Every finding on record at Clapps Nursing Center Inc

Based on observation and staff interviews the facility failed to allow cookware to air dry before being stored and failed to ensure dishes were stacked clean on the food service tray line. Findings included: During an observation of the kitchen on 10-26-18 at 10:00am with the Dietary Manager the following issues were found: 1. 1 small rectangle metal pan had small brown pieces stuck to the sides of the pan. 2. 2 large steam pans were stacked wet. 3. 10 clear plastic dessert cups were placed in a plastic container that had water in the bottom and the dessert cups were stacked together wet. 4. 16 plastic soup bowls had food particles lining the bottoms and sides of the bowls and the upper rims of the bowls were worn and stained. 5. 6 ceramic dinner plates had food particles on the plate. 6. 3 plastic divided plates located on the tray line had food particles stuck to the plates. The Dietary Manager was interviewed on 11-26-18 at 10:20am and stated she was not sure what had happened but felt the issues were caused by her weekend staff and that she would speak with them about making sure cookware was dry and the dishes clean before stacking them. An interview was conducted with the Administrator and the Director of Nursing on 11-28-18 at 3:50pm. The Administrator stated he had spoken with the kitchen staff about not heating soup in the plastic bowls. He said he expected his staff to follow the Federal Regulations.

Based on record review, observation and staff interviews the facility failed to make fluids available to 1 of 3 residents (Resident #79) who were unable to request something to drink in between meals. Findings included: Resident #79 was admitted to the facility initially on 10-28-08 and then readmitted on [DATE] with multiple [DIAGNOSES REDACTED]. Resident #79's care plan dated 9-5-18 revealed a goal that the resident will have basic needs communicated daily. The interventions for that goal were as followed; observe resident for basic needs, maintain consistent and predictable routine and anticipate needs. Goal number 2 for Resident #79 was that he would be free from signs and symptoms of a urinary tract infection. The interventions for that goal were as followed; encourage and assist with fluids, monitor intake and output, monitor for signs and symptoms of dehydration. The quarterly Minimum Data Set((MDS) dated [DATE] revealed Resident #79 was severely cognitively impaired and needed extensive assistance with one person for eating. The resident was not coded for any behaviors or mood issues. A review of the quarterly dietary review dated 10-24-18 revealed the resident was on a pureed diet with need for tray set up with follow up for assistance and feeding. The review documented the resident did not use adaptive equipment and did not receive supplements. An observation and resident interview was conducted on 11-26-18 at 3:30pm. Resident #79 motioned that he wanted a drink. The resident's room did not have a water pitcher, juice or any other type of fluids available for the resident. When asked to put on his call bell for staff assistance, Resident #79 was not able to use his call bell to call for assistance. On 11-27-18 at 8:35am Resident #79's room was observed not to have a water pitcher, juice or any other fluids available for the resident. During an interview on 11-27-18 at 8:35am with the activities assistant who was feeding Resident #79 she stated the resident was not on any fluid restrictions that she was aware of and thought the resident may not have a water pitcher because the facility was replacing them in some of the resident's rooms. An interview with nurse #1 occurred on 11-27-18 at 3:52pm. The nurse stated Resident #79 was not on any fluid restrictions and that he received fluids on his meal tray and with his medications. The nurse also stated he was unaware Resident #79 did not have a water pitcher in his room. Nursing Assistant (NA) #1 was interviewed on 11-27-18 at 3:58pm and she stated she had already replenished the residents water in their rooms but that she did not know why Resident #79 did not have any but thought he was on fluid restriction. She also stated she did not offer the resident any fluids during the shift other than at meal times. The NA denied ever seeing Resident #79's call light on so she did not know if the resident was able to use his call light to obtain staff assistance. During an interview with Nursing Assistant (NA) #2 on 11-28-18 at 8:10am she stated she usually made sure the residents had something to drink in their rooms in-between meals and did not know why Resident #79 did not have any thing in his room. She also stated she had only offered fluids to Resident #79 during meal times. NA #2 stated Resident #79 sat in the dayroom most of the day and that she had not seen him use his call bell. The Administrator and Director of Nursing were interviewed on 11-28-18 at 3:50pm. The Administrator stated the resident could ask for something to drink in between meals and he believed the residents had water pitchers in their rooms. He also stated he expected his staff to follow Federal Regulations and indicated that every resident should have a water pitcher in their room.

Based on record review and staff interviews the facility failed to develop a comprehensive plan of care for a resident with recurrent urinary tract infections (UTI ' s). This was evident for 1 of 4 residents reviewed for UTI ' s (Resident #50). Findings Included: Resident #50 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. A quarterly minimum data set ((MDS) dated [DATE] for Resident #50 revealed a [DIAGNOSES REDACTED]. Review of the medical record for Resident #50 revealed she was treated with antibiotics for UTI ' s on 4/16/18, 6/6/18, 8/9/18 and 9/6/18. An interview on 11/29/18 at 11:32 am with the MDS Nurse revealed if a resident had a pattern of UTI ' s with antibiotic treatment there should be a care plan developed that addressed the potential for and / or actual UTI. She stated there should be interventions identified on the care plan for treatment of [REDACTED]. An interview on 11/29/18 at 1:24 pm with the Director of Nurses revealed it was her expectation that UTI ' s were care planned.

Based on record review and staff interviews the facility failed to revise a care plan for a resident with significant weight loss. This was evident for 1 of 5 residents reviewed for nutrition (Resident #91). Findings Included: Resident #91 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. A care plan dated 8/2/18 for Resident #91 stated the resident was ordered a therapeutic, mechanically altered diet related to diabetes management. Intakes were good to fair, resident was able to feed self. Supplementation provided for additional nutritional support related to infection. Interventions included to monitor weight, intake and labs per facility protocol. A quarterly minimum data set ((MDS) dated [DATE] for Resident #91 revealed she had experienced a significant weight loss, was not on a prescribed weight loss program and current weight was 199 pounds (lbs.). Review of the medical record for Resident #91 revealed a weight of 197.2 lbs. on 11/16/18, 198.8 lbs. on 10/19/18, 203 lbs. on 10/5/18, 207.6 lbs. on 9/10/18 and 223.4 lbs. on 5/4/18. This reflected an 11.6% weight loss in 6 months. An interview on 11/29/18 at 9:30 am with the Registered Dietitian (RD) revealed she had started working at the facility in (MONTH) (YEAR). She stated a resident with significant weight loss should have their care plan updated with the weight loss and any new interventions. The RD explained there was some inconsistency with this process and she had not updated Resident #91 ' s care plan with the significant weight loss. An interview on 11/29/18 at 11:37 am with the MDS nurse revealed dietary staff were responsible for updating the care plans when residents experienced a significant weight change. She stated Resident #91 ' s care plan should have been updated. An interview on 11/29/18 at 1:28 pm with the Director of Nurses and Administrator revealed they expected care plans to be updated for residents when their health condition changed.

Based on observation, record review, resident and staff interviews the facility failed to provide grooming to include removal of facial hair for a resident that was dependent on staff. This was evident for 1 (Resident #99) of 4 residents reviewed for activities of daily living (ADLs). Findings Included: Resident #99 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. A task care plan dated 3/27/18 for Resident #99 identified she required AM and PM care by the nursing assistants (NAs), was scheduled for a whirlpool on Mondays and a shower on Wednesdays. A quarterly minimum data set ((MDS) dated [DATE] for Resident #99 revealed she required extensive, one-person assist with personal hygiene, was not coded for refusal of care and her cognition was intact. An observation on 11/26/18 at 1:10 pm of Resident #99 revealed she was lying in bed and noted to have dark facial hair above and below her lips that extended around the sides of her face and chin. Resident #99 stated the staff hadn ' t shaved her in 3 days and she didn ' t know why. Resident #99 added she didn ' t want to have facial hair and didn ' t want to look like a man. An interview on 11/27/18 at 2:51 pm with Nursing Assistant (NA) #5 revealed she was familiar with Resident #99. She stated the resident required total care that included shaving her facial hair. NA #5 added this should be done every other day or when the resident requested. An interview on 11/28/18 at 10:47 am with NA #6 revealed she was the NA for Resident #99 on 11/26/18. She stated this was her first day working with the resident on her own. NA #6 added she remembered providing a bed bath for the resident but could not recall if she had shaved her face. She stated that she would have documented what care she had provided for the resident in the kiosk. An interview on 11/28/18 at 10:51 am with Nurse #5 revealed she was the nurse for Resident #99. She stated the NAs should include shaving of facial hair as part of routine care and it should be provided daily or as needed. An interview on 11/28/18 at 10:56 am with Nurse Manager #6 revealed Resident #99 was currently receiving hormone replacement and that contributed to the increase in the resident ' s facial hair. She stated residents should be shaved daily, not just on their whirlpool or shower days. She explained each resident had a task care plan and shaving was a part of routine AM care. Review of the NA documentation with Nurse Manager #6 for Resident #99 revealed shaving had not been identified as being completed on 11/24/18, 11/25/18 or 11/26/18. An interview on 11/29/18 at 1:33 pm with the Director of Nursing and the Administrator revealed it was their expectation that residents receive grooming that included removal of facial hair as needed.

Based on observations, record review, and staff interviews the facility ' s Quality Assessment and Performance Improvement Committee (QAPI) failed to maintain implemented procedures and monitor the interventions that were put in place following the annual recertification of 12/7/17. This was for a recited deficiency in the area of development of a comprehensive care plan (F-656). This deficiency was re-cited during the annual recertification and complaint survey of 11/29/18. The continued failure of the facility during 2 federal surveys of record showed a pattern of the facility ' s inability to sustain and effective QAPI program. Findings included: This tag is cross referenced to: F 656 - Based on record review and staff interviews the facility failed to develop a comprehensive plan of care for a resident with recurrent urinary tract infections (UTI ' s). This was evident for 1 of 4 residents reviewed for UTI ' s (Resident #50). During the recertification survey of 12/7/17 the facility was cited for failure to develop a care plan for 1 o 4 residents (Resident #64) who had an indwelling catheter, utilized a communication book and had a [DIAGNOSES REDACTED]. An interview on 11/29/18 at 1:50 pm with the Administrator revealed he expected the staff to follow state regulations.

Based on observations, resident interview, staff interview and record review, the facility failed to honor food preferences for 1 of 3 residents (Resident #33) reviewed for choices. Finding included: Resident #33 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Sheet ((MDS) dated [DATE] revealed that Resident #33 had a Brief Interview for Mental Status (BIMS) score of 15. The resident was cognitively intact and able to make decisions on daily life. The resident required extensive assistance with transfer, dressing, toilet use and bathing. The resident was also coded to have limited assistance with eating and personal hygiene. A review of Resident #33 admission dietary preferences dated 11/10/17 indicated liked: cranberry juice, unsweet tea, and meat with sauce. Disliked: coffee, water, milk, chicken, pork chops and fruit plates. Observation of Resident #33 meal ticket on 12/5/17 at 9:19am listed liked: milk. The meal ticket also listed disliked: dried beans, banana, potatoes and orange juice which is different from the admission preference list. At that point, I interviewed the resident and he indicated the meal ticket was incorrect and stated I tell them that every time they bring me my tray. I tell them I love dried bean, potatoes and orange juice. I also tell them I hate milk but they still bring it. The resident also stated he asked for oatmeal every morning. An observation on 12/5/17 at 9:34am, Nursing Assistant (NA) #4 brought in cereal to Resident #33 and stated there was no more oatmeal. An interview with NA #4 on 12/05/17 at 3:44pm revealed resident received a fruit plate for lunch. She stated the resident wanted the main dish which had potatoes and broccoli listed. NA #4 went back to the kitchen but it was not available. She further stated that because they are one of the last halls to get trays, on most occasions if a resident wanted something different, the items were discarded and dishwashing had already started. NA #4 indicated she offered the resident soup and crackers instead. An interview with Resident #33 on 12/6/17 at 10:08am, Resident #33 stated breakfast was good except I didn't get oatmeal, I got grits. He stated he preferred oatmeal. The meal ticket did not have updated dislikes. He indicated someone from dietary came in the morning of 12/5/17 and asked him what his likes and dislikes were and they would be updating his preferences. An interview with Resident #33 on 12/7/17 at 9:20am, stated breakfast was good but still did not get oatmeal. He further stated I tell those girls who bring the trays every morning. An interview with NA #2 on 12/7/17 at 9:42am revealed she usually worked the 200 hall. She stated Resident #33 did request oatmeal to be on his breakfast tray several times. She indicated that when he requests oatmeal on his breakfast tray she informs her nurse for that hall. An interview with Nurse #2 on 12/7/17 at 9:57am revealed she was aware of the grits versus oatmeal issue. Nurse #2 stated she was informed by NA #2 that Resident #33 preferred oatmeal over grits and had informed someone from dietary in the past. Nurse #2 could not remember the date or the person she spoke to. She stated that they told her they would make the changes to his preferences. An interview on 12/6/17 at 10:08am Resident #33 someone came in that morning and asked what he would like for lunch and dinner. He was given options for lunch and dinner and stated he requested lasagna for lunch and pepperoni pizza for dinner. An observation on 12/6/17 at 12:37pm, the resident's meal ticket indicated an ordered lunch as lasagna, salad without tomatoes, green beans, peach cobbler and garlic bread. Resident #33's tray had a pimento cheese sandwich, salad without tomatoes, green beans, peach cobbler and iced tea. The resident stated he told the person who brought the tray he didn't get what he had requested. An interview with the cook on 12/6/17 at 12:52 revealed the resident's daily menu request indicated he chose lasagna for lunch. She stated she asked the dietary manager if Resident #33 could have lasagna for lunch and was told to replace it with a pimento sandwich due to his physician diet order. She did not inform the resident of the change. An interview with Dietary manager (DM) on 12/6/17 at 12:42pm revealed she instructed the cook to change Residents #33's lunch tray to a pimento cheese sandwich from lasagna because of his potassium restrictions. The dietary manager stated she did not inform the resident of the change to the meal he requested. She did report Resident #33 like's foods high in potassium and she has sat down with him on 12/5/17 and instructed him on the importance of adhering to a low potassium diet. The DM further indicated she followed the physician ordered diet first. She revealed the NAs who took the orders for meals were not educated on the diet restrictions. She stated this is something we need to improve on. An interview with the Registered dietician (RD) on 12/6/17 at 12:45pm revealed Resident #33 preference list is limited due to the decreased potassium needs. She stated they try and balance the physician order [REDACTED]. An interview with the Administrator and the Director of Nursing (DON) on 12/7/17 at 8:08am revealed their expectation was residents get the diet that was ordered by the physician and would accommodate residents request if it's within the ordered diet. The DON stated she expected residents to be sent menu choices of what they could have according to the physician ordered diet and if the residents then changes their mind after receiving it, they can get what they want. The administrator indicated dietary should follow the physician orders [REDACTED]. An additional interview with the Dietary manager on 12/7/17 at 2:00pm reported all changes to dietary preferences should go to her as she is the one who can make those changes.

Based on observation, record review and staff interview the facility failed to develop a care plan 1 of 4 residents (Resident #64) who had an indwelling catheter, utilized a communication book, and had a [DIAGNOSES REDACTED]. The findings included: 1. Resident #64 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 required extensive assistance to complete activities of daily living (ADL's), had communication deficit and a [DIAGNOSES REDACTED]. The MDS assessment further revealed Resident #64 was cognitively intact as evidenced by a brief interview for mental status (BIMS) score of 15. a. Review of Resident #64 care plan revealed no care plan for the use of an indwelling catheter. Review of Resident #64 admission history and physical exam dated 5/5/17 revealed a problem master list that included fecal and urinary incontinence. The history of present illness stated, He also required Foley catheter placement a few days ago because of a distended abdomen with a large amount of retained urine. The impression/plan indicated Resident #64 had a [DIAGNOSES REDACTED]. Review of Resident #64 care area assessment (CAA) analysis of findings dated 5/12/17 stated [DIAGNOSES REDACTED]. Monitor for signs and symptoms of infection was implemented daily. Review of Resident #64 initial assessment physician note dated 6/5/17 revealed the resident was been for admission for services. the note revealed a [DIAGNOSES REDACTED]. The treatment plan stated, Foley catheter secondary to [MEDICAL CONDITION]: recent onset and continuous. Resident was treated for [REDACTED]. Resident was referred to urologist with recommendation to continue with indwelling catheter usage. A [DIAGNOSES REDACTED]. The plan indicated continue with indwelling catheter usage and need for urologist consult as indicted. Staff to maintain indwelling catheter with changes every 4 - 6 weeks or with complications. The note continued with the facility would consider initiation of acetic acid/sterile water flushes as indicated for management of sediment and to start discussion with RP about usage of an indwelling catheter with risk [MEDICAL CONDITION]/UTI secondary to nursing home residency. Will add cranberry to P(NAME) if acceptable to RP for promotion of urinary health. Observation of Resident #64 on 12/4/17 at 12:26pm revealed the resident to be receiving assistance with dining. A covered catheter bag was observed to hanging from the frame of the resident's bed. Interview with the Director of Nursing (DON) on 12/7/17 at 9:02am revealed it was her expectation that care plans reflect the resident's disease process. Interview with the MDS Coordinator on 12/7/17 at 11:12am revealed Resident #64 had a care plan for indwelling catheter use that was initiated on 12/6/17. She revealed the resident was admitted to the facility with a catheter and it should have been care planned upon his admission. Interview with the Administrator on 12/7/17 at 3:59pm revealed it was his expectation that Resident #64 indwelling catheter be care planned. b. Review of Resident #64 care plan revealed no care plan for Residents #64 communication sheet. Review of Resident #64 CAA analysis of findings dated 5/12/17 stated resident was alert, oriented x 3, however he was nonverbal and used a communication sheet to address his needs and answers questions. He was able to nod his head yes and no and would answer with a thumbs up for yes and thumbs down for no. the analysis of findings continued with the social worker interviewed resident #64 on 5/12/17 with the communication sheet and with yes and no questions. The CAA further stated 12/15 on the BIMS as Resident #64 could not pronounce the words due to his [MEDICAL CONDITION]. Resident #64 could communicate his needs daily through his communication sheet which had pictures and words. When he was ready to lay down he points to the bed. It further stated, will care pan his communication. Observation of Resident #64 on 12/6/17 at 7:20am revealed the resident to have a black communication book on his bedside table. Interview with the DON on 12/7/17 at 9:002am revealed it was her expectation that Resident #64 needs for communication be care planned. Interview with the MDS Coordinator on 12/7/17 at 11:12am revealed she was unaware Resident #64 utilized a communication sheet/book for a means of communication. She further indicated Resident #64 should have been care planned for his use of a communication device and she was unsure why the residents needs in communication was not developed. Interview with the Administrator on 12/7/17 at 3:59pm revealed it was his expectation that Resident #64 communication needs be care planned. c. Review of Resident #64 Care plan revealed no care plan for the [DIAGNOSES REDACTED]. Review of Resident #64 admission history and physical exam dated 5/5/17 revealed a problem master list that included [MEDICAL CONDITION]. The medications included [MEDICATION NAME] 200 milligrams (mg) by mouth twice daily and [MEDICATION NAME] 100mg by mouth every morning (a.m.). The admission history and physical exam further revealed Resident #64 had an allergy to [MEDICATION NAME]. Review of Resident #64 monthly physician note dated 8/10/17 revealed the resident was seen for follow up for [DIAGNOSES REDACTED]. The goal stated member had no [MEDICAL CONDITION] activity on current medication regimen by goal evaluation date. The treatment plan revealed [MEDICAL CONDITION] secondary to [DIAGNOSES REDACTED] was chronic and managed. Resident #64 had an allergy to [MEDICATION NAME]. No recent [MEDICAL CONDITION] activity and no information in medial record for last reported [MEDICAL CONDITION] activity. The note continued with [MEDICATION NAME] in place to be used with onset of [MEDICAL CONDITION] activity. The plan was to continue with current plan of care (P(NAME)) and m/e for need for titration of P(NAME) as indicated to reach/maintain goals. The physician note indicated there was a discussion with responsible party (RP) about usage of medications with side effects; risk and benefits of mediations and they were in agreement with its usage. The medications included [MEDICATION NAME]; [MEDICATION NAME]. Interview with the Director of Nursing (DON) on 12/7/17 at 9:02am revealed it was her expectation that care plans reflect the resident's disease process. Interview with the MDS Coordinator on 12/7/17 at 11:12 am revealed Resident #64 [DIAGNOSES REDACTED]. Interview with the Administrator on 12/7/17 at 3:59pm revealed it was his expectation that Resident #64 have a care plan in regard to his [DIAGNOSES REDACTED].

Based on observations, resident and staff interviews and record review, the facility failed to apply right hand splint as written by the Director of Therapy for 1 of 1 sampled residents with limited range of motion/contractures (Resident # 56). The findings included: Resident # 56 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent MDS (Minimum Data Set) dated 10/09/17, had documentation of Resident # 56 being assessed as having intact cognition. The assessment was coded as resident having functional impairment with limited mobility of bilateral upper extremities. A review of the care plan with a problem onset dated 9/07/17, included nursing to don both upper extremity hand splints 8 hours daily as tolerated due to risk of worsening contractures. A review of the documentation by the Director of Therapy dated 9/07/17 revealed nursing had been notified for the care plan to reflect BUE (bilateral upper extremities) hand splints to be worn 8 hours daily or to patient tolerance. The Skilled Services Provided section revealed training had been completed with nursing for carryover of training in how to donn and doff the BUE splints to decrease the risk of worsening contracture. The document read: Patient at this time is able to transition to nursing care for splint application. The treatment [DIAGNOSES REDACTED]. During a review of the resident's physician orders, an order dated 8/28/17 read: Place resting hand splint to left hand at hs (hour of sleep) and remove every AM (morning). No other orders were written to reflect BUE hand splints to be worn hours 8 daily or to patient tolerance since the discharge summary of the Director of Therapy and care plan had been updated on 9/07/17. An interview on 12/07/17 at 3:26 PM with Nurse # 8 revealed the nurse who wrote the order for Resident # 56 to wear a left hand splint and left off the order for the right hand splint. The nurse who wrote the order no longer worked in the facility. Observations on 12/04/17 at 11:37 AM, 12/05/17 at 3:58 PM, and 12/06/17 at 7:59 AM, revealed bilateral hand splints were placed on the nightstand in the room for Resident # 56. In an interview on 12/05/17 at 3:58 PM, Resident # 56 stated the splint for her left arm was worn at night. She continued to explain the right hand splint was supposed to be worn during the day but the staff had been too busy because they had been short-staffed and she did not want to bother them. An interview on 12/06/17 at 8:00 AM was conducted with NA (Nursing Assistant) # 2 who stated Resident # 56 had a slightly contracted right hand. She continued to explain a splint had been worn during the day but was stopped because of a cream applied during the day. The splint is now worn at night and taken off before the third shift nurse goes home. She added that only nurses have orders related to splints and the nurse would verbally communicate to the NA any special considerations. An interview on 12/07/17 at 6:52 AM was conducted via telephone with Nurse # 7. Nurse # 7 indicated she removed the splint to the left hand at the end of her shift each morning. She explained the right arm brace was not worn at night. An interview on 12/07/17 at 9:50 AM with the MDS Coordinator revealed care plans were put together by her department after receiving communication from the therapy department. The MDS Coordinator stated she was responsible for care plans to match the orders. She explained it was the MDS Coordinator's responsibility to ensure orders match the care plan. An interview on 12/07/17 at 10:50 AM with the Administrator revealed he was not aware staff had not applied the right hand splint for Resident # 56. He stated his expectation was for the care plan to reflect the resident's orders. An interview on 12/07/17 at 3:10 PM with the MDS Coordinator revealed the order for the right hand splint was reviewed and the nurse on the unit was handed the discharge summary from OT (Occupational Therapy) on 9/07/17. She wrote the order for the left hand splint and did not write the order for the right hand splint.

Based on observation, interviews, and review of the facility policy, the facility failed to ensure nursing staff performed hand hygiene after removing gloves during a dressing change for three separate wound sites and failed to disinfect the scissors used during the treatment for 1 of 1 resident (Resident # 38) and failed to wash hands between touching residents and prior to touching the end of straws residents used for consumption of fluids and while passing meal trays during 1 of 2 meal observations for 3 resident rooms on hall 700 (resident rooms #709 bed A and Bed B, 710 and 703). Findings included: 1. A review of the facility's policy entitled, Skin and Wound Management, adopted from the Nursing Services Policy and Procedure Manual for Long-Term Care 2001 MED-PASS, Inc. with a revision date of September 2013, revealed to wash and dry hands thoroughly each time before putting on clean gloves. Resident # 38 was admitted on [DATE] and readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of the most recent MDS (Minimum Data Set) dated 11/26/17, coded as an admission assessment, had documentation of Resident # 38 needing extensive assistance with activities of daily living, and as having a surgical incision and diabetic ulcers. An observation on 12/06/17 at 10:24 AM, revealed Nurse # 6 had not washed her hands after taking off dirty gloves used to remove the soiled dressing for a surgical site and continued to treatment. The nurse did not wash her hands again after taking off two other soiled dressings for 2 diabetic ulcers for Resident # 38. After the dressing was completed it was observed that Nurse # 6 did not decontaminate the scissors used before placing it into her pocket. In an interview on 12/06/17 at 10:40 AM, Nurse # 6 stated she did not wash her hands after taking off her dirty gloves before putting on clean gloves throughout the dressing change for Resident # 38. Nurse # 6 continued to explain she had forgotten to clean the scissors used during the dressing treatment. In an interview on 12/07/17 at 11:13 AM, the SDC (Staff Development Coordinator) stated her expectation and what she trained staff was to wash your hands with soap and water anytime you removed your gloves. She explained during a wound care dressing change, the nurse should wash hands before taking off an old dressing, then remove gloves, wash your hands with soap and water, and then put on new gloves to proceed with wound care treatment. The SDC revealed the scissors used during a dressing change should be cleaned with a wipe from the purple container (Germicidal Wipe) after the dressing change and before placed into a scrub pocket. An interview was conducted on 12/07/17 at 11:57 AM with the Assistant Administrator who stated it was her expectation that hands were to be washed after each time gloves were removed before putting on new gloves. The Assistant Administrator revealed Nurse # 6 had spoken to her about the occurrence and had told her she was just nervous and forgot. The Assistant Administrator continued to indicate that the scissors used during the dressing change should have been cleaned with a germicidal wipe after the dressing change before placed in her scrub pocket. An interview was conducted on 12/07/17 at 12:15 PM with the Administrator. He stated his expectation was for staff to clean their hands after removing gloves in any situation. He continued to reveal the scissors used during a dressing change should be cleaned before placed in the nurse's scrub pocket. 2. Review of facility policy titled, Handwashing/Hand Hygiene (revised August 2015) stated the facility considered hand hygiene the primary means to prevent the spread of infections. The policy interpretation and implementation included (2) all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. (3) hand hygiene products and supplies (sink, soap, towels, alcohol-based hand rub, ect.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. (7) use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b) before and after direct contact with residents; (l) after contact with objects (e.g., medical equipment) in the immediate vicinity of the residents; (o) before and after eating or handling food (p) before and after assisting a resident with meals. A continuous observation was conducted of meal service for hall 700 on 12/14/17 at 12:01pm through 12:20pm. a. Nursing assistant (NA) #9 was observed to enter room [ROOM NUMBER] and begin tray set up for bed B. NA#9 removed corn bread from its white paper packaging and placed the cornbread in her hands. She was further observed to remove silver wear from its white paper packaging and held the eating utensils with her hands. The bedside table was positioned in front of the resident. NA#9 physically touched the straw on both ends while removing the paper and placed the straw in the resident's fluids. b. NA#9 was observed to exit resident room [ROOM NUMBER], return to the meal cart located on the hall and retrieved resident meal tray for room [ROOM NUMBER] bed A. NA#9 was observed to position the resident's bedside table directly in front of the resident. NA#9 removed two straws from their original packaging and touched the end of the straws before placing them into the resident's fluids. NA#9 was observed to exit room [ROOM NUMBER] and return to the meal cart. c. NA#9 retrieved the meal tray for resident room [ROOM NUMBER] bed A. She was observed to directly touch the resident's silverware with her hands. d.NA#9 was observed to retrieve meal tray for resident room [ROOM NUMBER] bed A. The resident was assisted with donning a clothing protector and NA#9 adjusted the resident's bedside table height. NA#9 removed the resident's silverware from its white paper packaging and held the eating utensils with her hands. Further observed revealed NA#9 to open drinks and spread butter on the resident's bread. At 12:13pm the resident in room [ROOM NUMBER] was assisted by NA#9 with dining. Observations from 12:01pm through 12:20pm revealed NA#9 to not wash her hands between touching residents, adjusting bedside tables, touching silver wear, straws or prior to assisting a resident with dining. Interview with NA#9 on 12/4/17 at 12:50pm revealed she did not wash her hands between resident's meal tray set up. She stated the she did not have any hand sanitizer on her person. She further indicated she should have washed her hands or sanitize her hands when exiting the rooms and between meal set-up. Interview with the Administrator on 12/7/15 at 4:25 pm indicated his expectation was for staff to wash hands between touching residents and meal tray set up.

Based on observations, staff interviews and record reviews the facility failed to honor Resident #167 ' s choice to be served a Mechanical Soft sandwich at lunch and supper. This was evident in 1 of 4 residents in the sample reviewed for choices. Findings Included: Resident #162 was admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. A review of Resident #162 ' s annual comprehensive minimum data set ((MDS) dated [DATE] revealed that she required extensive assistance with eating, had experienced significant weight loss and had moderately impaired cognition. A review of Resident #167 ' s care plan dated 9/15/16 revealed that she was at high nutritional risk related to receiving a mechanically altered diet with poor to fair meal intake. The goal for Resident #167 was she would not experience any significant weight changes and would tolerate diet as ordered during the next 90 days. The approaches for Resident #167 included: Provide diet and supplements as ordered and honor food preferences. A review of the nutritional therapy evaluation dated 9/15/16 for Resident #167 revealed she received a Puree diet with a Mechanical Soft sandwich at the lunch and dinner meals and her average meal intake was 25 to 50%, A review of the October 2016 physician (MD) orders for Resident #167 revealed an order for [REDACTED]. A review of the MD progress note dated 10/7/16 for Resident #167 revealed that the resident had complained about receiving puree food and that her Responsible Party (RP) would like a Speech Therapy consult. The family would like her to receive a diet that would alternate between Mechanical Soft and Puree foods and would consider signing a waiver to allow the resident to eat the foods she likes for quality of life. The note also included that weight loss was anticipated for the Resident #167 with disease progression. An order was written on 10/7/16 for a Speech Therapy consult for diet upgrade. An observation of Resident #167 on 10/10/16 at 12:29 pm revealed she was sitting up in bed. Her lunch tray was delivered to her room. The meal card on her tray identified her name and a diet order for a Puree diet with a Mechanical Soft sandwich at lunch and supper. Her meal tray included a plate of puree food, a container of ice cream and 2 beverages. There was not a Mechanical Soft sandwich on the meal tray. The nursing assistant began feeding her and the Mechanical Soft sandwich was not provided. An observation of Resident #167 on 10/12/2016 at 5:59 pm revealed she was sitting up in bed. The meal card on her tray identified her name and a diet order for a Puree diet with a Mechanical Soft sandwich at lunch and supper. Her meal tray included a plate of puree food, a bowl of puree dessert and 2 beverages. There was not a Mechanical Soft sandwich on the meal tray. The nurse entered the room and stated she was coming to feed her; the Mechanical Soft sandwich was not provided. An interview with the Registered Dietitian (RD) on 10/13/16 at 9:33 am revealed that Resident #167 has had problems with not eating well. She stated that she received a Puree diet with a Mechanical Soft sandwich at lunch and supper. She stated that Resident #167 should have received a Mechanical Soft sandwich at her lunch and supper meals. An interview with the Dietary Manager on 10/13/16 at 11:14 am revealed that the diet order for Resident #167 was for a Puree diet with a Mechanical Soft sandwich at lunch and supper. He stated that she should have received the Mechanical Soft sandwich and confirmed that the sandwich was documented on her tray card. He stated that the dietary staff on the tray line should be checking the tray cards for accuracy. An interview with the facility Administrator on 10/13/2016 at 2:26 pm revealed that his expectation was that Resident #167 should have received the Mechanical Soft sandwich with her lunch and supper meals as ordered by the physician.

Based on observations, record reviews, resident and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately for 1 of 3 residents reviewed for incontinence (Resident #112). The facility failed to accuracy code on the MDS the dental status for 1 of 3 residents reviewed for nutrition. (Resident #162) 1. Resident #112 was admitted to the facility on [DATE] with cumulative [DIAGNOSES REDACTED]. Record review of the titled Bladder form (used by the Nursing Assistant (NA) to document whether the resident was continent or incontinent of urine) dated 5/27/16-6/02/16 revealed on 5/27/16 at 8:24 PM the resident was continent of urine. All the other times the resident was noted as incontinent of urine. Review of the admission MDS assessment dated [DATE] revealed the resident was coded as frequently incontinent of urine. Review of the quarterly MDS assessment dated [DATE] revealed the resident was coded as always incontinent of urine. Interview on 10/13/2016 at 10:23 AM with Nurse #3 revealed Resident #112 had always been incontinent of urine and bowels since admission to the facility. Interview on 10/13/2016 at 10:25 AM with NA #1 revealed Resident #112 had always been incontinent of bladder and bowel. Interview on 10/13/2016 at 10:35 AM with NA #2 revealed Resident #112 she had always been incontinent of urine and bowels. NA #2 stated I do not believe the resident could ever be continent of urine due to her mental status. Continued interview with NA #2 revealed the change in Resident #112 was initially being fed by gastrostomy tube and now eating a pureed diet. Interview on 10/13/2016 at 2:58 PM with NA #3 revealed her documentation on the bladder form for 5/27/16 regarding continence of urine was coded in error. NA #3 stated Resident #112 had been always incontinent of urine. The MDS coordinator who conducted the assessment on 6/02/16 was no longer employed at the facility and an interview was unsuccessful. Interview on 10/13/2016 at 3 PM with the Director of Nursing revealed the facility had made attempts to review the MDS assessments for accuracy by the use of a new program that would monitor for discrepancies. Interview on 10/13/2016 at 3:07 PM with the Administrator revealed he expected the MDS assessment be accurate. 2. Resident #162 was admitted to the facility on [DATE] and her [DIAGNOSES REDACTED]. A review of Resident #162 ' s admission Nursing assessment dated [DATE] revealed the resident had her own teeth and was edentulous. A review of Resident #162 ' s Speech Therapy evaluation dated 7/6/16 to 8/4/16 revealed that the resident had missing teeth. A review of the annual comprehensive Minimum Data Set (MDS) for Resident #162 dated 9/16/16 revealed her cognition was moderately impaired and she required extensive assistance with her activities of daily living (ADL ' s). The resident ' s MDS Assessment did not identify any dental concerns. An observation of Resident #162 on 10/12/16 at 5:59 pm revealed she was sitting up in bed and her dinner meal of a puree diet was in her room. The resident vocalized that her teeth hurt. An interview with MDS Nurse #1 and MDS Nurse #2 on 10/13/16 at 8:58 am revealed that they had not completed the resident ' s MDS dated [DATE]. An observation of Resident #162 with MDS Nurse #1 and MDS Nurse #2 revealed an examination of Resident #162 ' s mouth by MDS Nurse #1. She stated that she observed a cavity and missing teeth. She also stated that she would code Section L of the MDS for this resident as decay and missing teeth and she was going to do a correction to the MDS dated [DATE]. An interview with MDS Nurse #1 and MDS Nurse #2 on 10/13/16 at 4:41 pm revealed that MDS Nurse #2 had completed the MDS dated [DATE] for Resident #162. She stated that she was unable to examine the resident ' s mouth during the look back period for Section L of the MDS assessment dated [DATE] and she had coded Section L based on the Nurse Practioner ' s note dated 9/13/16. An interview with the Director of Nursing (DON) on 10/13/2016 at 5:00 pm revealed the coding was incorrect for the MDS dated [DATE], Section L for Resident #162.

Based on observations, record review, and staff interviews the facility failed ensure there were not duplicate MEDICATION ORDERS FOR [REDACTED]. Findings included: Resident #20 was admitted on [DATE] with the current [DIAGNOSES REDACTED]. The resident's MDS assessment dated [DATE] revealed the resident was cognitively intact. The resident had active [DIAGNOSES REDACTED]. The resident was on an antianxiety, antidepressant and a diuretic medication. A physician order [REDACTED]. Standing admission orders [REDACTED]. A specific order must be obtained from resident ' s Physician for continued administration after 24 hours. The physician ' s telephone order sheet dated 2/19/16 revealed [MEDICATION NAME] 12.5 mg was ordered by mouth every 12 hours as needed for nausea. The physician ' s monthly orders from 2/2016 through 10/2016 revealed the resident had [MEDICATION NAME] 12.5 milligrams (mgs) ordered by mouth every 12 hours as needed for nausea and [MEDICATION NAME] 25mg ordered by mouth every 12 hours as needed for nausea. The resident ' s Medication Administration Record [REDACTED]. The resident also had another order for [MEDICATION NAME] 25mg ordered by mouth every 12 hours as needed for nausea. Review of the MARs from 2/2016 through 10/2016 revealed both 12.5 mg and 25 mg of [MEDICATION NAME] had being given during those months. Pharmacy reviews were reviewed from 2/2016 through 10/2016. There were no recommendations made for [MEDICATION NAME]. Review of nursing notes from 8/2/16 through 10/1/16 revealed the resident did not have any adverse reactions to medications given. Resident #20 was observed in bed at 10/12/16 at 3:23 PM. The resident was observed lying in bed with no signs or symptoms of adverse reactions to medications noted. No signs of drowsiness were noted. Nurse #1 was interviewed on 10/12/16 at 4:53 PM. She stated that there were two orders for [MEDICATION NAME]. One was for [MEDICATION NAME] 12.5mg every 12 hours as needed for nausea and the other was for [MEDICATION NAME] 25mg every 12 hours as needed for nausea. She stated she was not sure which one the resident would get. She stated she needed to look into that. She stated that both were on the MAR for that day. Nurse #2 was interviewed on 10/12/16 at 5:09 PM. She stated they had standing orders of 25mg of [MEDICATION NAME] unless otherwise specified. She stated the resident had orders for both 25 mg and 12.5 mg of [MEDICATION NAME] by mouth as needed every 12 hours. Nurse #2 explained that on 2/19/16, the resident had orders for 12.5 mg of [MEDICATION NAME]. She stated that the 25 mg of [MEDICATION NAME] would be only for 24 hours unless the physician prescribed it. She stated that typically if the standing orders were used after 24 hours, then the MD would have to write an order for [REDACTED]. The pharmacy consultant was interviewed on 10/13/16 at 9:31 AM. She stated that for the pharmacy reviews, she would review each resident ' s chart which includes vital signs, nursing notes for behavioral changes, physician orders, look for [DIAGNOSES REDACTED]. She would also look at labs and would make sure the labs were being completed on time. She stated she would normally catch if a resident had two orders for the same medication but was not sure why it wasn ' t caught. She stated that the maximum dose is 50 mg for [MEDICATION NAME] and that having two separate orders for the medication was an oversight. She stated that [MEDICATION NAME] could be taken every 4 to 6 hrs. She explained an adverse effect of the medication would be drowsiness, and considering the other medications the resident was on, this medication could cause increased drowsiness. The Physician was interviewed on 10/13/16 at 9:57 AM. He stated the lower dose of [MEDICATION NAME] was better for elderly residents and that he thought he wrote for 12.5 mg of [MEDICATION NAME] as needed for nausea. He stated he was not recently made aware of any issues with [MEDICATION NAME] by pharmacy. He stated that the standing admission orders [REDACTED]. The Director of Nursing was interviewed on 10/13/16 at 11:15 AM. She stated if a resident needed a standing order the Physician would initiate the standing orders. She explained a standing order was supposed to be active for 24 hours only. She stated the pharmacist contacted the physician today (10/13/16) and discontinued the 25mg of [MEDICATION NAME] order. From looking at the MAR, she stated it appeared the standing order was for the 25mg of [MEDICATION NAME], and that the standing order should have been set up for 24 hours only. She added that she would expect for the nurse to follow up with the physician after 24 hours to determine whether the medication was still needed. A physician telephone order sheet dated 10/13/16 revealed [MEDICATION NAME] 25mg was discontinued.

Based on observations, record review, and staff interviews the facility failed to ensure the pharmacist identified a medication irregularity to prevent duplicate medication therapy for 1 of 5 sampled residents reviewed for unnecessary medications (Resident #20). Findings included: Resident #20 was admitted on [DATE] with the current [DIAGNOSES REDACTED]. The resident's Minimum Data Set ((MDS) dated [DATE] revealed the resident was cognitively intact. The resident had active [DIAGNOSES REDACTED]. The resident was on an antianxiety, antidepressant and a diuretic medication. A physician order [REDACTED]. Standing admission orders [REDACTED]. A specific order must be obtained from resident ' s Physician for continued administration after 24 hours. The physician ' s telephone order sheet dated 2/19/16 revealed Promethazine 12.5 mg was ordered by mouth every 12 hours as needed for nausea. Review of the physician ' s monthly orders from 2/2016 through 10/2016 revealed the resident had Promethazine 12.5 milligrams (mgs) ordered by mouth every 12 hours as needed for nausea and Promethazine 25mg ordered by mouth every 12 hours as needed for nausea. The resident ' s Medication Administration Record [REDACTED]. The resident also had another order for Promethazine 25mg ordered by mouth every 12 hours as needed for nausea. Review of the MARs from 2/2016 through 10/2016 revealed both 12.5 mg and 25 mg of Promethazine had being given during those months. Review of Resident #20 ' s monthly Pharmacy reviews from 2/2016 through 10/2016 revealed the facility ' s consultant pharmacist made no recommendations regarding the resident having two different physician orders [REDACTED]. Resident #20 was observed in bed at 10/12/16 at 3:23 PM. The resident was observed lying in bed with no signs or symptoms of adverse reactions to medications noted. No signs of drowsiness were noted. Nurse #1 was interviewed on 10/12/16 at 4:53 PM. She stated Resident #20 had two orders for Promethazine. One order was for 12.5mg every 12 hours as needed for nausea and the other was for 25mg every 12 hours as needed for nausea. She stated she was not sure which one the resident would get. She stated she needed to look into that. She stated that both of the resident ' s Promethazine orders were on the resident ' s MAR for that day. Nurse #2 was interviewed on 10/12/16 at 5:09 PM. She stated they will have standing orders of 25mg of Promethazine unless otherwise specified. She stated the resident had orders for 25mg and 12.5mg of promethazine by mouth as needed every 12 hours. On 2/19/16, an order was written for the resident to receive 12.5 mg of Promethazine. Nurse #2 stated the physician's order [REDACTED]. She stated that typically if the standing orders are used then the physician would have an order for [REDACTED]. The pharmacy consultant was interviewed on 10/13/16 at 9:31 AM. She stated that for the pharmacy reviews, she would review each resident ' s chart which includes vital signs, nursing notes for behavioral changes, physician orders, look for [DIAGNOSES REDACTED]. She will also look at labs and will make sure the labs are being completed on time. She would normally feel that she would catch if a resident had two orders for the same medication but was not sure why she did not identify that. Resident #20 had two orders for the administration of Promethazine. She stated that the maximum daily dose is 50 mg for Promethazine. The resident having two separate orders for the medication was an oversight. She stated that Promethazine can be taken every 4 to 6 hours. She explained an adverse effect of the medication would be drowsiness, and considering the other medications the resident was on, this medication could cause increased drowsiness. The Physician was interviewed on 10/13/16 at 9:57 AM. He stated the lower dose of Promethazine was better for elderly residents. He stated he thought he wrote an order for [REDACTED]. He stated that the standing admission orders [REDACTED]. The Director of Nursing (DON) was interviewed on 10/13/16 at 11:15 AM. She stated that if a resident needed a standing order the Physician would initiate the standing orders. A standing order is supposed to be for 24 hours. The DON stated the pharmacist contacted the physician today (10/13/16) and the physician discontinued Resident #20 ' s order for the administration of 25mg of Promethazine every 12 hours as needed for nausea. The DON explained from reviewing the resident ' s MAR, it appeared the standing order was for the 25mg of Promethazine and the standing order should only be set up for 24 hour hours. The DON stated if the resident had 2 different orders for the same medication, the electronic MAR indicated [REDACTED]. The DON stated her expectation for pharmacy reviews was for pharmacy to pick up on duplicate medications orders. Her expectation for medications was to assure setting up standing orders for only 24 hours and then following up with the physician if medication are needed. Further review of Resident #20 ' s medical record revealed a physician ' s telephone order dated 10/13/16 which discontinued the resident ' s order for Promethazine 25mg every 12 hours as needed for nausea.

Based on observation, record reviews, staff and resident interviews, the facility ' s Quality Assurance and Assessment (QAA) Committee failed to maintain procedures and monitor the interventions that the committee put into place following the October 29, 2015 recertification in the areas of Choices (F 242) and Assessment Accuracy (F278). These deficiencies F242 and F 278 were recited on the recertification survey of October 13, 2016. The continued failure of the facility during two consecutive federal survey of record (F242 and F 287) showed a pattern of the facility inability to sustain an effective Quality Assurance (QAA) Program. The findings included: This citation was cross referenced to: 1. F 242-. Based on observations, staff interviews and record reviews the facility failed to honor Resident #167's choice to be served a Mechanical Soft sandwich at lunch and supper. This was evident in 1 of 4 residents in the sample reviewed for choices. During the recertification survey conducted October 29, 2015, the facility failed to allow residents to make bathing choices that were significant for 2 of 4 resident review for activities of daily living during 2. F 278 - Based on observations, record reviews, resident and staff interviews, and the facility failed to code the Minimum Data Set (MDS) assessment accurately for 1 of 3 residents reviewed for incontinence (Resident #112). The facility failed to accuracy code on the MDS the dental status for 1 of 3 residents reviewed for nutrition. (Resident #162) During the recertification survey conducted October 29, 2015, the facility failed to 1) accurately code on the Minimum Data Set (MDS) assessment to reflect Preadmission screening and resident review (PASARR) for 1 of 1 resident in the sample reviewed for PASRR and 2) failed to accurately code the admission MDS to reflect the administration to 1 of 5 residents reviewed for pneumococcal vaccinations. Interview with Quality Assurance (QA) Nurse on 10/13/2016 at 3:30PM revealed the facility will continue to implement and monitor concerns and issues with repeat and new citation. Continued interview with the QA nurse indicated the QAA committee currently uses the Quality Assurance and Performance Improvement (QAPI) concept and the team will meet monthly to maintain procedures and monitor interventions that the committee had put in place. Further interview with the QA Nurse revealed that QAPI meeting was scheduled to meet after this survey.

Based on observations, staff interviews, interview with the dietitian and record review of the policy and procedure, the facility failed to date and label food items stored in the walk in dairy refrigerator. (2) The facility failed to date and label food item stored in the walk in refrigerator #2. (3) The facility failed to date and label food item stored in the dry storage area. These were evident during 1 of 2 observations in the kitchen. Findings included: Review of the facility policy entitled, Food Receiving and Storage, revised 12/08, revealed in part: Under Policy Interpretation and Implementation Step 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated. Observations during the initial tour of the kitchen conducted on 10/26/2015 at 2:46:07 PM with Cook #1 revealed the following identified concerns: 1. Dairy refrigerator: a. There were 26 ramekins which contained a thick white substance stored that were unlabeled and undated. Interview on 10/26/2015 at 2:46:07 PM with Cook #1 identified the substance as sour cream. b. There was a 1/3 full (3 quart) container of turkey salad (identified by Cook #1) stored and dated 10/16/15 but unlabeled. c. There were 3 plastic containers of fruit (one each of peaches, pears and pineapples) stored but not in their original containers. These containers were unlabeled and undated. d. There were 2 opened 80 ounce containers of fresh all breast chicken salad stored. One container was 3/4 full and one container was 1/2 full. These containers were undated. e. There was a ½ full 5 pound (lb.) container of pimento spread stored undated. f. There was a 5 lb. container of cottage cheese 3/4 full stored undated. g. There was a gallon size container of sliced ham stored out of the original package undated and unlabeled. h. There was shredded cheese out of the original container stored in a 1 gallon plastic bag unlabeled and undated. Interview on 10/29/2015 at 10:07:56 AM with the consultant dietitian and Certified Dietary Manager (CDM) was conducted. The CDM indicated his expectations were food items stored in the refrigerator and dry storage area be labeled and dated. The dietitian confirmed his expectation. Continued interview with the CDM revealed he recently (no date provided) conducted an in- service on dating and labeling stored food items. Interview on 10/29/2015 at 11:31:08 AM with the administrator and assistant administrator was held. The administrator and assistant administrator revealed their expectations were food items be labeled, dated and properly stored. 2. Walk in Refrigerator #2 a. There were 3 trays of plastic wrapped handmade sandwiches. One tray stored 13 sandwiches. Interview on 10/26/15 at 3 pm with Dietary aide #2 identified on one tray (3) peanut butter, (5) pimento cheese and (5) chicken salad sandwiches. One tray stored (1) peanut butter and jelly, (5) pimento cheese and (5) chicken salad sandwiches. The third tray stored (11) sandwiches (3) peanut butter and (8) cheese sandwiches. These trays or sandwiches were undated and unlabeled. Continued interview with Dietary aide #2 revealed food items once opened should be dated and labeled. b. There were 6 (6 inch) facility made pizzas stored in an unsealed plastic bag undated and unlabeled. Interview on 10/29/2015 at 10:07:56 AM with the consultant dietitian and Certified Dietary Manager (CDM) was conducted. The CDM indicated his expectations were food items stored in the refrigerator and dry storage area be labeled and dated. The dietitian confirmed his expectation. Continued interview with the CDM revealed he recently (no date provided) conducted an in- service on dating and labeling stored food items. Interview on 10/29/2015 at 11:31:08 AM with the administrator and assistant administrator was held. The administrator and assistant administrator revealed their expectations were food items be labeled, dated and properly stored. 3. Dried Storage area: a. There was a 1/2 full gallon plastic bag unlabeled and undated which contained a food item. On 10/26/2015 at 3:46:59 PM Cook #1 indicated the food item in the plastic bag was uncooked rice pilaf. Cook #1 indicated open food items should be stored with a label and date. Interview on 10/29/2015 at 10:07:56 AM with the consultant dietitian and Certified Dietary Manager (CDM) was conducted. The CDM indicated his expectations were food items stored in the refrigerator and dry storage area be labeled and dated. The dietitian confirmed his expectation. Continued interview with the CDM revealed he recently (no date provided) conducted an in- service on dating and labeling stored food items. Interview on 10/29/2015 at 11:31:08 AM with the administrator and assistant administrator was held. The administrator and assistant administrator revealed their expectations were food items be labeled, dated and properly stored.

Based on record review, resident and staff interviews and observations, the facility failed to allow residents to make bathing choices that were significant to the resident for 2 of 4 residents (Resident #70 and Resident #47) reviewed for Activities of Daily Living (ADL ' s). Finding Included: 1.) Resident #70 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. The Minimal Data Set ((MDS) dated [DATE] revealed that resident was severely cognitively impaired. Resident # 70 required extensive assistance in bed mobility, transfers, locomotion, dressing, and personal hygiene. Resident #70 also required physical help with bathing. Nursing Note dated 10/25/15 stated that resident #70 was alert and oriented times four and able to make needs known to staff verbally. Staff provided total care of Activities of Daily Living (ADL ' s) for resident using two person assistance and a mechanical lift. Resident #70 was interviewed on 10/28/15 at 2:50 PM. Resident stated that she had not received a whirlpool bath for three weeks. She was given a bed bath everyday but liked to have a whirlpool bath on Monday instead. Monday was her scheduled day to get a whirlpool bath. If she was given a whirlpool bath on Monday as scheduled, then she was fine with getting a bed bath the other days. The last three weeks the Nursing Assistant (NA) informed her they were not doing whirlpool baths on Mondays. She received a sponge bath instead but wanted a whirlpool bath. The Whirlpool bath schedule (no date) was reviewed and revealed resident #70 was scheduled to get a whirlpool bath on Mondays. Review of the Care Task sheet revealed documentation which indicated Resident #70 had received one whirlpool bath, one shower and two bed baths between 10/1/15 and 10/26/15. The Nursing Assistant (NA) #1 was interviewed on 10/28/15 at 2:24 PM. She stated she was responsible for giving residents the whirlpool baths every other Monday and Friday. She had not given any whirlpools this month. Some days the daily schedule would say no whirlpools would be given that day. On those occasions, Nursing Assistants would notify residents that no whirlpools would be given that day. She also stated that if a resident was scheduled for a whirlpool bath and it were cancelled, they would not be moved to a different day to receive a whirlpool bath. The Nursing Assistant (NA) #2 was interviewed 10/29/15 at 9:53 AM. He stated that the shower schedule was posted on the inside door of the shower room and also in the chart, which was how he knew the day and type of bath the resident was to receive. NA #2 reviewed the schedule and was aware Resident #70 was supposed to get a whirlpool bath on Mondays. Nurse #2 was interviewed on 10/28/15 at 2:28 PM. She stated there had been some issues with staffing on Mondays and they had to pull the Nursing Assistants to work the floor instead of giving whirlpool baths. She stated a resident could get a shower and any NA could give a shower to the resident. Only certain staff members could give whirlpool baths to residents. The NA would inform residents that they were not going to have a whirlpool bath that day. Nurse #2 said she remembered Resident #70 had complained to her before about not being able to have a whirlpool bath. An interview was conducted on 10/28/15 at 11:20 AM with the person responsible for scheduling the Nursing Assistants. She stated staff who give whirlpool baths were the last to be pulled to work the floor, and her expectation would be for the residents to get a whirlpool bath. The Administrator was interviewed on 10/29/15 at 9:29 AM. She stated her expectation was if they have the staff, then to provide whirlpool baths to residents. Resident # 47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was coded with no problems with short and long term memory (BIMS 15), had no mood or behavior problems, bathing required physical help with one person physical assist, transfers required extensive assist with 2 plus persons physical assist and ambulated in room with limited assist with 1 person physical assist. Review of the Task Care Plan dated 1/17/15 listed the following approaches: Whirlpool every Monday. Shower every Thursday 7-3. Interview with Resident #47 on 10/28/15 at 1:30 PM revealed that no one had ever asked her about a shower. She continued that she did not want a man giving her a shower. Asked for whirlpool because it helped her legs feel better. She would like the whirlpool twice a week. Interview on 10/28/15 at 11:30 AM with NA #3 (who was assigned to care for resident) revealed that Resident #47 did not like to have him do her showers. NA #3 continued that he could not find another NA to give her a shower. He had not thought about switching another resident for Resident #47 on shower days. He reported that he did not know what day her shower was scheduled. NA #3 indicated he had not notified the nurse about the resident ' s choice of not having males care for her. Interview on 10/29/15 at 10:29 AM with NA #3 revealed, when asked if Resident #47 received her routine whirlpool and showers, he replied, I think so. He continued that he did not know about the whirlpool. There was a certain person who only did the whirlpool bath. Interview on 10/28/15 at 10:32 AM with NA #4,( the whirlpool bath person), revealed that Resident # 47 was to get the whirlpools on Mondays and she had not had one in 3 weeks. NA #4 reported that she didn't work every Monday. She continued that when she arrived for work on Mondays, she just went in to see what her schedule said and did her job. Sometimes if someone called out, she would be the replacement for the call out. Interview on 10/28/15 at 10:43 AM with Nurse #5, (Resident # 47 ' s nurse), said she usually did not work on the 600 hall so she did not know why the resident was not getting her whirlpool baths. Interview on 10/28/15 at 11:05 AM with Nurse #6 revealed the whirlpool was not done. No reason had been provided. Interview on 10/28/15 at 11:10 AM with Nurse #7 revealed that she was the scheduler each week. If there was a call out, NA #4 would have to take care of the residents. We have staff members that we can pull from and sometimes staff who provided whirlpool baths have to be pulled. If staff was pulled, the resident will not get the whirlpool that day. NA #4 was the last person on the floor to be pulled. The whirlpool is an extra. They could be done a different day of the week. Nurse #7 indicated she had not realized that it had been 3 consecutive Mondays without a whirlpool bath. Further interview revealed her expectation and goal was to have whirlpools provided to residents by staff with special training to use the equipment. Interview on10/29/15 at 8:25 AM with Nurse #8 revealed that Resident #47 was alert and oriented, but was never told at Resident #47 did not want a male caregiver to give baths. Nurse #8 continued Resident #47 complained to her last week or week before and knew that she did not have her bath. NA #4 was working on the floor and no one was assigned to the whirlpool that day. Interview on 10/28/15 at 2:47 PM with the Administrator indicated the facility would have switched the assignment so that a male would not be caring for the resident. Further interview revealed NA #3 spoke to his peers only about Resident#47 not receiving showers or whirlpool.

Based on record review and staff interviews, the facility failed to: 1) accurately code on the Minimum Data Set (MDS) assessment to reflect Preadmission Screening and Resident Review (PASRR) for 1 of 1 resident in the sample reviewed for PASRR. (Resident #184), and 2) failed to accurately code the admission Minimum Data Set (MDS) to reflect the administration of the pneumococcal vaccination to 1 (Resident #190) of 5 residents reviewed for pneumococcal vaccination. Findings included: 1.) Resident #184 was admitted on [DATE] with cumulative [DIAGNOSES REDACTED]. Review of the PASRR Determination notification form revealed that Resident #184 was determined to be a PASRR level II since [DATE] with an expiration date of [DATE]. Resident #184 PASRR was renewed on [DATE] with an expiration date of [DATE]. Review of Resident #184 ' s Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Section A of the MDS was not coded to reflect PASRR determination. The Social Worker was interviewed on [DATE] at 10:43 AM. She stated that Resident #184 had a PASRR before he entered the facility and it was good for 60 days. The PASRR was completed on [DATE]. Resident #184 ' s PASRR expired on [DATE] and was admitted to the facility on [DATE]. She also stated it was the MDS coordinator ' s responsibility to code the PASRR section on the MDS. The Director of Nursing (DON) was interviewed on [DATE] at 11:24 AM. She stated that she was responsible for coding Resident #184 ' s MDS. She stated that Resident #184 ' s PASSR was not coded on the MDS, which was an oversight. That the MDS coordinators are typically responsible for coding section A of the MDS. The Administrator was interviewed on [DATE] at 9:28 AM. She stated that whoever is completing the assessment on the MDS is responsible for coding the PASSR section of the MDS. She stated that her expectation is for the MDS to be coded accurately. 2.) Resident #190 was admitted to the facility on [DATE] with admission [DIAGNOSES REDACTED]. A review of the physician orders [REDACTED]. A review of the Medication Administration Record [REDACTED]. A review of the 14 day admission Minimum Data Set ((MDS) dated [DATE]. Section O0300B, revealed the resident did not receive the pneumococcal vaccine because of medical contraindication . An interview with the MDS coordinator on [DATE] at 10:15 AM revealed information related to pneumococcal vaccine administration for residents was obtained from the hospital discharge summary or physician orders. The MDS coordinator stated, I think (Resident #190 ' s) pneumococcal vaccine information came from the hospital discharge note. It was contraindicated for some medical reason. Our facility reviewed the hospital discharge summary and ordered the pneumovac to be given. After we get permission from the facility doctor (MD) and the resident ' s family we have standing orders to give vaccines. This resident (Resident #190) did receive the vaccine during the look back period and it should be on the MDS, but isn ' t. An interview with the facility ' s administrator on [DATE] at 10:50 AM revealed her expectation was the MDS would be accurate.

Based on record review and staff interviews, the facility failed to develop a care plan to prevent falls for 1 (Resident # 190) of 3 residents assessed for fall risks. Findings included: Resident #190 was admitted to the facility on [DATE] with admission [DIAGNOSES REDACTED]. A review of the 14 day admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #190 had severe cognitive impairment. Resident #190 required extensive assistance of 2 or more persons with all activities of daily living (ADLs), including walking in the corridor and locomotion on and off the unit. The MDS also reflected 1 fall without injury since admission to the facility. A review of the nursing notes included entries related to Resident #190 falling on 9/17/15 at 10:43 PM, 9/22/15 at 12:54 AM, 10/2/15 at 2:51 PM, and 10/4/15 at 4:25 PM. No interventions were put into place after any of the falls. A review of the care area assessments (CAA) dated 9/9/15 and 9/10/15 revealed a CAA for Falls which read in part, Analysis of Findings-Resident is at risk for falls related to her [MEDICAL CONDITION], her cognitive impairment related to her recent surgery with anesthesia as well as her incontinence. She is working with therapy at this time to improve her balance as well as her cognitive abilities. Will care plan to keep her safe and to have no significant injury from falls. A review of the care plans 9/9/15 and 9/10/15 revealed no care plan related to falls or falls risks. A care plan was initiated on 10/21/15 related to falls for Resident #190. During an interview with the MDS coordinator on 10/28/15 at 10:15 AM she stated, A care plan should be done immediately after, or within 1-2 days after a fall. If the fall happened on the weekend, or on Friday after we all have left the facility, the care plan should be done within 3 days. A 14 day assessment was completed for (Resident #190) on 9/22/15 and it was coded as (Resident #190) having had 1 fall without injury during the look back period. Her care plan for falls was initiated on 10/21/15. There was no care plan for falls before then, but there should have been. An interview with the facility ' s administrator on 10/28/15 at 10:50 AM revealed the expectation was for care plans to be accurate and updated as needed. The administrator also stated, After the first fall we look at options to prevent another fall. I would expect the care plan to be updated to reflect those options. After 4 falls I would expect a care plan for falls to have been started, or I would expect an existing care plan for falls to be updated. During an interview with Nurse #1 on 10/28/15 at 11:20 AM, she revealed Resident #190 was a falls risk. She also stated Resident #190 knew how to make her needs known, and used the call bell appropriately. Nurse #1 also stated the nursing assistants (NA) could find all resident care needs in their kiosks (computer systems used by NAs to locate resident information and place charting entries) or ask the nurses questions related to resident care needs. An interview on 10/28/15 at 3:46 PM with the director of nursing (DON) revealed residents who fell received more frequent rounds or monitoring by the staff. The facility did not use an alarm system for fall risk residents, and falls were discussed in daily stand up meetings. The DON also stated a care plan should be updated after each fall.

Based on observations, record review and interviews with facility staff, the pharmacist and the pharmacy nurse, the facility failed to remove outdated medications from the medication rooms for 2 of 2 medication rooms. (Gold Hall and Green Hall). The findings included: Record review of the policy and procedure for Storage of Medications, undated, under the title of Monitoring for Expiration Dates of Stock Medication revealed, stock medications will be checked by third shift nurses nightly for expiration dates. Stock medications will be removed at least one month prior to expiration date. For example - If medication expires in October, remove medication in September. Observations on 10/29/15 at 8:40 AM of the Gold Hall medication room containing the stock medications for halls 500, 600, 700 and 800 halls revealed the following medications stored in the medication room, out of date: 3 bottles of Multivitamins with minerals, 100 tablets, expired 9/15/15. Interview on 10/29/15 at 8:45 AM with Nurse #3 revealed that the supply person checked the stock medications. The pharmacist checked them monthly. The nurses were to check the expiration dates when they pulled the medication to use. Nurse #3 placed the expired bottles of multivitamins in the pharmacy tote for pick up to be returned to the pharmacy. Observations on 10/29/15 at 9:09 AM of the Green Hall medication room containing the stock medications for halls 100, 200, 300 and 400 halls revealed the following medications were stored in the medication room, out of date: 2 bottles of Acetaminophen 325 mg. (milligram) tablets, 100 tablets, expired 7/15/15. Omeprazole 20 mg, 2 boxes, 42 tablets in each box, expired 2/15/15. On 10/29/15 at 9:14 AM gave the expired medications to Nurse #4. She said she was new and would take care of the medications. Interview on 10/29/15 at 9:16 AM with the supply clerk revealed that she usually looked at the stock mediations on Fridays when she put the newly received stock medications up. She continued that the pharmacist also looked at the stock medications. Interview on 10/29/15 at 9:25 AM with the Assistant Administrator revealed that her expectation was to not have any expired medications. Interview on 10/29/15 at 11:30 AM with the Pharmacist revealed that she did not check the stock medications when she was at the facility. She continued that the pharmacy sent out a nurse to check for expired stock medications. Interview on 10/29/15 at 11:45 AM with the pharmacy nurse revealed that she went through the medication rooms on Monday or Tuesday to check for expired stock medications. If she found any expired medications she would give them to the nurse on the hall. Record review of the Compliance Reports dated 10/27/15, provided by the facility revealed that the pharmacy nurse had looked at the medication cart for 700 hall, medication cart for 300 hall, medication cart for 400 and 300 even room numbers and the Gold medication room. Interview on 10/29/15 at 12:41 PM with the Director of Nursing (DON) revealed that the expired medications were sent back to the pharmacy. The DON continued that the night shift continued to check stock medications every night. She had two new nurses on third shift (night shift). The supply person ordered the stock medications and brought them to the supply room. The nurses were to check the expiration dates before use. Interview on 10/29/15 at 12:55 PM with the Quality Assurance Nurse revealed that there were no problems with expired medications.

Based on observations, record reviews and staff interviews, the facility failed to transfer Resident#48 using a mechanical lift device as ordered and as developed in the plan of care. This failure resulted in a fractured lower right leg. This was evident in 1 of 3 residents in the sample reviewed for accidents. Findings included: Resident# 48 has cumulative [DIAGNOSES REDACTED]. Osteopenia is a condition where bone mineral density is lower than normal. Review of the Minimum Data Set ((MDS) dated [DATE] revealed Resident #48 had impaired cognition and required extensive assistance for care. Resident#48 ' s balance standing was unsteady and only stabilized with staff assistance. Review of the careplan (undated) located in the Kiosk (computer system used by the nursing assistants to guide and document care) revealed approaches that included" _____(name of mechanical lift) for all transfers." Review of the computerized "Physician order [REDACTED]. Review of the nurses notes dated 5/20/12 at 11:10 p.m. revealed a nursing assistant (NA) summoned the nurse that there had been an accident. Two NAs reported that they were getting Resident #48 in the bed and her foot got caught. Resident #48 sustained a skin tear and her ankle hurts. The nurse assessed the resident and noted a 4 cm (centimeter) by 5 cm skin tear to the outer aspect of the right calf. A bruise was noted to the top of the lower leg. The nurse practitioner (NP) was notified and NP orders included an x-ray of the right leg and ankle, elevation, ice application and immobilization. Review of the x-ray report dated 5/21/12 revealed a "New minimally displaced acute fracture at mid/distal shaft of the tibia" of the right leg. A tibia fracture is a break in the bone of the lower leg or shin bone. Review of the orthopedist report of consultation dated 5/22/12 revealed a long leg cast was applied on the right leg as treatment for [REDACTED]. Review of the incident report dated 5/20/12 authored by Nurse#1 revealed "The CNAs (nursing assistant) came and got me and said theres (there) been an accident. They reported to me that they were getting _____(Resident's name) in the bed and her foot got caught. She has a skin tear and says her ankle hurts." An interview on 6/13/12 at 3 p.m. with Nurse#1 via the phone revealed on 5/20/12 she was told by NA#3 and NA#4 that they were putting the resident back to bed and her foot got caught on the bedrail. The interview revealed that when they heard the resident scream they immediately repositioned her. Nurse#1 indicated the resident had a skin tear. "I called the NP and x-rays were done the next morning. I could not remember if there was a lift in the resident ' s room or in the hallway." An interview on 6/13/12 at 1:30 p.m. with Nurse#2 revealed NA#3, assigned to resident, called NA#4 from the hallway to assist her in transferring the resident. "The aides used a 2 person transfer instead of the ___(name of the mechanical lift)." Review of the typed statement dated 5/24/12 of NA#3 revealed she had told Nurse#1 that the incident occurred while transferring Resident#48 back to bed when "they actual did not use the _____(name of mechanical lift) but had it there as a deception." Unsuccessful attempts were made to contact NA#3 and NA#4. Observation of the resident on 6/14/12 at 8:30 a.m. revealed the resident was out of bed with a cast on her lower right leg. An interview on 6/13/12 at 2:10 p.m. with nursing assistant #1 (NA#1) who was assigned to care for the resident revealed Resident#48 required the use of mechanical lift for transferring as far back as November 2011. NA#2 joined the interview and indicated that she was aware that the resident required a mechanical lift for transfers as far back as September 2011 An interview on 6/14/12 at 11 a.m. with the director of nurses (DON) revealed she was told by staff that Resident#48 had a skin tear and edema of the right ankle. The DON indicated she spoke to Nurse#1 who indicated she was told it happened during a transfer. The DON indicated she spoke with NA#4 over the phone who confirmed the incident happened during a ____(name of mechanical lift) transfer. During the interview the DON indicated that the information that she was hearing did not add up. Continued interview with the DON indicated the roommate of Resident#48 told the social worker that no lift was used to transfer the resident when this incident happened. Continued interview with the DON indicated she spoke with NA#4 for a second time and (NA#4) indicated a mechanical lift was not used. The DON revealed that NA#4 indicated to her that she was only helping NA#3 and did not know the resident required a mechanical lift for transfer. According to the interview with the DON, NA#4 was sent home for 2 days and retrained on the use of the ______(name of mechanical lift). The DON continued to indicate that she spoke with NA#3 on 5/23/12 or 5/24/12 initially who stated Resident#48's leg was injured during mechanical lift transfer. Then NA#3 admitted a mechanical lift was not used. During the interview the DON indicated NA#3 didn't think it was an issue not using a mechanical lift for a transfer. NA#3 knew from the Kiosk how to transfer the resident using a mechanical lift. Further interview with the DON indicated that NA#3 was not currently working in the facility and would not be returning to the facility. The DON indicated she spoke with NA#3 about being truthful, reporting the incident correctly and to follow the proper procedure in using the mechanical lift. The DON voiced that all staff that were on duty the week of 5/21/12 were in-serviced, the facility instituted the use of laminated signs for quick reference, discussed the incident in the stand up meeting and MDS nurse#1 and Staff Development Coordinator (SDC) conducted audits. An interview on 6/14/12 at 11:15 am with MDS nurse#1 revealed "only thing I did was repeat in-services to staff regarding pink colored and green colored signs that we would be implementing. I have not done an audit of the residents" regarding the incident involving Resident#48. MDS nurse#1 indicated when new orders come in for mechanical lifts, "I place the sign up." MDS nurse#1 indicated she "Don't do audits, just the signs." The SDC joined the conversation who indicated not all nursing staff had been in serviced as of 6/14/12. The in-services were a "Constant work in process." Continued interview with SDC indicated the next in-service would occur on 6/21/12 during the skills fair. SDC indicated that assistant director of nurses (ADON) and QA (quality assurance) coordinator did audits. An interview on 6/14/12 at 11:30 a.m. with the QA coordinator revealed she monitored the hall where the incident happened but these routine rounds were not documented as well as audits of other residents that may be at risk during transferring using the mechanical lift device On 6/14/12 at 11:41 am, an interview with the ADON and DON revealed the audits were done by the DON, ADON, and MDS nurse#1, and Rehabilitation Director. On 6/14/12 at 11:42 am a joint meeting with the administrator, DON, and ADON was held. The DON revealed that Nurse#2, the ADON, Rehabilitation Coordinator and herself conducted audits but did not document the findings. The DON indicated she expected her staff to follow the orders and use the mechanical lift as required. During an interview on 6/14/12 at 11:50 AM, Nurse#2, indicated that she did not do a formalized audit of the incident regarding Resident#48 . Nurse #2 further stated that the audit process included verbal communication from shift to shift, nursing to observe staff during lift/transfers. However, she did not have a list of the staff that she had observed or any documentation. An interview on 6/14/12 at 11:45 p.m. with ADON revealed a form titled ___(name of mechanical lift) Lift Use-Place would be initiated today (6/14/12) to audit the use of the mechanical lifts.