Every finding on record at Capitol Hill Healthcare Center

Based on observations and staff interviews, it was determined the facility failed to maintain a clean and sanitary environment for five of five residents who received nutrition and hydration via enteral tube feeding (Resident Identifier (RI) #50, RI #115, RI #125, RI #138, and RI #93). Specifically, the facility failed to ensure resident care equipment, walls, floors, window blinds, windows, bed rails and privacy curtains were free from heavy dried splatters of a tan colored substance; and failed to ensure floors were dusted and mopped under overbed tables that were positioned by the walls. The facility's failure had the potential to affect all 193 residents who resided at the facility. Findings include: 1. Observations of RI #50's room, who received nutrition and hydration via a feeding tube and was non-interviewable, on 03/29/21 at 10:30 AM, 03/30/21 at 8:13 AM, 03/31/21 at 8:30 AM, 04/01/21 at 8:00 AM revealed the tube feeding pump and stand, wall, floor, left upper bed rail, and privacy curtain were splattered with heavy amounts of a tan colored substance. Observations also revealed dirt and debris under the overbed table stationed against the wall at the foot of the bed. 2. Observations of RI #115's room, who received nutrition and hydration via a feeding tube and was non-interviewable, on 03/29/21 at 10:31 AM, 03/30/21 at 8:14 AM, 03/31/21 at 8:31 AM, 04/01/21 at 8:01 AM revealed the tube feeding pump and stand, wall, floor, right upper bed rail, window blinds and window, and privacy curtain were all splattered with heavy amounts of a dried tan colored substance. There was also dirt and debris under the two overbed tables stationed against the wall at the foot of the bed. The base of the suction machine and oxygen air flow compressor on the bedside nightstand were dirty and dusty and were also splattered with a dried tan colored substance. 3. Observations of RI #125's room, who received nutrition and hydration via a feeding tube and was non-interviewable, on 03/29/21 at 10:32 AM, 03/30/21 at 8:15 AM, 03/31/21 at 8:32 AM, 04/01/21 at 8:02 AM revealed the tube feeding pump and stand, wall, floor, and left upper bed rail, were splattered with heavy amounts of a tan colored substance. 4. Observations of RI #138's room, who received nutrition and hydration via a feeding tube and was non-interviewable, on 03/29/21 at 10:33 AM, 03/30/21 at 8:16 AM, 03/31/21 at 8:33 AM, 04/01/21 at 8:03 AM revealed the tube feeding pump and stand, privacy curtain, wall, floor, and left upper bed rail, were splattered with heavy amounts of a tan colored substance. 5. Observations of RI #93's room, who received nutrition and hydration via a feeding tube and was non-interviewable, on 03/29/21 at 10:34 AM, 03/30/21 at 8:17 AM, 03/31/21 at 8:34AM, 04/01/21 at 8:04 AM revealed the tube feeding pump and stand, privacy curtain, wall, floor, window blinds, and left upper bed rail, were splattered with heavy amounts of a tan colored substance. On 04/01/21 at 10:29 AM, an interview was conducted with Employee Identifier (EI) #10, a Housekeeper (HK), in the hall on the third floor. EI #10 was asked if she was assigned to the third floor daily. She responded that she was. She was asked to come into RI #115's room with the surveyor. EI #10 was shown the tube feeding pump and stand and was asked if she was responsible for cleaning them. She stated, No. She was shown and asked how often she cleaned the window blinds and bed rails and responded, Every day. She was asked how often and how she cleaned under the overbed tables against the wall. She stated she pulled them away from the wall and cleaned under them every day. On 04/01/21 at 10:59 AM, EI #9, the Housekeeping Manager (HKM), was asked to come to the third floor with the surveyor. We entered RI #115's room where EI #10 had just completed cleaning the window blinds; however, the window was still splattered with a tan colored substance. When asked if the housekeeping staff were responsible for cleaning the tube feeding pumps and stands, EI #9 stated the housekeeping staff were responsible. EI #9 was shown the bed rail with the tan colored substance dried on it and EI #9 stated, that must be from earlier today and scraped at it with her fingernail. EI #9 was shown the privacy curtain and EI #9 stated, Thursdays are when we put up clean privacy curtains. She was asked how often the housekeepers were to clean the tube feeding pumps, stands, walls, bedrails and floors and she stated, daily. EI #9 was also shown the dirt and debris under the overbed tables and asked if the housekeepers were to pull those away from the walls and clean under them and how often. EI #9 stated they should pull them out and clean under them daily. A policy was requested from EI #9 for cleaning resident care equipment and resident rooms at the time of the interview; however, it was not received prior to exit from the facility.

Based on interview, record review and review of a facility policy titled, NURSING MDS (Minimum Data Set) Resident Assessment Instrument, the facility failed to ensure Pressure Ulcers (PU) were accurately identified on RI (Resident Identifier) #30's Quarterly MDS assessment dated [DATE], on RI #58's Quarterly MDS assessment dated [DATE], and on RI #187's Quarterly MDS assessment dated [DATE]. The facility also failed to ensure RI #69's Quarterly MDS assessment date 12/19/18, did not code [MEDICATION NAME] as an anticoagulant medication. These deficient practices affected RI #30, RI #58, RI #69 and RI #187, four of 39 sampled residents whose MDS assessments were reviewed. Findings Include: Review of a facility policy titled, NURSING MDS Resident Assessment Instrument, with a revision date of 10/14, revealed the following: . Policy Explanation and Compliance Guidelines: The facility must conduct initially and periodically a . accurate . assessment of each resident's functional capacity. MDS Completion Process: 1. The MDS Coordinator will facilitate the MDS Team in completing . accurate assessments . 1) RI #30 was admitted to the facility on [DATE], and readmitted on [DATE]. RI #30's (MONTH) 2019 Physician order [REDACTED]. . 10/11/2018 . CLEAN RIGHT TR[NAME]HANTER/RIGHT UPPER OUTER THIGH WOUND . On 02/19/19 at 5:19 p.m., during the initial tour, the surveyor observed a [DEVICE] to RI #30's right hip area. A review of RI #30's Quarterly MDS assessment with an Assessment Reference (ARD) of 12/04/18, did not code RI #30 as having a PU during this assessment period. On 02/21/19 at 5:12 p.m., the surveyor conducted an interview with Employee Identifier (EI) #1, the RN (Registered Nurse) MDS Director. The surveyor asked EI #1 did RI #30 have any PUs. EI #1 said yes. The surveyor asked EI #1, on RI #30's Quarterly MDS assessment, dated 12/04/18, should RI #30 be coded as having a PU. EI #1 said yes. When asked if this was an accurate assessment, EI #1 said no, this was a coding error. 2) RI #58 was admitted to the facility on [DATE], and readmitted on [DATE]. RI #58's (MONTH) 2019 Physician order [REDACTED]. . Stress (Pressure) . Clean left heel and left bunion areas with wound cleanser . A review of RI #58's Quarterly MDS assessment with an ARD of 12/13/18, did not code RI #58 as having a PU during this assessment period. On 02/21/19 at 5:12 p.m., the surveyor conducted an interview with EI #1. The surveyor asked EI #1 did RI #58 have any PUs. EI #1 said yes. The surveyor asked EI #1, on RI #58's Quarterly MDS assessment dated [DATE], should RI #58 be coded as having a PU. EI #1 said yes. When asked if this was an accurate assessment, EI #1 said no, this was a coding error. 3) RI #187 was admitted to the facility on [DATE], and readmitted on [DATE]. RI #187's (MONTH) 2019 Physician order [REDACTED]. . Decubitus Ulcer . Clean left Ischial Tuberosity with wound cleanser . A review of RI #187's Quarterly MDS assessment with an ARD of 01/30/19, did not code RI #187 as having a PU during this assessment period. On 02/21/19 at 5:12 p.m., the surveyor conducted an interview with EI #1. The surveyor asked EI #1 did RI #187 have any PUs. EI #1 said yes. The surveyor asked EI #1, on RI #187's Quarterly MDS assessment dated [DATE], should RI #187 be coded as having a PU. EI #1 said yes. When asked if this was an accurate assessment, EI #1 said no, this was a coding error. 4) RI #69 was admitted to the facility on [DATE], and readmitted on [DATE], with the [DIAGNOSES REDACTED]. RI #69's (MONTH) 2019 Physician order [REDACTED]. . [MEDICATION NAME] Bisulfate ([MEDICATION NAME]) 75 mg (milligrams) Tablet . by mouth daily . RI #69's Quarterly MDS assessment with an ARD of 12/19/18, revealed RI #69 received an anticoagulant medication during this assessment period. On 02/21/19 at 4:05 p.m., the surveyor conducted an interview with EI #1. The surveyor asked EI #1 what anticoagulant RI #69 received when the 12/19/18, MDS was completed. EI #1 said RI #69 was receiving [MEDICATION NAME] which is an anti-platelet. The surveyor asked EI #1 did RI #69 receive an anticoagulant as well. EI #1 said no. EI #1 said the information on the MDS asked for the type anticoagulant not antiplatelet. EI #1 said she got the anticoagulant and antiplatelet mixed up. The surveyor asked EI #1 what was the facility's policy regarding accuracy of the MDS assessments. EI #1 said it was to make sure they were accurate.

Based on observation, interview, review of a facility skills check off sheet for EI (Employee Identifier) #6 LPN (Licensed Practical Nurse), titled BLOOD GLUCOSE MONITORING, review of a facility policy titled Hand Washing, review of a facility policy titled Gloves, and review of a facility policy titled Med (Medication) Pass Tips, the facility failed to ensure EI #6 performed a subcutaneous injection for Resident Identifiers (RI) #72 and #74 and a blood glucose test for RI #72 and #74, in a manner to prevent cross-contamination. EI #6 used the same glucometer to test blood glucose for RI #72 and RI #74 without disinfecting the glucometer before or after use on each resident, and before storage of the glucometer inside the medication cart. After testing blood on RI #72 and RI #74, EI #6 carried the contaminated glucometer and bottle of blood testing strips together in one hand to the medication cart. EI #6 administered a subcutaneous injection to RI #72 without wearing gloves. EI #6 administered an injection to RI #74, removed her gloves, and without washing her hands sat down to talk to RI #74's roommate touching the residents hands and bed. This affected RI #74 one of five residents observed for blood glucose testing, RI #72 and RI #74 two of two residents observed for insulin injections, and one of four nurses observed for glucose testing. Findings Include: A facility skills check off sheet for EI #6 titled BLOOD GLUCOSE MONITORING, dated 12/19/2017 documented the following: . Gathers all equipment needed . Disinfects glucometer after use . Review of a facility Infection Control policy titled Hand Washing with a revision date of 11/28/2016 revealed the following: . Policy: Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other . residents. Review of a facility Infection Control policy titled Gloves with an effective date of 7/10/2003 revealed the following: . Procedure: . 4. Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces, and before going to another resident, and wash hands immediately . Review of a facility Nursing policy titled Med Pass Tips with a revision date of 7/5/2007 revealed the following: . Procedure: . Injection Medication Administration . 5. Apply gloves 6. Identify injection site 7. injection . 8. Wash hands . On 3/28/2018 at 5:12 PM, EI #6 LPN, after checking RI #72's blood sugar, placed the used glucometer onto the medication cart surface and without cleaning it, placed it back into the medication cart drawer for storage. Then, EI #6 washed her hands and without wearing gloves, administered an insulin injection to RI #72, washed her hands and continued medication administration for another resident, while the used glucometer remained inside the medication cart. On 3/28/2018 at 5:40 PM, EI #6 continued with medication administration and for RI #74, carried a bottle of blood testing strips into RI #74's room and used the contaminated glucometer to attempt to check RI #74's blood sugar. There was not enough blood for the test to work and EI #6 removed her gloves. EI #6, without wearing gloves, checked RI #74's middle finger and asked if RI #74 was still bleeding. Without washing her hands, EI #6 returned to the medication cart with the glucometer and the bottle of testing strips to get a new lancet from the cart. EI #6 regloved and tested RI #74's blood sugar, placed the used glucometer on RI #74's overbed table, washed her hands, and carried the bottle of testing strips and the contaminated glucometer together in her bare hand to the medication cart. EI #6 placed the glucometer and test strips together on the medication cart and without cleaning the glucometer placed it back into the drawer of the cart along with the bottle of test strips. EI #6 without washing her hands began to prepare medication from the cart to administer to EI #74. After administering medication to RI #74 (an insulin injection and pills by mouth), EI #6 removed her gloves and without washing her hands touched RI #74's roommate and bed. On 3/28/2018 at 6:21 PM, EI #6 continued on with her medication administration with the used glucometer inside the medication cart. EI #6 was asked when she routinely cleaned the glucometer. EI #6 said, she usually cleaned it after two uses or if blood got on the glucometer. EI #6 stated, she would clean the glucometer before doing another blood test. When asked if that was the facility policy, EI #6 said, she thought the policy was to clean the glucometer after three to five uses. On 3/29/2018 at 3:15 PM, EI #7 RN (Registered Nurse) was asked when glucometers were to be cleaned. EI #7 said, after each use. When asked how he knew glucometers should be cleaned after each use, EI #7 replied, it was the facility policy as long as he could remember to clean after every finger stick. On 3/29/2018 at 4:09 PM, EI #6 LPN, was again interviewed. EI #6 was asked what should be done to prevent cross contamination during injections. EI #6 said, handwashing and glove use. EI #6 said, it was important to wear gloves during injections to prevent cross contamination. EI #6 was asked what should be done to prevent infection during blood testing. EI #6 said, washing hands and wearing gloves. EI #6 was asked why she touched a resident's hand after a finger stick without wearing gloves. EI #6 did not remember. EI #6, when asked why she got another lancet from the medication cart without handwashing after touching RI #74, replied, she was nervous. EI #6 was asked why it was important to wash hands (before and after) and wear gloves for fingersticks and injections. EI #6 replied, to prevent contamination. When asked if it was facility procedure to take the test strip bottle into a resident's room, EI #6 said, no ma'am, just take one. EI #6 said, she should not take the whole bottle in a resident's room due to the risk of contamination. On 3/29/2018 at 4:57 PM, EI #8 Infection Control Nurse, was asked what the policy was for infection control during blood glucose testing. EI #8 said, to follow the policy for sanitizing the glucometer in between patients. When asked what the potential harm was in not cleaning between residents, EI #8 replied, the next resident was put at risk for infection. EI #8 was asked what the policy was for infection control during blood glucose testing and injections. EI #8 said, to wash hands, wear gloves, gather equipment, sanitize the glucometer, wash hands before leaving the room, and use a barrier for supplies. EI #8 was asked why a nurse would administer an injection bare handed. EI #8 said, she did not know why. EI #8 said the potential harm for the resident if a nurse gave a bare handed injection was that the nurses hands might be contaminated. EI #8 said, the nurse should shake out one test strip and use the tray or barrier. When asked why the bottle should not be taken into a room, EI #8 said, cross contamination was the risk.

Based on a review of the facility's Minimum Data Set (MDS) assessments, Nurse's Notes and an interview with a MDS Coordinator, the facility failed to accurately code Resident Identifier (RI) #8's lower extremities for range of motion (ROM) on the 11/28/2016 MDS. The facility also failed to accurately code RI #9's MDS for falls on 10/04/2016, 11/09/2016, and 02/01/2017. This affected two of 27 residents for whom the MDS's were reviewed. Findings include: 1. RI #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Significant Change MDS with an assessment reference date (ARD) of 11/28/2016, revealed RI #8 had no limitation to either the right or left lower extremities. When reviewing section G for Functional Limitations in Range of Motion, this section was marked 0 indicating the resident had no impairment. On 02/09/2017 at 10:40 AM, RI #8 was observed in the activity room sitting in a geri chair with a blue device around the resident's left knee. On 02/09/2017 at 10:45 AM, Employee Identifier (EI) #3 was asked what the blue device was that RI #8 had around his/her left knee. EI #3 replied it was a device to keep the knee from contracting any further. EI #3 was asked if she would say that RI #8 had decreased ROM to his/her left leg EI #3 replied, Yes. EI #3 stated the resident was followed by Occupational Therapy from 9/13/2016 until 11/15/2016, then was discharged to Restorative Therapy. 2. RI #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the following MDS's, dated: 09/27/2016, 11/08/2016, and 01/27/2017, section J (Health Conditions), each indicated the resident had no falls since Admission/Entry or Reentry into the facility. A review of the Nurse's Notes dated 09/07/2016, revealed RI #9 had been observed on the floor in his/her room at 8:00 PM in a seated position. The Nurse's Notes dated 11/12/2016, at 1:11 PM revealed the resident had been observed on the floor at 10:30 AM with no apparent injuries. On 12/09/2016 at 2:23 PM, the nurses documented the resident was on the floor in his/her room at 12:10 PM with no apparent injuries. On 12/15/2016 at 10:36 PM, the Nurse's Notes indicated the resident was observed on the floor in the hallway with no apparent injuries. The Nurse's Notes dated 1/21/2017 at 10:32 PM, revealed the resident was again found on the floor in the day room area with no apparent injuries. The MDS Coordinator, EI #4, was interviewed on 02/08/17 at 4:30 PM. EI #4 was asked if falls should have been reflected on each of the resident's above MDS's. EI #8 replied, Yes.

Based on a review of the facility's Infection Control policy and Minimum Data Set (MDS) assessments, as well as two of two observations of incontinence care and interviews with nursing staff, the facility failed to ensure two Certified Nursing Assistants (CNA) washed their hands and changed their gloves prior to retrieval and application of barrier ointment and application of a clean brief to Resident Identifier (RI) #8 and RI #14. This affected two of two residents observed during the provision of incontinence care. Findings Include: A facility policy with a revision date of 11/28/2016, titled: INFECTION CONTROL . Hand washing revealed: Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection . Infection Control Protocol and Safety: 1) Wash your hands thoroughly with soap and water . d) When changing/removing gloves . 1) RI #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the MDS dated [DATE], revealed RI #8 was cognitively impaired and was incontinent of bowel and bladder. On 02/07/17, at 3:40 PM, a CNA, EI #2, was observed to enter RI #8's room and check him/her for incontinence. EI #2 said the resident was soaked and needed incontinence care. During the provision of incontinent care, EI #2 placed clean gloves on and applied moisture barrier to the resident's buttock and rectal area. Without changing her gloves, EI #2 continued to place the incontinent pad and the brief under the resident. EI #2 closed the brief, positioned the resident in bed and covered him/her with a sheet before removing the gloves she had worn to apply the moisture barrier to the resident's buttock and rectal area. EI #2 was interviewed on 02/07/2017 at 4:30 PM, she was asked what was the facility policy on changing gloves when applying moisture barrier to a resident's buttocks. EI #2 replied she was supposed to change her gloves before and after applying the moisture barrier. The Licensed Practical Nurse (LPN), EI #3, was interviewed on 02/09/2017 at 3:15 PM. EI #3 was asked when were CNAs supposed to wash their hands during incontinent care. EI #3 explained CNAs wash hands, put on gloves and provide the care. EI #3 said they then remove their gloves and wash their hands. The surveyor told EI #3 that EI #2 had provided incontinence care, removed her gloves, washed her hands and put on clean gloves. The surveyor told EI #3 that EI #2 applied moisture barrier cream to RI #8's buttocks then placed a clean underpad and brief under RI #8 without changing her gloves. EI #3 was asked if EI#2 should have changed her gloves. EI #3 replied Yes. 2) RI #14 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A Quarterly MDS with an Assessment Reference Date (ARD) of 12/27/2016, revealed RI #14 was totally dependent on staff for personal hygiene, and was always incontinent of bladder function. On 02/08/2017 at 9:10 AM, EI #1 was observed performing incontinent care for RI #14. After incontinent care was provided and prior to drying the perineal area, EI #1 failed to wash her hands after she removed her soiled gloves and donned new gloves. EI #1 reached into the top drawer of RI #14's bedside table and retrieved barrier ointment. EI #1 placed the ointment onto her left hand, rubbed her hands together and then rubbed the ointment onto RI #14's buttocks. EI #1 then placed the ointment back into RI #14's bedside table. EI #1 picked up a clean brief, placed it under RI #14 and secured it. EI #1 pulled the sheet and blanket over RI #14's chest without changing her gloves or washing her hands. On 02/09/2017 at 10:25 AM an interview was conducted with EI #1. EI #1 was asked what was the facility's policy regarding hand washing during incontinent care. EI #1 said hands should be washed when touching a resident and when gloves were dirty or changed. EI #1 was asked did she wash her hands or change her gloves after performing incontinent care and before she reached into the bedside drawer for the barrier ointment. EI #1 said no. EI #1 was asked did she wash her hands or change her gloves after performing incontinent care and before she placed the ointment back into the drawer. EI #1 said no. EI #1 was asked did she wash her hands or change her gloves after performing incontinent care and before she touched and placed the clean brief on RI #14. EI #1 said no. EI #1 was asked why she did not change her gloves and wash her hands. EI #1 responded, I knew I should have, I was nervous. EI #1 was asked what was the potential harm to a resident when gloves were not changed and hands were not washed. EI #1 said bacteria.

Based on observation, interview and record review the facility failed to ensure the following: 1. Staff did not handle a clean brief after providing incontinent care with the same soiled gloves to Resident Identifier (RI) #8; 2. Staff did not place soiled items on the floor after providing incontinent care to RI #8; 3. Staff failed to remove contaminated gloves before touching clean items on RI #16. This was observed on 1/5/16 during incontinent care and; 4. Licensed staff did not touch clean items with soiled gloves after providing wound care on RI #10, this was observed on 1/6/16. This affected 2 of 2 residents observed for incontinent care and 1 of 2 observations of wound care. Findings Include: 1 & 2. A review of a facility policy Perineal Care with an effective date 12/19/07 revealed .Purpose The purpose .are to provide cleanliness ., to prevent infections .Steps in the Procedure .11) Discard disposable items into designated containers. 12) Remove gloves and discard into designated container. Wash and dry your hands thoroughly. 13) Reposition bed covers . RI #9 was readmitted to the facility 07/08/2015 with [DIAGNOSES REDACTED]. On 1/5/16 at 5:00 PM Employee Identifier (EI) # 4, Certified Nursing Assistant (CNA) was observed performing incontinent care to RI #9. EI #4 cleaned the resident then rolled the soiled brief up and placed a clean brief. EI #4 then took the soiled rolled brief from under the resident and placed it on the floor. EI #4 placed the clean brief with the same soiled gloves, then positioned the bed covers. On 1/5/16 at 5:15 PM an interview was conducted with EI #4. EI #4 was asked when should she change gloves during incontinent care. EI #4 replied after cleaning bowel movement, before putting on the clean brief. EI #4 was asked what was the harm in touching the clean brief with soiled gloves. EI #4 replied infection and germs. EI #4 was asked where should she place the soiled items, she replied in a bag. EI #4 was asked if she should place soiled items on the floor, she replied no. EI #4 was asked what was the potential for harm in laying items on the floor. EI #4 replied it was unsanitary. On 1/7/16 at 11:15 AM an interview was conducted with EI #1 Director of Nursing. EI #1 was asked if staff should place a soiled brief on the floor of a residents room. EI #1 replied, we teach them to bag soiled items and not to place them on the floor. EI #1 was asked what should staff do with a soiled brief, she replied place it in a bag. A facility policy number 40-100-03 titled Perineal Care with an Effective Date of 12/19/07 documented .Purpose The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition .Infection Control Protocol and Safety 1) Wash your hands thoroughly with soap and water at the following intervals as indicated: a) Before the procedure; .c) Anytime they become soiled with blood or body fluids;d) When changing/removing gloves . 3) Maintain clean technique and isolation precautions as indicated. A facility policy number 50-50-13 titled Hand washing with an Effective date of 7/10/03 documented POLICY: Hand washing shall be regarded by this facility as the single most important means of preventing the spread of infections. Policy Interpretation and Implementation: 1) All personnel shall follow our established hand washing procedures to prevent the spread of infection and disease to other personnel, patients, and visitors. 2) Employees must perform appropriate twenty seconds (20) hand washing procedures under the following conditions: .f) After contact with blood, body fluids, excretions, secretions, mucous membranes, or nonintact skin; g) After handling items potentially contaminated with blood, body fluids, excretions, or secretions; i) After removing gloves; . 3. RI #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS) with an Assessment Reference Date of 11/09/15, indicated he/she has short and long term memory problems. He/she was totally dependant on staff for toilet use and personal hygiene. He/she was always incontinent of bowel and bladder. During an observation of perineal care for Resident Identifier (RI) #16 on 1/5/16 at 3:00 PM Employee Identifier (EI) #2, Certified Nursing Assistant (CNA) held the resident's labia open with her left gloved hand while providing care with her right gloved hand. EI #2 removed the left gloved hand from the labia and failed to remove her glove and wash her hands before touching the clean washcloths and towels. EI #2 further failed to remove her soiled gloves before applying RI #16's clean brief and clothing. An interview was conducted with EI #2 on 1/5/16 at 3:50 PM she was asked why she removed her gloved hand from RI #16's opened labia while providing perineal care. She EI #2 Well I'm left handed and I let go to get my rinse washcloth and towel to dry. EI #2 was asked should she have changed her gloves. EI #2 stated yes. She was asked should she have changed her gloves and washed her hands after she had cleaned and rinsed RI #16's hips and perineal area before touching clean items. EI #2 stated yes. EI # 2 was asked what the potential for harm was if she touched clean items with dirty gloves. EI #2 stated contamination and infection for the resident. An interview was conducted with EI #3 Licensed Practical Nurse Manager on 1/5/16 at 3:53 PM she was asked what care she had observed for RI #16. She stated peri-care. EI #3 was asked what she observed EI #2 doing wrong during the care. EI #3 stated cross contamination twice. EI #3 was asked what the potential for harm was if soiled gloves are used to touch clean items. She stated infection. EI #3 was asked what the potential for harm would be if EI #3 did not change her gloves and wash her hands before applying A&D Ointment after cleaning RI #16's labia/perineal area and touching the clean brief and clothing. EI #3 stated infection and cross contamination. An interview was conducted with EI #1 the Director of Nursing on 01/07/16 at 1:15 PM she was asked what type of infections the facility was currently monitoring. EI #1 included urinary tract infections. EI #1 was asked what the staff performing perineal care for a female resident should do before touching clean items after holding the labia open. She stated remove her gloves and wash her hands. EI #1 was asked what the potential for harm was if staff touched clean items with soiled gloves. EI #1 stated contamination. 4. RI #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Nursing Policy and Procedure for Wound Care revealed: .9. Discard disposable items into the designated container. Discard all soiled laundry, linen, towels, and washcloths into the soiled laundry container. Remove disposable gloves and discard into designated container Wash and dry your hands thoroughly, 10) Reposition the bed covers. Make resident comfortable . 11.)Wash and dry hands thoroughly. On 1/6/2016 at 8:30 AM, wound care was observed as it was provided by EI #5, one of the designated wound nurses. After the dressing had been removed and EI #5 used the clean gloved hands to assist RI #10 to turn to the right side by placing both hands on the buttocks. EI #5 then proceeded to measure the wound without washing hands or changing gloves. After wound care was completed EI #5 put the adult brief in place, gathered the dirty supplies then repositioned the residents legs and linen (covers) with gloved hands. EI # 5 continued to wear the contaminated gloves as she removed the trash out of the room where she touched to the door turned out the light and took all the dirty trash to the receptacles attached to the wound care cart. On 1/6/2016 at 5:10 PM when EI #5 was asked if her gloved hands were considered to be clean or dirty after both hands were used to position a resident. EI #5 stated they were dirty. When asked what was the harm, EI #5 stated it was a contaminated dressing change. On 1/7/2016 at 11:15AM an interview was conducted with EI # 1, Director of Nursing. EI # 1 was asked what was the potential for harm if staff touched clean items with soiled gloves. EI # 1 replied contamination.

Based on observation interview and record review the facility failed to ensure staff performed incontinent care to Resident Identifier (RI) #9 by wiping away from the urinary meatus. This was observed on 1/5/16 and affected one of two residents observed for incontinent care. Findings Include: A review of a facility policy Perineal Care with a effective date of 12/19/07 revealed .Steps in the Procedure .10) For a male resident: .b) Wash perineal area starting with the urethra and working outward . RI #9 was readmitted to the facility 07/08/2015 with a [DIAGNOSES REDACTED]. A review of a most recent Quarterly Minimum Data Set with an Assessment Reference Date of 10/20/15 revealed RI #9 total dependence on staff for toilet needs. On 1/5/16 at 5:00 PM Employee Identifier (EI) #4, Certified Nursing Assistant (CNA) was observed providing incontinent care for RI #9. EI #4 washed her hands and put on gloves, she then removed RI #9's brief. EI #4 wiped from the pubic area towards the urinary meatus three separate times changing wipes each time. On 1/5/16 at 5:15 PM an interview was conducted with EI #4. EI #4 was asked how was she trained to wipe during incontinent care. EI #4 replied up, away and in a circle around the penis. EI #4 was asked how did she wipe, she replied down towards the tip. EI #4 was asked what was the harm in wiping towards the tip of the penis or opening. EI #4 replied it could cause infection.

Based on record review and interview, the facility failed to ensure Resident Identifier (RI) #1's diet orders from the local hospital to the nursing facility were completely transcribed on admission. The instruction to feed the resident carefully was not transcribed. This affected RI #1, one of three residents sampled. Findings include: RI #1 was admitted to the facility on [DATE] from a local hospital. The local hospital's discharge orders dated 12/26/2014 indicated RI #1's diet as "... Pureed Diet (with Thick nectar liquid). Please feed carefully ... ." RI #1's admission physician's orders [REDACTED]. Diet orders: Pureed (with) nectar thick liquids ... ." In an interview on 01/08/2015 at 11:00 AM, Employer Identifier (EI) #1, the Admission Licensed Practical Nurse, was asked why RI #1's admission order did not state "please feed carefully". EI #1 said she did not put it on there. EI #1 was asked why she did not put it on the orders and she stated she did not know why. When asked what was the harm in not completely transcribing orders as the doctor writes them, EI #1 stated it could cause harm to the resident. This deficiency was cited as a result of the investigation of complaint/report number AL 529.

Based on observation, interview, and review of facility policy, the facility failed to ensure Employee Identifier (EI) #1, a male cook, wore a beard cover to contain his facial hair while preparing the 12/10/2014 supper meal in an attempt to prevent potential physical contamination of food. This had the potential to affect all 191 residents receiving meals from the dietary department. Findings Include: Review of the facility's policy titled "DIETARY Sanitation Personal Cleanliness and Standards for Sanitation", effective 07/10/2003, revealed the following: "...Policy: Seven out of ten poisonings caused by pathogens are due to poor hygiene of food handlers. Dietary personnel shall follow sanitary standards. Procedure: ... 4) Hair restraints should be worn at all times..." Review of the Food and Drug Administration Food Code 2013, Chapter 2 Management and Personnel, revealed the following: "... Hair Restraints 2-402.11 Effectiveness. (A) ... FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD..." During trayline observations on 12/10/2014 beginning at 4:00 PM, EI #1, a cook, was observed to have facial hair not contained by a beard cover while preparing salads as well as cooking multiple other food items in preparation of the supper meal. EI #1 was also noted placing items on the steam table and serving food items onto resident trays while not wearing a beard cover. EI #2, the Dietary Manager, was interviewed on 12/11/2014 at 7:20 AM. When asked what the facility's policy was regarding male staff with facial hair, EI #2 explained male staff with facial hair should wear beard covers anytime food could become potentially contaminated.

Based on observations, interview and record review the facility failed to ensure the call button was always in reach of residents for use. This affected Resident Identifier (RI) #3 and #19, two of 27 sampled residents. Findings include: The facility's policy titled: "Nursing Miscellaneous Call Light, Answering, effective date 05/01/03, number 40-240-01" was reviewed. The purpose documented was, "The purpose of this procedure is to respond to the resident's request and needs." The key procedural points listed included, "... 5) When the resident is in the bed or confined to a chair be sure the call light is accessible. ..." 1) RI #3 was last admitted to the facility on [DATE]. RI #3's [DIAGNOSES REDACTED]. Review of the current Quarterly Minimum Data Set (MDS) assessment, dated 10/27/2014 identified the resident with a "12" out of a possible 15, indicating the resident's cognition was intact. RI #3 was also identified as needing limited assistance to being totally dependent on staff with activity of daily living (ADL). RI #3 was listed as having upper and lower extremity impairment. Review of RI #3's careplans revealed a problem, dated 05/20/2014, for "ADLs/Functional):Self Care Deficit. Needs some assistance with ADLs." Approaches listed included: "05/20/2014 Nurse Aide - Call button in reach." On 12/09/2014 at 10:00 AM, during the initial tour of the facility, an observation was made of RI #3's room. The resident was complaining of pain in the legs. The surveyor looked for the call button and observed the button clipped to the sheet on the resident's left side up at the top of the mattress. RI #3 said the call button could not be reached. RI #3 was asked if the resident could use the call button. The resident replied, yes but the call button could not be reached. On 12/10/2014 at 8:35 AM, the call button was observed under a wedge that was placed behind the resident's back on the left side. 2) RI #19 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. RI #19's recent Quarterly MDS, dated [DATE], identified the resident as being understood in expressing ideas and wants, as well as understanding verbal content of others. The MDS also identified the resident as requiring extensive assistance to total dependence on staff with activity of daily living skills. The MDS identified the resident with having no impairment of upper extremity. Review of RI #19's careplans revealed the problem of "ADLs/ Functional Self Care Deficit, Needs some assistance with ADLs." An approach included, "07/01/2014 Nurse Aide - Call button in reach." On 12/09/2014 at 10:30 AM, during the initial tour of the facility, an observation was made of RI #19's room. RI #19 was lying in the bed. RI #19 was asked if the resident was able to use the call button. The resident nodded yes. The surveyor looked for the call button and did not see it. The surveyor asked out loud where the call button was, at which time the resident looked around. The call button was then observed lying on the floor at the head of the resident's bed out of reach. Review of the nurses notes dated 09/26/2014 at 2:51PM did reveal RI #19 was able to use the call button, as evidence by, "Resident has been putting on call light all day,..."

Based on observation, interview, and record review, the facility failed to ensure RI (Resident Identifier) #10's O2 (oxygen) concentrator was free of substance and debris. The facility also failed to ensure the O2 tubing was labeled and stored off of the floor. This was observed on two of three days of the survey. This affected one of two residents sampled for oxygen therapy. Findings Include: A review of the facility's policy and procedure: "Oxygen Administration" with a revision date of 07/25/07 revealed: "...The purpose of this procedure is to provide guidelines when performing this procedure:.. Supplies 1) Change tubing once a week..." A review of the facility's policy and procedure: "INFECTION CONTROL'' with an effective date of 07/10/03 revealed: "...b) Maintain a safe, sanitary, and comfortable environment for...residents..." RI #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #10's Quarterly Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating cognitively intact skills for daily decision-making. RI #10's MDS further revealed Oxygen Therapy was performed. A review of RI #10's physician orders [REDACTED]...01/22/14 Administer oxygen 2.0 liter/min(ute) (per nasal cannula) as needed...AM PM (for shortness of breath)..." On 01/22/14 during the initial tour at 10:50 AM, an observation was made of RI #10's O2 concentrator. The tubing and nasal cannula (n/c) were lying on the floor with no label or date. The O2 machine was soiled with particles and substance, yellow/brown in color, running down the front of the machine. On 01/22/14 at 3:50 PM, RI #10's O2 concentrator remained soiled as previously described. RI #10 was wearing O2 tubing that was not labeled or dated. On 01/23/14 at 7:50 AM (during a breakfast observation) RI #10's O2 concentrator remained soiled with particles, and the yellow/brown colored substance on the front of the machine. RI #10's O2 tubing (in use) was not labeled or dated. On 01/23/14 at 9:05 AM, RI #10's O2 concentrator remained soiled. The O2 tubing worn by RI #10, was not labeled or dated. On 01/23/14 at 11:50 AM, RI #10's O2 concentrator remained soiled with particles and the yellow/brown substance that was running down the front of the machine. The O2 tubing and n/c was contained inside a clear bag and placed on top of the concentrator, with no label and no date. On 01/24/14 at 11 AM, an interview was conducted with Employee Identifier (EI) #2, a Licensed Practical Nurse (LPN). EI #2 was asked how often the O2 concentrators were cleaned. EI #2 stated they were cleaned on Sundays. EI #2 was asked if RI #10's O2 concentrator was clean. EI #2 stated, "No." EI #2 was asked what was the substance on the front of the machine. EI #2 replied she did not know. EI #2 was asked what the potential for harm was in using a soiled O2 concentrator. EI #2 stated, "Just the looks." EI #2 was asked how often the tubing was changed for O2 concentrators. EI #2 stated, "Routine is changed on Sundays, PRN (as needed) is just placed in the room as needed." EI #2 was asked should the O2 tubing be labeled with the date it was placed on the machine. EI #2 stated, yes, it should be written on the tubing with a black marker. EI #2 was asked why RI #10's O2 tubing did not have a label and a date when it had been placed on the machine. EI #2 stated that RI #10's O2 was PRN. EI #2 was asked if RI #10's O2 tubing was the same tubing that was observed on the floor on 01/22/14. EI #2 stated that it was probably the same tubing. EI #2 was asked what was the potential for harm in using O2 tubing that had been on the floor. EI #2 stated, "infection control." EI #2 was asked what was the potential for harm in using O2 tubing that was not labeled. EI # 2 replied, "Don't know how long it has been there." An interview was conducted on 01/24/14 at 11:15 AM with EI #1, the Director of Nursing. EI #1 was asked how often were O2 concentrators cleaned. EI #1 stated they were cleaned per schedule. EI #1 was asked how often was O2 tubing changed. EI #1 stated it was changed weekly. EI #1 was asked if O2 tubing should have a date and label. EI #1 stated, yes it should. EI #1 was asked what the potential for harm was in using O2 tubing that had not been labeled. EI #1 explained if it was PRN, it may not have been used. EI #1 was asked what was the potential for harm in using O2 tubing that had been on the floor. EI #1 stated, "Potential for infection if the nasal cannula was on the floor." EI #1 was asked if O2 tubing had no label how would the nurse know if it was the same tubing that had been on the floor. EI #1 stated she would ask the nurse that changed the tubing out. EI #1 was asked what was the potential for harm in using a soiled concentrator. EI #1 stated, there was no harm.

Based on observation, interview and record review, the facility failed to ensure a Certified Nursing Assistant (CNA) washed her hands after providing incontinent care for RI (Resident Identifier) #4. This affected one of two residents observed during incontinent care. Findings Include: A review of the facility's policy and procedure: "INFECTION CONTROL...Hand washing..." with an effective date of 07/10/03 revealed "...Hand washing shall be regarded by this facility as the single most important means of preventing the spread of infections. ...2) Employees must perform appropriate...handwashing. ...g) After handling items potentially contaminated with blood, body fluids...secretions..." RI #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Acute Renal Failure, Convulsions, Urinary Retention, and Cerebral Artery Occlusion with Cerebral Infarction. A review of RI #4's Quarterly MDS (Minimum Data Set) revealed this resident had severely impaired cognitive skills for daily decision making. RI #4's MDS further revealed incontinence of bowel and an indwelling catheter. On 01/23/14 at 3:25 PM, the CNA, Employee Identifier (EI) #3 was observed providing incontinent care for RI #4. EI #3 cleaned the resident of bowel movement, and without washing hands or changing gloves, she opened a new brief and applied cream to RI #4's buttocks. EI #3 was further observed during catheter care for RI #4. EI #3 fastened RI #4's clean brief without washing hands or changing gloves after completing catheter care. An interview was conducted with EI #3 on 01/23/14 at 3:55 PM. EI #3 was asked when should she wash her hands. EI #3 stated, she should wash her hands before care and between care. EI #3 was asked why did she not wash her hands before putting on the clean brief. EI #3 stated that she forgot. EI # 3 was asked if she should have washed her hands before she fastened the new brief. EI #3 stated, "Yes." EI #3 was asked what was the potential for harm in not washing her hands after incontinent care. EI #3 stated, "Infection." An interview was conducted with the Director of Nursing (EI #1) on 01/24/14 at 11:15 AM. EI #1 was asked when should staff wash their hands. EI #1 stated before entering a room and whenever they change or remove gloves. EI #1 was asked should the staff wash their hands after providing incontinent care and catheter care, and before touching clean items while wearing the same gloves, such as a clean brief or applying cream to the perineal area. EI #1 stated, "Yes." EI #1 was asked what was the potential for harm in staff not washing their hands after incontinent care and wearing the same gloves to provide further care such as applying a brief and applying cream to the perineal area. EI #1 stated that if the gloves were visibly soiled, there would be a potential for the spread of infection.

Based on observations, interviews and record reviews the facility failed to ensure resident rooms and bathrooms were maintained in a comfortable and sanitary manner. This affected Room Locator (RL) #1-24 on four of seven units in the facility. Findings include: The job description for the "Director of Maintenance" (not dated) revealed: "...The primary purpose of your job position is to plan, organize, develop, and direct the overall operation of the Maintenance Department in accordance with current federal, state and local standards, guidelines, and regulations governing our facility, and as may be directed by the Administrator, to assure that our facility is maintained in a safe and comfortable manner... Personnel Functions ...Make daily rounds to assure that maintenance personnel are performing required duties and to assure that appropriate maintenance procedures are being rendered to meet the needs of the facility. ... Ensure that supplies, equipment, etc. are maintained to provide a safe and comfortable environment. Promptly report equipment of facility damage to the Administrator. ... Make periodic rounds to check equipment and to assure that necessary equipment is available and working properly. ... Maintain inventory and records according to established policies. ..." The job description of the "Maintenance Assistant" revealed: "...Maintain general plant and facility in good repair, ensuring a safe, clean and orderly environment. ... Ensure that the facility and its equipment is properly maintained for resident comfort and convenience. ...Ensure that equipment is cleaned and properly stored at the end of the shift. ... Perform routine maintenance and repair on the facility and equipment to include plumbing, plastering, electrical, carpentry, mechanical, etc., as directed in accordance with established procedures ...and perform cleaning duties wherever necessary. Service heating and cooling units/systems..." On 01/24/14, during the initial tour of the facility at 10:00 AM, the surveyors observed the following: Room Locator (RL) #20 - The room smelled of urine, the mattress on the A bed had three large (2 feet by 2 feet) yellow stains, and the floor tile by the window and air conditioner was broken. RL # 21 - The commode tank lid did not fit securely over the tank, the bowl of the hand sink was scratched and was dirty, and the wall plate over the call light was soiled with reddish-brown rust spots and a dark dried substance. RL #22 - Six ceiling tiles were water stained, brownish yellow in color, with a dirty appearance; two ceiling tiles had large (2 ft x 1 ft or more) water stains. Behind the wall base boards in the room, were holes. The air conditioning/heating unit was missing one filter; the other filter was covered with a layer of thick, gray, dust-like residue. RL #23 - The wall behind the head of the bed was scratched; some of these horizontal scratches were two to three feet in length. The bathroom door frames were significantly scratched, with rust and damage on the bottom. The bathroom doors were significantly scratched; the interior side of the doors had dark brown stains. Three ceiling tiles had brown stains on them. RL #24 - The interior side of the bathroom door had a hole in the mid-section. White spackling had been previously placed in the hole, but it still had some depth to the hole. The commode bowl was stained. The wall had not been repaired/painted where a soap dispenser had previously hung. RL #1- The front cover of the air-conditioner/heater was off and observed lying on top of the unit. The wall under the resident's T.V. had brown spots on it. RL #2- The air-conditioner/heater vent was not attached to the unit. A brown substance was observed in the vents. The bathroom sink had a visible crack in the plaster around the top and sides of the sink. The tank lid was not securely attached to the toilet. RL #3- The tank lid was not secure on the tank of the toilet. The ceiling tiles had brown spots on them. RL #4- The air conditioner (A/C) vent was loose and there was no cover over the control area (it was lying on top of the A/C unit). The bathroom sink had a crack in the plaster/putty around the sink. The tank lid was loose on the commode. RL #5- The front of the A/C unit was not attached. The surveyor was able to see outside through a crack on the right side of the unit and cold air was coming into the room through the crack. RL #6- The A/C had a broken vent. The A/C had debris inside the vent. RL #7- The A/C had debris observed behind the screen in the front of the unit. RL #8- The A/C vent had debris observed in the screen. RL #9- The A/C vent had debris in it. The bathroom ceiling tile over the toilet had a large brown stain and was bulging down in the middle. The toilet had a black substance around the rim inside the toilet bowl. The vent cover over the bathroom light had a "rust like" substance on it. RL #10- The bathroom ceiling tiles were brown and the frames around them had a "rust like" substance on them. The toilet seat had a yellow stain in the back of the toilet bowl under the rim that lead down to the hole in the center of the toilet. RL #11 - The front vent cover of the heater had a large accumulation of gray, dust-like residue. RL #12 - The vent cover of the heater had a large accumulation of light brown residue. The ceiling vent in the bathroom was rusted. Inside the bathroom sink there was a light brown stain by the drain. RL #13 - The heater contained light brown residue and dust-like residue. The bathroom ceiling vent contained a brown, rust-like residue. RL #14 - The heater had numerous particles including a screw inside the top vent. There was also broken slats on the front of the heater. RL #15 - The heater contained a large accumulation of light brown residue. There was also a large accumulation of brown and black residue and particles inside the top vent. RL #16 - The wall plate around the shower faucet handle contained a build-up of white residue. The white metal rack that stored a pump bottle of skin and hair cleanser had soap all over the metal holder. Rl #17 - The inside of the trash can in the bathroom contained a large amount of brown residue. There was also soap on the wall about two feet in length where it had dripped down the wall and created a puddle on the floor. The ceiling vent was rusted. RL #18 - There was a brown stain on a ceiling tile in the bathroom by the water sprinkler approximately 16 inches by twelve inches. The cover over the night light was not securely attached to the wall. The heater in the bedroom contained numerous particles inside the top vent. RL #19 - The ceiling vent and the toilet paper holder in the bathroom were rusted. On 01/24/14 at 10:35 AM, the Life Safety Director/Director of Maintenance, Laundry, Housekeeping and Security, EI (Employee Identifier) #5, was asked who was responsible for cleaning the heater vents. He said every Tuesday the department heads do rounds and they write down things that need to be done. EI #5 said one of his guys cleans the heaters and the next Tuesday the department heads check to make sure it was done. EI #5 was asked when the heaters were last cleaned. He said they were not cleaned on a routine schedule, but only as needed. EI #5 explained that maintenance takes each heater outside twice a year to clean them. EI #5 was asked if they keep the forms that the rounds are documented on. He said they did not. EI #5 showed a blank copy of a "Maintenance QA Checklist." EI #5 was asked what "Vents" meant. He said any vent in the room, the bathroom, and the AC vents. EI #5 was asked who was responsible for cleaning ceiling vents in the bathrooms. He said housekeeping. EI #5 was asked how often. He said they should check it every time they clean the bathroom, and they should clean everything in it. EI #5 was asked when the last twice-a-year cleaning of the heaters was done. He said last September or October. EI #5 was asked if that was documented. He said it was not. On 01/24/14 at 1:15 PM, the surveyor showed EI #5 the concerns in each room locator. In RL #11, the surveyor wiped the heater vent with her finger and gray, dust-like residue came off. In RL #12, EI #5 was asked if the ceiling vent in the bathroom contained rust. He said it did. EI #5 was asked what he does about that. He said they spray paint it. EI #5 was asked if that was something that should be seen on rounds. He said it it should. In RL #16, EI #5 was asked what the white residue was on the shower faucet plate. He said oxidation from hard water. He said housekeeping should clean the soap off the metal soap holder daily when they clean the bathroom. In RL #17, EI #5 was asked if he was aware of the stain in the sink. He said he was not, but it would come up with some acid. The soap was still on the wall and floor.

Based on observations, interviews, and document review, the facility failed to maintain the laundry room in a sanitary manner. This was observed on two of three days of the survey. Findings include: On 01/22/14 at 3:27 PM, in the room where the washing machines were located in the laundry area, the following was observed: 1. A blanket was lying on the floor, in between the wall and the right washer. 2. Another blanket was on the floor behind the right washer, touching the bottom and back of the washer. 3. An extremely large accumulation of dust-like residue was on the tops of the four washers, all the connection tubes and wires. 4. A plastic soda bottle littered the floor in between two washers. 5. A large piece of plastic pipe littered the floor behind the washers. 6. A piece of clear plastic wrapping was also on the floor behind the washers. The room with the four dryers was also observed. There was an accumulation of lint underneath and all around and down below, inside the right dryer. (This was not including the lint trap). On 01/22/14 at 4:00 PM, the technician from the chemical company was asked what the large piece of plastic pipe was. He said it was a broken electric valve that had been replaced. The technician was asked if it was realistic for the facility to clean off the dust and pick up the debris in the washer area. He said they could not eliminate it, but could keep it under control. The technician explained that the washer area was not an area with an ignition, but the lint in the dryers has a potential for fire because of the heat that is generated. On 01/23/14 at 7:58 AM, one of the laundry aides, EI (Employee Identifier) #4 was asked to remove the lint trap completely from the right dryer. Inside the area underneath the dryer was a large accumulation of lint all around, especially in the corners. The lint build-up was also on the electrical wires. EI #4 said they only clean the lint trap, and only every now and then clean underneath the inside. She said 90 percent of the time the maintenance workers clean the underneath/inside part of the dryer. EI #4 was asked why it was important to keep the lint cleaned out. She said it was a fire hazard and it was to keep the machines working properly. EI #4 was asked if she documented when she cleaned the lint trap. She said she did not. On 01/24/14 at 10:35 AM, the Life Safety Director/Director of Maintenance, Laundry, Housekeeping and Security, (EI #5) was asked who was responsible for cleaning behind the washing machines. He said one of the maintenance guys. EI #5 was informed of the concerns identified. He said the only potential for fire was with the dryers because they were the only thing combustible. EI #5 said they had a schedule to clean the top and back of washers and for cleaning the lint inside the dryers. EI #5 said he goes around and does routine checks and assigns it to be cleaned as it is needed. EI #5 was asked when the last time the lint was cleaned out. He called one of his workers on the walkie-talkie, and he said a week ago. There was no documentation of when these areas were cleaned. A review of the facility's job description for "Director of Maintenance" (no date) revealed: "...Make daily rounds to assure that maintenance personnel are performing required duties and to assure that appropriate maintenance procedures are being rendered to meet the needs of the facility. ...Ensure that supplies, equipment, etc., are maintained to provide a safe and comfortable environment. ...." A review of the facility's job description for "Maintenance Assistant" (no date) revealed: "...Ensure that the facility and its equipment is properly maintained... and perform cleaning duties wherever necessary. ..." A review of the facility policy titled, "Laundry lint" revealed: "...to maintain the cleanliness and operation of the dryers. ...Maintenance will clean lint in dryers and behind dryers quarterly."

This deficiency was written as a result of the investigation of complaint #AL 486. Based on observation and interviews, the facility failed to ensure food and coffee were served at palatably warm temperatures at three of three breakfast meals, and pork chops were tender and pleasing to the eye. This affected Resident Identifier (RI) #s: 2, 12, 21, 23, 24, and 27 as well as seven unsampled residents, but had the potential to affect all residents for whom meals were served in their rooms. Findings included: On 11/27/12 at 7:30 AM, RI #2 was observed to be in her room with her breakfast tray. RI #2 stated her breakfast and lunch meals were typically cold. On 11/28/12 at 8:14 AM, the roommate of RI #12 complained of cold coffee that morning. The unsampled resident stated he preferred his coffee hot. At 8:21 AM, staff delivered the breakfast tray to RI #12, which included a cup of coffee. RI #12 stated he did not drink coffee and agreed to allow the surveyor to check the temperature. The coffee registered 108 degrees (probing the thermometer through the plastic lid). The internal temperature of the beverage was warm but not hot to the touch. On 11/27/12 at 8:30 AM, RI #21 was observed to be in his room with his breakfast tray. RI #21 stated the grits were cold and he could cut them with a fork. He further stated that his coffee was cold. On 11/27/12 at 8:40 AM, RI #23 had not yet removed the lid from her coffee, stating she did not drink coffee. The surveyor checked the internal temperature of the coffee, which registered 95 degrees F, barely warm to the touch. The resident commented the food was served hotter in the dining room, than to the rooms. On 11/27/12 at 9:12 AM, RI #24 stated she needs to get staff to warm her coffee every morning. On 11/29/12 at 8:35 AM, Resident Identifer (RI) #27 was interview regarding her meals at the facility. During the interview the surveyor asked the resident how the food was at the facility. RI #27 responded "I would like it alright if it was hot, its usually cold." RI #27 was then asked if it was any particular meal that was cold. RI #27 explained that most of the meals are cold, and added that breakfast was the worst about being cold. During the initial tour of the facility on 11/27/12 between 07:35 and 9:15 AM: One unsampled resident complained of the service of cold coffee with his breakfast meal. The breakfast of another unsampled resident included buttered grits. The grits were not warm enough to melt the added margarine. The resident stated she did not plan to drink her coffee, and the surveyor requested a check of the temperature. Using a stem-type thermometer, the internal temperature registered 98 to 99 degrees Fahrenheit (F). An unsampled resident commented in the hallway, his coffee was cold this morning, as it was most mornings. One unsampled resident commented, "Sometimes the food is cold, especially grits." At 9:07 AM on 11/27/2012, during the initial tour of the facility an unsampled resident commented when asked that her breakfast that morning was cold. The room mate to this resident, another unsampled resident, stated her coffee was always cold. She further added that she was going to start eating in the dinning room because the food was cold by the time it reached her room. On 11/27/12 at 3:30 PM, a group meeting was conducted with 10 representative residents. Three residents (30%) stated the food was typically cold, four residents (40%) complained of cold grits, and four residents (40%) complained of cold coffee at the breakfast meal. On 11/28/12 between 5:30 and 6:10 PM, the supper meal was observed for 20 residents on the third floor. Twelve residents received fried pork chops. The average intake of the pork chops was 40%. The meat was less than 1/4 inch thick, and consisted primarily of a breaded coating. One resident commented the entree was "crunchy" and she could hardly taste the meat. Two other residents stated the meat was too hard and dry to chew. On 11/29/12 at 7:30 AM, trayline temperatures of the third floor dining room steam table were checked by facility staff. During the service of the breakfast meal in the third floor dining room, the two-well plate warmer was observed to not be heating. The china plates stored inside the warmer, were cool to the touch. This was confirmed by the trayline staff at 7:45 AM. Despite turning on the warming wells, the lowerator did not heat. The dietitian stated the facility had ordered new lowerators. At 8:45 AM the temperature of food served to the last room on the hall ("test tray") was taken by the surveyor in the presence of the facility dietitians. A comparison of the initial steam table temperatures and those of the test tray were as follows: FOOD ITEM INITIAL TEMP (F) TEST TRAY Coffee 144 114 Grits 190 123 Scrambled Eggs 148 129 Milk 38 48 The temperatures of the food cooled significantly after plating and delivery. On 11/29/2012 at 07:25 AM, the trayline was observed in the second floor dinning room. The server was observed to check the temperatures of all the food items on the line. At 7:30 AM, the facility's three well plate warmer was observed to be full of plates and not be plugged in. A cart was observed to have racks/trays of pre portioned coffee and juice. At. 7:35 AM, the surveyor requested that a test tray be made last and placed on the cart that was being made from Employee Identifier (EI) #2, Registered Dietitian. At 7:39 AM, the test tray was built and placed on the cart to be delivered. At 7:41 AM, the cart was observed to arrive on the unit and trays began being passed by one staff member. At 7:54 AM, the last resident received their tray and began to be feed by staff. The test tray was conducted by the surveyor in the presence of EI #2. The surveyor checked the temperatures of the items on the tray to be Cranberry juice, 53 F (degrees Farenheit); Coffee, 110 F; Scrambled eggs, 103 F; and Grits, 120 F. The surveyor tasted the scrambled eggs and noted them to be warm to taste but not hot. The surveyor then tasted the grits and noted them to be "room Temp. (temperature)" to taste. The surveyor further noted that the grits were formed into on mass that could be lifted off the plate from underneath with a fork. The surveyor placed whipped margarine spread on both the scrambled eggs and the grits. The spread was observed not to melt. On 11/29/12 at 12:45 PM, Employee Identifier (EI) #1 and EI #2, Registered Dietitians for the facility, were interviewed. During this interview EI #1 and EI #2 were asked what the temperature of the coffee was in the kitchen when it came from the pot. EI #2 responded that it is at the accepted safe water temperature. When asked why the plate warmers were not functioning on the second and third floors EI #2 explained that the facility had ordered new warmers due to the facility had been having problems with the warmers not working consistently.

Based on observation, interview and record review, the facility failed to clean and remove an unidentified yellow liquid from Resident Identifier (RI) #26's trash can. This affected 1 of 10 sampled continent residents. Findings Include: RI # 26 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #26's most recent Minimum Data Set (MDS) with an Assessment Reference Date of 10/19/12 documented the resident scored a 4 out of possible 15 on the Brief Interview for Mental Status (BIMS), indicating the resident was severely impaired for decision making. The MDS also revealed RI #26 was always continent of bowel and bladder and independent for toileting. On 11/29/12 at 7:40 AM, the surveyor observed a pair of panties and a trash bag liner lying on the floor of the resident's room by the resident's bed near the window. The resident's trash can did not have a liner in it, but contained a yellow liquid in the bottom of the trash can. The surveyor began a continuous tracking of RI #26 at 7:40 AM. At 7:43 AM, Employee Identifier (EI) #6 (Certified Nursing Assistant/CNA), entered the room to speak to the resident. The surveyor asked the CNA if the resident could get up and go to the restroom on her own. The CNA said she could. At 7:45 AM, the CNA left the resident's room and went into the hallway to get the resident's breakfast tray and went back into the resident's room and provided tray set up. At 7:50 AM, the CNA was still in the resident's room. The surveyor asked EI #6, what was in the resident's trash can . EI #6 replied, "It looks like urine". RI #26 spoke up and said she used it this morning saying, "I only had to go a little bit." EI #6 observed the panties and trash bag lying on the floor by the trash can. EI #6 replied, "It looks like that is what she did." At 7:55 AM, EI #6 left the room empty handed. The panties and trash bag remained on the floor and the liquid remained in the trash can. At 8:00 AM, EI #6 went into another resident's room and assisted them. The panties and trash bag remained on the floor and the liquid remained in the trash can. At 8:10 AM, RI #26 walked out of her room into the shower room/bathroom in the hallway. The panties and trash trash bag remained lying on the floor. The yellow liquid remained in the trash can. At 8:13 AM, RI #26 walked out of the shower room/bathroom and went back into her room and shut the door. The panties and trash trash bag remained lying on the floor. The yellow liquid remained in the trash can. At 8:15 AM, EI #6 knocked on the resident's door and went into the room. EI #6 opened the closet door and got the resident a shirt out and gave it to the resident and left the room. The panties and trash bag remained lying on the floor next to the trash can that contained the yellow liquid. At 8:30 AM, EI #10 (CNA) and EI #6 entered the resident's room and picked up the resident's tray and left the room. The panties and trash bag remained lying on the floor next to the trash can that contained the yellow liquid. At 8:40 AM, EI #6 went back into the resident's room and shut the door. At 8:42 AM, EI #6 left the resident's room. The panties and trash bag remained on the floor next to the trash can that contained the yellow liquid. At 8:43 AM, EI #6 entered the resident's room with a bag. She asked RI #26 if she was ready to go to the bathroom/shower room to get cleaned up. RI #26 said she was. At 8:44 AM, EI #6 and RI #26 left the resident's room and went into the bathroom/shower room in the hallway. The panties and trash bag remained on the floor next to the trash can that contained the yellow liquid. At 8:45 AM, EI #6 walked out of the shower room/bathroom and went into the resident's room and got clothes and went back into the shower room. The panties and trash bag remained on the floor next to the trash can that contained the yellow liquid. At 8:47 AM, EI #6 walked out of the shower room/bathroom and went into the resident's room and was observed making up RI #26's bed. EI #6 picked up RI #26's panties and the trash bag off the floor and left the room. The trash can that contained the yellow liquid remained in the room. EI #6 went back into the shower room/bathroom with the resident. At 8:55 AM, the trash can still contained the yellow liquid in it. EI #6 and RI #26 were still in the shower room/bathroom. At 9:02 AM, EI #6 went into the shower room/bathroom and shut the door. The trash can still contained the yellow liquid in it. At 9:04 AM, RI #26 and EI #6 walked out of the restroom. RI #26 was dressed and walking in her socks. RI# 26 looked at the surveyor and said she washed off. EI #6 went into the room with the resident and watched the resident put her shoes on. The surveyor was also in the resident's room. The trash can still contained the yellow liquid in it. At 9:05 AM, EI #6 and RI #26 were in the resident's room. The trash can was observed to have yellow liquid in it. RI #26 went out of the room with EI #6. EI #6 asked the Activity Director to take the resident to the activity room to have her nails done. RI #26 was taken off the unit by the Activity Director. From 9:05 AM until 9:50 AM, RI #26's room was continuously observed. During this time no staff were observed to enter the room. The yellow liquid was observed to remain in the resident's trash can as observed by the surveyor. On 11/29/12 at 10:00 AM, an interview was conducted with EI #6. EI #6 was asked what she observed in RI #26's trash can earlier that morning. EI #6 replied: "I am thinking urine since her panties and a trash bag was on the floor beside it; I got the panties up and they were damp." EI #6 was asked if RI #26 toilets herself. EI #6 replied, "Yes. She goes to the restroom; sometimes she gets confused and will use the trash can. That is what (name of another CNA) told me." EI #6 was asked what did she do after she observed RI #26's trash can with the yellow liquid/urine in it. EI #6 said she passed out RI #26's breakfast tray and she passed out the other trays on the hall. EI #6 said she told the nurse about it and the nurse said the resident gets confused. EI #6 was asked who is responsible for taking care of the resident's rooms. She said housekeeping cleans the rooms, they (CNAs), just get the residents up and make their beds. EI #6 was asked if she should have returned to clean up the trash can. EI #6 replied, " I can pour it out, but housekeeping would clean it." The surveyor asked EI #6 who picked up the trash. EI #6 replied, "Housekeeping does, If the CNA's see something on the floor, we get it; we don't do the trash." On 11/19/12 at 10:20 AM, an interview was conducted with EI #7, a Licensed Practical Nurse (LPN)/Charge Nurse. EI #7 was asked if a CNA is passing out trays and observed yellow liquid or urine in a resident's trash can, what would she expect them to do. EI #7 replied, "Once they deliver the resident's breakfast, go get gloves and get it out. They should do it before they deliver trays to the entire hall; they would empty it, wash up and go back to passing trays." EI #7 was asked if the CNA did not clean it up, would she consider it to be a dignity issue. EI #7 stated she did. The surveyor and EI #7 entered RI #26's room and observed the trash can. EI #7 was asked what she thought was in the trash can. EI #7 said, "Maybe urine; not sure." On 11/29/12 at 2:25 PM, an interview was conducted with EI #8, Registered Nurse (RN)/Unit Manager 2nd floor. EI #8 was asked if a CNA was delivering breakfast trays and observed urine/yellow liquid in a resident's trash can, what would she expect them to do. EI #8 said they should empty the trash or urine, wash their hands and continue with their meals. EI #8 said there should be more than one CNA working to help. EI #8 was asked if she had ever known RI #26 to use the restroom in her trash can in her room. EI #8 explained that RI #26 had on a different unit but that the resident had only been on the secure unit for approximately two weeks. On 11/29/12 at 3:23 PM, an interview was conducted with EI #9 (LPN/Charge Nurse). EI #9 was asked what she would expect a CNA to do if they saw urine or yellow liquid in a resident's trash can when they are passing out breakfast trays. EI #9 replied, " If she is passing out trays, she should finish, empty it, clean it and tell the charge nurse. Housekeeping does take the trash out, but in that situation, the CNA should empty it." A review of the facility's Certified Nursing Assistant Job Description (not dated), documented "...C. Housekeeping and Laundry Care...Empty resident trash containers according to facility policy and procedures...Safety Care...Remove potentially dangerous objects from floors..."

Based on observation, interviews and record review, the facility failed to clean fecal matter from the skin of Resident Identifier (RI) #6 following the provision of wound care on 11/29/12. This affected one of four residents for whom wound and incontinence care was observed. Findings include: A review of the facility's Policy and Procedure for "Perineal Care" dated 12/19/07, revealed the "Purpose." "The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections, and skin irritation, and to observe the resident's skin condition." RI #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set with an assessment date of 09/10/12 identified RI #6 as totally dependent upon staff for all activities of daily living, incontinent of bowel, and with the presence of an indwelling catheter. A review of the physician orders [REDACTED]. The physician orders [REDACTED]. On 11/29/12 at 9:15 AM, an observation of wound care was made. Employee Identifier (EI) #1 removed the dressing, cleaned the open wound on the resident's sacrum as ordered by the physician. When EI #1 completed the treatment to the wound, with the assistance of a Certified Nursing Assistant (CNA) EI #5. The resident's brief was secured and the resident was repositioned in the bed by the staff. The EI #5 was observed to cover the resident with a sheet and placed the call light within reach and EI #1 turned the feeding pump to the on position. At this point the Director of Nursing (DON) EI #4 told the staff, RI #6 had some stool between cheeks of the buttock and would need to be cleaned. On 11/29/12 at 9:20 AM, EI #1 was asked if she saw the stool between the cheeks of the resident's buttock. EI #1 replied "Yes." EI #1 was asked why they did not provide incontinence care to the resident. EI #1 replied she was concentrating on the wound care, they had the supplies for the incontinence care and were going to get another CNA to help get the resident cleaned up. EI #1 was asked why she did not clean the resident before putting the brief back on and positioning the resident in bed. EI #1 explained that she was trying to get the wound care done because she thought that was what the surveyor wanted to see.

Based on observations, record review, and interview the facility failed to accurately document the stage of Resident identifier (RI) #7's pressure ulcer. This affected one of seven sampled residents of whom pressure ulcers documentation's was reviewed. Findings include: A review of the facility's Policy and Procedure for "Charting and Documentation" dated 07/10/12, revealed the following: "Policy: Services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. Procedure: 1) Observations, medications administered, services preformed, etc., must be documented in the resident's clinical record by exception..." RI # 7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Date Set (MDS) with Assessment Reference Dated (ARD) of 11/05/12 revealed RI #7 Brief Interview for Mental Status (BIMS) was a one indicating the resident had severely impaired cognitive skills. The resident required total assistance for all activities of daily living including turning and repositions. The resident had a foley catheter and was incontinent of bowel. The Skin assessment on the MDS identified the resident had two unstageable pressure ulcers on admission to the facility. The MDS identified an unstageable pressure ulcer as the most severe tissue type of any pressure ulcer, saying the tissue is "Necrotic tissue (eschar)- black brown, or tan tissue that adheres firmly to the wound bed..." A review of the wound report dated 11/09/12, 11/13/12, 11/19/12, and 11/27/12 revealed the pressure ulcer on the resident's sacrum was documented as a stage two not as an unstageable wound. On 11/28/12 at 11:10 AM the pressure ulcer to the sacrum area of RI #7 was observed with the treatment nurse. The wound was observed to have eschar in the middle almost covering the wound and a pink area around the edges of the eschar. The wound measured 8 cm(centimeters) by 7 cm and 0.1 cm in depth. On 11/29/12 at 3:10 PM Employee identifier (EI) # 1 was interviewed and asked about the staging of RI #7's pressure ulcer. EI #1 replied she was sorry, saying she had hit the wrong button on the computer. EI #1 said the area on RI #7's sacrum should have been documented as unstageable not a stage two.

Based on observations, interviews and record reviews the facility failed to store tube feeding syringes in a manner to prevent potential contamination. This affected Resident Identifier (RI) #s 31, 32 and 33, three of eight residents sampled for tube feeding concerns. Findings include: The facility's policy number 40-170-10, Nursing, Food and Nutritional Services, Confirming Placement of Feeding Tubes with an effective date of 7/10/03 was reviewed. Section entitled Infection Control Protocol and Safety on Page 2 of 3, of this policy documented, "... 4) Clean reusable parts and/or devices after each use., 5) Clean reusable equipment before storing with other clean equipment. ..." a) RI #31 was readmitted to the facility 6/7/2011 with [DIAGNOSES REDACTED]. Section K of RI #31's most recent quarterly MDS (Minimum Data Set), dated 11/18/2011, assessed the his swallowing and nutritional status. Section K0500, Nutritional Approaches indicated RI #31 used a feeding tube for nutritional support. RI #31's January 2012 physician's orders [REDACTED]. The orders also documented RI #31 received Glucerna 1.5, one can enteral tube [MEDICATION NAME] t.i.d (three times daily) at 6 AM, 1 PM and 9 PM/HS (hour of sleep). The resident received all PO (by mouth) medications through his feeding tube. During the initial tour of the facility on 1/17/2012 at 5:30PM, RI #31 was in bed in his room. A 60 cc syringe was on top of the resident's overbed table. The syringe was stored inside a plastic bag dated 1/17/12 with the resident's name and room number also written on the bag. The plunger was stored inside the syringe tube and a white/opaque residue was observed inside the bottom of the syringe. b) RI #32 was readmitted to the facility 8/31/2011 with [DIAGNOSES REDACTED]. Section K of RI #32's most recent quarterly MDS (Minimum Data Set), dated 1/13/2012, assessed her swallowing and nutritional status. Section K0500, Nutritional Approaches indicated RI #32 used a feeding tube for nutritional support. RI #32's January 2012 physician's orders [REDACTED]. The resident received all PO (by mouth) medications through her feeding tube. During the initial tour of the facility on 1/17/2012 at 5:30PM, RI #32 was in her room seated in her geri-chair. A 60 cc syringe was stored inside a sealed plastic bag on the resident's overbed table. The bag was dated 1/17/12. The plunger was stored inside the syringe tube. There was a light pink-orange tinged residue inside the syringe. The residue appeared dry. No water droplets were visible in the syringe. c) RI #33 was readmitted to the facility 10/04/2010 with [DIAGNOSES REDACTED]. Section K of RI #33's most recent quarterly MDS (Minimum Data Set), dated 1/10/2012, assessed her swallowing and nutritional status. Section K0500, Nutritional Approaches indicated RI #33 used a feeding tube for nutritional support. RI #33's enteral feeding orders were documented on her January 2012 Physicians Orders for 2 Cal HN, one can [MEDICATION NAME] four times each day at 6 AM, noon, 6 PM and 12 AM. The orders included to flush the tube with 250 cc of water every 6 hours at 6 AM, noon, 6 PM and 12 AM. The resident received all PO (by mouth) medications through his feeding tube. During the initial tour of the facility on 1/17/2012 at 5:30PM, RI #33 was observed in her room lying in a low positioned bed. A 60 cc syringe was on top of a table in the room. The plunger was stored inside the syringe with a white/opaque residue at the bottom of the syringe. Water droplets were inside the bag. The bag was dated 1/17/2012 and had RI #33's initials and room number written on the bag. On 1/17/2012 at 7 PM, the surveyor asked EI #11, Licensed Practical Nurse (LPN), to come into RI #31's room to identify the residue inside his 60 cc syringe. EI #11 stated, "It must be some milk or something." The surveyor and EI #11 then went into RI # 33's room. When asked what was in RI #33's syringe EI #11 stated, "It must be some milk." The surveyor and EI #11 went into RI #32's room. When asked about the pink-orange tinged residue in the syringe, EI #11 stated she did not know what the substance was. EI #11 was asked by the surveyor why the three residents' syringes were stored soiled with sediment/residue. EI #11 stated she did not know. EI #13, LPN/Infection Control Nurse, was interviewed 1/20/12 at 4:50 PM. EI #13 was asked how the nurses should store 60 cc tube feeding syringes after used to flush, give medications or [MEDICATION NAME] feedings. EI #13 stated, "Wash it out, dry it, put it back into the bag separate--plunger not down in the barrel." She further added, if you have an antibiotic or medication that makes a stain the syringe should be thrown away and replaced with a new one. When asked if the plunger should be stored inside the tube with residue inside the tube, she stated, "No". EI #13 was asked what could happen if the nurses used a soiled syringe. She stated bacteria could grow on it and you could inject that into someone's [DEVICE] causing them to become ill.

Based on interviews and record review the facility failed to implement RI (Resident Identifier) #6's care plan for constipation after the resident went greater than three days without a bowel movement on 10/16/2011 to 10/22/2011, 11/02/2011 to 11/06/2011, 11/08/2011 to 11/12/2011, and 12/23/2011 to 12/26/2011. The facility further failed to implement the standing orders/constipation protocol for RI #6. This affected one of eighteen sampled residents. Findings Include: RI #6 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of RI #6's most recent Significant Change MDS (Minimum Data Set), with an assessment reference date of 09/28/2011, revealed the resident scored a one on the Brief Interview for Mental Status. A score of zero to seven indicates a resident is severely impaired for cognitive skills. Review of Section G, Functional Status of the same MDS revealed the resident was coded as requiring supervision and setup with toilet use. Review of Section H, Bladder and Bowel showed that RI #6 was coded as always incontinent of Bowel. A review of RI #6's care plan titled Constipation Care Plan with an initiation date of 09/28/2011 listed a problem of Potential for Constipation. A goal of "...Will have at least 1 BM (Bowel Movement) Q3 (every three) days..." was listed. Interventions listed for this care plan included "...If no BM for 3 days, initiate facility protocol for tx (treatment) of constipation..." for nurses and "...Report irregularities in stool of bowel movements to the nurse..." for nurse aides. A review of RI #6's bowel elimination record revealed that for the period of 10/06/2011 to 10/22/2011 (seven days) there was no documented bowel movements for the resident. Further review revealed that for the period of 11/02/2011 to 11/06/2011 (five days), 11/08/2011 to 11/12/2011 (five days), and 12/23/2011 to 12/26/2011 (four days) there were no documented bowel movements for RI #6. On 01/19/2012 at 10:56 AM, an interview was conducted with EI (Employee Identifier) #6 the Licensed Practical Nurse responsible for RI #6's care. When asked how often she reviews resident bowel movements, EI #6 explained that she would review them every other day. EI #6 was then asked why she reviewed the residents bowel movements, she stated for frequency and amount. The surveyor then asked EI #6 what the maximum amount of time a resident should go with out a bowel movement. EI #6 stated three days. When asked what the process was if a resident went greater than three days without a bowel movement, EI #6 explained the nursing staff would administer MOM (Milk Of Magnesia) per the facility's standing orders. When asked if the administration of MOM would be documented, EI #6 explained that it would be documented in the computer system in a nurses note. On 01/19/2012 at 11:45 AM, and interview was conducted with EI #7, the RN (Registered Nurse), Clinical Nurse Manager for the second floor. EI #7 was asked who was responsible for reviewing the residents bowel movement records. EI #7 explained that the CNAs (Certified Nursing Assistants) would review the records and report any irregularities to the nurses. She further explained that the nurses would then administer medications as indicated in the residents chart or standing orders. EI #7 was then asked how often the bowel movement records are reviewed and she replied "Daily". EI #7 was then asked to review the medical records for RI #6 for any documentation of the resident having had a bowel movement for the dates of 10/16/2011 to 10/22/2011, 11/02/2011 to 11/06/2011, 11/08/2011 to 11/12/2011, and 12/23/2011 to 12/26/2011. After EI #7 had completed her review of RI #6's medical record she was asked if there were any documented bowel movements by the residents during these time frames. EI #7 stated, "No." EI #7 was asked if there was any documentation indicating that treatment or medications had been given during these time frames. EI #7 stated, "No." In a follow up interview conducted at 8:35 AM, on 01/20/2012 with EI #6 she was asked what should have happened when RI #6 went greater than three days without having a bowel movement. EI #6 explained that the CNAs should have alerted the nursing staff and the nursing staff should have implemented the facility's standing orders for constipation treatment. A review of RI #6's January 2012 physician's orders [REDACTED]. Further review revealed a listed possible side effect for this medication was "...constipation...". A review of the facility's policy number 40-10-64 titled "Standing Orders", with an effective date of 7/10/03, revealed: "Policy: Nursing Administration Routine Standing Orders Procedure: ...5) Constipation...e) If no bowel movement noted as per resident's routine schedule, administer 1 [MEDICATION NAME] suppository or generic equivalent per rectum or give MOM (Milk Of Magnesia) or equivalent..." A review of RI #6's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A review of RI #6's Nurses Notes for the period from 09/01/2011 to 01/19/2012 revealed no documentation of RI #6 having received treatment for constipation. A review of RI #6's Physician's Progress notes for the months of September 2011, October 2011, November 2011, December 2011, and January 2012 revealed no documentation of the resident having been treated for constipation.