Every finding on record at Crowne Health Care of Greenville

Based on interviews, record review, review of the facility's abuse investigation and review of a facility policy titled, Abuse Policy, the facility failed to ensure Employee Identifier (EI) #2, a Certified Nursing Assistant (CNA)/Activities Assistant, implemented immediate protective measures on 11/30/2022 in accordance with the facility's abuse policy. On 11/30/2022 at approximately 10:30 AM, EI #2, CNA/Activities Assistant, found Resident Identifier (RI) #2 in a wheelchair at RI #1's bedside. RI #1 was in bed and uncovered with his/her private area exposed. EI #2 indicated she suspected something sexual in nature may have occurred, so she went to the doorway of the room to alert other staff she needed assistance. However, when she was unsuccessful in getting anyone else's attention, EI #2 left both RI #1 and RI #2 together in RI #1's room unattended. The facility's Abuse Policy indicated anytime there was an allegation of abuse, the facility will take all necessary steps to prevent further potential abuse. This deficient practice placed RI #1 and RI #2, two of three residents reviewed for abuse concerns, in immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment, or death. On 01/13/2023 at 10:40 AM, Employee Identifier (EI) #1, the Administrator, and EI #9, the Director of Nursing (DON), were provided a copy of the immediate jeopardy template and notified of the findings of substandard quality of care at the immediate jeopardy level in the area of 483.12 Freedom from Abuse, Neglect, and Exploitation, at F607-Develop/Implement Abuse/Neglect Policies. Beginning 11/30/2022 until 12/12/2022, the facility implemented corrective actions to correct the identified deficient practice and prevent recurrence; thus immediate jeopardy past non-compliance was cited. Findings Include: On 11/30/2022 at 12:23 PM, the State Survey Agency received an initial report from the facility regarding an allegation of possible sexual abuse between RI #1 and RI #2 that occurred on 11/30/2022 at approximately 10:30 AM. According to this initial report, EI #2, a CNA/Activities Assistant, witnessed RI #2 at RI #1's bedside seated in a wheelchair. EI #2 saw RI #1 in bed with the sheets pulled down and his/her legs open. EI #2 said it appeared RI #2 .snatched (his/her) hand back . away from RI #1 when she entered the room. The facility's Abuse Policy, dated October 2022, documented the following: It is the policy of Crowne Health Care of Greenville to ensure that each resident is free from verbal, sexual, physical, and mental abuse, neglect, misappropriation of resident's personal property and exploitation Training includes appropriate intervention methods that may become necessary to remove a resident from potential harm . Examples of steps that the facility may put in place immediately to prevent further potential abuse include .anything deemed necessary to protect residents . RI #1 was admitted to the facility on [DATE] with a diagnosis of Unspecified Dementia, Unspecified Severity with Behavior Disturbance. RI #1's Quarterly Minimum Data set (MDS) with an Assessment Reference Date (ARD) of 10/17/2022 documented the resident had a a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated the resident had severe cognitive impairment. RI #2 was readmitted to the facility on [DATE] with diagnoses to include Adjustment Disorder with Mixed Anxiety and Depressed Mood. RI #2's Quarterly MDS with an ARD of 10/16/2022 documented the resident had a BIMS score of 9 out of 15, which indicted the resident had moderate cognitive impairment. The facility's investigative summary, dated 12/07/2022, documented an allegation of sexual abuse was reported on 11/30/2022 at approximately 10:30 AM. The report indicated when EI #2, CNA/Activities Assistant, entered RI #1's room, she saw RI #2 appear to become startled and pull his/her hand back away from RI #1. EI #2 immediately reported the incident to EI #3, Registered Nurse (RN), and EI #8, CNA, who were both at the Nurse's Station, while leaving RI #1 and RI #2 in the room unattended. This report further indicated both RI #1 and and RI #2 were evaluated by a Licensed Psychologist on 12/01/2022, and it was determined neither resident was able to consent to sexual activity. Review of an interview conducted by the facility with EI #2 as part of their investigation on 11/30/2022, revealed EI #2 said she entered RI #1's room and observed RI #2 sitting in his/her wheelchair beside RI #1's bed. EI #2 said RI #1 was in bed with the covers pulled down and his/her legs open. EI #2 said she asked RI #1 to pull the covers back up but RI #1 said no. EI #2 indicated when she entered the room, RI #2 appeared startled and snatched his/her hand back. However, EI #2 said RI #2's back was to her, so she could not tell where his/her hand was. EI #2 told the facility she asked RI #2 to leave the room, but he/she did not, and only backed away from RI #1's bed. EI #2 said she then left the room to notify EI #3 and EI #8 of what she had seen. EI #2 confirmed EI #3 removed RI #2 from the room after she was notified. EI #3's signed witness statement, dated 11/30/2022, documented when EI #2 came to notify her of what she had seen, EI #3 went down to RI #1's room and RI #2 was sitting in the doorway to the room. EI #3 indicated she rolled RI #2 out of the room and let him/her know they should not be in RI #1's room. Review of an interview conducted by the facility with EI #8 as part of their investigation on 11/30/2022, revealed EI #8 confirmed RI #2 remained in the doorway to RI #1's room when they arrived after being notified of what EI #2 witnessed. EI #2, CNA/Activities Assistant, was interviewed on 01/11/2023 at 9:28 AM. When asked how she became aware of an incident involving RI #1 and RI #2 on 11/30/2022, EI #2 said when she entered RI #1's room on 11/30/2022, RI #2 was at RI #1's bedside in his/her wheelchair. RI #1 was in the bed with the covers pulled down and his/her legs wide open. She reported RI #2 appeared startled and snatched his/her hand back. EI #2 said she did not see RI #2 touch RI #1, but due to what she had seen, she suspected something sexual in nature may have possibly occurred. EI #2 said she asked RI #2 to move back from RI #1's bed, then stood in the doorway to get a CNA's attention. EI #2 said when she could not get a CNA's attention, she left the room and went to the Nurse's Station, where she informed EI #3 and EI #8 of what she had seen. EI #2 said they then went right back to RI #1's room. When asked how this situation should have been handled, EI #2 said, according to the abuse policy, she should have removed RI #2 from RI #1's room to make sure the residents were safe. EI #2 confirmed she was not able to see RI #1's room from the Nurse's Station. During an interview on 01/11/2023 at 10:44 AM, EI #3, RN, reported, EI #2 came to the Nurse's Station and said she needed to go down to RI #1's room. EI #3 reported when she entered RI #1's room, RI #2 was still sitting in a wheelchair in the doorway, so she removed RI #2 from the room. When asked if the facility's abuse policy was followed regarding protecting the residents, EI #3 said no, there was a potential for abuse when EI #2 left the residents in the room unattended. During an interview on 01/13/2023 at 11:20 AM, EI #8, CNA, confirmed when she and EI #3 entered RI #1's room on 11/30/2022, RI #2 was still sitting in the doorway. When asked if EI #2 should have left RI #1's room and left the residents unattended, EI #8 said she should have stayed in the room when she suspected abuse and used the call light to call for help, to make sure the residents were safe and not in harm's way. During an interview on 01/11/2023 at 11:18 AM, EI #4, Director of Social Services, said she was told EI #2 left RI #1's room after she suspected abuse. EI #4 said, EI #2 should have removed RI #2 from RI #1's room or stayed with them and called for help. She further stated the abuse policy was not followed because the residents should always be protected. On 01/11/2022 at 5:09 PM an interview was conducted with EI #1, Administrator/Abuse Coordinator. EI #1 said she was notified of an allegation of abuse involving RI #1 and RI #2 on 11/30/2022. When asked if EI #2 left both residents in RI #1's room unattended, EI #1 said, yes, EI #2 left the room to get more help. EI #1 was asked what EI #2 could have done when she found RI #2 in RI #1's room. EI #1 said she could have used the call light, yelled for help, and removed RI #2 from the room. ************************* The facility took immediate actions to correct the non-compliance by: - On 11/30/2022 the facility identified that EI #2 observed RI #2 in RI #1's room touching her/him inappropriately. EI # 2 left the rooms for seconds to report the incident to EI #3 and EI #8, who were both at the nursing station. As EI #3 and EI #8 entered the room, EI #3 removed RI #2 from the doorway so she could enter the room and check on RI #1. - On 11/30/2022 an investigation was initiated, the event was reported to ADPH (Alabama Department of Public Health) and local law enforcement. -On 11/30/2022 RI #1 was placed on one on one observation until an evaluation by a Licensed Psychologist was completed on 12/1/2022. - On 11/30/2022 EI #2 was informally inserviced on actions she can take if resident on resident abuse is observed/suspected, including staying with the residents or removing one resident from the room. - On 11/30/2022 education of all staff was initiated. Education was completed on 12/08/2022. - On 11/30/2022 an emergency Quality Assurance and Performance Improvement (QAPI) meeting was completed related to the incident involving RI #1 and RI #2. Follow-up QAPI meetings were held on 12/2/2022 and 12/5/2022. - On 12/1/2022 RI #1 and RI #2 were evaluated by a Licensed Psychologist, who determined neither resident could consent to sexual activity. - On 12/2/2022 Behavior monitoring began on RI #1 and RI #2, and is continuing. - On 12/7/2022 and 12/8/2022 resident council meetings were held to go over the abuse policy and procedures. - On 12/12/2022 monitoring was established to include: Allegations of abuse are monitored by the administrator to ensure compliance of the abuse policy, including, but not limited to, proper reporting actions after possible abuse is identified, separating the resident from the abuser, and protecting the victim. This monitoring will be reported weekly, and is ongoing for 6 months, and will be kept in the DON's office. ************************* After review of documentation supporting the above corrective actions, including the facility's investigation file, in-service/education records, QAPI documentation, and staff interviews, the survey team verified the facility implemented corrective actions from 11/30/2022 to 12/12/2022, thus immediate jeopardy past non-compliance was cited.

Based on interviews, record review, review of a facility policy titled Policy and Procedure Skin Assessment & (and) Pressure Ulcer Prevention and review of interviews from the facility's investigative file, the facility failed to provide evidence weekly skin assessments for Resident Identifier (RI) #1 were completed by the licensed nurses, Employee Identifier (EI) #'s 1 and 2; and further failed to ensure a CNA (Certified Nursing Assistant), EI #8 informed the charge nurse when RI #1 was observed to have redness to his/her buttocks on 05/22/2022. This deficient practice affected RI #1, one of three residents sampled for pressure ulcers. Findings include: Review of a facility policy titled Policy and Procedure Skin Assessment & Pressure Ulcer Prevention with a revised date of February 2020, revealed the following: Purpose: The purpose of this guideline is to help identify at-risk individuals for pressure ulcers and put interventions in place for prevention . Procedure: . 3. CNA's will do a body audit daily on each resident during ADL (Activities of Daily Living) care and report any abnormalities to the charge nurse. 4. A licensed nurse will perform a skin inspection on the day of admission/readmission and a minimum of weekly on each resident. The nurse will document the inspection in the American Health Tech (AHT) WAM (Wound Management Assessment) module . RI #1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #1's CARE PLAN FOR SKIN/RISK OF PRESSURE ULCERS, dated 05/05/2022, revealed: Problem Resident is at risk for pressure ulcers related to: Braden Scale Score of (15 was documented) (Mild risk: 15-18 was checked) . Sensory: (PVD was checked) . Approach . (Daily body audit was checked) . Dept [department] CNA) . (Weekly skin assessment was checked) . Dept (Licensed Nurse) . A review of the facility's investigative file revealed on 05/31/2022, an interview was conducted with EI #1, the LPN (Licensed Practical Nurse) caring for RI #1 on 05/18/2022. The following was documented: . 5) On the 18th Did you do a skin audit on (him/her)? I did . 6) Where did you document your skin audit? Under the daily check skin audit section. 7) I do not see it documented. It may not have saved . On 08/09/2022 at 2:52 PM, a telephone interview was conducted with EI #1/LPN. EI #1 said the DON (Director of Nursing) informed her of this after RI #1 skin breakdown after RI #1 had gone home. EI #1 said the DON told her RI #1's family member called and said he/she had skin breakdown when he/she got home. EI #1 said the facility did not have any documentation of the skin breakdown. The surveyor read EI #1's statement from 05/31/2022 and asked did she make that statement. EI #1 said she did and the Administrator asked her those questions. When asked why she was asked those questions, EI #1 said they could not find where she did a body assessment. EI #1 said after the incident the nurses are having someone look behind them daily to ensure skin assessments are being completed and documented. EI #1 said the DON showed her personally how to complete skin assessment documentation on the computer and the nurses were given a printed guide on how to complete. On 08/09/2022 at 3:56 PM, the surveyor conducted an interview with EI #4, the RN (Registered Nurse) unit manager where RI #1 had previously resided. EI #4 said body audits were to be done weekly on RI #1 while he/she was a resident in the facility. EI #4 said RI #1 should have had a body audit on May 11th and on May 18th (2022) prior to his/her discharge from the facility on 5/25/2022. EI #4 said EI #1 and EI #2, the LPNs assigned to care for RI #1 on the 11th would have been responsible for completing the body audits, and those assessments should have been documented under the Quality Assurance tab. When asked where there would be evidence RI #1's body assessments were done on the 11th and 18th, EI #4 said you would click on the completed assessments and put in the dates you are looking for and it will let you know if the body assessment had been completed. EI #4 said looking at the skin inspection report, it was saying no matching records were found (meaning no skin audits were documented as being performed on RI #1 while RI #1 was a resident at the facility). EI #4 said the CNAs should be notifying the nurses of any skin changes whether it was a skin tear, bruise or redness. EI #4 said looking at EI #8's interview, she said she (EI #8) did not report the dime size redness (she observed on RI #1's buttocks) to anyone. EI #4 said if the redness was something new EI #8 should have reported it. On 08/09/2022 at 4:50 PM, an interview was conducted with EI #9, the LPN Treatment Nurse. EI #9 said residents were receiving body assessments every week. EI #9 said the charge nurse on the hall would be responsible for completing the assessments. EI #9 said the assessment was to be documented in the WAM program in the computer. RI #9 said to ensure residents assessment are being completed, the charge nurses were re-educated on the skin check policy. On 08/09/2022 at 5:47 PM, an interview was conducted with EI #2, the LPN caring for RI #1 on 05/11/2022. EI #2 said he honestly did not remember performing a body assessment on RI #1. EI #2 said, he was taught how to document skin audits in the computer after the fact. EI #1 said he remembered an in-service where the Administrator showed him how to open the tab in the computer, which showed which resident needed skin assessments and what day and shift the assessment needed to be completed. A review of the facility's investigative file revealed on 05/31/2022, an interview was conducted with EI #8, the CNA caring for RI #1 on 05/22/2022 on the 2 PM - 10 PM shift. The following was documented: 1) what care did you provide to (RI #1) during your shift? I check him . 3) Did you see any skin breakdown/issues to (his/her) bottom when you provided care? . (his/her) bottom was a little red from where he had been laying on it . 4) Did you tell anyone? no I didn't tell anyone . On 09/08/2022 at 6:13 PM, the surveyor conducted an interview with EI #8. When asked why she was interviewed by the Administrator on 05/31/2022, EI #8 said, she was interviewed on 5/31/2022 by the Administrator who said when RI #1 got home the family said RI #1's bottom had something on it. RI #8 said the Administrator wanted to know if she (EI #8) had seen anything on RI #1's buttocks. EI #8 said she saw a little red mark on one of RI #1's buttocks cheeks and she told her (administrator) that she did not tell anyone about the red mark. EI #8 said this was the first time she had seen the red area on RI #1's buttock. EI #8 said the facility's protocol when you see something that could be a skin concern you should report it to the charge nurse. EI #8 said she did not report it because RI #1 said he/she did not need anyone to do anything for him/her. On 08/10/2022 at 10:05 AM, an interview was conducted with EI #6, the DON. EI #6 said nurses should be performing skin assessment/body audits on a schedule and should be performed weekly. EI #6 said from the facility's investigation it was found RI #1's weekly body audits had not been documented as being done. EI #6 said the staff not documenting the assessments were given written education which was a part of the facility's plan of correction. EI #6 said the entire nursing staff was educated on documentation of skin assessments. EI #6 said individual education to the two nurses failing to document skin assessments for RI #1 was completed, education to the nursing staff on the facility's P & P in skin inspection, Prevention of Pressure Ulcers, documenting on the WAM, and education was done on the WAM training points. EI #6 said because the allegation was about abuse, they also in-serviced on abuse. EI #6 said other residents who had the potential to be affected skin assessment not completed were being monitored, weekly on Mondays, and she looked at the skin assessments of all residents from the prior week. EI #6 said any skin assessments that were not completed or done timely were to be completed immediately. ******************************************************* Once the facility became aware RI #1's skin assessments had not been documented on as completed, the following corrective actions were implemented: On 06/07/2022, a 100% audit was completed on all active residents to determine if body audits were completed and documented on within the last week. Any skin audit missed would be performed and documented on by 06/11/2022. There were no residents identified who were missing weekly body audits. On 06/08/2022, EI #1 and EI #2 received a counseling on residents are to have weekly skin audits done per the charge nurse and this information must be documented in WAM. By 06/24/2022, all nurse were educated on the facility's Policy and Procedure for Skin Inspection, P&P for Prevention of Pressure Ulcers, Documentation Guidelines for WAM, and the WAM Training Points to include but not limited to how the WAM Scheduler works and how to document the Skin inspections in WAM. Any licensed nurses not educated by that date would not be allowed to work until they received education. Beginning 07/05/2022, the facility implemented a new system where the DON/ RN designee began reviewing skin assessments weekly. Ongoing on Mondays, this information was reviewed at the daily stand up meeting. The DON/RN manager would initial the Assessment Compliance Log and turn in to the Administrator. Beginning the week of 07/05/2022, the Administrator began monitoring to ensure scheduled skin audits had been documented as completed on residents. Any concerns found would be followed with further education and/or discipline as needed. No concerns were identified. ******************************************************* After review of the facility's investigation file, in-service/education records, staff interviews, review of the facility's monitoring audits records, and ensuring the facility's corrective actions were being implemented, past non-compliance was cited. This deficiency was cited as a result of the investigation of complaint/report number AL 949.

Based on interviews, record review, review of facility policies titled Policy and Procedure Skin Inspection, Notification of Change of Condition of a Resident and review of interviews from the facility's investigative file, the facility failed to ensure Resident Identifier (RI) #1's physician, responsible party, and Nursing Administration staff were notified when an open area was identified on RI #1's buttocks on 05/22/2022. This deficient practice affected RI #1, one of three residents sampled for notification. Findings include: The facility's policy titled Notification of Change of Condition of a Resident, with a revised date of 09/2011, revealed the following: Purpose: To ensure resident's rights and continuity of care by identifying and reporting a Significant in Physical, Mental and or Psychosocial well being. Procedure: Notify the Physician of status change. Notify the resident's legal representative or interested family member of status change . Document notification in the medical records . In addition, another facility policy titled Policy and Procedure Skin Inspection, dated February 2020, revealed the following: . Procedure: . 7. If skin concerns are found the CNA (Certified Nursing Assistant) is responsible for reporting these changes/concerns to the charge nurse. 8. The licensed nurse should notify the resident's physician, obtain orders for treatment . and notify the resident's sponsor. In addition, Nursing Administration is to be notified . RI #1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #1's ADMISSION ASSESSMENT BODY AUDIT, dated 5/05/2022, revealed RI #1 was not admitted with any skin concerns or open areas to his/her buttocks. On 08/09/2022 at 11:45 AM, a telephone interview was conducted with RI #1's spouse. RI #1's spouse said, he/she did not believe RI #1 was admitted to facility with anything on his/her buttocks. RI #1's spouse said, he/she or the doctor was not informed that RI #1 had developed an open area to the buttock before he/she was sent home. The facility's investigative file revealed on 06/06/2022, an interview was conducted with Employee Identifier (EI) #4, the RN (Registered Nurse) Unit Manager for the unit RI #1 resided on; and the staff member completing RI #1's ADMISSION ASSESSMENT BODY AUDIT on 05/05/2022. RI #4 documented the following: 1) . I never saw (his/her) bottom except during admission. On admission (he/she) did not have anything. 2) Were any issues reported to you R/T (related to) skin breakdown or issues to (his/her) bottom/sacrum? no . On 08/09/2022 at 3:56 PM, the surveyor conducted an interview with EI #4. EI #4 said RI #1 did not have any skin concerns to his/her buttocks on admission. EI #4 said she actually became aware, when RI #1's family member called back to the facility after RI #1 was discharged home and said RI #1 had sores on his/her bottom. EI #4 said prior to that, she had no knowledge RI #1 had skin concerns. EI #4 said yes, the family and the physician should have been notified, because that was a change in RI #1's skin. EI #4 said the notification should have been documented in the nurses' notes. A review of the facility's investigative file revealed on 06/01/2022, an interview was conducted with EI #5, the CNA caring for RI #1 on 05/22/2022. The following was documented: . 3) . he had a small area on his/her bottom . it was about nickel sized it was pinkish color it was missing skin . (Name) EI 3#/LPN was in the room when he/she was saying he/she had something there and about the cream. On 08/10/2022 at 8:27 AM, a telephone interview was conducted with EI #5/CNA. EI #5 said on 05/22/2022 was the first time she had provided care to RI #1. EI #5 said EI #3/LPN, the charge nurse, was in the room and heard what RI #1 said and saw the area on RI #1's butt. EI #3 was unavailable for interview, regarding RI #1's open area to the buttock, after several attempts to reach her by phone on 08/09/2022 at 2:28 PM, 08/10/2022 at 8:53 AM, and 08/10/2022 at 11:15 PM. On 08/10/2022 at 10:05 AM, in interview was conducted with EI #6, the DON (Director of Nursing). EI #6 said when EI #3 observed the open area to RI #1's buttocks, EI #3/LPN should have taken measurements, documented in WAM (Wound Assessment Manager), notified the family member, notified the physician and obtained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] On 08/15/2022 at 2:48 PM, a telephone call was received from RI #1's physician, he said, he would expect a call when staff identify a new wound concern. A review of RI #1's nurses notes revealed there was no evidence in the nurses notes RI #1's physician, family member or any Nursing Administrative staff had been notified of the open area to RI #1's buttock. ******************************************************* Once the facility was made aware RI #1's physician and family member had not been notified when RI #1 was identified to have an open area to the buttocks, the following corrective actions were implemented: On 05/22/2022, EI #5 the CNA, observed an open area to RI #1's buttocks. On 05/22/2022, EI #3 the assigned LPN failed to notify the physician, family member or Administrative staff of the open area. On 05/25/2022, RI #1 was discharged from the facility with no treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/27/2022, the family member of RI #1 informed the facility RI #1 had an opened area to his/her buttocks, which the family member had no knowledge of when RI #1 was discharged from the facility. The family member alleged abuse had occurred. On 05/27/2022, the facility reported the allegation of abuse to the Alabama Department of Public Health. From 05/28/2022 - 06/06/2022, the facility interviewed staff providing care to RI #1 while RI was a resident at the facility. The allegation of abuse was unsubstantiated. However, the facility's investigation revealed the resident had the open area on his buttocks before being discharged from the facility and staff failed to follow policy and procedure of notification when the area was identified. On 06/09/2022, EI #3/LPN received a counseling on what to do when there is a change in a resident's skin condition and who to report the change to. By 06/11/2022, a 100% body audit was completed on all residents to ensure any changes in skin condition had been identified, documented on, and a treatment based on the facility's treatment protocol had been initiated. No concerns were identified. By 06/24/2022, licensed nurses were educated on the facility's Policy and Procedure (P&P) for Skin Inspection, P&P for Prevention of Pressure Ulcers, Documentation Guidelines for WAM software in AHT [American Health Tech], and the WAM Training Points to include but not limited to the nurse is responsible for notification to the physician and resident representative of a change in status, and is responsible for initiating a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . By 06/24/2022, CNAs/NAs (Nursing Assistants) were educated on the facility Policy and Procedure for Skin Inspection, P&P for Prevention of Pressure Ulcers, and on reporting changes in skin condition to the charge nurse by use of verbal report. On 07/05/2022, the facility implemented a new system where the resident's physician/sponsor are to be notified of a change in condition that occurs with a resident by: -the resident's charge nurse, each shift, each day will be responsible to document on the 24-hour report, notify the MD (medical doctor)/Sponsor, and document an assessment in the medical record for any resident with a change in condition during their shift. -the unit RN manager will be responsible to monitor the system of documentation and notification daily. The RN manager is to review the 24-Hour Nursing Report for all the shifts since he/she last worked that unit, 72 hours, or since another unit manager has reviewed the 24-Hour Report, whichever is longest. He/she will then review each item listed on the shift report and ensure there is documentation in the medical record about the change in condition, and that the MD/sponsor were notified. The RN manager will then initial beside the last entry on the 24 hr report that is checked. When returning to duty the next day, he/she will resume this process with other entries on the report and initial beside the last entry checked. In the event of a weekend, the RN will begin from the last day worked and check each item on the daily shift reports up to current. The RN manager will make sure that there is at least one initial on each day's report to signify that day's report was reviewed and checked against the medical record. ******************************************************** After review of the facility's investigative file, in-service/education records, staff interviews, review of the facility's monitoring audits records, and ensuring the facility's corrective actions were being implemented, past non-compliance was cited. This deficiency was cited as a result of the investigation of complaint/report number AL 949.

Based on observation, interview, and a review of the United States Public Health Services Food Code and a facility document titled TEMPERATURE CHART-STORAGE AREAS, the facility failed to ensure dietary staff: 1. prevented the buildup of residue in the tea urn valve; 2. did not allow wet nesting of multiple sheet pans; 3. made certain the freezer temperatures were maintained at zero degrees or below and 4. washed hands after handling dirty dishes and before touching clean dishes. This had the potential to affect all 107 residents receiving meals from the kitchen. Findings Include: A review of the Food Code, 2013 Recommendations of the United States Public Health Services, Food and Drug Administration, pages 139 and 148 revealed: 4-6 CLEANING OF EQUIPMENT AND UTENSILS . Objective 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces and Utensils. (A) EQUIPMENT-CONTACT SURFACES AND UTENSILS shall be clean to sight and touch. 4-9 PROTECTION OF CLEAN ITEMS . Drying 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT AND UTENSILS; (A) Shall be air-dried . A review of a facility document titled TEMPERATURE CHART-STORAGE AREAS revealed: . PROPER TEMPERATURES Freezer (less than or equal to 0 ( degrees) F (Fahrenheit) . 1. On 5/2/19 at 7:38 a.m., the Surveyor asked Employee Identifier (EI ) #2, the Dietary Manager, to show the inside of the tea urn spigot to check for cleanliness. The valve had a dirty, brown residue build up around the inside. 2. The surveyor observed five sheet pans stacked together drying beside the three compartment sink. 3. The surveyor observed two of the three reach in freezer temperatures were above zero degrees. The first reach in freezer temperature observed was zero degrees, the second reach in freezer temperature observed was two degrees, and the third reach in freezer temperature was eight degrees. The surveyor again checked the temperatures of the second and third freezers on 5/2/19 at 10:10 a.m. Both freezers were showing a temperature greater than 0 degrees. An interview was conducted on 5/2/19 at 9:40 a.m. with the EI #2. EI #2 was asked, were wet pans supposed to be dried, stacked together. EI #2 separated the pans. EI #2 was asked, what was it called when they are stacked wet on each other. EI #2 stated, Wet Nesting. EI #2 was asked, were they supposed to wet nest. EI #2 stated, No, could set up bacteria, mold, could harm the resident. An interview was conducted on 5/2/19 at 10:11 a.m., with EI #2. EI #2 was asked, how often was the tea spigot cleaned. EI #2 replied, after every use. EI #2 was asked, when was it last cleaned. EI #2 replied, supposed to be cleaned yesterday, not for sure if it was cleaned, night shift was supposed to clean it. EI #2 was asked, how it looked earlier when the surveyor observed it. EI #2 replied, gunky, really nasty. EI #2 was asked, what was the potential for harm. EI #2 replied, bacteria, which could cause harm to the resident. EI #2 was asked, what was the temperature of the freezer supposed to be. EI #2 replied, zero or below. EI #2 was asked, what was the potential for harm. EI #2 replied, food set up bacteria, has to be thrown out immediately, can make the residents sick. 4. A review of the Food Code, U.S. Public Health Services, Food and Dug Administration, 2013, page 47 and 48 revealed: 2-301.14 When to Wash, FOOD EMPLOYEES shall clean their hands and exposed portions of their arms . immediately before engaging in FOOD preparation including working with exposed FOOD, clean equipment and UTENSILS, . and . (E) After handling soiled EQUIPMENT or UTENSILS; . On 5/2/19 at 9:45 a.m. a member of the kitchen staff EI #1, was observed handling the dirty dishes and not washing her hands before going to touch the clean dishes. After the observation EI #1, was asked, what was she supposed to do after working with dirty dishes, before going to work on clean dishes. EI #1 stated, Wash My hands. EI #1 was asked, had she done that every time. EI #1 replied, Yes. The Surveyor explained that she had been observed going from dirty to clean without washing her hands. EI #1 stated that she remembered changing her gloves, but not washing her hands. EI #1 was asked what was the potential for harm. EI #1 replied, it was unsanitary and could cause cross contamination.

Based on interview and resident record review, the facility failed to ensure Resident Identifier (RI) #44's Significant Change Minimum Data Set (MDS) Assessment was completed, in a timely manner, after RI #44 was admitted to hospice. This affected one of three residents reviewed for hospice admission. Findings include: RI #44 was admitted to the facility on [DATE]. A review of RI #44's (MONTH) 2019 physician orders [REDACTED]. A review of RI #44's MDS assessments revealed a Significant Change MDS was not completed until 2/18/19. On 5/2/19 at 3:40 PM, Employee Identifier (EI) #6 MDS Coordinator was asked when RI #44 was admitted to hospice. EI #6 said, (MONTH) 8, (YEAR). EI #6 said, she missed that one, but it was to be completed 14 days after admission to hospice. EI #6 was asked when was the Significant Change MDS completed for RI #44, after being admitted to hospice. EI #6 said, [DATE]. When asked when the MDS should have been completed, EI #6 said, by (MONTH) 26, (YEAR). EI #6 was asked why it should have been completed within 14 days after RI #44 was admitted to hospice. EI #6 replied, to show RI #44's condition, status, and to update the plan of care.

Based on observation, interview, record review, and review of the facility policy titled Preparation for Medication Administration the facility failed to ensure licensed staff administered eye drops to Resident Identifier (RI) #90 from a container that was dated when opened. This affected one of two residents observed receiving eye drops during medication administration. Findings include: Review of a facility policy titled Preparation for Medication Administration dated 1/2012 revealed the following: . Procedures . 6. Multi-dose medications, like . opthalmic's, . should be dated when opened . RI #90 was readmitted to the facility on [DATE]. On 5/2/19 at 11:30 AM, Employee Identifier (EI) #5 Licensed Practical Nurse (LPN) was observed during medication administration. EI #5 administered eye drops to RI #90 from a container that did not have an open date listed. On 5/2/19 at 11:39 AM, EI #5 was asked if the eye drops should have an open date. EI #5 said, yes, because they could only keep them on the cart for 30 days. When asked why only 30 days, EI #5 said, because they could get contaminated being passed around, hand to hand by nurses administering the medicine. EI #5 said, she could not accurately be sure how long the eye drops had been open.

Based on observation, interview, record review and review of a facility policy titled Preparation for Medication Administration the facility failed to ensure licensed staff did not stack medication cups, each one containing medication, on top of each other, after the cups had been placed on top of the medication cart. This affected Resident Identifier (RI) #71, one of seven residents observed during medication administration. Findings include: Review of a facility policy titled Preparation for Medication Administration dated 1/2012, revealed the following: . Policy Medications are administered as prescribed in accordance with good nursing principles and practices . RI #71 was admitted to the facility on [DATE]. On 5/2/19 at 8:05 AM, Employee Identifier (EI) #3 LPN (Licensed Practical Nurse), was observed during medication administration for RI #71. EI #3 stacked a medication cup containing liquid medication, from off the top of the medication cart, inside a medication cup containing a vitamin capsule upon entering RI #71's room. After the medication pass EI #3 was asked to explain if any part of the medication administration with RI #71, and how she handled the medications, could have been a concern with infection control. EI #3 said, she put the liquid medication on top of the other. EI #3 was asked what was the risk of that action. EI #3 replied, the risk of infection because the cup had previously been on the medication cart. On 5/2/19 at 3:08 PM, EI #4 Registered Nurse (RN) Infection Control, was asked, how multiple medication in cups should have been carried into a resident's room for administration. EI #4 said, on a paper plate from the kitchen. When asked what happened to medication inside plastic med cups that were stacked one inside the other to enter a room, EI #4 said, the medication becomes contaminated. EI #4 was asked how was contamination introduced when medication cups were stacked. EI #4 said, at the bottom, the medication cup was contaminated because it touched the top of the medication cart.

Based on interviews, a review of menus, record review, and a review of the facility policy titled, Menu Planning the facility failed to ensure residents were not served either rice or pasta for seven consecutive days. This was reported by RI (Resident Identifier) #39, one of six residents present in the Resident Council meeting on 5/02/18. This was observed for one of four weekly cycles of menus that residents were served from. Findings Include: A review of a facility policy titled, Menu Planning with a copyright date of 2010, revealed: Policy: Nutritional needs of individuals will be provided in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences (which are adjusted for age, gender, activity level and disability), through nourishing, well-balanced diets, unless contraindicated by medical needs. Procedure: 1. Regular and therapeutic menus are written to provide a variety of foods served on different days of the week, . RI #39 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #39 verbalized a concern of repetitive rice and pasta being served during the Resident Council meeting on 5/02/18. RI #39 stated he/she had spoken with the dietary staff on several occasions, but nothing was changed. A review of the menus for weeks one through four revealed the following on the week three menu. 1. Sunday, at the lunch meal, macaroni and cheese was served. 2 Monday, at the lunch meal, yellow rice was served. 3. Tuesday, at the supper meal, rice was served. 4. Wednesday, at the lunch meal, garden rice was served. 5. Thursday, at the lunch meal, buttered noodles were served. 6. Friday, at the supper meal, rice was served. 7 Saturday, at the lunch meal, parsley egg noodles were served and at supper, turkey and rice casserole was served. On 5/03/18 at 1:35 PM, an interview was conducted with EI (Employee Identifier) #1, the DM (Dietary Manager). EI #1 was asked on the third cycle of menus served, were the residents served pasta or rice on seven of seven days consecutively. EI #1 answered, Yes. EI #1 was asked had anyone complained of rice served to them five days in a row and she answered, Yes. EI #1 was asked what was done. EI #1 answered she had talked to the resident about their likes and dislikes, taken a statement, and followed up with the resident. EI #1 was asked did that approach address the frequency of rice served. EI #1 answered, Not really. EI #1 was asked should residents be served rice or pasta seven consecutive days. EI #1 answered No, but I was following the menu. EI #1 was asked why should residents not be served rice or pasta on seven consecutive days. EI #1 answered the residents could get tired of it. EI #1 was asked who was responsible for ensuring items on the menu were not served repetitively. EI #1 answered I am assuming the RD (Registered Dietitian), the person that signs off on the menu. EI #1 was asked what was the facility policy on serving a variety of foods. EI #1 answered, It should be served on different days to provide a variety. On 5/03/18 at 3:29 PM, an interview was conducted with EI #2, the Dietitian. EI #2 was asked if on the third cycle of menus, were the residents served pasta or rice on seven of seven days consecutively. EI #2 answered, I do not know. I have briefly looked at them but it has been a while. EI #2 was asked if residents should be served rice or pasta seven consecutive days and she answered, No. EI #2 was asked what was the facility policy on serving a variety of foods. EI #2 answered, In my opinion, try to serve a variety and what residents like. EI #2 was asked what was the concern of rice or pasta being served on seven consecutive days. EI #2 answered, They may not eat.

Based on interviews, record reviews, a review of facility documents titled, GRIEVANCE/CONCERN REPORT and EMPLOYEE CORRECTIVE ACTION REPORT, the facility failed to ensure RI (Resident Identifier) #1's clothes were changed between 3/11/2017 and 3/12/2017. This affected RI #1, one of three residents sampled for ADL (Activities of Daily Living) care. Findings Include: A complaint was filed with the State Agency regarding concerns with ADL care being provided to a resident and during the investigation, the following information was found: RI #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a Significant Change Minimum Data Set (MDS), dated [DATE], revealed RI #1 required extensive assistance with dressing, hygiene, toileting, and eating. RI #1 required the physical assistance of one person with bathing. The MDS also revealed RI #1 had a BIMS (Brief Interview of Mental Status) score of eight out of a possible fifteen. This indicated RI #1 was moderately impaired for decision making. RI #1's care plan for SELF CARE DEFICIT, with a problem onset date of 3/26/2017, revealed: Resident need extensive assistance with (his/her) daily care RT (related to) his/her terminal dx (diagnosis) of protein malnutrition, [MEDICAL CONDITION], he/she is a high risk for falls, has a poor safety awareness, has [MEDICAL CONDITION] episodes, has a weak knee that gives way at times. [DIAGNOSES REDACTED]. Approaches .*Provide privacy for bathing and dressing * Follow FMP (Functional Maintenance Plan) as indicated *Lotion to skin after bath/showers *Assist to bathing area via w/c (wheelchair); shower chair *Sponge bath on nonshower days . A review of a facility document titled, GRIEVANCE/CONCERN REPORT, dated 3/15/2017, reported by RI #1's family member, stated : .1. On Sat (Saturday) and Sun (Sunday) past weekend (3/11 and 3/12) (RI #1) was in the same clothes both days . The date the facility communicated with the person making the grievance/concern was on 3/22/2017. The form was signed by the former D.O.N (Director of Nursing), EI (Employee Identifier) #4. Another facility document titled, Grievance/Concern, dated 3/15/2017, stated RI #1's family member said: .(RI #1) per another family member had on the same clothes on Saturday 3/11 and Sunday 3/12. I investigated this concern and found that the aide assigned to (him/her) on Saturday evening 6P till 6A had let (him/her) sleep in (his/her) clothes that evening. (Disciplinary action were Taken) see attached in-service .the aide that had him/her on Sunday 6A till 2P had left him/her in the clothes that day which also told me that he/she had not sponged him/her on 3/12 per our Sunday protocol. (disciplinary actions were taken) see attached in-service. This document was signed by EI #4. A review of a facility document titled, EMPLOYEE CORRECTIVE ACTION REPORT, dated 3/11/17 with (said employee name), revealed: .NATURE OF REPORT, First Written Warning .On Sat. 3/11 6P-6A shift you were assigned to resident (RI #1). You did not change (RI#1) into (his/her) night clothes that evening at bedtime per family! RI #1 was in the same clothes Sun. as she was in Sat . The form was signed by (said employee), EI #4 and EI #5, Administrator. On 5/25/2017 at 4:01 p.m., an interview was conducted with EI #5. EI #5 was asked to discuss an incident where RI #1 had the same clothes on March 12-14, 2017, how she became aware of the incident and when. EI #5 stated, I know there was a grievance of him/her having the clothes on 2 days, I know there were 2 CNAs (Certified Nursing Assistant) disciplined, one on one shift and one on another on 3/11/ and 3/12/ in his/her clothes both days. The grievance was from RI #1's family member. EI #4 investigated and one aide had disciplinary action because she had not sponged him/her off or changed his/her clothes. Both aides were disciplined and inservice to the other staff. Through the grievance (was how EI #5 became aware of the incidence) The grievance was on 3/15/2017. EI #5 was asked if the incident was investigated, by whom and when. EI #5 responded, Yes, EI #4 on 3/15-3/22/17. On 3/22/17 (EI #4) spoke to ( RI #1's family member) about the outcome. EI #5 was asked what were the findings. EI #5 stated, That the CNA on the evening shift let the resident sleep in what he/she had on and the one Sunday morning left him/her in those clothes. Both CNAs had disciplinary action. EI #5 was asked what was done to correct it. EI #5 stated, In-service the staff. A review of In-Service Training Class Attendance Record was completed and indicated staff (both LPNs (Licensed Practical Nurses) and CNAs) were inserviced on 3/21/17 for dressing residents and other subjects.

Based on interviews and record reviews, the facility failed to ensure RI (Resident Identifier) #1's clothes were changed between 3/11/17 and 3/12/2017. This affected RI #1, one of three residents sampled for ADL (Activities of Daily Living) care. Findings Include: A complaint was filed with the State Agency regarding concerns with ADL care being provided to a resident and during the investigation, the following information was found: RI #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a Significant Change Minimum Data Set (MDS), dated [DATE], revealed RI #1 required extensive assistance with dressing, hygiene, toileting, and eating. RI #1 required the physical assistance of one person with bathing. The MDS also revealed RI #1 had a BIMS (Brief Interview of Mental Status) score of eight out of a possible fifteen. This indicated RI #1 was moderately impaired for decision making. RI #1's care plan for SELF CARE DEFICIT, with a problem onset date of 3/26/2017, revealed: Resident need extensive assistance with (his/her) daily care RT (related to) his/her terminal dx (diagnosis) of protein malnutrition, [MEDICAL CONDITION], he/she is a high risk for falls, has a poor safety awareness, has [MEDICAL CONDITION] episodes, has a weak knee that gives way at times. [DIAGNOSES REDACTED]. Approaches .*Provide privacy for bathing and dressing * Follow FMP (Functional Maintenance Plan) as indicated *Lotion to skin after bath/showers *Assist to bathing area via w/c (wheelchair); shower chair *Sponge bath on nonshower days . A review of a facility document titled, GRIEVANCE/CONCERN REPORT, dated 3/15/2017, reported by RI #1's family member, stated : .1. On Sat (Saturday) and Sun (Sunday) past weekend (3/11 and 3/12) (RI #1) was in the same clothes both days . The date the facility communicated with the person making the grievance/concern was on 3/22/2017. The form was signed by the former D.O.N (Director of Nursing), EI (Employee Identifier) #4. Another facility document titled, Grievance/Concern, dated 3/15/2017, stated RI #1's family member said: .(RI #1) per another family member had on the same clothes on Saturday 3/11 and Sunday 3/12. I investigated this concern and found that the aide assigned to (him/her) on Saturday evening 6P till 6A had let (him/her) sleep in (his/her) clothes that evening. (Disciplinary action were Taken) see attached in-service .the aide that had him/her on Sunday 6A till 2P had left him/her in the clothes that day which also told me that he/she had not sponged him/her on 3/12 per our Sunday protocol. (disciplinary actions were taken) see attached in-service. This document was signed by EI #4. A review of a facility document titled, EMPLOYEE CORRECTIVE ACTION REPORT, dated 3/11/17 with (said employee name), revealed: .NATURE OF REPORT, First Written Warning .On Sat. 3/11 6P-6A shift you were assigned to resident (RI #1). You did not change (RI#1) into (his/her) night clothes that evening at bedtime per family! RI #1 was in the same clothes Sun. as she was in Sat . The form was signed by (said employee), EI #4 and EI #5, Administrator. On 5/25/2017 at 4:01 p.m., an interview was conducted with EI #5. EI #5 was asked to discuss an incident where RI #1 had the same clothes on March 12-14, 2017, how she became aware of the incident and when. EI #5 stated, I know there was a grievance of him/her having the clothes on 2 days, I know there were 2 CNAs (Certified Nursing Assistant) disciplined, one on one shift and one on another on 3/11/ and 3/12/ in his/her clothes both days. The grievance was from RI #1's family member. EI #4 investigated and one aide had disciplinary action because she had not sponged him/her off or changed his/her clothes. Both aides were disciplined and inservice to the other staff. Through the grievance (was how EI #5 became aware of the incidence) The grievance was on 3/15/2017. EI #5 was asked if the incident was investigated, by whom and when. EI #5 responded, Yes, EI #4 on 3/15-3/22/17. On 3/22/17 (EI #4) spoke to ( RI #1's family member) about the outcome. EI #5 was asked what were the findings. EI #5 stated, That the CNA on the evening shift let the resident sleep in what he/she had on and the one Sunday morning left him/her in those clothes. Both CNAs had disciplinary action. EI #5 was asked what was done to correct it. EI #5 stated, In-service the staff. A review of In-Service Training Class Attendance Record was completed and indicated staff (both LPNs (Licensed Practical Nurses) and CNAs) were inserviced on 3/21/17 for dressing residents.

Based on observations, interview, and review of a facility documents titled, DIRECTOR OF MAINTENANCE JOB DESCRIPTION and MAINTENANCE ASSISTANT JOB DESCRIPTION, the facility failed to ensure toilet bolts were not protruding from the base, rusted, and uncapped. This was observed on two of two halls in the facility, RL (Room Locators) #1 through #19. Findings Include: A review of the Director of Maintenance Job Description revealed: .General Purpose: To plan, organize and direct the overall operation of the department in accordance with current federal, state and local standards, ensuring that the facility is maintained in a safe, comfortable condition . A review of the Maintenance Assistant Job Description revealed: .General Purpose: To maintain the grounds, facility and equipment in a safe and efficient manner in accordance with current federal, state and local standards, to ensure that a successful maintenance program is maintained at all times.Assist the Director of Maintenance in maintaining the facility in good repair; . maintenance and repairs of the facility, .promptly report .unsafe and hazardous conditions and defective equipment to the Director of Maintenance . During the initial tour of the facility, on 5/23/17 at 9:46 a.m., the following observations were made: RL #15, #16, and #17 were observed with 1 (inch) long rusted, uncapped toilet bolt protruding from the toilet base. RL #18 had a 1/2 long uncapped rusted toilet bolt protruding on one side of the toilet base. RL #19 had 1-1/2 long rusted, uncapped toilet bolts protruding from the toilet base. RL #10 had 1 long uncapped toilet bolts protruding from the toilet base. RL #7 had bolts that were flush with the toilet bowl nut but were uncapped. RL #8 had 1/2 long rusted, uncapped toilet bolts protruding from the toilet base. RL #1 had 1long rusted, uncapped toilet bolts protruding from the toilet base. RL #2 had 1/2 long uncapped toilet bolts protruding from the toilet base. RL #3 had ½-1 ½ protruding rusted toilet bolts at the base of the toilet, uncapped. RL #4 had protruding rusted toilet bolts ½-1 ½ at the base of the toilet, uncapped. RL #5 had ½-1 ½ rusted toilet bolts at the base of the toilet, uncapped. RL #6 had ½-1 ½ rusted toilet bolts at the base of the toilet, uncapped. RL# 9 had ½ toilet bolts at the base of the toilet, uncapped. RL #11 had rusted toilet bolts protruding ½-1 ½ inch at the base of the toilet, uncapped. RL #12 had rusted toilet bolts protruding ½-1 inch at the base of the toilet, uncapped. RL #13 had ½ rusted toilet bolts protruding at the base of the toilet uncapped. RL #14 had rusted toilet bolts ½-1 ½ protruding at the base of the toilet uncapped. A tour was conducted with EI (Employee Identifier) #1, Maintenance Director, on 5/25/2017 at 9:10 a.m. The surveyor showed EI#1 bathrooms with bolts protruding, rusted, and uncapped. On 5/25/2017 at 9:26 a.m., an interview was conducted with EI #1, Maintenance Director. EI #1 was asked who was responsible for resident areas to be free/safe from hazards. EI #1 stated, Maintenance to fix it, all staff should as well. EI #1 was asked who checked resident bathrooms in resident rooms. EI #1 stated, I make a PM checksheets and EI #2 (Maintenance Assistant) checks front halls and EI #3(Maintenance Assistant) checks back halls and they are with maintenance. EI #1 was asked were toilet bolts capped on all resident bathrooms. EI #1 stated, At one time they were but not all of them now. EI #1 was asked who monitors these were checked and were done. EI #1 stated, It's not on the check sheet to check them but it's under maintenance for toilets. EI #1 was asked what was observed during tour with the surveyor on 5/25/2017 at 9:10 a.m. EI #1 stated, Toilet bolts not capped. EI #1 was asked what was the concern of rusted uncapped toilet bolts protruding in the residents' bathrooms. EI #1 stated, It could cause injury to a resident. EI #1 was asked could this be a safety hazard/concern and why. EI #1 stated, yes, Because a resident could fall on it and it cause a skin tear.

Based on observation, medical record review, the facility's policy and procedure titled, Incontinent Care and Catheter Care Using Disposable Wipes, and staff interviews, the facility failed to ensure staff wiped the entire perineal area during incontinent care. This affected Resident Identifier (RI) #8, one of two residents observed during incontinent care. Findings Include: A review of the facility's policy titled, Incontinent Care and Catheter Care Using Disposable Wipes with a revised date of 12/2012, revealed: . OBJECTIVE: . cleanse the perineum, prevent infection and odors, and prevent skin breakdown . PROCEDURE: . 4. - clean entire perineal area (outer and inner .) with disposable wipe . RI #8 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #8's Annual Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 12/17/2016 revealed RI #8 was severely impaired for cognitive for daily decision making. The MDS further revealed under section H that RI #8 was frequently incontinent of bowel and bladder. On 03/16/2017 at 9:15 AM, the following observation was made during incontinent care: Employee Identifier (EI) #2, a Certified Nursing Assistant (CNA), did not wipe the entire perineal area (outer and inner). On 03/16/2017 at 9:15 AM, during an interview, EI #2 was asked why the entire perineal area (inner and outer) was not cleaned. EI #2 said she should have cleaned the entire area. EI #2 was asked why was it important to clean the entire area of the perineal area. EI #2 said to keep bacteria out. On 03/16/2017 at 2:45 PM, an interview was conducted with EI #3, Registered Nurse (RN)/Infection Control Nurse. EI #3 was asked when performing incontinent care, what should be done. EI #3 said clean the entire perineal area. EI #3 was asked why should the entire perineal area be cleaned. EI #3 said to prevent infection.

Based on observations, medical record review, and staff interviews, the facility failed to follow Resident Identifier (RI) #1's care plan to provide a straw to consume liquids. This affected RI #1, one of eleven sampled residents observed during meals. Findings Include: RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1's Significant Change Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 4 out of 15. This indicated RI #1 was severely impaired in cognition. RI #1 required supervision of oversight, encouragement or cueing while eating. A review of RI #1's Fiberoptic Endoscopic Evaluation Of Swallowing (FEES), dated 11/15/16 documented: . Reason for Referral: To R/O (rule out) aspiration: . Patient benefits from: Mechanical soft consistency food with thin liquid consistency from straw with single/small sips . During the initial tour on 03/14/17 at 3:00 p.m., a note was observed over RI #1's bed that documented: Patient must use straw. A Care Plan approach for RI #1 dated 11/15/16 documented: *Requires straws with thin liquids with single/small sips seated upright. On 03/15/17 at 12:10 p.m., RI #1 was observed at the lunch meal drinking tea from a glass with no straw and at 5:35 p.m., during the supper meal, RI #1 was again observed with no straw on the tray. RI #1 was a self feeder. On 03/16/17 at 9:02 a.m., Employee Identifier (EI) #5, Registered Nurse,Unit Supervisor, was asked why RI #1 needed a straw. EI #5 replied to drink fluids with because of aspiration from the rim of the cup. EI #5 was asked if she was aware that it (RI #1's need for a straw) was on RI #1's care plan. EI #5 replied yes. EI #5 was informed by the surveyor of the two observations on 03/15/17 of RI #1's lunch and supper meals when RI #1 did not receive a straw with those meals. EI #5 was asked if RI #1 was not provided a straw for those two meals, was the care plan followed. EI #5 replied no.

Based on observation, staff interviews, medical record review and the facility's policy and procedure titled, Incontinent Care and Catheter Care Using Disposable Wipes, the facility failed to ensure staff provided privacy during an observation of incontinent care for RI (Resident Identifier)#9. This affected RI #9, one of two sampled residents observed during incontinent care. Findings Include: A review of the facility's policy and procedure titled, Incontinent Care and Catheter Care Using Disposable Wipes with a revised date of 12/12, revealed the following: . Procedure: 1. Screen resident to provide privacy by closing the door, . RI #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #9's current Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/08/17 revealed RI #9's Brief Interview for Mental Status (BIMS) score of 13, indicating RI #9's cognition was intact. The MDS assessed RI #9 to require total assistance with Activities of Daily Living including toileting and personal hygiene. The MDS also assessed RI #9 as being frequently incontinent of bowel and bladder. On 03/15/17 at 9:55 AM, during an observation of incontinent care, the following was observed. Employee Identifier (EI) #4, Certified Nursing Assistant (CNA), closed the blinds, the curtains and the entrance door into the resident's room. EI #4 provided incontinent care to RI #9. EI #4 did not close the bathroom door that connected the bathroom to the other residents' room. On 03/15/17 at 10:15 AM, during an interview, EI #4 was asked what should be done to ensure the resident had privacy during care. EI #4 replied curtains pulled and doors closed. EI #4 also stated she should have closed the door to the bathroom, but she forgot to close the door. EI#4 was asked what would be the potential harm when the doors were not closed during resident care. EI #4 replied that would be violating the resident's privacy. On 03/16/17 at 9:50 A.M., during an interview with EI #1 (Director of Nursing/DON), the surveyor asked what doors are supposed to be closed during incontinent care. EI #1 stated all doors.

Based on observation, medical record review and staff interviews, the facility failed to provide RI (Resident Identifier) #1 with a straw during the lunch and supper meal on 03/15/17. RI #1 was identified by the facility to be at risk for aspiration. This affected RI #1, one of 11 sampled residents observed during meals. Findings Include: RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1's Significant Change Minimum Data Set ((MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 4 out of 15, which indicated RI #1 was severely impaired in cognition. The MDS revealed RI #1 required supervision of oversight, encouragement or cueing while eating. A review of RI #1's Fiberoptic Endoscopic Evaluation Of Swallowing (FEES), dated 11/15/16 documented: .Reason for Referral: To R/O (rule out) aspiration . Patient benefits from: Mechanical soft consistency food with thin liquid consistency from straw with single/small sips . RI #1's Functional Maintenance Plan (FMP), developed by Employee Identifier (EI) #6, Speech Therapist, dated 11/22/16 documented . Program(s) / Activity Type: Swallowing Maintenance . Patient is on a mechanical soft diet consistency with thin liquids. Patient benefits from drinking thin liquids from a straw . During the initial tour on 03/14/17 at 3:00 p.m., a note was observed over RI #1's bed that documented: Patient must use straw. On 03/15/17 at 12:10 p.m., RI #1 was observed at the lunch meal drinking tea from a glass without a straw and at 5:35 p.m., during the supper meal, RI #1 was again observed without a straw on the tray. RI #1 was a self feeder. On 03/16/17 at 9:02 a.m., EI #6 was asked who put the note in RI #1's room about using a straw. EI #6 replied she did. EI #6 was asked why she put the note in RI #1's room. EI #6 replied because of aspiration and penetration. EI #6 was asked what could be a concern for RI #1 if the resident was not provided with a straw to drink liquids. EI #6 replied RI #1 could choke. On 03/16/17 at 9:20 a.m., EI #5, Registered Nurse/Unit Supervisor, was asked why RI #1 needed a straw. EI #5 replied to drink fluids with because of aspiration from the rim of the cup. EI #5 was asked if she was aware that it (RI #1's need for a straw) was on RI #1's care plan. EI #5 replied yes. EI #5 was informed by the surveyor of the two observations on 03/15/17 at the lunch and supper meals when RI #1 did not receive a straw at those meals. EI #5 was asked what would be a concern for RI #1 not using a straw. EI #5 replied aspiration and pneumonia. EI #5 was asked if aspiration could be prevented if a straw was used. EI #5 replied yes.

Based on an observations, interviews, and record reviews, the facility failed to ensure: 1. A licensed nurse washed her hands in-between residents during medication pass. 2. Licensed nurses did not turn off the water faucets with their bare, wet hands. 3. A licensed nurse did not close the privacy curtain with gloved hands, and then provide care for RI (Resident Identifier) #5. 4. A licensed nurse cleaned RI #8's wound in a manner to prevent the potential for cross contamination. These deficiencies had the potential to affect RI #5, RI #8, RI #16, and RI #17, four of twenty one sampled residents. Findings include: POTTER and PERRY, Fundamentals of Nursing, 7th Edition, revealed: .Page 655 Chapter 34 Infection Prevention and Control . 2. If hands are not visibly soiled, use an alcohol-based waterless antiseptic agent for routinely decontaminating hands in all clinical situations: . c. After contact with body fluids or excretions, mucous membranes, non-intact skin, or . e. After contact with inanimate objects (including medical equipment) in the immediate area of the client . h. After removing gloves . .Page 658 Skill 34-1 . Steps . L. Turn off water with foot or knee pedals. To turn off hand faucet, use clean, dry paper towel; avoid touching handles with hands. Rationale . Prevents transfer of microorganisms. Wet towel and hands allow transfer of pathogens from faucet to hands. Faucet handles are contaminated . A review of the facility's policy titled, Handwashing Policy and Procedure, with a revision date of 2/2010, revealed, .Purpose: The use of appropriate handwashing and hand antisepsis practices are recommended to promote improved hand-hygiene practices and reduce the transmission of microorganisms to patient and personnel in the health-care setting. 3. Wash hands .between resident contact, and when otherwise indicated .to avoid transfer of microorganisms to other residents or environments. 6.When washing hands . Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet. 1. A review of RI #16's medical record revealed RI #16 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #16's Quarterly MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 12/09/15, revealed RI #16 had a BIMS (Brief Interview for Mental Status) score of 13. This score indicated RI #16 was cognitively intact. RI #16 required extensive to total assistance from staff for ADLs (Activities of Daily Living). A review of RI #17's medical record revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #17's Admission MDS with an ARD of 12/28/15, revealed RI #17 had severe cognitive impairment. RI #17 required total assistance from staff for ADLs. On 2/23/16 at 12:05 PM, EI (Employee Identifier) #3, an LPN (Licensed Practical Nurse), was observed administering medications to RI #16. EI #3 completed her medication pass for RI #16, left the room and went into RI #17's room. EI #3 touched the bed linens of RI #17. EI #3 left RI #17's room, entered the clean utility room and looked for an item in a cabinet. EI #3 then went and used a phone at the nursing station. EI #3 did not wash her hands between tasks. EI #3 emptied the trash on the side of the medication cart and then went into the clean utility room and washed her hands. EI #3 multitasked without washing her hands. On 2/25/16 at 10:00 AM, an interview was conducted with EI #3. EI #3 was asked when should she wash her hands during a medication pass. EI #3 stated, Before you prepare medications, after you prepare medications. If you touch dirty surfaces, wash, wash, wash, hand hygiene. EI #3 was asked when she washed her hands during the above observation. EI #3 stated, I washed my hands before you saw my medication set up. After I finished and handled the garbage, I washed my hands. The surveyor shared the above medication pass observation with EI #3 and asked what was the concern. EI #3 stated, Hand washing. EI #3 also stated, Before I went into RI #17's room, I should have washed my hands. There is a chance for cross contamination. An interview was conducted on 2/25/16 at 12:23 PM, with EI #2, the Infection Control Nurse and the Assistant Director of Nursing of the facility. EI #2 was asked when should staff members wash their hands during medication pass. EI #2 stated, In-between each resident. 2. A medication pass observation was done for RI #7, by EI #4 an LPN, on 2/24/16 at 12:05 PM. EI #4 entered RI #7's room and pulled the privacy curtain. EI #4 washed her hands and turned off the faucet with her bare wet hands. On 2/24/16 at 12:35 PM, an interview was conducted with EI #4. The surveyor asked EI #4 how she turned off the water faucet when she washed her hands. EI #4 stated, Oh, I should have gotten a paper towel to turn off the faucet then. On 2/24/16 at 5:05 PM, a medication pass was observed for RI #16, by EI #5, an LPN. EI #5 administered eye drops for RI #16, washed her hands and turned off the faucet with her bare wet hands. A call was placed to EI #5 to conduct an interview. The surveyor was unable to reach her. An interview was conducted on 2/25/16 at 12:23 PM, with EI #2. EI #2 was asked how were staff members trained to turn off the faucet during hand washing. EI #2 stated, After they wash their hands, they should turn the faucet off with a paper towel. The surveyor shared the above observations during medication pass and asked what was the concern. EI #2 stated, They cause cross contamination. 3. A review of RI #5's medical record revealed the resident was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #5's Admission MDS, with an ARD of 01/20/16, revealed RI #5 had moderate cognitive impairment skills for daily decision making. RI #5 was coded as requiring extensive to total assistance for ADLs. RI #5 had an Ileostomy and Gastrostomy-tube. RI #5 also had an indwelling Foley Catheter. A wound care observation was done for RI #5 on 2/24/16 at 9:00 AM, with EI #1, an LPN. EI #1 pulled a privacy curtain with her gloved hands and then checked RI #5's Ileostomy. An interview was conducted with EI #1 on 2/25/16 at 8:56 AM. EI #1 was asked what was the concern when the privacy curtain was pulled with gloved hands and then resident care was provided. EI #1 stated, The curtain is not clean, cross contamination. 4. A review of RI #8's medical record revealed the resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #8's Quarterly MDS, with an ARD of 01/01/16, revealed RI #8 had a BIMS score of 12. This score indicated RI #8 was moderately impaired. RI #8 was coded as requiring extensive assistance for ADLs. On 2/24/16 at 11:20 AM, wound care was observed for RI #8's Cellulitis of the lower left leg, by EI #1. EI #1 sprayed the lower area of the left leg with sterile normal saline. EI #1 patted over the wound area on the lower left leg four times without changing the position of the gauze. EI #1 changed the gauze and then patted the wound area five times without changing the position of the gauze. EI #1 changed the gauze and patted the wound on the lower left leg 4 times without changing the position of the gauze. EI #1 patted up and around RI #8's lower left leg while cleaning the wound. EI #1 did not clean the wound from clean to dirty. EI #1 was also observed to clean the wound on the lower left leg in a back and forth motion. An interview was conducted with EI #1 on 2/25/16 at 8:56 AM. EI #1 was asked how she cleaned RI #8's wound during the above observation. EI #1 stated, I just cleaned the ulcer. I sprayed it with normal saline after applying gloves, after washing my hands and applying gloves. I patted from the center out, changing the position with each wipe. The surveyor asked EI #1 when did she change position of the gauze and/or changed the gauze while cleaning RI #8's wounds. EI #1 stated, I thought I did change the position with each pat. The surveyor shared the above observation with EI #1 and asked her what the concern was. EI #1 stated, The concern is you are going to bring dirty to clean, after you have cleaned that area. There is a potential for cross contamination. An interview was conducted on 2/25/16 at 12:23 PM with EI #2. EI #2 was asked how were skilled nurses trained to clean resident's wounds. EI #2 stated, They are trained to pat dry from clean to dirty. I would pat and use another 4 X 4 (four by four gauze) with each pat. The surveyor shared the above observation of RI #8's wound care with EI #2, and asked what was the concern. EI #2 stated, Taking bacteria from clean to dirty.

Based on observation, record reviews, and interviews, the facility failed to ensure a licensed nurse did not clean RI (Resident Identifier) #5's wound in a manner to prevent the potential for cross contamination. This affected RI #5, one of three sampled residents observed for wound care. Findings Include: A review of Potter - Perry Fundamentals of Nursing 7th Edition, Chapter 34, page 655, Infection Prevention and Control, revealed: .The CDC (Center for Disease Control) recommends the following: 1. Wash hands with a non-antimicrobial soap or antimicrobial soap and water when hands are visibly soiled. 2. If hands are not visibly soiled, use an alcohol-based waterless antiseptic agent for routinely decontaminating hands in all other clinical situations: . e. After contact with inanimate objects (including medical equipment) in the immediate care of the client. h. After removing gloves. A review of Potter - Perry Fundamentals of Nursing 7th Edition, Chapter 48, page 1315, Skin Integrity and Wound Care, revealed: SKILL 48-3 Applying Dry and Moist Dressings . STEPS . 16. Apply dressing: A. Dry dressing (1) Apply sterile gloves. Rationale .Allows handling of sterile supplies without contamination. (2) Inspect wound . (3) Cleanse wound with solution: a. Clean from least-contaminated area to most-contaminated area . (4) Dry area. (5) Apply sterile dry dressing covering wound. (6) Apply [MEDICATION NAME] dressing if indicated. A review of the facility's policy titled, Handwashing Policy and Procedure, with a revision date of 2/2010, revealed, Purpose: The use of appropriate handwashing and hand antisepsis practices are recommended to promote improved hand-hygiene practices and reduce the transmission of microorganisms to patient and personnel in the health-care setting. 3. Wash hands .immediately after gloves are removed . A review of RI #5's medical record revealed the resident was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #5's Admission MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 01/20/16, revealed RI #5 had moderately cognitive impairment skills for daily decision making. RI #5 was coded as requiring extensive to total assistance for ADLs (Activities of Daily Living). RI #5 had an [MEDICAL CONDITION] and Gastrostomy-tube. RI #5 also had an indwelling Foley Catheter. On 2/24/16 at 9:00 AM, EI (Employee Identifier) #1, an LPN (Licensed Practical Nurse), was observed performing wound care for RI #5. RI #5 had 3 stage II (Two) pressure ulcers on the coccyx area. Two new pressure ulcers were identified during the wound care observation. One new wound was on the right buttocks that was 0.5 cm (Centimeters) in length and width. No depth was observed in the wound. The second new wound was on the left buttocks. It was 0.3 cm in length and width. No depth was observed in the wound. The third coccyx wound measured 2 cm long, 0.8 cm wide and 0.1 cm deep. EI #1 washed her hands, changed her gloves, and sprayed RI #5's coccyx with normal saline. EI #1 patted the wound area up and around 5 times. EI #1 changed the position of the gauze dressing once. EI #1 changed the gauze and patted the coccyx area 3 times around and across without changing the position of the gauze. EI #1 patted over all of the coccyx area. EI #1 did not clean the wound areas from clean to dirty. EI #1 removed her gloves and left the room to obtain a measuring device from the wound cart. She returned to the room and applied gloves. EI #1 did not wash her hands prior to applying her gloves. EI #1 measured RI #5's wounds. EI #5 washed her hands and applied gloves. RI #5 was resting on their buttocks on top of the folded linen saver that was soiled with stool. EI #1 stated that she needed to re-clean the wounds on the coccyx. She sprayed RI #5's coccyx and patted the area up, down, and around 4 times without changing the position of the gauze. An interview was conducted with EI #1 on 2/25/16 at 8:56 AM. EI #1 was asked how she was taught to clean resident's wounds. EI #1 stated, I was taught to wash my hands, apply gloves, and spray the wound with saline and let it run down the wound, and from the center of the wound, to the outside, pat dry using one gauze with each sweep going up. Start from the center and go up. Use a new side every time. The surveyor asked E #1 how did she clean RI #5's wound on the coccyx area. EI #1 stated, RI #5 had three different wounds. I sprayed and cleaned the middle and went up. EI #1 was asked if she cleaned each of RI #5's wounds separately. EI #1 stated, To the best of my recollection I did. It was very difficult with him. The surveyor shared the observation of RI #5's wound care on 2/24/15, with EI #1. EI #1 stated, I know that I should clean each wound separately. EI #1 was asked if she cleaned each one of RI #5's wounds separately. EI #1 stated, I don't think I got to that point. The surveyor asked EI #1 what was the concern when wounds were cleaned without changing the position of the gauze, and not wiped from clean to dirty. EI #1 stated, The concern is you are going to bring dirty to clean, after you have cleaned that area. There is a potential to cross contaminate. An interview was conducted on 2/25/16 at 12:23 PM, with EI #2, the Infection Control Nurse and the Assistant Director of Nursing of the facility. EI #2 was asked how were skilled nurses trained to clean resident's wounds. EI #2 stated, They are trained to pat dry from clean to dirty. I would pat and use another 4 X 4 (four by four gauze) with each pat. The surveyor shared the above observation of RI #5's wound care with EI #2, and asked what was the concern. EI #2 stated, Taking bacteria from clean to dirty.

Based observations, record reviews, and interview, the facility failed to ensure a physical therapy intervention was documented in the plan of care. This affected RI (Resident Identifier) #4, one of four residents sampled for contractures. Findings include: A review of the facility policy titled, "SUBJECT: Initial Evaluation/Plan of Care Policy: 3007 MANUAL: REHABILITATION POLICY AND PROCEDURE EFFECTIVE: 05/01/2011 ... Policy ...Treatment plans will be developed for all patients who are determined to be candidates for beneficial outcome from rehabilitation services. Procedure Based on an initial plan of care assessment of the patient's physical, cognitive, emotional and social status, a rehabilitation plan will be developed and documented in the patient's medical record. The rehabilitation treatment plan of care includes the following components: ... Initial assessment plan of care information will be documented in the patient's medical record, and will include: 1. Treatment modalities planned; 2. Equipment recommended for use; 3. Frequency and duration of treatment planned; ... Plan of Care (POC): 1. The Plan of Care is an individualized plan for each patient. In the POC, problems are identified and corresponding goals developed. ... The POC must be kept up-to-date with regard to current treatment and goals. ..." A review of the medical record for RI #4 revealed a re-admitted [DATE] with [DIAGNOSES REDACTED]. A review of a significant change Minimum Data Set assessment dated [DATE], revealed RI #4 was severely cognitively impaired for daily decision making skills. The resident was also assessed as requiring maximum assistance in transferring and all Activities of Daily Living (ADLs). This assessment also revealed RI #4 had upper and lower extremity impairment on one side. An observation was made on 1/21/2015 at 12:06 PM. RI #4 was up in a wheelchair at the bedside table, eating. The resident was observed with a hand roll splint in place on the left hand. An observation was made on 1/21/2015 at 12:47 PM when the meal was complete. RI #4 remained in the wheelchair with the hand roll splint in place. A review of the Therapist Progress and Plan of Care (POC) for RI #4 revealed no plan to include the use of the splint. The POC did not include when, where, or how the splint was to be used. An interview was conducted with EI (Employee Identifier) #5, an Occupational Therapist, on 1/22/2015 at 3:02 PM. EI #5 was asked if a POC was documented for RI #4 regarding the use of a splint. EI #5 answered, "No." EI #5 was asked why not. She answered it wasn't addressed initially. EI #5 was asked who was supposed to do the documentation in the POC. She answered, "I was." EI #5 was asked when was it supposed to be done. She answered, "When it was initiated." EI #5 was asked when was the splint supposed to be in place for RI #4. She answered, "When in the chair and in therapy." She was asked where was the documentation. EI #5 answered, "(There is) None. "EI #5 was asked what was the policy on documenting initial assessments and POCs when residents are admitted to therapy. EI #5 answered, "Add a new goal."

Based on observations, interviews, and record review, the facility failed to ensure oxygen concentrator external cabinet filters did not have a heavy accumulation of dust-like substance. This affected RI (Resident Identifier) #s 4, 5, 11, and 13, four of seventeen residents sampled. Findings include: A review of the facility's Policy and Procedure titled, "Oxygen Therapy, ..." with a revision date of 2/1/2011, revealed, "PROCEDURE: ... 7. Clean concentrator and filter with soapy water. Let filter air dry and replace. Replace mask, cannulas prefilled Humidifier bottles. Do all of this weekly and date. 10-6 Monday evening. ..." A review of a facility document titled, "LICENSED NURSE SKILLS COMPETENCY EVALUATION BASIC PRACTICE PROCEDURES," a skills check off used for new employees on hire and for annual inservicing of nurses, revealed, "SKILL ... Use and Care of Oxygen Concentrator and Tanks ..." A review of the medical record for RI #4 revealed a re-admitted [DATE] with [DIAGNOSES REDACTED]. A review of a significant change MDS (Minimum Data Set) assessment dated [DATE], revealed RI #4 was severely cognitively impaired for daily decision making skills. The resident was also assessed as requiring maximum assistance in transferring and all Activities of Daily Living (ADLs), non-ambulatory, and incontinent of bowel and bladder. A review of the medical record for RI #5 revealed a re-admitted [DATE] with [DIAGNOSES REDACTED]. A review of a Quarterly MDS assessment dated [DATE], revealed RI #5 had a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15. This score indicated the resident was cognitively intact for skills of daily decision making. The resident was identified as requiring maximum assistance with all ADLs. A review of RI #11's medical record revealed, the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a Quarterly MDS, with an Assessment Reference Date of 11/18/2014, for RI #11 revealed the resident had a BIMS score of 15 out of a possible score of 15. This indicated RI #11 was cognitively intact for decision making. The MDS also indicated that RI #11 required maximum assistance with all ADL's. 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 a Quarterly MDS, with an Assessment Reference Date of 10/07/2014, for RI #13 revealed, the resident3 had a BIMS score of 4 out of a possible score of 15. This indicated RI #13 had severe cognitive impairment for daily decision making. The MDS also indicated that RI #13 required minimal assistance with all ADL's. An observation was made during the initial tour of the facility on 1/20/2015 at 4:33 PM. An oxygen concentrator filter was observed with a heavy accumulation of dust-like substance present. This was observed on the concentrator in use by RI #11. An observation was made during the initial tour of the facility on Tuesday, 1/20/2015 at 4:38 PM. An oxygen concentrator filter was observed with a heavy accumulation of dust-like substance present. This was observed on the concentrator in use by RI #4. An observation was made during the initial tour of the facility on Tuesday, 1/20/2015 at 4:59 PM. An oxygen concentrator filter was observed with a heavy accumulation of dust-like substance present. This was observed on the concentrator in use by RI #13. An observation was made during the initial tour of the facility on Tuesday,1/20/2015 at 5:03 PM. A oxygen concentrator filter with a heavy accumulation of dust-like substance present. This was observed on the concentrator in use by RI # 5. An interview was conducted with EI (Employee Identifier) #4, a Licensed Practical Nurse (LPN), on 1/23/2015 at 8:45 AM. EI #4 was asked if she changed the Oxygen concentrator filters on a routine basis. EI #4 responded "Yes ma'am." EI #4 was asked how often were the filters changed. She responded, "I usually check them every week, I change out the nebulizer tubing and oxygen tubing and water. I check the filters at that time." EI #4 was asked who was responsible for changing the filters. She answered, "The nurses on the ten to six shift." EI #4 was asked when were the filters scheduled to be changed or cleaned. She answered, "You would have to check with the RNs (Registered Nurses), I just do it on Monday nights because I felt like it was my duty." EI #4 was asked if she had been inserviced on how and when to change Oxygen filters. She stated she had recalled an inservice in December. EI #4 was asked what would be the potential negative outcome if Oxygen concentrator filters were not changed weekly as scheduled. EI #4 answered, "Well, they (the residents) wouldn't be getting the air that they needed and (the concentrator) could stop running properly." On 01/23/2015 at 8:50 AM, an interview was conducted with EI #3, an LPN. EI #3 was asked if she changed oxygen concentrator filters on a routine basis. EI #3 replied, "Yes we do tubing, humidifier and cabinet filters." EI #3 was asked how often were they (the oxygen concentrator filters) changed. EI #3 replied, "Monday nights 10 PM - 6 AM shift." EI #3 was asked who was responsible for changing the (oxygen concentrator) filters. EI #3 replied, "The nurse on 10 (PM) - 6 (AM)." EI #3 was asked when were they (the oxygen concentrator filters) scheduled to be changed. EI #3 replied, "Monday night 10 PM - 6 AM shift." EI #3 was asked if she had been in-serviced on how and when to change the oxygen concentrator filters. EI #3 replied, "Yes". EI #3 was asked when was she in-serviced. EI #3 replied, "When we did our annual check off, which was in December (of) 2014." EI #3 was asked what the potential negative outcome could be if oxygen concentrator filters were not changed/cleaned weekly as scheduled. EI #3 replied, "They can get clogged, I don't know anything else."

Based on observation, interview, and record review, the facility failed to ensure incontinence care was provided in a manner to prevent the potential for infection to Resident Identifier (RI) #1, This affected one of two residents observed for incontinence care. Findings included: The facility Policy/Procedure for Incontinent Care and Catheter Care Using Disposable Wipes, with a revision date of 12/20/12, stated the objective of the policy is, "To cleanse the perineum, prevent infection and odors, and prevent skin breakdown." The procedure revealed: "... 5... clean the penis, scrotum and inner thighs while using a clean area of the wipe or a clean wipe for each stroke. Place the soiled wipe in a disposable plastic bag. 6. Turn the resident to their side. Clean the buttocks and anal area, moving upwards toward the back in the same manner that you cleaned the perineal area." A review of RI #1's medical record revealed, the resident was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. RI #1 had been diagnosed with [REDACTED]. The Significant Change in status Minimum Data Set (MDS), with an assessment reference date of 12/25/14, indicated RI #1 had both long and short term memory impairment and was severely impaired of decision making skills. The MDS also revealed RI #1 was always incontinent of both bowel and bladder and was dependent upon staff for hygiene and bathing. On 1/22/15 at 9:30 AM, Employee Identifier #1, a CNA (Certified Nursing Assistant), was observed to provide incontinence care for RI #1. When the resident was turned to the side to provide care to the rectal area, EI #1 failed to provide cleansing to the buttocks. The anal area was swiped twice with the same disposable wipe. The diaper was left off and a pad was placed underneath RI #1 because the resident was staying in bed. On 1/22/14 at 10:30 AM, EI #1 was asked about the process of providing the incontinent care. EI #1 stated the buttocks were not swiped and the rectum had been swiped with the same wipe two times. When asked how the care should have been provided, EI #1 stated "Supposed to wipe sides first then the rectum upwards." When asked if that is what he had done, EI #1 stated, "I didn't wipe sides but I did wipe rectum twice."