Every finding on record at Cloverdale Rehabilitation and Wellness

Based on observations, interviews, review of a facility policy titled Infection Control Isolation Droplet Precautions for COVID-19, and a document titled PPE (personal protective equipment) Education, the facility failed to ensure trash and linen receptacles were available inside the transmission based precaution rooms for the disposal of contaminated linens, trash, and PPE. As a result, staff were having to discard used PPE after exiting the rooms. This was noted with four of four rooms identified by the facility as being under transmission based precautions. Findings include: A review of a facility policy titled Infection Control Isolation Droplet Precautions for COVID-19, indicated, . Doffing Step 6: Exit Patient Care Area - As you exit the only item of PPE remaining is your N95 respirator . A review of a document titled PPE Education, located beside a KIOSK (electronic terminal on the wall for documentation) on the 400 Hall wall, indicated, .Instruction: After Donning PPE, enter resident room and provide care. When the care is complete you must Doff (take off) All PPE in the resident's room and place in Red Barrels except N95 masks. Doff (take off) PPE before exiting resident room . On 03/29/2022 at 12:21 PM, lunch trays were observed being passed to resident rooms on the 400 Hall. Employee Identifier (EI) #8, Certified Nursing Assistant (CNA), while gowned and gloved, served a tray to the resident in room [ROOM NUMBER]. EI #8 removed the gown and gloves in the hall after leaving the room and disposed of the used PPE in a red top trash and linen receptacle located across the hall from room [ROOM NUMBER]. On 03/29/2022 at 12:31 PM, EI #9, Certified Occupational Therapy Assistant (COTA), was observed exiting room [ROOM NUMBER]. EI #9 removed a gown, gloves, and shoe covers and disposed of them in the red top linen and trash receptacles located across the hall from room [ROOM NUMBER]. On 03/29/2022 at 12:31 PM, an interview was conducted with EI #9. EI #9 stated she removed the PPE outside the room because there were no waste receptacles in the rooms to dispose of used PPE. On 03/30/2022 at 8:49 AM, there was an observation of red lid linen and trash receptacles located on the right side of the hallway, between rooms [ROOM NUMBERS], 404 and 406, and 406 and 408. There were no red top trash or dirty linen receptacles located outside of Rooms 401, 403, 405, or 407 on the left side of the hallway. On 03/30/2022 at 9:37 AM, an interview was conducted with EI #10, CNA. EI #10 stated when leaving an isolation room, staff were to take off all PPE. After coming out of the room, EI #10 described that staff were to remove their gown, remove their head and foot covers, and sanitize their hands. EI #10 stated that the receptacles for the used PPE were in the hall. EI#10 acknowledged staff should be taking everything off in the room before exiting. On 03/30/2022 at 10:14 AM, an interview was conducted with EI #18, RN Infection Control Preventionist. EI #18 stated with a new admission who was not vaccinated, the new resident was placed on transmission based precautions, specifically droplet precautions, for 14 days. EI #18 noted if a resident was on precautions, a droplet precautions sign was placed on the door to notify staff to put on PPE before entering the room. EI #18 stated PPE was removed after leaving the room and disposed of in receptacles outside the room. EI #18 stated some staff removed the PPE at the door and some removed it at the receptacles. EI #18 stated that potentially infectious agents could be brought into the hallway when removing PPE outside the room. EI #18 said that if someone was walking down the hall as the PPE was removed, then the infection could potentially be spread to other parts of the building. EI #18 stated there were no linen or trash receptacles in the rooms to dispose of the PPE. On 03/30/2022 at 4:02 PM, an interview was conducted with EI #2, Director of Nursing. Per EI #2, if a resident was on transmission based precautions, the linen and trash barrels were located outside their door. EI #2 stated that PPE was disposed of outside a resident's room at the doorway. On 03/30/2022 at 4:17 PM, an interview was conducted with EI #1, Administrator. After reading over the facility's policy, EI #1 stated the policy indicated PPE should be removed before exiting a resident room. EI #1 stated that a negative potential outcome of not following the policy would be transmission of pathogens to someone else. On 03/31/2022 at 08:13 AM, EI #18, the Infection Control Preventionist, and the surveyor went to the 400 Hall, and EI #18 confirmed the following rooms were on transmission based precautions: 401, 402, 403, and 406.

Based on record review, observations, interviews, and review of the facility's policy titled Pharmacy Unnecessary Drugs, the facility failed to ensure Resident Identifier (RI) #73, who received [CONDITION(S)] medications, was monitored for adverse effects (side effects) of the medications. The deficient practice affected RI #73, one of five sampled residents reviewed for unnecessary medications. Findings include: A review of the facility's policy titled Pharmacy Unnecessary Drugs, dated 07/2014, revealed: Policy: Each resident's drug regimen shall be free of unnecessary drugs. Procedure: .2. A comprehensive assessment of the resident's drug therapy must include: .Recognition of potential side effects . A review of RI #73's Face Sheet revealed the facility admitted RI #73 to the facility on [DATE] with diagnoses that included [CONDITION(S)], [CONDITION(S)], and Mood Disorder due to Known Physiologic Condition with Depressive Features. A review of RI #73's admission Minimum Data Set (MDS), dated [DATE], revealed RI #73 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated RI #73 was cognitively intact. The MDS also indicated RI #73 had received an antipsychotic medication five days during the seven-day assessment look-back period. A review of RI #73's comprehensive care plans, last updated 03/28/2022, indicated RI #73 was at risk for side effects due to [CONDITION(S)] medication usage needed to address [CONDITION(S)] and was at risk for side effects due to antidepressant medication usage needed for complaints of depressed mood and difficulty resting during hours of sleep. The care plans lacked interventions directing staff to monitor RI #73 for side effects of the medications. A review of RI #73's Physician Orders for March 2022 revealed the following orders: -[MEDICATION(S)] (antipsychotic agent) 5 milligrams (mg) by mouth once daily for a diagnosis of [CONDITION(S)], order date 03/30/2022 - [MEDICATION(S)] (antidepressant agent) 20 mg by mouth once daily, order date 03/30/2022 - [MEDICATION(S)] (antipsychotic agent) 117 mg/0.75 milliliters (mL), ordered on 03/16/2022 to be administered on 03/18/2022 - an order to monitor for any inappropriate behaviors twice daily. RI #73's Physician Orders contained no orders to monitor RI #73 for adverse effects/side effects related to the above medication orders. A review of RI #73's Electronic Medication Administration Record (eMAR) for February 2022 and March 2022 revealed no monitoring for side effects related to RI #73's [CONDITION(S)] medications. Review of RI #73's Abnormal Involuntary Movement Scale (AIMS), dated, 02/08/2022, revealed RI #73 was scored as a zero for abnormal facial movements. However, an observation on 03/28/2022 at 2:37 PM revealed RI #73 exhibited tongue thrusting (an uncontrollable movement usually caused from long-term use of antipsychotics) throughout the initial resident interview. The resident expressed no complaints at that time. On 03/29/2022 at 12:00 PM, RI #73 was observed eating lunch in the resident's room. RI #73 reported they were aware of some of their abnormal mouth movements, including tongue thrusting/rolling and lip puckering/smacking, stating some of their prior medications probably caused the movements. RI #73 also reported he/she was missing teeth, which the resident stated added to the movements. On 03/30/2022 at 1:34 PM, Employee Identifier (EI) #12, Certified Nursing Assistant (CNA), stated RI #73 had had no behaviors or side effects she had noticed while RI #73 had been on the hall. When asked what kinds of symptoms she would alert the nurses to, EI #12 stated she would let the nurses know if a resident slept more than normal. Per EI #12, CNAs were asked to document behaviors in the kiosk (a point of care electronic charting system) such as yelling, screaming, and things like that. EI #12 denied any issues with RI #73 and added staff only documented when there was a behavior, noting RI #73 would, therefore, have nothing documented. On 03/30/2022 at 2:20 PM, EI #14, Registered Nurse (RN) Supervisor, was interviewed. EI #14 stated she believed all residents had standing orders to monitor for behaviors as needed on their eMARs. However, EI #14 indicated the eMAR did not include any resident-specific or targeted behaviors for each resident. EI #14 was unsure if the behavior and adverse effect/side effect monitoring was placed on the eMAR from a physicians order or if it was automatic, depending upon the types of medications ordered. During an interview on 03/30/2022 at 2:35 PM, EI #13, Charge Nurse, stated RI #73 was fairly new to her. When asked what she knew about RI #73, she stated RI #73 was receiving some [CONDITION(S)] medications, and seemed pleasant, noting she didn't really know the resident that well. EI #13 said since RI #73 was on some [CONDITION(S)] medications, she would expect there to be something in place to monitor for any side effects and symptoms. On 03/30/2022 at 2:50 PM, EI #15, RN Admissions Nurse, explained that when any resident was started on a [CONDITION(S)] medication, and the order was put into the system, there is a box to check on the screen that activates the adverse effect monitoring and symptom review. EI #15 stated there should be symptom and adverse effect monitoring for any resident receiving antidepressants, antipsychotics, antianxiety, and hypnotic medications. On 03/30/2022 at 3:10 PM, EI #16, RN Medical Records/Risk Management Nurse, reviewed RI #73's eMAR and orders. EI #16 stated RI #73's orders did not have the box checked to prompt the side effect monitoring. EI #16 indicated had the information been entered correctly, the monitoring would have been added to the end of RI #73's eMAR. During an interview on 03/30/2022 at 4:42 PM, EI #1, Administrator, indicated any resident on an antipsychotic should be monitored for symptoms and side effects. On 03/31/2022 at 10:25 AM, the facility's consulting Clinical Pharmacist, was interviewed. The Pharmacist stated if a resident was on multiple psychotropics, then side effects needed to be monitored.

Based on observations and staff interviews, one (1) of two (2) of the facility's environmental staff contaminated their clothing during environmental cleaning. Additionally, the facility failed to ensure one (1) of two (2) laundry staff mouth and nose were covered by a mask, when in the presence of others, and while handling facility linens. These failures occurred during a COVID-19 pandemic. The findings include: 1. During a concurrent observation and interview on 07/27/2020 at 2:10 p.m., accompanied by the Director of Nursing (DON); Environmental Staff (ES) #1 wiped the floor with a cloth, then placed the cloth in her uniform pocket. She entered Resident #1's room, performed environmental services (cleaned high touch surfaces/bathroom, emptied trash can, and mopped the floor, in close proximity to Resident #1. ES #1 acknowledged, that she was aware of the COVID-19 pandemic. The DON stated, environment staff should not place contaminated cloths in their pockets after cleaning the floor. 2. During a concurrent observation and interview on 07/27/2020 at 2:38 p.m., accompanied by the DON, Laundry Staff (LS) #1 was observed folding linens. LS #1 made conversation, and continued to fold the linens, without her nose or mouth covered by a mask, and confirmed that her face mask was in her pocket. LS #1 acknowledged, that she was aware of the COVID-19 pandemic. The DON stated, she expected laundry staff to wear their facial mask, when talking to others, and when handling facility linens, or resident clothing.

Based on interviews, review of Resident Identifier (RI) #65's medical record, hospital records and the facility's investigation file, the facility failed to ensure Employee Identifier (EI) #4, a Certified Nursing Assistant (CNA) followed RI #64's care plan when she transferred the resident from the wheelchair to the bed on 5/16/2018. EI #4 transferred the resident by herself instead of the two person assist as listed in the care plan. While trying to get the legs of the Hoyer lift under the bed, EI #4 pushed over the fall mat and when she did that, the Hoyer lift rocked a little and the resident flipped out of the sling and landed on the fall mat but hit his/her head on the legs of the Hoyer lift. RI #65 sustained a skin tear to the left arm and a laceration to the back of the head. After assessment by the licensed nursing staff, RI #65 was transferred to the local hospital's emergency room (ER) for evaluation and treatment. RI #65 was transferred back the nursing facility on 5/16/2018 after the laceration was repaired with four staples. This deficient practice affected RI #65, one of three residents reviewed for falls. Findings include: RI #65 was admitted to the facility on [DATE] with an admit [DIAGNOSES REDACTED]. RI #65's Annual Minimum Data Set with an assessment reference date of 1/31/2018 indicated the resident was severely impaired in cognitive skills, with a Brief Interview for Mental Status (BIMS) of 0. RI #65 was assessed as being totally dependent on staff, with two plus person physical assist for transfers. RI #65's care plan titled (RI #65) is dependent on staff for ADL (activities of daily living) care r/t (related to) multiple comorbities . with a problem onset date of 4/25/2018 had an approach of . Dependent x2 staff members for transfers via hoyer lift . RI #65's Resident Incident Report indicated on 5/16/2018 at 5:40 PM, RI #1 fell out of the Hoyer lift while being transferred from the chair to the bed by EI #4, a CNA. RI #65 was transferred to the emergency room after sustaining a skin tear to the left arm and a laceration to the back of the head. On 6/14/2018 at 2:35 PM, an interview was conducted with EI #4, the CNA who transferred RI #65 on 5/16/2018. When asked how the resident should be transferred, EI #4 stated with Hoyer lift and two people. EI #4 acknowledged she did not have a second person present when she transferred RI #65 on 5/16/2018. RI #65's local hospital's ED (Emergency Department) Physician Documentation with a service date of 5/16/2018, documented . Chief Complaint: Fall injury . Initial Comments . Patient . present to the ER via EMS (emergency medical services) from Cloverdale Manor with a head injury from a fall out of a hoyer lift . Patient is unable to communicate with the physician because (he/she) has Dementia . Injuries/Pain Location: head, upper extremity (2 skin tears to the left wrist) . Loss of Consciousness: no loss of consciousness . According to the hospital record, an X-ray of the left wrist was performed, which revealed osteopenia but no fracture. The Computed Tomography (CT) of the head revealed a posterior-scalp hematoma with no acute intracranial finding. The CT of the cervical spine revealed no acute finding. RI #65's scalp laceration was repaired with four staples. RI #65 was transferred back the nursing facility on 5/16/2018, with instructions to remove the staples in seven days. The INCIDENT INVESTIGATION signed by EI #7, a Licensed Practical Nurse, documented . Narrative of investigation: ON 5/16/2018 AT 5:40 PM RESIDENT WAS BEING TRANSFERRED VIA HOYER LIFT. AS THE STAFF WAS PUSHING THE HOYER LIFT OVER THE LANDING MAT THAT IS BESIDE THE BED. THE LIFT TILTED OVER CAUSING THE RESIDENT TO FLIP OUT OF SLING AND ONTO THE FLOOR. RESIDENT NOTED WITH LACERATION TO THE BACK OF THE HEAD AND SKIN TEARS TO THE LEFT HAND AND WRIST AREA. CHARGE NURSE ASSESSED RESIDENT AND PROVIDED FIRST AIDE AND NEUR[NAME]HECKS. RESIDENT WAS ALERT AND ORIENTED TO PERSON. CHARGE NURSE NOTIFIED AMBULANCE SERVICE FOR TRANSPORT TO (hospital) ER (emergency room ) FOR EVAL (evaluation) AND TREATMENT. CHARGE NURSE NOTIFIED DON (Director of Nursing), MD (Medical Doctor), HOSPICE, AND RESIDENT REPRESENTATIVE R/T (related to) FALL. IMMEDIATE EDUCATION ON PROPER HOYER LIFT TRANSFERS. WRITTEN EDUCATION ON HALLS R/T PROPER TRANSFERS. WILL CONTINUE TO OBSERVE During an interview with EI #6, the DON, on 6/14/2018 at 4:26 PM, she was asked about RI #65's fall on 5/16/2018. According to EI #6, the resident pulls his/her legs up in a ball. The CNA (EI #4) thought the resident was going to slide out of the wheelchair, so she decided to put the resident back to bed. While trying to get the legs of the Hoyer lift under the bed, EI #4 pushed over the fall mat and when she did that, the Hoyer lift rocked a little and the resident flipped out of the sling and landed on the fall mat but hit his/her head on the legs of the Hoyer lift. When asked how the resident should be transferred, EI #6 stated with two people. ************************* As a result of the identified deficient practice, the facility immediately put the following corrective actions in place to prevent recurrence: On 5/16/2018, RI #65 was assessed and transferred to the local hospital's emergency room for evaluation and treatment. On 5/16/2018, RI #65's physician and family were notified of the incident. On 5/16/2018, EI #4, the CNA was provided education on how to properly transfer a resident with a Hoyer lift. On 5/17/2018, members of the facility's Quality Assurance Committee met and developed an action plan related to the improper transfer of the resident. On 5/17/2018, the facility issued EI #4 a safety violation with a final warning and 60 day probation. Beginning 5/17/2018 until 6/5/2018, all full time nursing staff received training on the facility's policy and procedure for use of the Mechanical Lift. On 5/18/2018, the facility updated RI #65's care plan to include the actual fall on 5/16/2018 with an approach of the reminder signs on the wall in RI #65's room to alert the staff to move the landing mats during transfers using the mechanical lift. On 5/18/2018, the facility placed a sign in the resident's room to alert the staff to move the landing mat out of the way during mechanical lift transfers. On 5/21/2018, EI #4 received instruction/training on Hoyer lift use per policy and procedure and performed return demonstration using proper technique. On 5/26/2018, EI #4 completed training on the policy and procedure for Mechanical Lift and Resident Falls. On 6/5/2018, EI #4 completed training for the Safe Use of the Mechanical Lift. ************************* After verifying the corrective actions implemented by the facility, observations of Mechanical lift transfers while on-site and interviews conducted, F 656 was cited at a scope and severity of level G, Past Non-Compliance.

Based on interviews, review of the facility's policy titled CERTIFIED NURSING ASSISTANT MECHANICAL LIFT, Resident Identifier (RI) #65's medical record, hospital records and the facility's investigation file, the facility failed to ensure Employee Identifier (EI) #4, a Certified Nursing Assistant (CNA) transferred RI #65 from the wheelchair to the bed with a Hoyer lift and two person assist. EI #4 transferred the resident by herself on 5/16/2018. While trying to get the legs of the Hoyer lift under the bed, EI #4 pushed over the fall mat and when she did that, the Hoyer lift rocked a little and the resident flipped out of the sling and landed on the fall mat but hit his/her head on the legs of the Hoyer lift. RI #65 sustained a skin tear to the left arm and a laceration to the back of the head. After assessment by the licensed nursing staff, RI #65 was transferred to the local hospital's emergency room (ER) for evaluation and treatment. RI #65 was transferred back the nursing facility on 5/16/2018 after the laceration was repaired with four staples. This deficient practice affected RI #65, one of three residents reviewed for falls. Findings include: The facility's policy titled CERTIFIED NURSING ASSISTANT MECHANICAL LIFT with a revision date of (MONTH) 2014, documented Policy A Mechanical lift will enable staff to safely lift and transfer the total care resident, or a resident who has fallen greatly reducing the possibility of injury to the resident and to staff . PR[NAME]EDURE . Note: Two staff members will operate the mechanical lift during all transfers . RI #65 was admitted to the facility on [DATE] with an admit [DIAGNOSES REDACTED]. RI #65's Annual Minimum Data Set with an assessment reference date of 1/31/2018 indicated the resident was severely impaired in cognitive skills, with a Brief Interview for Mental Status (BIMS) of 0. RI #65 was assessed as being totally dependent on staff, with two plus person physical assist for transfers. RI #65's care plan titled (RI #65) is dependent on staff for ADL (activities of daily living) care r/t (related to) multiple comorbities . with a problem onset date of 4/25/2018 had an approach of . Dependent x2 staff members for transfers via hoyer lift . RI #65's Resident Incident Report indicated on 5/16/2018 at 5:40 PM, RI #1 fell out of the Hoyer lift while being transferred from the chair to the bed by EI #4, a CNA. RI #65 was transferred to the emergency room after sustaining a skin tear to the left arm and a laceration to the back of the head. On 6/14/2018 at 2:35 PM, an interview was conducted with EI #4, the CNA who transferred RI #65 on 5/16/2018. According to EI #4, the resident (RI #65) was sitting sideways in the chair. EI #4 then got the Hoyer lift and placed the resident in bed because it looked like RI #65 was sleepy. When asked how the resident should be transferred, EI #4 stated with Hoyer lift and two people. EI #4 acknowledged she did not have a second person present when she transferred RI #65 on 5/16/2018. RI #65's local hospital's ED (Emergency Department) Physician Documentation with a service date of 5/16/2018, documented . Chief Complaint: Fall injury . Initial Comments . Patient . present to the ER via EMS (emergency medical services) from Cloverdale Manor with a head injury from a fall out of a hoyer lift . Patient is unable to communicate with the physician because (he/she) has Dementia . Injuries/Pain Location: head, upper extremity (2 skin tears to the left wrist) . Loss of Consciousness: no loss of consciousness . According to the hospital record, an X-ray of the left wrist was performed, which revealed osteopenia but no fracture. The Computed Tomography (CT) of the head revealed a posterior-scalp hematoma with no acute intracranial finding. The CT of the cervical spine revealed no acute finding. RI #65's scalp laceration was repaired with four staples. RI #65 was transferred back the nursing facility on 5/16/2018, with instructions to remove the staples in seven days. The INCIDENT INVESTIGATION signed by EI #7, a Licensed Practical Nurse, documented . Narrative of investigation: ON 5/16/2018 AT 5:40 PM RESIDENT WAS BEING TRANSFERRED VIA HOYER LIFT. AS THE STAFF WAS PUSHING THE HOYER LIFT OVER THE LANDING MAT THAT IS BESIDE THE BED. THE LIFT TILTED OVER CAUSING THE RESIDENT TO FLIP OUT OF SLING AND ONTO THE FLOOR. RESIDENT NOTED WITH LACERATION TO THE BACK OF THE HEAD AND SKIN TEARS TO THE LEFT HAND AND WRIST AREA. CHARGE NURSE ASSESSED RESIDENT AND PROVIDED FIRST AIDE AND NEUR[NAME]HECKS. RESIDENT WAS ALERT AND ORIENTED TO PERSON. CHARGE NURSE NOTIFIED AMBULANCE SERVICE FOR TRANSPORT TO (hospital) ER (emergency room ) FOR EVAL (evaluation) AND TREATMENT. CHARGE NURSE NOTIFIED DON (Director of Nursing), MD (Medical Doctor), HOSPICE, AND RESIDENT REPRESENTATIVE R/T (related to) FALL. IMMEDIATE EDUCATION ON PROPER HOYER LIFT TRANSFERS. WRITTEN EDUCATION ON HALLS R/T PROPER TRANSFERS. WILL CONTINUE TO OBSERVE During an interview with EI #6, the DON, on 6/14/2018 at 4:26 PM, she was asked about RI #65's fall on 5/16/2018. According to EI #6, the resident pulls his/her legs up in a ball. The CNA (EI #4) thought the resident was going to slide out of the wheelchair, so she decided to put the resident back to bed. While trying to get the legs of the Hoyer lift under the bed, EI #4 pushed over the fall mat and when she did that, the Hoyer lift rocked a little and the resident flipped out of the sling and landed on the fall mat but hit his/her head on the legs of the Hoyer lift. When asked how the resident should be transferred, EI #6 stated with two people. ************************* As a result of the identified deficient practice, the facility immediately put the following corrective actions in place to prevent recurrence: On 5/16/2018, RI #65 was assessed and transferred to the local hospital's emergency room for evaluation and treatment. On 5/16/2018, RI #65's physician and family were notified of the incident. On 5/16/2018, EI #4, the CNA was provided education on how to properly transfer a resident with a Hoyer lift. On 5/17/2018, members of the facility's Quality Assurance Committee met and developed an action plan related to the improper transfer of the resident. On 5/17/2018, the facility issued EI #4 a safety violation with a final warning and 60 day probation. Beginning 5/17/2018 until 6/5/2018, all full time nursing staff received training on the facility's policy and procedure for use of the Mechanical Lift. On 5/18/2018, the facility placed a sign in the resident's room to alert the staff to move the landing mat out of the way during mechanical lift transfers. On 5/21/2018, EI #4 received instruction/training on Hoyer lift use per policy and procedure and performed return demonstration using proper technique. On 5/26/2018, EI #4 completed training on the policy and procedure for Mechanical Lift and Resident Falls. On 6/5/2018, EI #4 completed training for the Safe Use of the Mechanical Lift. ************************* After verifying the corrective actions implemented by the facility, observations of Mechanical lift transfers while on-site and interviews conducted, F 689 was cited at a scope and severity of level G, Past Non-Compliance.

Based on observation, interviews, and review of Resident Identifier (RI) #84's medical record, the facility failed to ensure Employee Identifier (EI) #1, a Registered Nurse (RN) washed her hands and changed her gloves after cleaning the front perineal area, before cleaning the buttocks and after her gloves became soiled while performing incontinence care on RI #84. This affected RI #84, one of one resident sampled for bladder and bowel incontinence. Findings include: RI #84 was readmitted to the facility on [DATE] with an admit [DIAGNOSES REDACTED]. RI #84's Significant Change in Status Assessment with an assessment reference date of 5/6/2018 indicated RI #84 was totally dependent on staff for toilet use and always incontinent of bowel and bladder. During an observation of incontinence care on 6/12/2018 at 11:40 AM, EI #1, a RN was observed to not wash her hands or change gloves after cleaning RI #84's front perineal area, before cleaning RI #84's buttocks and after getting stool on her gloves . In an interview on 6/12/2018 at 12:09 PM, EI #1, a RN was asked, what should be done after cleaning stool from the front perineal area before moving to the buttocks during perineal care. EI #2 stated, Change gloves and wash hands. EI #2 was asked, what should be done if you get stool on your gloves while cleaning the buttocks. EI #2 stated, Change gloves and wash hands. EI #2 was asked what the potential for harm was. EI #2 stated, Infection. In an interview on 6/14/2018 at 3:34 PM, EI #3, the Assistant Director of Nursing/Infection Control Nurse was asked, what should be done after cleaning the front perineal area and before cleaning the buttocks. EI #3 replied, change gloves, wash hands, and apply new gloves. EI #3 was asked, what should be done if you get stool on your gloves while cleaning the buttocks. EI #3 replied, take gloves off immediately, wash hands, apply new gloves and finish. When asked what the potential for harm was, EI #3 replied, it would cause an infection.

Based on observations, a review of the facility's policies titled, Dietary Personnel Standards and Dietary Ice and staff interviews, the facility failed to ensure: 1) the walk in freezer was free of ice coming down from the top of the freezer onto a baking pan on the top shelf. The pan had an accumulation of built up frozen ice. There was also a box of sweet potato patties, underneath the baking pan, that had an accumulation of ice on the top of the box; 2) dietary staff had his mustache covered while plating the 04/11/17 supper meal; and 3) the ice scoop was not inside the ice machine lying on top of the ice. This had the potential to affect 119 residents who receive meals from the kitchen out of the 121 residents who reside in the facility. Findings Include: 1) On 04/11/17 at 4:30 p.m., the walk in freezer was observed with ice coming down from the top right side of the ceiling into a baking pan that was on the top shelf. There was also a build up of frozen ice on top of a box of sweet potato patties that was underneath the baking pan. On 04/11/17 at 4:35 p.m., Employee Identifier (EI) #1, Dietary Manager, was asked how often the walk in freezer was checked for ice build up. EI #1 replied weekly by maintenance. EI #1 was asked when was the last time it was checked. EI #1 replied she would have to look at the maintenance logs. EI #1 was asked how long had the build up been a problem. EI #1 replied about a month. EI #1 was asked what would be a concern if the ice were to melt that was on top of the box. EI #1 replied it could contaminate the food. 2) The facility's policy titled DIETARY PERSONNEL STANDARDS, with a revised date of 07/14, documented: Policy Dietary personnel shall follow sanitary standards. Procedure . 2 . a. Hair nets, covering all of the hair, must be worn at all times while on duty . On 04/11/17 at 4:45 p.m., during the supper meal, a dietary staff member was observed plating food at the steam table with his mustache uncovered. On 04/13/17 at 10:05 a.m., EI #1 was asked why the male staff, who was plating the supper meal on 04/11/17, did not have his beard covered. EI #1 replied she did not notice that. EI #1 was asked what would be a concern if a mustache was not covered while plating food. EI #1 replied hair could fall out and get in the food, and it could contaminate the food. 3) The facility's policy titled, DIETARY ICE, with a date of 01/10, documented: Policy Ice shall be maintained and served to residents in a sanitary manner. Procedure 1. Ice shall be handled, transported, and stored in such a manner as to be protected against contamination. . 3. and scoops shall be kept clean and shall be stored and handled in a sanitary manner . On 04/11/17 at 4:50 p.m., the ice scoop was observed inside the ice machine. On 04/11/17 at 4:52 p.m., during an observation of the ice machine, EI #2, dietary aide, stated she had placed the ice scoop in the ice. EI #2 was asked what could be the potential harm with the ice scoop stored inside the ice machine. EI #2 replied there could be germs in the ice.

Based on observations during meals times, medical record review, and staff interviews, the facility failed to ensure Resident Identifier (RI) #6 was provided the opportunity to use regular eating utensils during meals. This affected one of 13 sampled residents observed during meals. Findings Include: RI #6 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A care plan for RI #6 with a problem onset date of 03/24/17, documented: . At Risk for altered nutrition .Approaches . Plastic silverware q (every) meal On 04/11/17 at 5:05 p.m., RI #6 was observed at the supper meal using plastic utensils to eat with. On 04/12/17 at 12:30 p.m., RI #6 was observed at the lunch meal using plastic utensils to eat with. On 04/12/17 at 4:15 p.m., RI #6 was asked why he/she used plastic utensils to eat with. RI #6 replied she/he did not know, but that was what the facility had given her/him. RI #6 was asked would he/she like to use regular utensils to eat with. RI #6 replied he/she sure would. On 04/13/17 at 8:00 a.m., RI #6 was observed at the breakfast meal using plastic utensils to eat with. On 04/13/17 at 10:00 a.m., Employee Identifier (EI) #7, Social Worker, was asked why RI #6 used plastic utensils. EI #7 replied there were some behaviors in 2015 that the doctor may have put him/her on suicide precautions, which might have included plastic silverware. On 04/13/17 at 10:05 a.m., the facility was asked to provide documentation about why RI #6 used plastic utensils. The facility did not provide any documentation as to why RI #6 had to use plastic utensils.

Based on interviews and medical record review, the facility failed to ensure Resident Identifier (RI) #1's fall(s) were accurately coded or included on the Minimum Data Set (MDS) assessment dated [DATE], in Section J Health Conditions, to identify RI #1 had sustained any fall(s) or fracture(s) within the last 31 -180 days. This affected RI #1, one of 21 sampled residents whose MDS was reviewed. Findings Include: RI #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's medical record revealed Departmental Notes dated 9/7/2016, at 2:09 P.M., documented the following: RESTORATIVE NURSING . ON 09/02/2016 AT 3:00 PM RESIDENT IS NOTED TO BE FOUND ON FLOOR IN (HIS/HER) BATHROOM. RESIDENT ATTEMPTED TO TOILET SELF AND DID NOT CALL FOR ASSISTANCE. (SHE/HE) WAS FOUND LYING ON RIGHT SIDE AND COMPLAINING OF RIGHT HIP PAIN . TRANSFERRED TO (LOCAL HOSPITAL) ER (emergency room ) FOR EVALUATION. RESIDENT DID HAVE A RIGHT HIP FX (FRACTURE) . A review of RI #1's medical record revealed a 5 day reentry MDS assessment with an Assessment Reference Date (ARD) of 09/14/2016, assessed RI #1, in Section C (Cognitive Patterns), to have a Brief Interview for Mental Status (BIMS) summary score of 12, indicating moderately impaired cognition. Section J (Health Conditions), including J 1700 Fall History on Admission/Entry or Reentry, assessed that RI #1 did not fall any time in the last month or in the last two to six months and had no fracture related to a fall in the six months prior to admission/entry or reentry. The facility failed to accurately assess and identify RI #1 as sustaining a fall with injury. On 4/13/17 at 11:00 a.m., the surveyor conducted an interview with the MDS/Care Plan Coordinator, Employee Identifier (EI) #5, Licensed Practical Nurse(LPN). The surveyor asked EI #5 who was responsible for completing Section J on the MDS assessment to ensure falls are captured/coded and accurate on the assessment. EI #5 said the restorative department. On 4/13/17 at 2:03 P.M., the surveyor conducted an interview with EI #6, Restorative Coordinator. The surveyor asked EI #6 who was responsible for completing the section J on the MDS assessment (9/14/16) to ensure falls were captured/coded, and the assessment was accurate. EI #6 said that would have been her. The surveyor asked EI #6 if the fall on 09/02/16 was not captured on the MDS assessment, would that assessment be an inaccurate assessment. EI #6 said yes.

Based on observation, record review, a review of the facility's policy titled, NURSING COMPREHENSIVE CARE PLAN (DEVELOPING) and staff interview, the facility failed to ensure licensed staff developed a care plan for Resident Identifier (RI) #12's oxygen (O2) use. This affected one of five residents sampled for use of O2. Findings Include: A review of the facility's policy titled, NURSING COMPREHENSIVE CARE PLAN (DEVELOPING) with a revised date of 07/2014, revealed: . Policy . The facility develops a comprehensive plan of care . that includes measurable objectives . needs that are identified in the comprehensive assessment. 1. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . RI #12 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #12's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/20/2017, revealed the resident had a Brief Interview for Mental Status (BIMS) score of a 3, which indicated RI #12 was severely impaired in cognition. A review of RI#12's April 2017 physician's orders [REDACTED]. Order Date .04/04/17 . OXYGEN- O2 PER NASAL CANNULA . AT 3L (Liter)/ (per) MIN (Minute). The following observations were made of RI #12's Oxygen concentrator: 04/11/2017 at 5:00 p.m. - Oxygen at 2L/NC (nasal cannula) 04/12/2017 at 12:15 p.m. - Oxygen at 2L/NC 04/13/2017 at 7:35 a.m. - Oxygen at 2L/NC 04/13/2017 at 11:05 a.m. - Oxygen at 2L/NC A review of RI #12's Care Plans revealed no Care Plan was developed for RI #12's O2 usage. On 04/13/2017 at 12:07 p.m., an interview was conducted with Employee Identifier (EI) #5, Licensed Practical Nurse (LPN)/Care Plan Coordinator and EI #8, LPN. EI #5 was asked who developed the Care Plan for O2 for RI #12. EI #5 said she or EI #8 did. EI #5 was asked where was the admitting Care Plan for O2. EI #5 said it was not done. EI #5 was asked should there have been an O2 Care Plan done after admission to the facility. EI #5 said yes. EI #5 was asked why was it important for the resident to have a O2 Care Plan. EI #5 said to be current and up to date with the physician's orders [REDACTED].>

Based on observations, medical record review, a review of the facility's Job Description and Performance Standards, and staff interviews, the facility failed to ensure a Licensed staff member followed physician's orders [REDACTED]. This affected RI (Resident Identifier) #12, one of five residents sampled for the use of O2. Findings Include: A review of the facility's Job Description and Performance Standards without a date, revealed the following: . Medication Nurse . 4. Administer medications to residents . in accordance with the physician's orders [REDACTED]. A review of Potter and Perry, FUNDAMENTALS OF NURSING Ninth Edition, page 626, revealed the following: . Standards . follow the six rights of medication administration . 2. The right dose . RI #12 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #12's April 2017 physician's orders [REDACTED]. Oxygen-02 PER NASAL CANNULA VIA (BY) CONCENTRATOR AT 3L (liter)/ (per) MIN (Minute). The following observations were made of RI #12's Oxygen concentrator: 04/11/17 at 5:00 p.m. - Oxygen at 2L/NC (nasal cannula) 04/12/17 at 12:15 p.m. - Oxygen at 2L/NC 04/13/17 at 7:35 a.m. - Oxygen at 2L/NC 04/13/17 at 11:05 a.m. - Oxygen at 2L/NC On 04/13/17 at 10:30 a.m., during an interview with Employee Identifier (EI) #9, Licensed Practical Nurse (LPN), the surveyor provided RI #12's physician's orders [REDACTED].#12's Oxygen be set at. EI #9 stated at 3L/NC, which was written on April the fourth. The surveyor informed EI #9 RI #12's Oxygen had been set at 2L/NC since 04/11/17. EI #9 replied the Oxygen was not set correct. EI #9 also stated RI #12 was on Oxygen because the resident had Chronic [MEDICAL CONDITION] Unspecified with [MEDICAL CONDITION] (oxygen deficiency) and Hypercapnia (excessive carbon [MEDICATION NAME] in the bloodstream) and Acute [MEDICAL CONDITION] Unspecified with [MEDICAL CONDITION] or Hypercapnia. The surveyor asked why was the Oxygen not set on 3L. EI #9 stated that was an error and it was the Charge Nurses' responsibility to ensure the correct setting for the oxygen. EI #9 stated she was the Charge Nurse for today (04/13/17) and she had checked the setting and the Oxygen was set at 3L. The surveyor informed EI #9 of the above observations, for three of three days of the survey and requested to observe RI #12's Oxygen setting. At 11:10 a.m., the surveyor and EI #9 observed the Oxygen setting. The surveyor asked EI #9 what was RI #12's Oxygen set at. EI #9 stated 2L. The surveyor asked what was the potential harm when Oxygen is not set at the physician's orders [REDACTED].#9 replied [MEDICAL CONDITION].

Based on observations, record review of a facility's policy titled, NURSING OXYGEN THERAPY and interview with facility staff, the facility failed to ensure Resident Identifier (RI) #12's Oxygen (O2) was set at 3L (liters)/ (per) Nasal Cannula (NC) per physician's orders [REDACTED]. RI #12 is a resident identified by the facility as having a [DIAGNOSES REDACTED]. This affected RI #12, one of five residents sampled for the use of O2. Findings Include: A review of a facility's policy titled, NURSING OXYGEN THERAPY with a revised date of 07/2014, revealed: . Oxygen therapy is administered only as ordered by the physician . The physician's orders [REDACTED]. RI #12 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #12's Annual Minimum Data Set (MDS) with a Assessment Reference Date (ARD) of 03/20/2017, revealed the resident had a Brief Interview for Mental Status (BIMS) score of a 3, which indicated RI #12 was severly impaired in cognition. A review of RI#12's April's 2017 physician's orders [REDACTED]. Order Date .04/04/17 . OXYGEN- O2 PER NASAL CANNULA . AT 3L (Liter)/ (per) MIN (Minute). The following observations were made: 04/11/2017 at 5:00 p.m. - Oxygen at 2L/NC (nasal cannula) 04/12/2017 at 12:15 p.m. - Oxygen at 2L/NC 04/13/2017 at 7:35 a.m. - Oxygen at 2L/NC 04/13/2017 at 11:05 a.m. - Oxygen at 2L/NC On 04/13/17 at 10:30 a.m., during an interview with Employee Identifier (EI) #9, Licensed Practical Nurse (LPN), the surveyor provided RI #12's physician's orders [REDACTED].#12's Oxygen be set at. EI #9 stated at 3L/NC, which was written on April the fourth. EI #9 also stated RI #12 was on Oxygen because the resident had Chronic [MEDICAL CONDITION] Unspecified with [MEDICAL CONDITION] (oxygen deficiency) and Hypercapnia (excessive carbon [MEDICATION NAME] in the bloodstream) and Acute [MEDICAL CONDITION] Unspecified with [MEDICAL CONDITION] or Hypercapnia. The surveyor asked why was the Oxygen not set on 3L. EI #9 stated that was an error and it was the Charge Nurses' responsibility to ensure the correct setting for the oxygen. EI #9 stated she was the Charge Nurse for today (04/13/17) and she had checked the setting and the Oxygen was set at 3L. The surveyor informed EI #9 of the above observations, for three of three days of the survey and requested to observe RI #12's Oxygen setting. At 11:10 a.m., the surveyor and EI #9 observed the Oxygen setting. The surveyor asked EI #9 what was RI #12's Oxygen set at. EI #9 stated 2L. The surveyor asked what was the potential harm when Oxygen is not set at the physician's orders [REDACTED].#9 replied [MEDICAL CONDITION].

Based on observation and interviews with facility staff, the facility failed to ensure floor tiles were not sunken in and separated on the 300 hall. This had the potential to affect all ambulatory residents on the 300 hall, one of eight halls located in the facility. Findings Include: On 04/13/17 at 9:30 a.m., the walkway floor tiles at the double doors on the 300 hall were observed sunken in and separated. There were seven tiles that were sunk in the middle of the tiles and a filler looking substance in some of the separated areas. There were three ambulatory resident observed walking in this area. On 04/13/17 at 9:35 a.m., Employee Identifier (EI) #3, Maintenance, was asked how long had the sunken tiles been a problem. EI #3 replied about six months and further explained that the drought caused the ground to shrivel up. EI #3 was asked what could be the potential harm. EI #3 replied somebody could trip. On 04/13/17 at 2:25 p.m., EI #4, Maintenance Director, was asked if he was aware of the floor tiles that were sunken on the 300 hall. EI #4 said yes and agreed the crack needed to be repaired.

Based on observation, interviews, and review of facility policies and the Food and Drug Administration Food Code 2013, the facility failed to ensure: 1) Trays were dried in a manner to allow air circulation; 2) Food items in the walk-in cooler were discarded when the use-by-date was exceeded; 3) Raw sausage patties were not stored directly on top of a box of fully cooked bacon; 4) Food items in the freezer were labeled with an item name; 5) Staff verified the temperature of the onion rings added to the steam table during the supper meal on 03/09/2016 were held at a temperature of 135 degrees Fahrenheit (F) or greater; and 6) Staff working on the service line washed hands and changed gloves in a manner to prevent contamination ofter touching his face. These failures had the potential to affect all 126 residents for whom meals were prepared and served during the course of the survey. Findings Iinclude: 1) Review of the facility policy titled DIETARY DISHWASHING MACHINE, revised 07/2014, revealed the following: .Procedure . 9. Air-dry dishes. 10. Store dishes on designated shelving units to prevent nesting . During the initial tour of the kitchen on 03/08/2016 beginning at 3:38 PM, meal trays were observed on a drying rack stacked on their sides, one on top of the other (wet nested), not allowing air circulation. Employee Identifier (EI) #5, currently in training for the Dietary Manager position, removed three trays and stated they were wet. Small droplets of water were noted between the trays. EI #6, the Dietary Manager, stated the trays were stacked too close together and should be stacked to allow air circulation. During an interview on 03/10/2016 at 8:20 AM, EI #6 stated items should be separated and air dried after washing to prevent nesting and potential mold growth. 2) Review of the facility's policy titled DIETARY USE OF LEFTOVERS, revised 01/2013, revealed the following: Policy Leftovers will be properly handled and used. Procedures . 2. items should include a use by/discard date . During the initial tour of the kitchen on 03/08/2016 beginning at 3:38 PM, a gallon sized plastic bag of pancakes was noted in the walk-in cooler. The pancakes were labeled as follows: Pancakes 2-29-16 Use by 3-7-16. During an interview on 03/10/2016 at 8:20 AM, EI #6, the Dietary Manager, stated items in the walk-in cooler should be discarded after seven days. EI #6 said storing items past their use by dates could make someone sick. 3) Review of the Food and Drug Administration Food Code 2013, Chapter 3 Food, page 68, revealed the following: .Preventing Food and Ingredient Contamination 3-302.11 Packaged and Unpackaged Food -Separation, Packaging, and Segregation. (A) FOOD shall be protected from cross contamination by: (1) . separating raw animal FOODS during storage, preparation, holding, and display from: .(b) Cooked READY-TO-EAT FOOD . During the initial tour of the kitchen on 03/08/2016 beginning at 3:38 PM, an open box of raw sausage patties was observed sitting directly on top of a box of fully cooked bacon. On 03/10/2016 at 8:20 AM, EI #6, the Dietary Manager, said the sausage should have been stored on the bottom. 4) Review of the Food and Drug Administration Food Code 2013, Chapter 3 Food, page 70, revealed the following: . 3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding FOOD that can be readily and unmistakably recognized . working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT . shall be identified with the common name of the FOOD . During the initial tour of the kitchen on 03/08/2016 beginning at 3:38 PM, a clear plastic bag was observed in the walk-in freezer labeled open 2/11/16. The bag was not labeled with an item name. EI #6, the Dietary Manager identified the item as steak fingers. 5) Review of the facility's policy titled DIETARY FOOD TEMPERATURES, dated 01/2010, revealed the following: . Procedure . 3. Repeat this procedure until all hot food temperatures have been taken. 5. Temperatures should be taken periodically to ensure hot foods stay above 135 (degrees) F . During trayline observations on 03/09/2016, EI #7, the cook, was observed checking the temperatures of items on the service line. The onion rings were batch cooked, and at 4:31 PM staff added another batch of onion rings to the ones already checked for temperature. Staff did not check the temperature of the second batch when it was removed from the fryer or when it was placed on the service line. During an interview on 03/10/2016 at 8:20 AM, EI #6, the Dietary Manager, said the temperatures of all items except bread should be checked. When asked how staff should handle items, such as the onion rings, when they are cooked in batches, EI #6 said staff should use what is there first before adding anymore and also check the temperature. When asked what potential harm could occur in not checking the temperature of items added to the steam table, EI #6 said the item could fall below temperature levels. 6) Review of the facility's policy titled DIETARY HANDWASHING, dated 01/2010, revealed the following: Policy Hand washing is the single most important method to reduce the spread of infection. Dietary staff will wash hands . at other times hands have been soiled . Trayline was observed on 03/09/2016 beginning at 4:00 PM. EI #7, the cook, was observed taking temperatures of items on the steam table. EI #7 was sweating profusely with sweat observed dripping down the sides of his face and nose. At 4:34 PM, EI #7 was observed using his right arm to wipe his face. He did not change gloves or wash his hands and continued checking temperatures of foods on the steam table. At 4:6 PM, EI #7 was again observed wiping his face with his right hand. He then checked the temperature of sandwhiches and placed serving utensils into the foods without first washing his hands or changing gloves. EI #7, the cook, was interviewed on 03/09/2016 at 5:06 PM. He said he should have washed hands and changed his gloves after he wiped his face because it was sweat and could cause contamination.

Based on observations, interviews, record review and review of a facility policy titled PHARMACY SELF-ADMINISTRATION OF DRUGS BY RESIDENTS, the facility failed to ensure the Licensed Practical Nurse (LPN), Employee Identifier (EI) #4, remained with Resident Identifier (RI) #s 8 and 20 on 03/09/16 and with RI #14 on 03/10/16, while the residents were receiving a nebulizer treatment. RI #20, one of three residents observed during medication pass, and RI #s 8 and 14 were not assessed to self-administer their nebulizer treatments. This affected three of three residents sampled for self administration of medications. Findings Include: A review of a facility policy titled PHARMACY SELF-ADMINISTRATION OF DRUGS BY RESIDENTS, with a revised date of 07/14, documented: . Policy Residents in our facility may self administer their medications if it is determined that they are capable of doing so and they express their wish to do so. Procedure 1. As part of their overall evaluation, the staff and practioner will assess each resident's mental and physical abilities, to determine whether a resident is capable of self-administering medications . 1. RI #20 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #20's medical record revealed Physician order [REDACTED]. IPRAT-ALBUT ([MEDICATION NAME]-[MEDICATION NAME]) 0.5-3(2.5) MG (MILLIGRAMS)/3 ML (MILLILITERS) GIVE ONE VIAL PER (BY) NEBULIZER TREATMENT QID (FOUR TIMES A DAY) . On 03/09/16 at 8:50 a.m., during the morning Medication Administration Observation, the surveyor observed EI #4, a LPN, administer oral medications to RI #20 while the resident sat on the side of the bed. On 03/09/16 at 8:55 a.m., EI #4 poured one vial of [MEDICATION NAME] solution into a hand held nebulizer reservoir, and turned the nebulizer machine on. EI #4 left out of the room and RI #8 was left alone and out of the line of sight while the [MEDICATION NAME] treatment continued to infuse. The surveyor continue to observe RI #20 while EI #4 pushed the medication cart to the other end of the hallway. On 03/09/16 at 9:03 a.m., EI #4 returned to RI #20's room and left out of the room at the same time, while the breathing treatment continued to infuse. On 03/09/16 at 9:15 a.m., the surveyor observed the [MEDICATION NAME] treatment had stopped misting and the nebulizer machine had been turned off by RI #20. When the surveyor asked RI #20 why the machine was turned off, RI #20 said because that's what is done all the time. RI #20 said the nurse does not return to the room and turn the machine off. On 3/10/16 at 1:50 p.m., the surveyor conducted an interview with EI #4, the LPN responsible for administering medication to RI #20. The surveyor asked EI #4 should the nurse leave any medication at the bedside or with the resident for them to administer to themselves. EI #4 said no. The surveyor asked EI #4 if RI #20 had been assessed to self administer the breathing treatments. EI #4 said no. The surveyor asked EI #4 who is responsible for conducting the assessment for a resident to self administer their breathing treatment. EI #4 said she did not know. The surveyor asked EI #4 if RI #20 had a physician order [REDACTED]. EI #4 said no, not that she was aware of. The surveyor asked EI #4 if there was a care plan for RI #20 to self administer the Nebulizer treatments. EI #4 said she did not know. A review if RI #20's Respiratory care plans revealed there were no approaches on the resident's care plan to indicate the resident was assessed and care planned to self administer the IPRAT-ALBUT 0.5-3(2.5) MG/3 ML ONE VIAL PER NEBULIZER QID. 2. RI #8 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. On 3/9/16 at 11:43 a.m., the surveyor observed RI #8 sitting on the side of the bed with the Nebulizer Machine operating sitting at the foot of the bed. RI #8 was holding a hand-held nebulizer and a breathing treatment was in progress. There was no nurse or staff member in RI #8's room while this medication was being administered at this time. The surveyor observed RI #8 to turn off the nebulizer machine and unplug if from the electrical outlet and place the hand-held nebulizer on the night stand next to the bed. RI #8 said the nurse left it like that all the time. A review of RI #8's Respiratory care plan revealed there were no approaches on the resident's care plan to indicate the resident was assessed, and care planned to self administer the nebulizer treatment. Also, the facility staff was not able to produce any evidence of a physician order [REDACTED]. On 03/10/16 at 2:15 p.m., the surveyor conducted an interview with EI #4, the LPN responsible for administering medication to RI #8. The surveyor informed EI #4 of the observation of RI #8. EI #4 said if asked the same questions about RI #8's nebulizer administration, the same answers she gave for RI #20 would be the same for RI #8. On 3/10/16 at 2:25 p.m., the surveyor conducted an interview with the Director Of Nursing (DON), EI #2. The surveyor asked EI #2 what she expected the nurses to do when they administer Nebulizer treatments. EI #2 said keep the (medication) cart close to the door, keep a close eye on the resident. EI #2 said they (the nurse) do not have to stay in the room with the resident while the treatment is running. The surveyor asked EI #2 what is the facility's process for a resident to self administer medication such as a nebulizer treatment. EI #2 said they do not have a policy for a resident to self administer a nebulizer treatment. The surveyor asked EI #2 if it was okay for a resident to hold the medication while the nebulizer treatment was infusing and the medication nurse leave the resident alone to administer the breathing treatment. EI #2 said, their policy did not address that. 3. RI #14 was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. On 03/10/16 at 8:00 a.m., the surveyor observed RI #14 sitting on the side of the bed. RI #14 was holding a hand-held nebulizer and a breathing treatment was in progress. There was no nurse in RI #14's room at this time. On 03/10/16 at 8:01 a.m., the surveyor observed RI #14 turn off the nebulizer machine and place the hand-held nebulizer in it's stand. On 03/10/16 at 5:40 p.m., the surveyor conducted an interview with EI #4, the LPN responsible for administering medication to RI #14 on 03/10/16 on the 6 A - 6 P shift. The surveyor asked EI #4, when a resident is administered a nebulizer treatment, how was that done. EI #4 said she would walk in the room and put the medication in the reservoir. EI #4 said she would turn on the machine and instruct the resident when they saw the mist stop they were done with the treatment. EI #4 said she would be on the outside of the room and would tell the resident if she did not make it back into the room before they were done, they could turn it off. The surveyor asked EI #4 had RI #14 been assessed as being capable of administering the nebulizer treatment. EI #4 replied, No. The surveyor asked EI #4 had she ever been told that residents have to be assessed before they could administer their own breathing treatments. EI #4 said, no. On 03/10/16 at 6:53 p.m., the surveyor conducted an interview with EI #2, the DON. The surveyor asked EI #2, how did the facility determine if a resident is able to self administer their own medications. EI #2 said if the resident asked to administer their own medication, the facility would do an assessment. EI #4 said the facility would get a physician's orders [REDACTED]. The surveyor asked EI #2, if a resident is capable of self administering their medication, should that be on their care plan. EI #2 replied she would think so. EI #2 said it would be on the care plan so that any one that had access to the care plan would know the resident is capable of administering their own medications. A review of RI #14's Respiratory care plan revealed there were no approaches on the resident's care plan to indicate the resident was assessed, and care planned to self administer the nebulizer treatment.

Based on interview and record review, the facility failed to accurately code Resident Identifier (RI) #14's use of Oxygen therapy on the most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE]. This affected RI #14, one of 24 sampled residents whose MDS assessments were reviewed. Finding Include: RI #14 was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. RI #14's December 2015 Physician order [REDACTED].> . IPRAT-ALBUT ([MEDICATION NAME]-[MEDICATION NAME]) 0.5-3(2.5) MG (milligrams)/3 ML (milliliters) GIVE ONE VIAL PER NEBULIZER TREATMENT Q (every) 8 HOURS . OXYGEN- 02 PER NASAL CANNULA VIA (by way of) CONCENTRATOR AT 3 L (liters)/MIN (minute). WHILE IN ROOM AND PRN (as needed) . RI #14's December 2015 eMAR (electronic Medication Administration Record) revealed the Iprat-[MEDICATION NAME] nebulizer treatment and RI #14's Oxygen had been administered as ordered. A review of RI #14's Quarterly MDS Assessment with an Assessment Reference Date (ARD) of 12/07/15, revealed under Section O: Respiratory Treatments, RI #14 was not coded as having utilizing Oxygen therapy during this assessment period. On 03/10/16 at 2:38 p.m., the surveyor conducted an interview with Employee Identifier (EI) #3, the Care Plan Coordinator. The surveyor asked EI #3, did RI #14 receive any type respiratory therapy. EI #3 said RI #14 had 02 at 3 litters while in the room and PRN (as needed). The surveyor asked EI #3 should the oxygen have captured on the 12/07/15 Quarterly MDS assessment. EI #3 replied, Yes . The surveyor asked EI #3 was RI #14's Quarterly MDS assessment for 12/07/15 accurate. EI #3 replied, No. Section O is not coded correctly.

Based on record review and interviews, the facility failed to ensure Resident Identifier (RI) # 5 ' s care plans were revised or updated to reflect interventions for a fall that occurred on 10/11/15. This affected one of six sampled resident reviewed for falls. Findings Include: Review of the facility's policy titled, ADMINISTRATIVE INCIDENT REPORTS, with a revision date of 07/14, revealed the following: . Process: f. Restorative implements interventions, completes summary on investigation and findings, and updates the care plan as indicated. RI #5 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #5's Prone for falls Care plan, with a problem onset date of 03/04/2016, revealed no interventions (approaches) for the 10/11/15 fall to inform staff in order to prevent reoccurrence of the fall. On 3/10/15 at 2:06 PM, Employee Indentifer (EI #3), the Careplan Coordinator was interviewed and asked when should the care plan been updated. EI #3 replied the care plan was reviewed every three months but everytime there is a change it was to be updated (careplan). EI #3 was asked should the care plan have be updated with all types of falls. EI #3 stated, Yes ma'am and interventions should be put in place. EI #3 was asked why was RI #5's fall interventions for the 10/11/15 fall not updated to the care plan. EI #3 informed me she was not sure but EI #8 could provide a better answer. On 3/10/16 PM, EI #8, the Restorative Nurse was interviewed and asked when should the care plan be updated. EI #8 replied it should be updated immediately when you make a change, and quarterly. EI#8 further replied the care plan should always be current. EI #8 was asked should the care plan be updated with all types of falls interventions. EI #8 replied if was not something directly related to the resident she may not put it on the care plan. EI #8 was asked why RI #5's care plan was not updated with interventions for RI #5's fall on 10/11/15. EI #8 stated, I guess my thought process should be, maybe I should have put it on there, It is not the end result. EI #8 was asked what was the purpose of the care plan. EI #8 replied to show what they was doing for the resident. EI #8 was asked what the facility's policy on updating care plans. EI #8 replied it was to be updated immediately and current. EI #8 was asked what potential harm may occur if the fall interventions are not updated on the care plan. EI #8 replied, further injuries to the resident could occur and further decline in independence.

Based on observation, interviews and record review, the facility failed to ensure a Certified Nursing Assistant (CNA) cleaned Resident Identifier (RI) #13's penis and scrotum or wiped RI #13's buttock in an upward motion when providing incontinence care on 3/9/16. This affected one of two residents who were observed for incontinence care. Findings Include: A review of the facility's policy titled, NURSING ASSISTANT PERINEAL CARE, with a revised date of 07/14, revealed the following: Policy: Perineal care serves to cleanse the perineum, provide comfort and dignity and assist in preventing infection, skin breakdown and odors. Perineal care will be done after each incontinent episode and whenever necessary. 6 . Clean the rectal area with upward [MEDICAL CONDITION], washing from front of body to back of body . Males . 1. Clean the penis with a circular motion at the head of the penis. 2. Gently pull the foreskin back and wash . 3. clean the shaft of the penis in a downward direction. 4. Be sure to clean the scrotum . RI #13 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #13's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 01/04/2016 revealed the resident had a BIMS (Brief Interview for Mental Status) of 5 which indicated RI #13 was severly impaired in cognition. The Functional Status section of the MDS documented RI #13 required total dependence with Personal Hygiene and Bathing. A review of RI #13's Requires assist with ADL's Care plan, with a problem onset date of 01/05/2016, revealed RI #13 requires total assist with all dressing, toileting, personal hygiene, and bathing per direct care staff. On 3/9/16 at 9:03 AM, during the provision of incontinence care on RI #13, Employee Identifier (EI) #9, a CNA was observed by the surveyor to fold RI #13's brief between the legs and then took a clean wipe and wiped across the pubic area, down the left groin area then the right after flipping to a clean side of the wipe each time. EI #9 then slightly turned RI #13 towards her (resident right), and with another clean wipe wiped the buttocks in a downward direction toward the scrotum, then wiped the crease (rectal area)from the top toward the scrotum. After turning RI #13 to the left EI #9 wiped the right side of the buttock and crease area from the top downward toward the scrotum. EI #9 did not clean RI #13's penis or scrotum during the incontinent care observation. EI #9 did not use the correct technique in wiping the buttocks or rectal area in an upward motion from front to back On 3/10/16 at 3:08 PM, EI #9, a CNA, was interviewed and asked how incontinence care should be perform on a male. EI #9 replied, take one of the wipes and go across the top then throw it away, go to the left, discard that (wipe) then go across to the right and discard that (wipe). Hold the penis in the hand and clean the top and take another one (wipe) and go down the side, throw it away turn the resident to the left and wipe from front to back and throw it away. EI #9 was asked if she did that, she replied she tried to do as much as she could. She explained further that she didn't do incontinence care as she normally does. EI #9 was asked what potential harm could occur in not cleansing the penis and scrotum or wiping the buttocks from top to bottom toward the scrotum during incontinence care. EI #9 replied they could catch a bacterial infection or breakdown. On 3/10/16 at 3:36 PM, EI #10, the Assistant Director of Nursing(ADON)/Infection Control Coordinator was interviewed and asked if the penis should be cleansed during incontinence care. EI #10 stated, Yes. EI #10 was asked if it was an acceptable practice of the facility for a staff member to perform incontinence care and not cleanse the penis and scrotum or to cleanse the buttock area from the top down toward the scrotum. EI #10 stated, No. EI #10 was asked what was the facility policy on performing incontinence care on a male. EI #10 replied to pull the foreskin down and clean the scrotum as well. EI #10 was asked what was the potential harm in not cleansing the penis and scrotum or wiping the buttocks area from the top toward the scrotum during incontinence care. EI #10 replied the entrance of infection into the urinary tract.

Based on observation, interviews and record review, the facility failed to ensure a Certified Nursing Assistant (CNA) washed or sanitized her hands after removing dirty gloves and prior to applying a clean pair during the provision of incontinence care on RI #13. This affected one of two residents observed for incontinence care. Findings Include: Review of the facility's policy titled, INFECTION CONTROL STANDARD PRECAUTIONS with a date of 03/14, revealed the following: . 1. Hand hygiene . d. Wash hands after removing gloves . 2. Gloves . a. Wear gloves (clean, non-sterile) when you anticipate direct contact with blood, body fluids, mucous membranes, non-intact skin, and other potentially infected material. RI #13 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #13's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 01/04/2016 revealed the resident had a BIMS (Brief Interview for Mental Status) of 5 which indicated RI #13 was severly impaired in cognition. The Functional Status section of the MDS documented RI #13 required total dependence with Personal Hygiene and Bathing. A review of RI #13's Requires assist with ADL's care plan, with a problem onset date of 01/05/2016, revealed RI #13 requires total assist with all dressing, toileting, personal hygiene, and bathing per direct care staff. The MDS further revealed RI #13 was always incontinent of urine. On 3/9/16 at 9:03 AM, during the provision of incontinent care on RI #13, Employee Identifier (EI) #9, a CNA was observed by the surveyor to remove RI #13's dirty diaper and with the same gloves on obtained a clean wipe and wiped the bed off. EI #9 pulled the dirty linen from under RI #13 and used a clean wipe to wipe RI #13's buttock and crease area from top towards the scrotum, removed her gloves and applied a clean pair without washing or sanitizing her hands. The RN (Registered Nurse) poured [MEDICATION NAME] ointment into EI #9's hand and EI #9 placed the ointment on the resident buttocks. EI #9 removed her gloves and pulled the clean linen and diaper all the way under RI #13. EI #9 then applied another pair of gloves and fastened RI #13's brief. EI #9 then pulled off RI #13's old gown, and then took her gloves off. EI #9 lowered RI #13's bed down to the lowest position. EI #9 then proceeded to wash her hands in RI#13's restroom. On 3/10/16 at 4:16 PM, EI #9, a CNA, was interviewed and asked what should be done when taking off a pair of gloves and before donning a clean pair. EI #9 replied to wash hands, dry them before applying another pair. EI #9 was asked if she did this when performing incontinence care on RI #13 on 3/9/16. EI #9 stated, No. EI #9 was asked what was the facility policy on washing hands when changing gloves. EI #9 replied when one pair of gloves are taken off and before touching clean stuff, wash hands and reapply gloves. EI #9 was asked what potential harm can arise from not washing hands after taking off a dirty pair of gloves and before applying a clean pair. EI #9 replied, cross contamination, infection and you can spread infection from resident to resident. On 3/10/15 at 3:36 PM, in an interview with EI #10, the ADON (Assisted Director of Nursing)/ Infection Control Coordinator, EI #10 was asked what was the facility policy on changing gloves during incontinence care. EI #10 replied to wash your hands after taking your gloves off and before putting another pair on. EI #10 further stated to wash hands when going from dirty to clean. EI #10 was asked, what was the facility policy on hand washing. EI #10 replied, wash hands before putting on gloves and taking them off and during resident contact. EI #10 was asked what potential harm can occur if hands are not washed after taking off gloves during incontinence care and placing another pair on. EI #10 replied entrance of infection. EI #10 further informed the surveyor, entrance of infection, bacteria, and UTI (Urinary Tract Infection) can occur in not changing gloves when going from clean to dirty.

Based on observation, interview and record review the facility failed to ensure RI (Resident Identifier) #13, a resident with a history of weight loss, received a planned supplement with lunch on 2/27/13. This affected 1 of 8 sampled residents with weight concerns. Findings Include: A review of a policy titled "Dietary Nourishments and Supplements" dated 01/10 documented "...Policy...Staff delivers and administers supplements to residents..." RI #13 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #13's most recent significant change minimum data set (MDS), with an assessment reference date (ARD) of 2/18/13, revealed a score of 4 on the brief interview of mental status (BIMS) indicating RI #13 had cognitive impairment. Section K of the MDS indicated RI #13 was on a mechanically altered diet. A review of a document titled "Resident Weight Record 2013" revealed the following weights for RI #13: 12/31/12 108.6 lbs (pounds), 2-11-13 102.8 lbs, 2-18-13 107.6 lbs and 2-25-13 103.0 lbs. A review of RI #13's care plan with a problem onset date 2/18/13 revealed "...Approaches... Provide snack/supplement as specified by RD (registered dietitian)/CDM (certified dietary manager) and upon request by resident..." A review of a document titled "Dietary Progress Notes" "...12-11-12 wt (weight) update...will add ice cream sandwich with lunch-will cont (continue) to observe..." A review of a document titled "Dietary Progress Notes" revealed "...2-12-13 Res (resident) re-admits...Cont (continue) ice cream sandwich L/S (lunch/supper)- will cont (continue) to observe.." A review of a document titled "Nutritional Evaluation Assessment" dated 2/12/13 documented the following "...Nutritional plan/diet order...ice crm (cream) s/w (sandwich) L/S (lunch/supper)..." A review of RI #13's tray card for 2/27/13 at lunch revealed "...serve with lunch...Ice Cream Sand (sandwich)..." The surveyor completed an observation of RI #13's lunch meal on 2/27/13 at 11:05 AM. The meal consisted of milk, tea, water, macaroni, green beans, chopped meat, cake and a roll. At 11:30 AM the resident was finished eating and was taken back to her room. No ice cream sandwich was observed by the surveyor on RI #13's lunch tray. An interview was conducted with EI (Employee Identifier) #1, Dietary Manager on 2/28/13 at 10:30 AM. EI #1 reported she was familiar with RI #13. EI #1 was asked what supplements RI #13 were supposed to receive and she stated an ice cream sandwich with lunch and supper. EI #1 was asked who was responsible for putting the ice cream sandwich on the tray. EI #1 stated dietary, it is sent with her meals. EI # 1 was asked if RI #13 received an ice cream sandwich with her lunch on 2/27/13 and she stated EI #2, Restorative Certified Nursing Assistant (CNA), reported the resident consumed 25% of her meal and EI #2 reported she did not remember seeing the paper for the ice cream sandwich. EI #1 was asked if RI #13 was a weight loss and she stated yes. EI #1 was asked if RI #13 should have received an ice cream sandwich at lunch on 2/27/13 and she stated yes. EI #1 was asked if RI #13 did not receive an ice cream sandwich what could the negative outcome be; she stated RI #13 could lose weight. An interview was conducted with EI #2, Restorative CNA, on 2/28/13 at 10:45 AM. EI #2 stated she was familiar with RI #13. EI #2 was asked what she did with RI #13's tray on 2/27/13 at lunch. EI #2 explained she charted what RI #13 consumed. EI #2 was asked if she remembered if an ice cream sandwich was on RI #13's tray on 2/27/13 at lunch. EI # 2 stated she did not recall seeing the wrapper when the tray was picked up. EI #2 stated she charted on the food that was on the tray. EI #2 was asked if RI #13 usually eats her ice cream sandwich and she stated usually she will eat the ice cream sandwich when it is on the tray. EI #2 was asked if she asked anyone if they had given RI #13 an ice cream sandwich at lunch. EI #2 stated she could not remember who was asked, but they said they were not sure.