Every finding on record at Brown Nursing Home

Based on observations, interviews and review of the (YEAR) U.S. (United States) Public Health Service Food Code, the facility failed to ensure: 1) a styrofoam cup was not stored in the sugar bin; 2) dust was not in the ice scoop holder; crumbs were not in the convection oven and 3) the Cook was not handling food with bare hands. These deficient practices had the potential to affect 60 of 60 residents receiving meals from the dietary department. Findings Include: 1) On 11/13/2018 at 3:30 p.m., the surveyor observed a styrofoam cup in the sugar bin. This was observed during the initial tour of the kitchen and the Dietary Manager, Employee Identifier (EI) #2 was present. At this time, the surveyor conducted an interview with EI #2. The surveyor asked EI #2, what was in the sugar bin. EI #2 said a stryofoam cup. The surveyor asked EI #2 what was the potential harm with the stryofoam cup being in the sugar bin. EI #2 said it could break off in the sugar bin. 2) A review of the (YEAR) U.S. Public Health Service Food Code revealed: 4-6 CLEANING Of EQUIPMENT AND UTENSILS .4-601.11 .(A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch .(C) NonFOOD -CONTACT SURFACE .shall be kept free of an accumulation of dust. On 11/13/2018 at 3:30 p.m., during the initial tour of the kitchen, the surveyor observed dust like particles in the ice scoop holder and crumb like particles on the back of convection oven. At that time, the surveyor conducted an interview with EI #2. The surveyor asked EI #2 what were the particles in the ice scoop holder. EI #2 said it could be dust. The surveyor asked EI #2 what was the potential harm with dust in ice the scoop holder. EI #2 said possibly, if on the scoop, it (dust) could get in the ice. The surveyor asked EI #2 how often was the ice scoop holder cleaned . EI #2 said every couple of months. The surveyor asked EI #2 what were the particles on the back of the convection oven. EI #2 said it looked like crumbs. The surveyor asked EI #2 how often was the oven cleaned. EI #2 said monthly. The surveyor asked EI #2 what was the potential harm with crumbs on the convection oven. EI #2 said it could possibly attract pests. 3) A review of the (YEAR) U.S. Public Health Service Food Code revealed: . 3-301.11 Preventing Contamination from Hands . (B) . EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as .tongs, single-use gloves . On 11/14/2018 at 5:15 p.m., the surveyor observed the tray line. The Cook, EI #3, was observed picking up the hot dog buns with his bare hands and opening them up. On 11/15/2018 at 4:41 p.m., the surveyor conducted a telephone interview with EI #3. EI #3 was asked did he pick up the hot dog buns with his bare hands. EI #3 said yes. EI #3 said he got nervous and forgot. EI #3 said he should have used the tongs, but he was nervous and scared.

Based on observation, interviews and record review, the facility failed to ensure the staff properly secured Resident Identifier (RI) #27's pants to prevent them from falling and exposing his/her buttocks and genitals while ambulating in the hallway, upon returning from the bathroom. This deficient practice affected RI #27, one of 22 sampled residents observed for dignity. Findings Include: RI #27 was originally admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of RI #27's most recent Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/05/2018, documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated RI #27 was cognitively intact and independent for daily decision making. RI #27's Care Plan with a problem onset date of 10/26/2012, revealed the following: .(RI #27) requires limited to extensive assist with most ADL's (Activities of Daily Living). Risk factors are [MEDICAL CONDITION] . Approaches . Benefits from verbal cues for sequencing for completing bathing, dressing, grooming . On 11/15/2018 at 8:36 a.m., RI #27 was observed coming from the restroom crossing the hallway when his/her pants fell down exposing his/her buttocks and genital area. On 11/15/2018 at 8:43 a.m., the surveyor conducted an interview with Employee Identifier (EI) #4, RI #27's assigned Certified Nursing Assistant (CNA). The surveyor asked EI #4 if RI #27's pants had a draw string. EI #4 said he was not sure and he was going to check. The surveyor asked EI #4 did he try to adjust the draw string after pulling RI #27's pants up. EI #4 said he did not check. The surveyor asked EI #4 how could this have the potential to affect RI #27. EI #4 said it would embarrass RI #27. On 11/15/2018 at 3:33 p.m., the surveyor interviewed RI #27. The surveyor asked RI #27 how did this (pants falling down) make him/her feel. RI #27 said it made him/her feel totally rough. The surveyor asked RI #27 what was meant by rough. RI #27 stated it made him/her feel uncomfortable.

Based on interview and record review, the facility failed to ensure Resident Identifier (RI) #19's Significant Change (SC) Minimum Data Set (MDS) assessment, dated 08/27/18, accurately reflected RI #19 was receiving Hospice services during this assessment period. This deficient practice affected RI #19, one of 20 sampled residents whose MDS's were reviewed. Findings Include: RI #19 was admitted to the facility on [DATE], and readmitted on [DATE] with a [DIAGNOSES REDACTED]. RI #19's physician's orders [REDACTED]. admitted to Alacare Hospice for Adult Failure to Thrive . A review of a certification form for RI #19 from Alacare Home Health and Hospice revealed RI #19 was certified for Hospice services from 08/17/18 to 11/14/18. RI #19's SC MDS assessment, with an Assessment Reference Date (ARD) of 08/27/18, did not reflect RI #19 was receiving Hospice services during this assessment period. On 11/15/18 at 10:16 a.m., the surveyor conducted an interview with Employee Identifier (EI) #1, a Registered Nurse (RN)/MDS Coordinator. The surveyor asked EI #1 was RI #19 receiving Hospice services. EI #1 said yes. The surveyor asked EI #1 when did the Hospice services begin. EI #1 said RI #19 was admitted to Hospice on 08/17/18. The surveyor asked EI #1 did the Hospice service capture on the 08/27/18, SC MDS. EI #1 said no. EI #1 said it should have because that was the reason for the SC MDS. EI #1 said it was just an error.

Based on interview, record review and review of a facility policy titled, Care Planning Policy and Procedure, the facility failed to ensure a care plan was developed for Resident Identifier (RI) # 35's usage of the diuretic, [MEDICATION NAME]. This deficient practice affected RI #35, one of 22 sampled residents whose plan of care was reviewed. Findings Include: Review of a facility policy titled, Care Planning Policy and Procedure, with a revision date of 02/18, documented: Policy: The care plan is a guide for all staff on a course of action that will attain or maintain a resident's highest practicable level of well being. The care plan will be written in accordance with professional standards of practice and documentation . Procedure: 1. Facility staff will complete a care plan to meet the basic care needs of the resident . 2.baseline care plan . includes the initial goals of the resident and services and treatments to be administered by the facility and personnel acting on behalf of the facility . RI #35 was admitted to the facility on [DATE], and readmitted on [DATE], with a [DIAGNOSES REDACTED]. RI #35's (MONTH) (YEAR) Physician order [REDACTED]. This order had a start date of 08/10/18. RI #35's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 09/26/18, revealed RI #35 was receiving a diuretic. On 11/15/18 at 3:31 p.m., the surveyor conducted an interview with Employee Identifier (EI) #1, a Registered Nurse (RN)/MDS Coordinator. The surveyor asked EI #1 was RI #35 receiving the medication [MEDICATION NAME]. EI #1 said yes. The surveyor asked EI #1 should RI #35 be care planned for the use of [MEDICATION NAME]. EI #1 said yes. When asked to show the surveyor where RI #35 had been care planned for the use of [MEDICATION NAME], EI #1 said she did not see a care plan for [MEDICATION NAME]. The surveyor asked EI #1 who would have been responsible for ensuring a care plan was implemented for [MEDICATION NAME]. EI #1 said she would have been responsible.

Based on observations, interviews and a review of a policy titled, Food Safety and Sanitation, the facility failed to ensure that dietary staff wore a hair restraint properly while working in the kitchen. This was observed on one of three days and had the potential to affect 58 residents being served meals from the kitchen. Findings Include: A review of an undated facility policy, titled, Food Safety and Sanitation, revealed: Policy: . c. All staff are required to have their hair styled so that it does not touch the collar . * Hair restraints are required and should cover all hair on the head. On 02/07/2018 at 08:51 AM, an observation was made of EI (Employee Identifier) #1, Dietary Worker with her hair partially covered. EI #1 had her hair up in a tall bun. The hair restraint partially covered the bun and part of the top of the head. The hair was not covered past the top portion of the head, leaving half of the head all of the way around uncovered. The portion which was uncovered was from the front half of the head, around the ears, around to the base of the neckline. On 02/07/2018 at 11:01 AM, an observation was made of EI #1 with the hair net not covering the entire head, only the crown area of the head was covered. EI #1 was involved with setting up trays and rolling the cart out of the kitchen. An observation was made at the same time of EI #2, Dietary Worker. EI #2 had a piece of hair hanging out of the hair net on the right side near the ear. EI #2 was assisting behind the tray line. On 02/08/2018 at 08:27 AM, a interview was conducted with EI #1. EI #1 was asked when should hair be covered in the kitchen. EI #1 replied, Before you walk in the door if possible. EI #1 was asked who should cover hair in the kitchen. EI #1 stated, Everyone, including facial hair. An example of the observation on 2/7/2018 at 8:51 AM and 11:01 AM of EI #1 with only the crown of her hair covered, was explained to EI #1 during the interview. EI #1 was asked if that was an appropriate way to cover the hair. EI #1 stated, No it's not. EI #1 was given an example of the observation on 2/7/2018 at 11:01 AM of EI #2, a dietary staff member with a portion of her hair about 1/4 inch wide and four inches long exposed near her ear outside of the hair restraint. EI #1 was asked if that was an appropriate way to cover the hair. EI #1 stated, No. EI #1 was asked why should hair be restrained. EI #1 said, Hair can shed and fall in the food. EI #1 was asked what was the potential harm of hair not being restrained. EI #1 stated, Maybe a danger of hair falling in the food and could contaminate it. EI #1 was asked what was the policy on restraining hair. EI #1 replied, Have it up out of the way not hanging down. On 02/08/2018 at 08:34 AM, an interview was conducted with EI #3, the Dietary Manager. EI #3 was asked when should hair be covered in the kitchen. EI #3 stated, Anytime you're in the kitchen working. EI #3 was asked who should cover hair in the kitchen. EI #3 stated, Everyone. EI #3 was provided an example of the observation on 2/7/2018 at 8:51 AM and 11:01 AM of EI #1 with only the crown of her hair covered. EI #3 was asked if that was an appropriate way to cover the hair. EI #3 stated, No you should cover your hair fully. EI #3 was given an example of the observation on 2/7/2018 at 11:01 AM of EI #2, a dietary staff member with a portion of her hair about 1/4 inch wide and four inches long exposed near her ear outside of the hair restraint. EI #3 was asked if that was an appropriate way to cover the hair. EI #3 stated, No she should have tucked it in and washed her hands. EI #3 was asked why should hair be restrained. EI #3 replied, You don't want hair to get in the food. Hair can be dirty with disease and bacteria. Hair should be covered fully. Its unpleasant to have hair in your food. EI #3 was asked what was the potential harm of hair not being restrained. EI #3 stated, Somebody may not eat their food and not get the calories they need from the food. Or, we would have to spend more time making more food or could make someone sick. EI #3 was asked what was the policy on restraining hair. EI #3 said, Anytime you are in the kitchen you should cover your hair fully.

Based on record review, interview and a facility policy titled, Care Planning Policy and Procedure, the facility failed to ensure a care plan was in place for the use of antipsychotic medication. This affected Resident Identifier (RI) #31, one of 18 sampled residents. Findings Include: A facility policy titled, Care Planning Policy and Procedure with a revised date of 07/2011, revealed: Policy: The care plan is a guide for all staff on a course of action that will attain or maintain a resident's highest practicable level of well being. The care plan will be written in accordance with professional standards of practice and documentation. Procedure: . 3. Clinical judgement must be used in the identification of problems and potential problems in developing the plan of care . 6. The care plan team will develop measurable goals for the improvement, prevention, or maintenance of the resident's status . RI #31 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #31's February 2018 Physician order [REDACTED]. A review of RI #31's care plans did not reveal a care plan for the use of an antipsychotic medication. On 02/08/2018 03:07 PM, an interview was conducted with Employee Identifier (EI) #6, Licensed Practical Nurse (LPN)/Minimum Data Set (MDS) Nurse. EI #6 was asked if RI #31 was on a psychoactive medication. EI #6 said yes, [MEDICATION NAME] 25 mg at night. EI #6 was asked did RI #31 have a care plan for psychoactive medication use. EI #6 said no. EI #6 was asked if RI #31 should have had a care plan for psychoactive medication use. EI #6 said yes. EI #6 was asked why RI #31 did not have a care plan regarding psychoactive medication. EI #6 said she missed it. EI #6 was asked why RI #31 should be care planned for psychoactive medication use. EI #6 said to tell the side effects and what to look for. EI #6 was asked, to her knowledge, had there ever been a care plan for RI #31's psychoactive medication. EI #6 said, I really don't know that. EI #6 checked the computer to check for a care plan for psychoactive medications. No care care plan was found for psychoactive medication.

Based on observation, a facility document titled, Housekeeper Job Overview and interview, the facility failed to keep Room Locator (RL) #1 free of an unknown odor and the carpet on RL#'s 1 -7 free of stains. This was observed on one of three days of the survey and affected two of three halls in the facility. Findings Include: A review of a document titled Housekeeper Job Overview documented: .Perform daily housekeeping activities to assure that the facility is maintained in a clean .manner . The following observations were made on 2/08/18 at 10:15 a.m. : 1) an unknown odor and stain in the hallway in front of RL #1, 2) a bleach stain by RL #2, 3) stains observed in front of RL #3, 4) a yellow stain in front of RL#'s 4 and 5, 5) a black stain in front of room RL #6 and 6) a stain and dirty area in front of RL #7. On 2/8/18 at 10:30 a.m., an interview was conducted with Employee Identifier (EI) # 7, Housekeeping Supervisor. EI #7 was asked how often the carpet was cleaned. EI #7 replied it was last cleaned on 2/6/18. EI #7 further stated the carpet was vacuumed everyday and deep cleaned weekly. EI #7 was asked if she had noticed stains on the carpet. EI #7 replied yes, in front of RL#4 and the room next to it. EI #7 was asked if she smelled the odor in front of RL#1 . EI #7 replied yes. EI #7 further stated she was unsure of the source of the odor. EI #7 was asked if the stained areas on the carpet could be cleaned. EI #7 stated she would try and use spot shot for the areas. EI #7 further stated some of stains were rust and the spot shot would not work. EI #7 was asked if those areas should be cleaned. EI #7 replied yes. The surveyor and EI # 7 observed stains on the hallway to include wear and tear, also stains in front of RL #'s 1, 2, 4, 5 and 6. Stains on the carpet in front of the bathroom near RL#3 and stains on the carpet in front of RL#7 were also observed.

Based on record review, observation and interview the facility failed to ensure that Resident Identifier (RI) #16 who self administered his/her own Atrovent NS (Normal Saline) nasal spray was assessed as competent and safe to do so. The facility further failed to ensure a doctor's order for the self administration of RI #16's nasal spray was obtained. This affected 1 of 9 residents observed during the medication pass. Findings Include: RI #16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A facility policy entitled: 7.20 SELF ADMINISTRATION OF MEDICATIONS with an effective date of 01/12, documented: Policy Residents who desire to self administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and the other residents of the facility and if it has been ordered by the physician. Procedures 1. Upon request of a resident to self-administer medications, the interdisciplinary care plan team and physician will be consulted for evaluation. 3. The interdisciplinary team will assess the resident's ability to self- administer medications safely at least quarterly and as needed. A. The resident is instructed in the use of the package, purpose of the medication, reading of the label, and scheduling of medication doses. B. The resident is then requested to read the label on each package and indicate at what time the medication should be taken and any other special instructions for use. C. The resident is asked to demonstrate the removal of the medication from the package and, in the case of nonsolid dosage forms such as an inhaler, demonstrate the steps involved in administration . E. The results of the interdisciplinary team assessment are recorded in the medical record . An observation was made during Med-pass on 01/05/17 at 8:30 a.m. of a Licensed Practical Nurse (LPN) Employee Identifier (EI) #8, Charge Nurse, handing a nasal spray to RI #16 and then RI #16 administered the nasal spray to both nostrils unassisted by the nurse. RI #16's January 2017 physician's orders [REDACTED].#16 to self administer his/her nasal spray. Further review of the resident's medical record found no evidence of an interdisciplinary assessment of RI #16's ability to self administer medications safely or any evidence of care planning for self administration of the nasal spray. An interview was held on 01/05/2017 at 9:40 a.m., with EI #8. EI #8 was asked if she had seen an assessment for RI #16 which stated he/she was proficient and safe to give/administer his/her own nasal spray. EI #8 replied no. EI #8 was then asked if there was a doctor's order or direction on the MAR (Medication Administration Record) that indicated the resident could give his/her own medication. EI #8 replied there was not. When asked what might be the potential harm of not assessing the resident's proficiency and ability to administer medication to them-selves safely, EI #8 stated that they could take too much medicine, take the wrong medication, place the medication in the mouth or the wrong site. An interview was held on 01/05/2017 at 9:55 a.m., with EI #2 the Director of Nursing (DON). EI #2 was asked was it customary at this facility to do an assessment of residents wishing to self administer medications to ensure they are safe and proficient to administer their own medications. EI #2 replied the intra-disciplinary team should do an assessment of the safety of the self administration. EI #2 was then asked do the doctors at this facility write an order for [REDACTED].#2 replied that if the facility had a resident who self administered, they would require a doctor's order. EI #2 was asked, what was the potential harm, to the residents who had not been assessed to ensure they were safe and proficient to administer their own medications. EI #2 explained for any resident who is not assessed, they could administer to the wrong route or overdose, or not take the medication. EI #2 was asked was there an assessment done for RI #16 to self administer medications. EI #2 replied no. On 01/05/2017 at 10:08 a.m., an interview was held with EI #1, the Administrator. EI #1 was asked, was it customary at this facility to do an assessment of residents wishing to self administer medications to ensure they are safe and proficient to administer their own medications. EI #1 replied yes. EI #1 was then asked do the doctors at this facility write an order for [REDACTED].#1 stated she would have to refer to the policy for step by step instructions. EI #1 was asked what was the potential harm to the resident if it was not ensured they were safe and proficient to administer their own medications. EI #1 replied if the nurse was present she would be there to observe and respond to any concerns identified. EI #1 was asked if the facility residents who self administered their medications kept their medications at the bedside. EI #1 replied that she was not aware of any residents who self administered their medications and the medications were not left at the bedside. EI #1 was then asked why did RI #16 self administer his/her nasal spray. EI #1's reply to this was that she would have to review his medical chart and speak with the charge nurse. EI #1 was asked would the staff notify her if the facility had any residents who self administered their own medication. EI #1 responded, Not necessarily.

Based on record review and interview, the facility failed to ensure: 1. Resident Identifier (RI) #1's Bowel and Bladder Assessment was conducted to reveal an accurate account of RI #1's normal bowel and bladder pattern, and 2. RI #4's Quarterly MDS (Minimum Data Set) assessment, with an ARD (Assessment Reference Date) of 11/26/2016, reflected RI #4 was receiving Hospice Care and continuous O2 (Oxygen) use. This affected two of 13 sampled residents whose assessments were reviewed. Findings Include: 1. A review of a facility policy titled Urinary Incontinence Evaluation and Treatment Guidelines, with a revised date of 07/2011, revealed the following: . Assessment: . 1 . the restorative nurse will initiate a 7 day pattern setting evaluation form . on all incontinent residents. This nurse will also initiate the process of evaluating the resident's urinary and bowel incontinence. 2. During the 7-day evaluation/observation period the restorative nurse, or the designee, will assess the resident, review the medical record, interview the resident . 3. Utilizing the resident's Seven Day Pattern Setting . the nurse will document the assessment . This assessment will be titled Bowel and Bladder Assessment/Urinary Incontinence and Indwelling Catheter . A review of a document titled, BOWEL & (and) BLADDER RETRAINING PROGRAM with dates of 09/8, 09/9, 09/10, 09/11, 09/12, 09/13, and 09/14/2016, revealed the seven day bowel and bladder pattern for RI #1. The form was completed incorrectly and did not provide an accurate measurement of RI #1's bowel and bladder pattern. RI # 1 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #1's most recent annual MDS with a ARD of 10/05/2016, revealed RI #1's Brief Interview for Mental Status (BIMS) score was 14, which indicated resident was cognitively intact. The MDS further revealed RI #1 was frequently incontinent of urine and occasionally incontinent of bowel. On 01/04/2017 at 2:35 p.m., an interview was conducted with EI #7, the LPN (License Practical Nurse) MDS Coordinator. EI #7 was asked how often were bowel and bladder assessments to be completed on residents. EI #7 said with the quarterly and yearly MDS. EI #7 was asked was she familiar with RI #1. EI #7 said yes. EI #7 was asked when was RI #1 assessed for bowel and bladder. EI #7 said on the September 2016 assessment. EI #7 was asked if RI #1 was continent or incontinent of bladder. EI #7 said RI #1 was incontinent and occasionally used a bed pan. EI#7 was asked, in reviewing RI#1's Bowel & Bladder Retraining form, who completed this form. EI #7 said the CNA's (Certified Nursing Assistant) that was assigned to the resident. EI #7 was asked, in reviewing the Bowel and Bladder Retraining form, were some of the entries completed incorrectly. EI #7 said yes, it did not give a clear picture. EI #7 was asked if the form gave an accurate account of RI #7's bowel and bladder retraining or pattern. EI #7 said no. 2. A review of a facility document titled, Timely Completion of MDS Assessments with a date of January 2015, revealed the following: . Policy: The facility must conduct . accurate, and standardized assessment of each resident's functional capacity . Further review of RI #4's December 2016 and January 2017 physician's orders [REDACTED]. Both orders also revealed RI #4 was ordered Oxygen on 04/18/2016. RI #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #4's most recent Quarterly MDS assessment with a ARD (Assessment Reference Date) of 11/26/2016, revealed resident had a BIMS (Brief Interview for Mental Status) score of 10, indicating RI #4 was moderately impaired cognitively for daily decision making. Section O of RI #4's MDS did not have Hospice checked as a program received by the resident, nor did RI #4's MDS reflect his/her continuous use of Oxygen. On 01/05/2017 at 10:41 a.m. ,an interview was conducted with EI (Employee Identifier) #7, LPN (License Practical Nurse) MDS Coordinator. EI #7 was asked if RI #4 used Oxygen. EI #7 said she would have to look at RI #4's physician's orders [REDACTED].#4's physician's orders [REDACTED].#7 was asked if RI #4 was to receive Oxygen continuous or PRN (as needed). EI #7 explained she assumed it was continuous. EI #7 was asked if Oxygen was checked on RI #4's recent MDS for RI #4's use of Oxygen. EI #7 said no. On 01/05/2017 at 3:17 p.m. ,another interview was conducted with EI #7. EI #7 was asked when she reviewed RI #4's 11/26/2016 quarterly MDS, was Hospice care checked. EI #7 said no. EI #7 was asked should it have been checked. EI #7 said she was sure it should have been checked. EI #7 was asked why it had not been checked. EI #7 explained she had missed it. EI #7 was asked why it should have been reflected on RI #4's MDS. EI #7 said because RI #4 was under Hospice Care.

Based on record review and interview the facility failed to ensure a Care Plan was developed for RI (Resident Identifier) #4's use of continuous O2 (Oxygen). This affected one of 13 sampled residents whose Care Plans were reviewed. Findings Include: A review of a facility policy titled, Care Planning Policy and Procedure with a revised date of 07/2011 revealed the following: Policy: The care plan is a guide for all staff on a course of action that will attain or maintain a resident' s highest practicable level of well being. A review of RI #4's physician's orders [REDACTED].@ (at) 2L (Liters) per (by means of) nasal cannula. In reviewing RI #4's Care Plans, RI #4 did not have a Care Plan developed for his/her use of continuous O2. RI #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #4's most recent Quarterly MDS with an ARD (Assessment Reference Date) of 11/26/2016 revealed resident had a BIMS (Brief Interview for Mental Status) score of 10, indicating RI #4 was moderately impaired cognitively for daily decision making. On 01/05/2017 at 10:41 a.m. ,an interview was conducted with EI (Employee Identifier) LPN (License Practical Nurse) MDS Coordinator, #7. EI #7 was asked if RI #4 used O2. EI #7 said she would have to look at the MD (Medical Doctor) orders. EI #7 was asked when she reviewed RI #4's MD orders what did she find. EI #7 said she assumed RI #4 used O2 continuous. EI #7 was asked should RI #4 have a Care Plan for O2 use. EI #7 replied she would have to look. EI #7 reviewed RI#4's Care Plans. EI #7 was asked when she reviewed RI #4's Care Plans did she locate a Care Plan for RI #4's use of O2. EI #7 said no.

Based on record reviews, observations and interviews the facility failed to ensure: 1) cocoa in dry storage was sealed tightly in a container, 2) a dietary worker washed her hands between washing dirty dishes and clean dishes. This had the potential to affect 59 of 64 residents served meals from the kitchen. Findings Include: A review of a facility policy titled, Food Storage with no revised date revealed: .Procedure: 4. Plastic containers with tight-fitting covers must be used for storing . 1) On 1/3/2017 at 4:35 p.m., the surveyor toured the kitchen along with the dietary manager. On a shelf in dry storage, was a five pound bag of pure cocoa in a container with no lid on the container. On 1/5/2016 at 9:26 a.m., an interview was conducted with the dietary manager, (Employee Identifier) EI #3. EI #3 was asked what type of container was the cocoa in on 1/3/2017. EI #3 replied, a round plastic container. EI #3 was asked how was it sealed in the container. EI #3 replied, it did not have a lid on it. EI #3 was asked why was it not sealed. EI #3 replied, the lid had touched the floor. EI #3 was asked what was the facility policy on sealing food items after opened. EI #3 replied, seal tightly, with open and use by date. EI #3 was asked what was the potential harm when food items were not sealed. EI #3 replied, cross contamination. EI #3 was asked who was responsible for sealing food items after use. EI #3 replied, the person that opened them. EI #3 was asked when should food items be sealed. EI #3 replied, immediately after being opened. A review of a policy titled, Hand Washing with no revised date reveal: .Procedure: 2. How to wash hands: Turn on the faucet using a paper towel to avoid contaminating the faucet. Wet hands and forearms with warm water . and apply an antibacterial soap. Scrub well with soap and additional water as needed . 2) On 1/4/2017 at 9:05 a.m., the surveyor observed EI #6, dietary aide washing dishes. The worker was working on both the dirty side and the clean side in the dish room. The worker left the dirty side to go to the clean side of the room. She went to the sink to wash her hands and another worker was washing her hands. She placed her hand in the sink with the other worker and never used any soap. She started putting clean dishes in a rack. On 1/5/2017 at 9:42 a.m., an interview was conducted with EI #5, dietary aide. EI #5 was asked when she was washing her hands did another worker wash her hands in the sink with her. EI #5 replied, yes. EI #5 was asked did the worker use soap. EI #5 replied, no. EI #5 was asked what did the facility policy say on how to wash hands. EI #5 replied, use paper towel to turn on the faucet. Wet her hands with water, use soap up and down on her hands and use paper towels to turn the water off. EI #5 was asked what was the potential harm when hand washing is not done properly. EI #5 replied, bacteria. On 1/5/2017 at 9:50 a.m., an interview was conducted with EI #6, dietary aide. EI #6 was asked did she wash her hands in the sink while another worker was washing her hands. EI #6 replied, yes. EI #6 was asked why did she wash her hands at the same time another worker was washing her hands. EI #6 replied, she was impatient. EI #6 was asked how should she wash her hands. EI #6 replied, for 20 seconds, turn water on, use soap on hands and use a paper towel to turn the faucet off. EI #6 was asked when should she wash her hands. EI #6 replied, all the time and whenever you touch something. EI #6 was asked did she use soap when washing her hands at the same time another worker was washing her hands. EI #6 replied, no ma'am. EI #6 was asked what was the potential harm when hand washing was not done properly. EI #6 replied, germs and contamination.

Based on record review, observation and interviews, the facility failed to ensure the dumpster door was not opened and debris was not on the ground around the dumpster. This had the potential to affect all residents residing in the facility. Findings Include: A review of a facility document titled, Garbage and Refuse with an effective date of February 1, 2013 revealed: .STANDARD: Garbage and refuse containers should be free from cracks or leaks and covered when not in use.Process: f .garbage should not .be left outside the dumpster . On 1/3/2017 at 4:50 p.m., the surveyor along with the dietary manager, EI(Employee Identifier) #3 along with the surveyor observed the dumpster on the outside. There were two dumpsters. Dumpster one was not closed and there was trash around dumpster two. There were leaves, cups, gloves, and several wooden sticks around the dumpster. On 1/5/2017 at 9:22 a.m., an interview was conducted with the dietary manager, EI #3. EI #3 was asked when did she observe the dumpster opened. EI #3 replied, on January 3, 2017 when she went outside. EI #3 was asked when was the dumpster checked last. EI #3 replied, before she left that evening at 4:00 p. m. EI #3 was asked why was it important to keep the dumpster doors closed. EI #3 replied, to keep trash inside and rodents from getting in. EI #3 was asked what did she see around the dumpsters. EI #3 replied, gloves and leaves. EI #3 was asked which dumpster was opened. EI #3 replied, the first one. EI #3 was asked was the dumpster opened. EI #3 replied, yes. EI #3 was asked what was the potential harm when the dumpster door was opened. EI #3 replied, debris can get on the outside. On 1/5/2017 at 3:05 p.m., the surveyor conducted an interview with the maintenance director, EI #9. EI #9 was asked when did he check the dumpster last. EI #9 replied, we check everyday. EI #9 was asked why was the dumpster opened on 1/3/2017. EI #9 replied, someone did not pull it all the way closed.

Based on record review and interview, the facility failed to ensure the Bowel and Bladder Retraining Program form for RI (Resident Identifier) #1 was completed to accurately reflect RI #1's normal Bowel/Bladder pattern. This affected one of 13 sampled residents. Findings Include: A review of a facility policy titled, Documentation Guidelines with a revised date of March 2015 revealed the following: Policy 1-Documentation in the medical record should be complete, accurate . A review of a facility document titled, BOWEL &(and) BLADDER RETRAINING PROGRAM with dates of 09/08,09/09, 09/10, 09/11, 09/12, 09/13 and 09/14/2016 revealed entries entered incorrectly. Some of the entries should have captured when RI #1 had episodes of incontinence and when the resident was toileted. The staff that completed the form was to use the letter I for incontinence and the letter T for toilet. The form completed had letters O's and V's, which did not clearly reflect if RI #1 was toileted or if the resident had episodes of incontinence. RI # 1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's most recent annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 10/05/2016 revealed RI #1's BIMS (Brief Interview for Mental Status) score of 14, which indicated resident was cognitively intact. The MDS further revealed RI #1 was frequently incontinent of urine and occasionally incontinent of bowel. On 01/04/2017 at 2:35 p.m. an interview was conducted with RI (Resident Identifier) #7, LPN (License Practical Nurse) MDS Coordinator. EI #7 was asked when she reviewed RI #7's Bowel and Bladder Retraining Program form, who completed RI #1's form. EI #7 said the CNA (Certified Nursing Assistant) assigned to the resident. EI #7 was asked when she reviewed the form were some of the entries completed incorrectly. EI #7 replied yes, it did not give a clear picture. EI #7 was asked which areas were completed incorrectly. EI #7 explained the areas on the form that were incorrect were the areas in the columns for voided(urinate). EI #7 was asked what should have been placed in those areas of the form. EI #7 said, I's for incontinence and T's for toileting. EI #7 further explained the O's and V's written on the form were incorrect. EI #7 was asked if this was an accurate account of RI #1's bowel and bladder pattern. EI #7 said no. EI #7 was asked should it have been. EI #7 said yes. EI #7 was asked, what was the potential harm in CNA's not accurately completing the Bowel and Bladder Retraining Program form. EI #7 said skin breakdown.

Based on observations, interviews, and review of facility policies, the facility failed to ensure: 1) the dish machine reached and maintained a minimum temperature of 125 degrees Fahrenheit (F) while in use; 2) staff washed hands and changed gloves after handling dirty dishes and before removing clean dishes from the dish machine; 3) staff allowed dishes to remain in contact with the sanitizing solution for the minimum amount of time specified by the manufacturer; 4) ham and an open container of thickened tea stored in the walk-in cooler were labeled with a use by date; further, the facility failed to ensure food was discarded by the use by date; and 5) canned goods were not stored directly on the floor of the dry storage area. These failures had the potential to affect all 65 residents for whom meals were prepared and served during the survey. Findings Include: 1) On 11/17/2015 at 1:20 PM, dietary staff were observed utilizing the low temperature dish machine. The data plate listing the manufacturer specifications of use indicated the following requirement: water temperature 125 degrees F minimum. Four cycles were observed, none of which reached 125 degrees. The observations are as follows: Cycle 1: Wash Temperature: 105 degrees F / Rinse Temperature:114 degrees F Cycle 2: Wash Temperature: 110 degrees F / Rinse Temperature: 116 degrees F Cycle 3: Wash Temperature: 110 degrees F / Rise Temperature: 116 degrees F Cycle 4: Wash Temperature: 110 degrees F / Rinse Temperature: 120 degrees F On 11/19/2015 at 8:05 AM, staff were again observed using the dish machine. During the first cycle observed, the thermometer initially read 120 degrees F, but once started dropped to 110 degrees and went as high as 114 degrees during the rinse. A service/repair man for the dishmachine was interviewed on 11/19/2015 at 10:25 AM. He stated the machine should be run at a temperature of at least 125 degrees. He said the temperature gauge may initially read 125-130 degrees but will drop 5-10 degrees. He explained the temperature should recover after a few washes. The repair man stated 130 degrees was necessary to remove grease from the dishes. Employee Identifier (EI) #1, the Dietary Manager was interviewed on 11/19/2015 at 1:35 PM. EI #1 stated the dishmachine should be used at a temperature of 125 degrees. She said if dishes were washed at a temperature below 125 degrees it could potentially result in infection or food borne illness. 2) Review of the facility's policy Handwashing, dated 2013, revealed the following: Policy: Staff will wash hands as frequently as needed throughout the day . Procedure: . 1. When to Wash Hands: .After handling soiled equipment or utensils . to prevent cross contamination when changing tasks . On 11/17/2015 at 1:20 PM, dietary staff were observed utilizing the dish machine. EI #2 removed a rack from the dish machine and placed a rack of dirty water pitchers into the machine. Then, with dirty gloves, EI #2 removed the clean pitchers from the machine. With the same gloves, EI #2 loaded a rack of water pitcher lids and placed the rack into the dish machine. Without changing gloves or washing hands, EI #2 then removed the rack of clean lids from the machine. On 11/19/2015 at 8:05 AM, EI #2 was again observed utilizing the dish machine. Wearing gloves, EI #2 loaded a rack of dirty dishes including trays, plates, and bowls. She then placed the rack into the dish machine. Without changing gloves or washing hands, EI #2 removed the rack of clean dishes from the machine. During an interview on 11/19/2015 at 1:35 PM, EI #1, the Dietary Manager, stated staff should wash their hands and change gloves when going from dirty to clean. When asked what could potentially occur if staff used the same gloves to load dirty dishes and then remove the clean rack from the machine, EI #1 said that would be disgusting and could cause infection or illness. 3) Review of the facility's undated policy titled Manual Ware Washing- 3 Compartment Sink revealed the following: Policy: To prevent the spread of bacteria that may cause food borne illness, the 3 compartment sink is used to wash, rinse and sanitize pot, pans, and other utensils Process: .Third Sink Sanitizing . Immerse rinsed pots/utensils in sanitizer per manufacturer instructions . On 11/19/2015 at 8:05 AM, EI #3, a cook, was observed washing dishes in the three compartment sink. After washing and rinsing the pans, EI #3 placed them into the third sink containing sanitizing solution. The level of the sanitizing solution was very low and two pans were not fully submerged. EI #3 quickly, in one motion, swished the pans around in the water, and placed them in the rack to dry without allowing adequate contact time. The bottle of sanitizer used indicated a required contact time of one minute. During an interview on 11/19/2015 at 1:35 PM, EI #1, the Dietary Manager, stated staff should either rewash items that were too large to submerge in the sanitizing solution or use the dish machine because she did not think they would be sanitized properly. EI #1 did not know the manufacturer's specified contact time. 4) During the initial tour of the kitchen on 11/17/2015 at 1:20 PM, a plastic container of ham was observed without a use by date. A second container of ham was also observed stored in the walk-in cooler past its use by date of 11/15/2015. A 46 ounce opened container of thickened tea was observed with an open date, but no use by date. During an interview on 11/19/2015 at 1:35 PM, EI #1, the Dietary Manager, stated ham and tea should both be labeled with an open date and a discard date. She said if the items were not labeled with a use by date, they would not know if the items were still good. EI #1 further stated that items exceeding their use by dates should be discarded or they could potentially cause food borne illness. 5) Review of the facility's policy Food Storage, dated 2013, revealed: . Procedure: .3. Food items will be stored on shelves . 11. Food is stored a minimum of 6 inches above the floor . During the initial tour of the kitchen on 11/17/2015 at 1:20 PM, two 6 pound cans were observed directly on the floor of the dry storage area. The cans were being used to prop the door open. During an interview on 11/19/2015 at 1:35 PM, EI #1, the Dietary Manager, stated canned goods should be stored on racks. EI #1 admitted she had seen staff using cans on the floor to hold the door to the dry storage area open. She said keeping the canned foods on the floor could potentially cause rust, moisture, or dents.

Based on observation, record review, and interview, the facility failed to ensure Resident Identifier (RI) #1 was provided care in accordance with RI #1's care plans as evidenced by staff providing a mixed consistency food item for the 11/18/2015 lunch meal. This affected RI #1, one of 13 residents for whom care plan were reviewed. Findings Include: RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1's care plan addressing a mechanically altered diet listed an intervention dated 02/17/2015 for mechanical soft diet, no mixed consistencies. RI # 1's November 2015 physician's orders [REDACTED].DIET: MECHANICAL SOFT DIET. NO MIXED CONSISTENCIES . On 11/18/2015 at 12:05 PM, RI #1 was observed eating lunch, which included a bowl of chicken noodle soup. The soup was placed in an insulated mug and had broth, noodles, and chunks of chicken. During an interview on 11/18/2015 at 3:59 PM, Employee Identifier (EI) #5, the Speech Therapist, explained No Mixed Consistencies meant no foods that consist of both solids and liquids, such as chicken noodle soup. EI #6, the Care Plan Coordinator/ Registered Nurse, was interviewed on 11/19/2015 at 7:55 AM. EI #6 stated RI #1's nutritional care plan included an intervention for a mechanical soft diet and no mixed consistencies. EI #6 was unsure what No Mixed Consistencies meant. EI #6 said she she addresses the diet orders that are provided to her on the care plan.

Based on observation, record review, and interview, the facility failed to ensure Resident Identifier (RI) #1, a resident at risk for aspiration, was not provided chicken noodle soup on 11/18/2015, which posed the potential for aspiration. This affected RI #1, one of seven sampled residents with orders for a mechanically altered diet. Findings Include: The facility's packet containing information for therapeutic diet orders did not address orders for NO MIXED CONSISTENCIES. RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 02/17/2015 a Fiberoptic Endoscopic Evaluation of Swallowing (FEES) was conducted to rule out aspiration and to determine the extent and severity of dysphagia. The FEES report indicated RI #1 had difficulties with dual consistency items and the recommendation was made for RI #1 to avoid dual/mixed consistencies. RI #1's care plan addressing a mechanically altered diet listed an intervention dated 02/17/2015 for mechanical soft diet, no mixed consistencies. RI # 1's November 2015 physician's orders [REDACTED].DIET: MECHANICAL SOFT DIET. NO MIXED CONSISTENCIES . On 11/18/2015 at 12:05 PM, RI #1 was observed eating lunch, which included a bowl of chicken noodle soup. The soup was placed in an insulated mug and had broth, noodles, and chunks of chicken. RI #1 was observed lifting the cup of soup and raising it to his/her mouth. RI #1 was coughing but stated he/she was okay and continued to cough. RI #1 then explained the facility used to provide tomato soup. RI #1 indicated he/she preferred soup with nothing in it due to a problem chewing. While discussing the soup, RI #1 repeatedly attempted to clear his/her throat. RI #1's tray card for the lunch meal listed the following: .DIET: MS (mechanical soft), NO MIXED CONSISTENCIES . During an interview on 11/18/2015 at 3:59 PM, Employee Identifier (EI) #5, the Speech Therapist, explained No Mixed Consistencies meant no foods that consist of both solids and liquids, such as chicken noodle soup. When asked why RI #1 had orders for NO MIXED CONSISTENCIES, EI #5 explained RI #1 could not have mixed consistencies because of the results of the FEES, indicating delayed chew and extra liquids. EI #5 said RI #1 could potentially aspirate. During an interview with EI #1, the Dietary Manager, on 11/18/2015 at 4:13 PM, EI #1 said RI #1 should not have received chicken noodle soup unless it was drained well. She said if RI #1 received chicken noodle soup that was not drained, it could potentially cause aspiration.

Based on observation, record review and interviews, the facility failed to ensure Resident Identifier (RI) #1 was provided a mechanical soft diet with NO MIXED CONSISTENCIES as ordered by the physician. Further, the facility failed to ensure residents with diet orders for No Concentrated Sweets were served a sugar free cookie for dessert on 11/17/2015 as planned. These failures affected RI #1 and had the potential to affect all 16 residents with orders for No Concentrated Sweets. Findings Include: Review of the facility's undated policy titled Therapeutic Diets revealed: POLICY Therapeutic diets are prepared and served as ordered by the attending physician. 1. Therapeutic diet orders are planned, prepared and served with supervision or consultation from a qualified dietitian . A special diet is defined as any deviation from the regular diet . PROCEDURES Therapeutic diets must be prepared and served in accordance with the physician's written orders . 1) The facility's packet containing information for therapeutic diet orders did not address orders for NO MIXED CONSISTENCIES. RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI # 1's November 2015 physician's orders [REDACTED].DIET: MECHANICAL SOFT DIET. NO MIXED CONSISTENCIES . On 11/18/2015 at 12:05 PM, RI #1 was observed eating lunch, which included a bowl of chicken noodle soup. RI #1 indicated he/she preferred soup with nothing in it due to a problem chewing. RI #1's tray card for the lunch meal listed the following: .DIET: MS (mechanical soft), NO MIXED CONSISTENCIES . During an interview with EI #1, the Dietary Manager, on 11/18/2015 at 4:13 PM, EI #1 explained NO MIXED CONSISTENCIES meant not much fluid in with the solids. EI #1 said chicken noodle soup was considered mixed consistency and stated RI #1 should not have received chicken noodle soup unless it was drained well. She said if RI #1 received chicken noodle soup that was not drained, it could potentially cause aspiration. 2) Review of the preplanned menu for the 11/17/2015 supper meal listed the following preplanned desserts: Regular/ No Added Salt, Mechanical Soft, Puree, and Bland/Soft: brownie Liberal Renal: slice of angel food cake No Concentrated Sweets: sugar free cookie. Review of the nutritional information for the brownies indicated one serving of brownie contained 29 grams of carbohydrates, of which 19 grams were sugars and less than 1 gram from dietary fiber. Sugar was the first ingredient listed. The nutritional information for the sugar free cookies indicated one serving contained 22 grams of carbohydrates, of which 2 grams were dietary fiber, 4 grams sugar alcohol and 0 grams from sugars. Trayline proceedings were observed on 11/17/2015 beginning at 4:45 PM. There were no sugar cookies observed. Staff only served brownies and angel food cake as the dessert. Employee Identifier (EI) #1, the Dietary Manager, was interviewed on 11/17/2015 at 5:55 PM. EI #1 stated she had the sugar free cookies available but staff had served the brownies and cake instead. EI #1 said residents with orders for No Concentrated Sweets should have received a sugar free cookie instead but the staff forgot. She stated serving brownies instead of the sugar free cookies could cause high blood sugars.

Based on observations, record review, and interviews, the facility failed to ensure: 1) Resident Identifier (RI) #8 did not have an indwelling foley catheter inserted for a Stage Two Pressure Ulcer to the coccyx; 2) RI #5 was checked for the need of incontinence care on 08/18/2015 from 5:15 AM until 9:50 AM, a period of 4 hours and 35 minutes; and 3) RI #1 was provided incontinence care in a manner to prevent Urinary Tract Infections [MEDICAL CONDITION]. These failures affected RI #s 1, 5, and 8, all with history of UTIs, three of five residents sampled for UTIs. Findings Include: 1) Review of the facility's policy titled INDWELLING FOLEY CATHETER INSERTION, dated May 2013, revealed the following: .PURPOSE: To provide continuous bladder drainage due to a Stage III or IV pressure ulcer in an area exacerbated by incontinence. RI #8 was readmitted to the facility on [DATE]. RI #8's most recent Quarterly Minimum Data Set (MDS) Assessment, dated 07/06/2015, indicated RI #8 had an in-house acquired Stage Two Pressure Ulcer, with an onset date of 03/27/2015. On 07/29/2015 a physician's orders [REDACTED].#8 for a foley catheter for wound healing for 14 days. RI #8 was care planned on 07/29/2015 for .Potential for complications related to use of catheter for wound healing. Prior to the catheter, RI #8 was care planned to have incontinent briefs changed every two hours and as needed. On 08/03/2015, Employee Identifier (EI) #16, the Wound Nurse, documented RI #8's wound as a Stage Two Pressure Ulcer to the coccyx, measuring 1 centimeter by 2.5 centimeters by 0.1 centimeter. On 08/13/2015 a second physician's orders [REDACTED].#8's foley catheter for 14 more days for wound healing. Review of RI #8's Daily Wound Evaluation documentation from 07/29/2015 through 08/17/2015 indicated RI #8's coccyx wound remained a Stage Two. EI #16, the Wound Nurse, was interviewed on 08/19/2015 at 8:56 AM. EI #16 explained the order for RI #8's catheter was written on 07/29/2015 to promote wound healing. EI #16 said at the time the order was written RI #8's wound was a Stage Two. EI #16 said she asked the Assistant Director of Nursing if they could obtain an order for [REDACTED].#16 said the order for the catheter was re-written on 08/13/2015 for 14 more days because the wound was not yet healed. EI #16 said when RI #8's wound presented with slough, causing an increased Pressure Ulcer Scale for Healing (PUSH) score, indicating deterioration, she asked for a catheter. However, in a subsequent interview, EI #16 said she had incorrectly assessed RI #8's wound and the PUSH score calculation was not correct. When asked what other approaches could have been attempted prior to inserting a catheter, EI #16 stated checking and changing more often would have been an option. EI #16 also said that catheters were generally warranted for Stage Three or greater wounds. EI #16 also explained the risk of infection linked to catheter use and said RI #8 had a history of [REDACTED]. During an interview on 08/19/2015 at 3:40 PM, EI #18, the Licensed Practical Nurse (LPN) responsible for assessing residents' bowel and bladder status, stated she had been taught a catheter was warranted in Stage Three pressure ulcers or higher. EI #18 also explained the facility could have checked RI #8 more often than every two hours prior to considering the use of a catheter. 2.) RI #5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #5's annual Minimum Data Set (MDS) with an assessment reference date of 8/11/15 revealed long and short term memory loss and severely impaired cognition. RI #5 was totally dependent on staff for all Activities of Daily Living Skills (ADLs) and had upper and lower impairments on both sides. RI #5 was always incontinent of bowel and bladder. A Care Plan for RI #5 with a problem onset date of 9/21/12 revealed the following: .Requires total care with ADL's such as .toileting .due to dementia,[MEDICAL CONDITION] with [MEDICAL CONDITION], incontinence without sensory awareness. The approach listed for this problem documented: . Monitor for incontinence and change diaper or pad q (every) 2 hrs/rounds/PRN (hours/rounds/as needed) . Another Care Plan for RI #5 with a problem onset date of 9/21/12 documented: .3. Potential for skin break down related to .incontinence of bowel and bladder. The approach listed for this problem documented: .Check change for incontinence and q (every) 2hrs (hours) and prn (as needed) . On 8/18/2015 from 5:15 AM until 9:50 AM, RI #5 was observed by the surveyor. During that time, four hours and 35 minutes, staff did not check RI #5 for incontinence. At 9:50 AM, EI #4, CNA (Certified Nursing Assistant) provided incontinent care for RI #5 stating that the brief was wet. There was a small amount of stool in the brief. On 8/18/2015 at 10:50 AM, EI #4 was asked who was responsible for taking care of RI #5. EI #4 said that she was. When asked when she usually provided incontinent care for RI #5, EI #4 said she tried to do it every two hours. When asked why RI #5 had not had incontinent care until 9:50 AM, EI #4 said she had been busy working since she got to work. EI #4 admitted that incontinent care (every 2 hours as care planned) was important to prevent skin breakdown. On 8/20/2015 at 9:45 AM, EI #5, DON (Director of Nursing) was asked how CNAs know what incontinent care to provide for RI #5. EI #5 said it should be in the plan of care. When asked why timely incontinent care was important, EI #5 stated that it was important for infection control, skin protection, and comfort. 3.) The facility policy titled Incontinent Care and Catheter Care Using Disposable Wipes with a revised date of 12/12, revealed the following: .OBJECTIVE: To cleanse the perineum, prevent infection and odors, and prevent skin breakdown. PROCEDURE: .4.clean entire perineal area. moving from front to back. 6. Turn the resident on their side. Clean the buttocks and anal area, moving upwards toward the back. RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1's quarterly Minimum Data Set (MDS) with an assessment reference date of 7/09/15 revealed long and short term memory loss with severely impaired cognition, extensive to total assistance with Activities of Daily Living Skills (ADLs), total assistance from staff for personal hygiene, and always incontinent of bowel and bladder. On 8/20/2015 at 11:50 AM, EI #8, CNA (Certified Nursing Assistant) provided incontinent care for RI #1. While wearing gloves, EI#8 first cleaned RI #1's buttocks in a right side lying position, placed the clean brief, and then with RI #1 supine, the perineal area was cleaned. While wearing the same gloves used to clean the buttocks and perineum, EI #8 applied moisture barrier to the buttocks with RI #1, again, right side lying. On 8/20/2015 at 12:10 PM, EI #8 was asked how she was trained to provide incontinent care. EI #8 said to clean the buttocks and then the front. When asked why she would clean the back first, EI #8 said that she always started from the back and if there was a bowel movement (BM) that spread to the front she would clean the front first. EI #8 agreed that RI #1 had not had a BM. When asked what could be the harm in wiping the buttocks before the front without changing gloves, EI #8 stated, You are pushing the front to the back and should go back and do the bottom again. When asked what could be the harm in not changing gloves when moving from back to front, EI #8 said that it could cause infection in the front area.

Based on observations, record review, and interviews, the facility failed to ensure Resident Identifier (RI) #4's Comprehensive Care Plans were updated to reflect an intervention listed on RI #4's 05/28/2015 Functional Maintenance Plan (FMP) following discharge from Speech Therapy that RI #4 should not be left unattended when eating meals in the resident's room. The facility further failed to ensure RI #5's plan of care was updated to reflect a new FMP dated 12/10/2014. This affected RI #s 4 and 5, two of eleven residents for whom care plans were reviewed. Findings Include: 1) RI #4 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #4 had a FMP initiated on 05/28/2015 following RI #4's discharge from Speech Therapy. The FMP indicated RI #4 should never be left in RI #4's room unattended when eating. The FMP further indicated RI #4 needed cues to slow down, drink every few bites, and eat slowly. However, RI #4's current Comprehensive Care Plans were not updated to reflect this new approach. RI #4's Nutritional Care Plan listed the following intervention: . Able to feed self some foods but requires staff to feed (RI #4) majority of meal. The Care Plan did not specify RI #4 should not be left unattended in the room while eating meals as indicated on the FMP. RI #4's most recent Minimum Data Set Assessment, a quarterly assessment, dated 06/23/2015, indicated RI #4 required extensive assistance of one staff member when eating. Employee Identifier (EI) #1, Licensed Practical Nurse (LPN)/ Restorative Nurse, was interviewed on 08/20/2015 at 9:45 AM. After reviewing RI #4's chart and the 05/28/2015 FMP, EI #1 stated RI #4 had not had any other speech evaluations since then so the FMP was current. EI #1 stated the FMP indicated RI #4 required cues to slow down, drink every few bites and eat slowly. EI #1 said RI #4 should never be left unattended when eating. EI #2, the Care Plan Coordinator, was interviewed on 08/20/2015 at 11:29 AM. EI #2 explained she had been instructed not to list the specifics of the FMPs on the care plans because the FMPs were also part of the plan of care. EI #2 said it was important for staff not to leave RI #4 unattended when eating because it was a swallowing precaution. A follow-up interview was conducted with EI #1, the Restorative Nurse, on 08/20/2015 at 2:28 PM. EI #2 stated there was no policy regarding FMPs. When asked how the FMP should be incorporated into the Care Plans, EI #1 stated a copy of the FMP is placed in the book along with the Care Plans. EI #1 explained if the care plans and the FMP do not match, the Care Plans should be updated to reflect the changes. 2.) RI #5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan for RI #5 with a problem onset date of 09/21/12 revealed the following: .Requires total care with ADL's (Activities of Daily Living) .due to dementia,[MEDICAL CONDITION] with [MEDICAL CONDITION], contractures. The approach listed for this problem revealed the following: .Apply. L grip roll splint .after breakfast and remove at 2pm QD (every day). Check skin for redness or irritation Q (every) 2 Hours while splint is in use. Apply at 0800 am and remove at 1400 (2:00 PM). A FMP for RI #5 dated 12/10/14 did not include the use of any devices or splints for the left hand. RI #5's physician's orders [REDACTED]. Check Skin For Redness Or Irritation Q (every) 2 Hours While Splint Is In Use. RI #5's August 2015 RESTORATIVE NURSING form revealed the following .Order Date: 8/06/13 .APPLY LEFT GRIP ROLL SPLINT.AFTER BREAKFAST AND REMOVE AT 2pm QD (daily). RI #5's Annual Minimum Data Set ((MDS) dated [DATE], revealed the following: long and short term memory loss and severely impaired cognitive skills for daily decision making. RI #5 was totally dependent on staff for all Activities of Daily Living Skills (ADLs) and had upper and lower impairments on both sides. RI #5 was documented on this assessment to have worn a splint or brace for 6 days. On 8/19/2015 at 8:30 AM, RI #5 was observed in bed wearing a splint on the left hand/wrist. On 8/19/2015 at 9:45 AM, EI (Employee Identifier) #3, Restorative CNA, was asked who routinely applied splints. EI #3 said she or the other restorative CNA usually apply splints. EI #3 said that another CNA was helping and applied the splint on 8/19/2015. When asked why RI #5 was observed wearing the splint on 8/19/2015 and not on 8/18/2015, EI #3 stated, That particular splint was D/C'd (discontinued) a few months. When asked how the CNA had access to the splint, EI #3 said that it must have been in RI #5's closet. When asked what the resident was supposed to have in each hand, EI #3 said it should have been bath cloths. When asked about the difference in the splint orders, EI #3 said she would have to get the restorative nurse, EI #1. On 8/19/2015 at 9:55 AM, EI #1, Restorative LPN (Licensed Practical Nurse), when asked why RI #5's orders and care plans were not updated to reflect the FMP dated 12/10/2014, stated that she was out on medical leave during that time and was not sure who was responsible for restorative while she was out of work. EI #1 admitted that you could injure the resident if orders and care plans were not updated to reflect a new FMP. On 8/20/2015 at 9:55 AM, EI #5, RN/DON (Registered Nurse/Director of Nursing) was asked why RI #5's orders and care plans were not updated to reflect the FMP dated 12/10/2014. EI #5 said she was not at the facility during that time and was not sure who had those duties at the time. When asked what should have been done when the new FMP was provided, EI #5 said the physician orders [REDACTED].

Based on observations, record review, and interviews, the facility failed to ensure care plans were followed for Resident Identifier (RI) #s 4, 5, and 11. For RI #4, the facility failed to provide fluids in a kennedy cup, which allowed the resident to drink independently. They further failed to provide RI #4 water at bedside in a manner accessible to the resident. For RI #5, the facility failed to ensure staff monitored for incontinence every two hours as care planned. For RI #11, the facility failed to ensure Certified Nursing Assistants (CNAs) assisted RI #11 with removing dentures at night for cleaning and storage. These failures affected RI #s 4, 5, and 11, three of eleven residents for whom care plans were reviewed. Findings Include: An undated facility document titled Providing the Care by the Care Plan revealed the following: .Review each resident's care plan regularly . Perform your resident's care according to the care plan . 1) RI #4 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #4's most recent Minimum Data Set Assessment, a quarterly assessment, dated 06/23/2015, indicated RI #4 was totally dependent on two staff for transfers and required extensive assistance of one staff member when eating. The assessment also documented RI #4 had impaired range of motion of both upper and lower extremities. RI #4's current care plan addressing nutrition and hydration listed the following interventions: - Encourage to drink all liquids on meal tray - Provide fresh water at bedside every shift - Provide a kennedy cup On 08/18/2015 at 8:00 AM, RI #4 was observed eating breakfast in the resident's room. RI #4 was provided 8 ounces of coffee, 8 ounces of water, and 8 ounces of milk; however, when setting up RI #4's tray, staff only poured the milk and coffee into kennedy cups. The water remained in a regular glass with a plastic lid over it. At 8:28 AM, staff entered the room to assist RI #4 with completing breakfast. Staff then removed RI #4's breakfast tray from the room, with the water untouched. Staff did not offer RI #4 any water. The staff member left the kennedy cups containing milk and coffee in the resident's room. Following breakfast on 08/18/2015 at 8:50 AM, Employee Identifier (EI) #10, a CNA, was asked which of RI #4's beverages should be provided in a kennedy cup. EI #10 stated it did not really matter which ones they placed in the kennedy cups. EI #10 explained the kitchen sends two kennedy cups out on RI #4's tray and if another was needed the CNAs had to go get another one from the kitchen. EI #10 said RI #4 was unable to drink beverages from a regular glass. On 08/18/2015 at 9:30 AM, a Restorative CNA entered RI #4's room to do Range of Motion Exercises. While in the room, the CNA did not offer RI #4 water or encourage fluid intake. RI #4 still had the kennedy cups containing coffee and milk from breakfast. There was no water at RI #4's bedside. At 9:50 AM, RI #4 was observed in the room with the kennedy cups from breakfast. RI #4 had consumed 100 percent of the milk and 50 percent of the coffee. There was no water at bedside. A pitcher was noted on the dresser/television stand across the room out of the residents reach. At 11:39 AM, RI #4 was again observed in the room in bed with the kennedy cups from breakfast on the over-the-bed table. There was no water accessible to RI #4. At 11:42 AM, EI #8, a CNA, entered RI #4's room with a lunch tray. EI #8 explained that two kennedy cups come on the trays but said staff should go get more if more than two beverages are provided. On 08/19/2015 at 9:45 AM and again at 10:45 AM, RI #4 was observed in the room in bed with a large plastic pitcher on the over-the-bed table. There was no kennedy cup available for RI #4's water. On 08/19/2015 at 12:10 PM, after a CNA removed RI #4's lunch tray, the plastic pitcher was on RI #4's table but there was no kennedy cup to allow RI #4 to consume the water independently. On 08/19/2015 at 5:20 PM, RI #4 was observed in the room with the supper tray on the table. RI #4 received coffee, tea and water. The tea and coffee were placed in a kennedy cups with lids; however, the tea did not have a straw. The water was in a regular glass. RI #4 stated he/she was unable to drink out of the glass and would need to get another one. At 5:26 PM, a CNA entered the room and removed the supper tray. The CNA placed a straw in RI #4's tea and left it on the over-the bed-table, but did not offer to pour the water into a kennedy cup. On 08/20/2015 at 7:20 AM, RI #4 was observed in bed in the room. There were no beverages at RI #4's bedside. A large plastic pitcher was noted on the television stand/dresser across the room not accessible to RI #4. A kennedy cup with brown liquid was also noted on top of the refrigerator, out of RI #4's reach. Again at 8:20 AM, RI #4 was observed in bed without any beverages on the over-the-bed table within the resident's reach. The water pitcher was still noted on the television stand/dresser, across the room, not accessible to RI #4. At 8:40 AM, EI #11, a CNA, was asked what the facility's policy was on providing water to residents. EI #11 stated she just gave it to RI #4 whenever she needed it and explained water should be placed on the table by the bed between meals so RI #4 could reach it. The surveyor and EI #11 then entered RI #4's room and EI #11 stated there were no fluids available to RI #4. EI #11 then pointed to the water pitcher on RI #4's dresser and said RI #4 could not get to it. The CNA then placed the pitcher on the over-the-bed table. EI #11 explained RI #4 was unable to drink out of the pitcher because she needed the kennedy cups. When asked why it was important to make sure RI #4 was provided with something to drink between meals, EI #11 said to maintain hydration. EI #12, Licensed Practical Nurse (LPN)/ Charge Nurse, was interviewed on 08/20/2015 at 9:23 AM. EI #12 stated CNAs should make sure residents have something to drink at all times. EI #12 said the beverages had to be kept on the table so the residents could get to them. EI #12 explained RI #4 required the kennedy cups because of tremors and stated RI #4 would not be able to drink out of the big water pitchers. EI #12 explained that if fluids were not accessible to RI #4 throughout the day, it could result in dehydration. On 08/20/2015 at 11:20 AM, EI #2, the Care Plan Coordinator, was interviewed. EI #2 stated RI #4 should be encouraged to consume all fluids on meal trays and be provided fresh water at bedside. EI #2 also stated RI #4 should have a pitcher as well as a kennedy cup so staff could pour the water into it for the resident to consume. After discussing the observations, EI #2 stated staff were not following RI #4's care plan if a kennedy cup was not available. During an interview with EI #5, the Director of Nursing, on 08/20/2015 at 11:45 AM, EI #5 stated RI #4 should have a kennedy cup for all fluid intake. When asked what providing at bedside meant, EI #5 said in reach. EI #5 further explained RI #4's fluids should be provided in a kennedy cup within reach. 2.) RI #5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Care Plan for RI #5 with a Problem Onset: (date of) 09/21/12 documented: . Requires total care with ADL's such as .toileting .due to [MEDICAL CONDITION] with [MEDICAL CONDITION], incontinence without sensory awareness . The approach listed for this problem documented: . Monitor for incontinence and change diaper or pad q (every) 2 hrs/rounds/PRN (hours/rounds/as needed) . RI #5's Annual Minimum Data Set ((MDS) dated [DATE], documented: long and short term memory loss and severely impaired in cognitive skills for daily decision making. RI #5 was totally dependent on staff for all Activities of Daily Living Skills (ADL's) and was always incontinent of bowel and bladder. On 8/18/2015 from 5:15 AM until 9:50 AM, RI #5 was observed by the surveyor. During that time, four hours and 35 minutes, staff did not check RI #5 for incontinence. At 9:50 AM, EI #4, CNA (Certified Nursing Assistant) provided incontinent care for RI #5. On 8/18/2015 at 10:50 AM, EI #4 was asked who was responsible for taking care of RI #5. EI #4 said that she was. When asked when she usually provided incontinent care for RI #5, EI #4 said she tried to do it every two hours. When asked why RI #5 had not had incontinent care until 9:50 AM, EI #4 said she had been busy working since she got to work. EI #4 admitted that incontinent care (every 2 hours as care planned) was important to prevent skin breakdown. On 8/20/2015 at 9:45 AM, EI #5 was asked how CNAs know what incontinent care to provide for RI #5. EI #5 said it should be in the plan of care. When asked why the care plan was not followed, EI #5 stated, I can't answer for that. 3.) RI #11 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #11's care plan with a problem onset date of 11/23/12, revealed the following: .11. Requires limited assistance of one with. hygiene. The approach revealed the following: .Ensure dentures are soaked every night and applied every morning . RI #11's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status score of 10 out of 15, which indicated moderately impaired cognition. RI #11 required limited assistance from one staff for ADLs which included denture care. On 8/17/2015 at 4:00 PM during the initial tour of the facility, two empty denture cups were on the shelf over the sink in RI #11's bathroom. One cup was labeled TEETH. The other cup was labeled with RI #11's name. On 8/18/2015 at 5:17 AM, the two empty denture cups remained on the shelf over the sink in RI #11's bathroom. RI #11 was in bed. RI #11's top denture was lying on the bed side table. On 8/18/2015 at 6:20 AM, RI #11 got up, took the top denture to the bathroom, rinsed them, and put them in (the resident's) mouth. When asked about staff assisting with cleaning the dentures, RI #11 said that nobody would want to do that and further stated, I clean them the best I can. On 8/19/2015 at 9:10 AM, EI #6, CNA (Certified Nursing Assistant) was asked if she took care of RI #11 on 8/17/2015 on second shift. EI #6 replied, yes. EI #6 was asked if RI #11 had dentures. EI #6 stated that she had not been working at the facility long enough to know. When asked how she knew what care to provide, EI #6 said there was a care plan. When asked what the care plan said about dentures, EI #6 stated, I hadn't looked at it for her because she is independent. I ask (RI #11) if (RI #11) needs anything, (the resident) will tell you no. When asked why she did not look at the care plan, EI #6 said that the resident knew what was going on. On 8/20/2015 at 9:40 AM, EI #5, RN/DON (Registered Nurse/Director of Nursing), was asked how CNAs were trained to take care of dentures. EI #5 said CNAs were to follow the care plan for supervision or hands on assist for oral care and storage of dentures. When asked why EI #6 did not follow the plan of care for denture care for RI #11, EI #5 said she could not answer why.