair, including mustache and beard. EI #3 replied, it should be covered. EI #3 was asked if he had his mustache and beard covered. EI #3 replied, no. On [DATE] at 11:30 AM, EI #4, a dietary staff was observed in the kitchen removing the drink cart from the walk in refrigerator. EI #4 was observed with her hair at the neck not covered in the hair net. EI #4 was asked what was the policy for covering hair. EI #4 replied, all her hair should all be under the net. EI #4 was asked if all of her hair was under the net. EI #4 replied, no. EI #4 was asked what was the harm in all of her hair not being under the net. EI #4 replied, hair could fall in resident's food or drink. On [DATE] at 8:40 AM, during an interview with EI #2 DM, he was asked what was the policy on expired foods. EI #2 replied, the staff should remove bread, the delivery person usually rotated it; it was overlooked. EI #2 was asked when should expired food remain in the food prep area. EI #2 replied, it should not. EI #2 was asked who responsible for ensuring foods were not expired. EI #2 replied, the DM, cooks and kitchen supervisor. EI #2 was asked what was the harm in bread past the expiration date in the food prep area. EI #2 replied, the potential for bacteria. EI #2 was asked when should the ice scoop remain in the ice machine. EI #2 replied, according to our policy, never. EI #2 was asked what was the policy on the ice scoop in the ice machine on the ice. EI #2 replied, must use a clean scoop to remove ice. EI #2 was asked what was the harm in the ice scoop on the ice inside the ice machine. EI #2 replied, the potential for collection of bacteria. EI #2 was asked what was the policy on covering hair when in the kitchen, to include beard and mustache. EI #2 replied, all staff were required to wear a hair net. EI #2 was asked what was the harm in staff with hair, to include facial, not contained in a hair restraint. EI #2 replied, there was the potential that loose hair could fall in the food contaminating the food.

Based on record review, interview and review of a facility policy titled: Comprehensive Care Plans, the facility failed to develop a care plan for Resident Identifier (RI) #14 when admitted to hospice services. This affected one of three residents sampled for hospice services. Findings Include: A review of a facility policy titled: Comprehensive Care Plans, no date, revealed: Policy: It is the policy of .to develop and implement a comprehensive person-centered care plan for each resident, .that includes measurable objectives and timeframes to meet a resident's medical, nursing .needs . RI #14 was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. On 11/27/18 at 5:01, PM RI #14's record was reviewed. A review of RI #14's (YEAR) (MONTH) Physician order [REDACTED]. HOSPICE .FOR ENDSTAGE [MEDICAL CONDITION] . A review of RI #14's Care Plan revealed no care plan for hospice services. On 11/27/18 at 5:15 PM, an interview was conducted with Employee Identifier (EI) #1, Assistant Director of Nursing/ Minimum Data Set (MDS). EI #1 was asked when was RI #14 admitted to hospice. EI #1 replied, 5/31/18. EI #1 was asked where was the care plan for hospice. EI #1 reviewed the care plan record and replied, there was no care plan. EI #1 was asked should a care plan be done when a resident is admitted to hospice. EI #1 replied, yes. EI #1 was asked who was responsible for developing the care plan. EI #1 replied, the MDS office. EI #1 was asked what was the harm in not having a care plan for hospice. EI #1 replied, only verbiage, everything was done for the resident the facility staff provided the care.

Based on observation, interview and review of a facility policy titledDistribution of Ice, the facility failed to ensure a Certified Nursing Assistant (CNA) passing ice to the residents on the units did not use the same bag to give multiple residents ice, allowing the bag to touch the over the bed tables and the water pitchers for each resident. This affected Resident Identifier #'s 14,1,74 and 26 and was observed on 11/17/18. This deficient practice had the potential to affect 69 of 81 residents receiving ice. Findings Include: A review of an undated facility policy titled, Distribution of Ice, no date, revealed: .Procedure: . 3. Ice will be placed in a disposable bag and emptied into each resident's individual water pitcher. RI #14 was readmitted to the facility on [DATE]. RI #1 was readmitted to the facility on [DATE]. RI #74 was readmitted to the facility on [DATE]. RI #26 was readmitted to the facility on [DATE]. On 11/27/18 at 9:00 AM, the surveyor observed Employee Identifier (EI) #5, CNA passing ice. EI #5 filled a plastic bag with ice from the ice cooler. EI #5 went in RI #14's room, placed the bag of ice on RI #14's overbed table, then opened the water pitcher and put half the ice in the pitcher. The bag observed touching the pitcher. Then EI #5 went to RI #1, placed the remaining ice in the bag on the over the bed table, opened the pitcher, took the pitcher to the sink and changed the water, then put the remaining ice in RI #1's pitcher. RI #14 and RI #1 were roommates. EI #5 left the room returned to the ice cooler and placed the bag on the cart in front of cooler. EI #5 sanitized her hands and went to the next hall. EI #5 picked up the previously used bag and filled it with more ice, then went into RI #74's room and added half the ice to the water pitcher. EI #5 then went to RI #26's room, placed the remaining bag of ice on the bed side table and changed the water in the pitcher. EI #5 added the ice from the same bag used in the previous rooms to RI #26's water pitcher. On 11/27/18 at 10:03 AM, an interview was conducted with EI #5. EI #5 was asked how was she suppose to give ice to residents. EI #5 replied, get a clean bag for each resident, put ice in it and take into the room. EI #5 was asked if she used one bag for both RI #14 and 1. EI #5 replied, yes. EI #5 was asked if the bag touched the water pitchers as she poured the ice in them. EI #5 replied, yes, she suppose it did. EI #5 was asked if she went to the other hall and gave ice to RI #74, then go to RI #26's room and place ice in the water pitcher. EI #5 replied, yes. EI #5 was asked when should she use the same bag filled with ice and take into other residents room. EI #5 replied, she should not. EI #5 was asked what could the risk be in using the same bag for passing ice to multiple residents. EI #5 replied, contamination from one resident to another as she went from one then more residents. EI #5 was asked how many residents were given ice. EI #5 replied, all except the tube feeders. On 11/29/18 at 8:31 AM, an interview was conducted with EI #6, Director of Nursing / Infection Control. EI #6 was asked what was the policy on passing ice to individual residents. EI #6 replied, they were to use an individual bag for each resident. EI #6 was asked when should staff use one bag for multiple residents. EI #6 replied, never. EI #6 was asked what was the risk of staff passing ice using the same bag for multiple residents. EI #6 replied, cross contamination.

Based on observation, interviews and a review of a facility policy titled, Handling Soiled Linen the facility failed to ensure Laundry Staff washed her hands between dirty and clean clothes handling. This was observed on one of three days of the survey. This had the potential to affect 53 of 78 residents whose clothes were laundered by the facility. Findings Include: A review of a facility policy titled, Handling Soiled Linen with no revised date revealed: Policy: It is the policy of this facility that linens are handled, stored, processed, and transported so as to prevent the spread of infection.Policy Explanation and Compliance Guidelines: . 3.h. Wash hands after contact with soiled linen. On 10/19/2017 at 8:27 a.m., the surveyor observed laundry staff putting on one glove and a hospital type gown. The worker start loading the washer with dirty clothes. After she loaded the washer, she pulled off her one glove, apron and went to the clean side of the laundry room. The worker did not wash her hands. She started folding and hanging clean clothes. On 10/19/2017 at 12:00 p.m., the surveyor conducted an interview with (Employee Identifier) EI #2 Housekeeping/Laundry. EI #2 was asked what PPE (Personal Protective Equipment) did she have on when putting clothes into the washer. EI #2 replied, a gown and one glove. EI #2 was asked what did she do after pulling off her glove. EI #2 replied, she started folding and hanging clothes. EI #2 was asked did she wash her hands prior to hanging and folding clothes. EI #2 replied, not after she put the dirty clothes in the washer. EI #2 replied, she just took the dirty glove off. EI #2 was asked how many gloves did she have on. EI #2 replied, one. EI #2 was asked what did the facility policy say regarding washing her hands after putting dirty clothes in the washer. EI #2 replied, wash your hands after soil laundry. EI #2 was asked when should she wash her hands in the laundry room. EI #2 replied, after everytime she touch something nasty. EI #2 was asked did she have residents clothes on her arm when taking clothes from the washer to the dryer. EI #2 replied, yes ma'am. EI #2 was asked what was the potential harm to the residents when handling dirty items and proceed to touch and hang clean clothes. EI #2 replied, cross contamination. On 10/19/2017 at 3:00 p.m., the surveyor conducted an interview with EI #1, DON (Director of Nursing). EI #1 was asked should a worker wash her hands after putting dirty clothes in the washer and proceeding to fold and hang clothes on the clean side of the laundry room. EI #1 replied, yes ma'am. EI #1 was asked what was the potential harm to the resident when a worker loaded the washer with dirty clothes and proceed to hang and fold clothes. EI #1 replied, the potential for passing germs.

Based on observation, interviews and record reviews, the facility failed to ensure a licensed staff cleaned Resident Identifier (RI) #9's right hip wound from the least-contaminated area, which is the center of wound, to most contaminated area, the surrounding skin on 10/07/2015, during a wound care observation. This affected RI #9, one of three resident observed for wound care. Findings Include: A review of a Potter and Perry FUNDAMENTALS OF NURSING, Eight Edition, copyright 2013, Chapter 48, Skin Integrity and Wound Care, page 1219 revealed the following: . 9. Clean wound with solution. Clean from least-contaminated area, which is the incision or center of wound, to most contaminated area, which is the outside of incision and surrounding skin. RI #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #9's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed RI #9 had short-term and long-term memory problems with cognition. Under Section M-Skin Condition, RI #9 was identified to have 2 Stage 2's, 1 Stage 3, 2 stage 4's and 7 Unstageable ulcers. A review of RI #9's Wound Assessment Report with a date of 10/06/15, revealed RI #9's Right Hip Pressure ulcer was a Stage 4 with measurements, Length-9.00 cm (centimeters), Width- 6.00 cm, and Depth- 0.30 cm and had a moderate amount of serous drainage. A review of RI #9's Physician order [REDACTED]. CLEAN RIGHT HIP WITH NORMAL SALINE. APPLY NON-ADHERENT PADS AND DRY DRESSING TWICE DAILY. On 10/07/15 at 12:44 PM, EI (Employee Identifier) #2, the LPN (Licensed Practical Nurse) during the wound care performance on RI #9's right hip was observed by the Surveyor to wash her hands, apply clean gloves, removed the old dressing off RI #9's right hip and identified the drainage on the old dressing as serosanguineous. EI #1 the ADON (Assistant Director of Nursing), was present to assist EI #2. EI #2 washed her hands re-applied clean gloves, then cleansed around top edge of wound with a normal saline pad then with another normal saline pad, cleansed around the bottom edge of the wound. EI #2 washed her hands, re-gloved applied non-adherent pad and foam dressing to wound and then washed her hands. On 10/08/15 at 5:15 PM, the Surveyor conducted an interview with EI #2. EI #2 was asked what was her titled or position. EI #2 replied she was an LPN Treatment Nurse. EI #2 was asked how long she has worked in that position at the facility. EI #2 replied, almost four years. EI #2 was asked how should a wound be cleaned. EI #2 replied, from the inside out, from cleanliness to dirtiness. The Surveyor then informed EI #2 of her observation of RI #9's right hip wound cleaning. EI #2 was asked how did she clean RI #9's right hip wound. EI #2 stated, I cleaned it from the center out discard it and with the other one in my hand, cleaned around it and discard it. EI #2 was asked what the facility's policy on cleaning a wound was. EI #2 replied, to follow the physician orders. EI #2 was asked what was there a potential for when a wound is not cleaned properly or correctly. EI #2 replied a potential for infection and the wound not healing properly. On 10/08/15 at 5:28 PM, the Surveyor conducted an interview with EI #1, the ADON. EI #1 was asked how should a wound be cleansed. EI #1 replied, clean the inner with one (pre-soaked Normal Saline Pad) and clean the outer with one, clean from inside out. The Surveyor informed EI #1 of her observation of RI #9's right hip wound cleaning. EI #1 was asked what was her observation of the cleaning of RI #1's right hip wound. EI #1 replied she didn't pay it no mind. EI #1 said she was just an axillary person to flip. EI #1 was asked what was the facility's policy on cleaning a wound. EI #1 replied, she is the Wound Care Nurse and we were taught from inner outer. EI #1 was asked what was there a potential for when a wound is not clean properly or correctly. EI #1 replied for the wound not to heal, further infection and the wound will get worst.

Based on observation, interview, and review of the Food and Drug Administration Food Code 2013, the facility failed to ensure Mighty Shakes and juices were stored in a manner to prevent potential contamination from spilled juice and an accumulation of water. The facility further failed to ensure vegetable soup and chicken fingers stored in the walk-in freezer were labeled with an item name. These failures had the potential to affect all 75 of 75 residents receiving meals from the kitchen. Findings Include: 1) Review of the Food and Drug Administration Food Code 2013 revealed the following: "... Preventing Contamination from the Premises 3-305.11 Food Storage. (A)... FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination..." During the initial tour of the kitchen on 10/28/2014 beginning at 1:15 PM, the surveyor observed Mighty Shakes stored in an upright reach-in cooler located in the dry storage room. Eight Mighty Shakes were stored in a bin in direct contact with water. When the cartons were picked up they were dripping water. When the surveyor asked EI (Employee Identifier) #1, the Certified Dietary Manager, where the water had come from, he stated it had probably occurred because the shakes were frozen and when they thawed, condensation or frost caused a water residue. In the walk-in cooler, the surveyor observed nine apple juice cups stored in a bin containing spilled juice. EI #1 stated some of the juices had busted. Also in the walk-in cooler was a bin containing 4 cranberry juice cups stored in direct contact with water. EI #1 stated the water was probably a result of putting them in the bin frozen. In a follow-up interview with EI #1 on 10/29/2014 at 5:34 PM, the surveyor asked why the Mighty Shakes and juices had been stored in a bin containing water. He stated they were pulled from the freezer and placed in the bins and when they thawed the bins collected the condensation. When asked what potential harm could occur if the Mighty Shakes or juices were stored in water or spilled juice, EI #1 stated there would be a potential for contamination. 2) Further review of the Food and Drug Administration Food Code 2013 revealed the following: "... 3-6 FOOD IDENTITY, PRESENTATION, AND ON-PREMISES LABELING... Labeling 3-602.11 Food Labels. ... (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement..." During the initial tour of the kitchen on 10/28/2014 beginning at 1:15 PM, the surveyor observed a bag of frozen vegetable soup (identified by the Certified Dietary Manager) in the walk-in freezer without a label. EI (Employee Identifier) #1, the Certified Dietary Manager (CDM) stated the item should have been labeled with the item name when it was removed from the box. A bag of frozen breaded food not labeled with an item name was also noted in the walk-in freezer. EI #1 identified the item as chicken tenders and stated the item should have been placed back in the box. A follow-up interview was conducted with EI #1 on 10/29/2014 at 5:34 PM. When asked how items stored in the freezer should be labeled, EI #1 stated if in the original box, items should be labeled with an item name.

Based on observation, interview, and record review, the facility failed to ensure Employee Identifier (EI) #2, a Certified Nursing Assistant (CNA), changed her gloves and washed her hands after cleaning Resident Identifier (RI) #9's buttocks and prior to applying Laniseptic barrier cream and a clean brief. This affected RI #9, a resident currently being treated for [REDACTED]. Findings include: Review of the facility's undated policy titled "Topic: Peri-care/ Incontinent Care" revealed the following: "...Policy: Incontinent care/peri-care will be provided by staff as needed after each incontinent episode using the non-rinse peri-wash. Procedure: . . . 10. After care has been provided . . . Remove gloves and wash your hands prior to any further care . . . " Resident Identifier (RI) #9 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of RI #9's Quarterly Minimum Data Set ((MDS) dated [DATE], revealed RI #9 suffered severe cognitive impairment. The MDS further revealed RI #9 was totally dependent on staff for toileting and was always incontinent of bowel and bladder. A review of RI #9's medical record revealed a urine culture was collected on 10/17/2014. The results were reported on 10/21/2014, and RI #9 was started on [MEDICATION NAME] 500 mg (milligrams), one capsule four times a day for ten days for UTI. On 10/29/2014 at 2:45 PM, Employee Identifier (EI) #2, a CNA, donned gloves and cleaned RI #9 of a small amount of incontinent stool. When incontinent care was completed to the rectal area and buttocks, EI #2 put a clean brief under RI #9 and applied barrier cream to the rectal area and buttocks. EI #2 did not change her gloves or wash/sanitize her hands. On 10/29/2014 at 2:55 PM, a brief interview was conducted with EI #2, the CNA that provided incontinent care to RI #9. EI #2 was asked what the facility's policy regarding hand washing and changing gloves after incontinent care was. EI #2 replied to remove dirty gloves and wash hands, then to put on clean gloves to apply a clean brief and the barrier cream. EI #2 was asked if she had done this, and EI #2 replied that she had not. On 10/30/2014 at 12:50 PM, EI #3, the Director of Nursing (DON)/ Infection Control Nurse, was asked what the facility's policy was on hand washing. EI #3 replied to wash hands before and after procedures and any contact with a resident. EI #3 was also asked when gloves should be changed during incontinent care. EI #3 stated anytime gloves are soiled. EI #3 also explained that before putting on gloves, staff should wash hands. EI #3 was asked what a CNA should do prior to applying a clean brief and barrier cream during incontinent care. EI #3 said the CNA should reapply clean gloves. EI #3 was asked what was the potential for harm when not changing dirty gloves and washing/sanitizing hands before applying barrier cream and clean brief during incontinent care. EI #3 replied there was a potential for infection. EI #3 said RI #9 had a history of [REDACTED]. When asked what potential harm could occur for RI #9 as a result of EI #2 performing incontinent care inappropriately, EI #3 stated her infection could continue.

Based on observation, interview and record review, the facility failed to ensure a Certified Nursing Assistant (CNA), Employee Identifier (EI) #2, removed dirty gloves, then washed/sanitized her hands and reapplied clean gloves before applying Laniseptic cream and a clean brief during the provision of care to prevent cross contamination. This affected Resident Identifier (RI) #9, one of two residents observed for incontinent care. Findings Include: The facility's Policy and Procedure titled "Hand washing and Hand Sanitizer use," revised 3/18/03 revealed: " Standard Proper hand washing technique or use of hand sanitizer is used for the Prevention of infectious diseases. Policy All personnel working in the long-term facility are required to wash their hands or use hand sanitizer before and after resident contact, before and after performing any procedure, ... and when hands become obviously soiled..." The facility's undated policy titled "Topic: Peri-care/ Incontinent Care" revealed the following: " Policy: Incontinent care/peri-care will be provided by staff as needed after each incontinent episode using the non-rinse peri-wash. Procedure: . . . 10. After care has been provided, . . . Remove gloves and wash your hands prior to any further care. . . . Infection Control: Always wash hands prior to and immediately after providing care to the resident. Always wear gloves when providing care to residents. . . . Do not provide care to the peri-anal area of a Resident, then begin cleansing other areas of the resident. Wash hands, apply new gloves and then complete care to other areas. " Resident Identifier (RI) #9 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #9's Quarterly (MDS) Minimum (MDS) data set [DATE] indicated severe impairment in cognition. RI #9's MDS also showed the resident was totally dependent on staff for toileting and was always incontinent of bladder and bowel. On 10/29/2014 at 2:45 PM, Employee Identifier (EI) #2, a CNA, donned gloves and cleaned RI #9 of a small amount of incontinent stool. When incontinent care was completed to the rectal area and buttocks, EI #2 put a clean brief under RI #9 and applied barrier cream to the rectal area and buttocks. EI #2 did not change her gloves or wash/sanitize her hands. On 10/29/2014 at 2:55 PM, EI #2 was asked by the surveyor what the facility's policy was regarding cleaning a resident's rectal area and buttocks then applying barrier cream and a clean brief. EI #2 said the facility's policy says to remove dirty gloves, wash hands, then put on clean gloves before applying barrier cream and a clean brief. When EI #2 was asked if this is what she had done, EI #2 replied no; she stated she had removed her gloves (soiled) after applying the barrier cream. EI #2 was asked what potential harm could occur by not washing her hands and changing her gloves. EI #2 replied infection control. On 10/30/14 at 12:50 PM, EI #3, the Director of Nursing (DON)/ Infection Control Nurse, was asked what the facility's policy was on hand washing. EI #3 replied to wash hands before and after procedures and any contact with a resident. EI #3 was also asked when gloves should be changed during incontinent care. EI #3 stated anytime gloves are soiled. EI #3 also explained that before putting on gloves, staff should wash hands. EI #3 was asked what a CNA should do prior to applying a clean brief and barrier cream during incontinent care. EI #3 said the CNA should reapply clean gloves. EI #3 was asked what was the potential for harm when not changing dirty gloves and washing/sanitizing hands before applying barrier cream and clean brief during incontinent care. EI #3 replied there was a potential for infection.

Based on observations, interviews and review of a facility policy titled "Use by Dates", the facility failed to ensure: (1) bowls were clean and without dried food debris, (2) the equipment (dishmachine) was functioning properly to effectively sanitize food-Contact Surfaces and Utensils, and (3) a container of sliced peaches was not labeled with a use by date. These deficient practices have the potential to affect 77 of 77 residents receiving meals from the kitchen. Finding Include: 1) On 10/21/13 at 11:18 a.m., during the initial tour of the kitchen, the surveyor observed two (2) of 12 bowls with dried food debris on them. The Certified Dietary Manager (CDM), EI #2, identified one of the bowls had dried cereal on it and the other bowl had dried grits. On 10/23/13 at 9:00 a.m., the surveyor conducted an interview with EI #2. The surveyor asked EI #2, when his staff removes clean dishes from the dishwasher, do they check to ensure the dishes are clean. EI #2 said they (dietary staff) were suppose to. On 10/24/13 at 9:10 a.m., the surveyor conducted an interview with EI #4, the dietary staff assigned to work the dish room on 10/21/13. The surveyor shared with EI #4 the observation of the two bowls with dried food debris. The surveyor asked EI #4, why did she think that had occurred. EI #4 stated she didn't know. EI #4 said, she usually looks at the bowls and pureed plates when they come out of the dishwasher to make sure food was not left on them. EI #4 stated, if she saw food left on the dishes she would run them again. EI #4 stated, she usually squirts the dishes with water (sprayer) to ensure all the food is off before she run them through the dishmachine. EI #4 said she must have just overlooked that. EI #4 replied mostly she check her dishes as they come out of the machine to make sure no food particles are left on the dishes. 2) A review of a "Routine Preventive Maintenance" report from (name of company that services the facility's dishwasher) dated 09/27/2013, revealed the following: "... COMMENTS: Inspected dishwasher ... Noticed machine missing rinse jets, need to be replaced ..." On 10/23/13 at 9:00 a.m., the surveyor conducted an interview with the CDM, EI #2. The surveyor asked EI #2, had the kitchen had problems with the dishwasher. EI #2 stated the facility had a guy to come in on Tuesday (10/22/13) and the guy saw where a couple of the the rinse heads were off and the dishwasher wasn't rinsing properly. The surveyor asked EI #2 how often was the dishwasher serviced. EI #2 replied they were checked monthly. On 10/24/13 at 10:20 a.m., the surveyor conducted a second interview with EI #2. The surveyor asked EI #2, was he aware the dishwasher had missing rinse jets. EI #2 stated he did not know that until the other day (10/22/13). The surveyor asked EI #2, who would have been responsible for replacing the missing rinse jets on 09/27/13. EI #2 replied usually (name of company that services the dishwasher) has the responsibility, but the facility has to give them the authority to order the part. The surveyor asked EI #2, who reviews the "Routine Preventive Maintenance" report sheets. EI #2 said he did. EI #2 said the report sheets are e-mailed to him and he usually kept them on file. The surveyor asked EI #2, was 10/22/13 the first time be became aware of the missing rinse jets. EI #2 replied yes. An attempt was made to contact (name of company that services the facility's dishwasher) on 10/24/13 at 8:04 a.m. The surveyor received a call from a representative from the company on 10/28/13, and returned the call at 7:36 a.m. The surveyor asked the representative what was the purpose of the rinse jets. The representative stated to rinse the dishes off. The surveyor asked the representative do the rinse jets also help with the sanitizing of the dishes in the rinse cycle. The representative stated, absolutely. The surveyor asked the representative what would be some of the consequences of a missing rinse jet. The representative replied, the dish machine would not rinse properly. Food Code 4-7 Sanitation of Equipment and Utensils ... 4-701.10 Food-Contact Surfaces and Utensils, documented: "Equipment Food-contact Surfaces and Utensils shall be sanitized." 3) A review of a faility policy titled "Use by Dates", no date, documented: "Use by date" is a new requirement All items placed in refrigerator for storage are to have a date of when the product must be used by or discarded." On 10/21/13 at 11:23 a.m., during the initial tour of the kitchen with the CDM, the surveyor observed a container of sliced peaches with no label on the container. On 10/23/13 at 9:00 a.m., the surveyor conducted an interview with the CDM, EI #2. The surveyor asked EI #2 why did the container of peaches not have a label on the container. EI #2 said his kitchen supervisor, EI #5, said she had marked the container and the label fell off. EI #2 presented to the surveyor a label marked "Peaches 10/21/13." On 10/24/13 at 10:20 a.m., the surveyor conducted a second interview with EI #2. The surveyor asked EI #2, when his staff labels a container, what did he expect them to place on the label. EI #2 said usually the open date and the use by date. The surveyor asked EI #2, what date did 10/21/13 (the date on the label presented to the surveyor) represent. EI #2 said the use by date. On 10/24/13 at 10:56 a.m., the surveyor conducted an interview with EI #5, the Dietary Supervisor. The surveyor informed EI #5 on 10/21/13, on the initial tour of the facility, a container of peaches in the refrigerator did not have a label. EI #5 stated, she informed EI #2 she had already labeled the container of peaches and the label must have fallen off. EI #5 stated, she found the label on the second shelf. The surveyor asked EI #5, when labeling an item, what should be on the label. EI #5 said, the date we opened it (the food item in the container) and the name of the item. The surveyor asked EI #5 should the use by date be on the label as well. EI #5 said yes. EI #5 stated the use by date would be for 3 days. The surveyor showed EI #5 the label with "Peaches 10/21/13" on it, and asked EI #5 did she see a use by date on the label. EI #5 stated, no.

Based on interview, record review and review of a facility's policy titled "Care Plan", the facility failed to ensure Resident Identifier (RI) #6 had a care plan developed for the utilization of an antipsychotic medication. RI #6, one of five (5) residents sampled for anti-psychotic drug use was affected. Findings Included: A facility's policy titled "Care Plan" no date documented the following: "Responsibility The following individuals may have responsibility for completing the care plan specific to state professional licensing requirements. -RN (Registered Nurse) ... Policy All residents must have a care plan ... - All disciplines involved in providing services's to a resident should attend a care planning conference to coordinate care and develop the resident care plan. - The interdisciplinary care plan is reviewed, revised, and updated quarterly and more frequently if warranted by a change in residents condition ..." RI #6 was originally admitted to the facility on [DATE], and readmitted [DATE], with [DIAGNOSES REDACTED]. A review of RI #6's medical record revealed a physician progress notes [REDACTED]. "... Patient has a history of poorly controlled hypertension, [MEDICAL CONDITION] reflux, dementia and diabetes. She is seen with nursing staff today and appears stable. She is somewhat combative during finger sticks so we will have to start her on a mild anti-psychotic. There is a history of dementia ... 4. Agitated behavior and she is demented. We will start her on [MEDICATION NAME] 7.5 mg (milligrams) every evening." Signed by the facility's Medical Director Employee Identifier (EI) #6. Further review of RI #6's medical record revealed a Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/23/13. In Section C - Cognitive Patterns, RI#6 was assessed to have a Brief Interview Mental Score (BIMS) score of 2. In Section C1300A, RI #6 was assessed to have signs of [MEDICAL CONDITION], inattention, this behavior was present and fluctuated (comes and goes, changes in severity). In Section C1300B, Signs of [MEDICAL CONDITION]: disorganized thinking Behavior present, fluctuates (comes and goes, changes in severity. In Section E - Behavior E0900; wandering; presence and frequency (3) Behavior of this type occurred daily. In Section G - Functional Status, RI #6 was assessed to need limited assistance with walking in room and corridor, locomotion on and off the unit and with eating. In Section N - Medications, RI #6 was assessed in section NO410A medication received: Days: anti-psychotic 7 (days). RI #6's had "Physician Orders" dated October 2013, which included "[MEDICATION NAME] 0.5 MILLIGRAMS BY MOUTH EVERY EVENING. DEMENTIA WITH PSYCHOTIC FEATURES. Generic: [MEDICATION NAME] ..." Six (6) months after RI #6 was started on this Anti-psychotic medication, from March 29, 2013 - October 24, 2013, the facility failed to developed a care plan for the [MEDICATION NAME] usage. On October 24, 2013 at 10:30 a.m., when the surveyor questioned the facility staff about RI #6's care plan for the Anti-psychotic medication EI #3, a RN (Registered Nurse), the Care Plan Coordinator/Assistant Director Of Nursing (ADON) presented to the surveyor a care plan for RI #6. This care plan was titled "Potential for drug induced side effects due to the use of Rispedal ([MEDICATION NAME]) for dementia with psychotic features." On 10/24/13 at 10:30 a.m., the surveyor conducted an interview with EI #3, the Care Plan Coordinator/ADON. The surveyor asked EI #3 if RI #6 had a Care Plan for the anti-psychotic medication [MEDICATION NAME]. EI #3 reviewed RI #6's medical record. EI #3 said she did not see a Care Plan for the [MEDICATION NAME]. EI #3 said she missed it and she did not write a care plan for it ([MEDICATION NAME]). The surveyor asked EI #3 when was EI #6 started on [MEDICATION NAME]. EI #3 said it (the [MEDICATION NAME]) was started in August 2013. EI #3 said the Care Plan is for monitoring for the potential side effects. The surveyor asked EI #3 who was responsible for developing Care Plans for the residents. EI #3 stated, I am.

Based on observations, interviews and record reviews, the facility failed to check and change and release the seat belt every hour as care planned. This affected one of four residents sampled for restraints. Findings include: Resident Identifier (RI) # 4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #4 had a Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/08/13 which identified her with a BIMS (Brief Interview for Mental Status) of 6, indicating severe cognitive impairment. RI #4 required extensive assistant with one person physical assist for all transfers and bed mobility. RI #4 was documented as requiring total assistance with dressing and toileting. The MDS also identified RI #4 with a "Trunk Restraint" used daily when in chair. The Care Area Assessment (CAA) Summary dated 8/08/13 identified on the CAT (Care Area Trigger) for Physical Restraints summarized the Analysis of Findings: "Ms. (name of resident) is up to wheelchair daily and she has a seatbelt while up in chair due to she is unaware of safety needs. She is not able to stand independently but requires total assist with transferring. She has a personal alarm to her wheelchair as well. The seatbelt is released hourly for toileting, self exercise, and meals. ... Will continue with plan of care and will follow up as indicated." The facility's Restraint Policy (undated) documented: "Physical Restraints ... Restraints released every hour for repositioning while out of bed, and every two hours for positioning while in bed, toileting, self-exercise and at meals unless contraindicated, Nursing staff will sign off every shift on their Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. ..." RI #4 had several Care Plans which informed staff to release the resident every hour. They are as follows: 1) Routine Care Plan (not dated) under the approaches: " ... FYI (For your information) - Place in wheelchair with seat belt. Release q (every) 1 hour for repositioning, self exercise, toileting, and meals. ..." 2) ADL (Activities of Daily Living) Care plan dated 08/29/13 under the approaches: "... Up in wheelchair with seatbelt while out of bed releasing hourly for toileting, self exercise and meals ..." 3) Incontinent Care Plan dated 8/29/13 listed as an approach: "... Check and change every 1 hour when up in chair and every 2 hours when in bed and PRN (as needed)." 4) Potential for falls Care Plan dated 08/29/13 under the approaches to obtaining no falls: "... Apply seatbelt to be used while in wheelchair. Release every hour for repositioning, toileting, exercise and meals. ... Check and change every 1 hour when up in chair and every 2 hours when in bed and PRN (as needed). CNA (Certified Nursing Assistant) to check resident every 1 hour on 11 - 7 shift. If awake, offer to assist with toileting ... Check hourly on 11 - 7 if showing movement in bed, get her up and place in chair at nurses desk. ... Observe for slumping or leaning while in wheelchair. Reposition PRN. ... ." 5) Potential for Skin Breakdown Care Plan dated 8/29/13 documented: " ... Remind and assist to reposition q (every) 2 hrs. while in bed and hourly while up in chair ... Check and change every 1 hour when up in chair and every 2 hours when in bed and PRN ..." 6) Restraint Use Care Plan dated 8/29/13 documented: " ... Use wheelchair with seatbelt while up. Release every 1 hour for exercising, repositioning. toileting and meals. ... Check and change every 1 hour when up in chair and every two hours when in bed and PRN ..." Observations were made of RI #4 on 10/22/13 through 10/24/13. Through these continuous observations, RI #4's seatbelt was not release every hour according to her plans of care. An observation on RI #4 was made on 10/22/13, from 2:00 PM until 3:42 PM. No staff member checked on her, repositioned her or took off her safety belt. An interview with a CNA, Employee Identifier (EI) #8, on 10/22/13 at 5:15 PM revealed CNA's don't always release the seat belt every hour because the resident is hard to catch up with. EI #8 said RI #4 was constantly in motion and was a wanderer in the halls and resident's rooms. On 10/23/13 at 10:00 AM another CNA, EI #9 was interviewed. She revealed that she checked on RI #4 every hour by asking if she needed to go to the bathroom and seeing that she is alright. Later EI # 9 said she did not think RI #4 knows if she has to go to the restroom or not. She stated that the resident was a wanderer and will go into residents rooms at times. The surveyor asked EI #9 did she release RI #4's seat belt every hour. EI #9 said no, she only released the belt when she was getting her up out of the chair to go to the restroom, to bed, or at meals. On 10/23/13 from 3:35 PM until 5:35 PM, when the Activity Director came and took her to supper, she had no staff to check her, reposition her or to remove her safety belt. An interview with the Director of Nursing, EI #7 took place on 10/24/13 at 10:30 AM. When EI #7 was told that through continuous observation it was discovered there were no one hour contact from the CNA's or anyone to remove RI #4's safety belt. EI #7 stated, I was unaware that the staff are not removing it every hour.

Based on observations, interview, record review and review of a facility policy titled "Decubitus Ulcer", the facility failed to ensure RI (Resident Identifier) #8, a resident with a history of pressures ulcers, dressing to her coccyx was changed on 10/21/13. Finding Include: A facility policy titled "Decubitus Ulcer", no date, documented: "Purpose Care of decubitus ulcers relieves pressure, restores circulation, and promotes skin regeneration in the affected area. It also prevents infection and promotes healing of the decubitus. Policy ... care will be done on all residents on a regular basis ..." RI #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Quarterly MDS (Minimum Data Set) assessment, with an ARD (Assessment Reference Date) of 09/05/2013, identified RI #8 to have a BIMS (Brief Interview for Mental Status) of 8, indicating moderately impaired cognition. RI #8 was also identified to be totally dependent on staff for all Activities of Daily Living. Under Section M0150-Skin Conditions, RI #8 was coded at Risk for Pressure Ulcers. A review of RI #8's care plan titled "Actual for skin breakdown as evidenced by reoccurring skin breakdown present to coccyx ..." with a Problem Onset date of 09/20/2013, documented the following Approaches "... Clean Coccyx with Normal saline apply santyl and foam dressing q (every) day and PRN (as needed) until healed ..." On 10/21/13 at 3:40 p.m., the surveyor observed RI #8 lying in bed on a pressure relieving mattress. RI #8 was positioned to her right side by her assigned CNA (Certified Nursing Assistant). A dressing dated 10/20 was observed to the residents coccyx. On 10/21/13 at 6:55 p.m., RI #8 was observed to remain in bed. The same dressing, dated 10/20, remained intact to RI #8's coccyx. On 10/24/13 at 8:50 a.m., the surveyor conducted an interview with EI (Employee Identifier) #1, an LPN (Licensed Practical Nurse) standing in for the regular treatment nurse. The surveyor asked EI #1 how long she had been providing treatments on residents. EI #1 stated roughly around September the 27th (2013). The surveyor asked EI #1 was she responsible for doing (performing) all the treatments in the facility. EI #1 said she was responsible for performing the treatment as long as she was not working on a medication cart. When asked if she performed treatments on 10/20/13, EI #1 replied she was working on a medication cart and she was responsible for doing RI #8's treatment. The surveyor shared with EI #1 that on 10/21/13, the surveyor had observed the dressing to RI #8's coccyx to be dated 10/20. The surveyor asked EI #1 did she change the dressing on that day (10/21/13). EI #1 stated, "No mam. It was so crazy I couldn't remember if I had changed it or not." The surveyor asked EI #1 how often should the dressing be changed. EI #1 stated once a day unless it gets soiled then it could be changed more frequently. The surveyor asked EI #1 what was the rational for changing dressings daily. EI #8 replied, "To clean out the wound bed and put in new medication or treatment to promote the healing process."

Based on observation, record review and interviews, the facility failed to accurately document the stage of Resident Identifier (RI) #1's pressure sore. This affected one of two sampled residents for whom wound care was observed. Findings include: The facility's policy and procedure related to "Decubitus Ulcer" describes a Stage II ulcer as: "A partial thickeness of skin is lost ([MEDICATION NAME] layer has been lost, but the dermis is at least partially intact). This may present as blistering, surrounded by an area of redness and/or induration." A Stage III ulcer is described as: "A full thickenss of skin is lost, exposing the subcutaneous tissues. This presents as a shallow crater (unless covered by an eschar, thick brown or yellow crust). It may be draining." RI #1 has resided in the facility since 11/14/08, with [DIAGNOSES REDACTED]. The facility's "Weekly Pressure Ulcer Progress Report" documented the finding of a pink Stage II ulcer on 10/08/12, 2.0 cm (centimeters) long by 2.2 cm wide by 0.2 cm deep on the resident's coccyx. This wound steadily decreased in size each week until 10/29/12. The treatment with each dressing change was [MEDICATION NAME]. On 10/29/12 the wound had increased in size to 3.0 cm long by 1.8 cm wide by 0.2 cm depth, according to the "Weekly Pressure Ulcer Progress Report." The color of the wound was now documented as "yellow pink." [MEDICATION NAME] treatment was discontinued. Treatment was changed to Dakins solution for wound cleaning, with the application of Santyl and Hydrogel, and cover with foam dressing. Nurse's Notes of 10/29/12 describe the wound as 50% pink and 50% yellow tissue. On 11/15/12 at 9:00 AM, the surveyor observed the Treatment Nurse, Employee Identifier (EI) #1, provide wound care to RI #1. EI #1 measured the decubitus ulcer on resident's coccyx. The size of the wound bed had decreased to 2.2 cm long by 2.0 cm wide and 0.2 cm deep. The wound bed contained a small amount of yellow slough. On 11/15/12 at 12:50 PM, the surveyor asked EI #1 to describe the wound from her 10/29/12 documentation. EI #1 stated the wound bed was 50% pink and 50% yellow; the center of the wound was yellow, the outside perimeter was pink. EI #1 stated they called the physician and got a change in treatment orders that day, from [MEDICATION NAME] to Dakins, Santyl and Hydrogel. The surveyor asked what stage would "yellow/pink" be classified as. EI #1 replied, Stage III. When asked why she had not documented the change in wound from a Stage II to a Stage III, EI #1 explained she had been trained at a previous facility, that unless there was loose slough present, the wound was considered a Stage II. On 11/16/12 at 1:15 PM, the Director of Nursing (EI #2) was interviewed. When asked what her definition of a Stage II wound was, EI #2 explained it could be a blister; but if the wound had slough, it was a Stage III.