Every finding on record at Crowne Health Care of Montgomery

Based on record reviews, interviews, and a review of the facility policy Tube Feeding Administration, the facility failed to ensure licensed staff did not initial the Medication Administration Record (eMAR) for bolus tube feeding for Resident Identifier RI #1. This deficient practice was cited as a result of the investigation of complaint # AL 405 and affected RI #1, one of one resident's sampled for tube feeding. Findings Include: A review of an undated facility policy titled Tube Feeding Administration, revised on 5/21, revealed . Procedure: 1. Check the physician's order on the eMAR prior to gathering supplies.9. Feedings will be given by one of the methods below. Bolus Feeding Method . J. Document procedure on eMAR. Closed System via Infusion Pump . R. Document the feeding on the eMAR. RI #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Physician orders for RI #1 revealed . 6/4/21 DC (discontinue) Glucerna . when supply complete . Glucerna .1 can QID (four times a day) . written by Employee Identifier EI #2, Assistant Director of Nursing. A review of the June eMAR for RI #1 revealed . Continuous Feeding PER PUMP PER TUBE . start date 5/26/21 . BOLUS FEEDING PER SYRINGE PER TUBE . Start Date: 6/7/21. In reviewing the eMAR for 6/7/21 EI #4 and EI #6 initialed the bolus as given and the continuous feeding was left blank. On 6/8/21, EI #3 and EI #5 initialed the bolus as given and the continuous feeding was blank. On 6/28/21 at 4:30 PM, an interview was conducted with EI #3, Licensed Practical Nurse (LPN). EI #3 was asked what was RI #1's tube feeding order. EI #3 replied, continuous feeding. EI #3 was told by the surveyor she signed the eMAR at 5:00 PM giving a bolus feeding; EI #3 was asked if she gave a bolus feeding. EI #3 replied, no RI #1 had continuous feedings. EI #3 was asked what could she tell the surveyor about the bolus feeding; she replied she did not recall the bolus feeding. EI #3 was asked why did she sign the bolus feeding on the MAR. EI #3 replied, it was a mistake. On 6/29/30 at 9:40 AM, an interview was conducted with EI #1, Director of Nursing (DON). EI #1 was asked what type of tube feeding was RI #1 receiving. EI #1 replied, RI #1 was getting continuous feeding, the order was to discontinue the continuous feeding when the current supply was out then to start the bolus feeding. EI #1 was asked when should nurses sign both continuous and bolus feeding. EI #1 replied, they should have signed one or the other. On 6/30/21 at 11:51 AM, an interview was conducted with EI #4, LPN. EI #4 was asked what tube feeding RI #1 was receiving. EI #4 replied, Glucerna continuous. EI #4 was asked, if she had ever administered the feeding by bolus. EI #4 replied, no always continuous. EI #4 was told the surveyor had reviewed the eMAR for 6/7/21 and saw where she initialed giving the bolus feeding at 5 PM and 9 PM, then asked why she initialed giving it if she did not. EI #4 replied, she had no idea she only gave the continuous feeding. EI #4 was asked if she should have initialed giving bolus if she did not. EI #4 replied, no RI #1 never got it by bolus. On 6/30/21 at 11:54 AM and at 1:30 PM attempts were made to contact EI #6, LPN. On 7/1/21 at 9:00 AM EI #6 returned the call and an interview was conducted. EI #6 was asked what shift she worked and what could she recall about RI #1's tube feeding. EI #6 replied, she worked the 7 to 3 shift, and RI #1 got Glucerna by the pump she said she could not recall how much, and the feeding was started on the evening shift. EI #6 was asked how RI #1 got the bolus feeding. EI #6 replied, RI #1 did not get a bolus feeding it was to start when the continuous supply ran out. EI #6 was asked how was the tube feeding being documented on the MAR. EI #6 replied, she was now aware they were signing both off. EI #6 was asked if both continuous and bolus feedings were given. EI #6 replied, they were not, RI #1 never got the bolus feeding. EI #6 was asked why did she initial both feedings. EI #6 replied, in error. EI #6 was asked what did it mean when initialing the eMAR. EI #6 replied, it indicates being done, but she knew she did not give RI #1 the bolus feeding. On 6/30/21 at 12:35 PM, an interview was conducted with EI #5, LPN. EI #5 was asked what type of feeding was RI #1 receiving. EI #5 replied, continuous to be started every evening. EI #5 was asked why she initialed the eMAR for bolus feeding on 6/8/21. EI #5 replied the way she read the eMAR they would bolus feed if they did not have the continuous feeding. EI #5 was asked, did RI #1 get both continuous and bolus feeding. EI #5 replied, no, only the continuous. EI #5 was asked if she should have initialed the bolus if it was not done. EI #5 replied, no. EI #5 was asked why did she initial the bolus feeding. EI #5 replied, she thought it was to give bolus if they did not have continuous feeding, it was to start after no supply left. On 6/30/21 at 12:45 PM a follow up interview was conducted with EI #1, DON. EI #1 was asked when was RI #1's tube feeding to be changed. EI #1 replied, not sure, the order was written 6/4/21, the start would depend on when the continuous supplies ran out. EI #1 was asked what was RI #1's tube feeding. EI #1 replied, Glucerna continuous until that supply ran out, then was to start the Glucerna cans bolus. EI #1 was asked if RI #1 was to receive continuous and bolus feeding at the same time. EI #1 replied, no. EI #1 was asked how many nurses initialed the bolus feeding. EI #1 replied, four, EI #3, EI #4, EI #5 and EI #6. EI #1 was asked, why the nurses initialed the bolus feeding. EI #1 replied, she did not know, possibly in error. EI #1 was asked what would the concern be in the nurses signing the bolus feeding when it was not given. EI #1 replied a documenting error as RI #1 did not get the bolus feedings.

Based on interviews, review of the facility's Abuse Policy, the facility's investigation file, and other facility documents, the facility failed to ensure Resident Identifier (RI) #28 and other residents were protected from potential abuse after RI #28 reported to two Certified Nursing Assistant (CNAs) that EI #4, a CNA had hit him/her. The two CNAs reported the allegation of physical abuse to the Licensed Practical Nurse (LPN) who was on duty at the time of the incident. The LPN reported the allegation of physical abuse to the Registered Nurse (RN) Supervisor. The RN Supervisor, who was responsible for initiating an investigation and reporting the allegation of physical abuse to the Abuse Coordinator and the Alabama Survey Agency, failed to assess RI #28's for injuries, initiate an investigation, remove EI #4 from resident care and report the allegation of physical abuse to the facility's Abuse Coordinator and the Alabama Department of Public Health. The facility's Abuse Coordinator was made aware of the allegation of physcial abuse until 3/6/2021. EI #4, a CNA was allowed to remain in the facility and work an additional four days, until 3/6/2021, after it was reported that she had hit a resident, RI #28. This deficient placed RI #28, one of three sampled residents reviewed for abuse, in immediate jeopardy as it was likely to cause serious injury, harm, impairment or death. On 4/16/2021 at 3:50 PM, the Administrator, Assistant Administrator and Director of Nursing (DON) notified of the finding of immediate jeopardy in the area of Freedom from Abuse, Neglect and Exploitation, F607. Findings include: Contained within the facility's investigation file was a typed documented dated 3/12/2021, which documented . Re: (RI #28/EI #4 Allegation of Physical Abuse . On February 28, 2021, (EI #4), CNA, came out of (RI #28's) room and told staff members including (EI #5), LPN, (EI #7), CNA, and (EI #8), CNA, that (RI #28) hit her . After (EI #4) left the hall, (EI #7) and (EI #8) asked (RI #28) if (he/she) hit (EI #4) and (he/she) stated, Yes but only because she hit me first. (EI #7) and (EI #8) stated that (RI #28) didn't say where (EI #4) hit (him/her). (EI #5) stated she notified (EI #6), RN, about the incident but (EI #6) stated she did not make Abuse Coordinator or SS (Social Services) aware. The incident was not reported to SS until Saturday, March 6, 2021. SS and RN supervisor immediately dismissed (EI #4) from her duties and sent her home. SS went to (RI #28) to ask (him/her) what happened. (RI #28) stated (he/she) did not know what SS was talking about . (RI #28) stated that (he/she) did not remember that. SS asked (RI #28's) roommate about the incident. Resident stated (he/she) didn't remember an incident like that occurring either . Following our investigation, we are unable to substantiate the allegation of physical abuse . Protection The facility's Abuse Policy, dated November 2016 documented, . Anytime that the nursing home receive an allegation of abuse . take all necessary steps to prevent further potential abuse . the employee(s) involved will be suspended until completion of the investigation . If the investigation substantiates abuse the employee will be terminated. While the investigation is being conducted, accused individual not employed by the facility will be denied unsupervised access to the resident . A review of EI #4's Employee Timesheet, indicated EI #4 worked in the facility on 3/1/2021, 3/2/2021, 3/5/2021 and 3/6/2021. In an interview on 4/14/2021 at 11:59 AM, EI #2, the Director of Nursing (DON) was asked why EI #4, a CNA, was not removed from the schedule due to allegation of physical abuse. EI #2 replied, management did not become aware of allegation until 3/6/2021. Once management became aware, EI #4 was suspended immediately. In an interview on 4/14/2021 at 12:17 PM, EI #1, the Administrator was asked why EI #4 was not removed from schedule on 2/28/2021 when there was an allegation of abuse against her. EI #1 replied, because it was not reported to management until 3/6/2021. When asked if the facility's policy was followed, EI #1 answered, no. Investigation The facility's Abuse Policy dated November 2016 documented, Anytime that the nursing home receive an allegation of abuse initiate an immediate investigation and take the necessary steps to prevent further potential abuse . An investigation of the incident must be initiated immediately by the administrator or his/her designee . Perform a physical assessment of the resident . On 4/14/2021 at 10:49 AM, a telephone interview was conducted with EI #6, the Registered Nurse (RN) Supervisor on duty when RI #28 reported to the staff an allegation of physical abuse. When asked if she initiated an investigation into the allegation of physical abuse, EI #6 said no. In an interview on 4/14/2021 at 11:59 AM, EI #2, the DON was asked where was the documentation of RI #28's assessment after the resident informed the staff that he/she had been hit by a CNA. EI #2 replied a body audit was not performed until 3/6/2021. When asked should the resident have been assessed for injury after the allegation of physical abuse, EI #2 stated, yes on 2/28/2021. During an interview on 4/15/2021 at 2:54 PM, EI #1, the Administrator was asked what should have happened on 2/28/2021 when RI #28 informed the staff that he/she had been hit by EI #4, a CNA. EI #1 stated the CNA should have been suspended, an investigation should have been initiated, and a body audit of RI #28 should have been completed. EI #1 stated the facility should have taken the same actions they did on 3/6/2021 when management became aware. Reporting The facility's Abuse Policy dated November 2016 documented Anytime that the nursing home receive an allegation of abuse . the facility must report the alleged violation to various officials, which may include law enforcement and Alabama Department of Public Health . reported immediately, but not later than 2 hours after the allegation is made, if the event that cause the allegation involves abuse or result in serious bodily injury, or not later than 24 hour if the events cause the allegation do not involve abuse . On 4/14/2021 at 10:49 AM, a telephone interview was conducted with EI #6, the Registered Nurse (RN) Supervisor on duty when RI #28 reported to the staff an allegation of physical abuse. When asked if she reported the allegation of physical abuse, EI #6 said she forgot. In an interview on 4/14/2021 at 11:08 AM, EI #3, the facility's Social Worker was asked when she became aware of the allegation of physical abuse regarding RI #28 perpetrated by EI #4. EI #3 replied, she became aware of the allegation on 3/6/2021 around 11:00 AM. During an interview on 4/15/2021 at 7:01 PM, EI #1, the Administrator acknowledged the incident between RI #28 and EI #4 was an allegation of physical abuse that should have been reported within two hours. When asked if the facility's policy was followed, EI #1 said no. According to the ADPH's Online Incident Reporting System, the allegation of physical abuse between RI #28 and EI #4 was initially reported to the State Survey Agency on 3/8/2021 at 3:03 PM. ************************* Once the allegation of physical abuse was reported to the facility's Administrator, the following corrective actions were implemented * On 3/6/2021, RI #28 was assessed for injuries; none noted * On 3/6/2021, EI #4 was placed on suspension. EI #4's employment with the facility was terminated on 3/12/2021 * On 3/6/2021, RI #28's physician and sponsor were notified of the allegation of physical abuse * On 3/6/2021, the facility initiated an investigation into the allegation of physical abuse; the facility was unable to substantiate the allegation of physical abuse * On 3/8/2021, the facility reported the allegation of physical abuse to the State Survey Agency * On 3/9/2021, EI #6, RN Supervisor, received a warning for not immediately reporting the allegation of physical abuse * On 3/12/2021, EI #5, the Licensed Practical Nurse (LPN) was educated on the facility's abuse policy and procedures * On 3/31/2021, a resident council meeting was held; the facility's abuse policy and procedures were reviewed with all in attendance ************************* After review of the facility's investigation file, in-service/education records, the facility's Quality Assurance plan, staff and resident interviews, the facility implemented corrective actions from 3/6/2021 to 3/31/2021, thus immediate jeopardy past non-compliance was cited.

Based on observation, interview and review of facility policies titled Labeling & Dating, Use and Storage of Food Brought in by Family and Visitors, Policy-Expired Foods in Refrigerator, and a facility document titled Labeling & Dating Rules, the facility failed to ensure: 1. that Bacon and Sausage Links in the walk-in cooler were dated with open date and in a sealed package; 2. broken eggs were not placed on top of unbroken eggs and 3. the air conditioning exhaust vent above clean trays and cups used for resident meals was not covered with a thick layer of dust. The facility further failed to ensure all food items in the unit refrigerators contained a name and date and that refrigerators were clean. These deficient practices had the potential to affect all 115 residents that received meals from the facility kitchen. Findings Include: A review of a facility document titled Labeling & Dating revealed, .2. Refrigerated storage- a. All items must have a received date and to be used or discarded by the appropriate expiration date of the product. d. Every item which has been opened must have an opened date and use by date. Find the appropriate use by date from the Label & Dating Rules chart. A review of a facility document titled Labeling & Dating Rules revealed All Items Must be Sealed, Dated Labeled . Every item which has been opened must have an opened date. Every item which has been removed from the freezer to thaw, must have a thaw date. A review of a facility policy titled Use and Storage of Food Brought in by Family and Visitors with a date of ,d+[DATE] revealed Policy Explanation and Compliance Guidelines: . 2. All food items that are . brought in must be labeled with content and dated. a. The facility may refrigerate labeled and dated prepared items in the nourishment refrigerator.d. If not consumed within 3 days, food will be thrown away by facility staff. A review of a facility document titled Policy-Expired Foods in Refrigerator with a date of [DATE] revealed Housekeeping will check for expired items in refrigerator. Fridays are the assigned day for inspection . No name items will be discarded when checked. No date items discarded when checked. Refrigerator will be wiped out at this time. On [DATE] at 5:12 PM, during the initial kitchen tour an observation was made of a ceiling vent covered with a solid layer of dark gray dust with clumps of dust hanging in between vent slots. Air was noted to be blowing through the vent as evidenced by hanging clumps of dust were moving. Below the vent were drying racks containing bowls and coffee mugs. On [DATE] at 5:15 PM, an observation was made of the walk-in cooler. In the cooler was a cardboard box containing bacon. The surveyor lifted the lid of the box and observed bacon in plastic packaging that was opened and unsealed. There was no open date on the box or plastic packaging. Employee Identifier (EI) #19, a cook, was asked when the box of bacon was opened. EI #19 replied, she could not tell but it was probably opened that day when kitchen staff were prepping bacon for breakfast the next day. EI #19 was asked to look in the box of bacon and tell surveyor what she saw. EI #19 replied, that the package of bacon was open and there was no open date. EI #19 was asked what should be done when a box of bacon was opened. EI #19 replied, it needed to be wrapped and dated with open date. An observation was made of a box of Country Sausage links. The box was open, and the plastic packaging was unsealed and there was no open date. EI #19 was asked when the box of sausage was opened. EI #19 replied, she did not know but when they opened things they wrap it up and put a date sticker on it. An observation was made of a box of pasteurized eggs. Inside the box, on top was a gray divider with moist egg yolk on it, under the divider on top of a layer of eggs, were two broken eggs leaking egg white and yolk. An observation was made of a box of 37 yogurt cups in the original box, the box read Best if used by [DATE]. EI #19 was asked what does Best if used by [DATE] mean. EI #19 replied, that was the expiration date and the yogurt cups should have been thrown out. On [DATE] at 8:15 AM, an observation was made of the unit 3E refrigerator. Inside the refrigerator there was a 2 liter bottle of soda partially filled that did not have a date or name on it, one bottle of salad dressing that had been opened with there was no date or name on it and a plastic grocery bag that contained an opened bag of pizza rolls that was not dated and had no name on it. On [DATE] at 9:05 AM, a second observation was made of the air conditioning vent in the kitchen. The vent was still covered with dust and clumps of dust observed moving due to air movement. EI #9, Kitchen Manager was asked what the area under the vent was used for. EI #9 replied, it was part of the tray line where they put clean trays. There was also several crates of glasses and bowls in the same area. On [DATE] at 5:09 PM, an interview was conducted with EI #10, District Kitchen Manager regarding the dirty air conditioning vent over the dishes on the tray line. EI #10 was asked to look at the vent and describe what he saw. EI #10 replied, he saw lots of dust accumulated. EI #10 was asked what was under the vent. EI #10 replied, dishes. EI #10 was asked who was responsible for cleaning the vent. EI #10 replied, maintenance but kitchen staff must tell them it needs cleaning. EI #10 was asked what the risk was by having a dirty vent over the serving area. EI #10 replied, the dust could drop in the dishes. EI #10 was asked how the dirty vent above the clean trays and dishes could affect the residents. EI #10 replied, it could contaminate the dishes food was served on. On [DATE] at 7:20 AM, an observation was made of the 2nd Hall unit refrigerator. Inside the refrigerator was a dried yellow substance on the back of the refrigerator, as well as the bottom. There was a glass jar of dip that had a name on it but no date, and a stainless-steel drink container with a glove over the top of it. EI #11, a Registered Nurse (RN) was asked what should be done when putting food items in the refrigerator. EI #11 replied, it should have the name and date on it and it should be wrapped or covered. EI#11 was asked who was responsible for cleaning the refrigerator. EI #11 replied, 11p-7a shift nurse and it was supposed to be done weekly. EI #11 was asked what should be done with items with no labels. EI #11 replied, the items should be thrown out. [DATE] at 8:10 AM, an interview was conducted with EI #2, Director of Nursing (DON). EI #2 was asked who the refrigerators on the units were for. EI #2 replied, the residents and staff. EI #2 was asked what the policy was on cleaning the unit refrigerators. EI #2 replied, the refrigerators should be defrosted and cleaned weekly and as needed. EI #2 was asked what should be done when putting outside food and drinks in the unit refrigerators. EI #2 replied, food should have a name on it and dated. [DATE] at 9:10 AM, an interview was conducted with EI #13, Maintenance Manager. EI #13 was asked who was responsible for cleaning the air conditioning vent in the kitchen. EI #13 replied, dietary notified them when it needed cleaning. EI #13 was asked when it was supposed to be cleaned. EI #13 replied, there is nothing on the cleaning tier to say when it must be cleaned. EI #13 was asked why it was important to have a clean air conditioning vent. EI #13 replied, for the air that comes flowing through it. EI #13 was asked how a dirty air conditioning vent in the kitchen could affect the residents. EI #13 replied, it would not affect the residents because it was not over the food or anything. [DATE] at 10:00 AM, an interview was conducted with EI #9. EI #9 was asked What should be done after a box of bacon is opened and the plastic packaging is opened. EI #9 replied, put an open date on it and wrap up so it is not exposed. EI #9 was asked why it was important for the plastic packaging to be sealed. EI #9 replied, so air would not get in it, and no cross contamination. EI #9 was asked what should be done with broken eggs. EI #9 replied, discard, throw them away, cannot be used if broken. EI #9 was asked what the risk was if broken eggs were leaking yolk and egg white. EI #9 replied, Salmonella was possible. EI #9 was asked who was responsible for checking expiration dates on food. EI #9 replied, she was. EI #9 was asked what should be done with expired food. EI #9 replied, should be thrown away. EI #9 was asked how it could affect the residents if served expired yogurt. EI #9 replied, it could make them sick. EI #9 was asked who was responsible for ensuring that food stored in the cooler is stored properly. EI #9 replied, the stock person or the kitchen manager.

Based on observations, interviews, record review, and review of a facility policy titled Policy and Procedure for Oxygen Administration the facility failed to ensure the oxygen tubing for Resident Identifier (RI) #4 was changed weekly. This affected one of one resident sampled for respiratory care. Findings Include: A review of a facility policy titled Policy and Procedure for Oxygen Administration with a date of 07/2016 revealed, .Procedure: . Change the . cannula/mask tubing at least weekly, date and initial the bottle on 3-11 PM and as needed (PRN) whenever it is changed. Resident Identifier (RI) #4 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #4's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Oxygen (O2) at two liters (2L) per nasal cannula (NC) as needed for shortness of breath (SOB) . On 04/12/21 at 5:21 PM, the surveyor observed the resident's oxygen in use at 2 liter. The tubing was dated 03/31/21. On 04/13/21 at 11:16 AM, an observation was made of RI #4's oxygen in use. The date on the tubing remained 03/31/21. On 04/13/21 at 2:55 PM, another observation was made of RI #4's oxygen in use with the tubing dated 03/31/2021. On 04/15/21 at 8:30 AM, an interview with Employee Identifier (EI) #15, a Registered Nurse (RN) Supervisor was conducted. EI #15 was asked, what date did she observe on RI #4's oxygen tubing the day before (04/14/21). EI #15 replied, March 31, 2021. EI #15 was asked, according to the facility's policy how often should the oxygen tubing be changed. EI #15 stated, weekly. EI #15 was asked, what should have been done regarding RI #4's oxygen tubing. EI # 15 said, the tubing should have been changed on the 6th. EI #15 was asked, why was it important to change the tubing on the oxygen concentrator. EI # 15 replied, to prevent infection. On 04/15/21 at 9:23 AM, an interview with EI #14 a Licensed Practical Nurse (LPN) Charge Nurse was conducted. EI #14 was asked, what date did she observe on RI #4's oxygen tubing. EI #14 said, March 31, 2021. EI #14 was asked when should RI #4's oxygen tubing be changed. EI #14 stated, every Wednesday on 3-11 PM shift by the Charge Nurse. EI #14 was asked, when should RI #4's oxygen tubing have been changed. EI #14 replied, April 7, 2021. EI #14 was asked, why was it important to change out the oxygen tubing timely. EI #14 stated, it could become infected with germs.

Based on observation, interviews, and review of facility policy titled Incontinent Care and Catheter Care Using Disposable Wipes the facility failed to ensure Employee Identifier (EI) #16 , Certified Nursing Assistant (CNA) changed gloves after removing the soiled brief and before applying a clean brief while providing incontinent care to Resident Identifier (RI) # 58. This affected RI #58, one of one sampled residents reviewed for bladder and bowel incontinence. Findings include: A facility document titled Incontinent Care and Catheter Care Using Disposable Wipes with a revised date of 12/2012 revealed . PROCEDURE: .2. Apply gloves . 4. Female- clean entire perineal area . 9. Remove and dispose of gloves, wash hands. Apply new gloves. 10. Apply new dry incontinence pad . 12. Remove gloves and wash hands . RI #58 was admitted to the facility on [DATE]. On 4/13/21 at 9:17 AM, an observation was made of EI #16, CNA providing incontinent care to RI #58. EI #16 did not change gloves after removing the soiled brief and before applying the clean brief. EI #16 touched the resident's bed covers, call light, and curtain while wearing the same soiled gloves. On 4/14/21 at 12:09 PM an interview was conducted with EI #16. EI #16 was asked, while providing incontinent care for a resident with a brief wet or soiled with urine, when did the staff providing care change gloves. EI #16 replied, after finishing the procedure and if staff have touched anything outside of the resident's brief, then staff changed gloves. EI #16 was asked, should she change gloves after removing a wet or soiled brief and before applying the clean brief. EI #16 replied, yes. EI #16 was asked, on 4/13/21 while providing incontinent care to RI #58, when did she change gloves. EI #16 replied, she did not change gloves during the procedure. EI #16 was asked, why was it important to change gloves after removing a wet or soiled brief and before applying the clean brief. EI # 16 replied, infection control, to stop the spread of infection and germs. EI #16 was asked, who was responsible to ensure incontinent care was provided according to policy and infection control standards. EI #16 replied, herself and supervisor, which was EI #17, Registered Nurse (RN), Assistant Director of Nursing (ADON). EI #16 was asked, what was the potential harm to a resident when a staff member removed a soiled brief and provided perineal care and with same gloves applied clean brief and touched the call light. EI #16 replied, re-spread germs from dirty brief to clean brief. On 4/14/21 at 12:28 PM an interview was conducted with EI #17, ADON/ RN Supervisor for the Hall. EI #17 was asked, when providing incontinent care, when should staff change gloves. EI #17 replied, when the gloves get soiled or moving from dirty to clean. EI #17 was asked, when should a staff member providing incontinent care not change gloves after removing a brief wet with urine and before applying the clean brief. EI #17 replied, never. EI #17 was asked, what was the potential harm to a resident when a staff member removed a soiled brief and provided perineal care and then with the same gloves applied a clean brief and touched the call light. EI #17 replied, contamination, she touched clean areas with dirty gloves. EI #17 was asked, why was it important to change gloves after removing a wet or soiled brief and before applying the clean brief. EI #17 replied, they did not want to contaminate or do anything that might cause infection.

Based on observations, interviews, record review and review of a facility policy titled Incontinent Care and Catheter Care Using Disposable Wipes and Hand Hygiene Policy and Procedure, the facility failed to ensure: 1) a Certified Nursing Assistant (CNA), Employee Identifier (EI) #9 did not place a blanket on the bare floor to use as a barrier for soiled washcloths when providing incontinent care to (Resident Identifier) RI #133 on 10/09/19; and 2) a medication nurse washed her hands after removing soiled gloves, before and after touching RI #18 and RI #109, and before returning to the medication cart to prepare medications on 10/09/19, during the evening medication pass administration. These deficient practices affected RI #133, one of one sampled resident observed for incontinent care and RI #'s 18 and 109, two of five residents observed during medication administration. Findings Include: 1) Review of a facility policy titled, Incontinent Care and Catheter Care Using Disposable Wipes, with a revised date of 12/12, revealed the following: . PR[NAME]EDURE : . 7. Place soiled items in/on a bag/barrier . RI #133 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. RI #133's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 08/28/19, revealed RI #133 was assessed as having a score of 5 on the Brief Interview for Mental Status, indicating severely impaired cognition. RI #133 was also assessed as being totally dependent on staff, with one person physical assist, for personal hygiene. On 10/09/19 at 2:59 p.m., the surveyor observed a staff member push RI #133 in his/her wheelchair into RI #133's room. The staff member assisted RI #133 to bed and placed a blanket over RI #133. On 10/09/19 at 3:03 p.m., RI #133's assigned CNA, EI #9, entered RI #133's room with several washcloths. EI #9 placed the washcloths at the foot of RI #133's bed along with a box of gloves and a clean adult brief. EI #9 gloved, removed the blanket from off of RI #133 and placed the blanket at the foot of the bed. After removing RI #133's sweat pants and retrieving a basin of water from RI #133's bathroom, EI #9 removed the blanket from the foot of the bed, placed it on the bare floor, then proceeded to provide incontinent care for RI #133, placing the soiled washcloths on top of the blanket. On 10/09/19 at 3:23 p.m., the surveyor conducted an interview with EI #9. The surveyor asked EI #9 where did she place the washcloths after she finished cleaning RI #133 during the incontinent care. EI #9 said on the blanket on the floor. The surveyor asked EI #9 where should the blanket and used washcloths have been placed. EI #9 said they could have been placed at the foot of the bed. On 10/10/19 at 1:46 p.m., the surveyor conducted an interview with EI #10, the Registered Nurse Unit Manager/ADON (Assistant Director of Nursing). The surveyor asked EI #10 where should the CNAs place dirty linen and washcloths after they have provided incontinent care. EI #10 said there should have been something on the bed to place the dirty linen in. The surveyor asked EI #10 should the linen and washcloths be placed on the floor. EI #10 said no. The surveyor asked EI #10 what could this be considered when placed on the bare floor. EI #10 said an infection control issue. 2) A review of the facility's policy titled, Hand Hygiene Policy and Procedure, with a revised date of 06/17 revealed: Purpose: Hand hygiene is recommended to reduce the transmission of infection to residents, staff and visitors in the health-care setting. Procedure: . 3. Perform hand hygiene after contact with blood, body fluids, mucous membranes, . between resident contacts, . prior to donning and after gloves are removed. and when otherwise indicated to avoid transfer of organisms to other residents or environments. 4. It may be necessary to perform hand hygiene between tasks and procedures on the same resident to prevent cross contamination of different body sites. Resident Identifier (RI) #18 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #109 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 10/9/19 at 3:46 p.m., Employee Identifier (EI) #7, a Licensed Practical Nurse, was observed leaving the medication cart to get lancets. EI #7 returned to the medication cart and placed the lancets inside the medication cart. EI #7 did not wash her hands prior to preparing medications for RI #109. On 10/9/19 at 3:58 p.m., EI #7 entered RI #109's room. EI #7 did not wash her hands before or after touching the resident, before or after applying gloves, after giving eye drops or before administering nasal spray. EI #7 did not wash her hands after she left the room and returned to the medication cart. EI #7 placed the eye drops and the nasal spray inside the medication cart. EI #7 touched the computer, the mouse, and the medication cart. EI #7 proceeded to move over to the other medication cart and started preparing medications for RI #18. EI #7 went into RI #18's room and did not wash her hands prior to applying gloves or after giving an injection. On 10/09/19 at 4:42 p.m. an interview was conducted with EI #7. EI #7 was asked, what should have been done when she returned to the medication cart each time, before preparing medications. EI #7 stated, I need to wash my hands. After third time of sanitizing, I wash my hands. EI #7 was asked, what should have been done before she put gloves on. EI #7 stated, I should wash my hands. EI #7 was asked, what should be done after removing gloves. EI #7 stated, Wash my hands. EI #7 was asked, did she do that every time. EI #7 stated, Not in (RI #109's) room, I took my gloves off after each eye (drop) and didn't wash hands before doing nasal spray. EI #7 was asked, what should be done before touching the resident. EI #7 replied, Wash Hands. EI #7 was asked, if she had done that. EI #7 stated, No I didn't.

Based on interview, record review and review of a facility policy titled, Timely Completion of MDS (Minimum Data Set) Assessments, the facility failed to ensure Resident Identifier (RI) #46's Annual MDS assessment, dated 10/16/18, did not code RI #46's use of the medication [MEDICATION NAME] as an anticoagulant. This deficient practice affected RI #46, one of 36 sampled residents whose MDS assessments were reviewed. Findings Include: Review of a facility policy titled Timely Completion of MDS Assessments, dated 01/15, revealed: .Policy: The facility must conduct . accurate . assessments . A review of Mosby's (YEAR) NURSING DRUG REFERENCE, 30th edition, page 28, revealed the classification of [MEDICATION NAME] was a platelet aggregation inhibitor. RI #46 was admitted to the facility on [DATE], and readmitted on [DATE], with the [DIAGNOSES REDACTED]. RI #46's Annual MDS assessment, with an Assessment Reference Date (ARD) of 10/16/18, revealed RI #46 received an anticoagulant during this assessment period. RI #46's (MONTH) 2019 Physician order [REDACTED]. The [MEDICATION NAME] had a start date of 08/01/17. On 01/17/19 at 5:19 p.m., the surveyor conducted an interview with Employee Identifier (EI) #2, a RN (Registered Nurse)/ MDS Coordinator. The surveyor asked EI #2 was RI #46 receiving an anticoagulant medication. EI #2 said RI #46 was receiving [MEDICATION NAME]. The surveyor asked EI #2, on RI #46's Annual MDS assessment dated [DATE], was RI #46 coded as receiving an anticoagulant. EI #2 said yes. The surveyor asked EI #2 what was the classification of [MEDICATION NAME]. EI #3 said [MEDICATION NAME] was an antiplatelet medication. The surveyor asked EI #2 should the [MEDICATION NAME] be coded as an anticoagulant. EI #2 said no. When the surveyor asked EI #2 was RI #46's Annual MDS assessment dated [DATE], an accurate assessment, EI #2 said no.

Based on observations, interviews, record review and review of a facility policy titled, Care Planning Policy and Procedure, the facility failed to ensure: (1) a care plan was developed for the use of RI #128's PRN (as needed) Oxygen (02) use; and (2) Resident Identifier (RI) #267's care plan for the approach for the resident to have a liberalized renal diet was followed. These deficient practices affected RI #128 and RI #267, two of 36 sampled residents whose care plans were reviewed. Findings Include: (1) A review of an undated facility policy titled, Care Planning Policy and Procedure, revealed: Policy: The care plan is a guide for all staff on a course of action that will attain or maintain a resident's highest practicable level of well being . Procedure: . 7. The team should develop specific approaches for the staff to use in order to provide continuity of care for the individual resident . RI #128 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #128's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 12/04/18, revealed RI #128 received 02 therapy during this assessment period. A review of RI #128's (MONTH) 2019 Physician order [REDACTED]. On 01/15/19 at 3:22 p.m., RI #128 was observed sitting in his/her wheelchair with his/her 02 in use infusing at 2 liters per minute. On 01/16/19 at 8:14 a.m., RI #128's 02 continued to infuse at 2 liters by way of nasal cannula. On 01/17/19 at 5:03 p.m., the surveyor conducted an interview with Employee Identifier (EI) #2, a RN (Registered Nurse)/MDS Coordinator. The surveyor asked EI #2 was RI #128 receiving 02 therapy. EI #2 said yes, PRN. The surveyor asked EI #2 should RI #128 be care planned for the 02 therapy whether using it PRN or routinely. EI #2 said yes. The surveyor asked EI #2 could she show the surveyor where RI #128 was care planned for the 02 therapy. EI #2 looked in the computer and in the care plan book and stated she did not see where RI #128 was care planned for the use of the oxygen. The surveyor asked EI #128 what was the purpose of a resident having a plan of care. EI #2 said mainly for communication with staff on how to take care of the resident. (2) RI #267 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of RI #267's (MONTH) physician orders [REDACTED]. A review of RI #267's care plan titled, I have [MEDICAL CONDITION] and have to go to [MEDICAL TREATMENT], dated 12/27/18, revealed the following: . Approaches . Give Liberalized Renal diet . per MD (medical doctor) order . On 01/16/19 at 8:10 a.m., RI #267 was observed eating breakfast. The tray card revealed DIET: Regular, LCS (low concentrated sweets). On the tray were eggs, grits, bacon, biscuit, cranberry juice and tea. On 01/16/19 at 5:46 p.m., RI #267 was observed eating supper. The tray card revealed DIET: Regular, LCS. On the tray was steak, rice, squash, fruit cup, roll and tea. On 01/17/19 at 3:48 p.m., during an interview with EI #2, Care Plan Coordinator, the surveyor provided a copy of RI #267's chart for review of physician's orders [REDACTED]. The surveyor asked what approach was listed on the care plan for the diet. EI #2 stated, give the diet as ordered. The surveyor provided a copy of RI #267's tray cards, dated 01/16/19 and 01/17/19 and asked what diet the resident was currently receiving. EI #2 stated, According to this a regular lcs. The surveyor provided a copy of the physician's signed diet order and communication form and asked what type of diet was ordered and when. EI #2 stated, On 01/10/19 it was a liberalized renal diet. The surveyor asked was RI #267's care plan being followed for diet as ordered. EI #2 stated,No.

Based on observations, interviews, record reviews and a review of the facility's policy titled, Diets Available on the Menu, the facility failed to ensure staff followed Resident Identifier (RI) #267's diet order. This affected one of nine residents whose meals were observed. Findings Include: A review of the facility's policy titled, Diets Available on the Menu dated 12/12, revealed the following: .Procedure: 1. Diets will be offered as ordered by the physician . RI #267 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #267's Physician order [REDACTED]. 1/10/19 . LIBERALIZED RENAL DIET . On 01/16/19 at 8:10 a.m., RI #267 was observed eating breakfast. The tray card revealed: DIET: Regular, LCS (low concentrated sweets). On the tray were eggs, grits, bacon, biscuit, cranberry juice and tea. On 01/16/19 at 5:46 p.m., RI #267 was observed eating supper. The tray card revealed DIET: Regular, LCS. On the tray was steak, rice, squash, fruit cup, roll and tea. On 01/17/19 at 11:44 AM, during an interview with Employee Identifier (EI) #7, Licensed Practical Nurse/LPN, the surveyor provided a copy of RI # 267's tray cards, chart, and current physician's orders [REDACTED].#267 currently receiving, what was ordered by the physician and when. EI #7 stated, Based on the tray card (he/she) is receiving regular low [MEDICATION NAME] sweets. The surveyor asked when was RI #267 admitted and what was the current physician diet order. EI #7 stated, 12/27/18 and according to the physician's orders [REDACTED]. The surveyor asked was the liberalized renal diet and a regular lcs diet the same. EI #7 stated, No. The surveyor asked what diet should RI #267 be on and why. EI #7 stated, Liberalized renal diet due to [MEDICAL TREATMENT] and it has no salt. The surveyor asked what the potential for harm was with RI #267 receiving a regular lcs diet. EI #7 stated, Fluid overload. On 01/17/19 at 02:53 PM, during an interview with EI #6, (Certified Dietary Manager) CDM, the surveyor provided RI #267's chart, physician's orders [REDACTED]. EI #6 was asked what was this considered as. EI #6 stated, A physician's orders [REDACTED]. EI #6 stated, No. The surveyor asked, since the order was not followed, what was the potential harm for this resident. EI #6 stated, (He/She) might have gotten something she did not want or could not have.

Based on observation, interviews, record review and a review of the facility's policy titled, Policy and Procedure for Aseptic Technique With Dressing Changes, the facility failed to ensure staff did not use unclean gloves to apply a clean dressing to Resident Identifier (RI) #57's right ankle and sacral wounds. This affected one of one resident observed during wound care. Findings Include: A review of a policy titled, Policy and Procedure for Aseptic Technique With Dressing Changes with a revised date of 06/17, revealed: .f. Cleanse wound .i. Remove gloves, perform hand hygiene, and apply clean gloves . RI #57 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #57's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/31/18, revealed RI #57 had one Stage 3 pressure ulcer and one Stage 4 pressure ulcer. On 01/17/19 at 09:20 AM, Employee Identifier (EI) #8, Licensed Practical Nurse (LPN) was observed during the wound care of RI #57. EI #8 washed her hands and applied gloves. EI #8 removed the dressing from the right ankle and purulent (thick) drainage was present. EI #8 removed her gloves, washed her hands and applied clean gloves. EI #8 cleaned the wound with normal saline spray and dry 4 x(by) 4 gauze. EI #8 repeated this process. EI #8 placed a dry 4x4 gauze to the wound. Skin prep was placed on the outer area of the wound. Without washing her hands or changing gloves, EI #8 removed the Puracol wound dressing from the package and placed it in the wound bed and covered it with Dermafilm dressing. After applying the dressing, EI #8 removed her gloves, washed her hands and removed the dressing to RI #57's sacrum. EI #8 removed her gloves, washed her hands and applied clean gloves. EI #8 cleaned the wound with normal saline spray and 4x4 gauze. EI #8 folded the [MEDICATION NAME] dressing and placed it in the wound bed, and covered it with Dermafilm dressing. EI #8 did not wash her hands or change her gloves after cleaning the wound and before applying a clean dressing. On 01/17/19 at 09:45 AM, during an interview with EI #8, the surveyor asked, after cleaning RI # 57's wounds and before applying a clean dressing, what should be done. EI #8 stated, Change gloves and wash my hands. The surveyor asked was that what she did both times with both wounds. EI #8 stated, No. The surveyor asked what was the potential for harm. EI #8 stated, Infection. On 01/17/19 at 04:15 PM, an interview was conducted with EI #4, (Registered Nurse) RN Supervisor/Infection Control Nurse. The surveyor asked what should staff do after cleaning a wound and before applying a clean dressing. EI #4 stated, When dirty is done, remove your gloves, wash hands and then apply clean gloves.

Based on record review and interview, the facility failed to ensure the menu was followed during the dinner meal on 01/16/19 for RI #107. This affected Resident Identifier (RI) # 107, a resident who had a renal diet order and received the turkey pot pie from the kitchen on 01/16/19. Findings Include: RI #107 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #107's (MONTH) 2019 physician's orders [REDACTED].>A review of RI #107's most current Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/26/18, revealed RI #107 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. A review of RI #107's meal tray card for the supper meal on 01/16/19, revealed: .INSTRUCTIONS: Renal . A review of the menu for 01/16/19, revealed LS (Low Salt) Turkey Pot Pie was to be served for the supper meal for residents who received a renal diet. On 01/17/19 at 02:35 PM, an interview was conducted with RI #107. During the interview, RI #107 informed the surveyor the turkey pot pie he/she received at the 01/16/19 dinner meal was too salty and he/she could not eat it. On 01/17/19 at 02:53 PM, an interview was conducted with EI #6, Certified Dietary Manager (CDM). EI #6 was asked if LS Turkey Pot Pie was served at dinner on 1/16/19 to residents with a renal diet order. EI #6 said no. EI #6 was asked what the menu said for renal diets for that meal. EI #6 said LS Turkey Pot Pie. EI #6 was asked if she followed the menu. EI #6 said no. EI #6 was informed RI #107 reported he/she received the Turkey Pot Pie and it was too salty, so he/she did not eat it. EI #6 was asked to tell the surveyor how that happened with RI #107 being on a renal diet. EI #6 said because it was not a low salt pot pie. EI #6 was asked what was the danger in that. EI #6 said because there was too much salt in it, it could make RI #107 sick.

Based on observations, interviews and record reviews, the facility failed to ensure the turkey pot pie served on 01/16/19, at the dinner meal was not overly salted. This had the potential to affect any resident who received the turkey pot pie from the kitchen during the dinner meal on 01/16/19. Findings Include: On 01/15/19, during the initial tour of the facility, there was a complaint voiced concerning the food at the facility being too salty. On 01/16/19 at 06:19 PM, the Surveyor and Employee Identifier (EI) #6, Certified Dietary Manager (CDM), took a test tray to the vacant dining room. The temperature of each food item was taken and was within normal limits. All of the food appeared and smelled appetizing. When tasted by the Surveyor, the turkey pot pie was too salty. EI #6 agreed with the Surveyor and stated, It is probably the gravy that we make it with that made it too salty. We will change that. On 01/17/19 at 02:53 PM, an interview was conducted with EI #6. During the interview, EI #6 voiced there was too much salt in the turkey pot pie. EI #6 was asked what was the danger for any resident, regardless of their diet order, to get food high in salt. EI #6 said some people could get high blood pressure from it.

Based on observations, interviews, record review and review of the facility's policy titled, Hand Hygiene Policy and Procedure, the facility failed to ensure: (1) Resident Identifier (RI) #36's nebulizer machine was not stored on the floor on three of three days of the survey and (2) a medication nurse, Employee Identifier (EI) #7, washed her hands after removing gloves and before touching other items during the morning medication pass observation on 01/17/19. These deficient practices affected RI #36, one of three sampled residents receiving nebulizer treatments and RI #7, one of eight residents observed during medication administration observations. Findings Include: (1) RI #36 was admitted to the facility on [DATE], and readmitted on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #36's (MONTH) 2019 Physician order [REDACTED]. A review of RI #36's (MONTH) 2019 E-MAR (Electronic Medication Administration Record) revealed RI#36 last received a nebulizer treatment on 01/02/19. On 01/15/19 at 3:40 p.m., the surveyor observed RI #36's nebulizer machine sitting on the floor in RI #36's room. RI #36 said he/she received treatments as needed and the last one he/she had was after the first of the year. On 01/16/19 at 1:06 p.m., RI #36's nebulizer machine remained on the floor. On 01/17/19 at 7:56 a.m., the surveyor observed RI #36's nebulizer machine to remain on the floor. On 01/17/19 at 2:03 p.m., the surveyor conducted an interview with EI #3, the Assistant Director of Nursing (ADON)/Unit Manager of the floor RI #36 resided on. The surveyor asked EI #3 did RI #36 receive nebulizer treatments. EI #3 said RI #36 did. The surveyor asked EI #3 how often did RI #36 receive the treatments. EI #3 said PRN. When asked should the machine be stored on the floor when not in use, EI #3 said no. The surveyor asked EI #3 what was there a potential for when stored on the floor. EI #3 said that would be an infection control issue. On 01/17/19 at 03:00 p.m., the surveyor conducted an interview with EI #4, the Infection Control nurse. The surveyor asked EI #4, when a resident was using a nebulizer machine, where should the machine be stored while in the room. EI #4 said on the bedside table or night stand. The surveyor asked EI #4, when stored on the floor what was that a potential for, EI #4 said cross contamination. (2) A review of a facility policy titled, Hand Hygiene Policy and Procedure revealed: .Procedure: .3. Perform hand hygiene .after gloves are removed .to avoid transfer of microorganisms to other residents or environments . RI #9 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #9's current Quarterly Minimum Data Set ((MDS) dated [DATE], revealed RI #9's Brief Interview for Mental Status (BIMS) score was a 5, indicating RI #9 had severe impairment in cognition. On 01/17/19 at 09:02 AM, EI #7, Licensed Practical Nurse (LPN), was observed during medication pass. EI #7 dispensed NitroDur ([MEDICATION NAME]) 0.1 mg/hr (milligram/hour) patch for administration to RI #9. EI #7 applied a glove to her right hand, removed the medication, then removed her glove. Without washing her hands, EI #7 touched the computer/mouse, opened the medication cart drawer and wrote her initials and date on the medication label. EI #7 applied a glove to her right hand and applied the NitroDur patch to RI #9's left upper chest area. EI #7 removed her glove and touched the computer/mouse pad. EI #7 did not wash her hands after removing her glove. On 01/17/19 at 09:06 AM, during an interview with EI #7 , the surveyor asked what should be done after gloves were removed and before applying clean gloves or touching other items. EI #7 stated, Wash hands. The surveyor asked was that done every time she removed her gloves. EI #7 stated, No. The surveyor asked what was the potential for harm. EI #7 stated, Infection. On 01/17/19 at 04:15 PM, during an interview with EI #4, the surveyor asked what should staff do after removing gloves. EI #4 stated, Hand hygiene including alcohol wipes and gel, soap and water.

Based on observations, interview, the 2013 Food Code, and the facility's policies and procedures for General Food Preparation and Handling, Handling Clean Equipment and Utensils, Food Safety and Sanitation, Personal Hygiene Training, Food Temperatures and Use and Storage of Food Brought in by Family or Visitors, the facility failed to ensure: 1) food carts were not rolled through a dirty puddle of water prior to service; 2) soup bowls were clean and dry; 3) an employee was wearing a hair net in the kitchen; 4) one of four nourishment refrigerators was not at a temperature of 48 degrees Fahrenheit (F); 5) one of four nourishment refrigerators was not missing a thermometer to measure the temperature; and 6) there was evidence that the temperatures of four of four nourishment refrigerators had been monitored to ensure temperatures were at 41 degrees F or below. This had the potential to affect all residents receiving meals from the kitchen. Findings include: The 2013 Food Code of the United States Public Health Service (USPHS) and the Food and Drug Administration (FDA) included the following: . Hair Restraints 2-402.11 Effectiveness. (A) . FOOD EMPLOYEES shall wear hair restraints . that are . worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; . 3-501.16 Time/Temperature for Safety Food, Hot and Cold Holding. (A) . TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: . (2) At . (41 (degrees) F) or less. 4-302.12 Food Temperature Measuring Devices. (A) FOOD TEMPERATURE MEASURING DEVICES shall be provided and readily accessible for use in ensuring attainment and maintenance of FOOD temperatures . 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) . cleaned EQUIPMENT and UTENSILS . shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination . 6-501.12 Cleaning, Frequency and Restrictions. (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. The facility's policy and procedures for General Food Preparation and Handling, dated 2013 included: . 1. The kitchen is kept neat and orderly. a. The kitchen and equipment are clean and sanitized as appropriate. 2. Food Storage . b. Potentially hazardous food is refrigerated . 3. Food Preparation . h. any utensil or serving dish must be thoroughly cleaned and sanitized prior to use. The facility's policy and procedures for Handling Clean Equipment and Utensils, dated 2013 included: . 2. Clean equipment and utensils will be stored in a clean, dry location in a way that protects them from splashes, dust, or other contamination. The facility's policy and procedures for Food Safety and Sanitation, dated 2013 included: . 2. Employees c. Hair restraints are required and should cover all hair on the head. The facility's policy and procedures for Personal Hygiene Training, dated 2013 included: . 4. Wear a hair restraint in the kitchen . The facility's policy and procedures for Food Temperatures, dated 2013 included: . 1. Take temperatures often to monitor for safe food holding temperature ranges of at or below 41 (degrees) F . 5. avoid the following methods: Holding foods in the temperature danger zone (41 (degrees) to 135 (degrees) F). 6. Unit refrigerators will be monitored for temperatures that maintain foods at or below 41 (degrees) F. The facility's policy and procedures for Use and Storage of Food Brought in by Family or Visitors, dated 11/28/2017 included: . Policy: . food must be handled in a way to ensure the safety of the resident. Policy Explanation and Compliance Guidelines: . 5. All refrigeration units will have internal thermometers to monitor temperatures. All units must be maintained at internal temperatures that are deemed safe for food storage according to state and federal standards. I.) During the initial tour of the kitchen on 12/04/17 at 3:42 p.m., a puddle of dirty water was observed on the floor by the wall under the dish return window and near the door to the hall from the kitchen. At 5:17 p.m., food carts were observed being rolled though the dirty puddle and into the kitchen. These carts were then loaded with resident's meal trays from the trayline and taken to the residents halls for delivery. Employee Identifier (EI) #4, the Dietary Manager, was interviewed on 12/06/17 at 4:04 p.m. When asked what would be the problem with the wheels of the meal carts rolling through the puddle of dirty water and traversing throughout the kitchen and then onto the resident's halls, EI #4 said potential contamination. II.) During the initial tour of the kitchen on 12/04/17 at 4:06 p.m., EI #4 identified two trays of 6-ounce plastic soup bowls as being ready for use. Upon inspection, the bowls had crumbs on them and they were not dry. When asked what would the problem be, EI #4 said the bowls were too close to the steamer and the food preparation area. EI #4 further said a resident could have received a wet or dirty bowl and that bacteria could be a problem as a result of the crumbs and moisture. III.) During the initial tour of the kitchen on 12/04/17 at 4:19 p.m., EI #5, a Dietary Aide, entered the kitchen without a hair net. When asked what should she do regarding a hair net, EI #5 said put it on before entering the kitchen. When asked why, EI #5 said to prevent hair from getting in the food and throughout the kitchen. IV.) On 12/06/17 at 2:33 p.m., a nourishment refrigerator was observed with EI #6, a Registered Nurse (RN) Unit Manager. The temperature of the nourishment refrigerator was 48 degrees F. The items in the nourishment refrigerator at risk for bacterial growth were an opened bottle of grape juice and some tubes of whole milk yogurt. EI #6 was not sure how often the nourishment refrigerator temperature was checked. On 12/06/17 at 2:59 p.m., a nourishment refrigerator was observed with EI #8, a RN Unit Manager. The nourishment refrigerator did not have a thermometer. EI #8 said the thermometer was broken a couple of days ago and a new one had been requested. EI #8 said she usually checked the nourishment refrigerator temperature Monday through Friday, but did not record it anywhere. On 12/06/17 at 4:42 p.m., EI # 7, a RN Unit Manager, said there was no documentation of the nourishment refrigerator temperatures that she was aware of, but she did check the temperature each morning that she worked. During an interview on 12/06/17 at 4:04 p.m., EI #4, the Dietary Manager, said Food Service did not have anything to do with the nourishment refrigerators on the residents' halls. During another interview at 4:49 p.m., EI #4 was asked about the importance of checking refrigerator temperatures. EI #4 said refrigerator temperatures needed to be checked to make sure food was staying at the correct temperature to prevent food borne illness. When asked what would be the problem with not documenting refrigerator temperatures, EI #4 said documentation was needed to prove the food was being kept at a safe temperature. During an interview on 12/06/17 at 5:06 p.m., EI #6 said she found out there were no temperature logs for the nourishment refrigerators. When asked what went in the nourishment refrigerator, EI #6 said anything the family brings in for a resident or something like a nutritional supplement. EI #2, the Director of Nursing was interviewed on 12/06/17 at 5:01 p.m. EI #2 said there was no written documentation of the nourishment refrigerators' temperatures. EI #2 said she was aware of the nourishment refrigerator without a thermometer and said there was a work order for a new thermometer to be obtained.

Based on observation, interviews, review of the document titled SMOKING SAFETY OBSERVATIONS, and medical record review, the facility failed to ensure Resident Identifier (RI) 22's smoking assessment dated [DATE], assessed RI #22's left upper ROM (Range of Motion) accurately. This deficient practice affected RI #22, one of two residents sampled for smoking. Findings Include: RI #22 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a facility document titled SMOKING SAFETY OBSERVATIONS 2.0 OF (Name OF RI #22) . COLLECTED 11/20/2017 15:09:46 (3:09 p.m.) BY (Name OF EI #11) (LPN) (COMPLETE) documented: SMOKING SAFETY ASSESSMENT . Total or limited ROM in arms or hands: No . On 12/05/17 at 8:15 a.m., an interview was conducted with RI #22. RI #22 was asked, who goes to smoke with him/her. RI #22 said he/she smokes alone. RI #22 said he/she had a stroke six years ago. RI #22 said he/she uses his/her right side because he/she can not use the left side. RI #22 was observed only able to use his /her right upper extremity. On 12/05/17 at 9:00 a.m., an interview was conducted with Employee Identifier (EI) #11, a Licensed Practical Nurse (LPN)/Minimum Data Set (MDS) Coordinator. EI #11 was asked if RI #22 have total or limited range of motion in his/her arms or hands. EI #11 said, no. The surveyor shared with EI #11, when RI #22 was observed by the surveyor, RI #22 could not use his/her left hand/arm at all. The surveyor also shared with EI #11 that RI #22 had stated that he/she could not use the left arm. EI #11 said she thought she saw RI #22 use both arms. EI #11 was asked, what type of ROM assessment did she do when she completed RI #22's smoking assessment. EI #11 answered she had not done an assessment. The surveyor asked EI #11, based on RI #22's smoking assessment dated [DATE], regarding ROM, was the assessment correct. EI #11 said no. EI #11 was asked how did she determine RI #22 had no total or limited ROM to his/her bilateral upper extremities (arms and hands). EI #11 said, she did not think plural. EI #11 said she thought about the arm/hand that RI #22 uses.

Based on observations, staff interviews, record review and review of the facility's policies titled Care Planning Policy and Procedure and Following the Plan of Care, the facility failed to ensure: 1) Resident Identifier (RI) #137's care plan had an approach addressing the resident's toenails; and 2) RI #85 had a care plan with intervetions to aide in the prevention of contractures. This affected RI #'s 137 and 85, two of 41 sampled residents whose plan of care was reviewed. Findings Include: A review of the facility's policy and procedure titled Care Planning Policy and Procedure with a revised date of 07/2011, revealed the following: Policy: The care plan is a guide for all staff on a course of action that will attain or maintain a resident's highest practicable level of well being. 6. The care plan team will develop measurable goals for the improvement, prevention, or maintenance of the resident's status . 7. The team should develop specific approaches for the staff to use in order to provide continuity of care for the individual resident . 1) RI #137 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #137's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed RI #137's Brief Interview for Mental Status (BIMS) score of 10, indicating cognition moderately impaired. The MDS also assessed RI #137 as requiring total care for personal hygiene and bathing. A review of RI #137's care plan titled Resident requires total care with ADL's (Activities of Daily Living) such as: . grooming . with a problem onset date of 10/27/17, did not reveal an approach regarding toenail care. On 12/04/17 at 4:15 p.m., during the initial tour, the following observation was observed to RI #137's toenails to both feet. RI #137's daughter was at the bedside at this time. Left foot - all 5 digits toenails were long, 1st digit toenail was curved toward the 2nd digit. The 2nd, 3rd and 4th digit toenails were jagged; right foot - all 5 digits toenails were long and jagged, 1st digit toenail was curved inward toward the 2nd digit. After observing RI #137's toenails, the daughter stated it had been about two months since RI #137's toenails had been cut. On 12/07/17 at 11:30 a.m., an observation of RI #137's toenails and bilateral feet were observed with EI #15, the Treatment Nurse. When EI #15 observed RI #137's toenails on the left foot, she stated the toenails had fungus and were long and thick, the great toenail curved toward 2nd toe, the 3rd digit toenail was loose with redness around the toenail, but the area was balanceable. EI #15 described the right foot as the toenails having fungus and was thick and long, the 4th digit toenail was jagged, the 2nd, 3rd and 4th digit toenails were long and the great toe nail was curved toward the 2nd digit. A review of a letter written by Employee Identifier (EI) #16, LPN (Licensed Practical Nurse) dated 12/07/17, regarding the Podiatrist visits to the facility, revealed the following: . There is no notation as to if (RI #137) refused the visit for October 9th and 10th . On 12/07/17 at 3:10 p.m., during an interview with EI #16, an LPN, the surveyor provided a copy of RI #137's Activities of Daily Living care plan with a problem onset date of 10/27/17 to RI #16 to review. After reviewing, the surveyor asked who was responsible for RI #137's toenails to be kept clean, trimmed and cut. EI #16 stated the care plan did not document anything regarding the resident's toenails, but it should have addresses the toenails as well. 2) RI #85 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a facility policy titled Following the Plan of Care with a date of 10/13/16 documented: . All Nursing staff will be educated on the importance of following the plan of care for each resident . A review of RI #85's quarterly MDS with a Assessment Reference Date (ARD) of 09/27/2017, indicated RI #85 was moderately impaired in cognition. The MDS further revealed RI #85 was totally dependent on staff for all ADL's and had impairment to the upper and lower extremities. A review of RI #85's Care Plan with a Problem Onset date of 01/12/2017 documented: . Potential for alteration in skin integrity/at risk for pressure formation related (R/T) [DIAGNOSES REDACTED]. On 12/05/17 9:15 a.m., RI #85 was observed in bed, supine with a pillow between his/her legs and no bilateral hand devices for contractures were observed. On 12/05/17 at 5:00 p.m., RI #85 was observed lying on the left side with no hand devices in either hand. On 12/06/17 at 1:15 p.m., RI #85 was observed up in the Geri chair with a pillow between the legs, a wash cloth was rolled and in the right hand, no device was in the left hand, both hands were contracted. On 12/07/17 at 3:22 p.m., an interview was conducted with EI #17, a Registered Nurse (RN) Supervisor. EI #17 was asked what did the Care Plan reveal regarding RI #85 having wash clothe in his/her hands. EI #17 said, it revealed to have wash cloths to both hands at all times and the Care Plan was not followed. EI #17 was asked who was responsible to ensure the Care Plan was followed. EI #17 said the Certified Nursing Assistants and all the nurses. EI #17 was asked what was the potential harm in not having the wash cloths in both hands at all times. EI #17 said the contractures could get worse.

Based on observation, staff interviews, record review and review of the facility's policy titled Care Planning Policy and Procedure and a Tobacco Free Property Policy, the facility failed to ensure: 1) staff reviewed and revised Resident Identifier (RI) #137's care plan to include toenail care; and 2) RI #22's care plan was revised to reflect RI #22 could keep his/her cigarettes and lighter during the day. This affected RI #137 and RI #22, two of 41 residents whose plan of care was reviewed. Findings Include: 1) A review of the facility's policy and procedure titled Care Planning Policy and Procedure with a revised date of 07/2011, revealed the following: . 3. Clinical judgment must be used in the identification of problems and potential problems in developing the plan of care . RI #137 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #137's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed RI #137's Brief Interview for Mental Status (BIMS) score of 10, indicating cognition moderately impaired. The MDS also assessed RI #137 as requiring total care for personal hygiene and bathing. A review of RI #137's care plan titled Resident requires total care with ADL's (Activities of Daily Living) such as: . grooming . with a problem onset date of 10/27/17, did not reveal an approach regarding toenail care. A review of a letter written by Employee Identifier (EI) #16, dated 12/07/17, regarding the Podiatrist visits to the facility, revealed the following: . There is no notation as to if (RI #137) refused the visit for October 9th and 10th . On 12/04/17 at 4:15 p.m., during the initial tour, the following observation was observed to RI #137's toenails to both feet with a daughter at the resident's bedside: left foot - all 5 digits toenails were long, 1st digit toenail was curved toward the 2nd digit. The 2nd, 3rd and 4th digit toenails were jagged; right foot - all 5 digits toenails were long and jagged, 1st digit toenail was curved inward toward the 2nd digit. After observing RI #137's toenails, the daughter stated it had been about two months since RI #137's toenails had been cut. On 12/07/17 at 11:30 a.m., an observation of RI #137's toenails, bilateral feet, were observed with EI #15, the Treatment Nurse. EI #15 observed RI #137's toenails on the left foot and stated the toenails had fungus, were long and thick and no jagged edges. The great toenail curved toward 2nd toe, the 3rd digit toenail was loose with redness around the toenail, but the area was balanceable. The right foot toenails had fungus, thick and long. The 4th digit toenail was jagged. The 2nd, 3rd and 4th digit toenails were long. The great toe nail was curved toward the 2nd digit. The surveyor asked what was the potential harm to RI #137. EI #15 stated skin tears and cuts. On 12/07/17 at 3:10 p.m., during an interview with EI #16, LPN. The surveyor provided a copy of RI #137's Activities of Daily Living care plan with a problem onset date of 10/27/17 to review. After reviewing, the surveyor asked who was responsible for RI #137's toenails to be kept clean, trimmed and cut. EI #16 stated the care plan did not document anything regarding the resident's toenails, but it should have address the toenails as well. 2) RI #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a facility policy titled . Tobacco Free Property Policy with a revised date of 08/24/16, documented: This policy has been established to protect and promote the health and safety of residents, staff, and visitors of (Name of Facility) . Residents' cigarettes and lighters are to be kept in the medication cart on their assigned unit. Review of a facility document titled, Care Plan revealed: (Name of RI #22) . Problem/Need Problem Onset: 04/19/2016 Potential for injury related to smoking/ . Goal & (and) Target Date Resident not to have an injury related to cigarettes/ . Approaches . Sign out to go smoke on Corner, next to facility. On 12/05/17 at 5:08 p.m., an interview was conducted with EI #11, a Licensed Practical Nurse (LPN)/MDS Coordinator. EI #11 was asked, where are smoking materials supposed to be kept. EI #11 said, (RI #22) carries them throughout the day and turns them in at night. The surveyor shared with EI #11, the smoking policy reveals cigarettes and lighters are to be kept in the medication cart on the resident's unit. The surveyor asked EI #11 where was it documented that RI #22 could keep his/her cigarettes and lighter with him/her during the day. EI #11 replied she had not seen any documentation and she did not think it was on RI #22's care plan. EI #11 reviewed RI #22's care plan and stated there was no approach on the care plan for RI #22 to keep his/her cigarette and lighter with him/her during the day. On 12/07/17 at 1:57 p.m., an interview was conducted with EI #2, Registered Nurse (RN)/Director of Nursing (DON). EI #2 was asked, where were RI #22's cigarettes and lighter kept. EI #2 said, he/she keeps them during the day and turns them in at night. The surveyor asked EI #2, did she have any documentation of where RI #22 keeps his/her cigarettes and lighter, since the policy revealed they should be kept in the medication cart. EI #2 replied, the care plan does not specify when RI #22 gets them and keeps them.

Based on observations, interviews, record review and Potter and Perry's Fundamentals of Nursing, the facility failed to ensure: 1) a Licensed Nurse, Employee Identifier (EI) #13, followed RI #262's Treatment Administration Physican Orders, dated August 19 and 20, 2017, for daily wound dressing changes; and 2) followed RI #85's Physician order [REDACTED]. These deficient practices affected RI #262 and RI #85, two of 41 sampled residents whose Physician order [REDACTED]. Finding Include: 1) A review of Potter and Perry's Fundamentals of Nursing, ninth edition, with a copyright date of 2017, Chapter 23, Legal Implications in Nursing Practice, page 311, documented: . Health Care Providers' Orders . Nurses follow health care providers' orders unless they believe that the orders are in error . RI #262 was originally admitted to the facility on [DATE] and readmitted on [DATE], with a [DIAGNOSES REDACTED]. RI #262's August 2017 physician's orders [REDACTED].#262 was to receive the treatment: Clean WD (wound) #3 Lt (left) Great Toe Trauma with NS (normal saline) spray pat dry, skin prep, periwound let dry apply Santyl oint (ointment) to wound bed cover with moistened 4 x (by) 4 et (and) secure with lg (large) dermadress qd (every day) / prn (as needed) . The surveyor observed RI #262's August 2017 eTAR (electronic Treatment Administration Record) with the Director Of Nursing, Employee Identifier (EI) #2. EI #2 informed the surveyor that EI #12 (a former employee) had received an Employee Memorandum, Written Warning for Improper Documentation, Failure to Follow Physician order [REDACTED].#262's dressing were not performed by EI #12. On 12/05/17 at 9:00 a.m., the surveyor made attempts to contact EI #12 by phone, to inquire about RI #262's dressing change not being conducted on August 18 and 19, 2017. The attempts were unsuccessful. On 12/07/17 at 3:20 p.m., the surveyor conducted an interview with EI #2, the Director Of Nursing (DON). The surveyor asked EI #2 if there was a physician's orders [REDACTED]. EI #2 said yes. The surveyor asked EI #2 did EI #12 follow the physician's orders [REDACTED].#2 said, no. This deficiency was written as a result of complaint/report #AL 442. 2) RI #85 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #85's Quarterly Minimum Data Set (MDS) with a Assessment Reference Date (ARD) of 09/27/2017 indicated RI #85 was moderately impaired in cognition. The MDS further revealed RI #85 was totally dependent on staff for all Activities of Daily Living (ADL) and had impairment to upper and lower extremities. A review of RI #85's Physician order [REDACTED]. . needs a rolled up wash rag in palm of each hand at all times . On 12/05/17 at 9:15 a.m., RI #85 was observed in bed, supine with a pillow between legs and no bilateral hand devices for contractures were observed. On 12/05/17 at 5:00 p.m., RI #85 was observed lying on the left side with no hand devices in either hand. On 12/06/2017 at 1:15 p.m., RI #85 was observed up in the Geri chair with a pillow between the legs, a bath cloth was rolled and in the right hand, no device was in the left hand, both hands were contracted. On 12/07/2017 at 3:22 p.m., an interview was conducted with EI #17, a Registered Nurse (RN) Supervisor. EI #17 was asked what did the Physician order, dated 11/20/2017, reveal regarding the wash cloth in RI #85's hands. EI #17 said RI #85 was to have a bath cloth in both hands at all times to prevent him/her fingernails from going into the skin and to help with the contractures. EI #17 was asked who was responsible to ensure the Physician order [REDACTED].#17 said the Certified Nursing Assistants and all the nurses. EI #17 was asked what was the potential harm in not having the wash cloths in both hands at all times. EI #17 said the contractures could get worse.

Based on observation, staff interviews, record review and review of the facility's policy titled Care Planning Policy and Procedure, the facility failed to ensure staff provided toenail care to Resident Identifier (RI ) #137's toenails. This deficient practice affected RI #137, one of 41 residents sampled for ADL care. Findings Include: A review of the facility's policy and procedure titled, Care Planning Policy and Procedure with a revised date of 07/2011, revealed the following: . 3. Clinical judgment must be used in the identification of problems and potential problems in developing the plan of care . RI #137 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #137's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed RI #137's Brief Interview for Mental Status (BIMS) score of 10, indicating cognition moderately impaired. The MDS also assessed RI #137 as requiring total care for personal hygiene and bathing. A review of RI #137's care plan titled Resident requires total care with ADL's (Activities of Daily Living) such as: . grooming . with a problem onset date of 10/27/17, did not reveal an approach regarding toenail care. On 12/04/17 at 4:15 PM, during the initial tour, the following observation was observed to RI #137's toenails to both feet with a daughter at the resident's bedside: left foot all 5 digits toenails were long, 1st digit toenail was curved toward the 2nd digit. The 2nd, 3rd and 4th digit toenails were jagged;right foot - all 5 digits toenails were long and jagged, 1st digit toenail was curved inward toward the 2nd digit. After observing RI #137's toenails, the daughter stated it had been about two months since RI #137's toenails had been cut. On 12/07/17 at 11:30 AM, an observation of RI #137's toenails, bilateral feet, were observed. with EI #15, Treatment Nurse. Employee Identifier, (EI) #15 observed RI #137's toenails on the left foot and stated the toenails had fungus, were long and thick and no jagged edges. The great toenail curved toward 2nd toe, the 3rd digit toenail was loose with redness around the toenail, but the area was balanceable. The right foot toenails had fungus, thick and long. The 4th digit toenail was jagged. The 2nd, 3rd and 4th digit toenails were long. The great toe nail was curved toward the 2nd digit. The surveyor asked what was the potential harm to RI #137. EI #15 stated skin tears and cuts. On 12/07/17 at 3:10 p.m., during an interview with EI #16, LPN, the surveyor provided a copy of RI #137's Activities of Daily Living care plan with a problem onset date of 10/27/17 to review. After reviewing, the surveyor asked who was responsible for RI #137's toenails to be kept clean, trimmed and cut. EI #16 stated the care plan did not document anything regarding the resident's toenails, but it should have address the toenails as well.

Based on observation, interview, record review and review of a facility policy titled Care planning and Procedure, the facility failed to ensure Resident Identifier (RI) #85 had hand rolls to aide in the decline of contractures of the hands. This affected RI #85, one of nine residents sampled for Range of Motion (ROM). Findings Include: A review of a facility policy titled Care Planning Policy and Procedure with a revised date of 07/2011 documented: . Policy: The care plan is a guide for all staff on a course of action that will attain or maintain a resident's highest practicable level of well being. RI #85 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #85's quarterly Minimum Data Set (MDS) with a Assessment Reference Date (ARD) of 09/27/2017 indicated RI #85s was moderately impaired in cognition. The MDS further revealed RI #85 was totally dependent on staff for all Activities of Daily Living (ADL) and had impairment to upper and lower extremities. A review of RI #85's Physician order [REDACTED]. needs a rolled up wash rag in palm of each hand at all times . A review of RI #85's . Care Plan with a Problem Onset: 01/12/2017 Potential for alteration in skin integrity/at risk for pressure formation related (R/T) [DIAGNOSES REDACTED]. On 12/05/17 09:15 a.m., RI #85 was observed in bed, supine with a pillow between legs and no hand devices bilateral for contractures. On 12/05/17 at 5:00 p.m., RI #85 was observed lying on the left side with no hand devices in either hand. On 12/06/2017 at 1:15 p.m., RI #85 was observed up in the Geri chair with a pillow between the legs, a bath cloth was rolled and in the right hand, no device was in the left hand, both hands were contracted. On 12/07/2017 at 3:22 p.m., an interview was conducted with Employee Identifier (EI) #17 Registered Nurse (RN) Supervisor. EI #17 was asked what did the Physician order [REDACTED]. EI #17 said to have a bath cloth in both hands at all times, to prevent him/her fingernails from going into the skin and to help with the contractures. EI #17 was asked who was responsible to ensure RI #85 had wash clothes in both hands's at all times. EI #17 said the Certified Nursing Assistants and all the nurses. EI #17 was asked what was the potential harm in not having the wash clothes in both hands at all times. EI #17 said the contractures could get worse.

Based on observation, interview, and record review, the facility failed to implement measure for pain management, as directed in Resident Identifier (RI) #1's plan of care to minimize pain when the resident exhibited signs and symptoms and voiced complaints of pain. The facility failed to thoroughly assess this resident by completing a head to toe assessment when the resident voiced complaints of pain and failed to timely notify the transport service; when an abnormality of RI #1's left hip was identified. On 9/27/12, after shift change at 7 AM, a Certified Nursing Assistant (CNA) reported to a Registered Nurse (RN) that RI #1, a cognitive impaired resident, admitted with a history of falls and rib fractures, was complaining of pain. The CNA immediately notified the RN. The RN stated she only assessed the resident's ribs. The RN did not complete a head to toe assessment of the resident, failing to identify pain in the resident's left hip. The RN failed to administer any pain medication for the resident's complaint. The 7 AM - 3 PM, Licensed Practical Nurse (LPN) was also notified by the same CNA that the resident was acting abnormal. The LPN completed a head to toe assessment and discovered the resident's hip was out of alignment. Even though the resident complained of pain to the LPN, the LPN failed to administer any pain medication to RI #1. The RN/Unit Manager documented she was summoned to RI #1's room at 8:40 AM. A review of the run sheet (documentation of times events occur) for the ambulance company that transported RI #1 to the local emergency roiagnom on [DATE], revealed the ambulance company was not notified until 9:51 AM and transported RI #1 to the local hospital for evaluation at 10:12 AM, allowing the resident to go un-medicated for more than 1 1/2 hours. On 9/27/12 at 1:30 PM, the facility received a phone call from the sponsor who stated the resident was being admitted to hospital for a fractured left hip, fractured of the left ribs and [MEDICAL CONDITION] Fibrillation. This affected one of one resident sampled for Incidents and Accidents. Findings Include: RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS), with an assessment reference date of 8/14/12, revealed RI #1 had a Brief Interview of Mental Status (BIMS) score of 7, which indicated severe cognitive impairment. RI #1 required supervision for transfers (oversight, encouragement or cueing) and required limited assistance with one person physical assist for dressing, hygiene, and toileting. A review of RI #1's "CAT (Care Area Trigger) Worksheet Problem Area: 19. Pain," with an assessment reference date of 8/14/12, revealed the following: "... Noted with compaints (complaints) of pain to her right side. Daughter reports old rib fractures on that side. X-ray revels (reveals) they are old and healed. Noted with falls since her admit and pain to follow after that. Pain meds (medications) given prn (as needed) for her pain. Staff will continue to monitor and address as needed ..." RI #1's Care Plan for "I am at risk for pain related to Kyphosis, Depression, Scoliosis," dated 8/27/12, included the following approaches: "Pain medications as ordered and indicated ... Nursing staff to coordinate with MD (Medical Doctor) to give pain medication for optimum control of pain ..." RI #1's September 2012 Physician order [REDACTED]." A review of RI #1's "Nurse's Notes" revealed the following: "9/26/12 ... 3-11 (3:00 PM to 11:00 PM shift) Very unsteady gait - leaning to left side ... backwards. Several attempts keep in w/c (wheelchair) unsuccessful. Several attempts to put in bed unsuccessful. 2115 (9:15 PM) in bed resting quietly - laying sideways - bed in low position. ..." "9/27/12 0840 (8:40 AM) Summoned to resident's room by CNA who states resident is C/O (complaining of) pain in L (left) side upon movement. Upon assessment, writer notes that resident is unable to move her L leg (without) crying out in pain in what appears to be her hip. ... MD (Medical Doctor) notified v/o (verbal order) received to send to ER (emergency room ) for Xray. Sponsor notified. (signed by Employee Identifier (EI) #19 (a RN and Unit Manager/UM))" EI #19 completed a " Resident Incident Report " on 9/27/12 documenting, " ...CNA went into room to get resident up (she is usually already up ambulating in unit when staff arrives) and dressed for the day. CNA states that when resident attempts to move, she cried out in pain and grabbed her ribs. CNA stated the resident was also wet with urine when resident is always continent. CNA also stated that resident stated that she " fell and broke her ribs " . Rt (Resident) has fallen x3 in last week. Upon assessment, resident noted lying in bed with PJ (Pajama) top and no bottom. Noted to have pain on movement to her left hip and left ribs. Small skin tear with bruise to left lateral forearm, small quarter sized bruise (re/purple) noted to the left side of head above ear and tip ear has a purple bruise ...Bed alarm was noted on bed and was functioning..." An attached second page was noted with this "Resident Incident Report" that documented the "Involved Person's Statement." CNA, EI #13 statement in this section documented, " ... (EI #13), CNA reported pain and dried blood on her PJ and sheets/pillow case when she made first rounds at 0730 AM ... " On 12/3/12 at 8:55 AM, EI #13 was interviewed. A review of EI #13's clock-in report for 9/27/12 revealed she clocked in at 7:38 AM. EI #13 was asked to recall what occurred on 09/27/12 when she observed RI #1. EI #13 said she had come in to work and during her first rounds RI #1 was asleep, so she did not bother her. EI #13 said she saw RI #1 again before breakfast trays and RI #1 said her leg was hurting. EI #13 asked RI #1 what happened to her leg and RI #1 said, "I fell ." EI #13 said she told EI #9 (the 7 AM - 3 PM LPN) that RI #1 was complaining of pain. On 11/28/12 at 9:45 AM, EI #9 (the 7 AM - 3 PM LPN) was interviewed. A review of EI #9's clock-in report for 9/27/12 revealed she clocked in at 7:18 AM. EI #9 stated she arrived on the unit around 7 AM. EI #9 said a little past 7 AM, she and the off-going nurse, night shift nurse (EI #27) walked from room to room to observe each resident that they were responsible for providing their care. The surveyor asked EI #9 what did the off going shift nurse report to her about RI #1. EI #9 stated the night nurse, EI #27 told her RI #1 was observed on the floor that night, but EI #9 didn't know what time it was. The surveyor asked did she get a report that RI #1 had any pain. EI #27 stated when she made rounds RI #1 did not complain of pain, but15 to 20 minutes after her rounds, the EI #13 reported to her the RI #1 was in pain. EI #9 said she went and assessed the resident. During the assessment, EI #9 stated she touched RI #1's left hip and RI #1 hollered. EI #9 stated RI #1 ' s leg was out of alignment, swollen, and painful to touch. EI #9 said she immediately called EI #19, the RN Unit Manager. EI #27 (the 11 PM - 7 AM LPN) was interviewed on 11/28/12 at 8:10 AM. A review of EI #27's clock-out report for 9/27/12 revealed she clocked out at 7:40 AM. EI #27 said the last time she saw RI #1 was around 6 AM. When asked if the CNAs had reported anything on RI #1 that night, EI #27 said not throughout the night. EI #27 further said that morning around 7:30 AM, when the new shift came in, the 7-3 CNA (RI #13) is the one that came out and told EI #6 and told her about RI #1. On 12/4/12 at 8:30 AM, during a third interview with EI #9, the surveyor asked what pain medications she administered to RI #1. EI #9 stated, "I didn't give her any pain meds, we just got her ready to go out." The surveyor asked why not. EI #9 replied, "I have no idea." The surveyor asked what was policy and procedure if a resident complains of pain. EI #9 stated assess for pain and administer pain medications. The surveyor asked what she should have done regarding RI #1's pain. EI #9 stated, "I should've gave her something for the pain." The surveyor asked where was her documentation to reflect her initial assessment of RI #1's left hip and RI #1's complaining of pain with movement. EI #9 reviewed RI #1's chart and stated, "I didn't do a note." The surveyor asked what should have been done. EI #9 stated, "I should have documented something." The surveyor asked was it policy and procedure to document abnormal findings during an assessment. EI #9 replied, "Yes." The surveyor asked was policy and procedure followed for documenting abnormal findings for RI #1. EI #9 replied, "No." A review of RI #1's September 2012 Medication Administration Report (MAR) revealed the "Tylenol 650 mg PO Q4H PRN (Pain)" was not administered at any time from 9/1/12 through 9/27/12. On 11/30/12 at 2:08 PM, during an interview with EI #19 (RN/Unit Manager), the surveyor asked what time were you made aware of the incident with RI #1 on 9/27/12. EI #19 said around 7:30 AM to 7:40 AM, the CNA (EI #13) had already called EI #6 and I was at the nurses ' station talking with EI #27. EI #13 and EI #27 told me the resident was complaining of pain in her ribs on her left side. During EI #27's interview on 11/28/12 at 8:10 AM, she was asked if RI #1 was given any pain medicines. EI #27 replied she had already counted (narcotics) and had passed over the keys. EI #27 further stated she did not know if anyone had given RI #1 any medication. When asked how long EI #27 stayed on the unit, EI #27 stated she had clocked out around 7:45 AM. When asked if she checked on RI #1, EI #27 stated she had gone down and looked at her, but had not done anything. EI #27 stated at that time RI #1 was awake, complaining and holding her side. EI #27 was asked if she checked to see if there was any injury to the side RI #1 was holding. EI #27 replied no, she had gone and told the med nurse who was taking over for her (EI #9). On 11/29/12 at 4:50 PM, EI #6 (a RN) was interviewed. A review of EI #6's (a RN) time sheet for 9/27/12 revealed a hand written entry of 7:30 AM for time in. The surveyor asked EI #6 what she knew regarding RI #1, when the resident was discharged to the hospital on [DATE]. EI #6 stated EI #13 (the CNA) told her (EI #6) the resident was complaining of rib pain. EI #6 stated she asked the resident if she was hurting and the resident stated yes. EI #6 also stated she palpated the resident's ribs, which were tender to touch. EI #6 stated she notified the doctor and got an order for [REDACTED]. The surveyor asked where was the documentation to reflect her assessment, notification of the physician and the x-ray order. EI #6 reviewed RI #1's chart and stated, "I guess it's not in there." A review of RI #1's medical record the facility failed to provide evidence of EI #6's assessment of RI #1 ' s condition, notification of the physician and the x-ray order. On 12/2/12 at 3:15 PM, during a second interview with EI #6, the surveyor asked on 9/27/12 what type of an assessment was done with RI #1. EI #6 stated she assessed the resident's rib pain. The surveyor asked was a head to toe assessment done. EI #6 stated, "No, not for rib pain." During a third interview with EI #6, on 12/3/12 at 8:45 AM, the surveyor asked after she observed and palpated RI #1's ribs, what type of pain medication did she administer. EI #6 stated she did not administer any pain medication, she reported that information to the LPN. The surveyor asked was the area painful to touch. EI #6 stated, "Yes." The surveyor asked with basic nursing, what should be done when a resident sustains an injury. EI #6 stated an assessment should be done. The surveyor asked what type of an assessment. EI #6 stated her nursing judgment says where the resident is complaining of pain. The surveyor asked after assessing the resident, what she determined was the reason the resident's ribs being tender to touch. EI #6 stated, "I don't know what the cause." The surveyor asked what further assessment she did to determine the cause of the resident's rib pain. EI #6 stated she asked the resident what happened and the resident pointed to her ribs. EI #6 also stated she called the doctor for a chest x-ray; because the daughter had informed her (EI #6) that the resident had a history of [REDACTED]. The surveyor asked after the ribs were assessed, should she have done an assessment for further injuries. EI #6 stated, "No." The surveyor asked knowing the resident had a history of [REDACTED]. EI #6 replied, "I'm not gonna answer that." The surveyor asked why not. EI #6 replied, "Why should I." The surveyor stated your nursing judgment did not dictate a full assessment and a full assessment should have been done. The surveyor asked who discovered the hip was out of alignment. EI #6 stated (name of EI #19 (RN/UM)). The surveyor asked before or after she assessed the resident. EI #6 stated, "After." The surveyor asked should she have discovered that the hip was out of alignment during her assessment. EI #6 said, "Not from a complaint of rib pain." The surveyor asked if she had done a full head to toe assessment, would she have discovered RI #1's hip was out of alignment. EI #6 stated, "Sure." A review of RI #1's September 2012 Medication Administration Report (MAR) revealed the "Tylenol 650 mg PO Q4H PRN (Pain)" was not administered at any time from 9/1/12 through 9/27/12. A review of Potter and Perry, Fundamentals of Nursing, 6th Edition, Copyright 2005, page 673 revealed the following: "Physical assessment enables the nurse to assess patterns reflecting health problems and to evaluate the client's progress ... A complete health assessment involves a more detailed review of a client's condition...A physical examination is a head-to-toe review of each body system that offers objective information about the client and allows the nurse to make clinical judgments. ... A complete physical examination is performed ... for the client's admission to a hospital ...The nurse uses physical assessment for the flowing reasons: * To gather baseline data about the client's health * To supplement, confirm, ...data obtained in the nursing history * To confirm and identify nursing diagnoses *To make clinical judgment about a client's changing health status and management... A complete assessment is needed to form a definitive diagnosis..." An interview with the Social Worker revealed the facility failed to immediately notify the ambulance company to transport RI #1 to the local hospital for evaluation. On 12/04/12 at 11:02 AM, during an interview with EI #23 (the Social Worker), the surveyor asked when did EI #19 notify you of the need to get an ambulance for RI #1. EI #23 stated EI #19 asked for a medical necessity form, which Social Services fills out. The surveyor asked what time was it. EI #23 stated she received an overhead page around mid-morning. EI #19 informed her (EI #23) that the resident was favoring her side and she (EI #19) wanted to get the resident checked out. EI #23 said she completed the medical necessity form and gave it to EI #19. EI #23 stated less than an hour later, EI #19 called her and stated that the ambulance had not picked the resident up and asked had she (EI #23) called the ambulance. EI #23 told EI #19 she did not call the ambulance, because all that was asked of her (EI #23) was a medical necessity form. A review of the (name of ambulance)'s Patient Care Report revealed the following: "... Date of Service 09/27/2012 ... Patient Name: (RI #1) ... Location: (Name & Address of Nursing Home) ... Destination: (Name & Address of Hospital) ...Times Recvd (Received): 09:51 09-27-12 ...At scene: 09:58 09-27-12 ...Transport: 10:12 09-27-12 ... At dest. (destination): 10:19 09-27-12 ... " Per the "Emergency Department Chart," RI #1 arrived at the hospital on [DATE] at 10:27 AM. RI #1 was admitted to the hospital. Per a physician consultation report, dated 9/27/12, RI #1 had a Left Acetabular Fracture. EI #29's (a hospital MD) physical exam revealed "pain with range of motion of her left hip." EI #29 described the injury to the family as "a very bad injury." EI #29 further stated an extensive surgery would be required. It was decided surgery would not be in RI #1's best interest. Instead, RI #1 would be kept non-weightbearing in Bucks boot for comfort. On 11/26/12, during the initial tour of the facility, RI #1 was observed to be in a low bed with the left leg in Bucks traction with 10 pounds of weight attached. On 11/27/12 at 2:30 PM, RI #1 was observed to be out of bed in a Geri chair in the hallway. While in the chair RI #1's left leg was in a long foam leg brace on the left side that allowed the leg to be held straight. On 11/27/12 at 5:30 PM, EI #8 (the Medical Director) described RI #1 as a classic little frail lady, very mobile. When asked about RI #1's injury, EI #8 stated his best estimate for the cause of the injury was a fall. When asked if RI #1 could walk after this type fall/injury. EI #8 stated not very much, I would think no.