Every finding on record at Collinsville Healthcare & Rehab

Based on observations, interviews, and review of facility policies titled POLICY AND PROCEDURE ON LABELING AND DATING FOOD ITEMS and POLICY AND PROCEDURE CLEANING INSTRUCTIONS: HOOD (and) FILTERS, the facility failed to ensure the kitchen was maintained with food labeled and a clean environment on 02/10/2025 during the initial kitchen tour when the following observations were made: 1) food items in dry storage and the freezer were not labeled with an opened and use by date; 2) vents in the stove hood were not free of dust and grease like substance. This had the potential to affect 161 of 161 residents receiving meals from the kitchen. Findings include: 1) An undated facility policy titled POLICY AND PROCEDURE ON LABELING AND DATING FOOD ITEMS documented: . ALL READY TO EAT FOODS THAT IS PREPPED IN FACILITY MUST HAVE LABEL THAT INCLUDES: NAME OF FOOD AND USE BY OR EXPIRATION DATE. On 02/10/2025 at 5:32 PM during the initial tour of the kitchen, observations were made with the Dietary Manager (DM). In the dry storage area a bag of coconut flake had no opened or use by date; a bag of artificial flavor gelatin dessert had an opened date of 01/06/2025 and no use by date; a bag of cinnamon sugar blend had an opened date of 10/31 with no year and no use by date. In the freezer, a bag of nine chicken patties had no opened date or use by date; a second bag of six chicken patties were open and had no opened or use by date; and seven chicken fingers in a bag had no opened or use by date; a bag of squash and a bag of garlic biscuits were open and had no opened or use by date. On 02/12/2025 at 04:04 PM an interview was conducted with the DM. The DM stated, the facility policy on labeling and dating was every item that was opened must be labeled with the name of the item, the date it was opened, and a use by date. The DM stated, items should be labeled and dated so staff would know it was out of date and needed to be discarded. The DM stated, undated food items can make people sick if the item was opened too long. The DM stated, any employee that opened an item was responsible for labeling and dating the item. When asked about staff being trained on labeling food, the DM stated, she reminded staff daily to label items. The DM stated, the coconut and cinnamon blend sugar in dry storage had no opened or use by date on it. The DM said, the items in the freezer not labeled and dated were breaded chicken patties, chicken fingers, and garlic biscuits. The DM said, the potential harm to residents when items were not labeled with opened and use by dates, was food could be stored too long and it could make residents sick. On 02/12/2025 at 04:31 PM an interview was conducted with the Registered Dietician (RD). The RD stated, items should be labeled so employees would know by what date to use the items. The RD stated, food items should be labeled with the food name, the date it was opened, and the expiration date. The RD stated, when food was not labeled with an opened and use by date it could be spoiled or grow bacteria. 2) An undated facility policy titled POLICY AND PROCEDURE CLEANING INSTRUCTIONS: HOOD (and) FILTERS documented: . POLICY STOVE HOOD AND FILTERS WILL BE CLEANED AT LEAST MONTHLY . On 02/10/2025 at 5:32 PM, during the initial tour of the kitchen, dust and a grease like substance was observed on the stove hood vents. On 02/12/2025 at 4:13 PM an interview was conducted with the DM. The DM stated, there was dust on the vents on 02/10/2025, when the surveyors came in the vents were dirty. The DM stated, the vents were dirty because it had been a couple of weeks since they were cleaned and it was a medium amount of dust on the vents. The DM stated, the facility policy on cleaning the vents was once a month. The DM stated, staff should run the vents through the dishwasher or take them outside and clean them. The DM further stated, it was important that the stove hood vents were cleaned so it would help with the smoke going up in the hood. On 02/12/2025 at 4:20 PM an interview was conducted with the RD who stated, it was important the stove vents were cleaned because particles could fall in the food and be a potential for contaminating the food. The RD stated, staff had been in-serviced on the danger of dust in the stove hood vents in the last six months. The RD stated, the vents were dirty on 02/10/2025 and they needed to be cleaned.

Based on observations, interviews, resident record review, and review of the facility policy titled Privacy/Dignity Protocol Prior to Providing Resident Care, the facility failed to ensure Housekeeping (HK) #8, delivering breakfast meal trays, honored residents' right to privacy when she failed to knock on doors and gain permission to enter residents' rooms before entering on 02/11/2025. This had the potential to affect Resident Identifier (RI) #112 and RI #143, two of 27 sampled residents. Findings include: Review of a facility policy titled Privacy/Dignity Protocol Prior to Providing Resident Care, with an revised date of 06/02/2016, revealed the following: 1. Knock and gain permission before entering resident's room . 3. Identify yourself and ask the resident's permission to perform the procedure. 1) RI #112 was admitted to the facility on [DATE] with a re-admitted [DATE] and had diagnoses to include: Bipolar Disorder, Anxiety Disorder, and Mood Disorder. 2) RI #143 was admitted to the facility on [DATE] and had diagnoses to include: Dementia, Psychotic Disturbance, Mood Disturbance, and Anxiety. On 02/11/2025 at 8:47 AM, Housekeeper (HK) #8 was observed delivering breakfast meal trays to RI #112 and #143 without knocking, announcing herself, or waiting for permission before entering rooms. On 02/11/2025 at 08:58 AM, the surveyor asked RI #112 if he/she minded staff entering her room without knocking, announcing him/herself while delivering breakfast meal trays. RI #112 responded, he/she would like someone to knock on the door before entering. When asked how he/she felt about that, RI #112 replied, it made him/her feel uncomfortable at times and like he/she did not have privacy. On 02/12/2025 at 07:40 AM during an interview with HK #8, she said, she should knock or ask to enter a resident room before entering. HK #8 was asked if she knocked on residents' doors before entering while passing meal trays, she said, no. When asked if she should have knocked or announced herself before entering the room, she said, yes. HK #8 said, not knocking on residents' doors before entering would be a privacy issue. On 02/12/2025 at 07:55 AM the Administrator said, before staff enter resident rooms they should knock on the door the concern of not knocking before entering was a dignity issue.

Based on observation, interviews, resident record review, and review of a facility policy titled Administration of medication the facility failed to ensure Registered Nurse (RN) #6 took action to protect Resident Identifier (RI) #99's right to privacy, during medication administration, when RN #6 failed to ensure the Electronic Medication Administration Record (EMAR) screen was properly closed and not displaying information about RI #99 while she stepped away from the medication cart on 02/11/2025 on Station Three. This deficient practice affected RI #99, one of seven residents observed during medication administration. Finding include: Review of a facility policy titled Medication Administration Policy and Procedure with an revised date of 01/10/2025 revealed the following: . Additional Medication-Pass Procedures: . Privacy: Each resident has the right to have privacy . Ensure the eMAR is not able to be seen by others. RI #99 was admitted to the facility on [DATE] with diagnoses to include Diabetes Mellitus, Hypertension, and Chronic Pain. RI #99's February 2025 EMAR revealed RI #99 was receiving Metoprolol 25 mg (milligrams) by mouth twice a day for Hypertension and Norco 5-325 mg by mouth four times a day for Chronic Pain. On 02/11/2025 at 4:50 PM the surveyor observed RI #99's name and two listed medications, Metoprolol and Norco, on the EMAR screen were visible for anyone walking by an unattended medication cart on Station Three. On 02/11/2025 at 4:59 PM Registered Nurse (RN) #6 was asked about the EMAR screen left open on Station Three with RI #99's information exposed. RI #6 said, she was about to give RI #99 medication and she left RI #99's EMAR open and went to make a telephone call and left the information for RI #99 on the screen. RN #6 said, it was a privacy concern and anyone walking by could have viewed the resident's information. RN #6 said, she had her back turned toward the cart and she should have had the privacy screen on the EMAR when she was away from the medication cart. RN #6 said, it would be important to ensure the EMAR screen was closed so anyone who walked by would not be able to see RI #99's information. On 02/11/2024 at 5:27 PM Registered Nurse (RN) #7, the Unit Manager, was asked about EMAR screens when nurses were away from medication carts. RN #7 said, the privacy screen should be used when the nurse was away from the medication cart. RN #7 said, it would be important for the EMAR screen to be closed when the nurse was away from the medication cart to ensure resident's information was kept confidential. RN #7 said, RN #6 did not follow company policy.

Based on an interviews, resident record review, and review of the Centers for Medicare & (and) Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately to reflect care needs and services at the time the assessments were completed. Specifically: 1) Resident Identifier (RI) #74's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 12/05/2024 documented RI #74 was receiving hospice services during the assessment period when RI #74 was not receiving hospice services; and 2) RI #92's quarterly MDS assessment with an ARD of 01/03/2025 documented RI #92 was utilizing a trunk restraint during the assessment period when trunk restraints were not used for RI #92. These deficient practices affected RI #74 and RI #92, two of 35 sampled residents whose MDS assessments were reviewed. Findings include: Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.19.1, dated 10/2024, revealed the following: . SECTION O: SPECIAL TREATMENTS, PROCEDURES, AND PROGRAMS Intent: The intent of the items in this section is to identify any special treatments, procedures, and programs that the resident received during the specified time periods. Hospice Care Code residents identified as being in a hospice program . SECTION P: RESTRAINTS AND ALARMS Intent: The intent of this section is to record the frequency that the resident was restrained . at any time during the day or night, during the 7-day look-back period. 1) RI #74 was admitted to the facility on [DATE] and readmitted on [DATE], and had diagnoses to include Alzheimer's Disease and Anxiety Disorder. RI #74's Physician's Orders were reviewed and revealed an order dated 06/05/2024 that documented RI #74's hospice services were discontinued. Further review of RI #74's orders revealed RI #74 had not received hospice services after 06/05/2024. RI #74's quarterly MDS assessment with an ARD of 12/05/2024 documented RI #74 was receiving hospice services during the assessment period. On 02/13/2025 at 1:23 PM the surveyor conducted an interview with the Licensed Practical Nurse (LPN)/Care Plan/MDS nurse. The MDS nurse said RI #74's hospice services had been discontinued in June of 2024. When asked why RI #74 was coded as receiving hospice services on the quarterly MDS assessment dated [DATE], the MDS nurse said, it was a coding error and the assessment was not an accurate assessment. 21055 2) RI #92 was admitted to the facility on [DATE] and readmitted on [DATE] and had diagnoses to include Muscle Weakness and Abnormalities of Gait and Mobility. On review of RI #92's quarterly MDS assessment with an ARD of 01/03/2025 RI #92 was coded as using a trunk restraint less than daily during the assessment period, when RI #92 did not use a trunk restraint. On 02/11/2025 at 11:53 AM RI #92 was observed sitting in his/her wheelchair and there was no trunk restraint observed being used. On 02/12/2025 at 9:19 AM RI #92 was observed in bed and there was no trunk restraint in use. On 02/13/2025 at 1:23 PM in a continued interview with the MDS nurse, the MDS nurse said, RI #92 did not use any type of restraint. The MDS nurse said, RI #92's 01/03/2025 quarterly MDS assessment was coded in error for a trunk restraint. The MDS nurse said, this would not be an accurate assessment. When asked why it would be important to ensure the residents' MDS assessments were accurate, the MDS nurse said, because MDS assessments reflect how residents were taken care of. The MDS nurse said, the inaccurate MDS assessments were errors.

Based on observations and staff interviews, the facility failed to maintain social distancing for three (3) of 10 residents on the memory care unit (Resident #s 1, 2 and 3). These failures occurred during a COVID-19 pandemic, and had the potential to affect all residents, that resided on the memory care unit. The findings include: During concurrent observations and interviews on 07/28/2020 at 12:07 p.m., accompanied by the Director of Nursing (DON), and the Administrator in Training (AIT), Residents #s 1, 2 and 3 were observe in close proximity to each other, in the day room. There were seven (7) other residents present in the day room also. Unit Manager (UM) #1 was present in the day room, and exited the dayroom at 12:10 p.m. The aforementioned residents remained in close proximity upon UM #1's exit. At 12:11 p.m., UM #1 re-entered the day room, where the residents were located, and did not recognize or address concerns with social distancing. At 12:15 p.m., UM #1 after prompted regarding social distancing concerns, confirmed and stated, Residents #s 1, 2 and 3 were 1 feet or less apart. During an interview on 07/28/2020 at 12:19 p.m., the DON stated, she expected residents to be six (6) feet apart. The DON also indicated she expected the staff to be attentive and redirect residents as needed. The facility was unable to provide a policy that addressed social distancing, at the time of the identified concern.

Based on a closed record review and interview, the facility failed to ensure a discharge summary was completed for Resident Identifier (RI) #156 after discharge from the facility on 11/2/19. This affected one of three closed records reviewed for discharges. Findings include: RI #156 was admitted to the facility on [DATE] and discharged on [DATE]. RI #156 had [DIAGNOSES REDACTED]. A closed record review on 11/20/19 at 12:29 p.m. revealed a physician's orders [REDACTED]. There was no discharge summary in RI #156's chart. On 11/21/19 at 8:52 a.m., an interview was conducted with Employee Identifier (EI) #1, Assistant Director of Nurses. EI #1 was asked, who was responsible for completing the discharge summary on a resident. EI #1 replied that she, the Director of Nurses, and EI #2, the other Assistant Director of Nurses did them. EI #1 was asked, when were discharge summaries done. EI #1 replied, normally they did them within the first 48 to 72 hours after discharge. EI #1 was asked, did RI # 156 have a discharge summary. EI #1 replied, no, he/she did not. EI #1 was asked, why RI #156 did not have one. EI #1 replied that it was just an over sight. EI #1 was asked, what was the potential concern of not having a discharge summary. EI #1 replied, no one would know where RI #156 went or what the reasoning was.

Based on observation, interviews, and review of a facility policy titled Collinsville Health Care and Rehab Medication Administration Policy and Procedure, the facility failed to ensure that Employee Identifier (EI) #3, Licensed Practical Nurse (LPN), did not place Resident Identifier (RI) #146's eye drops in her pocket prior to administration. This affected one of two residents observed for eye drop administration during medication pass. Findings include: A facility policy titled, Collinsville Health Care and Rehab Medication Administration Policy and Procedure, revised 5/7/18, documented, . Additional Med Pass Procedures: . B. Infection Control . 3) Medications must be administered without the possibility of contamination. RI #146 was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. An observation was made on 11/20/19 at 5:00 p.m., during medication pass with EI #3. EI #3 left RI #146's room to get a box of Kleenex, then returned and placed RI #146's eye drops in her pocket to wash her hands. She then came out of the bathroom and got a pair of gloves and had the eye drops in her hand. EI #3 put on the gloves and administered the eye drops. An interview was conducted with EI #3 upon exiting the resident's room. EI #3 was asked what she did with the eye drops before she went into the bathroom. EI #3 replied, she had them in her pocket. EI #3 was asked if she should place eye drops in her pocket. EI #3 replied, probably not. EI #3 was asked what was the potential concern of placing eye drops in her pocket. EI #3 replied, contamination. An interview was conducted on 11/21/19 at 9:05 a.m., with EI #2, Assistant Director of Nurses/Infection Control. EI #2 was asked if a nurse should place eye drops in her pocket. EI #2 replied, no. EI #2 was asked, what was the potential concern of a nurse placing eye drops in her pockets. EI #2 replied, infection.

Based on observations, interviews and reviews of facility's policies titled, Dietary Services, Proper Hand Washing and Glove Use, Monitoring Food Temperatures for Meal Services, and Serving Temperatures for Hot and Cold Foods the facility failed to ensure: 1) staff washed his hands after dropping a glove to the floor and putting on a new glove, 2) the temperature of the milk was taken and recorded before serving to the residents and, 3) a dishwasher changed her contaminated apron before handling clean trays, her apron touched the clean trays on the tray line. This had the potential to affect 172 of 172 residents receiving meals from the kitchen. Findings Include: 1) A review of a facility policy titled Dietary Service with a revised date of 9/01/17 revealed: Policy Hand Hygiene is necessary to prevent the spread of bacteria that may cause food borne illnesses, Dietary employees shall clean their hands in a handwashing sink A review of a facility policy titled, Proper Hand Washing and Glove Use, with an (YEAR) Edition date revealed: Guideline: All employee will use proper hand washing procedures and glove usage . Procedure: 3. All employees will wash hands upon entering the kitchen from any other location. 6. Hands are washed before donning gloves and after removing gloves. 7. Gloves are changed any time hand washing would be required. or if the gloves become contaminated by touching .other non-food contact surface, such as door handles and equipment On 9/25/18 at 11:47 a.m., (Employee Identifier) EI #3 aide, came from the storage area. The surveyor observed EI #3 drop his glove on the floor. EI #3 picked up the glove with his ungloved hand. EI #3 put the glove in the trash container with his ungloved hand. He did not wash his hands before putting a clean glove on. On 9/27/18 at 8:30 a.m., an interview was conducted with EI #3. EI #3 was asked when should he wash his hands in the kitchen. EI #3 replied, before every task or changing gloves. EI #3 was asked why should he wash his hands in the kitchen. EI #3 replied, because of contamination, working and cleaning everything. EI #3 was asked what was the facility policy on washing his hand in the kitchen. EI #3 replied, use soap for 20 second. EI #3 was asked did he drop a glove to the floor, pick it up off the floor, put it in the trash, and put on a new glove without washing his hands. EI #3 replied yes. On 9/27/18 at 9:52 a.m., the surveyor conducted an interview with EI #1, Dietician. EI #1 was asked when should hands be washed in the kitchen, according to the facility policy. EI #1 replied, when entering the kitchen, at the beginning of the shift, when returning from break, after using the toilet and after hands touch anything unsanitary. EI #1 was asked what did number six of the policy say. EI #1 replied, before putting on gloves and after removing gloves. 2) A review of a facility policy titled, Monitoring Food Temperatures for Meal Service with a edition date of (YEAR) revealed: Guideline: Food temperatures will be monitored daily to prevent food borne illness and ensure foods are served at palatable temperatures. Procedure: 1. Prior to serving a meal, food temperatures will be taken and documented for all hot and cold foods to ensure proper serving temperatures. 2. The temperature for each food item will be recorded on the Food Temperature Log. A review of a policy titled, Serving Temperatures for Hot and Cold Foods with no date, revealed: .Procedure: .7. The cook will take temperatures of hot and cold food items using approved food thermometers prior to each meal served. Food Temperatures will be recorded on menu A review of a document titled, Dietary Department, with a date of 9/25/18 revealed no recording for the milk temperature at the lunch. On 9/25/18 at 12:03 p.m., the Surveryor was at the tray line. The surveyor observed no one taking the temperature of the milk. On 9/26/18 at 4:44 p.m., the surveyor conducted an interview with EI #2, Dietary Manager. EI #2 was asked what was the temperature of the milk on 9/25/18. EI #2 replied, 34 degrees. (EI #2 reported the temperature that was documented on the cooler log for the temperature inside of the cooler). EI #2 was asked why was no milk temperature taken on 9/25/2018 at the lunch meal. EI #2 replied, because she did not know she had to write the temperature down. EI #2 was asked who was responsible for checking the temperature of the milk. EI #2 replied, the first cook on first shift and first cook on second shift. EI #2 was asked why should milk temperature be taken. EI #2 replied, because it was a cold food. EI #2 was asked what was the facility policy on checking the temperature on the milk. EI #2 replied, they do not have a policy. EI #2 was asked what was the potential harm in not checking the temperature on the milk before giving it to the residents. EI #2 replied, because it may be too hot. EI #2 was asked where was it documented that the milk was 34 degrees on 9/25/2018 at the lunch meal menu. EI #2 replied, there was no documentation. EI #2 was asked when the surveyor asked who took the milk temperature what did she reply. EI #2 replied, nobody because they had not. EI #2 was asked where did she record the temperature of the milk on the 9/25/2018 lunch meal. EI #2 replied, she did not record it at lunch. EI #2 was asked did she put it on the menu at the lunch meal. EI #2 replied, no. On 9/27/18 at 8:20 a.m., the survyor conducted an interview with EI #1. EI #1 was asked what did the facility policy say regarding taking the temperature of cold food. EI #1 replied, food items will be tempted and documented and any food that the food temperature was not taken will not be served. EI #1 was asked should milk temperature be taken according to the policy for all cold food. EI #1 replied, no. 3) On 9/25/18 at 11:28 a.m., the surveyor observed EI #4, dietary aide washing pots and pans in the wash sink of the three compartment sink. EI #4 was working on both the clean side and dirty side of the dish room. EI #4 was putting dishes away when a divider rod touched her apron. EI #4's apron touched the dirty sink and water was splashing on her apron as she washed dishes. EI #4 never changed her apron from the dirty side to the clean side of dishwashing. EI #4 also reached over in the wash sink to get food debris out. EI #4's apron touched the inside of the dirty sink. On 9/25/18 at 12:03 p.m., EI #4 brought clean plates and trays to the tray line. EI #4 put plates in the dish warmer and trays were put on a table across from the tray line. As EI #4 was taking the trays to the table six trays touched the front of her apron. On 9/27/18 at 9:09 a.m., EI #4 was asked on what side of the dish room did she work on 9/25/18. EI #4 replied, she was the dish washer that day. EI #4 was asked did she put away dishes from the clean side on that day. EI #4 replied, yes. EI #4 was asked did she change her apron on 9/25/18 while in the dish room washing dishes. EI #4 replied she did not change her apron. EI #4 was asked when washing pots and pans did dish water from the wash sink splash on her apron. EI #4 replied she did not see it. EI #4 was asked when she took trays and plates to the steam table did the trays touch her apron. EI #4 replied she took trays and plates, but did not feel the trays touching her. EI #4 was asked did she work both the clean and dirty side of the dish room on Tuesday 9/25/2018. EI #4 replied, she did. On 9/27/18 at 9:57 a.m., the surveyor conducted an interview with EI #2. EI #2 was asked did EI #4 work on the dirty side and clean side of the dish room on 9/25/18. EI #2 replied, yes, she did. EI #2 was asked why was the staff working both the dirty and clean side of the dish room without changing their apron. EI #2 replied, because they feel like they are not touching the clean dishes. EI #2 was asked was there a possibility for cross contamination when staff work both the clean side and dirty side of the dish room. EI #2 replied, she did not see it would be.

Based on observations, interviews, record review and review of facility policies Medication Administration, and Policy and Procedures for following Physician Orders, the facility failed to ensure Resident Identifier (RI) #67's tube feeding and water flush bag was labeled properly with the contents, time, date and nurse initials. The facility further failed to ensure the water flush was infusing at 30 cc (cubic centimeters) an hour as ordered by the physician. This was observed on 9/25/18 and affected one of five residents sampled for receiving tube feedings. Findings Include: A review of a facility policy titled . Medication Administration . with a revised date of 5/7/18 documented: Policy: To ensure each resident receives medication in a manner which ensures they only receive medication which is ordered by their physician. Procedure: .27. Controlled medications: [REDACTED]. Administration of Continuous Tube Feeding- To ensure proper labeling completed on Tube Feeding Bottle/Container and Water Bag label, at the time the formula/water is hung, the following information must be documented on each label: 1. Tube Feeding Bottle/Container must be properly labeled with the following information: a. Resident Name b. Room Number c. Date d. Start Time e. Rate per hour f. Nurse Initial 2) Water Bag must be properly labeled with the following information: a. Resident Name b. Room Number c. Date d. Time e. Rate f. Formula/Water g. Volume per day h. Any additions of water (Amount & Time) i. Nurse Initial * Note: Ensure tube feeding bottle/container rate, water bag rate, and pump settings are labeled and set according to physician's orders [REDACTED]. A review of a facility policy, with no date, titled, . Policy and Procedure for following Physicians Orders, included the purpose, To ensure licensed staff follow orders prescribed by physician. RI #67 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #67's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/10/18, revealed: RI #67 had a Brief Interview for Mental Status (BIMS) of severe impairment for daily decision making. Section K - Swallowing/Nutritional Status indicated RI #67 had a feeding tube and received tube feedings. On 9/25/18 at 12:01 p.m., the surveyor observed RI #67 with a tube feeding hanging. The feeding container revealed: Glucerna 1.5 calories in the container, the pump revealed the feeding infusing at a rate of 45 milliters (ml)/ hour (hr). The label revealed no date, no time and no initials. The flush bag was also observed with no label of contents, no time, date or initials. The flush was infusing at a rate of 35 ml/hr (milliliters), as was observed on the pump. A review of RI #67's (MONTH) (YEAR) Physician order [REDACTED]. On 9/25/18 at 12:05 p.m., an interview was conducted with Employee Identifier (EI)#6, Registered Nurse, Charge Nurse. EI #6 went to RI #67's room with the surveyor. EI #6 was asked what did she see wrong with the Glucerna and the water flush bag (self fill bag). EI #6 replied, the Glucerna had no date, no time, no initials and the flush bag did not include a label of contents, date or time. EI #6 was asked what was the facility's policy and procedure on the labeling of tube feeding and the flush bag. EI #6 replied, to label, date, time and initial when the bag was hung. EI #6 was asked why was it important to label, time, date and initial the contents of a tube feeding. EI #6 replied, so the nurses know who hung it, what was in it, the time and date it was hung. EI #6 was asked how would she know what was in the flush bag. EI #6 replied, she would not know what the bag was filled with because it was not labeled. EI #6 was asked who was responsible to ensure the feeding bottle and fill bag were labeled, dated, timed and initialed. EI #6 replied, the nurse that hung it. On 9/25/18 at 4:40 p.m., EI #6 went to RI #67's room with the surveyor. EI #6 was asked what did the physician order [REDACTED]. EI #6 replied, to infuse at 30 ml/hr. EI #6 was asked what was the H2O infusing at. EI #6 replied 35 ml/hr. EI #6 was asked what was the potential harm in the H2O infusing at a rate of 35 ml/hr and not 30 ml/hr as ordered. EI #6 replied because of fluid overload and RI #67 had [MEDICAL CONDITIONS] and [MEDICAL CONDITIONS]. EI #6 was asked was the physician's orders [REDACTED]. EI #6 replied no it was not followed. EI #6 was asked why was the order not followed. EI #6 replied, I do not know.

Based on staff and resident interviews, resident's medical record review, observation and review of Potter and Perry's Fundamentals of Nursing, the facility failed to ensure two licensed nurses, Employee Identifier (EI) #1 and EI #5, followed Resident Identifier (RI) #1's Physician Orders, dated 4/11/18, for Terconazole cream 0.4% vaginal cream. The facility did not began the treatment until (MONTH) 14, (YEAR). This deficient practice affected RI #1, one (1) of four (4) residents sampled. Finding Include: 1. A review of Potter and Perry's Fundamentals of Nursing, ninth edition, with a copyright date of (YEAR), Chapter 23, Legal Implications in Nursing Practice, page 311, documented: . Health Care Providers' Orders . Nurses follow health care providers' orders unless they believe that the orders are in error . A review of a facility policy and procedure titled Medication Administration, with a revised date of 2/20/13, documented: Policy: To ensure each resident receives medication in a manner which ensures they only receive medication which is ordered by their physician. Procedure: . 18. If a medication error occurs, the person administering the medication is responsible for notifying the Director Of Nursing (DON)/Designee immediately . (If resident's primary physician is not available, the facility Medical Director will then be notified for instructions) . DON/Designee will be responsible for ensuring the physician's orders [REDACTED]. RI #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #1's medical record revealed Physician order [REDACTED]. Physician order [REDACTED].@ (at) bedtime for 7 days . A review of RI #1's Treatment Record (TAR) for the month of (MONTH) (YEAR) was conducted. The TAR revealed RI #1 had received the Terconzole cream on 4/14/18 as indicated by the nurses' initials. The TAR also revealed RI #1 did not receive the Terconzole cream on the 14th and 15th of April. The Terconzole was not given again until 4/16/18. On 05/02/18 at 8:30 a.m., the surveyor conducted an interview with the facility's Medical Director. The surveyor asked the Medical Director if RI #1 not receiving the Terconazole cream would cause any harm. The Medical Director said no, and it would not be harmful mixing the two creams (Terconzole and [MEDICATION NAME]). The Medical Director said the two creams would not be as effective (given together). The surveyor asked the Medical Director did RI #1's yeast infection worsen from missing a couple of doses. The Medical Director said no. The surveyor asked the Medical Director in his professional opinion was there any harm to RI #1. The Medical Director said no. On 05/02/18 at 10:40 a.m., the surveyor conducted an interview with EI #1, the nurse responsible for giving the medication on (MONTH) 14, (YEAR). The surveyor asked EI #1 which dose of Terconazole cream did she not give. EI #1 said she did not give the dose scheduled for (MONTH) 14 and 15, (YEAR). EI #1 said she initialed the TAR for the medication being given and forgot to go back and circle it. EI #1 said she had intentions to go back and this was a big lesson learned. On 05/02/18 at 3:12 p.m., the surveyor conducted an interview with EI #5, Licensed Practical Nurse. The surveyor asked EI #5 if she had failed to administer any scheduled medications to RI #1. EI #5 said there was one treatment for [REDACTED]. She said RI #1 had 2 vaginal creams ordered at the same time. The surveyor asked EI #5 when should the first dose of the Terconazole cream been started in (MONTH) (YEAR). EI #5 said (MONTH) 13, (YEAR) at 10 p.m., bedtime. The surveyor asked EI #5 who was responsible for starting the first dose of Terconazole cream on RI #1 in (MONTH) (YEAR). EI #5 said she guess that would have been her. The surveyor asked EI #5 if there was any reason why she did not start the medication. EI #5 said yes. EI #5 said RI #1 was taking [MEDICATION NAME] vaginal cream at bedtime on the 3-11 shift. EI #5 said she knew RI #1 only got the [MEDICATION NAME] once a week on Friday. EI #5 said she gave the Terconazole which was scheduled at the same time (bedtime), but for seven days. EI #5 said it was at 10 p.m. and the physician's office was closed. EI #5 said since this incident she had been inserviced on signing her name on the Treatment Record and circle for not given. EI #5 said she was inserviced to write a physician's orders [REDACTED]. The surveyor asked EI #5 if she received any inservice or training related to Medication Administration and omissions of medication since the incident. EI #5 said yes sir, by the pharmacist. On 05/03/18 at 8:34 a.m. the surveyor conducted a phone interview with the Certified Registered Nurse Practitioner (CRNP) who ordered the Terconazole cream for RI #1 to start on 4/13/2018. The surveyor asked the CRNP in her opinion was there any harm as a result of RI #1's Terconazole cream being rescheduled 3 days later from the original date. The CRNP said no, as long as the patient got the full treatment that was ordered for seven days. On 5/3/18 at 9:20 a.m., the surveyor conducted an interview with the Assistant Director Of Nursing (ADON), EI #2. The surveyor asked EI #2 had there been any concerns voiced from RI #1's family regarding care. EI #2 said yes, the vaginal cream Terconazole (treatment). EI #2 said a family member had called and asked about RI #1 not receiving the vaginal cream. EI #2 said an investigation was started and it was found that the cream (for RI #1) should have been administered on (MONTH) 13, 14, and 15, (YEAR).

Based on staff interviews, resident record review, and review of a facility's policy titled Medication Administration, the facility failed to ensure a licensed staff member did not sign her initials on the Treatment Record (TAR) prior to administering Terconazole cream 0.4% to Resident Identifier (RI) #1. Employee Identifier (EI) #1 failed to circle her initials on the TAR indicating RI #1 did not receive the Terconazole cream 0.4%. Furthermore, this pertinent information was not documented in RI #1's medical record on 4/14/18. This deficient practice affected RI #1, one (1) of four (4) residents sampled. Findings Include: A review of a facility policy and procedure titled Medication Administration, with a revised date of 2/20/13, documented: Policy: To ensure each resident receives medication in a manner which ensures they only receive medication which is ordered by their physician. Procedure: . 16. Document on your MAR after the resident has taken the medication. Initial and circle any medication not administered, then document reason on back of your MAR (Medication Administration Record) . RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1 received a physician's orders [REDACTED].@ (at) bedtime for 7 days . On 5/3/18 at 9:20 a.m., the surveyor conducted an interview with the Assistant Director Of Nursing (ADON), EI #2. The surveyor asked EI #2 had there been any concerns voiced from RI #1's family about care. EI #2 said yes, the vaginal cream Terconazole (treatment). EI #2 said a family member had called and asked about RI #1 not receiving a vaginal cream. EI #2 said an investigation was started and it was found that the cream (for RI #1) should have been started on (MONTH) 13, (YEAR). EI #2 said she had the facility's consultant pharmacist to come to the facility and provide education on medication (med) pass. EI #2 said the pharmacist inserviced EI #1, the medication nurse and other nurses regarding when to sign the MAR/(TAR). EI #2 said the pharmacist also gave inservces to the nurses regarding when to document on the MAR/(TAR) why the medication are not given, and circle with initials. On 05/02/18 at 10:40 a.m., the surveyor conducted an interview with EI #1, Licensed Practical Nurse. The surveyor asked EI #1 which dose of Terconazole cream did she not give. EI #1 said she did not give the dose scheduled for (MONTH) 14 and 15, (YEAR). EI #1 said she initialed the TAR that the medication was given and forgot to go back and circle. EI #1 said there was an emergency in the facility on the front hall and a resident was in respiratory distress. The surveyor asked EI #1 if she should had signed the TAR before giving the med. EI #1 said no, she should not have signed it. EI #1 said she had intentions to go back and this was a big lesson learned. The surveyor reviewed RI #1's (MONTH) (YEAR) Treatment Record with the Terconazole cream 0.4% vaginal cream listed. The (MONTH) 14, (YEAR) date had EI #1's initials documented. There was no documented evidence on the TAR or in RI #1's medical record indicating this medication treatment had not been provided on this day. This citation was written as a result of the investigation of complaint/report number AL 674.

Based on observation, interview, medical record review, and a review of POTTER AND PERRY'S FUNDAMENTALS OF NURSING, the facility failed to ensure a Certified Nursing Assistant (CNA) washed her hands and changed her gloves while performing the incontinence care of Resident Identifier (RI) #3. This affected RI #3, one of one sampled resident observed for incontinence care. Findings Include: A review of POTTER AND PERRY'S FUNDAMENTALS OF NURSING, NINTH EDITION, CHAPTER 29, page 459 revealed: . Infection Prevention and Control . TABLE 29-6 Centers for Disease Control and Prevention Isolation Guidelines Standard Precautions . for Use with All Patients Standard precautions apply to all blood, . all body fluids, . excretions . Perform hand hygiene before, after, and between direct contact with patients . Perform hand hygiene after contact with blood, bodily fluids, . excretions . and immediately after gloves are removed. Remove gloves and perform hand hygiene between patient care encounters . RI #3 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/20/17 at 10:49 a.m., Employee Identifier (EI) #1, a CNA, did not wash her hands before and after removing her gloves, after wiping the buttocks, or before and after touching the resident while providing incontinence care to RI #3. An interview was conducted on 12/20/17 at 10:59 a.m. with EI #1. EI #1 was asked when were hands supposed to be washed. EI #1 replied, Before and after taking a resident to the bathroom. EI #1 was asked if she had washed her hands before and after taking RI #3 to the bathroom. EI #1 replied, No ma'am. EI #1 was asked what other times should hands be washed. EI #1 replied hands should be washed after wiping the buttocks. EI #1 was asked what should be done before applying gloves and after gloves are removed. EI #1 replied, Wash hands. EI #1 was asked what was the potential for harm in not washing hands while performing incontinence care. EI #1 replied, Infections.

Based on observations, interviews and record reviews of the 2013 Food Code, the facility failed to: 1. maintained Time/Temperature control of stored frozen food, (individual cups of ice cream) during storage inside the walk-in freezer. 2. prevent potential contamination of flour/meal from equipment such as cups and utensils used to dispense and observed to be stored on top of the food with handles touching the food. The above practices posed the potential for food contamination and compromised food safety. This had the potential to affect all 170 residents receiving meal trays from dining services as evidenced by a review of the facility's Diet List. Findings include: I. A review of the Food Code U.S. Public Health Service and FDA (Food and Drug Administration) 2013 revealed the following: 3-501.11 Frozen Food. Stored frozen FOODS shall be maintained frozen . On 9/05/2017 at 6:20 PM, ice cream (individual cups) were observed stored in the walk-in freezer. An individual cup was selected and pressure applied. Finger indentations remained on the container. An interview with Employee Identifier (EI) #5, the Dietary Manager/DM, and EI #6, the Registered Dietitian/RD, on 9/7/17 at 12:00 PM. EI #5 and EI #6 confirmed that the ice cream did not remain frozen during storage and that the internal temperature of the cup of ice cream measured to be + 4 or 6 degrees Fahrenheit. 2. A review of the Food Code U.S. Public Health Service and FDA (Food and Drug Administration) 2013 revealed the following: . Preventing Contamination from Equipment, Utensils . 3-304-12 (B). In food that is not TIME/TEMPERATURE CONTROL FOR SAFETY FOOD with their handles above the top of the FOOD within containers or EQUIPMENT . On 9/06/2017 at 10:10 AM, the storage bin for cornmeal was observed to have a pitcher with handle touching food inside the bin. On 9/6/2017 at 11:50 AM, the flour bin was observed with a cup stored inside. The RD was made aware of the observation of the flour bin. On 9/07/2017 at 12:00 PM, EI #5 was interviewed in the presence of the EI #6. EI #5 was asked where should scoops be stored when used for corn meal or flour. EI #5 replied not in the cornmeal. EI #5 was informed of how the scoops were stored and said a measuring cup was in the cornmeal and a cup was on top of the flour. EI #5 verbalized, Staff said they knew better, but forgot. EI #5 said there was a potential for bacterial contamination.

Based on staff interview and a review of the facility's policy and procedure titled, Abuse, Neglect, and Exploitation, and a review of personnel files, the facility failed to ensure licensure verification was completed for a new hire, Employee Identifier (EI) #3, prior to employment. This affected one of six personnel files reviewed. Findings Include: A review of the facility's policy and procedure titled, Abuse, Neglect, and Exploitation, dated 01/06/17 revealed the following: . The facility must: . 3. Not employ or otherwise engage individuals who: . d. credentials' checks should be conducted on employees prior to or at the time of employment, by facility administration . On 09/07/17 at 11:00 a.m, during a review of personnel files, EI #3's, Registered Nurse/RN, file did not have documentation for verification of licensure. On 09/07/17 at 11:25 a.m., during an interview with EI #4, Human Resources, the surveyor asked where was the licensure check for EI #3. EI #4 replied she verified but no documentation to reflect that she checked EI #3's license. The surveyor asked how could EI #3's license be validated as active or not without documentation. EI #4 replied it could not be validated. '

Based on observation, medical record review, a review of a facility's policy titled, Policy and Procedure for Comprehensive Care Plans and staff interview, the facility failed to develop a care plan for Resident Identifier (RI) #2 to float bilateral heels. This affected one of 24 sampled residents whose care plans were reviewed. Findings Include: A review of a facility's policy titled, Policy and Procedure for Comprehensive Care Plans documented the following: . Plans of Care are developed by the interdisciplinary team, to coordinate and . communicate care approaches and goals for the resident related to clinical [DIAGNOSES REDACTED]. 1. The services that are to be furnished to attain or maintain the resident's highest practicable physical, . well being . RI #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #2's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/21/201,7 revealed RI #2's Brief Interview for Mental Status (BIMS) score of 15, indicating cognition intact. The MDS further revealed under section M RI #2 was at risk of developing pressure ulcers. A review of RI #2's September Physician order [REDACTED]. FLOAT BILATERAL HEELS WHEN IN BED . A review of RI #2's care plan with a problem onset date of 09/01/2017, revealed the following: . PREVENTATIVE SKIN Potential alteration in skin integrity/pressure formation R/T (related to ): *Hx (History) pressure areas . Further review of the care plan did not revealed any approaches to float bilateral heels. RI #2 was observed with bilaterals heels resting on bed and not floating off of the bed on the following dates: 09/06/2017 and 09/07/2017, two of three survey days. An interview was conducted on 09/07/2017 at 11:00 a.m., with Employee Identifier (EI) #12, Licensed Practical Nurse (LPN)/Care Plan Coordinator. EI #12 was asked was RI #2 care planned for floating heels. EI #12 said no and it was an oversight. EI #12 was asked why should RI #2 be care planned for floating the heels. EI #12 said RI #2 has a history of skin breakdown to the heels and also for the Certified Nursing Assistants (CNA) to know how to care for RI #2.

Based on observations, medical record review and a review of Legal Implications in Nursing Practice the facility failed to follow Resident Identifier (RI) #2's physician's orders [REDACTED]. This affected one of five resident's sampled for pressure sores. Findings Include: A review of Chapter 23 Legal Implications in Nursing Practice page 305 documented: . Health Care Providers' Orders. The health care provider (physician or advanced practice nurse) is responsible for directing medical treatment. Nurses follow health care providers' orders . RI #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #2's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/21/201,7 revealed RI #2's Brief Interview for Mental Status (BIMS) score of 15, indicating cognition intact. The MDS further revealed under section M RI #2 was at risk of developing pressure ulcers. A review of RI #2's September Physician order [REDACTED]. FLOAT BILATERAL HEELS WHEN IN BED . The following was observed on 09/06/2017 and 09/07/2017: RI #2 was positioned in bed lying on her back, bilateral heels not floated. On 09/07/2017 at 10:55 a.m., an interview was done with Employee Identifier #13, Registered Nurse (RN)/Charge Nurse. EI #13 was asked were the Physician orders [REDACTED].#13 said no. EI #13 was asked why were the bilateral heels to be floated. EI #13 said RI #2 has a history of stage one pressure to the bilateral heels. EI #13 was asked who was responsible to ensure the Physician orders [REDACTED].#13 said the nurses and the charge nurse.

Based on observation, medical record review, a review of a facility's policy titled, Policy and Procedure for Comprehensive Care Plans and staff interview, the facility failed to ensure Resident Identifier (RI) #2 bilateral heels were floated to prevent skin breakdown. This affected RI #2, a resident identified with a history of pressure ulcers to bilateral heels, one of five sampled residents identified with pressure sores. Findings Include: A review of a facility's policy titled, Policy & (and) Procedure for Skin Assessment & Pressure Ulcer Prevention dated 6/26/12, revealed the following: Policy A. to help identify at risk residents for pressure ulcers . Procedure: . 2. As risk factors are identified, preventative skin measures will be implemented. A review of a facility's policy titled, Policy and Procedure for Comprehensive Care Plans documented the following: . Plans of Care are developed by the interdisciplinary team, to coordinate and . communicate care approaches and goals for the resident related to clinical [DIAGNOSES REDACTED]. 1. The services that are to be furnished to attain or maintain the resident's highest practicable physical, . well being . RI #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #2's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/21/201,7 revealed RI #2's Brief Interview for Mental Status (BIMS) score of 15, indicating cognition intact. The MDS further revealed under section M RI #2 was at risk of developing pressure ulcers. A review of RI #2's September Physician order [REDACTED]. FLOAT BILATERAL HEELS WHEN IN BED . A review of RI #2's care plan with a problem onset date of 09/01/2017, revealed the following: . PREVENTATIVE SKIN Potential alteration in skin integrity/pressure formation R/T (related to ): *Hx (History) pressure areas . Further review of the care plan did not revealed any approaches to float bilateral heels. RI #2 was observed with bilateral heels resting on bed and not floating off of the bed on the following dates: 09/06/2017 and 09/07/2017, two of three survey days. An interview was conducted on 09/07/2017 at 11:00 a.m., with Employee Identifier (EI) #12, Licensed Practical Nurse (LPN)/Care Plan Coordinator. EI #12 was asked was RI #2 care planned for floating heels. EI #12 said no and it was an oversight. EI #12 was asked why should RI #2 be care planned for floating the heels. EI #12 said RI #2 has a history of skin breakdown to the heels and the resident's heels should be floated while in bed.

Based on observation, staff interview and a review of the facility's policy titled, Incontinent Care and Standard Precautions Infection Prevention and Control, the facility failed to ensure: 1. staff did not apply a protective cream to Resident Identifier (RI) #5 perineal area with soiled gloves and did not apply a stained cloth diaper; 2. staff wiped RI #15 from front to back, visualize the perineal area, use the same area of the peri-wipe only once and removed soiled gloves before applying a clean diaper. 3. RI #4 and RI #17 had a valid justification for the use of an indwelling catheter. This affected two of five residents observed during incontinent care and two of two sampled residents with indwelling catheters. Findings Include: A review of the facility's policy and procedure titled, Incontinent Care, without a date, revealed the following: . PR(NAME)EDURE: . (wiping from front to back) change area of the wet wipe . (Change area of the wet wipe after each wipe/contact with resident's skin) . Separate . using a clean wipe . wiping from front to back . C) Dispose of wet wipe . (Avoid touching the bag . 9. cleanse each buttock wiping from front to back . A review of the facility's policy and procedure titled, Standard Precautions Infection Prevention and Control without a date, revealed the following: .Procedures: 1. b. Perform Hand Washing . 4. When changing/removing gloves . h. Change gloves during resident care if the hands will move from a contaminated body site . to a clean body site . 1. RI #5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #5's Annual Minimum Data Set assessment dated [DATE] revealed RI #5's Brief Interview for Mental Status (BIMS) score of 12, indicating cognition moderately impaired. The MDS assessed RI #5 as requiring extensive assistance with toileting and personal hygiene; and RI #5 was frequently incontinent of bladder and always incontinent of bowel. On 09/06/17 at 11:00 a.m., the following was observed during incontinent care: Employee Identifier (EI) #7, Certified Nursing Assistant/CNA and EI #8, Registered Nurse/RN, washed their hands and applied gloves. EI #7 provided incontinent care to RI #5. EI #7 applied a protective cream to RI #5's perineal area and buttocks and a cloth diaper with yellowish colored stains to RI #5 without removing her soiled gloves. On 09/06/2017 at 11:20 a.m., during an interview with EI #7, the surveyor asked what should be done with gloves after cleaning and before applying a protective cream to the resident. EI #7 stated she should have changed her gloves. EI #8 replied that was not what EI #7 had done. EI #7 stated the potential harm to the resident would be skin infection and a UTI. The surveyor asked what color stains were on the cloth diaper. EI #7 stated yellow and she should have gotten another diaper. 2. RI #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #15's Quarterly MDS assessment dated [DATE] revealed RI #15's BIMS score of 9, indicating cognition moderately impaired. The MDS assessed RI #15 as requiring extensive assistance with toileting and personal hygiene; and RI #15 was frequently incontinent of bladder and occasionally incontinent of bowel. A review of RI #15's care plan titled, URINARY/BOWEL, with a problem onset date of 04/07/17, revealed the following: . Hx (History) UTI . On 09/06/17 at 11:40 a.m., the following was observed during incontinent care: EI #9, CNA and EI #10, CNA, washed their hands and applied gloves. EI #9 wiped RI #15's perineal area from back to front. EI #9 wiped RI #15's groin and buttocks twice using the same area of the peri-wipe. After wiping RI #15's perineal area, EI #9 applied a clean brief to RI #15 and did not change her soiled gloves. On 09/06/17 at 12:00 p.m., during an interview with EI #9 and EI #10, the surveyor asked EI #9 what direction should she wipe. EI #9 stated from front to back, but that was not what she had done. EI #9 also stated she did not visualize and wipe all of RI #15's perineal area. The surveyor asked how many times should she use the same area of the peri-wipe. EI #9 replied once. EI #10 stated that was not what EI #9 did every time she wiped. EI #10 also stated that could cause a UTI. EI #9 also stated she should have change her gloves after cleaning RI #15 and before applying a clean brief. 3. RI #4 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #4's Significant Change MDS assessment dated [DATE] revealed RI #4 had short and long term memory problems and was severely impaired in cognitive skills for daily decision making. The MDS also assessed RI #4 with an indwelling catheter. A review of RI #4's medical record revealed the following: . 5/22/17 Has displaced non-healing fx (fracture) femoral neck leave foley in for pain relief d/t (due to) repositioning . (MD's signature) 5/23/17 A review of RI #4's PHYSICIANS ORDERS for May 2017 revealed the following: . 5/16 . Foley Cath #16 fr (french) (with) 10 ml (milliliter) bulb, . (r/t (related to) pathological fractures) . A review of RI #4's PHYSICIANS ORDERS for June 2017 revealed the following: . 6/2/17 D/C (discontinue) . Foley Cath #16 F (french) (with) 10 ml bulb . On 09/07/17 at 12:50 p.m., during an interview with EI #11, RN, the surveyor asked what was the [DIAGNOSES REDACTED]. EI #11 reviewed RI #4's chart and stated pathological fx/pain and the MD wrote the note. EI #11 stated the f/c was placed on 05/16/17 and d/c'd on 06/02/17. 4. RI #17 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #17's Significant Change MDS assessment dated [DATE] revealed RI #17 BIMS score of 3, indicating severe impairment in cognition. The MDS also assessed RI #17 to have an indwelling catheter. On 09/07/17 at 12:30 p.m., during an observation of RI #17, the resident was up to the wheelchair, with a foley catheter in a privacy bag with yellow urine observed in the tubing. A review of RI #17's medical record revealed the following: . (RI #17) is a patient of mine. He/She requires a permanent Foley Catheter due to a [DIAGNOSES REDACTED]. A review of RI #17's PHYSICIANS ORDERS for July 2017 revealed the following: . 7/16/17 Foley Cath #18 Fr (French) (with) 10 ml (milliliter) bulb r/t (related to) Tibial Fx . On 09/07/17 at 12:55 p.m., during an interview with EI #11, RN, the surveyor asked what was the [DIAGNOSES REDACTED]. EI #11 reviewed RI #17's chart and stated Tibial/fibial fracture. EI #11 stated the f/c was placed on 07/16/17 and continued on 07/31/17.

Based on record review, an observation, staff interview and a review of the facility's policy titled, Standard Precautions Infection Prevention and Control,the facility failed to ensure: 1. staff washed their hands after removing gloves after providing care for Resident Identifier (RI) #3; 2. staff did not touch RI #5's clean linen with soiled/contaminated gloves, 3. staff did not pick up plastic bags off the floor and place on of Resident Identifier (RI) # 5's bed; This affected RI #5 and RI #3, two of five residents observed during incontinent care. Findings Include: A review of the facility's policy and procedure titled, Standard Precautions Infection Prevention and Control without a date, revealed the following: . Procedures: 1. b. Perform Hand Washing . 4. When changing/removing gloves . e. Remove gloves after contact with a resident and/or the surrounding environment . h. Change gloves during resident care if the hands will move from a contaminated body site ( . perineal area) to a clean body site . RI #5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #5's Annual Minimum Data Set assessment dated [DATE] revealed RI #5's Brief Interview for Mental Status score of 12, indicating cognition moderately impaired. The MDS assessed RI #5 as requiring extensive assistance with toileting and personal hygiene; and RI #5 was frequently incontinent of bladder and always incontinent of bowel. On 09/06/17 at 11:00 a.m., the following was observed during incontinent care: Employee Identifier (EI) #7, Certified Nursing Assistant/CNA and EI #8, Registered Nurse/RN, washed their hands and applied gloves. EI #7 picked up plastic bags that was on the floor and placed them on the resident's bed. EI #7 provided incontinent care to RI #5. EI #7 was observed to remove her soiled gloves, touch the resident's linen and did not wash her hands. EI #7 then applied clean gloves and continued the incontinent care. EI #7 removed her soiled gloves again, and touched the resident's clean linen and brief. EI #7 did not wash her hands after removing her soiled gloves and before touching the resident's clean linen and brief. On 09/06/2017 at 11:20 a.m., during an interview with EI #7, the surveyor asked what should be done after gloves are removed and before applying clean gloves. EI #7 stated to wash her hands, but that was not what she had done. EI #7 stated she only washes her hands at the beginning of care. EI #7 also stated she picked up the plastic bags off the floor and placed them on the resident's bed. EI #7 said she touched the resident's covers, clean brief and pads after she removed her gloves and she did not wash her hands. EI #7 and EI #8 stated not washing hands after removing gloves and touching resident's linen could be a infection control issue and cross contamination. 2. On 09/6/20/17 at 10:00 AM, the following was observed during incontinent care for RI #3. EI #1 washed her hands and applied clean gloves at the beginning and at the end of the provision of incontinent care. EI #1 did not change her gloves and wash her hands when going from dirty to clean. On 9/8/2017 at 12:30 p.m., an interview was held with the Infection Control Nurse, EI #2. EI #2 was asked what should staff do when gloves are removed. EI #2 stated to wash hands.

Based on staff interview and a review of the facility's policy and procedure titled, Labwork & (and) Physician Notification, the facility failed to ensure licensed staff obtained results of a Urinalysis Culture and Sensitivity (UA C & S) for Resident Identifier (RI) #5. This affected one of six sampled residents identified with a history of a Urinary Tract Infection [MEDICAL CONDITION]. Findings Include: A review of the facility's policy and procedure titled, Labwork & Physician Notification without a date, revealed the following: . Procedure: . 2. the facility is responsible for the timeliness of the services . RI #5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #5's Annual Minimum Data Set assessment dated [DATE] revealed RI #5's Brief Interview for Mental Status (BIMS) score of 12, indicating cognition moderately impaired. The MDS assessed RI #5 as requiring extensive assistance with toileting and personal hygiene; and RI #5 was frequently incontinent of bladder and always incontinent of bowel. A review RI #5's discharge hospital note dated 08/31/17 revealed the resident had a UTI. Further review of the medical record did not reveal a UA C & S result. On 09/06/17 at 1:15 p.m., during an interview with Employee Identifier (EI) #14, Registered Nurse/Unit Manager, the surveyor asked where was the information related to the UTI and C & S results. EI #14 reviewed RI #5's medical record and stated she called the hospital on [DATE], but no results were given. The surveyor asked what had been done since 09/04/17 to determine if the resident had a UTI or not. EI #14 replied, Honestly after that nothing. The surveyor asked why not. EI #14 stated, Honest mistake. The surveyor asked how did she know if the resident had a UTI or not. EI #14 said, I don't know, but I will get the report.