Every finding on record at Convalescent Nursing and Rehab Center

Based on observations, interviews and review of the facility's policy titled Hand Hygiene the facility failed to ensure: 1) Employee Identifier (EI) #2 and EI #4, both Licensed Practical Nurses (LPNs) washed and/or sanitized their hands before they put gloves on; and 2) EI #3 and EI #4, both LPNs placed a barrier down before placing items used during medication administration and wound care on top of the medication and treatment carts. These deficient practices affected Resident Identifier (RI) #1 and RI #2, two of three residents observed for medication administration; and RI #3, one of one resident observed for wound care. Findings include: 1) The facility's policy titled Hand Hygiene dated April 2020, documented Purpose: To provide guidelines to employees for proper and appropriate resident hand hygiene techniques that will aid in the prevention of the transmission of infections. Policy: All employees shall adhere to resident hand hygiene as outlines in this policy . Procedure: . 2. When to Perform Hand Hygiene Appropriate Hand Hygiene should be performed: . h. Before and after glove use . During medication pass observation on 8/19/2020 at 4:11 PM, EI #2, an LPN applied gloves to obtain RI #1's fingerstick blood sugar, without washing and/or sanitizing her hands. In an interview on 8/20/2020 at 11:13 AM, EI #2, an LPN acknowledged that she did not wash her hands before she applied gloves when she obtained RI #1's fingerstick blood sugar. When asked why she didn't, EI #2 stated she was nervous. 2) During medication pass observation on 8/19/2020 at 4:24 PM, EI #3, an LPN laid a Kleenex and gloves on top of her medication cart without a barrier. EI #3 used the Kleenex and gloves when she instilled eye drops in RI #2's eyes. In a telephone interview on 8/20/2020 at 1:35 PM, EI #3, an LPN was asked where she placed the Kleenex and gloves that was removed from medication cart prior to entering RI #2's room. EI #3 replied, on top of the (medication) cart. When asked if there was a barrier on the medication cart, EI #3 said no. EI #3 was asked what the concern was, and she replied, infection control and contamination. 3) The facility's policy titled Hand Hygiene dated April 2020, documented Purpose: To provide guidelines to employees for proper and appropriate resident hand hygiene techniques that will aid in the prevention of the transmission of infections. Policy: All employees shall adhere to resident hand hygiene as outlines in this policy . Procedure: . 2. When to Perform Hand Hygiene Appropriate Hand Hygiene should be performed: . h. Before and after glove use . On 8/20/2020 at 10:08 AM, EI #4, the LPN Treatment Nurse was observed to place gloves on top of papers on the treatment care. EI #4 then put those same gloves on, without washing or sanitizing her hands prior to performing RI #3's wound care. In an interview on 8/20/2020 at 10:49 AM, EI #4, the LPN Treatment Nurse was asked where she placed gloves prior to entering RI #3's room. EI #4 replied, on top of the treatment cart on some papers. When asked if that was a clean surface, EI #4 said no. When asked why should gloves not be placed on a potentially contaminated surface prior to use in wound care, EI #4 answered, could transmit bacteria and infection to the wound. EI #4 was asked should the gloves have been placed there and she said no, not without a barrier. EI #4 acknowledged that she should have washed her hands before she put gloves on.

Based on observations, interviews, review of the facility's policies titled, Handwashing CC-INFC-28, Cleaning and Disinfecting Glucose Monitoring Systems INFC-73, the ASSURE BRILLIANCE COMPREHENSIVE SERVICE & SUPPORT PROGRAM, a facility document and www.merriam-webster.com, the facility failed to ensure Employee Identifier (EI) #1, a Registered Nurse and EI #8, a Licensed Practical Nurse (LPN) cleaned and disinfected a multi-use glucometer between resident use. During medication pass observation on 7/31/2019 beginning at 3:47 PM, EI #1, a RN failed to clean and disinfect the multi-use glucometer when she performed finger stick blood sugar monitoring for RI #37, RI #66, RI #69 and RI #98. EI #1 further failed to wash her hands prior to and after she removed gloves and place a barrier down on the residents' over-bed table, bed and/or furniture. During medication pass observation on 8/1/2019 beginning at 5:34 AM, EI #8, a LPN failed to disinfect the multi-use glucometer when she performed finger stick blood sugar monitoring for RI #2, RI #14 and RI #18. These deficient practices affected RI #2, RI #14, RI #18, RI #37, RI #66, RI #69 and RI #98, seven of 10 residents observed for finger stick blood sugar monitoring and placed these residents in immediate jeopardy for serious injury, harm, impairment or death. The facility has 33 residents who require finger stick blood sugar monitoring. On 8/4/2019 at 3:26 PM, the Administrator, Director of Nursing and the Nurse Quality Advisor were notified of the finding of immediate jeopardy in the area of Infection Control, F 880. Findings include: The facility's undated policy titled Handwashing CC-INFC-28 documented Purpose: To provide guidelines to employees for proper and appropriate handwashing techniques that will aid in the prevention of the transmission of infections. Policy: All employees shall adhere to handwashing procedure as outlined in this policy. Handwashing shall be regarded by the facility as the single most important means of preventing the spread of infections. Procedures: . When to Wash Hands . 7. After contact with blood, body fluids, secretions, excretions, mucous membranes, or broken skin; 8. After handling items or equipment potentially contaminated with a resident's blood, body fluids, excretions, or secretions; 9. After removing gloves; . The facility's policy titled Cleaning and Disinfecting Glucose Monitoring Systems INFC-73 revised (MONTH) 2010, documented Purpose: To ensure that correct cleaning and disinfecting of the Glucose Monitoring System is followed to prevent the potential transmission of infectious organisms . Policy: The Glucose Monitoring System will be cleaned and disinfected between residents . Procedure: 1. The glucose monitoring system is cleaned/disinfected after each resident with Gluco-Chlor Disinfecting Wipes . The ASSURE BRILLIANCE COMPREHENSIVE SERVICE & SUPPORT PROGRAM revised (MONTH) (YEAR), documented Cleaning and Disinfecting the Assure Prism multi Blood Glucose Monitoring System To minimize the risk of transmitting blood-borne pathogens, the cleaning and disinfection procedure should be performed as recommended in the instructions below . The meter should be cleaned and disinfected after use on each patient . Guidelines for cleaning and disinfecting the Assure Prism multi: + Always were the appropriate protective gear, including disposable gloves. + Open disinfectant package. + Wipe the entire surface of the meter using the towelette at least 3 times vertically and 3 times horizontally to clean blood and other body fluids from meter. + Dispose of the towelette. + Allow the exterior to remain wet for 1 minute, then wipe meter dry using a dry cloth. + Use caution as to not allow moisture to enter the test strip port, data port or battery compartment, as it may damage the meter . CLEANING AND DISINFECTING FAQ (frequently asked questions) . What will happen if a blood glucose meter is not cleaned and disinfected after use? Per the CMS (Centers for Medicare and Medicaid Services) F(Federal) - Tag 880 guideline, surveyors may issue a citation if they observe no cleaning and disinfecting of meters after a blood glucose test as they would not be in compliance with CMS F-Tag 880 . Why is Cleaning and Disinfecting of blood glucose meters such a high priority? Blood glucose meters are at high risk of becoming contaminated with bloodborne pathogens such as [MEDICAL CONDITION] Virus (HBV), [MEDICAL CONDITION] (HCV) and Human Immunodeficiency Virus ,[MEDICAL CONDITION]. Transmission of [MEDICAL CONDITION] from resident to resident has been documented due to contaminated blood glucose devices. According to the Centers for Disease Control and Prevention, cleaning and disinfecting of meters between resident use can prevent the transmission of [MEDICAL CONDITION] through indirect contact. How often do blood glucose meters need to be cleaned and disinfected? Per CMS F-Tag 880 Transmittal 55, blood glucose meters need to be cleaned and disinfected after each use for individual resident care . During medication pass observation on 7/31/2019 beginning at 3:47 PM, EI #1, a RN was observed to place the glucometer on the over-bed-table of RI #66, without a barrier. EI #1 did not wash or sanitize her hands before she put gloves on. After piercing the right middle finger of RI #66, to obtain a finger stick blood sugar, EI #1 did not clean and disinfect the glucometer. The glucometer used by EI #1 was an Assure Prism multi Blood Glucose Monitoring System. Without the cleaning or disinfecting the multi-use glucometer, at 4:00 PM, EI #1 proceeded to gather supplies to perform a finger stick blood sugar for RI #69. EI #1 laid the same glucometer used previously during RI #66's finger stick blood sugar, alcohol wipe and lancet on RI #69's bed. After pricking the left middle finger of RI #69 to obtain blood for the finger stick blood sugar, EI #1 placed the glucometer on the credenza in the resident's room without first placing a barrier. EI #1 discarded of the supplies and then laid the glucometer on top of the medication cart, without cleaning or disinfecting the multi-use glucometer. EI #1 removed her gloves but did not wash her hands. Without the cleaning or disinfecting the multi-use glucometer, at 4:05 PM, EI #1 proceeded to gather supplies to perform a finger stick blood sugar for RI #98. EI #1 used the same glucometer previously used during RI #66 and RI #69's finger stick blood sugar. EI #1 put gloves on without washing or sanitizing her hands. EI #1 placed the glucometer of RI #98's bed and over-bed-table, without first placing a barrier down. After EI #1 pricked the left middle finger of RI #98 to obtain blood for the finger stick blood sugar, EI #1 took her gloves off and did not wash or sanitize her hands. EI #1 placed the glucometer, without a barrier, on the medication cart without cleaning or disinfecting the multi-use glucometer. Without the cleaning or disinfecting the multi-use glucometer, at 4:08 PM, EI #1 proceeded to gather supplies to perform a finger stick blood sugar for RI #37. EI #1 placed the glucometer previously used during RI #66, RI #69 and RI #98's finger stick blood sugar, an alcohol wipe, gloves and a lancet on RI #37's over-bed-table, without placing a barrier down first. EI #1 did not wash her hands before she put gloves on or after she removed her gloves. After obtaining RI #37's blood sugar, EI #1 placed the glucometer on the medication cart without cleaning or disinfecting the multi-use glucometer. During an interview on 8/1/2019 at 11:57 AM, EI #1, RN was asked when she should wash her hands when wearing gloves. EI #1 answered, after the gloves are removed. When asked when she should wash her hands during a finger stick blood sugar, EI #1 replied, After you get done. EI #1 was asked did she wash her hands after removing her gloves when she obtained the finger stick blood sugar for RI #66. EI #1 replied, I can't really remember but I don't think so. EI #1 further acknowledged that she could not remember if she washed her hands after she removed her gloves during the finger stick blood sugar for RI #69, RI #98 and RI #37. When asked what she should do to clean and disinfect the glucometer, EI #1 stated, to take a Clorox wipe and wipe the glucometer off. EI #1 explained that she didn't use the Clorox wipe because there were none on her medication cart. EI #1 was asked if RI #66 was the first resident she performed a finger stick blood sugar for on 7/31/2019. EI #1 answered, she believed so. When asked if she cleaned and disinfected the multi-use glucometer after performing RI #66's finger stick blood sugar, EI #1 replied No ma'am. When asked if she cleaned and disinfected the multi-use glucometer after performing RI #69's finger stick blood sugar, EI #1 replied, No I didn't clean after any of them (residents). EI #1 acknowledged that she did not clean or disinfect the glucometer after obtaining RI #98's and RI #37's finger stick blood sugar. When asked what the concern was with not washing her hands after putting gloves on and taking them off, EI #1 said the spreading of germs. EI #1 was asked what the concern was with not cleaning and disinfecting the multi-use glucometer after each residents' finger stick blood sugar. EI #1 answered, Germs. When asked what she be placed down before putting a glucometer and other supplies on a resident's over-bed-table, bed and furniture, EI #1 said I have no idea, make sure area is clear. EI #1 was asked why she didn't clean and disinfect the multi-use glucometer between resident use. EI #1 stated she was nervous. EI #1 acknowledged she had been trained by the Staff Development Nurse, EI #5, on proper infection control procedures; however, she did not perform the procedures on 7/31/2019 as trained to do so. In an interview on 8/1/2019 at 3:12 PM, EI #3, the Director of Nursing (DON) stated she witnessed EI #1, a RN, perform finger stick blood sugars on 7/31/2019. EI #3 stated she witnessed EI #1 take the glucometer out of the drawer on the medication cart. According to EI #3, EI #1 did not clean (or disinfect) the glucometer before she performed the finger stick blood sugars. EI #3 stated she noticed EI #1 did not have gloves or a barrier in her hand, so she (EI #3) assumed the observation would not go well. When asked what the potential for harm was in not cleaning and disinfecting the glucometer, EI #3 replied, infection. In a follow-up telephone interview on 8/2/2019 at 10:57 AM, EI #1, a RN was asked how she was taught to clean and disinfect the glucometer, EI #1 replied, before using the glucometer, wipe it down then lay it on a barrier, clean the resident's finger then prick it to check the blood sugar; inform the resident what his/her blood sugar is; then wash your hands and rub down the glucometer. EI #1 was asked to explain what she meant by rub down the glucometer. EI #1 stated, the front, the buttons and the back and make sure the glucometer is dry before performing another finger stick blood sugar. During medication pass observation on 8/1/2019 at 5:34 AM, EI #8, a Licensed Practical Nurse was observed to perform a finger stick blood sugar for RI #18. EI #8 pricked the right middle finger of RI #18 and afterwards discarded of the lancet and test strip in the sharps container. EI #8 used a germicidal (McKesson) wipe and cleaned the glucometer, then wrapped the glucometer in a paper towel. At 5:50 AM, EI #8 unwrapped the previously glucometer from the paper towel and gather her supplies to perform a finger stick blood sugar for RI #2. After obtaining the resident's blood sugar, EI #8 cleaned the glucometer with a wipe and wrapped it in a paper towel. At 6:26 AM, after obtaining RI #14's finger stick blood sugar, EI #8 cleaned the glucometer with a germicidal wipe then wrapped the glucometer in a paper towel to dry. In an interview on 8/2/2019 at 12:39 PM, EI #8, a LPN was asked how she was trained to clean and disinfect the glucometer. EI #8 replied, after putting on gloves, to place the glucometer on a paper towel, then get a McKesson disposable wipe and wipe the front of the glucometer. After the glucometer was cleaned, place the glucometer on a paper towel for at least 5 minutes to let it air dry. On 8/1/2019 at 3:45 PM, an interview was conducted with EI #4, the Assistant Director of Nursing/Infection Control Nurse. EI #4 was asked what should be done before and after removing gloves prior to and following a finger stick blood sugar. EI #4 replied, wash your hands. When asked what should be placed before laying a glucometer and other supplies on a resident's over-bed-table, bed and/or other furniture, EI #4 answered A barrier, paper towel, plastic tray with paper towel underneath. EI #4 was asked, when should the glucometer be cleaned and disinfected and she stated, before and after resident use. When asked to explain the steps as to how staff should clean and disinfect the glucometer, EI #4 replied, put on gloves and use an antibacterial wipe to clean the glucometer then place the glucometer on a tray for five minutes. After the finger stick has been obtained, the nurse should remove her gloves, wash her hands, dispose of the lancet and wipe down the glucometer with an antibacterial wipe and place it in a paper towel and let it dry for five minutes. EI #4 was asked what the glucometer should be cleaned and disinfected with. EI #4 replied, Antibacterial germicidal wipes. When asked what the potential for harm was in not cleaning and disinfecting the glucometer after each use, EI #4 answered The potential for transmitting germs from one resident to another. Blood borne pathogens. In an interview on 8/3/2019 at 10:57 AM, EI #5, the Staff Development Coordinator was asked, what was the concern of not following the manufacturer's recommendations for the cleaning and disinfecting of the glucometer. EI #5 answered, the concern was the glucometer could not be cleaned and disinfected properly and there could possibly be a spread of infections. During a follow-up interview with EI #3, the DON on 8/3/2019 at 3:36 PM, she was asked, what was the concern of not following the manufacturer's recommendations for the cleaning and disinfecting of the glucometer. EI #3 replied, spread of blood borne pathogens and damage to the equipment. When asked if the disinfectant wipe was effective if it was not being used according to the manufacturer's recommendations, EI #3 said possibly no. In a document provided by the facility dated 8/2/2019, the facility has a total of 48 residents diagnosed as having Diabetes. Of the 48 residents diagnosed with [REDACTED]. The document further indicated there were residents residing in the facility with a communicable disease, one of which required finger stick blood sugar monitoring. A communicable disease, as defined by www.merriam-webster.com, is an infectious disease transmissible by direct contact with an affected individual or the individual's discharges or by indirect means. ************************* On 8/4/2019 at 9:16 PM, the facility submitted an acceptable Removal Plan, which documented Generations of Vernon Removal Plan F 880 Infection Control 1. The registered nurse who failed to clean and disinfect the Assure Prism multi-use glucometer according to the manufacturer's recommendations between each resident when performing finger stick blood sugars on RI #66, RI #69, RI #98 and RI #37 was suspended on 7/31/19 pending a facility investigation and will not return to work until she goes through a thorough orientation re-training on cleaning and disinfecting the Assure Prism multi-use glucometer according to manufacturer's recommendations between each resident when performing finger stick blood sugars. 2. All Assure Prism multi-use glucometers were properly cleaned and disinfected per manufacturer's recommendations on 8/3/19 by licensed nurses after they received re-training on cleaning and disinfecting the Assure Prism multi-use glucometer by the Nurse Consultant using a manufacturer's approved recommendation germicidal wipe, PDI Super Sani-Cloth. 3. Licensed staff present on 8/2-8/3/19 were re-trained on cleaning and disinfecting the Assure Prism multi-use glucometers by the Nurse Consultant and Clinical Coordinator by lecture, return demonstration and verbalization of understanding of the process to clean and disinfect the Assure Prism multi-use glucometer at the following times: 8/2/19 9:13 p - 10:00 p 8/3/19 8:15 a.m. - 10:13 a.m. 8/3/19 10:20 a.m. - 10:35 a.m. 8/3/19 6:45 p.m. - 7:15 p.m. There are 33 residents who receive finger stick blood sugar monitoring and one of those 1 resident has a communicable disease. Date of alleged immediacy removed on 8/4/19. ************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F 880 was lowered to a D level on 8/4/2019, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on observation, interview and review of Resident Identifier (RI) #37's medical record, the facility failed to ensure Employee Identifier (EI) #1, a Registered Nurse (RN) did not perform a finger stick blood sugar on RI #37, a non-diabetic resident, who was not ordered finger stick blood sugar monitoring. This deficient practice affected RI #37, one of 15 residents observed for medication pass. Findings include: RI #37 was readmitted to the facility on [DATE]. RI #37 has a medical history to include [DIAGNOSES REDACTED]. During medication pass observation on 7/31/2019 at 4:08 PM, EI #1, a RN performed a finger stick blood sugar on RI #37. RI #37's physician's orders [REDACTED].>During a telephone interview on 8/2/2019 at 10:57 AM, EI #1, a RN acknowledged that she had performed a finger stick blood sugar for RI #37 on 7/31/2019. When asked why she obtained a finger stick blood sugar on RI #37, EI #1 stated the resident was supposed to have it and she had always done a finger stick blood sugar for RI #37. RI #37's NURSE'S NOTES dated 8/2/2019 4:15 PM, documented (Medical Director) notified that resident received a finger stick blood sugar check on 7/31/19 that was not ordered . In an interview on 8/2/2019 at 3:44 PM, EI #3, the Director of Nursing was asked why finger stick blood sugar monitoring was done on RI #37. EI #3 replied that she would have to review RI #37's medical record that she didn't see an order for [REDACTED].#37 had a physician's orders [REDACTED].#3 answered there was no order for it. When asked what the potential for harm was in obtaining a finger stick blood sugar without a physician's orders [REDACTED].

Based on observations and interviews, the facility failed to ensure a Licensed Practical Nurse (LPN) did not place her finger in a plastic pouch containing crushed medication for RI #89. This deficient practice affected RI #89, one of four residents observed during medication administration. Findings Include: RI # 89 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. RI #89's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 05/14/18, revealed the resident received intake (nutrition/medication) by feeding tube. On 06/26/18 at 4:41 p.m., during medication administration, the surveyor observed Employee Identifier (EI) #7, a Licensed Practical Nurse (LPN), put her ungloved finger into the pill crush bag. On 06/26/18 at 5:30 p.m., the surveyor interviewed EI #7. EI #7 was asked when she put her finger into the pill crush bag, what was it considered. EI #7 said infection control. EI #7 was asked what effect would that have on the resident. EI #7 said it could give him/her the germs she had on her hand. EI #7 was asked what type of effect could the germ cause. EI #7 said the resident could get sick.

Based on observation, interview, medical record review and a facility's document titled, SMOKING SAFETY ASSESSMENT, the facility failed to ensure Resident Identifier (RI) #84, had on a smoking apron, as assessed, according to the smoking safety assessment during the smoke break on 06/27/18 at 11:30 a.m. This affected RI #84, one of four residents sampled for smoking. Findings Include: A review of RI #84's SMOKING SAFETY ASSESSMENT, with a date of 3/6/17, documented: .10. Safety: Does the resident need a smoke apron? Yes. RI #84 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #84's Significant Change MDS (Minimum Data Set) with an ARD ( Assessment Reference Date) of 08/25/17, revealed the resident was severely cognitively impaired, and was assessed for current tobacco use. On 06/27/18 at 11:30 a.m., the surveyor observed RI #84 on the smoking porch, smoking without a smoking apron. Employee Identifier (EI) #8, a Certified Nursing Assistant (CNA), was present during smoking time. EI #8 was asked how would she know when a resident should have on an apron. EI #8 said it was a list of residents who required a smoking apron in a book. EI #8 was asked should RI #84 have had on an apron. EI #8 said yes, according to the paper work in the book. EI #8 was asked was the apron on when RI #84 began to smoke. EI #8 said, No it was not. EI #8 was asked what was the potential harm to RI #84 not wearing a smoking apron. EI #8 said, Burning himself.

Based on observation and interviews, the facility failed to ensure a Certified Nursing Assistant (CNA) did not serve Resident Identifier (RI) #62's baked potato with an unclean glove during the lunch meal on 06/26/18. This deficient practice affected RI #62, one of seven sampled residents observed during meal time. Findings Include: RI #62 was readmitted to the facility on [DATE]. On 06/26/18 at 11:56 a.m., EI (Employee Identifier) #4, a CNA, was observed serving RI #62's lunch tray. The CNA was observed taking a glove from her jacket pocket, putting it on her right hand. She picked up RI #62's baked potato with the gloved hand and removed it from the aluminum foil and placed it on RI #62's plate. On 06/26/18 at 12:37 p.m., an interview was conducted with EI #4. EI #4 was asked did she serve and set up RI #62's lunch tray. EI #4 said yes. EI #4 was asked was she wearing gloves when she took RI #62's baked potato out of the aluminum foil. EI #4 replied yes, on her right hand. EI #4 was asked where did she get the glove. EI #4 stated out of her jacket pocket. EI #4 was asked was her pocket considered clean. EI #4 said to her it was, but to infection control, no. EI #4 was asked should gloves be placed in her pocket. EI #4 replied no. EI #4 was asked what was the concern with using unclean gloves when preparing a resident's meal. EI #4 answered it was an infection control issue.

Based on observations, interviews, medical record review and review of a facility policy titled, Self-help eating devices are available for those needing them, the facility failed to ensure Resident Identifier (RI) #62 was provided weighted utensils during lunch meals on 06/26/18 and 06/27/18. This affected RI #62, one of seven sampled residents observed during meal time. Findings Include: Review of a facility policy titled, Self-help eating devices are available for those needing them, with no date, documented: .PR[NAME]EDURE: 1. Residents are reviewed on admission, and at least quarterly, for need of adaptive devices. 2. Adaptive devices in use are .provided for each meal. RI #62 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #62's medical record revealed the following: RESIDENT CARE PLAN .Problem 12/20/17 Potential for Alteration in Nutrition .Interventions .19.) Utilized Weighted Utensils. On 06/26/18 at 11:56 a.m., RI #62 was observed during the lunch meal. RI #62 was observed eating the meal with regular fork with hand shaking and food falling from fork back onto the plate and tray. No weighted utensils were present during this meal. On 06/27/18 at 7:38 p.m., an interview was conducted with Employee Identifier (EI) #2, Registered Nurse/MDS (Minimum Data Set) Coordinator. EI #2 was asked was RI #62 care planned for assistive devices while eating. EI #2 said yes, a divided plate, weighted utensils and a cup with lid for milk. EI #2 was asked should RI #62 receive those assistive devices with meals. EI #2 replied yes.

Based on interviews, medical record review and a review of a facility document titled,Restorative Nursing Treatment Schedule, the facility failed to ensure that RI (Resident Identifier) #83 was provided restorative care for ambulation. This deficient practice affected RI #83, one of twenty four sampled residents receiving restorative care. Findings Include: RI # 83 was readmitted to the facility on [DATE]. RI #83's medical history included Cerebral Infarction and [MEDICAL CONDITION]. On 06/27/18 at 10:21 a.m., RI #83 stated to the surveyor Restorative was supposed to be walking her/him 3 times a week, but restorative had not been doing it. RI #83's Quarterly MDS ( Minimum Data Set) with an ARD (Assessment Reference Date) of 04/19/18, revealed a BIMS (Brief Interview for Mental Status) score of 14 indicating RI #83 was cognitively intact for daily decision making. The MDS also revealed RI #83 used a wheelchair for mobility and required extensive assistance of two plus persons for transfers. RI #83's Functional Maintenance Program form documented: . Start of Maintenance 4/23/18 .Ambulation .Hemi-Walker . RI #83's care plan titled, Potential for contractures R/T ( related to) Basal Ganglia Stroke with decrease mobility, non-amb (ambulatory) had an intervention, dated 4/23/18, of Amb (ambulate) c-(with) hemi walker 5-6 x (times)/wk (week) .RESP. (Responsible) PARTY . Restorative CNA (Certified Nursing Assistant) . RI # 83's Restorative Nursing Treatment Schedule form revealed RI #83 had not ambulated 5-6 times a week, for three weeks in (MONTH) (YEAR) and had not ambulated 5-6 times a week for the month of (MONTH) (YEAR). On 06/27/18 at 3:41 p.m., an interview was conducted with EI (Employee Identifier) #5, a Restorative CNA. EI #5 was asked if RI #83 had a Functional Maintenance Program. EI #5 said, Yes. EI #5 was asked what was RI #83's performance areas for the Functional Maintenance Program. EI #5 said RI #83 ambulated, sat down and stood up. EI #5 was asked how many times a week should RI #83 ambulate. EI #5 said, 5-6 times a week. EI #5 was asked to review RI #83's Nursing Treatment Schedule form and tell the surveyor if RI #83 ambulated 5-6 times a week for the months of (MONTH) and (MONTH) of (YEAR). EI #5 said, No. EI #5 was asked what was the potential harm with not providing restorative care for ambulation for RI #83 or any resident. EI #5 said, A decline in mobility. On 06/27/18 at 4:03 p.m., an interview was conducted with EI #6, a Restorative CNA. EI #6 was asked, according to RI #83's Functional Maintenance Program how many times a week was she/he scheduled to ambulate. EI #6 said 5-6 times a week. EI #6 was asked if RI #83 ambulated with restorative 5-6 times a week for the months of (MONTH) and (MONTH) (YEAR). EI #6 said, No Ma'am. EI #6 was asked what was the potential harm with not providing restorative care for ambulation for RI #83. EI #6 said,(She/He) would decline, not walk as far.

Based on observations, interviews and review of an unnamed facility policy, and facility policies DENTED OR DAMAGE CANS, CARE CENTER DIETARY EMPLOYEES DRESS CODE, and Record of Food Temperatures the facility failed to ensure: 1. on 5/10/2017, dietary staff took the temperature of fried chicken, baked potatoes, chicken noodle soup, a second pan of potato salad, and document the food items temperatures, 2. a dented can was not in with regular food cans and 3. a dietary worker's hair was completely covered by a hair net. This had the potential to affect 113 of 116 residents who received meals from the kitchen. Findings Include: 1) A review of a facility policy with no name or date, revealed: POLICY: Temperatures of food on the serving line will be checked . before tray service begins to assure food is being served at the correct temperature. A review of a document titled, Record of Food Temperatures revealed there was no documentation for the second and third pan of chicken on 5/11/2017. The Temperatures sheet showed no documentation for baked potatoes, chicken noodle soup and no documentation for a second pan of potato salad. On 5/10/2017 at 12:13 p.m., the surveyor observed the cook, (Employee Identifier) EI #8, cooking chicken. When the chicken was taken out of the fryer, the cook did not take the temperature of it or write the temperatures down. EI #9, Dietary aide, was asked to continued cooking chicken. EI #9 cooked chicken several times and did not take the temperatures of the chicken or write it down. On 5/11/2017 at 8:50 a.m., the surveyor conducted an interview with EI #8. EI #8 was asked did she fry chicken on 5/10/2017. EI #8 replied, yes ma'am. EI #8 was asked what was the temperature of the second and third pan of chicken. EI #8 replied, she did not think any one took the temperatures. EI #8 was asked who wrote down the temperature of the second and third pan of chicken. EI #8 replied, nobody. EI #8 was asked who took the temperature of the second pan of potato salad. EI #8 replied, nobody. EI #8 was asked who wrote down the temperature of the potato salad. EI #8 replied, nobody. EI #8 was asked who took the temperature of the baked potatoes. EI #8 replied, nobody. EI #8 was asked who took the temperature of the chicken noodle soup. EI #8 replied, nobody. EI #8 was asked was the chicken noodle soup documented. EI #8 replied, it was not. EI #8 was asked what did the facility policy say regarding taking food temperatures on the tray line. EI #8 replied, when it came out of the oven it should be 165 degrees F (Fahrenheit) and holding temperature should be at 140 degrees F and every food temperature should be taken. EI #8 was asked who was responsible for taking food temperatures. EI #8 replied, the head cook. EI #8 was asked who was responsible for writing temperatures down. EI #8 replied, the assistant cook. EI #8 was asked what was the potential harm when resident food temperatures were not taken. EI #8 replied, you would not know if the food was at the right temperatures or if it was done. On 5/11/2017 at 9:10 a.m., a telephone interview was conducted with EI #9. EI #9 was asked did she fry chicken on 5/10/2017. EI #9 replied, yes. EI #9 was asked what was the temperature of the second and third pan of chicken. EI #9 replied, she did not take the temperatures. EI #9 replied, EI #8 should have. EI #9 was asked who wrote down the temperature of the chicken. EI #9 replied, she thought EI #8 did. EI #9 was asked what did the facility policy say regarding taking food temperatures on the tray line. EI #9 replied, the head cook was supposed to take the temperatures and write them down. EI #9 was asked what was the potential harm when residents' foods were not tempted. EI #9 replied, food may be cold, the resident will refuse the food or sickness. On 5/11/2017 at 1:00 p.m., the surveyor conducted an interview with EI #7, dietary manager. The dietary manager was given the temperature log and asked questions from it. EI #7 was asked to tell the surveyor the temperatures of the third pan of chicken on the temperature sheet. EI #7 replied, it was not taken. EI #7 was asked was it documented. EI #7 replied, no. EI #7 was asked what did the facility policy say regarding taking food temperatures on the tray line. EI #7 replied, they were supposed to take temperatures of every thing they put on the the tray line. EI #7 was asked what was the potential harm when resident food was not tempted. EI #7 replied, food borne illness and sick from potential hazards. EI #7 was asked where was it recorded that the second pan of potato salad was documented. EI #7 replied, it was not there. EI #7 was asked where was the documentation for the chicken noodle soup and baked potatoes documented on the temperature sheets. EI #7 replied, it was not recorded on the temperature sheet. 2) A review of a facility policy titled, DENTED OR DAMAGED CANS with no revised date revealed: .Procedure: 1. All canned foods are checked for dents, .when they are rotated into existing stock. 2. Any cans found to be dented, with bulges . be placed away from canned foods that will be used for the cycle menu . On 05/9/2017 at 10:55 a.m., the surveyor toured the dry storage along with the EI #7. The surveyor observed a six pound can of salad sliced beets on a shelf with a dent on the side at the bottom. On 5/11/2017 at 1:10 p.m., the surveyor conducted an interview with EI #7. EI #7 was asked what can in dry storage was dented. EI #7 replied, a beet can. EI #7 was asked why was it in with regular food cans. EI #7 replied, she did not know. EI #7 was asked where should dented cans be placed. EI #7 replied, placed in the room under a table away from regular cans. EI #7 was asked who was responsible for removing dented cans from the shelves. EI #7 replied, she was. 3) A review of a policy titled, CARE CENTER DIETARY EMPLOYEE DRESS CODE with a revised date of 2/6/09 revealed: .All hair must be covered with a hair net . On 5/10/2017 at 10:25 a.m., EI #9, dietary aide, was serving food. The hair on the left side and right side of her head was out of the net. The back of the hair was not in the net. On 5/11/2017 at 9:15 a.m., the surveyor conducted a telephone interview with EI #9. EI #9 was asked what was the facility policy on wearing hair nets. EI #9 replied, all hair suppose to be covered. EI #9 was asked was all of her hair inside the hair net. EI #9 replied, probably not. EI #9 was asked why was it important that she wear a hair net in the kitchen and all of her hair was inside the hair net. EI #9 replied, you did not want hair in the food. EI #9 was asked what food did she cook. EI #9 replied, chicken. On 5/11/17 at 1:16 p.m., an interview was conducted with EI #7. EI #7 was asked what was the facility policy on wearing hair nets. EI #7 replied, everyone in the kitchen need to wear hair nets to cover their hair. EI #7 was asked did EI #9's hair net cover all of her hair on 5/10/2017. EI #7 replied, no.

Based on observations, interviews and review of a facility policy titled JOB DESCRIPTION . Director of Maintenance, the facility failed to ensure: (1) the screws/bolts securing the commodes to the floor were covered, and (2) the baseboard in Room Locator (RL) #3 was not broken. These deficient practices affected RL #1 through RL#26 on four of five units of the facility, and were observed at least one day during the three days of the survey. Findings Include: A review of the facility's job description titled, . Director of Maintenance ., revealed the following: . Must maintain the care and use of supplies, equipment, etc., and maintain the appearance of maintenance areas; must perform regular inspections of residents rooms/units for order, safety, and proper performance of equipment . (1) On 5/09/17 at 10:30 a.m., the following observations were made of the bolts on the bathroom commodes: RL #17 had caps off and bolt was exposed about one and one-half inch. RL #19 had caps off both sides and bolt was exposed about one and one-half inch. RL #20 had caps off both sides bolt was exposed about one-half inch. RL #21 had a cap off the left side facing the toilet. RL #22 had no cap on right side. RL #23 had left side cap off. RL #24 had caps off both sides and was exposed about one-half inch. RL #25 had both caps off both sides and exposed about one and one-half inch. On 5/09/17 between 10:45 a.m., and 12:30 p.m., during the tour, the following observations were made of the bathroom commodes: RL #13 bathroom with exposed toilet screws. RL #4 bathroom with exposed toilet screws. RL #5 commode screws at floor were exposed. RL #9 commode screws at floor were exposed. RL #7 exposed screws at commode floor. RL #8 commode screws exposed at floor. On 5/09/17 at 11:57 a.m., the following observations were made of RL #2. The bolts over the commode were not covered. On 5/09/17 at 12:10 p.m. the following observations were made of RL #1. The caps were off the bolts on commode. On 5/10/17 at 12:34 p.m. the following observations were made of the bathroom commodes. RL # 6 two screws were exposed. RL #10 two screws were exposed. RL #11 two screws were exposed. RL # 12 two screws were exposed. RL # 14 two screws were exposed. RL # 15 one screw was exposed and one screw was missing. RL # 16 one screw was exposed and one screw was missing. RL # 18 two screws were exposed. On 5/10/17 at 12:40 p.m. the following observations were made of RL #3's commode. Two screws were exposed with no caps. On 05/10/17 at 2:23 p.m., the surveyor observed the screws at the base of the commode in RL #10 were uncovered. On 05/10/17 at 4:33 p.m., the surveyor observed the screws at the base of the commode in RL #8 were uncovered. On 05/10/17 at 5:17 p.m., the surveyor observed the screws at the base of the commode in RL #22 were uncovered. On 5/10/17 at 5:30 p.m. the following observations were made of the bathroom commodes. RL #13 had exposed screws where commode was attached to the floor. RL #4 had exposed screws where commode was attached to the floor. RL #5 had toilet screws at floor that were exposed. RL #9 had toilet screws at floor that were exposed. RL #7 had toilet screws at floor that were exposed. RL #8 had toilet screws at floor that were exposed. On 05/10/17 at 5:56 p.m., the surveyor observed the screws at the base of the commode in RL #16 were uncovered. On 05/11/17 at 8:38 a.m., the surveyor observed the screws at the base of the commode in RL #10 remained uncovered. On 05/11/17 at 8:45 a.m., the surveyor observed the screws at the base of the commode in RL #8 remained uncovered. On 05/11/17 at 8:55 a.m., the surveyor observed the screws at the base of the commode in RL #16 remained uncovered. On 05/11/17 at 9:08 a.m., the surveyor observed the screws at the base of the commode in RL #22 remained uncovered. On 5/11/2017 at 2:00 p.m., an interview was conducted with Employee Identifier (EI) #10, Director of Maintenance. The surveyor and EI #10 made observations of the commodes in the following room locators: RL #1 through RL #25. EI #10 was asked what he saw in regards to the screw at the base of the commode in RL #1. EI #10 said two screws sticking up. EI #10 was asked if the screws were exposed and if the caps were on them. EI #10 replied they do not have the covers. EI #10 was asked what was the harm to the resident in the screws being exposed. EI #10 said they could get a skin tear. EI #10 was asked what he saw in regards to the screw at the base of the commode in RL #2. EI #10 said two screws at the base. EI #10 was asked if there were caps on the exposed screws. EI #10 replied no ma'am. EI #10 was asked what was the harm to the resident in the screws being exposed. EI #10 said if you step on it, a skin tear. EI #10 was asked what he saw in regards to the screw at the base of the commode in RL #3. EI #10 said two screws sticking up. EI #10 was asked if there were caps on the exposed screws. EI #10 replied no. EI #10 was asked what was the harm to the resident in the screws being exposed. EI #10 said skin tear. EI #10 was asked what he saw in regards to the screw at the base of the commode in RL #4. EI #10 said two screws. EI #10 was asked if there were caps on the exposed screws. EI #10 replied there were no caps. EI #10 was asked what was the harm to the resident in the screws being exposed. EI #10 said skin tear. EI #10 was asked what he saw in regards to the screw at the base of the commode in RL #5. EI #10 said two screws. EI #10 was asked if there were caps on the exposed screws. EI #10 replied there were no caps. EI #10 was asked what was the harm to the resident in the screws being exposed. EI #10 said skin tear. EI #10 was asked what he saw in regards to the screw at the base of the commode in RL #6. EI #10 said two anchor bolts. EI #10 was asked if there were caps on the exposed screws. EI #10 replied there were no caps. EI #10 was asked what was the harm to the resident in the screws being exposed. EI #10 said skin tear. EI #10 was asked what he saw in regards to the screw at the base of the commode in RL #7. EI #10 said two anchor bolts. EI #10 was asked if there were caps on the exposed screws. EI #10 replied there were no caps. EI #10 was asked what was the harm to the resident in the screws being exposed. EI #10 said skin tear. EI #10 was asked what he saw in regards to the screw at the base of the commode in RL #8. EI #10 said two anchor bolts. EI #10 was asked if there were caps on the exposed screws. EI #10 replied there were no caps. EI #10 was asked what was the harm to the resident in the screws being exposed. EI #10 said skin tear. EI #10 was asked what he saw in regards to the screw at the base of the commode in RL #9. EI #10 said two anchor bolts. EI #10 was asked if there were caps on the exposed screws. EI #10 replied there were no caps. EI #10 was asked what was the harm to the resident in the screws being exposed or missing. EI #10 said skin tear. EI #10 was asked what he saw in regards to the screw at the base of the commode in RL #11. EI #10 said two anchor bolts. EI #10 was asked if there were caps on the exposed screws. EI #10 replied there were no caps. EI #10 was asked what was the harm to the resident in the screws being exposed. EI #10 said skin tear. EI #10 was asked what he saw in regards to the screw at the base of the commode in RL #12. EI #10 said one anchor bolt. EI #10 was asked if there were caps on the exposed screws. EI #10 replied there was no cap. EI #10 was asked if any of the screws were missing. EI #10 said one was missing. EI #10 was asked what was the harm to the resident in the screws being exposed or missing. EI #10 said skin tear. EI #10 was asked what he saw in regards to the screw at the base of the commode in RL #13. EI #10 said two anchor bolts. EI #10 was asked if there were caps on the exposed screws. EI #10 replied there were no caps. EI #10 was asked what was the harm to the resident in the screws being exposed. EI #10 said skin tear. EI #10 was asked what he saw in regards to the screw at the base of the commode in RL #14. EI #10 said two bolts. EI #10 was asked if there were caps on the exposed screws. EI #10 replied there were no caps. EI #10 was asked what was the harm to the resident in the screws being exposed. EI #10 said skin tear. EI #10 was asked what he saw in regards to the screw at the base of the commode in RL #15. EI #10 said one bolt. EI #10 was asked if there were caps on the exposed screws. EI #10 replied there was no cap. EI #10 was asked if any of the screws were missing. EI #10 said one bolt was missing. EI #10 was asked what was the harm to the resident in the screws being exposed or missing. EI #10 said skin tear. EI #10 was asked what he saw in regards to the screw at the base of the commode in RL #16. EI #10 said one bolt. EI #10 was asked if there were caps on the exposed screws. EI #10 replied there was no cap. EI #10 was asked if any of the screws were missing. EI #10 said one bolt was missing. EI #10 was asked what was the harm to the resident in the screws being exposed or missing. EI #10 said skin tear. EI #10 was asked what he saw in regards to the screw at the base of the commode in RL #17. EI #10 said two bolts. EI #10 was asked if there were caps on the exposed screws. EI #10 replied there were no caps. EI #10 was asked what was the harm to the resident in the screws being exposed. EI #10 said skin tear. EI #10 was asked what he saw in regards to the screw at the base of the commode in RL #18. EI #10 said two bolts. EI #10 was asked if there were caps on the exposed screws. EI #10 replied there were no caps. EI #10 was asked what was the harm to the resident in the screws being exposed. EI #10 said skin tear. EI #10 was asked what he saw in regards to the screw at the base of the commode in RL #19. EI #10 said two bolts. EI #10 was asked if there were caps on the exposed screws. EI #10 replied there were no caps. EI #10 was asked what was the harm to the resident in the screws being exposed. EI #10 said skin tear. EI #10 was asked what he saw in regards to the screw at the base of the commode in RL #20. EI #10 said two bolts. EI #10 was asked if there were caps on the exposed screws. EI #10 replied there was no cap. EI #10 was asked what was the harm to the resident in the screws being exposed. EI #10 said skin tear. EI #10 was asked what he saw in regards to the screw at the base of the commode in RL #21. EI #10 said one bolt. EI #10 was asked if there were caps on the exposed screws. EI #10 replied, there was no cap. EI #10 was asked if any of the screws were missing. EI #10 said one bolt was missing. EI #10 was asked what was the harm to the resident in the screws being exposed or missing. EI #10 said skin tear. EI #10 was asked what he saw in regards to the screw at the base of the commode in RL #22. EI #10 said two bolts. EI #10 was asked if there were caps on the exposed screws. EI #10 replied, there were no caps. EI #10 was asked what was the harm to the resident in the screws being exposed. EI #10 said skin tear. EI #10 was asked what he saw in regards to the screw at the base of the commode in RL #23. EI #10 said two bolts. EI #10 was asked if there were caps on the exposed screws. EI #10 replied one cap. EI #10 was asked if any of the screws were missing. EI #10 said one cap was missing. EI #10 was asked what was the harm to the resident in the screws being exposed or missing. EI #10 said skin tear. EI #10 was asked what he saw in regards to the screw at the base of the commode in RL #24. EI #10 said two bolts. EI #10 was asked if there were caps on the exposed screws. EI #10 replied, there were no caps. EI #10 was asked what was the harm to the resident in the screws being exposed. EI #10 said skin tear. EI #10 was asked what he saw in regards to the screw at the base of the commode in RL #25. EI #10 said two bolts. EI #10 was asked if there were caps on the exposed screws. EI #10 replied, there were no caps. EI #10 was asked what was the harm to the resident in the screws being exposed. EI #10 said skin tear. (2) On 5/09/2017 at 12:10 p.m., an observation was made of the baseboard in RL #3. The baseboard was observed to be broken. On 5/11/2017 at 3:10 p.m., an interview was conducted with EI #10. The surveyor and EI #10 made observations of the baseboard in RL #3. EI #10 was asked what he saw on the baseboard facing the resident's bed on the left side. EI #10 said there was a chunk tore out of it and that it was broken. EI #10 was asked should it be broken. EI #10 said no ma'am. EI #10 was asked what was the concern with the baseboard being broken. EI #10 stated, Looks cosmetically not pleasing to the eye.

Based on observations and interviews, the facility failed to ensure residents were not served milk in disposable paper cartons. This deficient practice affected nine of 14 residents observed on the Men's Unit, 10 of 12 residents observed on the 300 Left Hall Unit during the lunch meal on 05/10/17, eight of 11 residents observed on the 300 Left Hall Unit during the dinner meal on 05/10/17, and five of 21 residents observed in the main dining room during the lunch meal on 05/11/17. Findings Include: On 05/10/17 at 12:04 p.m., the surveyor observed 14 residents being served the lunch meal in the dining room on the Men's Unit. Nine of the 14 residents were served milk in disposable paper cartons. On 05/10/17 at 12:48 p.m., the surveyor observed eight residents being served the lunch meal in one dining room on the 300 Left Hall. Seven of the eight residents were served milk in disposable paper cartons. On 05/10/17 at 12:49 p.m., the surveyor observed four residents being served the lunch meal in another dining room on the 300 Left Hall. Three of the four residents were served milk in disposable paper cartons. On 05/10/17 at 6:01 p.m., the surveyor observed seven residents being served the dinner meal in one of the dining rooms on the 300 Left Hall. Five of the seven residents were served milk in disposable paper cartons. On 05/10/17 at 6:02 p.m., the surveyor observed four residents being served the dinner meal in another dining rooms on the 300 Left Hall. Three of the four residents were served milk in disposable paper cartons. On 05/11/17 at 12:08 p.m., the surveyor observed 21 residents being served the lunch meal in the main dining room. Five of the 21 residents were served milk in disposable paper cartons. On 05/11/17 at 1:25 p.m., the surveyor conducted an interview with Employee Identifier (EI) #11, a Registered Nurse Clinical Coordinator. The surveyor asked EI #11 how should milk in disposable cartons be served to the residents. EI #11 said the milk had to be opened and a straw should be placed in the milk. The surveyor asked EI #11 did the facility serve milk in glasses. EI #11 replied, No. The surveyor asked EI #11 had she ever heard that it was a dignity issue to serve milk in a disposable carton. EI #11 replied, Yes. The surveyor asked EI #11 how should milk be served. EI #11 said milk should be served in a cup. On 05/11/17 at 2:46 p.m., the surveyor conducted an interview with EI #4, the Assistant Director of Nursing. The surveyor asked EI #4 how should the resident's milk be served. EI #4 replied, In a glass. The surveyor asked EI #4 what was it considered when milk was not served in a glass. EI #4 +replied, It could be a dignity issue.

Based on observation, interview, medical record review and review of a facility policy titled, Storage and Destruction of Medications, the facility failed to ensure Lorazepam (Ativan) injectables were secured in a permanently affixed compartment in the medication refrigerator. This was observed on 5/10/17, and affected four vials of stock Lorazepam injectable and Lorazepam injectable for Resident Identifier (RI) #'s 18, #25, #26, and #27. This was observed in the Hall 2 medication room and affected one of three medication rooms. Findings Include: A review of an undated facility policy titled Storage and Destruction of Medications revealed A. Storage of Medications . Procedure: . Controlled substances must be stored separately from other medications in a locked drawer or compartment. All controlled substances must be stored behind TWO locks in a permanently affixed compartment specifically designated for controlled medications. A review of an untitled facility form dated March 2015 revealed Refrigerator Narc (Narcotic)Stat Box Medication Lorazepam 2 mg (milligram)/ml (milliliters) Qty (quantity) 4 . RI #18 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of RI #18's admitting physician's orders [REDACTED].Ativan 1 mg IM (intramuscular) or IV (intravenously) Q (every) 2H (hours) PRN (as needed) . RI # 25 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #25's physician's orders [REDACTED].LORAZEPAM 2 MG/ML VIAL INJECT 0.5 ML (1MG) INTRAMUSCULARLY . RI #26 was admitted to the facility 2/06/17, with a [DIAGNOSES REDACTED]. A review of a physician's orders [REDACTED]. Ativan 1 mg Im x (times) 1 now . RI #27 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #27's Physicians orders dated 2/1/17 revealed; . LORAZEPAM 2 MG/ ML VIAL INJECT 2 MG . On 5/10/17 at 3:50 p.m. an observation of the Hall 2 medication room was conducted with Employee Identifier (EI) #5, Licensed Practical Nurse. EI #5 unlocked the refrigerator and when the surveyor asked what was in the bottom drawer, EI #5 took the drawer out and placed it on the counter. The following medications were observed in the bottom drawer in the medication refrigerator: four stock vials of Lorazepam Injectable, a bag with RI #18's name on it with seven vials of Lorazepam, a bag with RI #25's name on it with 15 vials of Lorazepam, a bag with RI #26's name on it with four vials of Lorazepam and a bag with RI# 27's name on it with nine vials of Lorazepam in it. On 5/10/17 at 4:50 p.m., an interview was conducted with EI #1, Corporate Registered Nurse. EI #1 was asked how was Lorazepam stat injectable stored. EI #1 replied it was stored in the bottom drawer of the medication refrigerator in the Drug room. EI #1 was asked how should the stat injectable Ativan be stored. EI #1 replied in a non removable box in the refrigerator behind two locks. EI #1 was asked what was the policy on storing refrigerated controlled medications. EI #1 replied, in a non-removable box in the refrigerator. EI #1 was asked what was the harm in refrigerated controlled Ativan not being stored properly. EI #1 replied, it could be removed without staff knowledge.

Based on observations, interviews, medical record review and review of a facility policy titled Perineal Care, the facility failed to ensure: (1) a Certified Nursing Assistant (CNA) did not use Resident Identifier (RI) #15's wash basin to provide incontinent care for RI #5 on 05/10/17, and (2) a CNA changed her contaminated gloves, after removing bowel movement from RI #1, and washed her hands before touching the clean incontinent adult brief of RI #1 on 05/10/17. These deficient practices affected RI #1 and 5, two of two residents observed for incontinent care, and two of six residents sampled for bowel and bladder concerns. Findings Include: (1) A review of an undated facility policy titled Perineal Care revealed: Purpose: To provide cleanliness and comfort to the resident . Equipment and Supplies: Wash basin . RI #5 was readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. RI #15 was readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. On 5/10/17 at 9:30 a.m., Employee Identifier (EI) #6, CNA, was observed providing incontinent care for RI #5. EI #6 gathered supplies to include a basin of water. EI #6 carried out the incontinent care procedure without concerns. Upon her picking up the basin of water to take to the bathroom to empty the water, RI #15's name was noted marked in black lettering on the basin. An interview was conducted on 5/10/17 at 9:40 a.m., with EI #6. EI #6 was asked what name was on the basin, she replied RI #15's. EI #6 was asked who was RI #15 and she replied bed A resident. EI #6 was asked who was the resident she had just provided care for. EI #6 replied RI #5. EI #6 was asked what the harm was in using another resident's wash basin to provide care. EI #6 replied cross contamination. EI #6 was asked where was RI #5's basin. EI #6 replied in the bathroom, EI #6 went on to add she just picked up the wrong one. An interview was conducted on 5/11/17 at 9:00 a.m., with EI #4, Registered Nurse, Infection Control. EI #4 was asked what was the policy on use of bath basins when providing resident care. EI #4 replied, all residents' personal equipment was used then stored. EI #4 was asked if it would be acceptable for staff to use the wash basin for RI #15 to give care to RI #5. EI #4 replied no, it could cause cross contamination. 2) RI #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 04/11/17, identified RI #1 as needing extensive assistance with personal hygiene. RI #1 was also assessed as being totally incontinent of bowel and bladder. On 05/10/17 between 9:06 a.m. - 9:11 a.m., the surveyor observed EI #13 and EI #14, (both CNAs), provide incontinent care to RI #1. EI #13 removed liquid oozing fecal matter from RI #1's buttocks. EI #13 used a dampened soapy washcloth and wiped RI #1's inner buttocks twice using different areas on the washcloth. EI #13 removed her gloves and washed her hands in the bathroom. EI #13 gloved and used another dampened washcloth to wipe RI #1's right then left buttocks. EI #14 handed EI #13 a clean adult brief, and without changing her contaminated gloves, EI #13 placed the clean adult brief beneath RI #1. EI #13 also touched the clean draw sheet and pulled RI #1's gown down with the contaminated gloves still on. On 05/10/17 at 7:13 p.m., the surveyor read back the above observation and asked EI #13 what should she have done before she touched the clean adult brief. EI #13 said she should have changed her gloves and washed her hands. The surveyor asked EI #13, what was it called when a clean item was touched after a dirty item had been touched. EI #13 replied, Contamination. On 05/11/17 at 1:25 p.m., the surveyor conducted an interview with EI #11, a Registered Nurse/Clinical Coordinator. The surveyor asked EI #11, when the CNAs provide incontinent care for the residents, what should they do before touching clean items such as the adult brief. EI #11 said the CNAs should remove the old gloves and wash their hands or use gel and reapply clean gloves. The surveyor asked EI #11 what was it considered when a clean item was touched with contaminated gloves. EI #11 replied, Cross-contamination. On 05/11/17 at 2:17 p.m., the surveyor conducted an interview with EI #4, the Infection Control Nurse. The surveyor asked EI #4, what should the CNAs do before touching a clean item such as an adult brief after they had provided incontinent care for a resident. EI #4 said the CNAs should remove those soiled gloves, wash their hands or use a hand sanitizer and put on clean gloves. The surveyor asked EI #4 what was there a potential for when that was not done. EI #4 replied, Cross-contamination. You are taking something from dirty to clean.

Based on interview, record review and review of a facility policy titled MDS (Minimum Data Set) Assessment 3.0 Responsible Discipline, the facility failed to ensure Resident Identifier (RI) #1's, 09/14/16 Initial MDS and 04/11/17 Quarterly MDS was coded accurately to reflect RI #1's use of scheduled pain medications. This deficient practice affected RI #1, one of 21 sampled residents whose MDS's were reviewed. Findings Include: A facility policy titled MDS (Minimum Data Set) Assessment 3.0 Responsible Discipline ., with a revised date of October 2010, documented: Purpose: To define the responsible discipline for sections of the Minimum Data Set (MDS) 3.0 . Procedure: 21 . all disciplines that complete any portion of the MDS should sign their name, give their title and the section(s) they completed. Their signature certifies the accuracy of the information . RI #1 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. RI #1's September 2016 Medication Administration Record [REDACTED]. An Initial MDS assessment with an Assessment Reference Date (ARD) of 09/14/16, assessed RI #1 as having a [DIAGNOSES REDACTED].g. (for example) [MEDICAL CONDITION] joint disease (DJD), [MEDICAL CONDITION], and [MEDICAL CONDITION] arthritis (RA). Under Section J - Pain Management, RI #1 was not coded as having received any scheduled pain medications during this assessment period. RI #1's April 2017 MAR indicated [REDACTED]. RI #1's Quarterly MDS assessment with an ARD of 04/11/17, Under Section J - Pain Management, did not code RI #1 as having received any scheduled pain medications during this assessment period. On 05/11/17 at 12:23 p.m., the surveyor conducted an interview with Employee Identifier (EI) #12, the Licensed Practical Nurse/MDS Staff member completing Section J on RI #1's MDS's. The surveyor asked EI #12 was RI #1 receiving any pain medications. EI #12 said RI #1 was receiving Tylenol 325 mg two BID, Topical Biofreeze to his/her knees four times a day and [MEDICATION NAME] 5, 1/2 tablet every six hours for pain. The surveyor asked EI #12, during the month of April 2017, was RI #1 receiving pain medications. EI #12 replied, RI #1 was receiving Tylenol 650 mg twice a day and Biofreeze to his/her bilateral knees. The surveyor asked EI #12 should those medications have captured on RI #1's 04/11/17 MDS assessment. EI #12 replied, Yes. The surveyor asked EI #12 did the information capture on RI #1's MDS assessment. EI #12 replied, No it did not. The surveyor asked EI #12 was this an accurate assessment. EI #12 replied, No Ma'am it is not. The surveyor asked EI #12 was RI #1 receiving pain medications in October 2016. EI #12 said, according to the date (date pain medication started) on the April MAR, RI #1 started the pain medications on 09/07/16. The surveyor asked EI #12 should the pain medications have captured on the 09/14/16 MDS. EI #12 replied,Yes. The surveyor asked EI #12 did the information capture on the MDS. EI #12 said the routine pain medication did not. The surveyor asked EI #12 was this MDS assessment an accurate assessment. EI #12 replied, No Ma'am. The surveyor asked EI #12 why was it important to ensure the resident's MDS assessments were accurate. EI #12 said because you are truly capturing the residents strengths and weaknesses to adequately assess their needed care and for care plan purposes.

Based on observation, interview and record review, the facility failed to ensure staff did not touch Resident Identifier (RI) #7's food with their bare hands during the lunch meal observation on 03/23/16. This affected one of 9 residents whose meals were observed. Findings Include: A facility Policy: Titled Special Feeding Program .Purpose: To ensure that all residents receive meal service that meets their needs. Procedure: . Bread or any other food is not handled by the Certified Nursing Assistant's bare hands . dated February 17, 2016. RI #7 was admitted to the facility on [DATE]. RI #7's most current Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/20/2016, Section G: Letter H Eating, documented RI #7 required extensive assistance with one person physical assist for eating. According to RI #7's current physician's orders [REDACTED]. RI #7's Care Plan, number 16 dated 7/17/15, documented, feed resident PRN (as needed) all meals and snacks. On 03/23/16 at 12:02 PM, RI #7 was observed in the dining room sitting at the table. Employee Identifier (EI) #1 Certified Nursing Assistant (CNA) was sitting beside RI #7. The CNA (EI #1) picked up the resident's hamburger using her bare hands and gave him/her a bite of the burger. During an interview on 03/24/16 at 5:00 PM, EI #1 was asked why she didn't wear gloves to feed RI #7. EI #1 stated she was told not to wear gloves, just to wash her hands before feeding. EI #1 acknowledged she picked up RI #7's hamburger and gave him/her a bite with her bare hands. EI #1 was asked what was the potential for harm when touching a resident's food with her bare hands. EI #1 stated, Bacteria and Germs. An interview was conducted with EI #2, Director of Nursing (DON) on 03/24/16, at 4:07 PM. EI #2 stated EI #1 (CNA) told her about the incident where she had touched a resident's food without gloves during the lunch meal observation on 03/23/16. EI #2 was asked what was the potential for harm if staff touched food without gloves. EI #2 replied, spreading of germs; they have been taught to wash their hands and not to touch the food without gloves.

Based on observations, interviews and record review, the facility failed to ensure: 1. A bag of brown sugar was properly sealed and labled with a use by date on 7/14/15. 2. Five steam table pans and one pot was properly thoroughly air dryed. This was observed during the initial tour on 7/14/15. A review of a facility's document, with no date titled Dietary Inservice revealed the following : 1. Anytime a dry food item is opened and there is an unused portion left over it will be properly stored in an airtight container or in a plastic zip-lock bag or plastic bag with a twist tie and labeled with an opened date and a use by date by the employee who opened the product. A review of a facility's document (undated) titled STORAGE PROCEDURES, FOOD revealed the following: . Open boxes of food will be enclosed in bags and sealed with a twist. On 7/16/15 at 12:50 PM an interview was conducted with EI (Employee Identifier) #7, Dietary Manager. EI #7 was asked how were staff trained on food storage. EI #7 said any leftovers should be in a ziplock bag, put a use by date on it and seal, if it is a bag, we tie it up. EI #7 was asked what did the policy say about how food was to be stored. EI #7 said food needed to be in a ziplock bag, sealed or tied up with a use by date. EI #7 was asked why was a bag of brown sugar not sealed on 7/14/15 at 1:20 PM during the initial tour. EI #7 no ma'am I can't. EI #7 was asked what was the potential harm in a bag of brown sugar not being sealed properly. EI #7 said rodents and dust could get into it. A review of a facility's document (undated) titled Dietary Inservice revealed the following : 1. All utensils, steam table pans, dishes, pots and pans must be air dried after being washed prior to storage. Storage of wet utensils, steam table pans, dishes, pots and pans can cause the growth of bacteria. Ensure that all kitchen equipment is allowed ample time to air dry before storing. On 7/16/15 at 12:50 PM, an interview was conducted with EI #7. EI #7 was asked how were staff trained regarding storage of steam table pans and pots after being washed. EI #7 said they are supposed to let them air dry and put in correct storage area. EI #7 was asked what did the policy say about storage of steam table pans and pots after being washed. EI #7 said let air dry and put in correct storage. EI #7 was asked could she tell the surveyor why were five steam table pans and one pot wet nesting on 7/14/15 during the initial tour. EI #7 said they didn't let them air dry. EI #7 was asked what was the potential harm of steam table pans and a pot wet nesting after being washed. EI #7 said bacteria could grow.

Based on observations, interviews and record review the facility failed to ensure a CNA (Certified Nursing Assistant) was seated at eye level when feeding Resident Identifier (RI) #13 on 7/15/15 during the lunch meal. This affected one of six sampled residents observed assisted with feeding during meal observations. Findings Include: A review of the facility document titled Feeding Aide Course Outline, no date, documented: . Manuel: Assisted Dining- The Role and Skills of Feeding Assistants. Feeding Techniques . Eye contact and position of nutrition aide . Competency Test -Feeding. Fed (feed) resident on eye level . RI #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Quarterly MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 5/23/15 identified RI #13 as having short term and long term memory problems with cognitive skills for daily decision making was severely impaired. RI #5 was assessed to be totally dependent on staff for eating. On 7/15/15 at 12:47 P.M., the surveyor observed a CNA, EI (Employee Identifier) #3 standing while feeding RI #13 the lunch meal. RI #13 was observed seated in her Geri chair in her room at this time. On 7/15/15 at 12:58 P.M., the surveyor conducted an interview with EI #3. The surveyor asked EI #3, what was her position when feeding RI #13. EI #3 stated I was standing up. EI #3 was asked, what should have been her position when feeding RI #13. EI #3 stated Standing up in front of RI #13. EI #3 was asked how was she taught to feed the residents. EI #3 stated, The way RI #13 was sitting, to stand right in front of RI#13 and feed RI #13. EI #3 was asked what was the potential harm in standing up feeding a resident. EI #3 stated, None. On 7/16/15 at 10:01 A.M., the surveyor conducted an interview with EI #2, the RN (Registered Nurse), Staff Developer. The surveyor asked EI #2, how often are the CNA's trained on feeding resident with assistance. EI #2 stated, in their CNA certification and annually if we have a problem. EI #2 was asked what are the CNA's trained on concerning their position when feeding a resident. EI #2 stated, Sit down at eye level. EI #2 was asked how was a CNA to be positioned when assisting with feeding a resident. EI #2 stated, Sitting at eye level. EI #2 was asked if it was an acceptable practice of this facility for a CNA to stand above a resident and feed the resident. EI #2 stated, No. EI #2 was asked what was the potential harm in a staff member standing up feeding a resident. EI #2 stated that it was A dignity issue, they may feel intimidated if someone is standing over them.

Based on interviews and record review, the facility failed to ensure an order was obtained for Resident Identifier (RI) #2 for [MEDICATION NAME] and [MEDICATION NAME] levels for March 2015 and a [MEDICATION NAME] level for May 2015. Findings Include: In Potter and Perry, Fundamentals of Nursing, Eight Edition, 2013, page 305 documented the following: .Nurses follow health care providers' orders. The nurse is responsible for transcribing written orders correctly. The facility policy titled Laboratory Orders not dated, documented: Purpose: To ensure laboratory results are appropriately handled Policy: Nursing service follows the laboratory procedure to ensure that lab results are obtained as scheduled. Procedure: .2. Licensed Nurse, or designee, shall obtain the labs ordered by the physician. .4. The Licensed Nurse, or designee, will document on the Lab Scheduling/Tracking the name of the resident, the lab work to be done, and the date the lab is to be obtained. .7. When the lab has been obtained the Licensed Nurse will record this on the Lab Scheduling/Tracking form. .9 The Licensed Nurse, or designee, will forward the lab results to the Physician. 10. The Licensed Nurse or designee, will review all labs scheduled routinely to ensure all scheduled labs have been drawn and results have been received. RI #2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #2's Quarterly Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status score of 3 out of 15 which indicated severely impaired in cognition. RI #2 was also documented with a [MEDICAL CONDITION] Disorder on this assessment. RI #2's physician's orders [REDACTED]. Lab Orders [MEDICATION NAME] Level monthly. Carbamazepepine ([MEDICATION NAME]) 200 MG (milligrams) Take 3 Tablets (600 mg) . ordered 10/23/14, for muscle spasms. [MEDICATION NAME] ([MEDICATION NAME]) 50 mg tablet Take 3 tablets (150 mg) . ([MEDICAL CONDITION]). On 07/16/15 at 12:00 PM, Employee Identifier (EI) #1, Director of Nurses, was asked if the labs requested were on RI #2's July 2015 physician's orders [REDACTED].#2's physician's orders [REDACTED]. EI #1 was asked were the physician's orders [REDACTED].#1 replied no, but she did not know why. EI #1 was asked what could be the potential harm for not following physician's orders [REDACTED].#1 replied RI #2 could have a [MEDICAL CONDITION] because we did not know the levels at that time.

Based on interview and record review the facility failed to ensure there were three signatures on the narcotic destruction record for 07/14/15. This affected one of 10 months of controlled drug destruction reviewed. Findings Include: A review of the facility policy titled, Procedure: B. Destruction of Medications not dated, revealed the following: . Destruction of controlled substances must be witnessed by a third person (law enforcement official, licensed nurse, etc.) in addition to the Director of Nursing (or Assistant Director of Nursing) and the Consultant Pharmacist. A review of the drug destruction forms by the surveyor revealed only 2 signatures for 07/14/15, on the controlled substance destruction forms. On 07/16/15 at 1:10 PM, an interview was conducted with EI (Employee Identifier) #1, DON, (Director of Nurses). EI #1 was asked to review the forms for Drug Destruction dated 07/14/15 for a third signature. EI #1 was asked if she saw three signatures on the forms for that day. She replied no. EI #1 was asked should there be three signatures for drug destruction for controlled substances. She said yes. EI #1 was asked what the facility policy regarding signatures for controlled substances and destruction. EI #1 said three people should be present.

Based on observations, interview and record reviews, the facility failed to ensure a CNA (Certified Nursing Assistant) washed her hands and did not handle urine soiled bath linen with her bare hands and touched the residents bedside table, bath basin, incontinent supplies and door knob after the incontinent care of RI (Resident Identifier) #8 on 07/15/15. This affected 1 of 2 residents observed during incontinence care. Findings Include: The facility's policy titled: Handwashing (CC-INFC-28), not dated Purpose: To provide guidelines to employees for proper and appropriate handwashing techniques that will aid in the prevention of the transmission of infections. .6. After handling used dressings, specimen containers, contaminated tissues, linen, etc. .C. Gloves. .d. If handling soiled linen or items that may be contaminated; . RI #8 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #8's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/13/15 indicated RI #8 required extensive assistance from staff with toilet use and was always incontinent of bladder and bowel. On 07/15/15 at 11:05 AM, after an incontinence care observation EI #4, CNA, took her gloves off. EI #4 then picked the wet soiled bath linen up with her barehands and placed the soiled linen in a bag. EI #4 did not wash her hands and then touched clean items and objects in the resident's room. EI #4 touched the door knob when she exited the room. EI #4 went down the hall and opened the door to the soiled utility room and disposed of the bags. EI #4 then went into the clean utility room and washed her hands. On 07/15/15 at 12:00 PM, an interview was conducted with EI #4. EI #4 was asked to tell the surveyor what she did after she took her gloves off with the dirty linen after incontinence care with RI #8. EI #4 said she picked dirty linen up with my barehands. EI #4 was asked did she touch the dirty linen with no gloves on and then touched the basin, bath supplies and the closet door then exited the room and touched the doorknob to the room and went to the soiled and clean utility room and opened the doors. EI #4 said yes she did. EI #4 was asked should she have had gloves on before touching dirty bath linen used during incontinent care. EI #4 said yes. EI #4 was asked what should she have done. EI #4 said I should have covered the resident, washed my hands and went and got gloves. EI #4 was asked what was the potential harm in touching dirty linen and not washing your hands and then touching clean items/objects. EI #4 said spread germs. On 07/16/15 at 11:30 AM, a interview was conducted with EI #8, ADON (Assistant Director of Nursing)/Infection Control, RN (Registered Nurse). EI #8 was asked what was the policy and procedure on handwashing and gloving. EI #8 said change gloves and wash hands when going from dirty to clean and upon leaving the room after a procedure. EI #8 was asked what was the potential harm with not washing hands and not using gloves when going from dirty to clean. EI #8 said cross contamination and the spread of infection. EI #8 was asked when should gloves be worn during incontinent care. EI #8 said always. EI #8 was asked when should bare hands be used during incontinent care. EI #8 said never. EI #8 was asked what was the potential harm in not washing hands after incontinent care and after touching dirty linen and then touching clean items/objects. EI #8 said cross contamination and increase the risk of infections.