Every finding on record at Clay County Nursing Home

Based on record review, observations, interviews, review of a Facility Assessment and Activity Calendars, and review of an Activities policy, the facility failed to provide adequate facility-sponsored group or individual/independent activities to meet the interests of and support the physical, mental, and psychosocial well-being of Resident Identifier (RI) #65, one of two residents reviewed for activities in the secured Memory Care Unit (MCU). Findings included: A review of a policy titled Activities, last reviewed in June of 2021, revealed, . It is the policy of [the facility] to provide an activities program that is appropriate to the needs and interests of each resident that shall encourage self-care, resumption of normal activities, maintenance of optimal self-functioning and contact with the environment .Procedure .The planned activities program shall be suited to the needs, abilities, and interests of each resident .A variety of supplies and equipment shall be available to satisfy the activities needs and interests of the residents . A review of a Facility Assessment, dated 10/31/2021, indicated Activities .A. Special consideration is given to offer activities according to the resident population in order to meet their cultural needs, religious needs and their preferences .Activities may be offered on an in-room basis or as doorway activities during times of infectious outbreaks. Under section 2.1 regarding the general care provided, the assessment directed staff to provide person-centered/directed care and psychosocial/spiritual support, noting staff should .find out what resident's preferences and routines are; what makes a good day for the resident; what upsets him/her and incorporate this information into the care planning process. The facility assessment also directed staff to Provide opportunities for social activities/life enrichment (individual, small group, community. RI #65 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a Social History, dated 08/03/2013, revealed RI #65's recreational and leisure time interests included flowers, singing, religious music/music from certain [NAME], and sewing. Per the form, the resident was no longer able to engage in sewing. The form indicated the resident now mostly spoke on the phone and watched television, with particular television programs listed. A review of an Annual Minimum Data Set (MDS), dated [DATE], indicated RI #65 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of ten out of fifteen. A Preferences for Customary Routine and Activities section was completed, with the primary respondent identified as RI #65. Per the MDS responses, it was very important for the resident to listen to music that they liked, be around animals such as pets, do things with groups of people, do their favorite activities, go outside to get fresh air when the weather was good, and participate in religious services or practices. According to the MDS, it was somewhat important to the resident to keep up with the news and not very important for the resident to have books, newspapers, or magazines to read. Per the Care Area Assessment (CAA) Summary area, the care area for Activities did not trigger and no activities care plan resulted from the assessment. Review of RI #65's Long Term Care Plan, with an original date of 07/02/2019, revealed the document was last modified and printed on 02/24/2022. The plan contained a problem area regarding the resident's impaired ability to communicate related to cognitive loss secondary to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions directed staff to use simple, direct wording and to present one question, instruction, or statement at a time when speaking to the resident. The care plan also directed staff to play instrumental music for the resident to sing along to. A review of a Quarterly MDS assessment, dated 02/24/2022, indicated RI #65 now had severe cognitive impairment as evidenced by a (BIMS) score of three out of fifteen. According to the MDS, RI #65's hearing and vision were adequate and speech was unclear. Per the assessment, RI #65 could sometimes make themselves understood and sometimes understood others, had continuously present disorganized thinking and delusions, and had behaviors including wandering that occurred one to three days of the lookback period. The MDS indicated RI #65 was able to walk in their room, in the corridor, and on the secured unit independently with the use of a walker, but had not moved to and returned from an off-unit location during the 7-day lookback period for activities of daily living (ADLs). The MDS identified that RI #65's lifetime occupation was business office. A review of March 2022 NH [Nursing Home] Monthly Orders revealed RI #65 May participate in individual activity/social plan of care. A review of hospital Patient Progress Notes, dated 03/02/2022, revealed a Nursing Activities & Physical Assessment care plan conference summary section. The section indicated, Resident .wears a [WanderGuard] bracelet [departure alert system bracelet typically worn on the ankle] and wants to leave often and goes to the doors shaking them and gets very upset because [they] can't get out. A review of a January 2022 calendar, February 2022 [Facility name] Activities Calendar, and 'March 2022 calendar revealed 0-2 activities per day were planned for residents, with two days in January 2022 having no activities planned. On the February 2022 calendar, the facility listed an activity for Unit 1 [long-term care (LTC) unit] and the same activity for Unit 2 (MCU), such as Bingo, with Unit 2 activities offered in the morning and Unit 1 activities offered in the afternoon. The March 2022 calendar showed that activities were offered at 10:00 AM and 2:00 PM only. A review of the calendars revealed there were no evening activities offered and there was no activity calendar tailored for residents on the MCU. A review of a January 2022 Activity Participation Record revealed RI #65 attended a new year's party on 01/04/2022, bean bag on 01/07/2022, and, on 01/16/2022, the resident was in the dining room sitting at the piano and singing with staff. Per the record, the resident also attended a birthday party on 01/26/2022 and played corn hole on 1/30/2022. A review of a February 2022 Activity Participation Record revealed RI #65 played bingo on 02/01/2022 and attended a Valentine's Party on 02/14/2022. Per the review, on 02/23/2022, a family member came to visit, and the resident went to church with their family member. The record also revealed the came into the dining room, where music was playing, for a snack on 02/27/2022 and attended a flea market on 02/28/2022. A review of a March 2022 Activity Participation Record revealed RI #65 participated in spa day on 03/02/2022 and had their nails painted. Per the record, the resident participated in church on 03/06/2022 and, on 03/09/2022, attended bible study in the dining room and had nail care provided. According to the review, the resident had their picture taken (called mug shots) and a snack on 03/10/2022 and socialized in the lobby and was present for a St. Patrick's Story Time (trivia) event on 03/15/2022. An observation on 03/14/2022 at 9:45 AM revealed the memory care secured common area/lobby had a television mounted to the wall approximately 18 inches from the ceiling and approximately 2.5 feet above the chair rail height, which was noted to be well above eye level. The area contained four padded chairs in the room and a small portable music player. The nurses' station was near the center of the room and was surrounded on all four sides with acrylic sheets (Plexiglas). There were two rooms to the rear of the nurses' station where nurses and certified nurse aides (CNAs) were behind closed doors. One resident was sitting against the nurses' station turned towards the television, but the television volume was not loud enough for the surveyor to hear the news station. During an observation on 03/14/2022 at 9:45 AM, RI #65 was observed asleep in a chair in the corner of the common area. During an interview on 03/15/2022 at 11:27 AM, Employee Identifier (EI) #6, Licensed Practical Nurse (LPN), stated she hoped the surveyor could give staff some ideas regarding, .what to do with these people. During an observation on 03/15/2022 at 11:43 AM, RI #65 was observed banging on the nurses' station window and then trying to open the hook-and-eye latch on a half door entrance into the enclosed nurses' station. EI #6 brought RI #65 into the nurses' station, sat the resident down on a rolling desk chair, and relatched the hook-and-eye latch. EI #6 said to the surveyor, We don't know what to do with [the resident]. At that time, there were no activities going on in the secured unit. During an observation on 03/15/2022 at 12:49 PM, the lunch meal was in RI #65's room. At that time, RI #65 was standing at the secure unit door rattling the doors. On 03/15/2022 at 12:50 PM, EI #6 brought the resident back to the bedroom to eat lunch. EI #6 sat in the bedroom with RI #65 and redirected them to eat lunch and, at times, fed the resident bites of food. During an observation on 03/15/2022 at 2:05 PM, RI #65 was observed alone in the unsecured dining room (a transition area between Units 1 and 2; used as a dining room for Unit 1 residents plus activities for all residents), sitting in a chair with the television on a classic movie station. No staff or other residents were in the area despite previous assessments revealing the resident liked to be around groups of people. During an interview on 03/15/2022 at 2:36 PM, EI #6 and EI #9, LPN, stated RI #65 previously worked at the facility in the Admissions Department. During an observation on 03/15/2022 at 2:50 PM, there were five residents in the unsecured dining room, including RI #65. At the same time, EI #11, Activity Assistant, and EI #12, Occupational Therapist/Activity Director, were reading stories and asking trivia questions. On 03/15/2022 at 2:54 PM, RI #65 stood up from a chair, left their walker behind, walked up to the speaker at the table, and began touching things on the table. RI #65 did not answer any of the complex questions asked by staff during the activity. During an interview on 03/15/2022 at 3:42 PM, EI #9 stated EI #11 and EI #12 worked the whole building and did activities for the secured unit. EI #9 stated EI #12 started in the position about two months prior. EI #9 stated, It tickles [residents] to death to do activities. They did puzzles [in the secured unit] together before [COVID-19]. During an observation on 03/15/2022 at 3:50 PM, RI #65 entered an unlocked nurse's office looking for their baby. EI #6 redirected the resident to sit in the common area, stating she would look for RI #65's baby doll. During an interview on 03/16/2022 at 9:35 AM, EI #13, CNA who had been working in the unit for three years, said staff conducted reading and puzzles in the dining room, noting staff had to provide access to residents to the dining room or outside. EI #13 reported she had not seen anyone in the common area in groups lately. Per EI #13, RI #65 liked activities, such as crocheting and beading activities in the dining room. EI #13 stated EI #11 sometimes invited and escorted residents to go outside for snacks and fresh air. EI #13 stated activities staff needed to retrieve RI #65 for activities, stating RI #65 had an ankle WanderGuard and went to activities as often as the facility had them, maybe once a day. EI #13 stated that, for about three years, RI #65 had many baby dolls and usually carried them around and fed them. EI #13 noted she no longer saw the dolls as much, stating she thought staff took them away because RI #65 was putting food in the mouths of the dolls. During an interview on 03/16/2022 at 9:48 AM, EI #8, RN, said the facility had tables in the common area/lobby prior to COVID-19. Regarding activities, EI #8 stated staff took residents out to the dining room at 10:00 AM and 2:00 PM, noting residents had activities calendars in their rooms, but there was no posted calendars in the lobby. During an interview on 03/16/2022 at 11:55 AM, EI #11, who had worked at the facility for several years, said the present Activity Director, EI #12, was an Occupational Therapist who worked at the adjacent hospital's wellness center, noting the facility hired an Activity Manager who would start on 03/24/2022. EI #11 said activities included nails, bingo, bible study, games, and church, stating church services started two weeks prior. EI #11 stated Unit 2 (secured unit) residents were mixed in with more alert residents from Unit 1 for activities, noting the residents from Unit 2 wanted to do more activities than the residents from Unit 1. EI #11 noted that COVID-19 took a toll on the residents in the secured unit. EI #11 reported when she first started, the residents in Unit 2 loved to paint, do puzzles, watch television, listen to music to entertain themselves, and in the spring, they went outside to see a planter. EI #11 noted resident activities were important, stating Unit 2 residents now played bingo and went outside, stating the residents still had to maintain social distance. EI #11 confirmed the facility combined LTC and dementia residents in group activities. During an interview on 03/16/2022 at 12:07 PM, EI #12 said Unit 2 residents liked activities all the time, noting staff could conduct socially-distanced activities but the activity staff were the staff who transported residents to group activities. EI #12 stated that, before COVID-19, residents were more active and went to the dining room for activities. Per EI #12, RI #65 participated in either group or one-to-one activities an average of a couple of times a week, stating the resident liked to sing and dance, but could not participate in higher-functioning group activities. EI #12 noted activities staff did not have lower-functioning groups that would be appropriate for RI #65 or other residents on the Unit 2 secured memory care. During an interview on 03/16/2022 at 2:00 PM, EI #14, RN Infection Preventionist who had worked at the facility since 2014, explained that only residents who could remember to keep on their masks could go to group activities in the main dining room, noting residents who could not remember to wear a mask stayed in the lobby in the secured unit. EI #14 stated that any activities that occurred in the main dining room could also be conducted in the lobby in the secure unit. During an interview on 03/16/2022 at 2:37 PM, EI #15, Assistant Director of Nursing, stated the prior Activity Director left near the end of December 2021. EI #15 stated the expectation and goals were for residents to be involved in activities all the time. EI #15 stated, We could do so much more to increase the quality of care (sic - life) down there. We had tables down in the lobby too and had activities [in the MCU]. We [previously] had tables down in the lobby, too, and had activities down there. Now we do two activities a day for the whole building, at 10:00 AM and 2:00 PM, and they are mixed for the whole building. During an interview on 03/16/2022 at 3:23 PM, EI #5 stated her goal was for the secured unit low-functioning residents to attend one activity a day, noting they liked activities in the lobby. EI #5 stated, We prefer [MCU residents] come in and participate with the whole nursing home. EI #5 said that, over the last month, activities had been slow and the facility could only have fifteen residents in the dining room. EI #5 stated the facility was slowly getting back there, but was worried about getting things cleaned. EI #5 stated RI #65 needed to attend activities twice a day, but had previously gotten into other people's belongings, so the facility took RI #65 back into Unit 2 to listen to music. EI #5 noted that RI #65 liked to be active, but agitated other residents, so staff did things with RI #65 on the MCU. During an interview on 03/16/2022 at 4:05 PM, EI #4, Administrator, reported his expectation on the secured MCU was for the residents to do activities two times a day, stating, We need to make sure they are involved as much as possible, noting staff should check back with a resident if they refused an activity and have residents participate to the best of their abilities.

Based on interviews, review of SNF Beneficiary Protection Notification Review forms, and review of a policy titled Skilled Nursing Facility Advance Beneficiary Notice of Coverage (SNFABN), the facility failed to provide SNFABN forms to Resident Identifier (RI) #36, RI #66, or RI #216, three of three residents reviewed for proper SNFABN. Findings included: A review of the facility policy titled Skilled Nursing Facility Advance Beneficiary Notice of Coverage (SNFABN), last reviewed in June of 2021, indicated the facility would . issue SNFABN to beneficiaries as required by CMS [Centers for Medicare & Medicaid Services] . The facility will issue the SNFABN when a resident goes off Medicare days .The beneficiary or their authorized representative must sign the signature box to acknowledge that they read and understood the notice . On 03/14/2022 at 1:44 PM, RI #36, RI #66, and RI #216 were selected for review for provision of an ABN. Blank SNF Beneficiary Protection Notification Review forms were provided to Employee Identifier (EI) #16, Business Office Manager, to fill out. Amongst other requested information, the form asked if a SNFABN form was provided to a resident and, if not, why the form was not provided. On 03/16/2022 at 3:07 PM, EI #16 returned the SNF Beneficiary Protection Notification Review forms for RI #36, RI #66, and RI #216. A review of the forms revealed RI #36, RI #66, and RI #216 had been discharged from physical therapy/occupational therapy and were required to receive a SNFABN. On the forms, EI #16 confirmed that SNFABNs should have been issued for RI #36, RI #66, and RI #216, but were not. EI #16 stated that no one ever told her she had to issue SNFABNs. During an interview on 03/16/2022 at 3:32 PM, EI #5, Director of Nursing, said her expectation was for the SNFABN paperwork to be completed appropriately. During an interview on 03/16/2022 at 4:08 PM, EI #4, Administrator, said his expectation was for EI #16 to fill out the proper paperwork. He said EI #16 did not know about filling out the SNFABN and noted that EI #16 had proclaimed the billing office filled out SNFABNs.

Based on observation, staff interview record review, Centers for Disease Control and Preparedness (CDC) guidelines and review of the facility policy entitled, Personal Protective Equipment, the facility failed to ensure staff did not wear the same gown when caring for more than one (1) resident (extended use) with unknown COVID-19 status on one (1) of one (1) quarantine units. The facility also failed to have a policy on extended use of gowns that was consistent with CDC guidelines. This failure occurred during a COVID-19 Pandemic and had the potential to affect 22 of 71 residents due to cross contamination. The findings include: Review of the facility Resident Testing Log for COVID-19 revealed Resident #1, #2 and #3 tested positive for COVID-19 on 7/17/20. During an interview with the Director of Nursing (DON) on 7/22/20 at 11:15 a.m., she stated that the facility had a staff member who had been asymptomatic but who tested positive for COVID-19. After the staff member was identified as COVID-19 positive, the facility tested all residents and staff. The DON said three (3) residents on the Memory Care Unit (Unit 2) tested positive for COVID-19. Two (2) additional staff also tested positive. The DON stated that the residents who tested positive were now on a dedicated COVID-19 unit which was at the end of a hall on the Memory Care Unit. It was separated from the rest of the unit by a plastic barrier. Upon inquiry the DON confirmed that although all the other residents on Unit 2 tested negative initially and again on a second test, they were potentially exposed so the facility had put these residents on a 14 day quarantine for symptom monitoring. She added that the staff caring for these residents wore full PPE (gown, gloves, mask and face shield). On 7/22/20 at 1:20 p.m. the quarantine unit was observed with the Director of Nursing (DON). Upon entering the quarantine unit Nurse #1 was observed walking in the hall wearing a mask, face shield, disposable plastic gown and gloves. There were no isolation kits containing PPE, for donning prior to entering a resident's room, observed on the hall. During an interview with Nurse #1 on 7/22/20 at 1:30 p.m., she confirmed she wore the same gown, mask and face shield while caring for all residents on the quarantine unit. She stated that if she did go on a quick break outside she would go out the back exit door at the end of the hall and take of her gown, then spray it with sanitizer and hang it over the chain link fence that was near the door. Nurse #1 said she would put the gown back on before returning to the unit. Nurse #1 added that she would get a new gown the next day at the beginning of her shift. Upon inquiry Nurse #1 indicated that she was wearing gloves in the hall because the staff wore full PPE, including gloves, for the entire shift. She said that she sanitized her gloves as needed, like she would sanitize her hands as needed if she wasn't wearing gloves; in addition she said that she did change gloves between residents. During a telephone interview with the DON on 7/22/20 at 4:30 p.m., she confirmed that the facility practice and expectation for staff on the quarantine unit was to optimize the supply of gowns by wearing the same gown for the care of all residents for a full shift (extended use), unless it became soiled or damaged. The DON said that since the quarantine unit was a Memory Care unit the residents tended to congregate amongst themselves anyway and could potentially cross contaminate each other. She added that the facility had implemented full PPE on that unit as a protection for the staff to help them feel comfortable working on that unit. During a telephone interview with the DON on 7/23/20 at 8:00 a.m., she indicated that the facility used contingency capacity strategies for optimizing the supply of PPE due to limitations in availability. Upon inquiry the DON said the facility had 800 disposable gowns in stock and would be getting another shipment in the next few weeks. In addition she acknowledged they had cloth gowns that could be used as a contingency option. Review of the CDC guidance entitled Responding to Coronavirus (COVID-19) in Nursing Homes dated April 30, 2020 revealed, when a resident is confirmed to have COVID-19, regardless of symptoms, they should be transferred to the designated COVID-19 care unit. In addition HCP (health care providers) should use all recommended COVID-19 PPE for the care of all residents on affected units (or facility-wide if cases are widespread); this includes both symptomatic and asymptomatic residents. Maintain Transmission-Based Precautions for all residents on the unit at least until there are no additional clinical cases for 14 days after implementation of all recommended interventions. While the facility did follow the above CDC guidance and initiate a 14 day quarantine with transmission based precautions for the 22 affected residents on Unit 2, the facility did not have a policy that adequately addressed the extended use of PPE and did not follow the CDC guidance for extended as evidenced by the below facility policy and CDC guidance. Review of the facility policy entitled Personal Protective Equipment dated April 2020 revealed, extended use of gowns was included as a crisis capacity strategy for optimizing the supply of isolation gowns, however there was no further information to indicate under what circumstances extended use of the same gown with multiple residents was appropriate. Review of the CDC guidance entitled Strategies for Optimizing the Supply of Isolation Gowns dated March 17, 2020 revealed the following regarding extended use of isolation gowns: Consideration can be made to extend the use of isolation gowns (disposable or cloth) such that the same gown is worn by the same HCP when interacting with more than one patient known to be infected with the same infectious disease when these patients housed in the same location (i.e., COVID-19 patients residing in an isolation cohort). This can be considered only if there are no additional co-infectious [DIAGNOSES REDACTED]. The facility was [MEDICATION NAME] extended use of gowns with residents who were potentially exposed to COVID-19 but whose COVID-19 status was not known as they were still under a 14 day quarantine and observation for symptoms of COVID-19, despite two negative COVID-19 tests (completed before day 14). This practice did not comply with CDC guidelines which indicate extended use can only be practiced when residents have the same infectious disease (i.e., COVID-19 positive residents).

Based on observations, interviews, and review of Potter and Perry, FUNDAMENTALS OF NURSING, Ninth Edition, Chapter 48 Skin Integrity and Wound Care, the facility failed to ensure: 1) a Registered Nurse (RN) cleaned Resident Identifier (RI) #57's wound and washed hands and changed gloves prior to applying treatment (Venelex ointment); and 2) an RN removed gloves and washed hands after cleaning RI #169's wound, prior to applying the treatment. This affected two of two sampled residents reviewed for pressure ulcers and two of two wound care observations. Findings include: Review of Potter and Perry, FUNDAMENTALS OF NURSING, Ninth Edition, copyright (YEAR), Chapter 48 Skin Integrity and Wound Care, pages 1224-1225, revealed the following: . SKILL 48-2 TREATING PRESSURE ULCERS . Implementation 1. Perform hand hygiene . 2.expose ulcer and surrounding skin . apply clean gloves. 3. Clean ulcer thoroughly with normal saline or cleaning agent . 4. Remove gloves, perform hand hygiene, and apply clean or sterile gloves. 5. Apply topical agents as prescribed . 7. Remove gloves and dispose of soiled supplies. Perform hand hygiene. 1) RI # 57 was admitted to the facility on [DATE]. Review of RI #57's quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 4/23/19, revealed RI #57 had one stage 2 pressure ulcer at the time of the assessment. A review of RI # 57's physician's orders [REDACTED].Venelex ointment to left heel BID (two times a day) . On 05/15/19 at 8:50 AM, the surveyor observed Employee Identifier (EI) #1, RN/Wound Care Nurse, performing RI #57's wound treatment. Prior to beginning, EI #1 washed hands and put on gloves. She then adjusted the resident's bed, removed the heel booty, measured the wound, and then applied the Venelex ointment. EI #1 did not clean RI #57's wound prior to applying the ointment, nor did she wash hands or change gloves during the treatment. On 05/16/19 at 10:35 AM, an interview was completed with EI #1. EI #1 was asked what was the facility protocol on cleaning a stage 2 pressure ulcer. EI#1 replied, clean with normal saline. EI #1 was asked if she cleaned RI #57's wound prior to applying the treatment. EI #1 said no. The surveyor asked what was the potential negative outcome of not cleaning a wound prior to applying treatment. EI#1 replied, you would spread germs in the wound and it could cause infection. EI #1 was also asked when she washed hands and changed gloves during RI #57's wound treatment. EI #1 said before she started the treatment, and after it was complete. EI #1 explained, she should have washed the wound, then washed hands and changed gloves before applying the medicine to prevent cross contamination. 2) RI #169 was readmitted to facility 3/6/2019. A review of RI #169's (MONTH) 2019 physician's orders [REDACTED]. On 05/15/19 at 4:31 PM, the surveyor observed EI#1 performing wound care on RI #169. EI cleaned RI #169's wound using gauze and normal saline and discarded the soiled gauze in waste bag. Without washing hands or changing gloves, EI #1 then measured RI #169's wound and applied the Venelex ointment using her gloved finger. On 05/16/19 at 11:22 AM, an interviewed was completed with EI #1. EI #1 was asked if she washed her hands and changed gloves while performing RI #169's wound care. EI #1 replied, before and after, but not during. EI #1 said she should have washed her hands and changed gloves, but she was trying to hurry and finish and she forgot. On 05/15/19 at 12:08 PM, an interview was completed with EI #2, Infection Control Nurse. EI #2 was asked what would be the harm in not washing hands and changing gloves between clean and dirty. EI # 2 replied it could contaminate the wound and cause an infection.

Based on observation, interviews, and review of the facility's policies titled Medication Administration Route: Nebulizers and Infection Control Hand Hygiene, the facility failed to ensure: 1) Licensed staff washed and dried a nebulizer cup prior to placing it in a plastic bag after completing the nebulizer treatment for [REDACTED].# 5; 2) a Registered Nurse (RN) washed hands prior to applying gloves after completing wound care for RI # 169; and 3) an RN washed hands after completing wound care for RI # 57. These failures affected RI # 5, one of one resident observed for a nebulizer treatment, and RI #s 169 and 57, two of two residents observed for wound care. Findings Include: 1) A review of a facility Policy Titled : Medication Administration Route: Nebulizers, with a revised date of (MONTH) 22, 2014, documented: . 9. Clean . nebulizer cup with a clean paper towel. When dry, store in a plastic bag . RI# 5 was readmitted to the facility 3/19/2019 with a [DIAGNOSES REDACTED]. A review of RI #5's physician's orders [REDACTED]. On 5/15/19 at 10:14 AM, the surveyor observed Employee Identifier (EI) #3, Licensed Practical Nurse (LPN), administer a nebulizer treatment to RI # 5. After the treatment was completed, EI #3 placed the nebulizer cup in a plastic bag on the nebulizer machine without cleaning and drying the cup. An interview was completed with EI #3 on 5/15/19 at 11:33 AM. EI #3 was ask if she cleaned and dried the cup after the nebulizer treatment for [REDACTED]. EI # 3 replied no. An interview was completed with EI # 2, Infection Control Nurse, on 5/15/19 at 5:44 PM. EI #2 was asked what was the potential harm of not cleaning the nebulizer cup prior to placing it in a plastic bag after completing a treatment. EI # 2 stated there was a risk of growing bacteria in the moist environment, which could cause a respiratory or oral infection. 2) A review of a policy titled Infection Control Hand Hygiene, with an effective date of (MONTH) 5, 2014, documented: . B. Hand Hygiene with Hand Sanitizer . b. Before donning gloves . c. Before and After direct patient contact d. After contact with inanimate objects; and/or e. Before and after removing gloves . RI #169 was readmitted to the facility on [DATE]. A review of RI #169's (MONTH) 2019 physician's orders [REDACTED]. The surveyor observed EI #1, RN, complete wound care for RI #169 on 5/15/19 at 4:31 PM. EI #1 cleaned RI #169's wound using gauze and normal saline and discarded the soiled gauze in a waste bag. Without washing hands or changing gloves, EI #1 then measured RI #169's wound, applied the Venelex ointment using her gloved finger, and secured RI #169's brief. EI #1 then removed dirty gloves and applied new gloves, without washing or sanitizing her hands, and proceeded to seal the bag of waste, reposition RI #169, and lower the bed using the resident's bed controls. On 5/16/19 at 11:22 AM, an interview was completed with EI #1. EI #1 was asked if she washed her hands or changed her gloves during wound care for RI #169. EI # 1 replied before and after, but not during. EI #1 confirmed she had touched objects in the room, including bed linens and said this could result in cross contamination. An interview was completed with EI # 2, Infection Control Nurse, on 5/15/19 at 5:44 p.m. EI # 2 was asked should you remove gloves and wash your hands after wound care before touching any other surfaces. EI # 2 replied yes. EI#2 was asked what was the potential harm. EI #2 replied cross contamination and risk for infection. 3) A review of a policy titled Infection Control Hand Hygiene, with an effective date of (MONTH) 5, 2014, documented: . B. Hand Hygiene with Hand Sanitizer . b. Before donning gloves . c. Before and After direct patient contact d. After contact with inanimate objects; and/or e. Before and after removing gloves . RI # 57 was admitted to the facility on [DATE]. A review of RI # 57's physician's orders [REDACTED].Venelex ointment to left heel BID (two times a day) . On 5/15/19 at 8:50 AM, the surveyor observed EI #1 perform wound care for RI #57. After the wound care was completed, EI #1 removed her gloves, but did not wash her hands. EI #1 then touched other objects in the room, to include RI #57's bed linens, foot booty, bed control, and a pen. On 5/16/19 at 10:35 AM, an interview was completed with EI#1, Wound Care Nurse. EI # 1 was asked when should she have washed your hands during RI #57's wound care. EI #1 replied when she removed her gloves and before touching anything. EI#1 was asked what was the possible negative outcome of not washing her hands after removing gloves after wound care, prior to touching items in the resident's room. EI#1 replied cross contamination. An interview was completed with EI # 2, Infection Control Nurse, on 5/15/19 at 5:44 p.m. EI # 2 was asked should you remove gloves and wash your hands after wound care before touching any other surfaces. EI # 2 replied yes. EI#2 was asked what was the potential harm. EI #2 replied cross contamination and risk for infection.

Based on observations, interview, review of facility policies titled DEFROSTING MEATS and MIGHTY SHAKES, and review of the (YEAR) Food Code, the facility failed to ensure: 1) frozen raw chicken was not thawed under running water exceeding 70 degrees Fahrenheit (F). Further, at the time staff was preparing the chicken for the meal, the chicken measured 75.6 degrees F; and 2) thawed nutritional health shakes were labeled in a manner such that the use by date was evident. These failures had the potential to affect all 72 residents receiving meals from the dietary department. Findings include: 1) Review of the facility policy titled DEFROSTING MEATS, reviewed (MONTH) (YEAR), revealed the following: POLICY: A. Meats must be handled in a safe and sanitary manner. Since bacteria growth is not killed by freezing, then care must be taken in defrosting meats. 1. Remove frozen meat to be defrosted from freezer two days in advance. 3. All frozen meat is to be defrosted under refrigeration, unless cooking is to be done from frozen state. Review of the (YEAR) Food Code, Chapter3 Food, revealed the following: . 3-501.13 Thawing. . TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be thawed: . (B) Completely submerged under running water: (1) At a water temperature of 21 (degrees) C (Celcius) (70 degrees Fahrenheit) or below . On 6/19/18 at 9:49 AM , raw chicken was observed in a pan with water. Employee Identifier (EI) #2, Dietary Staff, said she just pulled the chicken from the cooler. EI #2 further explained she thawed the chicken in the sink under running water from about 8:00 AM until 9:15 AM, then placed it in the cooler. At the time of this observation, EI #2 said she had just removed the chicken from the cooler. The raw chicken was being battered by EI #2 for the lunch meal and measured 75.6 degrees F. The cold water side of the sink used to thaw the chicken was then checked, and would only get down to a temperature of 78 degrees F. EI #1, Supervisor for Dietary, was interviewed on 6/20/18 at 2:18 PM. EI #1 stated chicken should be thawed by pulling from the freezer and putting it in the cooler. When asked how it should be thawed if utilizing the sink, EI #1 said it should be thawed under cold water at a temperature of 64 degrees F. EI #1 was then asked how they monitored the temperature of the water in the sink staff use to thaw meat. EI #1 said, We don't monitor that. When asked how they could ensure the meat was safely thawed if they did not monitor the temperature of the water used to thaw the meat, EI #1 said she did not know how to answer that. After discussing the temperature of the chicken (75.6 degrees F when being battered by EI #2, EI #1 said the concern with that was that the chicken could cause harm to the residents. When asked if Maintenance does any water temperature checks in the kitchen, EI #1 said they only come if she calls them. EI #1 said they had not realized that sink was not getting cold enough until yesterday (6/19/18). EI #1 said had they checked the water temperature, they would have realized. 2) Review of the facility policy titled MIGHTY SHAKES, reviewed (MONTH) (YEAR), revealed the following: POLICY: When taking Mighty Shakes out of the freezer, the box must be labeled with date it is removed from the freezer and the thaw date when it is placed in the refrigerator. The thaw date is 14 days from the day the box is removed from the freezer. On 6/19/18 at 9:54 AM, a tray containing six thawed nutritional shakes was observed in the walk-in cooler. The shakes were labeled with residents' names and the current date, but did not indicate the thaw date or the use by date. During an interview with EI #1 (Jan Sheppard), Supervisor for Dietary, on 6/20/18 at 2:18 PM, EI #1 said Mighty Shakes/nutritional shakes should be labeled once they are thawed with the pull date and a 14 day use by date. EI #1 explained the shakes go out of date 14 days from the date they are thawed. EI #1 said if the thawed shakes were not labeled with that information, they were not labeled properly. When asked why it was important to ensure the shakes were labeled properly, EI #1 said it was important so that residents will not get sick.

Based on observation, interview, medical record review and a review of the facility's policy titled, SAFETY FROM SKIN TEARS, the facility failed to ensure Resident Identifier (RI) #31's geri-chair bilateral armrest did not have tattered, torn and exposed areas. This affected one of 1 resident observed in a gerichair. Findings Include: A review of the facility's policy titled, SAFETY FROM SKIN TEARS with a review date of (MONTH) (YEAR), revealed the following: POLICY . It is the policy of (name of facility) to attempt to keep residents safe from skin tears and bruising. PR[NAME]EDURE 1. Residents . at risk for skin tears or bruising will have protective padding applied to sharp/hard edges of devices that may cause harm. ( . side rails, arm rests .) RI #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a review of RI #31's current Quarterly Minimum Data Set ((MDS) dated [DATE], revealed RI #31's Brief Interview for Mental Status score of 3, indicating severe impairment in cognition. A review of RI #31's care plan for problem/concern revealed the following: . 5/3/2018 . Interventions: . Monitor and assess skin for rash, redness, broken skin areas On 6/19/18 at 11:20 AM, RI #31 was observed up to geri-chair in hallway confused, reclined, resident left arm positioned on left armrest. RI #31 was observed moving the left upper extremity without difficulty, bilateral geri-chair armrests, torn and tattered areas to bilateral armrests and exposed area to left outer armrest. On 06/19/18 11:25 AM, during an interview with Employee Identifier (EI) #5, Licensed Practical Nurse/LPN, she observed RI #31's geri-chair with the surveyor. The surveyor asked EI #5 to describe RI #31's geri-chair's bilateral armrests. EI #5 stated, Plastic black cover, see the threads, cover coming off on both sides. The surveyor asked what did the torn areas feel like. EI #5 stated, Rough. The surveyor asked EI #5 to describe the area at the front outer aspect on the left armrest. EI #5 stated, I can see the wood, it's hard. The surveyor asked what was the potential harm for RI #31 regarding the the armrests. EI #5 stated, Splinter from the wood, could get skin tear or a bruise.

Based on interviews, medical record review, and a review of the facility's policy titled NOTIFICATION OF CONDITION/ORDER CHANGES, the facility failed to ensure a licensed nurse documented Resident Identifier (RI) #29's left heel wound status and measurements were documented. This affected RI #29, one of 23 sampled resident reviewed documentation. Findings Include: A review of the facility's policy titled, NOTIFICATION OF CONDITION/ORDER CHANGES, with a revised date of (MONTH) (YEAR), revealed the following: POLICY . E. The nurse . shall document changes on the resident's medical record. RI #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the RI #29's pressure ulcer wound measurements for 06/12/18 and 06/15/18 revealed the left inner aspect of heel measured 2 x (by) 3 cm (centimeter) x 3 cm, and depth not measurable. On 06/20/18 at 4:25 PM, during an observation of RI #29's wound/pressure ulcer to the left heel with Employee Identifier (EI) #3 Registered Nurse/RN, RI #29's bilateral heels were floated and bilateral booties to feet. RI #29's left heel pressure wound measured 4.0 cm x 2.6 cm. On 06/20/18 at 4:28 PM, the surveyor asked EI #3 to describe RI #29's pressure wound. EI #3 stated, Stage II, dry, firm tissue, blanchable, peri-wound closed and pink, upper aspect of the wound with scabbed areas. On 06/21/18 at 8:53 AM, during an interview with EI #3, the surveyor asked where was the documentation to reflect the observation of the wound on Wednesday, 6/20/18. EI #3 stated, I didn't document. The surveyor asked why not. EI #3 stated, Because I usually measure on Friday. The surveyor asked what was policy regarding documentation, because the measurements had changed, according to previous measurements and the wound status had change. EI #3 stated, We document on the wounds once a week, because we measure on Friday. The surveyor asked by general nursing standard, when a change occurs regarding resident's status, and it is observed by a nurse, what should be done regarding documentation. EI #3 stated, You document any abnormal findings. The surveyor asked by general nursing standard, is that the only time you document is when there is an abnormal finding. EI #3 stated, No, several reasons we document. The surveyor asked what do you document when there is an improvement in a resident or when there was a decline. EI #3 stated, I don't know, I would document on the weekly sheet (points to the resident's wound sheet) the improvement. The surveyor asked was that what she did. EI #3 stated, No ma'am,. On 06/21/18 at 6:45 AM, during an interview with EI #4, Director or Nursing/DON, the surveyor asked when there was a change in a resident's wound status, what should be done. EI #4 stated, If there is a decline, we notify the family and the doctor. The surveyor asked what if measurements have increased in size, what should be done. EI #4 stated, we notify the doctor if the treatment is not working and notify the family. The surveyor asked what should be done regarding documentation of the increased wound size. EI #4 stated, We document the increase in size when the measurements are done.

Based on observation, interview, medical record review and a review of the facility's policy titled, MEDICATION ADMINISTRATION, the facility failed to ensure licensed staff did not leave the medication cart unlocked, unattended and out of staff's view at all times. This affected one of 8 residents and one of 4 nurses observed during medication pass. Findings Include: A review of the facility's policy titled, MEDICATION ADMINISTRATION with a revised date of (MONTH) (YEAR), revealed the following: . PR[NAME]EDURES; . 4. Medication carts should be in sight of nurse during preparation time and locked when unattended. RI # 8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #8's Quarterly Minimum (MDS) data set [DATE] revealed RI #8's Brief Interview for Mental Status score of 8, indicating moderately impairment in cognition. On 06/20/18 at 11:05 AM, the following was observed during medication pass: Employee Identifier (EI) #6, Registered Nurse/RN dispensed the following medications for administration to RI #8. 1. [MEDICATION NAME] 25/100 mg one po (by mouth) QID (four times a day) 2. K-Dur (potassium) 20 meq (milliequivalents) 3. [MEDICATION NAME] 300 mg one po QID 4. [MEDICATION NAME] 0.5 mg one po TID (three times a day) 5. [MEDICATION NAME] 100 units/ml (milliliter) 5 Units sq (subcutaneous) @ (at) 12 noon EI #6 entered the resident's room, medication cart unlocked. EI #6 back was to the resident's doorway and out of sight and view of the EI #6. EI # administered the resident's po medication with water and administered the insulin. On 06/20/18 at 11:12 AM, during an interview with EI #12, the surveyor asked what was wrong with the medication cart. EI #6 stated, Unlocked. the surveyor asked was the medication cart in her view at all times. EI #6 stated, No ma'am. The surveyor asked what was the facility's policy and procedure for medication cart when the car is not in the nurses' view. EI #6 stated, To be locked. The surveyor asked what was the potential harm when the medication cart is left unlocked and out of the nurses' visual/view. EI #6 stated, Someone could get in the cart and into the medications they do not need, anybody or the residents. The surveyor asked were there ambulatory or mobile residents on the hall. EI #6 stated, Yes ma'am.

Based on medication administration observations, staff interviews and review of the facilities' policies titled HAND HYGIENE POLICY and MEDICATION ADMINISTRATION ROUTE: EYES (Drops), the facility failed to ensure licensed nursing staff: 1) did not turn off the faucet with their bare hands during handwashing after administering medications to Resident Identifier (RI) #12 and RI #13; 2) did not place a bottle of eye drops on an unclean surface prior to administering to RI #4; 3) changed gloves prior to giving an insulin injection to RI #16; and 4) did not use gloves from their pocket during medication administration for RI #4, RI #10 and RI #16. These deficient practices affected RI #4, RI #10, RI #12, RI #13 and RI #16, five of six residents observed for medication administration. Findings included: 1) The facility's policy titled, HAND HYGIENE POLICY with a revised date of February 2017, documented the following: . PROCEDURES: A. Proper hand-washing technique includes: . 8. Turn off the faucets by gripping them with a dry paper towel . During medication administration observation on 05/10/17 at 8:31 a.m., Employee Identifier (EI) #6, a Licensed Practical Nurse (LPN) entered RI #13's bathroom to wash her hands after administering medications. After washing her hands, EI #6 turned off the faucet with her bare hands. During medication administration observation on 05/10/17 at 8:39 a.m., EI #6, a LPN entered RI #12's bathroom to wash her hands after administering medications. After washing her hands, EI #6 turned off the faucet with her bare hands. In an interview on 05/11/17 at 10:47 a.m., EI #6, a LPN was asked if she recalled washing her hands in RI #12's and RI #13's bathrooms. EI #6 replied, Yes ma'am. EI #6 was asked, did she turn off the faucets with her bare hands after she washed her hands. EI #6 said, Yes ma'am, I did. When asked should she have done that, EI #6 replied, No, I should have used a paper towel. EI #6 was asked, if this was an infection control issue. EI #6 answered, Yes ma'am. During an interview on 05/11/17 at 9:29 a.m., EI #3, the Infection Control Coordinator was asked, should an employee use their bare hands to turn off the faucet after handwashing. EI #3 said, No. 2) The facility's policy titled, MEDICATION ADMINISTRATION ROUTE: EYES (Drops) with a reviewed date of January 2017, documented POLICY: It is the policy of(NAME)County Nursing Home to give eye drops/gels/ointments in a safe and effective manner. PROCEDURE: *Note-Always drape overbed table if items need to be lain down . During medication administration observation on 05/10/17 at 9:02 a.m., EI #7, a LPN picked up a bottle of eye drops from RI #4's prepared overbed table and administered a drop in RI #4's left eye and then placed the bottle of eye drops on an unprepared surface (RI #4's nightstand) before administering a drop in RI #4's right eye. EI #7 then returned the bottle of eye drops to the prepared surface on the overbed table. In an interview on 05/11/17 at 10:37 a.m., EI #7, a LPN was asked, during medication pass did she put the bottle of eye drops on RI #4's nightstand. EI #7 said, Yes ma'am. When asked, should she have done that, EI #7 replied, No. EI #7 was asked, why not and stated because I had my clean field and should have set them on it. When asked, did she place that same bottle back onto the clean field, EI #7 answered, I guess I did. When asked if having the eye drops on an unclean surface was an infection control issue, EI #7 said, Yes ma'am. During an interview on 05/11/17 at 9:29 a.m., it was explained to EI #3, the Infection Control Coordinator that a nurse placed eye drops on an unclean night stand and then after administering the eye drops, placed the eye drop bottle back onto the clean surface (field). When asked should this have been done, EI #3 replied, No, she should not have done that, she contaminated her clean field. 3) During medication administration observation on 05/09/17 at 4:46 p.m., EI #2, a LPN put on gloves and enter RI #16's room. After entering the room, EI #2 pulled the privacy curtain and closed the blinds. While wearing the same gloves, EI #2 then administered an insulin injection in RI #16's abdomen. In a telephone interview on 05/11/17 at 9:16 a.m., EI #2, a LPN was asked should she have pulled the privacy curtain, closed the blinds and then gave RI #16's insulin injection wearing those same gloves. EI #2 said, no. When asked if not changing gloves after touching the privacy curtain and blinds before giving an injection was considered an infection control issue, EI #2 answered, she guessed so. During an interview on 05/11/17 at 9:29 a.m., EI #3, the Infection Control Coordinator was asked, should a nurse use gloves worn while pulling a privacy curtain and adjusting blinds to give a resident an insulin injection, EI #3 answered, No, ma'am. 4) During medication administration observation on 05/09/17 at 4:46 p.m., EI #2, a LPN EI #2 was observed to put gloves from the medication cart in her pocket. EI #2 then entered RI #16's room. EI #2 removed the gloves from her pocket, put them on and administered eye drops to RI #16. In a telephone interview on 05/11/17 at 9:16 a.m., EI #2, a LPN was asked if her pocket was clean. EI #2 said, she guessed not. When asked, if using gloves that was removed from a pocket was an infection control issue, EI #2 said she guessed so. During medication administration observation on 05/09/17 at 5:16 p.m., EI #5, a LPN pulled gloves from her pocket, put those same gloves on and emptied a nebulizer treatment into RI #10's reservoir for administration. In a telephone interview on 05/11/17 at 10:20 a.m., EI #5, a LPN was asked, if she used gloves from her pocket during the medication pass on 05/09/17. EI #5 said, yes ma'am. When asked, did the facility 's policy say to put gloves in your pocket, EI #5 replied, probably not. EI #5 was asked, was that an infection control issue and she answered, she guess it would be. During medication administration on 05/10/17 at 9:02 a.m., EI #7, a LPN was observed twice to pull gloves from her pocket. The gloves that EI #7 removed from her pocket, she put on and then administered eye drops to RI #4. In an interview on 05/11/17 at 10:37 a.m., EI #7, a LPN was asked did she use gloves out of your pocket. EI #7 said, Yes. EI #7 was asked, if her pocket was clean and she replied, I thought it was. When asked, did the facility 's policy indicate where to store gloves, EI #7 said, That we're supposed to put them in a bag. EI #7 was asked, was using gloves out of her pocket an infection control issue. EI #7 said, It is now, yes. During an interview on 05/11/17 at 9:29 a.m., EI #3, the Infection Control Coordinator was asked should an employee use gloves from their pocket to administer eye drops. EI #3 said, no. When asked, should a nurse use gloves from her pocket to prepare medication in the nebulizer. EI #3 answered, No, she shouldn't use gloves from her pocket for anything.

Based on observation, interview, review of Resident Identifier (RI) #10's medical record and the facility's policy titled, medications: [REDACTED]. On 05/09/2017, Employee Identifier (EI) #5, a Licensed Practical Nurse (LPN) emptied the [MEDICATION NAME] vial into the nebulizer reservoir, handed it to the resident to administer and exited the room. This affected one of six residents observed during medication pass observation. Findings included: The facility's policy titled, medications: [REDACTED]. PROCEDURE: 1. If a resident wishes to self-administer meds, a physician order [REDACTED]. Pharmacy will be notified. 3. The pharmacist will educate residents on the proper administration . 4. The MDS nurse will re-evaluate the resident's ability to self-administer meds . RI #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #10's Significant Change in Status Assessment with an assessment reference date of 03/08/2017 indicated RI #10 was cognitively intact with a Brief Interview for Mental Status (BIMS) of 14. RI #10's physician orders [REDACTED]. According to www.drugs.com, [MEDICATION NAME] is a sterile inhalation solution containing a combination of [MEDICATION NAME] and [MEDICATION NAME]. These medications ([MEDICATION NAME] and [MEDICATION NAME]) relax muscles in the airway and increase air flow to the lungs. During medication administration observation on 05/09/2017 at 5:16 p.m., EI #5, a LPN entered RI #10's room. EI #5 emptied the [MEDICATION NAME] vial into the nebulizer reservoir, handed it to the resident to administer and exited the room. On 05/11/2017 at 10:02 a.m., an interview was conducted with EI #4, a Minimum Data Set (MDS)/Care Plan LPN. EI #4 was asked, what steps are taken before a resident is considered safe to self-administer medications. EI #4 answered, the pharmacist comes over and goes step by step over how to use the medication. Then a MDS nurse completes a self-administration assessment. EI #4 was asked, had those things been done for RI #10. EI #4 replied, No. When asked if RI #10 self-administered any medication, EI #4 said, other than the breathing treatment, no ma'am. EI #4 was asked, if the breathing treatment was a medication. EI #4 said, yes, it's a medication. EI #4 further stated, the facility had never looked at it that way, but the breathing treatment was a medication. When asked if RI #10 should have had both those assessments before self-administering his/her nebulizer treatment, EI #4 answered, yes.

Based on observation, interview and review the facility's policy titled FOOD TEMPERATURES and the Food Code, the facility failed to ensure dietary staff reheated a pan of mixed vegetables to a temperature of 165 °F (degrees Fahrenheit) prior to serving residents. This was observed during the lunch meal on 5/10/17. This affected four residents who received the mixed vegetables at lunch. The RESIDENT CENSUS AND CONDITIONS OF RESIDENTS (Form CMS-672) dated 5/9/17 indicated the facility had a total of 74 residents. Findings include: The facility's policy titled FOOD TEMPERATURES with a review date of March 2017 documented, .C. Hot foods should be above 135 degrees. If temps (temperatures) on hot foods are between 41 and 135 they are to be taken off the line and reheated to proper temperature . Page 87 of the 2013 Food Code documented . Reheating for Hot Holding . TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the FOOD reach a temperature of at least 74 °C (Celsius) (165 °F) (Fahrenheit) . On 5/10/17 at 11:40 a.m., the dietary staff recorded the temperature of the mixed vegetables to be 99°F. Staff then removed the mixed vegetables to be reheated. At 11:45 a.m., the dietary staff brought the mixed vegetables back to the tray line. The temperature registered at 150 °F. At 11:55 a.m., the dietary staff began plating trays for the residents of the nursing home who ate in their rooms. The surveyor observed four plates prepared with the mixed vegetables to be served to residents. On 5/11/17 at 9:05 a.m., an interview was conducted with Employee Identifier (EI) #1, the Dietary Director. EI #1 was asked if it was correct to reheat the mixed vegetables to 150 °F. EI #1 replied no, it is not correct. EI #1 was asked what temperature should food be reheated to. EI #1 replied 165 °F. EI #1 was asked what was the potential harm of food not reaching the correct temperature. EI #1 replied it could cause illness or bacteria. EI #1 was asked how many residents received the mixed vegetables for lunch on 5/10/17. EI #1 replied, three or four residents who ate in their rooms.

Based on observation, staff interviews, review of Resident Identifier (RI) #7's medical record review, interviews, review of Fundamentals of Nursing and Mosby's 2017 NURSING DRUG REFERENCE, the facility failed to ensure RI #7's order for [MEDICATION NAME], an appetite stimulant, contained all required components of a complete physician's orders [REDACTED].#7. This affected RI #7, one of 14 residents for whom physician's orders [REDACTED]. Findings include: Chapter 32 titled Medication Administration page 623 of Fundamentals of Nursing with a copyright date of 2017, documented . FIGURE 32-5 Example of a medication prescription . Inscription: Contains the drug name, strength, and dose . RI #7 was admitted to the facility on [DATE]. RI #7's . EMERGENCY REQUEST FORM dated 04/10/17 documented . Orders/Response from Physician . [MEDICATION NAME] 1 tsp (teaspoon) po (by mouth) ac (before meals) & hs (at bedtime) . RI #7's monthly physician's orders [REDACTED]. [MEDICATION NAME] 1 tsp po AC & HS x 45 days for decreased appetite . Page 745 of Mosby's 2017 NURSING DRUG REFERENCE with a copyright date of 2017, indicated [MEDICATION NAME] was available in tablet and oral suspension form. The tablets were available in 20 milligram (mg) and 40 mg tablets. The oral suspension form was available in 40 mg/ml (milligram/milliliter) and 125 mg/ml. On 05/09/2017 at 5:10 p.m., Employee Identifier (EI) #2, a Licensed Practical Nurse (LPN) provided the bottle of RI #7's [MEDICATION NAME] for the surveyor's review. The bottle indicated RI #7 was ordered [MEDICATION NAME] oral suspension 40 mg/ml. On 05/10/2017 at 11:45 a.m., EI #2, a LPN was asked to list the required components of a physician's orders [REDACTED]. After reviewing RI #7's order for [MEDICATION NAME], EI #2 stated it apparently did not contain all of the required information because it was missing the strength of the medication. She explained when she received the order from the physician, she should have sent it back and asked for the strength to make sure they were giving it correctly. EI #8, the Director of Nursing, was interviewed on 05/10/2017 at 9:18 a.m EI #8 stated per nursing standards a physician's orders [REDACTED]. After reviewing RI #7's [MEDICATION NAME] order, EI #8 said the order did not contain the dosage. EI #8 said staff should have called the doctor to verify the dosage.

Based on observation, interviews and record review, facility staff failed to heat and serve food from their two steam tables at recommended temperatures, with no more than one re-heating. Facility staff further failed to transfer food to the steam table for service, without cross-contamination. This had the potential to affect all 66 residents for whom food was prepared and served at the time of this survey. Findings included: The 2013 Food & Drug Administration Food Code mandates under regulation 3-403.11(A): .Food that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the food reach a temperature of at least .165 degrees Fahrenheit (F) for 15 seconds. 1) On 07/06/16 between 11:16 and 11:30 a.m., the surveyor observed the morning cook (Employee Identifier/EI #3) remove foods from their heating sources and set up the lunch trayline in the main kitchen. During her check of each food temperature, EI #3 found the pan of pureed cornbread dressing to be suboptimal. EI #3 removed the pureed cornbread from the steam table, reheated it in the steamer, then replaced it on the steam table and rechecked the temperature, finding it to be 155 degrees F. EI #3 then reheated the pan of cornbread a second time, atop the stove, before the temperature reached a temperature above 165 degrees. The undated facility policy (reference # ) related to Storage and Use of Leftovers page 392, specifies: Hot foods are reheated only once. 2) At 11:30 a.m., EI #3 transferred a 1/3-size pan of hot giblet gravy from the oven into a steam well adjacent to a full-size pan of cornbread dressing, using a pair of thick oven mitts to protect her hands. As she lowered the pan of gravy into the steam well, EI #3's mitted left hand contacted the soft cornbread dressing, leaving an indentation 1/2 to 3/4 inch deep. 3) On 07/06/16 between 12:00 and 12:10 p.m., the surveyor observed the Certified Dietary Manager (CDM) as she checked the food temperatures on the dining room tray line. Finding pork loin, and ground turkey at substandard temperatures, the CDM sent each back to the main kitchen for reheating. At 12:10 p.m., the items were returned to the dining room steam table. The CDM rechecked the temperatures of each, finding the pork loin to be 160 degrees F (still slightly below the reheating recommendation), and the ground turkey to be 130 degrees F. The CDM then gave the Dietary Director (EI #4) the pan of ground turkey for reheating a second time. Upon return to the steam table at 12:25 p.m., the CDM measured the temperature of the ground turkey to be 144 degrees F. The CDM proceeded with the service of the lunch tray line. On 07/06/16 at 3:15 p.m., the surveyor interviewed the morning cook, EI #3, and the Dietary Director (EI #4). When asked what the potential hazard would be of contacting the cornbread dressing with her oven mitt, EI #3 responded, Cross contamination. When asked the temperature to which foods must be reheated, EI #3 was unsure and responded 155 degrees F. When asked how often food could be reheated, EI #4 incorrectly responded, two times. When asked what temperature the ground turkey should have been reheated to, EI #4 responded, 160 to 165 degrees F.

Based on observation, record review and interview the facility failed to ensure a Licensed Practical Nurse (LPN) did not touch Resident Identifier (RI) #6's medications with her bare hands. This was observed during medication pass observation on 7/6/16 and affected one of five nurses observed during medication pass. Findings Include: A review of a facility policy titled MEDICATION ADMINISTRATION ROUTE: PO with a revised date of July 23, 2014, revealed POLICY It is the policy of . to give PO (by mouth) medication in a safe and effective manner . RI #6 was admitted to the facility 9/16/2014 with a [DIAGNOSES REDACTED]. On 7/6/16 at 8:10 a.m., Employee Identifier (EI) #2, LPN was observed preparing and administering RI #6's medication. RI #6 asked EI #2 how many medications and EI #2 poured the medications into her own hand counting and explaining what each medication was. EI #2 then poured the medications from her hand into a cup of applesauce for the resident to take. On 7/6/16 at 8:15 a.m., an interview was conducted with EI #2. EI #2 was asked if she was suppose to touch residents medications with her bare hands. EI #2 replied no. EI #2 was asked if she touched RI #6's medications with her bare hands, she replied yes. EI #2 was asked what was the harm in touching resident medications with bare hands. EI #2 replied could have germs on my hands and pass them to the resident. On 7/7/16 at 9:50 a.m., an interview was conducted with EI #1, Infection Control Nurse. EI #1 was asked when should an LPN touch medications with their bare hands; she replied never. EI #1 was asked how should an LPN touch resident medications. EI #1 replied if they need to touch the medications they need to wash their hands and put on gloves. EI #1 was asked what would the harm be in an LPN touching a resident's medications with their bare hands. EI #1 replied cross contamination from the nurse to the resident.

Based on observation, interviews and record review the facility failed to ensure a Certified Nursing Assistant (CNA) changed gloves after providing incontinent care to Resident Identifier (RI) #1, before handling the clean brief. This affected 1 of 2 resident observations for incontinent care. Findings Include: A review of facility policy titled INCONTINENT CARE OF THE RESIDENT with a revised date March 23, 2011 revealed .PROCEDURE:. 9. Wet 6-8 bath cloths and lay to side. Add soap as needed. 12. MALE: Wash sides of penis.14. Use clean wet cloth and rinse.16. Remove gloves, wash hands, apply new gloves.19. Apply new diaper. RI #1 was readmitted to the facility 02/12/2015 with a [DIAGNOSES REDACTED]. A review of RI #1's most recent Minimum Data Set with an Assessment Reference Date of 4/11/2015 revealed RI #1 was severely cognitively impaired with long and short term memory problems. Further review revealed RI #1 was total dependence for toileting needs. On 6/10/15 at 10:00 AM, Employee Identifier (EI) #1 was observed providing incontinent care to RI #1. EI #1 cleaned the resident's front, then turned the resident and cleaned the resident of bowel movement. EI #1 placed the clean brief on the resident using the same with gloves with which she cleaned the resident. An interview was conducted with EI #1 on 6/10/15 at 10:15 AM. EI #1 was asked what was the policy for changing gloves during incontinent care. EI #1 replied wash hands then put on gloves before and after cleaning front, then change after cleaning back before touching the clean brief. EI #1 was asked did you change gloves and wash hands after cleaning bowel movement and before handling the clean brief. EI #1 replied no. EI#1 was asked what was the harm in not changing gloves before touching the clean brief. EI #1 replied, contamination. On 6/11/15 at 10:35 AM an interview was conducted with EI #2, the Infection Control Nurse. EI #2 was asked if it would be an acceptable practice for a CNA during incontinent care to clean bowel movement, then place the clean brief with the same gloves she did the incontinent care. EI #2 replied no. EI #2 was asked what was the procedure for changing gloves during incontinent care. EI #2 replied, they should change gloves any time they become soiled and then prior to placing the clean brief, and linens. EI #2 was asked what was the harm in staff not changing gloves prior to handling the clean brief. EI #2 replied it could increase infections in general and cross contaminate.

Based on observation, interview, and record review the facility failed to ensure a Certified Nursing Assistant (CNA) performed incontinent care on Resident Identifier (RI) #2 by cleaning in a front to back manner. This affected one of two residents observed for incontinent care. Findings include: RI #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #2's most recent Comprehensive MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 06/01/2015 revealed a BIMS (Brief Interview for Mental Status) score of 3 out of 15. RI #2 was identified as being severly cognitively impaired in daily decision making. RI #2 was also identified as being totally dependant on staff for all ADL's (Activities of Daily Living) and as being frequently incontinent of bowel and bladder. A review of the facility's policy and procedure titled, SUBJECT INCONTINENT CARE OF THE RESIDENT, with a revised date of March 23, 2011 revealed: .PROCEDURE:. 10. FEMALE: Wash one side of perineum front to back with soapy cloth, then dispose. Wash other side, dispose of cloth. Wash middle and dispose of cloth, repeat as necessary. 17. Repeat steps 9-12 with rectal area - remove pad. On 06/10/2015 at 11:25 AM the surveyor observed EI (Employee Identifier) #3, a CNA (Certified Nursing Assistant) providing incontinent care on RI #2. When she was cleaning the buttocks and anal area she wiped in a back to front motion. On 06/10/2015 at 12:10 PM, an interview was conducted with EI #4, a CNA. EI #4 was asked by the surveyor, when performing incontinent care on RI #2 what did she do when she wiped RI #2's buttocks. EI #4 said wiped the wrong way, back to front. EI #4 was asked what the facility policy says about which direction she should wipe during incontinent care. EI #4 stated front to back. EI #4 was asked if she did this when wiping RI #2. She stated no. EI #4 was asked why she didn't wipe front to back. She replied She was nervous. EI #4 was asked what was the potential harm in not wiping a resident front to back when performing incontinent care. She replied it would cause infection. On 06/11/2015 at 10:35 AM, an interview was conducted with EI #2, the Infection Control Nurse. EI #2 was asked which way to wipe during incontinent care. She said from front to back, away from the vaginal area wiping back. EI #2 was asked if it was an acceptable practice for a CNA to wipe the buttocks area from back to front. She said no. EI #2 was asked what was the harm in wiping incorrectly or in the wrong direction. EI #2 replied, cross contamination and it could cause infection.

Based on observation, record review and interview the facility failed to ensure the walls of Room Locator (RL) 1 -3 were free of scrapes and wear and tear. The facility further failed to maintain the door frames of RL # 4-18 free of scrapes and chipping paint. This was observed on two days of the survey and affected 1 of 2 units in the facility. Findings Include: A review of an undated policy titled Safety Policy: documented the following: .FORMALIZED MAINTENANCE PROGRAMS: The formalized maintenance program consists of specific preventative maintenance, inspections, tests and requirements in the form of schedules, specifically prepared. The following observations were made: On 6/10/15 at 5:00 PM, RL # 1-18 were observed to have scrapes, chipping paint and/or noticeable wear and tear. On 6/11/15 at 10:30 AM RL # 1-18 were observed to have scrapes, chipping paint and /or noticeable wear and tear. On 6/11/15 at 11:15 AM an interview was conducted with Employee Identifier (EI) # 3, Maintenance Director. EI # 3 stated the Maintenance Department was responsible for maintaining the building. EI # 3 stated the department received referrals for repairs from licensed staff and Certified Nursing Assistants and at times administration. EI # 3 was asked if he had received any work orders for Unit 2 in the facility. EI # 3 stated yes, they had repaired some sheet rock. EI # 3 was asked to describe RL # 1 -3. EI # 3 described scrapes, wear and tear and stated it would need to be replaced and repaired. EI # 3 was asked to describe RL # 4- 18. EI # 3 described scrapes and wear and tear and further stated they would need to be painted and sanded. EI # 3 further stated he felt the whole unit needed to be repaired and painted.

Based on record review, interview and observation the facility failed to ensure that licensed staff wore gloves when administering eyedrops to Unsampled Resident #1, nasal spray to Unsampled Resident #2 and an insulin injection to Unsampled Resident #3 on 7/15/14 during medication administration pass. This affected 3 of 5 residents observed for medication administration pass. Findings Include: Unsampled Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of unsampled resident #1's Admission MDS ( Minimum Data Set) Assessment with an ARD (Assessment Reference Date) of 5/25/14 revealed that unsampled resident #1 had a BIMS (Brief Interview for Mental Status) score of 15, indicating the resident was cognitively intact for daily decision making. A review of unsampled resident #1's physician's orders [REDACTED]. Unsampled Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of Unsampled Resident #2's most recent 30-day MDS assessment with an ARD of 5/23/14 revealed a BIMS score of 13 which indicates the resident was cognitively intact for daily decision making. A review of unsampled resident #2's Physician order [REDACTED]. Unsampled Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of unsampled resident #3's most recent Significant Change MDS with an ARD of 6/26/14 revealed a BIMS score of 14 which indicated he was cognitively intact for decision making. A review of unsampled resident #3's Physician order [REDACTED]...175-200=3 units..." A review of a facility document titled " Infection Control Staff Meeting " not dated revealed " ...Wearing Gloves: *nurses told to wear when giving injections ... *wear gloves at anytime there is a chance to spread infection or contaminate *gloves are to be changed between every resident ... " A review of a facility document titled, "Educational Services Attendance Sign-in Form" revealed that a Quarterly meeting was held on 03/07/14 where a class on infection control issues was taught and EI (Employee Identifier) #3, LPN (Licensed Practical Nurse) signed the attendance form. A review of a facility document titled, :4/30/14 Educational Services Attendance Sign-in Form", revealed that a class featuring pharmacy update and proper medication instructions was given. EI #3 signed the attendance form. A review of the facility's policy titled, " GLOVE USE " with a review date of May 2013, revealed, " POLICY: ...1. Gloves must be worn when there is a potential for coming into contact with body fluids ... " A review of the facility's policy titled, " MEDICATION ADMINISTRATION " with a revised date of 6/20/14 revealed, "POLICY: ...Anytime you directly touch a medication, follow hand washing protocol and wear gloves ... " A review of the facility's policy titled, "MEDICATION ADMINISTRATION ROUTE:SUBCUTANEOUS" with a revised date of April 2009 revealed, "POLICY: ...PORCEDURE: ...2. Apply gloves..." On 7/16/14 at 8:25 AM, the surveyor observed EI #3 administering AKWA eyedrops to unsampled resident #1 without wearing gloves. On 7/16/14 at 8:35 AM, the surveyor observed EI #3 administering [MEDICATION NAME] nasal spray to unsampled resident #2 without wearing gloves. On 7/16/14 at 9:00 AM, the surveyor observed EI #3 administering an insulin injection to unsampled resident #3 without wearing gloves. On 7/16/14 at 9:54 AM, an interview was conducted with EI #3. EI #3 was asked what she was taught about wearing gloves when administering eye drops, nasal spray and insulin injections. EI #3 stated she was supposed to wear gloves because it is in the policy, but she just works better without them. EI #3 was asked when administering eye drops to unsampled resident #1, nasal spray to unsampled resident #2 and an insulin injection to unsampled resident #3, did she wear gloves. EI #3 shook her head and said no ma ' am. EI #3 was asked why she did not wear gloves when administering the eye drops, nasal spray and insulin injection. EI #3 said she could just work better without them. EI #3 was asked should she have worn gloves when administering the eye drops, nasal spray and insulin injection. EI #3 said yes ma'am. EI #3 was asked what was the potential harm when she did not wear gloves when administering the eye drops, nasal spray or insulin injection. EI #3 said possible infection. On 7/17/14 at 7:40 AM, an interview was conducted with EI #1, DON (Director of Nursing). EI #1 was asked what was the facility's policy and procedure on wearing gloves when staff administer an insulin injection, eyedrops and nasal spray. EI #1 said gloves should be worn when administering insulin and eyedrops and when medication had to be opened. EI #1 was asked should nurses wear gloves when administering insulin injections, eyedrops and nasal spray. EI #1 said nurses should wear gloves when administering insulin and eyedrops. EI #1 was asked who trained the staff on the infection control program in this facility. EI #1 said EI #2, RN (Registered Nurse) infection control nurse. EI #1 was asked how often was the training done. EI #1 said two times a year and as needed along with daily observations. EI #1 was asked how she ensured staff understood what was being taught concerning infection control. EI #1 said they had question and answer sessions at the end of inservices along with the policy being handed out to staff. EI #1 further stated that EI #2 and pharmacy observe the staff. EI #1 was asked what areas were focused on in the infection control program. EI #1 said handwashing, glove wearing, isolation procedures, standard precautions, disposing of soiled material and incontinence (care). EI #1 was asked what was the potential harm if nurses do not wear gloves when administering an insulin injection, eyedrops and nasal spray. EI #1 said contamination, spread of infection and the integrity of the medicine could become compromised. On 7/17/14 at 8:04 AM, an interview was conducted with EI #2. EI #2 was asked how are infections controlled in the facility. EI #2 said that she talked with staff about when to wash hands and change gloves. EI #2 was asked if direct care staff were washing their hands and wearing gloves according to facility protocol. EI #2 said that to her knowledge, staff were washing hands and wearing gloves. EI #2 was asked how were infections tracked and trended in the facility. EI #2 said with the infection control log. EI #2 was asked how she monitored direct care staff to ensure they are washing hands and wearing gloves according to facility protocol. EI #2 said by observation where she walked up the halls and watched staff.

Based on observation, interview, and record review, the facility failed to ensure the stove top, grill and bottom of oven were free of more than one days accumulation of grease, grime and debris. This had the potential to affect 63 residents receiving meals from dietary. Finding include: The facility Policy for cleaning food contact surfaces dated 1/4/13, specified: "DAILY CLEANING PROCEDURE FOR OVENS AND STOVE TOPS Using pot and pan soap and hot water, scrub all areas of stove including splash guards and sides. When all surfaces are free of food particles or grime, sanitize area with quat sanitizer with a minimum concentration of 200 ppm (parts per million). Allow to air dry. This action is to be performed by the cooks." At 11:30 AM on 6/12/13, an observation was made underneath the oven, on the rack there was a build-up of grease-like substance. Observations were also made of grease accumulation (puddling) and debris on the stove top back burner and between the two burners and the grill. Grease accumulation was also observed on the sides of the stove and grill. EI #1, was with the surveyor during this observation. EI #1 said the stove and grill were wiped down daily. On 6/13/13 at 8:35 AM, an observation was again made of grease puddling and debris on the stove top back burner and between the two burners. This was also observed underneath the oven on the rack and the grill and sides. EI #1 was with the surveyor during this observation. On 6/13/13 at 11:15 AM, EI #1 was interviewed. The observations of the grease puddling on the back burner and between the two burners of the stove top, the build-up of debris on the stove and grill were reviewed with EI #1. The puddling of the grease looked to be the same amount and was on the same area that it had been observed on before. EI #1 was asked should they have been cleaned the night before. EI #1 responded with a yes. EI #1 was then asked should the accumulation on the sides of the stove and grill had been that much if they were cleaned daily. EI #1 said if they (staff) had cleaned it last night, no. Regarding the observations of the accumulation of debris under the oven on 2 of the 3 days of the survey, EI #1 said the oven should have been wiped down daily.