Every finding on record at Burns Nursing Home, Inc.

Based on interviews, Resident Identifier (RI) #103's medical record review, and a facility policy titled Care Plan, Comprehensive, the facility failed to ensure Employee Identifier (EI) #7 Certified Nursing Assistant (CNA), followed RI #103's care plan intervention to have two persons assistance for transfer of RI #103 using a mechanical (Hoyer) lift. On 01/06/2023 EI #7, attempted to transfer RI #103, using a mechanical lift, by herself and without the assistance of another staff member. EI #7 stated she observed RI #103 slipping out of the Hoyer lift sling pad. EI #7 stated she attempted to lower the resident, but the resident fell from the mechanical lift, hitting his/her head on the floor. As a result of the fall, RI #103 sustained a laceration to his/her scalp and a hematoma that required being sent to the emergency room for treatment. The laceration to RI #103's scalp required 20 sutures to close the skin. A Computerized Tomography scan (x-ray images) confirmed RI #103 suffered a fracture of his/her C2 vertebra (second vertebra of the cervical spine or neck). This deficient practice placed RI #103, one of three residents sampled for requiring a mechanical lift for transferring, in immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment or death. On 03/02/2023 at 10:36 AM, the Administrator, EI #1; the Director of Nursing, EI #2; and the facility's President, EI #12; were provided a copy of the immediate jeopardy template and notified of the findings at the immediate jeopardy level in the area of Comprehensive Resident Centered Care Plan, at F656-Develop/Implement Comprehensive Care Plan. The immediate jeopardy began on 01/06/2023 and continued until 01/13/2023, when the facility implemented corrective actions to correct the identified deficient practice and prevent recurrence; thus, immediate jeopardy past noncompliance was cited. Total census 50. Findings Include: A facility policy titled, Care Plan, Comprehensive, implemented 09/2016 and last reviewed/revised 01/2023 documented: Purpose: . The facility develops a comprehensive plan of care for each resident . to meet a resident's medical, nursing, and mental/psychosocial needs that are identified in the comprehensive assessment. The care plans will describe the following: 1. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Policy: .3 . f. Resident specific interventions that reflect the resident's needs and preferences . RI #103 was admitted to the facility on [DATE] and had diagnoses that included Alzheimer's Disease and Macular Degeneration. RI #103's annual Minimal Data Set (MDS), with an Assessment Reference Date of 11/07/2022 assessed RI #103 as a two person assist with transfers. RI #103's care plan for being at high risk for falls related to impaired balance and total dependence on two staff and mechanical lift for transfer staff was initiated on 08/22/2017 and revised on 10/14/2019. RI #103's care plan for an Activity of Daily Living (ADL) self care performance deficit related to weakness, Alzheimer's Dementia, Arthritis and Macular Degeneration was initiated on 08/22/2017 and revised on 05/10/2018 and documented an intervention as follows: . TRANSFER: The resident requires total assistance by 2 (two) staff to move between surfaces with use of Hoyer lift. RI #103's Incident Report dated 01/06/2023, prepared by EI #2, Registered Nurse (RN), Director of Nursing Services (DON), documented . Resident being transferred per (by) mechanical lift from shower bed . CNA verbalized resident began to slip out of lift pad. Attempted to assist. Resident fell to the floor and hit head. Immediate assessment completed. Laceration to the scalp measuring 4 cm (centimeter) x 4.5 cm noted. Hematoma noted at laceration site measures 9 x 6 cm. Moderate blood loss noted. EMS (Emergency Medical Services) contacted for transport to (name of hospital) for evaluation. RI #103's Emergency Department Record documented: . Details of the fall: The patient fell from an upright position. Onset: The symptoms/episode began/occurred acutely. Associate injuries: The patient sustained injury to the head, laceration, neck injury . Laceration . Wound repair of 4 cm . subcutaneous laceration to scalp. Skin closed with 20 . sutures. RI #103's hospital Radiology Report Details documented: Patient Name: RI #103's name . Procedure Date: 1/6/2023 . EXAM: CT (Computerized Tomography) Cervical Spine without contrast . IMPRESSION: Nondisplaced fracture through the posterior lamina of C2 with likely extension into the left C2-3 left facet . RI #103's hospital Discharge Summary Report documented: . Date of Admission: 01/06/23 . Patient . who was admitted . after a fall at the nursing home. During that fall, (he/she) suffered a scalp laceration and then x-ray confirmed C2 fracture. During . hospital stay, . (RI #103) has been fitted for a cervical collar. DISCHARGE DIAGNOSES: Include head laceration, nondisplaced fracture of C2 (cervical), . On 02/10/2023 at 9:13 AM, an interview was conducted with EI #7, CNA. EI #7 was asked what happened on 01/06/2023 when she transferred RI #103. EI #7 said during transfer from the shower bed, she lifted RI #103 up in the lift and noticed RI #103 was sliding to the right side and was not in the sling properly. EI #7 stated she attempted to grab the lift and RI #103 fell to the floor. When asked how many staff were required to transfer RI #103 with a mechanical lift according to the care plan, EI #7 said, there was supposed to be two people, but it was just her. She further stated, she knew better, and RI #103's care plan documented that two people were required to assist with transfer. EI #7 said she did not follow the care plan since she transferred the resident by herself and stated if there had been two people transferring RI #103, there would have been two people to watch RI #103 to make sure she/he was in the sling properly and it was a safe transfer. EI #7 further said, RI #103 sustained a laceration and was told he/she may have a C2 fracture. EI #7 said the care plan was to be followed to avoid situations such as falling and having an injury, such as the case with RI #103. EI #7 confirmed this fall could have been avoided if two people assisted with the lift. On 02/09/2023 at 12:30 PM, an interview was conducted with EI #8, Registered Nurse (RN). EI #8 reported she went to RI #103's room after the fall on 01/06/2023. EI #8 said EI #2 (DON/RN) assessed RI #103, who had a laceration to the back of his/her head. EI #8 was asked how did RI #103 fall. EI #8 said RI #103 fell from the lift from what she could see. EI #8 said RI #103 was care planned for a two person assist with a Hoyer lift. On 02/09/2023 at approximately 4:15 PM, an interview was conducted with EI #2, DON regarding the incident involving RI #103 on 01/06/2023. EI #2 said she was notified by a staff member that they needed assistance on the hall. When she arrived, she observed RI #103 on the floor with the mechanical lift in front of RI #103. EI #2 further said she noticed the sling was attached to the lift. EI #2 said she observed blood on the floor, and she immediately assessed RI #103's head and found a laceration to the scalp and a hematoma. EI #2 said, EI #7 told her she did not have anyone assisting her with the transfer of RI #103 with the mechanical lift. EI #2 said, two persons were required for mechanical lift transfers. EI #2 stated, RI #103 was also care planned for a two person assist for transfer and that EI #7 did not follow the care plan policy. A follow up interview conducted with EI #2 DON on 02/10/2023 at 4:35 PM. EI #2 said, EI #7 did not follow RI #103's care plan. EI #2 stated, RI #103 has always been a two person assist with transfer. EI #2 further stated the care plan should be followed to ensure accurate and safe care was provided to the resident. On 02/10/2023 at 4:05 PM, an interview was conducted with EI #10, RN/Care Plan Coordinator. EI #10 said the purpose of the care plan was to have a plan of care for the residents so all staff could follow the plan of care. EI #10 said RI #103 required a mechanical lift and two person assist for transfer. EI #10 was asked if EI #7 followed the plan of care for RI #103 when she transferred RI #103 by herself. EI #10 said, no. When asked if EI #7 should have followed the care plan for RI #103, EI #10 said, yes. On 02/10/2023 at 4:15 PM, an interview was conducted with EI #1, Administrator. EI #1 was asked what the facility determined about how RI #103 fell . EI #1 said the facility determined EI #7 transferred the resident by herself and RI #103 fell from the sling. EI #1 continued to say that it was his understanding RI #103 fell away from the lift and if someone had been on the other side, RI #103 would not have fallen. EI #1 said, a lift was required for RI #103's transfer and RI #103 was care planned for two person assist with transfer. EI #1 was asked if EI #7 followed RI #103's care plan. EI #1 said EI #7 did not follow the care plan, but she should have. EI #1 was asked what was the purpose of the care plan. EI #1 said for staff to know how to care for the resident. On 03/01/2023 at 2:00 PM an interview was conducted with EI #11, RI #103's attending Medical Doctor. EI #11 was asked what did non-displaced fracture through posterior lamina mean. EI #11 replied, the posterior lamina was at the back of the neck along the outer ring of the vertebrae. EI #11 was asked what risks were associated with a C2 or C3 fracture. EI #11 replied, if the fracture displaced, it could potentially cause paralysis but with a non-displaced fracture it would be limited to limited range of motion until healed. EI #11 was asked if RI #103's injuries were serious. EI #11 replied that anytime a resident had a neck fracture that it was considered serious. 29671 This deficient practice was cited as a result of the investigation of complaint/report number AL00042944. ********************************************************* The facility took immediate action to correct the noncompliance by: 1. Reported the incident to Alabama Department of Public Health (ADPH) 01/09/2023 and conducted an investigation. 2. Completed in-service with staff on following care guides with transfer using the mechanical lift. Completed 01/09/2023. 3. The Care Plan Coordinator and designee reviewed the care plan for each resident who required the use of a mechanical lift to ensure resident specific interventions were present. Completed 01/09/2023. 4. DON completed assessment for proper sling fit for each resident who used a mechanical lift, and this information was added to resident care plan, Plan Of Care (POC) task list, and color coded paper identifier on closet door for any resident care planned for mechanical lift. Care Plan will be update by the MDS Coordinator/Care Plan Coordinator, with weight loss/gain, as well as any assessments. Completed 01/09/2023. 5. Quality Assurance (QA) meeting held on 01/07/2023 to create plan of correction (POC). 6. QA/Root cause analysis (RCA) meeting held on 01/13/2023. 7. Monitoring for two-person assist compliance . The Director of Nursing (DON), Administrator, or designee, will monitor through direct observation mechanical lift transfers during rounds that will occur using mechanical lift audit tool. Weekly for 4 weeks and then; monthly for 6 months and then; quarterly. Start date 01/07/2023 - Ongoing. After review and verification of the information provided in the facility's corrective action plan, inservice/education records, monitoring tools and the facility's investigation, as well as staff interviews, the survey team determined the facility implemented corrective actions from 01/6/2023 through 01/13/2023 with ongoing monitoring implemented; thus, immediate jeopardy past noncompliance was cited.

Based on interviews, review of Resident Identifier (RI) 103's medical record, RI #103's hospital medical records, the Resident Incident Report, the facility Investigative Summary, a facility policy titled Safe Resident Handling/Transfer, the Arjo Sling/Size Guide, and a report submitted by the facility to the Alabama Department of Public Health Online Incident Reporting System, the facility failed to ensure Employee Identifier (EI) #7 Certified Nursing Assistant (CNA) followed the facility policy for Safe Resident Handling/Transfer when EI #7 transferred RI #103 on 01/06/2023. On 01/06/2023, EI #7 CNA attempted to transfer RI #103 using the mechanical lift (Hoyer lift) by herself and without obtaining assistance from other staff; and further, EI #7 failed to utilize the appropriate size sling to according to the RI #103's weight during transfer using the mechanical lift. EI #7 stated she observed RI #103 slipping from the mechanical lift sling, resulting in RI #103 falling from the lift and hitting his/her head on the floor. RI #103 sustained a laceration to the scalp, with a hematoma (blood collected or pooled under the skin). RI #103 was transported to the local hospital for evaluation. While at the hospital, RI #103 was found to have a laceration to the scalp that required 20 sutures to close the wound. A Computerized Tomography scan (x-ray images) confirmed RI #103 suffered a fracture of the C2 vertebra (second vertebra of the cervical spine or neck). This deficient practice placed RI #103, one of three residents sampled who required the use of a mechanical lift for transfers, in immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment or death. On 03/02/2023 at 10:36 AM, the Administrator, EI #1; the Director of Nursing, EI #2; and the facility's President, EI #12; were provided a copy of the immediate jeopardy templates and notified of the findings of substandard quality of care at the immediate jeopardy level in the area of Quality of Care, at F689-Free of Accident Hazards/Supervision/Devices. The immediate jeopardy began on 01/06/2023 and continued until 01/13/2023, when the facility implemented corrective actions to correct the identified deficient practice and prevent recurrence; thus, immediate jeopardy past noncompliance was cited. Total census 50. Findings Include: On 01/09/2023 the facility submitted an initial report to the State Survey Agency via the Alabama Department of Public Health Online Incident Reporting System. This report indicated RI #103 was transferred by mechanical lift and fell from the lift to the floor and had to be transferred to the hospital by Emergency Medical Services (EMS) and had a laceration to the scalp. A facility policy titled, Safe Resident Handling/Transfers, revised 11/2022 documented: . Policy: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident . Compliance Guidelines: . 8. The facility will ensure . appropriate . sizes of slings to accommodate residents . on proper sling sizing. 10. Two staff members must be utilized when transferring residents with a mechanical lift. RI #103 was admitted to the facility on [DATE] and had diagnoses that included Alzheimer's Disease and Macular Degeneration. Review of RI #103's annual Minimal Data Set (MDS) assessment with an Assessment Reference Date of 11/07/2022 revealed RI #103 was coded as a two person assist for transfer. RI #103's Incident Report dated 01/06/2023, prepared by EI #2, Registered Nurse (RN)/DON, documented . Resident being transferred per (by) mechanical lift from shower bed . CNA verbalized resident began to slip out of lift pad. Resident fell to the floor and hit head. Immediate assessment completed. Laceration to the scalp measuring 4 cm (centimeter) x 4.5 cm noted. Hematoma noted at laceration site measures 9 x 6 cm. Moderate blood loss noted. EMS contacted for transport to (name of hospital) for evaluation. A handwritten statement dated 01/06/2023, signed by EI #7 CNA documented: Was transfering (transferring) resident from the shower bed to (his/her) bed with the Hoyer lift. I started to turn the resident, and as I started to move (him/her) (he/she) started sliding out of the sling and then went backwards and hit (his/her) [NAME] (head). The nurse on the hall immediately came to address the situation . A handwritten statement dated 01/06/2023, signed by EI #8 RN documented: I was coming around the corner at nurses desk, when I heard a staff yelling, we need a nurse. resident . was laying on the floor, (his/her) left leg still in the sling. With CNA next to (his/her) and another staff member. As I got to resident I noticed blood under (his/her) head. I grabbed gloves and yelled for another nurse to come help me. Then I told the other nurse to get the DON. DON came running down the hall to assist me (with) the resident. I secured the residents head. DON provided wound care to laceration, dressing applied. EMS called. RI #103's Emergency Department Record documented: . Details of the fall: The patient fell from an upright position. Onset: The symptoms/episode began/occurred acutely. Associate injuries: The patient sustained injury to the head, laceration, neck injury . Laceration . Wound repair of 4 cm . subcutaneous laceration to scalp. Skin closed with 20 . sutures. RI #103's hospital Radiology Report Details documented: Patient Name: (RI #103's name) . Procedure Date: 1/6/2023 . EXAM: CT (Computerized Tomography) Cervical Spine without contrast . IMPRESSION: Nondisplaced fracture through the posterior lamina of C2 with likely extension into the left C2-3 left facet . RI #103's Discharge Summary Report documented: Date of Admission: 01/06/23 . Patient . who was admitted . after a fall at the nursing home . During that fall, (he/she) suffered a scalp laceration and then x-ray confirmed C2 fracture. During . hospital stay . has been fitted for a cervical collar . DISCHARGE DIAGNOSES: Include head laceration, nondisplaced fracture of C2 (cervical), . The facility Investigation Summary dated 01/09/2023 documented the following regarding EI #7 CNA: . due to the extent of the noncompliance with proper policy and procedure with result in physical injury to the resident, termination of employment would be effective immediately. Therefore, termination/resignation of employment effective 1/9/23. On 02/10/2023 at 9:13 AM, a phone interview was conducted with EI #7, CNA. EI #7 was asked what happened on 01/06/2023 when she transferred RI #103. EI #7 said during the transfer from the shower bed, she lifted RI #103 up in the lift and noticed she/he was sliding to the right side and was not in the sling properly. EI #7 said she attempted to grab the lift, but RI #103 fell to the floor. When asked about training on the proper use of the mechanical lift and the appropriate sling size for residents, EI #7 said, she had been trained but did not remember when. EI #7 said, determination of the sling size to use was made by the resident's weight and the slings were color coded by size and weight. When asked what RI #103's weight was, EI #7 did not know. However, EI #7 said, RI #103 was a large person, so she used a large sling which was a blue color. When asked what RI #103's care plan documented about transfer with a mechanical lift, EI #7 said, RI #103 was a two person assist for transfer. EI #7 said, if she had followed RI #103's care plan for two people transferring RI #103 with the mechanical lift, there would have been two people watching RI #103 to ensure RI #103 was in the sling properly for a safe transfer. EI #7 said, she was disciplined about not following procedures and policies for transfer of residents using the lift. EI #7 said, the accident with RI #103 could have been avoided if she had done the right thing, and two people had assisted RI #103 in the lift transfer. EI #7 said, now she understood the consequences of not following the policy. On 02/09/2023 at 12:30 PM, an interview was conducted with EI #8 RN. EI #8 said, she heard someone say they needed a nurse. EI #8 stated, when she got on the hall, she observed RI #103 on the floor and RI #7 was by RI #103's side. EI #8 stated, she observed blood on the floor. When asked how RI #103 came to be on the floor, EI #8 said, she assumed RI #103 fell from the lift. EI #8 stated that RI #103 required a mechanical lift for transfers and the facility's policy was to use a two person assist with a mechanical lift. EI #8 said, the DON came to assess RI #103, treated the laceration on RI #103's head, EMS was called, and they stayed with RI #103 until EMS arrived. On 02/09/2023 at approximately 4:15 PM, an interview was conducted with EI #2, RN/ DON. EI #2 was asked what happened regarding the incident with RI #103 on 01/06/2023. EI #2 said she was notified by a staff member and when she arrived at RI #103's room she observed RI #103 on the floor and the mechanical lift in front of RI #103. EI #2 stated she noticed the sling was attached to the lift, blood was on the floor, and upon assessment of RI #103's head, she found a laceration to the scalp and a hematoma. EI #2 said, EI #7 had reported she was transferring RI #103 from the shower bed to bed when RI #103 began sliding to the right, and before EI #7 could help RI #103, RI #103 came out of the head position of the sling and fell on the floor. EI #2 was asked how many staff assisted with the transfer. EI #2 said, EI #7 told her she did not have anyone assisting with the lift at the time of RI #103's transfer. EI #2 said, EI #7 should have had another person to assist her with transfer of RI #103, as it had always been the policy of the facility to require two person assistance for transfer of residents by mechanical lift. EI #2 said, RI #103 was also care planned for a two person assist for transfers. EI #2 stated, EI #7 did not use the correct size sling during the transfer of RI #103. EI #2 stated, EI #7 used the blue sling and the appropriate sling color for RI #103 was yellow. RI #103's Weights and Vitals Summary documented, RI #103's weight was 145 pounds on 01/02/2023. An ARJO SLING/SIZE GUIDE documented a medium size sling with a yellow color code was the appropriate sling size for RI #103's weight range of 121-165 pounds. The extra large (XL) with a blue color code was recommended for adults who weighed 308-440 pounds. On 02/28/2023 at 2:50 PM, a follow-up interview was conducted with EI #2 DON. EI #2 was asked what the facility's process was for selecting the proper sling size at the time of RI #103's fall. EI #2 reported, at that time, residents who required mechanical lifts were weighed at least monthly, staff performing the transfer would check the resident's documented weight and follow the manufacturer's guidelines. On 2/10/2023 at 4:15 PM, the Administrator, EI #1 was interviewed regarding the incident involving RI #103 falling on 01/06/2023. EI #1 stated the fall could have been avoided if there had been two people assisting with the transfer. EI #1 stated it has always been the policy of the facility to make sure residents were transferred by mechanical lift safely with two persons. EI #1 stated, EI #7 did not follow the facility's policy when transferring RI #103 with the mechanical lift. On 03/01/2023 at 2:00 PM an interview was conducted with EI #11, RI #103's attending Medical Doctor. EI #11 was asked what did non-displaced fracture through posterior lamina mean. EI #11 replied, the posterior lamina was at the back of the neck along the outer ring of the vertebrae. EI #11 was asked what risks were associated with a C2 or C3 fracture. EI #11 replied, if the fracture displaced, it could potentially cause paralysis but with a non-displaced fracture it would be limited to limited range of motion until healed. EI #11 was asked if RI #103's injuries were serious. EI #11 replied that anytime a resident had a neck fracture that it was considered serious. 29671 This deficient practice was cited as a result of the investigation of complaint/report number AL00042944. ********************************************************* The facility took immediate action to correct the noncompliance by: 1. Reported the incident to Alabama Department of Public Health (ADPH) 1/9/2023 and conducted an investigation. 2. Completed in-service with staff on following care guides with transfer using the mechanical lift, facility lift procedures with return demonstration. Completed 1/9/23. 3. The Care Plan Coordinator and designee reviewed the care plan for each resident who required the use of a mechanical lift to ensure resident specific interventions were present. Completed 1/9/23. 4. DON completed assessment for proper sling fit for each resident who used a mechanical lift and this information was added to resident care plan, Plan Of Care (POC) task list, and color coded paper identifier on closet door for any resident care planned for mechanical lift. Care Plan will be update by the MDS Coordinator/Care Plan Coordinator, with weight loss/gain, as well as any assessments. Completed 1/9/23. 5. Quality Assurance (QA) meeting held on 1/7/2023 to create plan of correction (POC). 6. QA/Root cause analysis (RCA) meeting held on 1/13/2023. 7. Monitoring for two-person assist compliance . The Director of Nursing (DON), Administrator, or designee, will monitor through direct observation mechanical lift transfers during rounds that will occur using mechanical lift audit tool. Weekly for 4 weeks and then; monthly for 6 months and then; quarterly. Start date 1/7/23 - Ongoing. After review and verification of the information provided in the facility's corrective action plan, inservice/education records, monitoring tools and the facility's investigation, as well as staff interviews, the survey team determined the facility implemented corrective actions from 01/6/2023 through 01/13/2023 with ongoing monitoring implemented; thus, immediate jeopardy past noncompliance was cited.

Based on observations, interviews and review of facility policies titled, Handling Clean Linen, Hand Hygiene, and Hand Hygiene Table, the facility failed to ensure: (1) Employee Identifier (EI) #5 Registered Nurse (RN) performed hand hygiene in a manner to prevent the spread of infection. EI #5 was observed exiting Resident Identifier (RI) #16's room wearing gloves and holding a plastic medication tray containing a medicine cup, a used insulin syringe, a used lancet, and a used alcohol swab. While wearing contaminated gloves, she put her hand in her pocket to retrieve keys. She opened the medication cart, picked up sanitizing wipes from the bottom drawer of medication cart, and cleaned the plastic medication tray. (2) a laundry staff member did not hold a clean sheet against her body and allow the clean sheet to touch the floor while folding. This deficient practice had the potential to affect all 50 residents in the facility. Findings Include: 1. A facility policy titled,Hand Hygiene, reviewed/revised 3/2020, documented Objective: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. In addition, resident care staff shall assist residents with their hand hygiene to prevent the spread of infection. Policy: . 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. A facility document titled, Hand Hygiene Table documented hand hygiene was indicated by either using soap and water or alcohol based hand rub . After handling items potentially contaminated with blood, body fluids, secretions, or excretions . On 02/07/2023 at 10:50 AM, EI #5 Registered Nurse (RN) came out of Resident Identifier (RI) #16's room wearing gloves and holding a plastic medication tray containing a medicine cup, a used insulin syringe, a used lancet, and a used alcohol swab. EI #5 placed the plastic tray on top of the West Hall medication cart. EI #5 disposed of the syringe and the lancet in the sharps container and threw away the alcohol swab and the medication cup in the garbage. EI #5 then while still wearing the same gloves, put her gloved right hand into her right pocket and retrieved the keys to the medication cart. EI #5 unlocked the medication cart and opened the bottom drawer of the medication cart to retrieve sanitizing wipes from the drawer. EI #5 proceeded to pull out a wipe from the sanitizing wipe container and started cleaning the plastic tray for medications. On 02/07/2023 at 10:58 AM, an interview with EI #5 was conducted. EI #5 confirmed she did not change her gloves after coming out of RI #16's room. EI #5 said she did she not change her gloves before she started to clean the plastic medication tray because she was nervous and focused on cleaning it. EI #5 stated the tray was used to carry resident's medicines. EI #5 said the things that were on the plastic medication tray were an alcohol swab that was used to clean RI #16's skin before injecting insulin, the insulin syringe with safety cap engaged covering the needle, the finger prick for RI #16's blood glucose check, and a medication cup. EI #5 said she should have changed gloves after throwing away the sharps and alcohol pad to eliminate contamination between residents. EI #5 said, hands should should be sanitized before entering a room, after providing care, leaving a room, touching contaminated surfaces, and any time hands are dirty. On 02/09/2023 at 10:33 AM, EI #3, Infection Preventionist was asked about what EI #5 had been observed doing. EI #3 said the nurse should have changed the gloves and performed hand hygiene before cleaning the tray. EI #3 said a nurse should never reach in her pocket with dirty gloves to retrieve the keys for the medication cart due to the the risk of cross contamination. EI #3 said using dirty gloves to open a medication cart or pick up anything in the medication cart was a risk for infection and cross contamination. EI #3 said the nurse should have changed gloves and performed hand hygiene. On 02/09/2023 at 12:31 PM, EI #2 Director of Nurses (DON) reported that 26 residents' medications were stored in the West Hall medication cart. 2. A facility policy titled, Handling Clean Linen implemented 11/2019 documented, . Policy: . It is the policy of this facility to handle, store, process, and transport clean linen in a safe and sanitary method to prevent contamination of the linen, which can lead to infection. 6. Carry clean linen with clean hands away from your body. 7. Do not place clean linen on the floor or other contaminated surfaces. On 02/09/2023 at 09:13 AM, an observation was made of EI #6, Housekeeping/Laundry staff folding a clean sheet. EI #6, while folding the clean sheet tucked it underneath her chin and against her clothing. EI #6 also while folding the clean sheet, allowed it to touch the floor. EI #6 then finished folding the sheet on the clean folding table and stacked it with other clean sheets. EI #6 picked up another clean sheet to fold, held the sheet up, allowed the sheet to touch the floor, and then put it on the clean folding table. On 02/09/2023 at 09:14 AM, EI #6 was asked about the observation made of her folding the sheet, allowing it to touch her clothing and the floor. EI #6 stated staff should never hold a sheet against their clothing. EI #6 said the risk of touching her clothing against the clean sheet was that her clothes were dirty and getting the sheets dirty. When asked what should have been done, EI #6 said she should have held it away from her body. When asked about the sheets touching the floor, EI #6 said clean laundry should never touch the floor. On 02/09/2023 at 09:15 AM, EI #4, Housekeeping Supervisor was asked about what had been observed while EI #6 was folding clean sheets. EI #4 said, staff should not allow sheets to touch the floor or hold them against their body. EI #4 said, sheets would be dirty if they touched the floor. EI #4 said the clean sheet should never touch the body of the person folding it and staff should hold it away from their bodies. On 02/09/2023 at 10:33 AM, EI #3, Infection Preventionist was asked about what had been observed while EI #6 was folding clean sheets. EI #3 said, the laundry should not have been held against the person folding it due to the risk of cross contamination. EI #3 said clean laundry should not touch the floor when being folded because of cross contamination.

Based on record review, interview, and Payroll Based Journal (PBJ) Report, the facility failed to report staffing data from July 01, 2022 - September 30, 2022, to Centers for Medicare & Medicaid Services (CMS). This affected one quarter of data reviewed during the survey. Findings Include: The PBJ report generated for the quarter of 07/01/2022 through 09/30/2022 documented: . This Staffing Data Report identifies areas of concern that will be triggered . Metric Failed to Submit Data for the Quarter . Triggered = No Data Submitted for Quarter . On 02/09/2023 at 2:46 PM, an interview was conducted with Employee Identifier (EI) #1, Administrator. EI #1 stated he was responsible for turning in PBJ data to CMS. EI #1 was asked why the PBJ data was not reported to CMS from 07/01/2022 through 09/30/2022. EI #1 explained the data was not turned in monthly due to a computer issue, that was only recently resolved. EI #1 explained he planned to manually enter the data into the [NAME] system prior to the due date on 11/14/2022 but was unable to meet the deadline. EI #1 stated it was important to report the data because it was used for the facility's star rating and reimbursement rate.

Based on observation, interview, medical record review and review of facility policies titled, MEDICATION ADMINISTRATION BY MOUTH and Self-Administration of Medication, the facility failed to ensure a licensed nurse remained with Resident Identifier (RI) #32, who had not been assessed for self-administration of medication, during the administration of [MEDICATION NAME] during medication pass observation on 08/21/19. This affected RI #32, one of four residents observed during medication pass observation and one of two nurses observed. Findings Included: A review of a facility policy titled, MEDICATION ADMINISTRATION BY MOUTH, with a REVISED DATE: 09/18/2014, documented: .9. The nurse will remain with resident/patient until medications are taken. A review of a facility policy titled, Self-Administration of Medication, with Date Implemented: (MONTH) (YEAR), revealed: .1.an assessment is conducted by the interdisciplinary team and results of the assessment are recorded on the Self-Administration Assessment Form, which is placed in the resident's medical record. 2. As part of the interdisciplinary team, a physician order [REDACTED]. The care plan must reflect resident self-administration and storage arrangements for such medications. RI #32 was admitted to the facility on [DATE]. A review of RI #32's medical record revealed no order for self-administration of any medications, no self-administration assessment form and no care plan for self-administration of medication. On 08/21/19 at 7:56 a.m., during medication pass observation, the surveyor observed Employee Identifier (EI) #1, Licensed Practical Nurse (LPN), mix RI #32's [MEDICATION NAME] in four ounces of water in a plastic cup and deliver it RI #32's bedside, along with other medications. EI #1 administered all medications except [MEDICATION NAME]. Surveyor observed EI #1 instruct RI #32 to drink his [MEDICATION NAME]. EI #1 then left RI #32's bedside and entered the bathroom to wash her hands out of direct sight of RI #32. When EI #1 returned to the bedside, RI #32 handed her three plastic cups, two that contained liquid in them. EI #1 did not question RI #32 about the liquid remaining in the cups or if he/she had taken the [MEDICATION NAME]. On 08/21/19 at 1:31 p.m., an interview was conducted with EI #1, LPN. EI #1 was asked how long should she remain with a resident when administering medications. EI #1 said, until they get completely done. EI #1 was asked did she remain with RI #32 while he/she drank the water that [MEDICATION NAME] was mixed in. EI #1 responded she did not guess she did. EI #1 was asked, did RI #32 have an order to self-administer medications. EI #1 said no. EI #1 was asked had RI #32 been assessed to self-administer medications. EI #1 replied she did not think so. EI #1 was asked was RI #32 care planned for self-administration of medications. EI #1 replied not that she knew of and she had not seen it if he/she was. When asked what was the concern with not remaining with a resident until all medication was consumed or administered, EI #1 answered, somebody else could have gotten it or he/she could not have taken it. On 08/21/19 at 4:18 p.m., an interview was conducted with EI #2, Registered Nurse (RN)/Infection Control Preventionist/Minimum Data Set (MDS) Coordinator. EI #2 was asked how long should a nurse remain with a resident during medication administration. EI #2 said until all the medicines are taken. EI #2 was asked what should be in place before a resident can safely self-administer medications. EI #2 replied, an assessment form, physician order [REDACTED]. EI #2 was asked what was the concern with a resident self-administering medications without the proper assessment, physician's orders [REDACTED]. EI #2 answered, they could get the wrong dose, the wrong time or if it was left somebody could come by and pick it up that did not need it and the resident it was intended for may not get it.

Based on observation, interviews, medical record review and review of Potter and Perry, Fundamentals of Nursing, Ninth Edition, the facility failed to ensure a licensed nurse: 1. cleaned Resident Identifier (RI) #32's nasal spray prior to recapping, 2. removed gloves and washed hands and applied clean gloves after administering RI #32's inhaler prior to administering his/her nasal spray, 3. cleaned RI #32's inhaler prior to recapping, 4. cleaned RI #32's [MEDICATION NAME] syringe prior to placing it back in a plastic sleeve, and 5. cleaned and dried RI #32's nebulizer mask and reservoir prior to storing it in a plastic bag. This affected RI #32, one of four residents observed during medication pass observation and one of two nurses observed. Findings Included: A review of of Potter and Perry, Fundamentals of Nursing, Ninth Edition, Chapter 29, Infection Prevention and Control, page 455, documented: .Cleaning. Cleaning is the removal of organic material .from objects and surfaces .When an object comes in contact with an infectious or potentially infectious material, it is contaminated .Reusable objects need to be cleaned thoroughly before reuse . RI #32 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 08/21/19 at 7:56 a.m., during medication pass observation, Employee Identifier (EI) #1, Licensed Practical Nurse (LPN), was observed administering RI #32's inhaler while wearing gloves. She then proceeded to administer RI #32's nasal spray while wearing those same gloves. EI #1 also recapped RI #32's nasal spray and inhaler without wiping or rinsing them off and returned a syringe used to administer RI #32's sublingual [MEDICATION NAME] back into a plastic sleeve without rinsing it prior to storing it in the medication cart. EI #1 was then observed returning RI #32's nebulizer mask and tubing back into a plastic bag without emptying the residue, rinsing and drying the reservoir. On 08/21/19 at 1:31 p.m., an interview was conducted with EI #1, LPN. EI #1 was asked what should she do after a resident has used an inhaler. EI #1 said wipe it off with a Kleenex or something like that. EI #1 was asked what should she do after a resident has used a nasal spray. EI #1 replied, same thing, wipe it off with a Kleenex or something. EI #1 was asked did she clean the inhaler before placing the cap back on it and storing it in the medication cart. EI #1 responded, no. EI #1 was asked did she clean the nasal spray after administering it to RI #32. EI #1 said no. When asked when she should wash her hands and change gloves during medication pass with different routes, EI #1 stated after each route. EI #1 was asked did she remove her gloves, wash her hands and apply clean gloves after administering RI #32's inhaler, before administering his/her nasal spray. EI #1 said no, she should have removed her gloves and went and washed them right then and put on a clean pair. EI #1 was asked did she clean the syringe used to administer RI #32's [MEDICATION NAME] before returning it to the medication cart. EI #1 replied no. EI #1 was asked what should she do after administering a nebulizer treatment before storing the tubing and pipe back in the plastic bag. EI #1 said she should have wiped it. EI #1 was asked did she pour out the residue after RI #32's treatment. EI #1 stated no. EI #1 was asked what was the concern with these issues. EI #1 answered infection control. On 08/21/19 at 4:18 p.m., an interview was conducted with EI #2, Registered Nurse/Infection Control Preventionist. EI #2 was asked, when should a nurse change gloves and wash her hands during medication pass. EI #2 said, before she goes in, after she finishes and each time she goes from one route to another she should change her gloves and wash her hands or at any time she was not sure if she had touched something. EI #2 was asked, what should a nurse do with an inhaler and/or nasal spray bottle after administration and prior to storing back in the medication cart. EI #2 replied, wipe or wash the mouthpiece or nasal tip if needed before placing it back in the plastic bag. EI #2 was asked, what should a nurse do after administering [MEDICATION NAME] sulfate by a syringe prior to storing it in the container. EI #2 replied, wash it and dry it and put it back in the container. EI #2 was asked what was the concern with not washing hands or changing gloves when needed or not cleaning inhalers, nasal sprays, nebulizer pipes and reservoirs prior to them being stored. EI #2 answered, spread of bacteria and infections.

Based on observations, record review, interviews, and review of a facility policy titled Infection Prevention and Control Program/Plan, the facility failed to ensure a Certified Nursing Assistant (CNA) performed hand hygiene between removing a pair of soiled gloves and re-gloving during incontinence care. This affected Resident Identifier (RI) #12, one of one resident observed during incontinence care. Findings include: RI #12 was readmitted to the facility on [DATE]. Review of RI #12's quarterly Minimum Data Set assessment, with an Assessment Reference Date of 7/02/18, revealed RI #12 had severely impaired cognition and required extensive assistance of one person for toileting and personal hygiene needs. RI #12 was always incontinent of both bowel and bladder. A facility policy titled, Infection Prevention and Control Program/Plan, revised (MONTH) (YEAR), revealed: Policy: It is the policy of this facility to establish and maintain an Infection Prevention and Control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Policy Explanation and Compliance Guidelines: . 4. Hand Hygiene Protocol: a. All staff shall wash their hands . after PPE (personal protective equipment) removal . Incontinence care for RI #12 was observed on 07/31/18 at 04:17 PM. Incontinence care was performed by Employee Identifier (EI)#3 and EI#4, both CNAs. During the care, while cleaning RI#12's bottom, EI#3 had stool on her glove. EI#3 removed the soiled glove and put on a new pair without doing hand hygiene. When EI#3 was finished wiping RI #12, she changed gloves again and did not do hand hygiene. An interview conducted with EI#3 on 07/31/18 at 04:35 PM. EI#3 was asked what should be done between removing soiled gloves and putting on a new pair. EI#3 replied, use germ x (sanitizer). EI#3 was asked if she did that every time she changed her gloved during the care. EI#3 said she did not think so. On 8/01/18 at 11:10 AM, the Infection Control Nurse, EI #5, was interviewed. EI #5 was asked what should be done after removing soiled gloves, before putting on a new pair. EI#5 replied, wash hands or use hand sanitizer. EI #5 said if that was not done, it could cause harm.

Based on observation and interview the facility failed to ensure the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/2/16 and 7/20/16 accurately reflected catheter and bowel and bladder status for RI (Resident Identifier) #'s 5 and 7. This affected two of eleven sampled residents whose MDS's were reviewed. Findings Include: 1) RI # 5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Disease of Nervous System. A review of RI # 5's most recent 14 day MDS with an ARD of 07/20/16 documented RI # 5 had an indwelling catheter. Section H0300 Urinary Continence was not marked to indicate Urinary status. 2) RI # 7 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI # 7's most recent quarterly MDS with an ARD of 06/02/16 documented the use of a external catheter and a ostomy. Section H0300 Urinary Continence was coded a 3 always incontinent. Section H0400 Bowel Continence was coded a 3 always incontinent. An interview was conducted with Employee Identifier (EI) # 2, Registered Nurse (RN) on 8/24/16 at 3:00 p.m. EI # 2 was asked if she completed the MDS with an ARD of 06/2/16 for RI # 7. EI # 2 replied yes. EI # 2 was asked if RI # 7 had a catheter. EI # 2 stated yes a Foley. EI # 2 was asked if Section H of the MDS documenting RI # 7 had an external catheter was correct. EI # 2 replied no it should be coded indwelling catheter. EI # 2 was asked if Section H0300 Urinary Continence was coded correctly. EI # 2 replied no it should be coded 9 not rated. EI # 2 was asked if Section H0400 Bowel Continence was coded correctly. EI # 2 replied no, it should be 9 because RI# 7 has a [MEDICAL CONDITION]. EI # 2 was asked if she completed the MDS for RI # 5 with an ARD of 07/20/16. EI # 2 replied yes. EI # 2 was asked if RI # 5 had a catheter. EI # 2 replied yes. EI # 2 was asked if Section H0300 for RI # 5 was coded correctly. EI # 2 replied no it should be 9 not rated because he/she has a catheter. EI # 2 was asked what is the harm of coding the MDS incorrectly. EI # 2 replied it is just miscoded. EI # 2 was asked why the MDS's were coded this way. EI # 2 replied it was a coding error.

Based on observation, interview and record review, the facility failed to ensure a Certified Nursing Assistant (CNA) washed her hands and changed her gloves while providing incontinent care for Resident Identifier (RI) # 3. The facility further failed to ensure the CNA changed the bath water in RI #3's basin after cleaning his/her perineal area. This affected one observation of incontinent care. Findings Include: A facility policy with a Revised date 9-6-2012, titled: . Perineal Care Objective: To cleanse the perineal area daily and as needed. To prevent skin breakdown. To maintain cleanliness Procedure: 6. Put on gloves 15. Change gloves after cleaning the perineal area. 16. If during care, if clean gloves come in contact with soiled item/linen, Change gloves again A facility policy with a Revised date 10-2014, titled: .Handwashing Objective: To prevent the spread of germs. To promote cleanliness RI #3 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/04/2016 identified RI #3 with a score of 02 for the Brief Interview for Mental Status which indicated he/she was severely impaired for cognitive status. Section H. identified him/her as (3) for Bowel and Bladder which indicated he/she was incontinent. During an observation of incontinent care and bath care on 08/24/16, at 9:05 a.m. Employee Identifier (EI) #1 was observed cleaning a brown substance identified as a bowel movement from RI #3's anal area. EI #1 failed to wash her hands and change her gloves after removing the bowel movement from RI #3's anal area and buttocks and continued to bath RI #3 placing the same gloved hands in RI #3's clean water basin. An interview was conducted with EI #1 CNA on 08/24/16, at 2:30 p.m. She was asked what care she had provided for RI #3. EI #1 replied, a bed bath and perineal care. EI #1 was asked what she should do after cleaning a bowel movement from a resident regarding gloves. She replied, change gloves. EI #1 was asked what training she had received from the facility related to changing gloves and washing her hands after cleaning a bowel movement. She replied, remove gloves wash hands put clean gloves on. EI #1 was asked if she should have changed her gloves and washed her hands after cleaning a bowel movement off of RI #3 before continuing to bath him/her. She replied, yes. EI #1 was asked why she did not wash her hands and change her gloves. She replied my mind was just jumping I was nervous and not feeling well. EI #1 was asked what the potential for harm was for failing to remove dirty gloves and wash her hands and re-applying clean gloves before touching clean items. She replied, the spread of bacteria. EI #1 was asked if she should have changed the water in the basin after she had just removed a bowel movement from RI #3's buttocks and bottom. EI #1 replied, yes. She was then asked what the potential for harm was for not changing the water in the basin. She replied, it can spread bacteria. An interview was conducted with EI #3 a CNA on 08/24/16, at 2:38 p.m. She was asked what EI #1 should have done after providing perineal care and removing a bowel movement from RI #3. EI #3 replied, wash her hand and change gloves. EI #3 was asked why EI #1 failed to remove her dirty gloves and wash her hands before continuing care. EI #3 replied, I think she got nervous. EI #3 was asked what the potential for harm was for failing to remove gloves, wash hands and re-glove after cleaning a bowel movement. EI #3 replied, spread of bacteria to other areas of the body. EI #3 was asked if EI #1 should have changed the water in the basin after cleaning RI #3's perineal area and removing a bowel movement. She replied, yes. EI #3 was asked what the potential for harm if the same water is used for bathing a resident that was used to clean a bowel movement from their bottom. EI #3 replied, bacteria can spread from the contaminated washcloth that was placed in the water.

Based on observations, interview, and review of the facility's policy, the facility failed to ensure food items stored in the cooler were labeled and dated. This deficient practice had the potential to affect 50 of 52 residents who received food from the kitchen. Findings include: The facility's undated document titled FOOD STORAGE documented POLICY: Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing . PROCEDURE: . 4. All containers must be legibly and accurately labeled . 13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 72 hours or discarded . 15. Refrigeration: . D. Foods should be covered, labeled, and dated . During the initial tour of the kitchen on 7/21/15 at 10:15 AM, in the cooler was a white liquid substance in a plastic container dated 7/15/15. Employee Identifier (EI) #1, the Dietary Manager, identified the white liquid substance as ranch dressing. EI #1 stated sauces and dressings are dated with an open date and discarded after three to four days. On 7/21/15 at 5:35 PM, an unlabeled clear container was found in the cooler; there was no label to indicate the type of food in the container or the use by date. On 7/23/15 at 9:08 AM, there were three clear containers in the cooler. One container was labeled chocolate pudding with a date of 7/22/15. The other two containers were labeled 7/22/15; the label did not specify what food items were in the containers. EI #1 stated the containers contained cabbage and Polish sausage. When asked what the facility's policy was for storing, labeling and discarding food, EI #1 stated the facility dated everything. EI #1 was asked what the potential harm was if items were not properly labeled or discarded. EI #1 replied, there was harm anytime food items were misdated or outdated.

Based on record reviews, observations and interviews, the facility failed to ensure that licensed staff pulled the privacy curtain or closed the door in a semi-private room while administering medications to RI (Resident Identifier) #9 and UR (Un-sampled Resident) #2 on 9/9/14. This affected 1 of 3 nurses observed during medication pass administration. Findings Include: A review of a facility document titled, "Resident Rights and Responsibilities" not dated, revealed: "...The right to Privacy and Confidentiality The Resident has the right to privacy...in receiving care, medical treatment and in health information. Resident's confidentiality must be maintained..." A review of a facility policy and procedure titled, "RESIDENT RIGHTS Resident Privacy and Confidentiality" with a date of 09/16/2013 revealed: "Policy: The resident has the right to privacy and confidentiality of clinical information Procedure: ...2.) ...Information regarding one resident should not be shared with other residents, or visitors. 3.) To maintain confidentiality of resident social and medical information; staff should exercise caution during discussions, of a confidential nature, with the resident. ..." A review of a facility policy and procedure titled, "RESIDENT RIGHTS Maintaining Resident Dignity" with a date of 16/09/2013 revealed: "...Procedure: ...12. Maintain resident privacy. ..." UR #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of UR #2's Order Summary Report with an order date of 07/29/2014 (These orders are renewable for 6 months unless otherwise stated or otherwise limited by law)documented:"[MEDICATION NAME] Capsule 6 MG (milligrams) Give 1 capsule by mouth two times a [MEDICATION NAME] tablet 10 MG Give 1 tablet by mouth two times a day, [MEDICATION NAME] Capsule 100 MG Give 1 capsule by mouth two times a [MEDICATION NAME] XR Tablet Extended Release 24 Hour 50 MG Give 1 tablet by mouth two times a day..." On 9/9/14 at 4:45 PM, EI #6 , LPN (Licensed Practical Nurse) was observed by the surveyor placing the above medications in a medication cup. EI #6 entered UR #2's room with the medications, explained the medications to the resident and gave the medications to the resident. UR #2's roommate was in the next bed. EI #6 did not pull the privacy curtain or close the door. EI #6 washed her hands and exited the room. RI #9 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #9's Order Summary Report with an order date of 08/29/2014 (These orders are renewable for 6 months unless otherwise stated or otherwise limited by law) documented: "[MEDICATION NAME] Tablet 25 MG Give 1 tablet by mouth two times a [MEDICATION NAME] Tablet 10 MG Give 1 tablet by mouth two times a [MEDICATION NAME] Tablet 2.5 MG Give 2.5 mg by mouth two times a day..." On 9/9/14 at 4:49 PM, EI #6, LPN was observed by the surveyor placing the above medications in a medication cup. EI #6 entered RI #9's room with the medications, explained the medications to the resident and gave the medications to the resident. RI #9's roommate was in the next bed. EI #6 did not pull the privacy curtain or close the door. EI #6 washed her hands and exited the room. On 9/9/14 at 5:09 PM, an interview was conducted with EI #6, LPN. EI #6 was asked what was she taught concerning resident privacy during medication administration pass. EI #6 said knock on the door and pull the privacy curtain between the two beds. EI #6 was asked if she pulled the privacy curtain between the two residents during medication administration pass. EI #6 said, "I did not pull the curtain, I should have." EI #6 was asked what was the potential harm if she did not pull the privacy curtain between the two residents during medication administration pass. EI #6 said if one resident were to get choked, the other resident could observe that. EI #6 was asked if she provided privacy between RI #9 and UR #2 during medication administration pass. EI #6 said no, she did not pull the curtain or close the door and she should have. On 9/11/2014 at 1:40 PM, an interview was conducted with EI#1, DON (Director of Nursing). EI #1 was asked was it protecting the residents' privacy and confidentiality when they received medications and the door was open and the privacy curtain was not pulled. EI #1 said, "No and I wouldn't want someone to know what medications I am taking."

Based on record review, observations and interviews, the facility failed to ensure that a CNA (Certified Nursing Assistant) provided dignity to UR (Un-sampled Resident) #1 while providing incontinent care on 09/10/2014. UR #1 was left with the peri area exposed while the CNA left the room to retrieve additional assistance. This affected 1 of 3 residents observed during incontinent care. Findings Include: A review of information received from the facility titled "Resident Rights and Responsibilities", no date, documented: "... The right to be treated with Dignity and Respect ... Residents should be...treated with dignity while assisting or providing care. ... The right to Privacy... The resident has the right to privacy as much as possible... in receiving care, medical treatment..." A review of "(Name of Facility) POLICY AND PROCEDURE" with a Implementation Date 16/09/2013 titled "Resident Rights Maintaining Resident Dignity" revealed: "Policy: It is the practice of this facility to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity ... Procedure: 1. All staff members are involved in providing care to residents to promote and maintain resident dignity ... 12. Maintain resident privacy..." UR #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. UR #1's most recent Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 08/25/2014 revealed a BIMS (Brief Interview for Mental Status) score of 3 out of 15, which indicated UR #1 was severely cognitively impaired for daily decision making. UR #1 was identified as requiring extensive assistance of two people for toileting and totally dependant on staff for other activities of daily living. UR #1 was also identified as being frequently incontinent of bowel and bladder. On 09/10/2014 at 4:10 PM the surveyor observed EI #3, CNA performing incontinent care on UR #1. EI #3 left the room to get additional assistance and left UR #1's perineal area exposed. UR #1 covered their perineal area with a clean pad that had been left on the bed. On 09/10/2014 at 4:50 PM the surveyor conducted an interview with EI #3, CNA. She was asked when she was providing perineal care on UR #1 and left the resident's beside what should she have done. She answered cover the resident. EI #3 was asked why she thought UR #1 covered themselves with a pad that had been left on the bed when she left her bedside. She answered UR #1 was a very private person. EI #3 was asked did she provide privacy for UR #1 while providing incontinent care. She replied no. EI #3 was asked what was the potential harm in not providing privacy and leaving the resident uncovered and leaving the bedside. She said dignity. On 09/11/2014 at 1:45 PM the surveyor conducted an interview with EI #1, DON (Director of Nursing). EI #1 was asked what were the CNA's taught about providing privacy to a resident when doing incontinent care and walking away from the bedside to obtain supplies or assistance. She replied cover the resident. EI #1 was asked why a resident would pull a pad over themselves during incontinent care if the CNA left the bedside and left them uncovered. She replied probably because there was a stranger in the room and because she, (EI #1) would be embarrassed if left in that condition. EI #1 was asked what was the potential harm in not providing privacy and leaving the resident uncovered and leaving the bedside. She replied UTI (urinary tract infection) and dignity.

Based on record review, observation and interviews, the facility failed to ensure that a CNA (Certified Nursing Assistant) wiped front to back while providing incontinent care for RI (Resident Identifier) #4, a resident with a history of UTI (Urinary Tract Infection), on 9/10/14. The facility further failed to ensure that a CNA separated and cleaned the labia of UR (Un-sampled Resident) #1, a resident with a history of UTI, during incontinent care on 9/10/14. This affected 2 of 3 residents observed for incontinent care. Findings Include: A review of a facility policy titled, "(NAME OF FACILITY) PERINEAL CARE" with a revised date of 9/6/2012, revealed: "...PROCEDURE: ...12. ...Separate the labia and wash, rinse and dry the urethral area first ...13. ...Always clean from front to back ... " A review of a facility document titled, "SIGN-IN-SHEET" with a date of 7/10/14 revealed that EI (Employee Identifier) #2 and EI #3 attended a perineal care education in-service and check-off. 1) RI #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #4's most recent Annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 09/02/2014 revealed that RI #4 had a BIMS (Brief Interview for Mental Status) score of 6 out of 15, which indicated RI #4 was severely impaired for daily decision making. The resident was further identified as needing extensive assistance for ADLs (Activities of Daily Living). The resident also was identified as being always incontinent of urine and frequently incontinent of bowel. A review of a facility urine culture report dated 03/05/2014 revealed that RI #4 was positive for Escherichia Coli; colony count >100,000. A review of a facility urine culture report dated 05/16/2014 revealed that RI #4 was positive for Escherichia coli; colony count >100,000 and Proteus mirabilis; colony count >100,000. On 9/10/14 at 11:39 AM, EI #2 was observed performing incontinent care for RI #4. EI #2 cleaned RI #4's front perineal area and then dried it appropriately. RI #4 was turned on their right side and EI #2 wiped downward on RI #4's right buttock with a wipe and then wiped downward on the left buttock with another wipe. EI #2 wiped downward and then upward in between RI #4's gluteal fold. EI #2 changed her gloves, washed her hands and placed a clean pad underneath RI #4. On 9/10/14 at 11:50 AM, an interview was conducted with EI #2, CNA. EI #2 was asked how she was taught to wipe when performing incontinent care. EI #2 said front to back. EI #2 was asked how she wiped when cleaning urine from RI #4's buttocks. EI #2 said she thought she wiped front to back. The surveyor informed EI #2 that she observed her closely during the incontinent care and documented all the steps that were taken during the incontinent care and she did not wipe front to back. EI #2 said, "OK, I believe you." EI #2 was asked what the potential harm was if she did not wipe front to back on a resident with a history of UTI. EI #2 said UTI and infection. On 9/11/14 at 1:25 PM, an interview was conducted with EI #1, DON (Director of Nursing). EI#1 was asked how CNAs were taught to wipe during incontinent care. EI #1 said the correct way, front to back. EI #1 was asked was it acceptable care for that facility for a CNA to wipe back to front on a resident who had a history of [REDACTED].#1 said no, it was not acceptable. EI #1 was asked what the potential harm was if a CNA did not wipe front to back on a resident with a history of UTI. EI #1 said potential for UTI. 2.) UR #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. UR #1's most recent Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 08/25/2014 revealed a BIMS (Brief Interview for Mental Status) score of 3 out of 15, which indicated UR #1 was severely cognitively impaired for daily decision making. UR #1 was identified as requiring extensive assistance of two people for toileting and totally dependant on staff for other activities of daily living. UR #1 was also identified as being frequently incontinent of bowel and bladder. On 11/22/2013 a urinalysis report revealed a growth of Entroococcus faecalis >100,000. On 12/15/2013 a vaginal culture revealed heavy growth of Escherichia Coli. On 09/10/2014 at 4:10 PM the surveyor observed EI #3, CNA performing incontinent care of UR #1. EI #3 did not separate the labia or wash down the middle of the labia while performing incontinent care. She also obtained wipes from a clean container using contaminated gloved hands. On 09/10/2014 at 4:50 PM an interview was conducted with EI #3, CNA. EI #3 was asked while performing incontinent care on UR #1 did she separate the labia and wipe. She replied I thought I did. EI #3 was asked why she did not separate the labia and wipe. She said she thought she did, but sometimes UR #1 gets frustrated. EI #3 was asked what was the potential harm in not wiping down the middle of the labia and separating it. She said infection. On 09/11/2014 at 1:45 PM an interview was conducted with EI #1, DON (Director of Nursing). EI #1 was asked if CNA's are taught to separate the labia on a female resident when doing Pericare. She said yes. EI #1 was asked what was the potential harm in not separating the labia and cleaning when doing incontinent care. She said urinary tract infection.

Based on record review, observations and interviews, the facility failed to ensure that a CNA (Certified Nursing Assistant) did not touch a clean pad with contaminated gloves and then place the contaminated pad underneath RI (Resident Identifier) #3 during incontinent care on 9/10/14. The facility also failed to ensure that a CNA did not place a contaminated gloved hand inside a container of clean wipes and then clean the resident with the contaminated wipes while providing incontinent care to UR (Un-sampled Resident) #1 on 9/10/14. This affected 2 of 3 residents observed for incontinent care. Findings Include: A review of a facility policy titled, "(NAME OF FACILITY) PERINEAL CARE" with a revised date of 9-6-2012 revealed: " ...PROCEDURE ...16. If during care, if clean gloves come in contact with soiled items/linen, Change gloves again. ...18. Change gloves. 19. Apply clean pad, diaper or pull up. ... " A review of a facility document titled, "In-Service" dated 9-13-13 revealed EI (Employee Identifier) #3 and EI #4 attended an in-service on incontinent/pericare and hand washing. 1. RI #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI 3's most recent Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 07/28/2014 revealed that RI #3 was severely cognitively impaired for daily decision making. RI #3 was identified as needing extensive physical assistance with ADLs (Activities of Daily Living). The MDS also revealed that RI #3 was always incontinent of bowel and bladder. On 9/10/14 at 3:20 PM, EI #4 was observed performing incontinent care for RI #3. EI #4 cleaned RI #3's buttocks and then touched a clean pad with contaminated gloves. EI #4 washed her hands and changed gloves and proceeded to place the contaminated pad underneath the resident. On 9/10/14 at 3:39 PM, an interview was conducted with EI #4, CNA. EI #4 was asked what should she have done after touching the clean pad with contaminated gloves before she placed it underneath the resident. EI #4 said she should have changed the pad. EI #4 was asked why she placed the contaminated pad underneath the resident. EI #4 said she was not thinking and that she makes a lot of dumb mistakes. EI #4 was asked what was the potential harm if she did not change the pad once she touched it with contaminated gloves and placed it underneath RI #3. EI #4 said the resident could get germs. On 9/11/14 at 10:10 AM, an interview was conducted with EI #5. EI #5 was asked how were infections prevented in the facility. EI #5 said through in-services, monitoring and skills fairs. EI #5 was asked how were infections controlled in the facility. EI #5 said isolation, treatments, handwashing and education. EI #5 was asked how were infections investigated in the facility. EI #5 said tracking and trending. EI #5 was asked if direct care staff were washing their hands according to facility protocol and EI #5 said yes. EI #5 was asked how she monitored direct care staff to ensure they were washing their hands according to facility protocol. EI #5 said staff were randomly monitored and during the skills fair, they were checked off on it. On 9/11/14 at 1:05 PM, an interview was conducted with EI #1, DON (Director of Nursing). EI #1 was asked if it was an acceptable practice for that facility for a CNA to touch a clean pad after cleaning a resident's buttocks and then place that contaminated pad underneath the resident. EI #1 said no, it was not. EI #1 was asked why was this not acceptable. EI #1 said because the clean area was contaminated. EI #1 was asked who instructed the staff on infection control. EI #1 said the assistant DON and EI #5. EI #1 was asked how often were infection control classes held. EI #1 said at least quarterly and at every inservice, infection control is mentioned. EI #1 was asked what areas were covered in the infection control classes. EI #1 said handwashing, peri-care and catheter care. EI #1 was asked how was it ensured that staff understood what was being taught to them during the infection control classes. EI #1 said by return demonstration and asking the staff questions. EI #1 was asked what was the potential harm if a CNA placed a contaminated pad underneath a resident. EI #1 said the resident could become contaminated with the pad and infection control issues. 2. UR #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. UR #1's most recent Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 08/25/2014 revealed a BIMS (Brief Interview for Mental Status) score of 3 out of 15, which indicated UR #1 was severely cognitively impaired for daily decision making. UR #1 was identified as requiring extensive assistance of two people for toileting and totally dependant on staff for other activities of daily living. UR #1 was also identified as being frequently incontinent of bowel and bladder. On 11/22/2013 a urinalysis report revealed a growth of Entroococcus faecalis >100,000. On 12/15/2013 a vaginal culture revealed heavy growth of Escherichia Coli. On 09/10/2014 at 4:10 PM the surveyor observed EI #3, CNA performing incontinent care of UR #1. EI #3 obtained wipes from a clean container using dirty gloved hands. On 09/10/2014 at 4:50 PM an interview was conducted with EI #3, CNA. EI #3 was asked after she cleaned UR #1's labia how she obtained additional wipes. She said with dirty gloves. EI #3 was asked what should she have done to obtain additional wipes. She said change gloves and get the clean wipes. EI #3 was asked what was the potential harm in obtaining additional wipes by placing dirty hands in a clean wipe container. She said infection control. On 09/11/2014 at 1:45 PM an interview was conducted with EI #1, DON. EI #1 was asked what the CNA's are taught about going from a dirty to a clean area. She replied not to go from dirty to clean areas without washing hands and changing gloves. EI #1 was asked what the potential harm was in going from a dirty to clean area without washing hands and changing gloves. She said potential for urinary tract infection.

Based on observation, interview and record review, the facility failed to ensure licensed staff cleaned the inside area of a pressure ulcer before applying ointment and a clean dressing. The facility also failed to ensure licensed staff washed their hands after cleaning a pressure ulcer and before handling clean supplies. This affected RI (Resident Identifier) # 8,one of one wound care observations. Findings include: Facility Policy titled "(Name of Facility) Wound Care" with a Revised date of 4-2009 documented the following: "Objective: To provide appropriate wound care...Procedure:...2. Gather supplies needed and take to resident's room or treatment room...4. Wash hands...11. Cleanse wound as ordered... 12. Apply medications as ordered. 13. Cover wound with dressing as ordered...19. Wash hands..." A review of RI #8's physician orders [REDACTED]. 2) Cleanse Stage IV (four) wound to coccyx with NS (normal saline) or w/c (wound cleanser) apply silver med antimicrobial hydro gel and cover with border foam dressing daily..." RI # 8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The significant change MDS (Minimum Data Set) dated 06/19/2013 assessed RI #8 as having a BIMS (Brief Interview for Mental Status) score of 9 indicating RI #8 had moderate cognitive loss. RI #8 was also assessed as requiring extensive assistance of two for bed mobility and personal hygiene, and with one stage IV (four) pressure ulcer. On 09/05/2013 at 9:10 AM wound care was observed for RI #8. EI (Employee Identifier) #1, LPN (Licensed Practical Nurse)/Wound Nurse was observed to clean the outer area of the pressure ulcer. Without cleaning the inside area which had a depth of .6 cm (centimeter), EI #1 applied the Silver Med Antibacterial Hydro Gel and covered the area with a dressing. After EI #1 had cleaned the area, she removed her gloves and without washing her hands went to the cart to obtain clean supplies. EI #1 was interviewed on 09/05/2013 at 9:40 AM. EI #1 was asked why she had not cleaned inside RI #8's wound. EI #1 stated she was nervous, that it(wound) was dirty on the inside since she no longer had a catheter and urine and feces could get into the wound. EI #1 was asked what should she had done after cleaning around the wound and removing her gloves before going to the cart for clean supplies. EI #1 stated she should have washed her hands because she had cleaned the wound.

Based on observation, interview and record review, the facility failed to ensure incontinence care was provided for RI (Resident Identifier) #8 in a manner to prevent the potential for urinary tract infections [MEDICAL CONDITION] for a resident with a history of urinary tract infections. This affected one of three residents sampled for UTIs and one of two incontinent care observations. Findings include: A review of the facility policy for "Perineal Care," with a revision date of 09/06/2012 revealed: "...Procedure: ...12. Female residents: Separate the labia and wash, rinse and dry the urethral area first using short downward swipes- turn your cloth to a clean area with each swipe, alternate from one side to the other and work in a downward motion from the front of the groin to the inside of the thighs. Rinse with a clean wash cloth. Dry thoroughly." RI # 8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The significant change MDS (Minimum Data Set) dated 06/19/2013 assessed RI #8 as having a BIMS (Brief Interview for Mental Status) score of 9 indicating moderate cognitive loss. RI #8 was also assessed as requiring extensive assistance of two for bed mobility and personal hygiene, and as having one stage IV (four) pressure ulcer. RI #8 was assessed as having a Foley catheter which had been removed. On 09/05/2013 at 9:10 AM, EI (Employee Identifier) #1, LPN (Licensed Practical Nurse)/Wound Nurse, entered the room to provide wound care. EI #1 found RI #8 wet. EI #1 provided incontinent care for RI #8. RI #8 was positioned onto her right side with the help of EI #3, CNA (Certified Nursing Assistant). EI #1, using disposable wipes, wiped RI #8's rectal area from the front to the back. Using a clean wipe, EI #1 wiped RI #8's buttocks. Without positioning RI #8 onto her back and cleaning any of the front area, EI #1 provided the wound care, replaced the soiled pad underneath RI #8, gathered her supplies and she and the CNA left the room. On 09/05/2013 at 9:40 AM, EI #1 was asked why she had not cleaned RI #8's front area. EI #1 stated that she was nervous and that she did not usually do incontinence care. EI #1 was asked why it was important to clean a female resident in the front. EI #1 stated it was to prevent urinary tract infections especially if they have a history of multiple UTIs. On 09/05/2013 at 10:35 AM, EI #3 was asked what had not been done when EI #1 was providing incontinence care for RI #8. EI #3 stated, EI #1 should have wiped RI#8 in front to clean the urine off. When asked why, EI #3 stated it was to prevent urinary tract infections. A review of three Urinalysis (UA) and Culture and Sensitivity (C&S) lab reports for RI #8 revealed the following: 1. 02/21/2013 UA Clarity - slightly cloudy [MEDICATION NAME] - positive Leukocytes - small WBC (White Blood Cells) 6-10 Bacteria - many C&S Gram negative rods colony count > (greater than) 100,000 Escherichia coli colony count > 100,000 2. 08/01/2013 UA Clarity - slightly cloudy Blood - trace Leukocytes - large WBC 6-10 Bacteria - moderate C&S Providencia Stuartii Colony count >100,000 CFU (Colony Forming Unit)/ML (milliliter) Gram Negative Rods 3.08/08/2013 C&S Proteus mirabilis >100,000 Escherichia coli >100,000

Based on observation, interview and record review, the facility failed to ensure Fentanyl Patches were in place during the 72 hour period by failing to check and document placement of the patches and observation of the patches being in place. This affected RI (Resident Identifier) #9, one of two residents with an order for [REDACTED]. Findings include: The IntegraCare Pharmacy policy revealed: " ...M. Transdermal Drug Delivery System (patch) ...Procedure ... Document administration on MAR (Medication Administration Record) along with site used. Check patch placement daily for patches applied less frequently than once a day." RI #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) dated 08/05/2013 assessed RI #9 as rarely being understood and understand others and with severely impaired cognitive skills for daily decision making. RI #9 was also assessed as requiring extensive assistance for dressing and bed mobility, totally dependent for personal hygiene and with limited range of motion for both upper and lower extremities. RI #9 was assessed as having indicators of pain or pain observed 3-4 days in the last 5 days. On 09/04/2013 at 12:15 PM, a medication pass was observed for RI #9. The LPN ( Licensed Practical Nurse) EI (Employee Identifier) # 2 entered RI #9's room to apply the Fentanyl Patch. EI #2 was not able to find the previous patch to remove it before applying a new patch. EI #2 asked a CNA (Certified Nursing Assistant) to assist her in turning RI #9 and was still unable to locate the patch. EI #2 placed a new Fentanyl Patch on RI #9's back. A review of the physician orders [REDACTED]." On 09/04/2013 at 12:30 PM, EI #2, LPN was asked where she documented the area of placement of the Fentanyl patch. EI #2 stated it was not documented. She further stated there was nowhere on the computer system to document. When asked where they document the patch is still in place after it is applied, EI #2 stated there was no place to document it. EI #2 was asked if she had observed RI #9 removing her patch. EI #2 stated when RI #9 was first admitted , she had noticed RI #9 picking at the patch, but not removing it. EI #2 stated they placed the patch where RI #9 can't reach it. The Registered Pharmacist, EI #5 was interviewed on 09/05/2013 at 11:35 AM. EI #5 was asked what the policy was for documenting placement and checking Fentanyl patches. EI #5 stated she wasn't sure and went behind the nurses desk and obtained a policy for the pharmacy for the patches. EI #5 was asked where the nurses documented the placement and checks on the Fentanyl patches. EI #5 stated it was documented on the electronic MAR. EI #5 further stated she had checked the MAR indicated [REDACTED]. EI #5 was asked since the Fentanyl patches were a controlled drug, did she think the placement and checking should be documented. EI #5 stated she did. A review of the MARs for June, July, August and September 2013 revealed only documentation that the patch had been applied every three days (72 hours) as ordered. No documentation was found where the nurse had placed the patch or that the patch had been checked during the 72 hours before a new patch was applied The CNA (Certified Nursing Assistant) EI #4 assigned to bathe RI #9 on 09/05/2013, was interviewed at 12:00 PM. EI #4 was asked if she had seen a patch on RI #9 when she was providing care for her. EI #4 stated she couldn't recall. When asked what she was instructed to do if a patch came off during care, she stated to take it to the nurse. EI #4 was asked if she had observed RI #9 remove or pick at her patch she stated she had not. The DON (Director of Nursing) EI #6 was interviewed on 09/05/2013 at 3:05 PM. When asked what was the facility's policy for documenting placement and checks on the Fentanyl patches were, EI #6 stated they did not have a policy. When asked how they ensured the patches stayed on for the 72 hours, she stated the CNAs and nurses are always in there giving care.

Based on observation, interviews, and record review, the facility failed to ensure that dietary staff knew how to calibrate a thermometer to ensure proper food temperatures. This had the potential to affect all 47 residents receiving food from the dietary department. Findings include: The facility's policy titled: "Calibrating and Sanitizing Thermometers" (not dated), revealed: "PURPOSE: Accurate, clean thermometers should be used for the measurement of food storage, cooking and serving temperatures. STANDARD: Thermometers should be calibrated, as needed, such as after an extreme temperature change, or if a thermometer has been accidentally dropped. PROCESS: I. Calibration: a. Prepare a 50/50 ice and water mixture. Submerge the sensor of the thermometer in the solution until the needle stops moving. Use a small wrench to turn the calibration nut until the thermometer reads 32 degrees Fahrenheit (F), or b. Use the boiling point method by submerging the sensor into boiling water until the needle stops moving. Use a small wrench to turn the calibration nut until the thermometer reads 212 degrees F. ..." The dietary job description for the cooks revealed: "Performance Requirements: 1. Able to read and write English. 2. Willing to train and participate in ongoing staff development programs. 3. Able to prepare and serve food according to menus and recipes provided 4. Understands importance of proper food handling techniques. ..." An observation was made on 08/10/11 at 11:45 AM, of dietary staff taking temperatures of food items. The head cook, Employee Identifier (EI) #7 placed 5 thermometers in foods on the steam table. EI #7 then put the lids on top of the food serving containers. The surveyor asked if this was the way she took temperatures. She said it was and then removed the lids and the thermometers. EI #7 placed the thermometers in a small glass of hot water then placed them back into the food. The food temperatures were: Hamburger meat: 168 degrees F. French fries: 150 degrees. Macaroni and Cheese (pureed): 152 degrees F. Mashed potatoes: 140 degrees. Cold pudding: 40 degrees F. Milk: 34 degrees F. Tuna Salad: 30 degrees F. EI #7 was asked how often she calibrates the thermometers. She replied, "Not sure." EI #7 was asked how she calibrates a thermometer. EI #7 said she puts it in ice water and then calls another dietary worker to help her. EI #8, a dietary aide/cook, approached EI #7 with a gallon pitcher full of ice and cold water. She placed the thermometers in the top of the ice pitcher. EI #8 used some of the thermometers that EI #7 had not used, but were in the same container with other thermometers. She pulled the thermometer up and said, "It's 138 degrees." The surveyor asked what she does now. EI #8 thought for a few moments and said, "I twist it with my bare hands until it reads 30 degrees." The surveyor asked EI #8 to show her how she twists the metal nut on the thermometer. EI #8 tried to twist the metal nut on the thermometer with her hands, but she could hardly move the needle on the thermometer. The surveyor asked EI #8 if she knew what the purpose was of the red plastic holders, which had a wrench on it. EI # 8 said she did not know what they were for, except to place the thermometers in to protect each thermometer. At 12:35 PM, the surveyor informed the Dietary Manager, EI #9, that the cooks did not know how to calibrate a thermometer. She stated she had just done an inservice on "Calibrating and Sanitizing Thermometers." The inservices revealed that on 04/28/11 all dietary staff were trained on the facility procedure for calibrating thermometers. EI #9 said she would be doing another inservice that day. At the supper meal on the same day at 5:45 PM, the night cook, EI #10, was asked to check the temperatures on the steam table. The menu included Tuna Salad Sandwiches, which had a temperature of 37 to 41 degrees F. The cucumber salad was 22 degrees F. Leftover cold chicken was 37 to 43 degrees F. The surveyor asked the cook what the temperature should be. EI #10 said, "thirty-two degrees to forty degrees." The surveyor asked EI #10 what she should do. EI #10, looking perplexed at the surveyor, said, "Re-do it in hot water, no, ice water?" The surveyor asked if she knew how to calibrate a thermometer. EI #10 responded, "No, I don't." Another dietary aide/cook, EI #11, took the thermometer, and using the wrench on the plastic holder, turned the needle down to zero and gave it to the surveyor. In an interview with the Dietary Manager, EI #9, on 08/10/11 at 6:10 PM, she stated she had been in-servicing the staff all day, and could not believe they did not know what to do. EI #9 provided a copy of the inservice that had been provided at 6:30 AM that morning. EI #7 and EI #8 attended that inservice. This inservice was provided prior to the surveyor observing any temperatures.

Based on observation and interviews, the facility failed to ensure controlled medications were securely stored by not having Ativan (a narcotic) stored under two locks. Findings include: On 08/11/2011 at 11:30 AM, the medication room refrigerator was checked for security of controlled medications. During this check there was a box in the refrigerator. The box had a combination lock on it. When the LPN (Licensed Practical Nurse), EI (Employee Identifier) #6, was asked what was in the box, she opened the lid without turning the combination on the lock, revealing it was not actually locked. The box contained 38 vials of Ativan 2 mg (milligram). EI #6 called for the (DON) Director of Nursing (EI #2), and she tried to lock the box and was unable to do so. The DON asked the Pharmacist (EI #5) to come to the medication room. EI #5 attempted unsuccessfully to lock the box. The Ativan was secured under one lock (the medication room door), not two locks as required by federal regulations. On 8/11/11 at 11:35 AM, EI #2 was asked who had placed the unlocked box in the refrigerator. EI #2 stated she had placed it in there the day before. EI #2 was asked who was responsible for checking the controlled drugs in the refrigerator to be sure they are locked under two locks. EI #2 stated that she and the Charge Nurses check them every day. When EI #2 was asked where she had obtained the box, she stated she had gone to the store and bought it the day before. EI #5 was interviewed on 08/11/11 at 11:50 AM. When asked who furnishes the locked boxes for the controlled medications in the refrigerator, he stated the pharmacy does. When asked if he was aware of the new box in the refrigerator, he stated he became aware of it yesterday, but the lock worked then. EI #5 was asked how often he checks the controlled medication in the refrigerator. EI #5 stated that he checks it every month when he does his monthly reviews. A review of the facility's policy, "Pharmacy Operations, Controlled Medications," dated 8-01 revealed: "...Only authorized licensed nursing and pharmacy personnel have access to controlled medications. All controlled substances must be stored behind two (2) locks in a permanently affixed compartment designed soley for controlled medications. The key to the controlled substance container cannot be the same key giving access to other non-controlled medications. ..."

Based on interview and record review, the facility failed to ensure RI (Resident Identifier) #4's medical record was complete and accurate by licensed nurses not documenting the monitoring and results of a laxative given. This affected 1 of 12 sampled residents. Findings include: The facility policy and procedure for "Constipation" (not dated) revealed the following: "Procedure: 1. Residents in the facility will be monitored for constipation. 2. CNA will chart if the resident has or has not had a bowel movement (bm) every shift. 3. Charge Nurse should monitor residents bm pattern as needed or if it is reported that a resident has not had a bm in 3 days. 4. If a resident reports they are constipated or no bm is recorded in the chart, the nurse should administer a laxative as ordered. 5. If no laxative is ordered, consult the standing order book and write the appropriate order for constipation as signed by the resident's doctor. 6. Follow up for results of laxative. 7. Chart results of laxative. 8. If no results, repeat and/or notify MD (Medical Doctor)." RI #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #4's "Admission Nursing Assessment," dated 08/02/11, revealed she was constipated and had not had a BM in eight days. A review of RI #4's MAR (Medication Administration Record) for August 2011 revealed she was given a laxative on 08/02/11 at 4:00 PM. A review of RI #4's "Nurses Notes" from 08/02/11 through 08/05/11 revealed no documentation of how nurses were monitoring RI #4's bowels, what the results of the laxative were, if her bowel sounds were checked, etc. There was also no documentation on the MAR indicated [REDACTED]. The only documentation regarding monitoring RI #4's laxative results was not until 08/05/11 on the ADL (Activities of Daily Living) sheet, which showed she had a BM that day, three days after the laxative was given. On 08/10/11 at 8:01 PM, EI (Employee Identifier) #4, an LPN (Licensed Practical Nurse), was asked if she gave RI #4 a laxative on 08/02/11. She said she did. EI #4 was asked if she reported this to the next shift nurse. She said she did. EI #4 was asked what time she gave the resident her medicine. She said about 5:30 PM. EI #4 explained that she should have documented the actual time it was given; 5:30 PM. EI #4 was asked if she worked the next day. She said she did. EI #4 was asked if RI #4 had a BM that day. She said she did not. EI #4 was asked what she should have done. She said she should have given another laxative or followed the standing orders or called the doctor, but they wanted to give the laxative more time to work, and they did not want to overmedicate her. EI #4 was asked if she informed the next shift that RI #4 had not had a BM yet. She said she did. EI #4 was asked if she monitored RI #4 after giving the laxative. EI #4 said she did; she checked her abdomen and listened for bowel sounds. EI #4 was asked if she documented all this information regarding RI #4. She responded, "No." On 08/10/11 at 8:00 AM, EI #3, an LPN, was asked if she monitored RI #4 for results of the laxative given. She said she did; she asked the resident if she was in pain, listened for bowel sounds, and felt her abdomen. EI #3 was asked if she documented this. She said she wrote "no distress" in the nurses notes. EI #3 was asked why she did not document more specifics with something so important. She said she did not know, but in hindsight she should have documented more specifically.