Every finding on record at Crowne Health Care of Citronelle

Based on record reviews and interviews, the facility failed to ensure Resident Identifier (RI) #6's medication, [MEDICATION NAME], dosage strength was included on the Medication Administration Records (MAR). A review of MARs from 08/2016 until 01/2017, revealed 20 occurrences of [MEDICATION NAME] having been administered without the dosage strength indicated on the MAR. This affected RI #6, one of fourteen residents whose medications were reviewed. Findings include: According to FUNDAMENTALS of NURSING (9th Edition), by Potter, Perry, . Standards are actions that ensure safe nursing practice . To prevent medication errors, follow the six rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these six rights: . 2. The right dose . A review of the Facility's Policy & Procedure titled, Medication Policies(:) Prescriber Medication Orders dated 01/12 revealed, . Procedures . 2. Documentation of the Medication Order A. Each medication order is documented in the resident's medical record with the date, and a record of the person receiving the order. The order is recorded on the physician's orders [REDACTED]. 3. Transcription of a physician's orders [REDACTED]. A medication order that is documented in resident's medical record with the date by the actual physician/nurse practitioner can be transcribed by non-licensed personnel and verified by a licensed nurse. This order is recorded on the physician's orders [REDACTED]. A review of the medical record revealed the current MEDICATION ORDERS FOR [REDACTED] A review of the MAR for RI #6 from 8/16 until 1/17, revealed 20 occurrences of [MEDICATION NAME] having been administered with no dose indicated on the MAR. A review of the original hand-written order for RI #6 dated 8/22/16, and signed off by the Physician revealed, . [MEDICATION NAME] 50 mg tab (tablet) (1) po (by mouth) PRN (as needed) itching. An interview was conducted with Employee Identifier (EI) #1, a Licensed Practical Nurse (LPN), at 3:24 p.m., on 1/5/17. EI #1 was asked what were the components of a complete medication order. She answered medication, dose, route, time, and Doctor's signature. EI #1 was asked how the medication orders appear on the MAR. She answered the orders are entered into the computer. EI #1 was asked what Nurse took or wrote the [MEDICATION NAME] order for RI #6 on 8/22/16. She answered EI #3, the Assistant Director of Nursing (ADON). EI #1 was asked what dose of [MEDICATION NAME] was ordered for RI #6. She answered 50 milligrams (mg.). EI #1 was asked what dose was indicated on the MAR indicated [REDACTED]. EI #1 was asked what was the concern of administering a medication from a MAR indicated [REDACTED]. I verified the written order with the (medication) card. EI #1 was asked what she did regarding the MAR indicated [REDACTED]. EI #1 was asked what was the facility policy regarding administering a medication without a specified dose. She answered, The policy is to have one. EI #1 was asked if that policy was followed. She answered, No. EI #1 was asked why. She answered, I honestly don't (know), human error. An interview was conducted with EI #2, an LPN, at 3:40 p.m., on 1/5/17. EI #2 was asked what were the components of a complete medication order. She answered, The right person, dosage, time, route, and medication. EI #2 was asked how the medication orders appear on the MAR. She answered they are typed into the computer. EI #2 was asked what Nurse took or wrote the [MEDICATION NAME] order for RI #6 on 8/22/16. She answered EI #3. EI #2 was asked what dose of [MEDICATION NAME] was ordered for RI #6. She answered, 50 mg. EI #2 was asked what dose was indicated on the MAR indicated [REDACTED]. EI #2 was asked what was the concern of administering a medication from a MAR indicated [REDACTED]. EI #2 was asked what she did regarding the MAR indicated [REDACTED]. EI #2 was asked what was the facility policy regarding administering a medication without a specified dose. She answered, Check your order. EI #2 was asked if that policy was followed. She answered yes. EI #2 was asked where that was documented. She answered I just gave her the medicine out of the pack. EI #2 was asked why and she answered, I don't know. An interview was conducted with EI #3 at 4:03 p.m., on 1/5/17. EI #3 was asked what were the components of a complete medication order. She answered, Your five rights, your medication, the dosage, the patient, the route of administration and right time. EI #3 was asked how the medication orders appear on the MAR. She answered, I took the order from the Doctor and entered it in to (name of computer program). EI #3 was asked what dose of [MEDICATION NAME] was ordered for RI #6. She answered, 50 mg. EI #3 was asked what dose was indicated on the MAR indicated [REDACTED]. EI #3 was asked what was the concern of administering a medication from a MAR indicated [REDACTED]. EI #3 was asked what was the facility policy regarding administering a medication without a specified dose. She answered, We are to follow the five rights. EI #3 was asked if that policy was followed. She answered, Apparently not. An interview was conducted with EI #4, the Director of Nursing (DON), at 4:16 p.m., on 1/5/17. EI #4 was asked what were the components of a complete medication order. She answered, Right resident, dose, time, medication, and route. EI #4 was asked how the medication orders appear on the MAR. She answered, The Nurse that writes the order usually puts it in to (name of computer program). EI #4 was asked what Nurse took or wrote the [MEDICATION NAME] order for RI #6 on 8/22/16. She named EI #3. EI #4 was asked what dose of [MEDICATION NAME] was ordered for RI #6. She answered, 50 mg. EI #4 was asked what dose was indicated on the MAR indicated [REDACTED]. EI #4 was asked what was the concern of administering a medication from a MAR indicated [REDACTED]. EI #4 was asked what was the facility policy regarding administering a medication without a specified dose. She answered, If it (the MAR) doesn't have a dose, go to the chart for clarification of the original handwritten order. EI #4 was asked if that policy was followed. She answered, I wasn't there.

Based on observation, interviews, and record review, the facility failed to provide account for 10 missing doses of medication for Resident Identifier (RI) #10. The medication, Hydroxyzine was missing from the medication cart where RI #10's medications were stored. The licensed staff members responsible for administering the medication could not provide evidence that this medication had been administered to RI #10. When asked where were the 10 doses of this medication, the licensed staff members stated they did not know. This affected medication belonging to Resident Identifier (RI) #6, one of fourteen residents whose medication were reviewed. Findings include: A review of the Facility's Policy and Procedure titled, Medication Storage(:) Storage of Medications and Biologicals dated 01/12 revealed, Policy Medications and biological are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures . 2. Only licensed nurses, authorized pharmacy personnel, and those lawfully authorized to administer medications (such as medication techs(technicians)) are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. 3. Except for those requiring refrigeration, medications intended for internal use are stored in a medication cart or other designated area. 13. Medication storage conditions are monitored on a routine basis and corrective action taken if problems are identified. A review of RI #6's medical record revealed RI #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the . CONSOLIDATED DELIVERY SHEETS . dated 8/22/16, for medications delivered to the facility, indicated RI #6 was dispensed . (quantity) 30 TAB (tablets) HYDROXYZINE HCL (hydrochloride) 50 MG (MILLIGRAM) . A review of the Medication Administration Record [REDACTED]. This indicated 10 tablets should have remained. An observation was made at 11:07 a.m., on 1/5/17 of the medication cart where RI #6's medications are stored. This observation was facilitated by Employee Identifier (EI) #1, a Licensed Practical Nurse (LPN), and EI #4, the Director of Nursing (DON). EI #1 was asked to provide the remaining supply of Hydroxyzine belonging to RI #6 so the dose given could be verified with the ordered dose. The medication was not present. An interview was conducted with EI #1, a Licensed Practical Nurse (LPN), at 3:24 p.m., on 1/5/17. EI #1 was asked where were the remaining 10 tablets of Hydroxyzine 50 mg that had not been administered to RI #6. She answered, I do not know. EI #1 was asked who was responsible for the safe-keeping of resident medications. She answered, Nurses and the Director of Nursing (DON). EI #1 was asked what was the facility policy on safe-keeping of resident medications. She answered, Keep in a locked medication room and our carts are locked at all times. EI #1 was asked if she knew what could have happened to those tablets. She answered, No, I do not. An interview was conducted with EI #2, an LPN, at 3:40 p.m., on 1/5/17. EI #2 was asked where were the remaining 10 tablets of Hydroxyzine 50 mg. that had not been administered to RI #6. She answered, I don't know. EI #2 was asked who was responsible for the safe-keeping of resident medications. She answered, Nurses. EI #2 was asked what was the facility policy on safe-keeping of resident medications. She answered, That they're supposed to be on a locked cart, double locked when not using (the cart). EI #2 was asked if she knew what could have happened to those tablets. She answered, No, I do not. An interview was conducted with EI #3, the Assistant Director of Nursing, at 4:03 p.m., on 1/5/17. EI #3 was asked where were the remaining 10 tablets of Hydroxyzine 50 mg. that had not been administered to RI #6. She answered, I don't know where they are. EI #3 was asked who was responsible for the safe-keeping of resident medications. She answered, All Nurses. EI #3 was asked what was the facility policy on safe-keeping of resident medications. She answered, Keep the med (medication) carts locked when unattended. EI #3 was asked if she knew what could have happened to those tablets. She answered, I don't know if they got destroyed. EI #3 was asked what was the concern of 10 Hydroxyzine 50 mg. tablets not being accounted for. She answered, Where are they. An interview was conducted with EI #4, at 4:16 p.m., on 1/5/17. EI #4 was asked where were the remaining 10 tablets of Hydroxyzine 50 mg. that had not been administered to RI #6. She answered, We are unable to locate them. EI #4 was asked who was responsible for the safe-keeping of resident medications. She answered, The Nurses. EI #4 was asked what was the facility policy on safe-keeping of resident medications. She answered, They are to be stored in a locked cart and double locked for narcotics. EI #4 was asked if she knew what could have happened to those tablets. She answered, They may have gotten put in the shred box by accident. EI #4 was asked what was the concern of 10 Hydroxyzine 50 mg. tablets not being accounted for. She answered, They could be somewhere in the building. An interview was conducted with EI #5, the Consultant Pharmacist, at 5:13 p.m., on 1/5/17. EI #5 was asked if there had been any concerns with non-controlled medications missing at the facility since becoming the Consultant in August of 2016. She answered, Yes in the beginning when we first took over. Not since then. EI #5 was asked what ongoing or interactive processes were in place to prevent this from occurring. She answered, We did inservicing. The Nurse Consultant and I. We did two inservices and no problems since. EI #5 was asked what was the concern of 10 Hydroxyzine 50 mg. tablets being unaccounted for in the facility. She answered not knowing where they were or who had them.

Based on record review and interview, the facility failed to ensure the Nurse included the dosage strength when transcribing an order to the Medication Administration Record (MAR) for Resident Identifier (RI) #6. The affected RI #6 one of fourteen residents whose medications were reviewed. Findings include: A review of the Facility's Policy and Procedure titled Medication Policies(:) Prescriber Medication Orders dated 01/12 revealed, Procedures . 2. Documentation of the Medication Order A. Each medication order is documented in the resident's medical record with the date, and a record of the person receiving the order. The order is recorded on the physician's orders [REDACTED]. 3. Transcription of a physician's orders [REDACTED]. A medication order that is documented in resident's medical record with the date by the actual Physician/nurse practitioner can be transcribed by non-licensed personnel and verified by a license Nurse. This order is recorded on the physician's orders [REDACTED]. A review of RI #6's medical record revealed RI #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the original hand-written order for RI #6 dated 8/22/16, and signed off by the Physician revealed, . [MEDICATION NAME] 50 mg tab (tablet) (1) po (by mouth) PRN (as needed) itching. The MARs from 08/2016 to 01/2017 revealed, . [MEDICATION NAME] HCI ([MEDICATION NAME] Acid)Tablet . was documented on the MARs without the dosage strength. An interview was conducted with Employee Identifier (EI) #1, a Licensed Practical Nurse (LPN), at 3:24 p.m., on 1/5/17. EI #1 was asked what were the components of a complete medication order. She answered medication, dose, route, time, and Doctor's signature. EI #1 was asked how the medication orders appear on the MAR. She answered the orders were entered into the computer. EI #1 was asked what Nurse took or wrote the [MEDICATION NAME] order for RI #6 on 8/22/16. She named EI #3, the Assistant Director of Nursing (ADON). EI #1 was asked what dose was indicated on the MAR when the medication was administered. She answered, It doesn't have one. An interview was conducted with EI #2, an LPN, at 3:40 p.m., on 1/5/17. EI #2 was asked what were the components of a complete medication order. She answered, The right person, dosage, time, route, and medication. EI #2 was asked how the medication orders appear on the MAR. She answered they were typed into the computer. EI #2 was asked what Nurse took or wrote the [MEDICATION NAME] order for RI #6 on 8/22/16. She named EI #3. EI #2 was asked what dose was indicated on the MAR when the medication was administered. She answered, It doesn't. An interview was conducted with EI #3 at 4:03 p.m., on 1/5/17. EI #3 was asked what were the components of a complete medication order. She answered, Your five rights, your medication, the dosage, the patient, the route of administration, and right time. EI #3 was asked how the medication orders appear on the MAR. She answered, I took the order from the Doctor and entered it in to (name of computer program). EI #3 was asked what dose was indicated on the MAR when the medication was administered. She answered, It doesn't. EI #3 was asked what was the concern of not transcribing a dosage to the MAR with a medication order. She answered, They could get the wrong dose. An interview was conducted with EI #4, the Director of Nursing (DON), at 4:16 p.m., on 1/5/17. EI #4 was asked what were the components of a complete medication order. She answered, Right resident, dose, time, medication, and route. EI #4 was asked how the medication orders appear on the MAR. She answered, The Nurse that writes the order usually puts it in to (name of computer program). EI #4 was asked what Nurse took or wrote the [MEDICATION NAME] order for RI #6 on 8/22/16. She named EI #3. EI #4 was asked what dose was indicated on the MAR when the medication was administered. She answered, No dose. EI #4 was asked what was the concern of not transcribing a dosage to the MAR with a medication order. She answered, The right medication was given to this resident.

Based on observations, interviews and record reviews, the facility failed to ensure resident's rooms and bathrooms were maintained in good repair as evidenced by: peeling wall paper, peeling and scuffed door frames, unpainted areas in rooms and bathrooms, scuffed areas on walls, missing closet doors, closet door off track and a hole in a bathroom wall observed on three of three halls during three days of survey in Area Locators (AL) #1, #2, #3, #6, #7, #8, #9, #10, #11, #12, #13, #15 (bathroom), #16, #17, #18 and #19. Findings include: 1) A review of a facility policy titled, Maintenance Service, dated November 2001, revealed, Policy Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. The following functions are performed by maintenance, but are not limited to: a. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. b. Maintaining the building in good repair . i. Providing routinely scheduled maintenance service to all areas. A review of an undated facility policy titled, Inspecting Resident/Patient Rooms, revealed, Introduction To ensure that the resident/patient rooms are as safe and comfortable as possible, routine inspections of the rooms should be done. General inspection The following steps should be taken when performing a general inspection on all resident/patient rooms.7 Visually check paint, door jams, and door closures, . A review of an undated facility document from the Preventive Maintenance Manual titled, Maintaining Walls and Ceilings (Painting), revealed, Introduction Frequent maintenance such as painting the walls and ceilings helps create an environment of which residents can be proud. During the initial tour of the facility on 11/3/15, the following was observed: 9:43 AM - AL (Area Locator) #17's bathroom had wallpaper peeling at the base board. 9:57 AM - AL #2's door frame with peeling paint. 10:03 AM - AL #3's wall behind bed A was observed with paint scuffed off approximately 2 feet by 3 feet above the bed rail. 10:27 AM - AL #16's bathroom vent on the side wall was coated over with paint. A tour was made of the facility on 11/5/15 at 2:53 PM. ALs #1, #2 and #3 were found with scuffed room door facings. The bathroom shared by these rooms (AL #1, #2 and #3) were found with the door facings scuffed, paint peeling from the walls and vents. AL #17 was observed with surface peeling on the bathroom wall. The bathroom shared by AL #14 and #16 had a vent that was heavily coated with paint and flaking. AL #13 was found with the door facing scuffed at the bottom. AL #18 was found with a hole in the wall below the sink on the right side. The paint was peeling on the wall above the baseboard measuring approximately 3 feet by 6 inches. During a tour with EI (Employee Identifier) #8, Maintenance Director, on 11/5/15 at 5:58 PM, EI #8 described the following rooms: In the bathroom shared by AL #1 and #2: The buckling of the paint and scuffed door jams, rough. In AL #3: Missing paint. The bathroom shared by AL #13 and #15: Door jams, beat up. AL #17: Door jams, beat up. AL #18: Paint peeling. AL #19: When baseboard came up, it peeled the paint off the sheet rock. On 11/5/15 at 6:24 PM, EI #8, Maintenance Director, was asked how should residents rooms be maintained. EI#8 answered, Like I do at home. EI #8 also indicated doors should not be rough and/or splintered because residents could get scratched. An interview was conducted with EI #1, DON (Director of Nursing), on 11/5/15 at 7:51 PM. EI #1 was asked about the resident's rooms with peeling paint and scuffed/splintered doors and door facing with peeling paint. EI #1 answered, it was not homelike and there was a potential for injury. EI #1 was asked if this was what the residents should expect and she answered, No ma'am. EI #1 was asked to explain closet doors missing and how this could make the residents feel. EI #1 did not know why the closet doors were missing, but stated it may be a dignity issue. 2) An observation was made on 11/3/15 at 9:43 AM of AL #17's bathroom. A grab bar was found mounted onto unpainted wood. At 10:44 AM of AL #15's bathroom sink was also observed mounted onto unpainted wood. During a tour of resident rooms on 11/5/15 at 5:58 PM, EI #8, Maintenance Director, was asked about the bathroom in AL #15 and #17. EI #8 acknowledged the wood needed to be painted in both bathrooms (AL #15 and #17). 3.) A tour of the 100 hall was made on 11/4/2015 at 10:00 AM. The following area locators had missing closet doors: AL #6, #7, #8, #9, #10 and #11. On 11/5/2015 at 6:06 PM, EI #8, Maintenance Director, confirmed the closet doors in AL #6, #7, #8, #9, #10 and #11 were missing. Also noted during this tour the closet door in AL #12 was off the track. On 11/5/2015 at 8:14 PM, an interview was conducted with EI #9, the Administrator. EI #9 was asked about the missing closet doors and how this could make residents feel. EI #9 explained that the missing closet doors were related to doors removed to put down flooring. Concerning the residents, EI #9 stated some may have an issue and some may not.

Based on observations, interviews, and record reviews, the facility failed to ensure: 1) Medications were not left unattended at bedside during a Medication Pass on 11/4/15 at 8:45 AM. This affected 1 of 5 nurses observed during medication administration. 2) Resident room doors and bathroom doors were maintained in a safe manor. Splintered doors were identified in AL (Area Locator) #s: 1, 2, 6, 7, 8, 10, 11, 13 and 20. This had the potential to affect 10 residents, identified by the facility, as high risk for skin tears residing in these rooms. 3a) Wheelchairs, one geri-chair, and one large cardboard box, were not stored in from the therapy exit to 200 hall impeding access to the hand rail on 11/3/15. This had the potential to affect 37 of 37 residents capable of mobility in the facility. 3b) Boxes of floor tiles and adhesive were not stored stacked in a hallway between the 300 hall of resident rooms and the activity room, traveled by unsupervised residents, on two of four days of survey. This had the potential to affect 37 of 37 residents capable of mobility in the facility. 3c) Blankets, covering boxes between the 300 hall of resident rooms and the activity room, were not found with the blanket edges lying in the floor of the hallway, creating a fall hazard where residents traveled unsupervised, on one of four survey days. This had the potential to affect 37 of 37 residents capable of mobility in the facility. Findings include: 1) RI #12 was admitted to the facility on [DATE]. RI #12's Admission MDS, with an ARD of 10/8/2015, revealed a BIMS score of 3 out of 15. This indicated that RI #12 was severely impaired for daily decision making skills. During a Medication Pass observation on 11/4/2015 at 8:45 AM, EI #3, an LPN, placed a medication tray on top of RI #12's over bed table. The medication tray contained three liquid medications in medication cups. When EI #3 went into the bathroom to wash her hands, she was out of sight of the resident as well as the medications sitting on the over bed table. On 11/5/2015 at 3:00 PM, an interview was conducted with EI #3, LPN. EI #3 was asked if she had been able to see RI #12's medications at all times. EI #3 said not when she was washing her hands. The LPN indicated that she could not take the mediations into the bathroom with her. EI #3 was asked what the potential negative effect could be when resident's medications are not in sight at all times. EI #3 stated RI #12's roommate could have come in the room and gotten them. On 11/6/2015 at 8:15 AM, an interview was conducted with EI #1, the Director of Nursing. EI #1 was asked what the nurses, who administer medications, were taught about keeping medications in their sight until taken by the resident. EI #1 stated medications were to be kept in sight. The medications were taken to the resident and kept in sight at all times. If the nurse was away from the cart, then the cart should be locked. EI #1 was asked why it was important to keep medications in sight at all times. EI #1 stated to prevent anyone from coming and taking the medications, other than the person they were prescribed for. 2) A review of a facility policy titled, Maintenance Service, dated November 2001, revealed, Policy Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. The following functions are performed by maintenance, but are not limited to: a. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. b. Maintaining the building in good repair and free from hazards. A review of an undated facility policy titled, Inspecting Resident/Patient Rooms, revealed, Introduction To ensure that the resident/patient rooms are as safe and comfortable as possible, routine inspections of the rooms should be done. General inspection The following steps should be taken when performing a general inspection on all resident/patient rooms.7 Visually check paint, door jams, and door closures . During a tour was with EI (Employee Identifier) #8, the Maintenance Director, on 11/5/15 at 5:58 PM, EI #8 described the following rooms: In the bathroom shared by AL #1 and #2: scuffed, rough door jams; the bathroom shared by AL #13 and #15: Door jams, beat up; in AL #17: Door jams, beat up. AL #7's room and bathroom doors were described as rough. AL #8 was described as having a splintered door edge. AL #10's room door and bathroom door were described as rough-edged. AL #11 was identified as having a room door that was rough. EI #8 described AL #20's room door as also having rough edges. Further observation was made on 11/6/15 at 3:50 PM of rooms where residents were identified by the facility as being at risk for potential skin tears. In AL #7 the room door and bathroom door had splintered edges. AL #8 had a room door and bathroom door with splintered edges. AL #10 had a splintered room door and splintered bathroom door; the splintered area from the door knob to the floor. AL #20 and AL #11 had room doors with splintered edges. AL #6 had a splintered bathroom door. AL #13 had a splintered room door and bathroom door. AL #1 and AL #2 had a quarter-sized splintered edge on the room door. According to a list provided by the facility on 11/6/2015 residents, who were at risk for skin tears, were located in AL #1, #2, #6, #7, #8, #10, #11, #13 and #20. On 11/5/15 at 6:24 PM, EI #8 was asked how should residents ' rooms be maintained. EI#8 answered, Like I do at home. EI #8 also indicated doors should not be rough and/or splintered because residents could get scratched. An interview was conducted with EI #1, DON, on 11/5/15 at 7:51 PM. EI #1 was asked what was the concern with peeling paint and scuffed/splintered doors and door facing with peeling paint. She answered, Not homelike, potential for injury. EI #1 was asked if this was what the residents should expect and she answered, No ma'am. When asked to explain closet doors missing and how this could make the residents feel, EI #1, did not know why the doors were missing and indicated, this maybe a dignity issue. An interview was conducted with EI #9, the Administrator, on 11/5/15 at 8:14 PM. EI #9 was asked what was the concern with splintered doors. He answered, (The) risk for skin tears. 3a) A review of a facility document posted at the Nurse's station documented: All wheelchairs & Geri chairs are to be in shower room or resident's room. This document was signed by EI #9, the Administrator. A review of a facility training document titled, Slips, Trips and Falls for Employees, revealed, . How Trips Occur: Trips occur when a person's foot contacts an object and they are thrown off balance. The main cause of tripping is when something is in a walkway and causes someone to trip. However, there are obvious solutions to prevent trips: keeping objects out of the walkway . A review of an undated facility policy titled, FUNDAMENTALS OF SLIP/TRIP/FALL PREVENTION, revealed, . Supply Areas and Maintenance Boxes and supplies are kept out of walkways and stored properly . An observation was made on 11/3/15 at 9:19 AM of nine wheelchairs, a geri-chair, and a large cardboard box lined up on the left side of the hallway; from the therapy doorway to the exit at the end of the 200 hall. An interview was conducted on 11/4/15 at 5:09 PM with EI #1, DON. EI #1 was asked if wheelchairs should line the hall where residents ambulate. She answered, No, because this would be a trip risk. An interview was conducted with EI #11, a CNA (Certified Nursing Assistant) on 11/6/15 at 8:55 AM. EI #11 was asked where were wheelchairs and geri-chairs supposed to be stored. EI #11 answered, Normally in the resident's room and shower room when not in use. EI #11 was asked where did the sign posted at the Nurse's station instruct wheelchairs and geri-chairs to be kept. The CNA (EI #11) answered, All wheelchairs and geri-chairs are to be in shower room or resident's room. EI #11 was asked why shouldn ' t the chairs be in the hall. EI #11 explained that it could be a hazard and someone could fall. 3b) An observation was made on 11/4/15 at 9:00 AM of cases of flooring tiles and cases of containers of adhesive stacked in the hallway between the 300 hall of resident rooms and the activity room. An observation was made on 11/4/15 at 9:52 AM. One staff member and two visitors walked past the stacked cases of floor tiles and adhesive. An observation was made on 11/4/15 at 10:26 AM. Two residents were present in the activities room, self-propelling in wheelchairs with no staff present. An observation was made on 11/4/15 at 10:28 AM, of a male resident walking down the hallway past the stacked cases. The resident ambulated with a shuffling gait and was unsupervised. An observation was made on 11/4/15 at 1:26 PM, of two unsupervised residents, one self-propelling in a wheelchair and another ambulating in a Merri-walker past the cases. An interview was conducted with EI #8, Maintenance Director, on 11/4/15 at 4:41 PM. EI #8 was asked what was the potential concern having boxes of tiles and adhesive stacked in the hallway. He answered, Potential of a resident to bust one open, knocked over. EI #8 identified the items in the hallway as: Eight cases of flooring adhesive contained twelve 30 oz. (ounce) containers. Thirty-nine boxes of flooring tiles with size 3 mm (millimeter) X 455 mm X 455 mm. Seventeen boxes of molding. One box of corner guards. Three-4 gallon buckets of flooring glue. EI #8 stated there was nothing in place to prevent the stacked boxes from falling. When asked if residents ever navigated the hall where the items were stacked without supervision, EI #8 answered, Yes. An interview was conducted with EI #1, DON on 11/4/15 at 5:09 PM. EI #1 was asked what was the potential concern with boxes tiles and adhesive stacked in the hallway. She answered, They're not secure, they could possibly fall. EI #1 was asked what was in place to prevent the boxes from falling. She answered, I don't see anything. EI #1 was asked if residents ever navigated the hall where the items were stacked without supervision. She answered, Yes ma'am, they do. 3c) An observation was made on 11/4/15 at 9:00 AM of boxes of flooring materials covered with blankets in the hallway between the 300 hall of resident rooms and the activity room. An observation was made on 11/4/15 at 10:28 AM of a male resident walking with a shuffling gait down the hallway past the boxes covered with the blankets. The blankets edges were noted on the floor. There was no supervision present at that time. An observation was made on 11/4/15 at 1:26 PM of one resident self-propelling in a wheelchair and one resident in a Merri-walker traveling past the blankets that were draped over the cases of flooring materials. Both residents were unsupervised. An observation was made on 11/4/15 at 3:02 PM of an unsupervised resident walking past the boxes covered with the blankets unsupervised. An interview was conducted with EI #8, Maintenance Director on 11/4/15 at 4:51 PM. EI #8 was asked what was the concern of the blankets laying on the floor in the hallway. He answered, It could be a trip and fall hazard because it's out in the way. EI #8 was asked if residents ever navigated the hall without supervision and he answered, Yes. An interview was conducted with EI #1, DON, on 11/4/15 at 5:09 PM. EI #1 was asked what was the potential concern with blankets laying on the floor in the hallway. The Administrator (EI #1) stated it was a potential trip hazard. EI #1 was asked if residents navigated the hall between the 300 hall and activities room without supervision. She answered, Yes ma'am, they do.

Based on observations, interviews and record reviews, the facility failed to ensure: 1. Washed utensils, trays and pans were allowed to air dry on 2 of 4 survey days. 2. A staff member did not wear a gemstone ring while working on the tray line on 1 of 4 survey days. 3. Staff used soap and water to wash their hands while in the kitchen on 2 of 4 survey days. 4. The thermometer was not sanitized prior to temping food items on the trayline on 1 of 4 survey days. 5. Staff had hair completely covered in the kitchen on 2 of 4 survey days. 6. Dented cans were not stored over the other food items. 7. Opened multi-use packages of food items were labeled with an open and or use-by date. This had the potential to affect all 63 residents receiving meals from the kitchen. Findings include: 1. A review of the 2013 Food Code revealed, . 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface SANITIZING solutions), before contact with FOOD; and (B) May not be cloth dried except that UTENSILS that have been air-dried may be polished with cloths that are maintained clean and dry. An observation was made on 11/3/15 at 9:31 AM of 3 wet baking pans stacked on the shelf at the 4 compartment sink. An observation was made on 11/4/15 at 9:10 AM of 3 serving utensils on the shelf at the end of the 4 compartment sink, sitting bottom side down with water pooling in the bottom that could not drain. The bowl used to puree foods had been washed and was in the fourth compartment lying on its side with water pooling inside. The blade used to puree food items was lying flat on the shelf near the utensils in standing water. An observation was made on 11/4/15 at 9:22 AM in the dishwashing room. EI (Employee Identifier) #12, a dietary aide, was stacking wet trays flat. An observation was made on 11/4/15 at 10:43 AM of 7 serving utensils that had been washed lying on the shelf at the end of the 4 compartment sink. Two of the utensils were lying top down in standing water and five were lying bottom side down in the standing water with water pooling inside each of them. On 11/4/15 at 10:57 AM, an observation was made of beans being placed in a wet bowl used to puree food items. A gray-handled serving utensil that had been lying in standing water was used to dip the beans. An interview was conducted with EI #14, the cook, on 11/4/15 at 11:28 AM during the trayline observation. EI #14 was asked to describe the shelf where she had taken a serving utensil from. She responded, You mean the water. An interview was conducted on 11/5/15 at 4:03 PM with EI #14. EI #14 was asked how washed dishes, pans, and utensils were supposed to be dried. She answered, They (are) supposed to air dry. An interview was conducted on 11/5/15 at 4:15 PM with EI #13, a dietary aide. EI #13 was asked how washed dishes, pans, and utensils were supposed to be dried. She answered, They are supposed to air dry. EI #13 was asked how these items should be stacked. She answered, Not on top of each (other), leaning so they can dry. An interview was conducted on 11/5/15 at 4:37 PM with EI #10, the Dietary Manager. EI #10 was asked how washed dishes, pans, and utensils were supposed to be dried. She answered, Set out to air dry. EI #10 was asked how these items should be positioned. She answered, Out of water, face down, and tilted. 2. A review of the 2013 Food Code revealed, . Jewelry 2-303.11 Prohibition. Except for a plain ring such as a wedding band, while preparing FOOD, FOOD EMPLOYEES may not wear jewelry including medical information jewelry on their arms and hands. An observation was made on 11/4/15 at 11:28 AM of EI #13 handling items such as lids to glasses with her left hand. EI #13's wedding ring was observed with 3 gemstones. An interview was conducted on 11/5/2015 at 4:03 PM with EI #14, the cook. EI #14 was asked what was the facility's policy on wearing jewelry in the kitchen. She answered, We were told by our manager before no jewelry except for band. No stones. EI #14 was asked what was the potential harm of staff wearing a ring with gemstones in it while handling food, ice, and et cetera. She answered, If one of the stones fell on or in the food, you wouldn't know. An interview was conducted with EI #13 on 11/5/15 at 4:15 PM. EI #13 was asked what was the facility's policy on wearing jewelry in the kitchen. She answered, We were told we could wear a wedding band. It won't happen again. EI #13 was asked what was the potential harm of staff wearing a ring with gemstones in it while handling food, ice, and et cetera. She answered, They could fall out into the food. An interview was conducted with EI #10 on 11/5/15 at 4:37 PM. EI #10 was asked what was the facility's policy on wearing jewelry in the kitchen. She answered staff should only wear a wedding band. EI #10 was asked what was the potential harm of staff wearing a ring with gemstones in it while handling food, ice, and et cetera. She answered, The stone could fall out into the food. 3. A review of the 2013 Food Code revealed, . 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLESERVICE and SINGLE-USE ARTICLES and: . (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; . (H) Before donning gloves to initiate a task that involves working with FOOD; and (I) After engaging in other activities that contaminate the hands. An observation was made on 11/3/15 at 9:31 AM during the initial tour of the kitchen of a dietart staff member picking a lid up off of the floor and then touching milk cartons without washing her hands. An observation was made on 11/3/15 at 9:48 AM of EI #10 re-entering the kitchen, opening the cooler and removing a thermometer without washing her hands. An observation was made on 11/4/15 at 8:57 AM of EI #12 using hand sanitizer, then entered the dishwashing room and moved plates with her bare unwashed hands. An observation was made on 11/4/15 at 12:18 PM of EI #13 using hand sanitizer while multi-tasking and handling glasses in the kitchen. An interview was conducted with EI #14, a cook, on 11/5/15 at 4:03 PM. EI #14 was asked when should hands be washed. She answered, After you touch anything with (your) hands that is not clean, when change gloves, or door knob when coming back in the kitchen. EI #14 was asked if it was acceptable to use hand sanitizer in the kitchen or dishroom. She answered yes. She reported that she uses it when she washes her hands with soap and water. EI #14 was asked if it was acceptable to use the hand sanitizer without soap and water. She answered, No. An interview was conducted with EI #13 on 11/5/15 at 4:15 PM. EI #13 was asked when should hands be washed. She answered, When coming in the building, when contaminated, and when re-entering the kitchen. EI #13 was asked if it was acceptable to use hand sanitizer in the kitchen or dishroom. She answered, Yea, you can, I was taught we could. EI #13 was asked who taught her. She answered, It's in there, nobody actually told us, it's in there to use. I use it before I touch the clean dishes. An interview was conducted with EI #10 on 11/5/15 at 4:37 PM. EI #10 was asked when should hands be washed. She answered, When you go out and come back in. When you feel like they or know they have been contaminated. EI #10 was asked if it was acceptable to use hand sanitizer in the kitchen or dishroom. She answered, When I came here they had it everywhere. I was taught not to. No. 4. A review of the 2013 Food Code revealed, .4-701.10 Food-Contact Surfaces and Utensils. Equipment Food-Contact Surfaces and Utensils shall be Sanitized An observation was made on 11/4/15 beginning at 10:57 AM during trayline. EI #14 was observed to check the temperature of the heated food items without sanitizing the thermometer. EI #14 removed the thermometer from the cup of ice water and placed it directly into the food items. An interview was conducted with EI #14 on 11/5/15 at 4:03 PM. EI #14 was asked when should the thermometer be sanitized when temping (checking temperatures) food items. She answered, After each item. EI #14 was asked what was the potential negative outcome of cross contamination in the kitchen. She answered, Residents can get real sick. An interview was conducted with EI #10 on 11/5/15 at 4:37 PM. EI #10 was asked when should thermometers be sanitized when temping food items. She answered, Before you put it in the food item. EI #10 was asked what was the potential negative outcome of cross contamination in the kitchen. She answered, A resident could get sick. 5. A review of the 2013 Food Code revealed, . 2-402.11 Effectiveness. (A) Except as provided in ¶ (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. An observation was made on 11/3/15 at 9:41 AM of EI #13 in the kitchen with hair exposed at the nape of the neck and right side of her face in front of her ear. An observation was made on 11/3/15 at 9:46 AM of EI #10 in the kitchen with hair exposed at the nape of the neck. An observation was made on 11/4/15 at 9:10 AM of EI #10 in the kitchen with hair exposed at the nape of the neck. An interview was conducted with EI #13 on 11/5/15 at 4:15 PM. EI #13 was asked how should hair be maintained while in the kitchen. She answered, Under a hair net, all covered up. An interview was conducted with EI #10 on 11/5/15 at 4:37 PM. EI #10 was asked how should hair be maintained while in the kitchen. She answered, All hair should be in the net. 6. Distressed Merchandise 6-404.11 Segregation and Location. Products that are held by the PERMIT HOLDER for credit, redemption, or return to the distributor, such as damaged, spoiled, or recalled products, shall be segregated and held in designated areas that are separated from FOOD, EQUIPMENT, UTENSILS, LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES. An observation was made on 11/3/15 at 9:31 AM during the initial tour of the kitchen of dented cans stored on a shelf above other food items. An observation was made on 11/4/15 at 10:34 AM of dented cans that remained stored above other food items. An interview was conducted on 11/5/15 at 4:03 PM with EI #14. EI #14 was asked if dented cans should be stored above other food items. She answered, It should be on the bottom. An interview was conducted on 11/5/15 at 4:15 PM with EI #13. EI #13 was asked if dented cans should be stored above other food items. She answered, No ma'am, but ours are. An interview was conducted on 11/5/15 at 4:37 PM with EI #10. EI #10 was asked if dented cans should be stored above other food items. She answered, No. 7. A review of the 2013 Food Code revealed, .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD. An observation was made on 11/3/15 at 5:22 PM of 3 large canisters that were unlabeled and undated. EI #13 identified one as corn meal. An observation was made on 11/4/15 at 8:52 AM of 6 bins of dry stored items with no label indicating the name or date opened. An interview was conducted on 11/5/15 at 4:03 PM with EI #14. EI #14 was asked how should opened, multi-use items be labeled in the kitchen. She answered, An open date and use-by date. An interview was conducted on 11/5/15 at 4:15 PM with EI #13. EI #13 was asked how should opened, multi-use items be labeled in the kitchen. She answered, It should be dated open and use-by date. An interview was conducted with EI #10 on 11/5/15 at 4:37 PM. EI #10 was asked how should opened, multi-use items be labeled in the kitchen. She answered, Open date and a use-by date and resealed.

Based on observations, record reviews, and interviews, the facility failed to ensure a licensed nurse knocked on a resident's door prior to entering the room or close the door after entering the room during Medication Pass. This affected RI (Resident Identifier) #'s 10 and 20, two of seven residents sampled for medication administration. Findings include: The review of a facility document titled, Oral Medication, dated 10/2014, revealed, . 10. Knock before entering the room . A review of the medical record revealed RI #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #20's Admission MDS, with an ARD of 10/13/2015, revealed a BIMS score of fifteen out of a possible fifteen. This indicated RI #20 was cognitively intact for daily decision making skills. On 11/3/2015 at 4:10 PM, an observation was made of medication pass for RI #20. EI #6 was observed to enter RI #20's room and not close the door behind her. EI #6 was observed going in to RI #20's room with medications to administer, including an insulin injection. EI #6 did not knock or close the door after entering the room. EI #6 administered insulin in the resident's abdomen. A review of the medical record for RI #10 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Admission MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 9/22/2015, revealed RI #10 had a BIMS (Brief Interview for Mental Status) score of eleven out of a possible fifteen. This indicated RI #10 was moderately impaired for daily decision making skills. RI #10 also required extensive assistance with all ADLs (Activities of Daily Living). An observation was made on 11/3/2015 at 4:35 PM of Medication Pass for RI #10. EI (Employee Identifier) #6, an LPN (Licensed Practical Nurse), was observed to prepare medications at the medication cart. EI #6 then opened the door to RI #10's room without knocking. The resident was up in the wheelchair. EI #6 did not close the door after entering the room for the administration of medications. A review of the medical record revealed RI #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #12's Admission MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 10/8/2015, revealed a BIMS (Brief Interview for Mental Status) score of three out of a possible fifteen. This indicated RI #12 was severely impaired for daily decision making skills. RI #12 was non-ambulatory and required assistance with all ADLs. An observation was made on 11/4/2015 at 8:45 AM of a medication pass for RI #12. EI #3 prepared RI #12's medications at the medication cart. With meds on a tray, EI #3 proceeded to RI #12's room and said knock knock but did not wait for a reply from the resident. After placing the medications on the overbed table, EI #3 walked across the room and opened the bathroom door without knocking. The person in the bathroom said something (unable to understand what the person said) and the nurse closed the door and said, Oh, I'm sorry. She looked at the surveyor and said, I didn't know anybody was in there. After a couple of minutes, the resident's roommate came out of the bathroom and left the room. An interview was conducted on 11/5/2015 at 4:50 PM with EI #6. EI #6 was asked how privacy and dignity were maintained for a resident. EI #6 said knock on the door, make sure they have privacy, close the door, the blinds, and pull the curtain. EI #6 was asked if she had provided privacy/dignity for RI #10 and RI #20 during the medication pass on 11/3/2015. EI #6 said she had forgotten to shut the door and she had not provided privacy. EI #6 was asked what could be the potential negative effect on a resident if privacy and dignity was not maintained. EI #6 stated the residents may not like for people to see them exposed. An interview was conducted on 11/5/2015 at 3:00 PM with EI #3. EI #3 was asked how a resident's privacy/dignity was maintained during medication pass. EI #3 said pull curtain or close the door. If the other resident was not in the room, close the door because staff want it to remain private. EI #3 was asked if privacy/dignity was provided for RI #12 during medication pas at 8:45 AM on 11/3/2015. EI #3 said she thought she did. The resident's roommate was in the bathroom and when the roommate left she thought she had closed the door. EI #3 was asked how she knew the roommate was in the bathroom. She said she tapped on the door before she opened it but did not wait for the resident to answer. The resident came out of the bathroom and then left the room. On 11/6/2015 at 8:15 AM, an interview was conducted with EI #1, the DON (Director of Nursing). EI #1 was asked how dignity/privacy was maintained for a resident. EI #1 said try not to expose any body parts. Staff should knock and walk into the room, tell the resident what they were going to do - if exposing skin, staff would close the door. EI #1 was asked why it was important for dignity/privacy to be maintained for residents. EI #1 stated it keeps the resident at their highest level of being, being courteous. EI #1 was asked what could be a potential negative outcome of not maintaining a resident's privacy/dignity. EI #1 said the resident could become embarrassed.

Based on observations, interviews, and record reviews, the facility failed to ensure medications were not left unattended at bedside during Medication Pass on 11/4/15 at 8:45 AM. This affected 1 of 5 nurses observed during medication administration. Findings include: A review of a facility document titled, . Policy #/Title 5.3 Storage and Expiration of Medications, Biologicals, Syringes and Needles Application LTC (Long Term Care) Facilities Receiving Pharmacy Products and Services from Pharmacy, revealed, . 3.3 Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by the residents and visitors. A review of the medical record revealed RI #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #12's Admission MDS, with an ARD of 10/8/2015, revealed a BIMS score of three out of a possible fifteen. This indicated RI #12 was severely impaired for daily decision making skills. RI #12 was non-ambulatory and required assistance with all ADLs. An observation was made on 11/4/2015 at 8:45 AM of the Medication Pass for RI #12. EI #3, an LPN, laid a medication tray on top of the over bed table. The tray had three liquid medications in medication cups sitting on top. When EI #3 went into the bathroom to wash her hands she was out of sight of the resident as well as the medications sitting on the over bed table. EI #3 started washing her hands with soap and water, leaned a little to the right, toward the bathroom door and asked the surveyor if she (the surveyor) could see the meds. The surveyor did not respond. The surveyor was standing just outside the bathroom door and was able to see the nurse, the resident and the medications. On 11/5/2015 at 3:00 PM, an interview was conducted with EI #3. EI #3 was asked if she had been able to see RI #12's medications at all times. EI #3 said not when she was washing her hands. She indicated that she could not take them to the bathroom with her. EI #3 was asked what the potential negative effect could be of not having a resident's medications in sight at all times. EI #3 stated RI #12's roommate could have come in the room and gotten them. On 11/6/2015 at 8:15 AM, an interview was conducted with EI #1. EI #1 was asked what the staff nurses (those who administer medications) were taught about keeping medications in their sight until taken by the resident. EI #1 stated medications were to be kept in sight. The medications were taken to the resident and kept in sight at all times. If the nurse was away from the cart then the cart should be locked. EI #1 was asked why it was important to keep medications in sight at all times. EI #1 stated to prevent anyone from coming and taking the medications, other than the person they were prescribed for.

Based on observations and interviews, the facility failed to ensure a licensed nurse administered medications in a manner to prevent the potential for cross contamination. This affected RI (Resident Identifier) #'s 12, 15, and 20, three of seven residents observed for medication administration. Findings Include: A review of the medical record revealed RI #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #20's Admission MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 10/13/2015, revealed a BIMS (Brief Interview for Mental Status) score of fifteen out of a possible fifteen. This indicated RI #20 was cognitively intact for daily decision making skills. On 11/3/2015 at 4:10 PM, an observation was made of medication pass for RI #20. EI (Employee Identifier) #6, an LPN (Licensed Practical Nurse), prepared medications at the medication cart. EI #6 placed [MEDICATION NAME], and [MEDICATION NAME] into a medication cup and poured Prostat liquid 30 ml (Milliliters) into a separate cup. These cups were placed on top of the unsanitized medication cart. EI #6 also prepared [MEDICATION NAME] Regular Insulin and Nicotine [MEDICATION NAME] Patch prior to entering RI #20's room. For transport into RI #20's room, the surveyor observed EI #6 pick up the medication cups from the top of the cart and stack the medicine cup containing the Prostat into the medicine cup containing the pills with her right hand. An interview was conducted on 11/5/2015 at 4:50 PM with EI #6. The surveyor shared the observation made during med pass. EI #6 was asked what could be the potential negative effect of administering medications to a resident from med cups that had been stacked on top of each other after sitting on an unsanitized surface. EI #6 stated it would be possible to pass germs, could be contaminating medications in the bottom cup. An interview was conducted on 11/6/2015 at 8:45 AM with EI #7, the Infection Control Nurse. EI #7 was asked how should a staff member transport medications into a room for administration to a resident. EI #7 stated the nurse should knock on the door prior to entering the room and tell the resident what they are going to do. EI #7 stated two trips should be made into the room if the nurse could not safely hold everything in one trip. EI #7 was asked if it was appropriate to stack medication cups on top of each other after sitting on an unsanitized surface to carry into the room. EI #7 said no. EI #7 was asked what could be the potential negative effect of administering medications to a resident from med cups that had been stacked on top of each other after sitting on an unsanitized surface. EI #7 said cross contamination. A review of the medical record revealed RI #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #15's Significant Change MDS, with an ARD of 8/17/2015, revealed a BIMS score of thirteen out of a possible fifteen. This indicated that RI #15 was cognitively intact for daily decision making skills. RI #15 was non-ambulatory and required assistance with all ADLs. On 11/3/2015 at 5:35 PM, an observation was made of RI #15 during medication pass. EI #5, an LPN, used hand gel prior to preparing medications for RI #15. As EI #5 took the medications from the cart, she dropped the medication cup with the two pills inside onto the floor. EI #5 reached down and, with her bare hand, picked up the medication cup and pills from the floor and discarded of them appropriately. EI #5 resumed medication pass for RI #15 without washing her hands. An interview was conducted on 11/5/2015 at 5:20 PM with EI #5. EI #5 was asked when hands should be washed during medication pass. EI #5 said that hands should be washed anytime she came in to contact with any body fluid, their spit. EI #5 was asked if it was appropriate to resume medication pass after picking something from off the floor and she said no, the hands needed to be washed. EI #5 was asked what had happened when she dropped EI #15's medication on the floor. EI #5 stated she probably got nervous and didn't think about it. She stated that she did not wash her hands. EI #5 was asked what could be the potential negative effect on the resident of a nurse not washing her hands after picking up something from the floor and then resuming med pass without washing their hands. EI #5 stated whatever germs were on the floor could be transmitted to the resident. An interview was conducted with EI #7 on 11/5/2015 at 6:50 PM. EI # 7 was asked when hands should be washed during medication pass. EI #7 said before the nurse got started and they can use hand sanitizer in between unless they go in and find something soiled, then the hands should be washed. EI #7 was asked what should be done if a medication cup with pills was dropped on the floor during medication pass. EI #7 stated the pills should not be given to the resident and they should pick up the pills to be destroyed. EI #7 was asked if it was appropriate to resume medication pass without washing hands after picking up a medication cup and a pill from the floor. EI #7 stated no because the floor was contaminated. EI #7 was asked what could be the potential negative effect of administering medications to a resident after picking something up from the floor without washing hands. EI #7 stated potential consumption or cross contamination of bacteria. A review of the medical record revealed RI #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #12's Admission MDS, with an ARD of 10/8/2015, revealed a BIMS score of three out of a possible fifteen. This indicated RI #12 was severely impaired for daily decision making skills. RI #12 was non-ambulatory and required assistance with all ADLs (Activities of Daily Living). An observation was made on 11/4/2015 at 4:35 PM during medication pass for RI #12. EI #3, an LPN, administering medications to RI #12 through the G (Gastric) Tube using a syringe and the plunger. After using the plunger, EI #3 was observed to lay the plunger on top of a plastic bag lying on top of a table at the bedside. The plastic bag was the one the syringe and plunger were stored. During the same medication pass, EI #3 was observed to grasp a medication cup with the index and middle finger of her right hand, placing her fingers down into the cup. EI #3 proceeded to place pills in the cup to be be crushed and administered to RI #12. An interview was conducted on 11/5/2015 at 3:00 PM with EI #3. EI #3 was asked where she had placed the plunger of the syringe during RI #12's med pass when it was not in use. She stated she had placed the plunger on the bag that it goes in. EI #3 was asked if the area had been sanitized and she said no. EI #3 was asked if the area on top of the plastic bag lying on a table at the bedside would be considered a clean place, EI #3 said no. EI #3 was asked why. EI #3 stated she had already touched the bag and it had been hanging on the feeding pump. EI #3 was asked what could be the potential negative effect of placing the plunger on an unclean area during medication pass. EI #3 stated she could be putting something in the residents stomach, germs. An interview was conducted on 11/5/2015 at 6:50 PM with EI #7. EI #7 was asked where the plunger should be placed when not in use. EI #7 said inside the plastic bag. EI #7 was asked if it would have been appropriate to place it on top of the plastic bag it had been stored in. EI #7 said preferably not. EI #7 was asked what the potential negative harm would be of using the plunger when it had been placed on an unclean surface. EI #7 stated cross contamination of bacteria off the outside of the bag onto the plunger could be transferred to the syringe as well as the resident.

Based on observations, interviews, and record reviews, the facility failed to ensure medications were administered as ordered by the physician. This affected RI (Resident Identifier) #14, one of seven patients observed for medication administration. Findings include: A review of a facility policy titled, Administration of Drugs, dated October 2014, revealed, Policy Drugs will be administered in a timely manner as prescribed by the resident's attending physician or the Center's Medical Director. Policy Interpretation and Implementation . 2. Drugs must be administered in accordance with the written orders of the attending physician. 7. Drugs may not be set up in advance and must be administered within one (1) hour before or after their prescribed time. 8. Unless otherwise specified by the resident's attending physician, routine drugs should be administered as scheduled. A review of the medical record indicated RI #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #14's Quarterly MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 10/5/2015, revealed RI #14 had a BIMS (Brief Interview for Mental Status) score of 15 out of possible 15 points. This indicated RI #14 was cognitively intact for daily decision making. RI #14 was non-ambulatory and required assistance with all ADLs (Activities of Daily Living). A review of the physician's orders [REDACTED]. [MEDICATION NAME] Capsule 100 MG (Milligrams) . Give 1 capsule by mouth every 12 hours for Urinary Health and Retention . [MEDICATION NAME] CR (Controlled Release) Tablet Extended Release 50-200 MG . Give 1 tablet by mouth two times a day related to SECONDARY PARKINSONISM . The start dates for each medication was 7/07/15. A review of RI #14's MAR (Medication Administration Record) indicated the [MEDICATION NAME] was to be administered at 9:00 AM and 9:00 PM. The [MEDICATION NAME] was to be administered at 9:00 AM and 5:00 PM. An observation was made of EI (Employee Identifier) #2, an LPN (Licensed Practical Nurse), on 11/4/15 at 10:07 AM administering medications to RI #14. The resident received [MEDICATION NAME] 100 MG and [MEDICATION NAME] 50/200 MG along with other medications. An interview was conducted with EI #2 on 11/4/15 at 10:11 AM. EI #2 was asked what time were RI #14's morning medications due. She answered at 9:00 AM and stated she was late administering medications. An interview was conducted on 11/6/15 at 7:59 AM with EI #2. EI #2 was asked how were medications to be administered regarding following MD (Medical Doctor) orders. She answered, Give it exactly as it is ordered. EI #2 was asked why. She answered, That's what the Doctor ordered and that is what he wants the resident on. That's the law. EI #2 was asked what was the facility policy on following physician's orders [REDACTED].#2 was asked what was the potential harm of not following MD orders. She answered, Harm to the resident, the wrong dosage. An interview was conducted on 11/6/15 at 8:03 AM with EI #1, the DON (Director of Nursing). EI #1 was asked how were medications to be administered regarding following MD orders. She answered, I'm gonna go by what the order says. EI #1 was asked why. She answered, Cause it's the regulation, law, and nursing practice. EI #1 was asked what was the facility policy on following physician's orders [REDACTED]. EI #1 was asked what was the potential harm of not following MD orders. She answered, Could be a potential medication error.

Based on observations, interviews, and record reviews, the facility failed to ensure there was no potential for cross-contamination during wound care for RI (Resident Identifier) #3. This was observed on one of two residents observed for wound care. Findings include: A review of the facility's policy titled, Dressings, Non-Sterile, dated May 2013, revealed, . Steps in the Procedure: . 1. Wash hands. 5. Place the equipment on the bedside stand or overbed table. Arrange the supplies so that they can be easily reached. 6. Explain the procedure. 7. Close the door. 8. Pull the cubicle curtain around the bed for privacy. 9. Position resident. 10. Put on disposable exam gloves. 11. Loosen tape and remove soiled dressing. 12. Pull glove over dressing and discard into appropriate receptacle. 13. Wash hands. 14. Put on clean gloves. 15. Observe the wound and surrounding skin. 16. Cleanse the wound. Use separate gauze for each cleansing stroke. Clean from the most contaminated area to the least contaminated area. 17. Use dry gauze to pat the wound dry. 18. Wash hands and apply new gloves. A review of RI #3's medical record revealed RI #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #3's Quarterly MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 08/24/15, indicated RI #3 was coded as requiring extensive assistance with bed mobility and dressing. RI #3 was totally dependent on staff to assist with transfer, locomotion and toileting. RI #3 had a BIMS (Brief Interview for Mental Status) score of three out of a possible fifteen, indicating RI #3 had severe mental impairment for daily decision making. RI #3 had an indwelling urinary catheter and [MEDICAL CONDITION]. On 11/4/15 at 10:19 AM, an observation was made during wound care for RI #3. EI (Employee Identifier) #2, an LPN (Licensed Practical Nurse), proceeded to pull the covers back off of the patient, and move the over bed table. EI #2 then closed the curtain more, and then, with the same gloved hands, rolled the patient to the right side. EI #17, an RN (Registered Nurse)/ADON(Assistant Director of Nursing), removed the old dressing and measured the wound. EI #17 donned clean gloves but did not wash her hands. EI #2 was holding the patient over so EI #17 could measure the wound, then both nurses removed their gloves but did not wash their hands prior to re-gloving. EI #2 and EI #17 then washed their hands and donned clean gloves. EI #2 rolled the patient farther to the right side and placed the bed pad and towel under the right hip of RI #3, holding RI #3's left side and hip. EI #2 took a saline bullet and irrigated the upper part of the wound which was the largest area. Saline ran down the wound. EI #2 wiped with a gauze pad from the top of the wound, (left hip) down towards the right hip and removed her gloves. There was no hand washing performed. EI #2 donned clean gloves and cleaned an area on the left buttocks by irrigating with a saline bullet. Saline dripped down the wound into the wound on the right buttocks. EI #2 used a 4x4 gauze pad to wipe the wound left to right. EI #2 cleaned the wound on RI #3's left buttocks, irrigating it with saline and a 4x4 gauze pad was used in an inner to outer motion to clean the wound. This process was repeated 3 times with the same gauze. On 11/5/15 at 3:26 PM, an interview was conducted with EI #2, an LPN. EI #2 was asked if she performed wound care on EI #3 on 11/4/2015. EI #2 stated, Yes, I did. EI #2 was asked if after washing her hands and donning gloves, what did she do and if she multitasked. She stated she shut the curtain a little more, pulled the covers back off the resident, and held open the red bag while the old dressing was removed. EI #2 stated she did several things. EI #2 was asked if she washed her hands and changed her gloves. EI #2 said no, she did not wash her hands. EI #2 was asked how she wiped the wound after irrigating the wound with saline. EI #2 stated, she wiped the wound with a 4x4 top to bottom. EI #2 was asked how the wound should have been wiped. EI #2 responded, inner to outer. EI #2 was asked how the top wound, left buttock was cleansed and if she washed her hands and changed her gloves. EI #2 stated she did not wash her hands or change her gloves and she had irrigated the wound with saline. EI #2 was asked if the saline dripped down to the wound under it. EI #2 stated, yes. EI #2 was asked what she did in cleaning the wound on the right buttocks that was under the left buttocks. EI #2 stated that her hands were not washed before cleaning this wound prior to cleaning the left buttocks but her gloves were changed. EI #2 was asked how wound care was suppose to be done. EI #2 stated irrigate with saline and clean with 4x4 gauze inner to outer. On 11/5/2015 at 6:16 PM, an interview was conducted with EI #17. EI #17 was asked how the wound care was performed on 11/4/2015 for RI #3. EI #17 stated she entered the room, pulled the curtain, washed her hands and put gloves on. She then positioned the patient for care, removed the soiled dressing, dressed EI #3, placed items in the red bag, removed gloves but did not wash her hands. She measured the wound and red bagged dirty supplies. EI #17 was asked how EI #2 performed wound care. EI #17 stated, the main thing she remembered was EI #2 cleaned the wound from the outside of the wound first and on the largest area she went from top to bottom. EI #2's irrigated saline was running into other areas of the wound not being cleaned at the time. EI #17 was asked how EI #2 did with hand washing and re-gloving. EI #17 stated EI #2 could have done better. EI #17 indicated after cleaning the different sections of the wound, EI #2 should have taken her gloves off and washed her hands each time. EI #2 did change her gloves several times while providing wound care but did not always wash her hands. EI #17 was asked what the potential harm was to RI #3. EI #17 responded infection, slow the healing process, and the wound could get worse.

Based on an observation, interviews, and record reviews, the facility failed to ensure a Certified Nursing Assistant (CNA): 1. Did not turn off the water faucet with bare hands prior to providing incontinence care for RI (Resident Identifier) #7 on 11/4/15; 2. The CNA changed the position of the wash cloth during incontinence care for RI #7; and 3. The CNA washed her hands and changed gloves after cleaning stool off of a resident, prior to applying a clean adult brief. This affected RI #7, one of two residents observed for incontinence care. Findings Include: A review of POTTER & PERRY Fundamentals of Nursing, 7th Edition, revealed, . page, 877-878 . 39-2 . Perineal Care . 3. Apply clean gloves, and assess genitals for signs of inflammation, skin breakdown, or infection. Discard gloves. Perform hand hygiene. 6. Prepare necessary equipment and supplies. 7. Assemble supplies at bedside. 8. Raise bed . 9. Apply clean gloves. 15. Provide perineal care. A. Female perineal care . (5) Separate labia with nondominant hand to expose urethral meatus and vaginal orifice. With dominant hand, wash downward from pubic area toward rectum in one smooth stroke . Use separate section of cloth for each stroke. A review of a facility document titled, Perineal Care, dated August 2014, revealed, . 14 For a female resident: . b. Wash perineal area, wiping from front to back. Fold washcloth or change washcloth with each downward stroke or use new pre-moistened wipe with each downward stroke. A review of a facility document titled, Handwashing, dated July 2015, revealed, Policy Handwashing shall be regarded by this Center as the single most important means of preventing the spread of infection. 1. All personnel shall follow our established Handwashing procedures to prevent the spread of infection and disease to other personnel, patients, and visitors. 2. Employees must perform appropriate Handwashing procedures under the following conditions: . g. After contact with blood, body fluids, excretions, secretions, mucous membranes, . l. Whenever in doubt; . 3. The use of gloves does not replace Handwashing. A review of RI #7's medical record revealed the resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #7's Annual MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 10/5/2015, revealed RI #7 had short and long term memory problems and had severe cognitive impairment for daily decision making skills. RI #7 required extensive assistance with all ADLs (Activities of Daily Living). RI #7 was always incontinent of bowel and bladder. On 11/4/2015 at 2:45 PM, the following was observed during incontinence care for RI #7. EI (Employee Identifier) #4, a CNA, washed her hands and turned the water faucet off with her bare hands. The resident was transferred to the bed via a standing lift. EI #4 washed her hands, turned off the faucet with her bare hands and applied gloves. EI #4 removed RI #7's shoes and pants then pulled the adult brief down between the resident's legs with gloved hands. EI #4 removed her gloves and obtained a basin of water. EI #4 put the basin of water on the bedside table and applied a pair of gloves. She wet the wash cloth and applied soap. EI #4 wiped the resident's left groin, the right groin, opened the labia and wiped down the middle of the labia. EI #4 cleaned the resident from front to back but did not change the position of the wash cloth with each wipe. EI #4 changed wash cloths and repeated the same steps. She did not change the position of the wash cloth. The resident was rolled to the right side. EI #4 wiped between the buttocks and removed a small amount of soft brown stool. She repeated 2 more times with a clean soapy washcloth. EI #4 then rinsed the resident's perineal area with a clean wet washcloth. EI #4 did not change gloves or wash her hands. EI #4 placed a clean brief onto RI #7. On 11/5/15 at 4:00 PM, EI #4 was interviewed via telephone. The surveyor asked EI #4 how she provided incontinence care for RI #7 during the above observation. EI #4 stated she laid RI #7 on the back, pulled off the brief and discarded the gloves. EI #4 explained she cleaned both sides of the labia, then the center labia from front to back. EI #4 stated she turned over RI #7 and she cleaned the resident with a different wash cloth from front to back. The surveyor asked EI #4 if she changed or folded the wash cloth between each wipe. EI #4 stated she wiped left, right, and center. EI #4 was asked when was the cloth folded. She answered after each wipe. The surveyor shared the above observation with EI #4. EI #4 then stated it was not her intention, it may have been just nerves. EI #4 was asked what was the potential negative outcome when the wash cloth was not changed or folded between wipes. EI #4 stated it could be a hazard of cross contamination, transferring germs. EI #4 was asked if she used her bare hands to turn off the faucet prior to providing incontinence care for RI #7. EI #4 said yes.

Based on observation, interview, and document review, the facility failed to ensure the tube feeding for RI (Resident Identifier) #12 was properly labeled on 1 of 4 survey days. This affected RI #12, one of two residents receiving tube feeding via gastric tube. Findings include: A review of the medical record revealed RI #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #12's Admission MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 10/8/2015, revealed a BIMS (Brief Interview for Mental Status) score of three out of a possible fifteen. This indicated RI #12 was severely impaired for daily decision making skills. RI #12 was non-ambulatory and required assistance with all ADLs. A review of RI #12's physician's orders [REDACTED]. An observation was made during medication pass on 11/4/2015 at 8:45 AM. The surveyor observed a tube feeding bag hanging on a feeding pump with formula still in the bag. The feeding pump was turned off and the tubing was not connected to the resident. The label on the bag read: [MEDICATION NAME] 240 cc 1800 (6:00 PM) [MEDICATION NAME] 240 cc 1800 No rate was written on the label. The surveyor asked EI (Employee Identifier) #3, an LPN (Licensed Practical Nurse), how would she know the rate the tube feeding should be infusing if it was not written on the label. EI #3 said it should be on the bag. EI #3 looked at the feeding bag and stated, I guess just look at the pump. EI #3 pressed a button on the pump and the pump read 60 cc. EI #3 then stated the rate would not be known, the rate was supposed to be written on the label. An interview was conducted on 11/5/2015 at 4:50 PM with EI #6. EI #6 was asked if she had hung RI #12's tube feeding on Tuesday and Wednesday evening, 11/3/2015 and 11/4/2015. EI #6 said yes. EI #6 was asked what time she had hung the feeding. EI #6 stated between 6:00 PM and 6:30 PM. EI #6 was asked what was the rate of the infusion. EI #6 stated she had to set it at 70 cc/hr. The surveyor shared the observation made on 11/3/2015 with EI #6. EI #6 stated that she had to set the pump at 70 cc every night. She stated that sometimes when she turns the pump on it will be on 60 or it could be on zero. EI #6 stated she thought maybe the night shift cleaned the pumps or something and that was why it would not return to the set rate of 70 cc.

Based on observations, interviews, and record reviews, the facility failed to ensure there was less than a 5.0% (percent) medication error rate as evidenced by a medication error rate of 5.714% during the survey. This affected RI (Resident Identifier) #14, one of seven residents observed for Medication Pass. Findings include: A review of a facility policy titled, Administration of Drugs, dated October 2014, revealed, Policy Drugs will be administered in a timely manner as prescribed by the resident's attending physician or the Center's Medical Director. Policy Interpretation and Implementation . 2. Drugs must be administered in accordance with the written orders of the attending physician. 7. Drugs may not be set up in advance and must be administered within one (1) hour before or after their prescribed time. 8. Unless otherwise specified by the resident's attending physician, routine drugs should be administered as scheduled. A review of the medical record indicated RI #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #14's Quarterly MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 10/5/2015, revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15 out of possible 15 points. This indicated RI #14 was cognitively intact for daily decision making. RI #14 was non-ambulatory and required assistance with all ADLs (Activities of Daily Living). A review of the physician's orders [REDACTED]. [MEDICATION NAME] Capsule 100 MG (Milligrams) . Give 1 capsule by mouth every 12 hours for Urinary Health and Retention . [MEDICATION NAME] CR (Controlled Release) Tablet Extended Release 50-200 MG . Give 1 tablet by mouth two times a day related to SECONDARY PARKINSONISM . The start dates for each medication was 7/07/15. A review of RI #14's MAR (Medication Administration Record) revealed, . [MEDICATION NAME] Capsule 100 MG .Give 1 capsule by mouth every 12 hours . Hours 0900 (9AM) 2100 (9PM) .[MEDICATION NAME] CR Tablet Extended Release 50-200MG . Give 1 tablet by mouth two times a day . Hours 0900 1700 (5PM) . An observation was made on 11/4/15 at 10:07 AM, of EI (Employee Identifier) #2, an LPN (Licensed Practical Nurse), administering medications to RI #14. The resident received [MEDICATION NAME] 100 MG and [MEDICATION NAME] 50/200 MG along with other medications. An interview was conducted with EI #2 on 11/4/15 at 10:11 AM. EI #2 was asked what time were RI #14's morning medications due. She answered at 9:00 AM and she indicated she was late.

Based on observations, interviews, and document reviews, the facility failed to ensure residents were offered a bedtime snack. This affected RI (Resident Identifier) #s 3, 11, 13, 18, and 19; five of nineteen diabetic residents. Findings include: A review of a facility menu for Cycle 1, 2015 revealed, . Sunday . BRK (Breakfast) . LUN (Lunch) . DIN (Dinner) . Snack of the Day . Monday . BRK . LUN . DIN . Snack of the Day . Tuesday . BRK . LUN . DIN . Snack of the Day . Wednesday . BRK . LUN . DIN . Snack of the Day . Thursday . BRK . LUN . DIN . Snack of the Day . Friday . BRK . LUN . DIN . Snack of the Day . Saturday . BRK . LUN . DIN . Snack of the Day . The daily menu included an evening snack. A review of a facility policy titled, Snacks (Between Meal and Bedtime), Serving, dated January 2015, revealed, . Purpose: The purpose of this procedure is to provide the resident with adequate nutrition. Steps in the procedure . 3. Ask the resident if he/she wishes to have a snack. Place the snack on the overbed table or serving area. 8. If the resident wishes to eat his/her snack later, or cannot eat now, check with the staff/Charge Nurse about serving the resident at a later time. Reporting and Documentation: The following information may be reported to the staff/Charge Nurse and may be documented in the resident's medical record: 1. The date and time the procedure was performed. 2. The amount of snack eaten by the resident (i.e. (in example), 50%, 75%, etc. {et cetera}). 3. Any problems the resident had with chewing or swallowing his/her food. A review of RI #3's current medical record revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #3's quarterly MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 08/24/2015, indicated RI #3 had a BIMS (Brief Interview for Mental Status) score of three out of a possible fifteen, indicating RI #3 had severe mental impairment for daily decision making skills. RI #3 required extensive assistance with bed mobility and dressing. RI #3 was totally dependent on staff to assist with transfer, locomotion and toileting. RI #3 required supervision with eating. A review of RI #11's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #11's Admission MDS dated [DATE] revealed RI #11 had a BIMS score of eleven out of a possible fifteen. This score indicated RI #11 was moderately impaired for daily decision making skills. RI #11 was assessed as requiring extensive assistance with all ADLs. A review of RI #13's medical record revealed the resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #13's Annual MDS dated [DATE] revealed RI #13 had a BIMS score of fourteen out of a possible fifteen. This score indicated RI #13 was cognitively intact for daily decision making skills. A review of RI #18's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #18's Quarterly MDS dated [DATE] revealed the resident had a BIMS score of seven out a possible fifteen, indicating RI #18 was severely impaired for daily decision making skills. RI #18 was assessed as requiring extensive staff assistance with all ADLs. A review of the medical record revealed RI #19 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #19's Quarterly MDS, assessment dated [DATE], revealed the resident had a BIMS score of fifteen out of a possible fifteen. This score indicated RI #19 was cognitively intact for daily decision making skills. During the Resident Council meeting held with residents on 11/03/2015 at 2:15 PM, RI #18 and RI #19 both voiced concerns. The two residents stated they had never received a bed time snack. An observation began at 6:31 PM on 11/4/15 through 8:25 PM on 11/04/2015 for the distribution of HS (Bed Time) snacks. CNAs (Certified Nursing Assistants) were observed offering HS snacks to residents that were diabetic. However, not all diabetics were offered an HS snack. RI #3 was asked if a bed time snack was offered and the answer was no. On 11/05/2015 at 1:55 PM, RI #13 was asked if they received a snack after supper on the previous night. RI #13 stated, No, they didn't bring me one. On 11/05/2015 at 2:10 PM, RI #11 was asked if they received a snack the previous night. RI #11 stated, No ma'am. Un-sampled residents were observed receiving snacks and were interviewed after they received their snacks on 11/04/2015. A total of five residents were observed on 11/04/2015 receiving a bed time snack between 8:05 PM and 8:25 PM. Each resident was asked how often they were offered a bedtime snack. The responses included: 1) every now and then, 2) far and few between, could not remember the last time, 3) only the second time since they (the resident) were admitted ; 4) first one in a long time; and 5) this was first time they (staff) had come to offer a bedtime snack. There were no non-diabetic residents observed to be offered a bed time snack on 11/04/15. On 11/4/15 at 6:45 PM, an interview was conducted with EI #15, a dietary aide. EI #15 was asked if a list was available of residents that were prepared HS snacks. EI #15 stated, (That there was) No list. An interview was conducted on 11/4/15 at 8:11 PM with EI #20, a CNA (Certified Nursing Assistant). EI #20 was asked how did she know who to offer snacks. EI #20 replied, To my diabetics. EI #20 was asked if she had offered RI #11, a diabetic, a snack and she answered, No, I didn't. On 11/5/15 at 5:24 PM, an interview was conducted with EI #16, a CNA. EI #16 was asked who was responsible for residents getting HS snacks. EI #16 stated, The CNAs and sometimes the nurses will help too. EI #16 was asked which residents were supposed to get HS snacks. EI #16 responded, The diabetic ones. EI #16 was asked what was the potential negative outcome of diabetic residents not receiving HS snacks. EI #16 replied, Go into a coma. EI #16 was asked what was the facility's policy on HS snacks. EI #16 responded, The CNAs are supposed to get them and (also for) any residents that ask. EI #16 was asked who was suppose to offer the snacks to the residents. EI #16 replied, CNAs. EI #16 was asked why were snacks not offered to all residents on 11/4/15. EI #16 stated, I don't know because we usually just give them to the diabetics unless someone asks. EI #16 was asked why would RI #11 and RI #13, both diabetics, not get offered an HS snack. EI #16 stated, I don't see any reason why. On 11/5/15 at 5:33 PM, an interview was conducted with EI #18, a CNA. EI #18 was asked who was responsible for ensuring the residents receive HS snacks. EI #18 stated, CNAs. EI #18 was asked which residents were supposed to get HS snacks. EI #18 answered, All of them except for tube feeding residents. EI #18 was asked what was the potential negative outcome of diabetic residents not receiving HS snacks. EI #18 replied, (Their) sugar could bottom out. EI #18 was asked, what was the facility's policy on HS snacks. EI #18 answered, Offer them. On 11/5/2015 at 5:37 PM, an interview was conducted with EI #6, an LPN (Licensed Practical Nurse). EI #6 was asked who was responsible for ensuring the residents received HS snacks. EI #6 stated, Everybody. EI #6 was asked which residents were supposed to get HS snacks. EI #6 responded, All of them. EI #6 was asked what was the potential negative outcome of diabetic residents not receiving HS snacks. EI #6 replied, Blood sugar dropping. EI #6 was asked what was the facility's policy on HS snacks. EI #6 responded, All residents are supposed to be offered a night time snack. EI #6 was asked why were snacks not offered to all residents on 11/4/15. EI #6 stated, I didn't know they weren't. EI #6 was asked why would RI #11 and RI #13, both diabetics, not get offered an HS snack. EI #6 stated, I didn't know they weren't. On 11/5/15 at 6:20 PM, an interview was conducted with EI #5, an LPN. EI #5 was asked who was responsible for ensuring the residents received HS snacks. EI #5 stated, Any of the staff that's here, that's the nurses or CNAs. EI #5 was asked which residents were supposed to get HS snacks. EI #5 responded, We offer them to anyone that wants one, but mostly the diabetics. We try to make sure the diabetics get one, but we try to have extra in case someone else wants one. EI #5 was asked what was the potential negative outcome of diabetic residents not receiving HS snacks. EI #5 replied, Their sugar could drop overnight. EI #5 was asked what was the facility's policy on HS snacks. EI #5 stated, I don't know. EI #5 was asked if residents other than diabetics were supposed to be asked if they wanted a snack. EI #5 replied, Yes ma'am. EI #5 was asked why RI #11 and RI #13, both diabetics, did not get offered a snack on 11/04/15. EI #5 stated, No one told me. The CNAs did not tell me. EI #5 was asked if diabetic residents were supposed to ask for HS snacks. EI #5 stated, Generally, no. On 11/5/15 at 7:51 PM, an interview was conducted with EI #1, the DON (Director of Nursing). EI #1 was asked who was responsible for ensuring the residents received HS snacks. EI #1 stated, The CNAs and nurses. EI #1 was asked which residents were supposed to get HS snacks. EI #1 responded, Offer for our diabetics, if non-diabetics want (one) they have to ask. EI #1 was asked what was the potential negative outcome of diabetic residents not receiving HS snacks. EI #1 replied, Low blood sugar that morning, [DIAGNOSES REDACTED]. EI #1 was asked what was the facility's policy on HS snacks. EI #1 stated, Don't remember. EI #1 was asked why were snacks not offered to all residents on 11/4/15. EI #1 responded, They should have been. EI #1 was asked why RI #11 and RI #13 did not get offered a snack. EI #1 stated, No ma'am. EI #1 was asked if she was aware residents were not being offered snacks. EI #1 replied, No ma'am. EI #1 was asked who monitors to ensure HS snacks were given. EI #1 stated, The Charge Nurse.

Based on observations and interviews, the facility failed to ensure a licensed nurse documented the administration of a controlled medication on the EMAR (Electronic Medication Administration Record). This affected RI (Resident Identifier) #12, one of seven residents observed for medication administration. Findings include: A review of a facility policy titled, Administration of Drugs, revealed, . 11. When PRN (as needed) drugs are administered, the nurse should record: a. The date and time administered; . A review of the medical record revealed RI #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #12's Admission MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 10/8/2015, revealed a BIMS (Brief Interview for Mental Status) score of three out of a possible fifteen. This indicated RI #12 was severely impaired for daily decision making skills. RI #12 was non-ambulatory and required assistance with all ADLs (Activities of Daily Living). A review of the November 2015 EMAR for RI #12 revealed the [MEDICATION NAME] was administered to the resident on 11/04/2015 at 4:42 PM. An observation was made during medication pass on 11/4/2015 at 9:20 AM. The surveyor observed EI #3, an LPN (Licensed Practical Nurse), prepare the [MEDICATION NAME] by pouring it into a medication cup. EI #3 entered the room with the medication cup in her hand. EI #3 handed the medication cup containing the [MEDICATION NAME] to RI #12. RI #12 took a sip of water, took the medication cup from EI #3 and swallowed the [MEDICATION NAME]. The resident then took another sip of water prior to taking the rest of their medications. An interview was conducted on 11/5/2015 at 3:00 PM with EI #3. EI #3 was asked if she had administered a dose of [MEDICATION NAME] to RI #12 on 11/4/2015. EI #3 stated she had given the [MEDICATION NAME] to RI #12. EI #3 was asked what time she gave the medication. EI #3 said about 9:30 AM. The surveyor showed EI #3 the November 2015 EMAR for RI #12. EI #3 was asked where the [MEDICATION NAME] was documented as being given. EI #3 stated it should be on there. After looking at the EMAR, EI #3 stated the documentation was not there, she did not see the documentation that she had given the [MEDICATION NAME] on the EMAR. EI #3 was asked what could be a potential negative outcome of not documenting on the EMAR when a medication had been administered. EI #3 said it would not be known when the last dose had been given. On 11/6/2015 at 8:15 AM an interview was conducted with EI #1, the DON (Director of Nursing). EI #1 was asked what employees were taught regarding documentation when medications were given. EI #1 stated they were taught to click the brick, when the medication was going to be given. She explained the nurse took the medication in the resident's room and administered it. After the medication was administered, the nurse clicked save, which documented the medication was administered at that time. The surveyor asked EI #1 what was the policy when a narcotic was administered. EI #1 said the narcotic sheet was signed out when the medication was pulled. The nurse then documented on the MAR. The surveyor asked where should it be documented. EI #1 said on the Electronic MAR and the Narcotic Sheet, on the controlled medications. The surveyor asked EI #1 was it appropriate for the nurse to document on the control book but not the electronic MAR . EI #1 said no, nurses had to document on both. EI #1 was asked what could be the potential negative outcome when a medication was administered but not documented on the electronic MAR. EI #1 stated if a nurse did not document, they had no way of knowing when it was last given.

Based on an observations, interviews, and record reviews, the facility failed to ensure: 1) A CNA (Certified Nursing Assistant) washed hands prior to providing incontinence care. This affected RI (Resident Identifier) #8, one of two residents observed for incontinence care. 2) A CNA did not lay wash cloths in a dirty sink and use them to provide incontinence care. This affected RI #8, one of two residents observed for incontinence care. 3) A CNA changed the position of the wash cloth during incontinence care for RI #1 4) A CNA cleaned the front of RI #1's perineal area in a manner to prevent the potential for cross contamination during incontinence care. 5) A CNA washed her hands after removing gloves, when stool was removed from RI #1during incontinence care. This affected RI #1, one of two residents observed for incontinence care. Findings include: A review of, "POTTER & PERRY... Fundamentals of Nursing...7th Edition," revealed: "...page 655...Chapter 34 Infection Prevention and Control... The CDC (Center for Disease Control Prevention) (2002 b) recommends the following: ... 2. If hands are not visibly soiled, use an alcohol-based waterless antiseptic agent for routinely decontaminating hands in all other clinical situations: ... c. After contact with body fluids or excretions, mucous membranes, ... d. When moving from a contaminated body site to a clean body site during client care. ... h. After removing gloves..." A review of, "POTTER & PERRY... Fundamentals of Nursing...7th Edition...reprint 2009," revealed: "...page- 878 and 879...39-2...Perineal Care... 3. Apply clean gloves, and assess genitalia for signs of inflammation, skin breakdown, or infection...Discard gloves. Perform hand hygiene... 10. If fecal material is present, enclose in a fold of underpad or toilet tissue...Cleanse buttocks and anus, washing front to back...Cleanse, rinse, and dry area thoroughly. ... 11. If gloves are soiled, perform hand hygiene and then apply new pair of gloves. ... 15. Provide Perineal care. ... B. Male perineal care... (3) Gently raise penis, and place bath towel underneath. Gently grasp shaft of penis. If client is uncircumcised, retract foreskin ... (4) Wash tip of penis at urethral meatus first. Using circular motion. Cleanse from meatus outward. ...Discard washcloth, and repeat with clean cloth until penis is clean. Rinse and dry gently. (5) Return foreskin to its natural position. (6) Wash shaft of penis with gentle but firm downward [MEDICAL CONDITION]. ... (7) Gently cleanse scrotum. ... 17. Remove clean gloves, dispose in proper receptacle, and perform hand hygiene. ..." The facility's Policy entitled, "Perineal Care," dated November 2001, revealed: "This procedure may involve potential/direct exposure to blood, body fluids, infectious diseases, air contaminants, and hazardous chemicals. Protective Barriers That May Be Needed Handwashing Gloves... Purpose The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Equipment and Supplies... 1. Wash Basin; 2. Towels; 3. Wash cloth; 4. Soap; ... 18. For a male resident: ... b. Wash perineal area starting with urethra and working outward. ... c. Thoroughly rinse perineal area in same order, using fresh water and clean washcloth. ... h. Wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks. ... i. Dry area 19. Remove disposable gloves... 20. Reposition the covers... 25. Wash hands. ..." A review of a facility document dated August 2014 and titled, "PREVENTING THE SPREAD OF INFECTIONS," revealed : "The single most important measure in the Prevention and control of infection is HANDWASHING! HANDWASHING: SOME POINTS TO REMEMBER ...Following are some instances when hand washing must be done: ...Before and after caring for each resident." A review of the medical record revealed RI #8 was admitted on [DATE], with [DIAGNOSES REDACTED]. RI #8 was on Hospice for comfort measures and was careplanned for incontinent episodes of bowel and bladder. The most recent Significant Change of Status MDS (Minimum Data Set) for RI #8, with an ARD (Assessment Reference Date) of 11/13/14, revealed a BIMS (Brief Interview for Mental Status) score of 3 out of a possible 15 points. This indicated RI #8 was severely impaired for daily decision making skills. This MDS also indicated RI #8 required extensive assistance with all of the ADLs (Activities of Daily Living.) RI #8 was coded as always incontinent of bowel and bladder. On 12/16/14 at 1:30 PM, an observation was made of incontinence care for RI #8. The incontinence care was performed by EI (Employee Identifier) #1, a CNA (Certified Nursing Assistant). EI #1 did not wash her hands prior to performing incontinence care. EI #1 was also observed laying washcloths in the bottom of the sink to wet them, without using a basin. EI #1 took a washcloth and wiped down the right side of the groin in a downward motion, and then took the same washcloth and wiped down the left side of the groin in a downward motion. EI #1 did not wipe the penis or scrotum. EI #1 turned RI #8 over to the right side, took off the adult brief and a quarter sized amount of stool was noted on it. EI #1 then placed a new adult brief on RI #8 without cleaning off the stool or washing the buttocks. EI #1 was asked to show the surveyor the adult brief and EI #1 acknowledged the stool, but did not clean RI #8. On 12/17/14 at 3:00 PM an interview was conducted with EI #1. EI #1 was asked why should hands be washed before performing incontinence care. EI #1 stated, "To prevent germs from (being) carried out from the hall to (RI #8). EI #1 was asked if she washed her hands prior to performing incontinence care for RI #8. EI #1 stated, "I used hand sanitizer in the hall." EI #1 was asked if clean washcloths were placed in the dirty sink and water ran over them prior to performing incontinene care for RI #8. EI #1 stated, "There was a washcloth already in the sink... I should have used a pan of water instead. The sink was dirty that's why I went and told Environmental Services to clean it." EI #1 was asked should clean washclothes come in contact with a dirty sink and then be used to perform incontinence care. EI #1 stated, "No ma'am." EI #1 was asked what was the proper way to perform incontinence care. EI #1 stated, "Front to back. You (retract the skin on) the penis and wash it good. Clean around it good, swap rags, go down and clean around (the) scrotum. You clean real good and change rags. Dry (RI #8) good. ... I always turn (RI #8) over and start on the bottom, from middle to back." EI #1 was asked why RI #8's penis and scrotal areas were not cleaned. EI #1 stated, "I told you, you got me bad. I wasn't prepared for all that when you came in." EI #1 was asked what was the proper way to clean the penis. EI #1 stated, "You skin back (retract the skin from) the penis and wash it good. You keep changing your gloves." EI #1 was asked if RI #8 had been cleaned, after stool was seen on the adult brief. EI #1 stated, "When I went to change it, I was just trying to get finished. You made me nervous." EI #1 was asked what potential harm could occur to a resident if stool was not removed from the skin. EI #1 stated, "It can cause a rash or breakdown." On 12/17/14 at 4:35 PM, an interview was conducted with EI #3, the Infection Control Nurse. EI #3 was asked should hands be washed prior to performing incontinence care. EI #3 stated, "Yes, to prevent cross contamination." The surveyor asked what would be the potential for cross contamination, when hands were not cleaned prior to performing incontinence care. EI #3 stated. "Potential for cross contamination." EI #3 was asked why should clean wash cloths not be placed in the bottom of a dirty sink, prior to using them to provide incontinence care. EI #3 stated, "Most definitely, cross contamination." The surveyor asked EI #3, what areas should be cleaned on a male during incontinence care. EI #3 stated, "The inner groin area should be cleaned. Start with the head of the penis and go down the shaft. If there is foreskin, retract the foreskin and continue to clean the penis in a downward motion. Clean around the testicles and lift the scrotum and make sure that area is cleaned. I would then turn the patient and make sure the buttocks and buttock folds are cleaned (in a) front to back motion. Clean the entire area, and then dry the resident. ..." The surveyor asked EI #3 what was the potential concern if the penis was not cleaned after a resident had a BM (bowel movement). EI #3 stated, "The same as above. Skin breakdown can occur, infection, not only urinary. Especially if they have Dementia, they can place their hands in those areas, and then touch their eyes, mouth, ... You don't want E (Escherichia) Coli in the eyes mouth or anywhere else." A review of RI #1's medical record revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #1's Quarterly MDS, with an ARD of 11/3/14, indicated RI #1 had short and long term memory problems and was severely impaired for daily decision making. RI #1 required extensive to total assistance with all activities of daily living. RI #1 was coded as always incontinent of bowel and bladder. On 12/16/14 at 3:35 PM, an observation was made of incontinence care for RI #1. The incontinence care was performed by EI #2, a CNA. EI #2 applied gloves and put water into a basin and added soap from the soap dispenser on the wall in the resident's bathroom. EI #2 washed her hands and applied gloves. EI #2 removed one of the padded side rails from RI #1's bed, then opened the adult brief and said RI #1 was dry. RI #1 was rolled onto the left side and the adult brief was removed. A small to moderate amount of loose brown stool was observed on RI #1's bottom. EI #2 wiped RI #1's buttock three times without changing the position of the wash cloth. EI #2 cleaned RI #1 by stroking in a back and forth motion. EI #2 changed position of the wash cloth. Stool was observed on the wash cloth. EI #2 stroked RI #1's bottom in a back and forth motion seven times without changing the position of the wash cloth. EI #2 continued to clean stool from RI #1's bottom. EI #2 dipped a clean wash cloth in the basin of soapy water. EI #2 stroked RI #1's bottom in a back and forth motion eight times. EI #2 did not change position of the wash cloth. EI #2 changed her gloves, but did not wash her hands after removing stool from RI #1's bottom. RI #1 was turned on to the back. EI #2 dipped the wash cloth that was obtained from RI #1's roommate's side of the room, into the basin of water with soap. EI #2 cleaned RI #1's perineal area by wiping down the front of the top of RI #1's penis. EI #2 then cleaned the shaft of the penis by wiping down and up, without changing position of the wash cloth. EI #2 changed position of the wash cloth then wiped down each side of the front of the perineal area between the upper thighs. EI #2 did not change position of the wash cloth. EI #2 did not clean under the scrotum of RI #1. EI #2 applied the adult brief. EI #2 did not rinse RI #1's perineal area. EI #2 repositioned RI #1 and pulled the covers up over the resident. EI #2 rinsed out the basin, then removed her gloves and washed her hands. On 12/16/14 at 3:35 PM, an interview was conducted with EI #2. EI #2 was asked when did she wash her hands while providing incontinence care for RI #1. EI #2 stated, "I rinsed them off before, but I did not wash them until after I finished. I get nervous." The surveyor asked EI #2 what direction did she wipe to cleaned RI #1's front of the perineal area, and to remove the stool from RI #1's bottom. EI #2 stated, "I was not doing peri (perineal) care. I was just cleaning RI #1 up, but I wiped him down. You did not ask me to do peri care. I just washed him up. I wiped down on the front." The surveyor asked EI #2 what direction did she wipe RI #1's bottom during the incontinence care. EI #2 stated, "I wiped up." The surveyor shared the above observation with EI #2. EI #2 stated, "I don't remember doing that, but I probably did. I was nervous." EI #2 was asked when did she change the position of the wash cloth while removing stool from RI #1's bottom. EI #2 stated, "I changed it. I can't tell you when, but I did change the position of the cloth." The surveyor asked EI #2 what direction should she wipe the resident during incontinence care. EI #2 stated, "On the front, I'm suppose to wipe down. On the back I'm suppose to wipe up." EI #2 was asked when should the position of the wash cloth be changed during incontinence care. EI #2 stated, "When I wipe down one side, I'm suppose to get another wash cloth." The surveyor asked EI #2 when should hands be washed during incontinence care. EI #2 stated, "I should have washed my hands before I started and then do the care, and then after." On 12/17/14 at 5:25 PM, an interview was conducted with EI #3, the Infection Control Nurse. EI #3 was asked when should staff wash their hands while providing incontinence care. EI #3 stated, "Before and after." The surveyor asked EI #3 should staff wash their hands after removing gloves when stool was removed from a resident's bottom. EI #3 stated, "If you have the opportunity safely, sometimes you cannot leave the resident." EI #3 was told another staff member was assisting to hold RI #1 onto the side. EI #3 stated, "They are taught to wash their hands before and after. They are taught to change gloves in-between. Wash hands in the beginning, do the procedure by wiping from front to back. Roll up the dirty laundry. Put on new gloves so you can touch the patient and pull the gown down. Most of the time you cannot leave in the middle safely, to wash hands." EI #3 was asked when should staff provide incontinence care, for example if a resident had stool, would incontinence care be necessary. EI #3 stated, "Yes, if they are soiled or wet." The surveyor shared the above observation. EI #3 was asked when should staff change position of the wash cloth during incontinence care. EI #3 stated, "They are taught to change position with every swipe. They are taught the four corner technique." The surveyor asked which direction should staff wipe the resident during incontinence care. EI #3 stated, "Front to back away from the urethra." EI #3 was asked should staff wipe a resident's bottom in a back and forth motion during incontinence care. EI #3 stated, "Staff are taught to wipe from front to back in a single motion." EI #3 was asked why should staff not wipe in a back and forth motion during incontinence care. EI #3 stated, "To prevent bringing feces into a clean area." The surveyor asked EI #3 what the concern was when hands were not washed after removing gloves, when stool was removed from a resident's bottom. EI #3 stated, "Cross contamination/self contamination, even." EI #3 was asked what the concern was when improper incontinence care was provided for a resident. EI #3 stated, "I would be concerned for skin breakdown and UTI (Urinary Tract Infections), and infections in other areas."

The facility failed to ensure: 1. Tube feeding tips were not left uncapped during the tour on 12/16/14. This affected RI (Resident Identifiers) #16 and RI #17, two of four sampled residents with G- (Gastrostomy) tubes. 2. An LPN (Licensed Practical Nurse) did not turn off the faucet with her bare hands during a medication pass observation on 12/16/14. 3. An LPN cleaned and dried a feeding tube syringe, during a medication pass observation on 12/16/14. This affected RI #11, one of one residents observed for medication administration via [DEVICE]. Findings include: 1) A review of RI #16's medical record revealed RI #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #16's Admission MDS (Minimum Data Set), with an (ARD) Assessment Reference Date of 11/17/14, revealed RI #16 had long and short term memory problems and was severely impaired for cognition. RI #16 required extensive to total assistance for all activities of daily living. During the tour of the facility on 12/16/14 at 8:40 AM, RI #16 was observed sitting up in bed with the head of the bed elevated. The tube feeding was off and the feeding bag tubing tip was not covered with a cap. The exposed tip of the tubing was hanging on the side of the feeding machine. Spots of formula were observed on the machine. A review of RI #17's medical record revealed RI #17 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #17's Quarterly MDS, with an ARD of 10/13/14, revealed RI #15 had a BIMS (Brief Interview for Mental Status) score of 15 out of a possible 15 points. This score indicated RI #17 was cognitively intact. RI #17 required extensive to total assistance for all activities of daily living. During the tour on 12/16/14 at 9:05 AM, RI #17 was out of the room. The tube feeding was off and the feeding bag tubing tip was not covered with a cap. The exposed tip of the tubing was hanging on the back of the machine. A small amount of formula was observed on the machine. An interview was conducted on 12/18/14 at 10:30 AM, with EI (Employee Identifier) #5, the Director of Nursing of the facility. The surveyor asked EI #5 how should the tube feeding tip be stored when the tube feeding was not connected, or in use. EI #5 stated, "They have caps that go on top of the tips." EI #5 was asked what the concern was, when the tube feeding tips were uncovered and dangling on the side of the pumps. EI #5 stated, "Potential for contamination." 2) A review of the facility's Policy entitled, "PREVENTING THE SPREAD OF INFECTIONS ...Handwashing," dated [DATE], revealed: "HANDWASHING: SOME POINTS TO REMEMBER... Turn off the water with a dry paper towel and discard it in an appropriate receptacle. Never touch the faucet with your hands after washing. The faucet is considered to be dirty! ..." A review of RI #11's medical record revealed RI #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #11's Quarterly MDS dated , with an ARD of 9/22/14, revealed RI #11 had a BIMS score of 12 out of a possible 15 points. This score indicated RI #11 was moderately impaired for cognition. RI #11 required extensive to total assistance for all activities of daily living. During a medication observation on 12/16/14 at 1:40 PM, an LPN, EI #4, set up medications to be administered to RI #11. EI #4 crushed a pink pill and put it in a medication cup and entered RI #11's room. EI #4 washed her hands and turned off the faucet with her bare hands. EI #4 administered the medication and formula to RI #11 via G tube. EI #4 washed her hands and turned off the faucet with her bare hands. EI #4 rinsed out the feeding tube syringe with water. EI #4 did not dry the syringe. Water was observed on the inside of the syringe and approximately 1-2 cc (cubic centimeters) of water was observed in the plastic bag that the syringe was placed in. There was a pink coating observed on the inside of the syringe. An interview was conducted with EI #3, the Infection Control Nurse, on 12/17/14 at 5:25 PM. The surveyor asked EI #3, how staff should turn off the faucet during handwashing. EI #3 stated, "Dry your hands, and use the paper towel to turn off the faucet." The surveyor shared the above observation with EI #3 and asked what the concern was. EI #3 stated, "I would be concerned that bacteria would develop in the water and with hands, a soiled hand used to turn the faucet off would contaminate the clean hands." An interview was conducted with EI #3, the Infection Control Nurse, on 12/17/14 at 5:25 PM. The surveyor asked EI #3, how staff should turn off the faucet during handwashing. EI #3 stated, "Dry your hands, and use the paper towel to turn off the faucet." The surveyor shared the above observation with EI #3 and asked what the concern was. EI #3 stated, "I would be concerned that bacteria would develop in the water and with hands, a soiled hand used to turn the faucet off would contaminate the clean hands."

Based on observations, record review and interview: FOOD STORAGE: 1) The facility failed to assure that food received frozen remained frozen during storage. (Food Code) "Temperature and Time Control 3-501.11 Frozen Food; Stored frozen foods shall be maintained frozen." Individual ice cream cups (two of two) were found to be soft to touch/feel. MANUAL DISHWASHING: 2) The facility failed to following correct manual dishwashing procedures, i.e. (for example) 3 compartment sink, correct water temperature, chemical concentration. 3) MIGHTY SHAKES: The facility failed to assure frozen mighty shakes, after thawing, were identified with a use by date per manufacturer's direction. "Use within 14 days after thawing." 4) PREVENT POTENTIAL CROSS-CONTAMINATION: A. Meal Tray Delivery Carts Staff failed to assure meal tray delivery carts were effectively disinfected between use of returned soiled trays and delivery of meal trays for the next meal to be served. B. HAND WASHING/GLOVE USE: Staff failed to utilize proper hand washing between touching/opening possibly soiled refrigerator handle and returning to serve hot foods on the tray line. C. SCOOP STORAGE: The facility failed to assure the measuring scoop/handle was not stored in the powdered thicken powder. The above practices posed the potential for food contamination and compromised food safety. This had the potential to affect all 56 residents receiving meal trays from dining services. Findings include: FOOD STORAGE: 1) The facility failed to assure that food received frozen remained frozen during storage. (Food Code) "Temperature and Time Control 3-501.11 Frozen Food; Stored frozen foods shall be maintained frozen." Individual ice cream cups (two of two) were found to be soft to touch/feel. On 5/12/13 at 3:45 p.m., during the initial kitchen tour, the ice cream storage freezer was monitored. Two of two individual cups of ice cream were soft to touch/feel as evidenced by finger indentations left when pressure was applied. The internal thermometer indicated +10 degrees F (Fahrenheit). The CDM (Certified Dietary Manager) EI (Employee Identifier) #3, was asked why the ice cream was soft. EI #3 said, no obviously not. The surveyor asked what do the regulation say. EI #3 said it should be harder than this, it's not what it should be. EI #3 said the ice cream had not just gotten there. MANUAL DISHWASHING: 2) The facility failed to follow correct manual dishwashing procedures, i.e. 3 compartment sink, correct water temperature, chemical concentration. A review of a facility policy titled "Three Compartment Sink Usages", no date, documented: "... 5. Assess water to ensure temperature is 65 degrees to 75 degrees and record ..." On 05/21/13 at 3:13 p.m., the surveyor observed the water in the final rinse sanitizing sink to be 98 degrees. The Dietary Manager, EI #3, directed the staff to let the water out. The surveyor asked EI #3 if the surveyor had not requested the test would the utensil be sanitized. EI #6 stated no, not at what had just been checked. The surveyor asked EI #3 were the dietary staff following policies and procedures, EI #3 stated no, no in the instance there. On 05/23/13 at 8:50 a.m., the temperature in the third sink was measured to be 102 degrees. On 05/23/13 at 4:40 p.m., the surveyor interviewed EI #3 about the pots and pans monitoring log. The surveyor asked EI #3 what was wrong with the log. EI #3 responded that they were not monitoring the temperature just the ppm (parts per million). 3) MIGHTY SHAKES: The facility failed to assure frozen mighty shakes, after thawing, were identified with a use by date per manufacturer's direction. "Use within 14 days after thawing." On 5/21/13 at 3:45 p.m., the surveyor observed mighty shakes in the walking refrigerator not to have a use by date. On 5/2213/ at 11:35 a.m., the surveyor observed a mighty shake on the tray line being served/place on a resident's meal tray. The surveyor asked EI #3 what does the manufacture's directions say. EI #3 said, use thawed product s within 14 days. The surveyor asked EI #3 what does her policy and procedures say. EI #3 said, she do not have a policy and procedure but she can get one. 4) PREVENT POTENTIAL CROSS-CONTAMINATION: A. Meal Tray Delivery Carts Staff failed to assure meal tray delivery carts were effectively disinfected between use for return of soiled trays and delivery of meal trays. According to manufactures technical data ... Multi-Quat Sanitizer ... Directions for use: non porous nonfood contact surface. Apply sanitizer use-solution with a cloth, mop sponge, sprayer or by immersion...treated surfaces must remain wet for 60 seconds. Wipe dry with a sponge, mop or cloth or allow to air dry. On 5/23/13 at 9:55 a.m., EI #7 was observed cleaning the tray delivery carts. EI #7 was asked by the surveyor how are the carts cleaned. EI #7 responded she cleans the carts with "Silver Soap" and hot water. Staff failed to assure meal tray delivery carts were effectively disinfected between use (return of soiled trays and prior to delivery of meal trays). a. Application procedure failed to comply with manufacturer's directions. b. Chemical concentration was inadequate. B. HAND WASHING/GLOVE USE Staff failed to utilize proper hand washing between handling of soiled and clean dishes. On 05/23/13 at 11:45 a.m., a food service worker plating food on the tray line was observed to have both hands gloved. The worker made numerous trips to the refrigerator. The worker opened the door with her gloved hands and removed chilled fruit. The worker returned to the tray line without washing her hands or changing her gloves. C. SCOOP STORAGE: The facility failed to assure the measuring scoop/handle was not stored in the powdered thicken powder. On 05/21/13 at 11:35 a.m., the surveyor observed a plastic scoop/handle stored in a 16 ounce container of Thick N Easy powder with a scoop stored inside.

Based on observations, record review and interviews, the facility failed to ensure Resident Identifier (RI) #5 received a Mighty Shake with each meal according to her plan of care. This deficient practice affected RI #5, one (1) of 15 residents whose plan of care was reviewed. Findings Include: A review of RI #5's care plan with the Focus area of "Therapeutic Diet R/T (Related To): [MEDICAL CONDITION](Hypertension)", with an initiated date of 9/26/2012, documented: "... Interventions ... ? Diet: NAS (No Added Salt), Puree, Mighty Shake with each meal ..." RI #5's Admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 04/15/2013, identified RI #5's BIMS (Brief Interview for Mental Status) as 0, indicating severe cognition. RI #5 was assessed as needing extensive assistance with eating and toilet use, as being totally dependent on staff for personal hygiene and bathing and was occasionally incontinent of bladder and frequently incontinent of bowel. A review of RI #5's Order Summary Report dated May 23, 2013 documented: ".. Dietary - Supplements ... Mighty Shake with meals for supplement ..." On 05/22/13 at 8:37 AM, RI #5 was observed sitting in a wheelchair at the dining room table. RI #5's was being fed the breakfast meal by a CNA (Certified Nursing Assistant), EI (Employee Identifier ) #2. There was no Mighty Shake served with the meal at this time. On 05/22/13 at 12:43 PM, RI #5 was again observed sitting in a wheelchair at the dining room table. RI #5's lunch meal had been served and again no Mighty Shake was observed with the meal. On 05/22/13 at 5:53 PM, RI #5 was observed lying in bed. RI #5's dinner meal was brought to the resident's room and there was no Mighty Shake served with the dinner meal. On 05/23/13 at 12:30 PM, RI #5 was observed sitting in her wheelchair in the dining room. The lunch meal had been served and no Mighty Shake was served with this meal. On 05/23/13 at 2:30 PM, the surveyor conducted an interview with EI #2, the CNA who fed RI #5 the breakfast meal on 05/22/13. When asked how she was familiar with RI #5, EI #2 stated she feeds and bathes the resident. EI #2 stated she was not aware that RI #5 was care planned to receive Mighty Shakes with each meal. The surveyor showed EI #2 RI #5's care plan and asked EI #2 what did RI #5's care plan say. EI #2 stated, "Mighty Shakes with each meal." The surveyor asked EI #2 who would be responsible for putting the Mighty Shake on the tray (meal tray). EI #2 stated Dietary. On 05/23/13 at 4:50 PM, the surveyor conducted an interview with EI #3, the facility's Dietary Manager. EI #3 stated some of her responsibilities were to make sure residents are receiving their supplements. The surveyor asked EI #3 how would her staff know which resident received a supplement. EI #3 stated it would be on the resident's tray card. The surveyor showed EI #3 RI #5's care plan and asked should RI #5 be receiving a Mighty Shake with meals. EI #3 stated, "Yes." The surveyor asked EI #3 did she know why RI #5 had not received the Mighty Shakes with her meals. EI #3 stated she didn't. EI #3 stated, "If it's on her tray card she should be receiving it. A review of RI #5's tray card dated 5/23/13 documented: "... Beverages: Mighty Shake, Sweet Tea ..." On 05/23/13 at 7:55 PM, the surveyor conducted an interview with EI #1, the facility's DON (Director of Nursing). EI #1 stated RI #5 was admitted with the order for the Mighty Shakes. EI #1 stated according to RI #5's care plan she should have been receiving the Mighty Shakes with each meal.