Every finding on record at Cullman Health Care Center

Based on observation, interview, review of a facility policy titled Waste Disposal, and review of the United States (U.S.) Food and Drug Administration (FDA) 2022 Food Code, the facility failed to ensure the side door on one of two dumpsters was not open during an observation on 10/17/2023. This had the potential to affect 85 out of 85 residents in the facility. Findings include: A facility policy titled Waste Disposal with a revised date of 12/01/2013 documented: . Procedure . 6. Dumpster doors and lids should be closed at all times. The U.S. FDA 2022 Food Code included the following: . 5-501.15 Outside Receptacles. (A) Receptacles and waste handling units for REFUSE, recyclables, and returnables used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers. (B) Receptacles and waste handling units for REFUSE and recyclables . shall be installed so that accumulation of debris and insect and rodent attraction and harborage are minimized . 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: . (B) With tight-fitting lids or doors if kept outside the FOOD ESTABLISHMENT. On 10/17/2023 at 8:16 AM, during initial kitchen tour, two outside facility dumpsters were observed. One dumpster door was observed to be partially open. On 10/17/2023 at 8:17 AM, an interview with Employee Identifier (EI) #10, the Assistant Dietary Manager was conducted. When asked what was the potential problem with the dumpster door being open, EI #10 said it could attract rodents. EI #10 said a potential concern to residents of the facility due to the dumpster door being left open would be rodents getting inside the facility. EI #10 said, the dumpster doors should not be open.

Based on observations, interviews, resident record review, and review of facility policies titled Management of Soiled Laundry, Cleaning & Disinfection Noncritical Resident Care Items,,, and Laundry, the facility failed to ensure: 1) Facility staff cleaned a Hoyer lift with the proper disinfectant spray after it was used on 10/17/2023; and 2) Clean linens were not placed in a dirty gray linen cart on 10/19/2023. These deficient practices were the result of an observation of one of one Hoyer Lift being used, and an observation of one dirty gray linen cart with clean linen being distributed in the clean linen room. Findings include: 1) A facility policy titled Cleaning & (and) Disinfection Noncritical Resident Care Items, revised 04/01/2019, documented the following: Policy The purpose of this procedure is to provide guidelines for disinfection of non-critical resident-care items. Procedure . 4. The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in resident care: . c. Non-critical items are those that come in contact with intact skin but not mucous membranes. 2) Most non-critical reusable items can be decontaminated where they are used (as opposed to being transported to a central processing location). d. Reusable items are cleaned and disinfected or sterilized between residents ( . durable medical equipment). On 10/17/2023 at 3:20 PM, an observation was made of Employee Identifier (EI) #9, Certified Nursing Assistant (CNA), coming out of a resident's room pushing a Hoyer lift, while holding a clear plastic bag of trash in her right hand. EI #9 pushed the Hoyer lift down the hall to the other side of the hallway and put the Hoyer lift in the bath room, threw away the trash in the dirty utility room, then came out of the dirty utility room and sanitized her hands with hand sanitizer. On 10/17/2023 at 3:22 PM, an interview with EI #9 CNA was conducted. EI #9 stated, she utilized the Hoyer lift for transfer of a resident to a wheelchair. EI #9 stated, she used the Fit Right Wipes in the resident's room to clean the Hoyer lift. EI #9 was asked if the Fit Right wipes were a sanitizer or disinfectant and EI #9 stated, no, they were for perineal care. EI #9 was asked what should have been used to clean the Hoyer lift and EI #9 stated, a sanitizer wipe should have been used to prevent spreading infection. EI #9 stated she did not wash or sanitize her hands until after she put the Hoyer lift in the bathroom down the hallway and after she threw the garbage away in the dirty utility room. EI #9 stated, she should not have pushed the Hoyer lift down the hall with the trash bag in her hand. EI #9 stated, holding the trash bag on the Hoyer lift was a risk for infection. EI #9 stated, she was educated to sanitize the Hoyer lift after each use to prevent infection. On 10/19/2023 at 10:27 AM, a telephone interview with EI #3 Infection Prevention Nurse/Licensed Practical Nurse (LPN) was conducted. EI #3 stated, the proper way to clean the Hoyer lift after use was to clean it with the disinfectant spray or disinfectant wipes. EI #3 stated, the disinfectant spray and disinfectant wipes were locked up in the dirty utility room. EI #3 stated, the disinfectant spray or wipes should be used after each use. When asked when should the Fit Right Wipes be utilized to clean the Hoyer lift, EI #3 stated, they should not be used to clean the Hoyer lift because the Fit Right Wipes were not a disinfectant. EI #3 said, the Fit Right Wipes were for perineal care. EI #3 was asked what was the risk of using fit right wipes on the Hoyer lift. EI #3 replied, the Fit Right Wipes would not kill the germs, it was not a disinfectant. 2) A facility policy titled Management of Soiled Laundry with an effective date of 08/01/2000 documented the following: . To provide guidelines for the proper disposition of laundry soiled with blood or body fluids that contain visible blood. Procedure . 2. Do not store soiled laundry with clean laundry. Another facility policy titled Laundry with an effective date of 08/01/2000 documented: Policy Soiled laundry contaminated with blood or other potentially infectious materials shall be handled as little as possible and with a minimum of agitation. On 10/19/2023 at 8:21 AM, Employee Identifier (EI) #8 and EI #7 were observed in the clean laundry room taking clean linen (towels and bed pads) out of a gray laundry cart and putting them on a clean laundry cart in the clean laundry room. An observation of the gray linen cart was made after all the linen was removed from the bin. The gray laundry cart had a white substance ring around the bottom sides of the cart with splashes of the white substances around the inside of the cart. There were linen strings, dirt, leaves, and dust particles on the bottom of the cart. There was also a wet large area on the bottom of the gray laundry cart. EI #7 pushed the gray laundry cart back into the dirty linen room with another gray laundry cart. On 10/19/2023 at 8:26 AM, an interview with EI #8 from laundry was conducted. EI #8 stated, dirty laundry was taken out of the facility, put in a van, and taken to another facility to be cleaned, then brought back in the van to the facility. EI #8 stated, the CNAs brought down the dirty laundry and placed it in the gray linen carts in the dirty laundry room. EI #8 stated, the laundry was for the whole facility. EI #8 stated, the dirty laundry was transported to the van in the gray laundry cart and the clean linen was brought back into the facility in the gray laundry cart. EI #8 said, the cart that had the clean linen in it, was a gray laundry cart she got out of the dirty laundry room. When asked if she cleaned the gray laundry cart, EI #8 stated, she sprayed it with Lysol. EI #8 was asked who was supposed to clean the gray laundry cart. EI #8 replied, no one ever told her who cleaned the carts. When EI #8 was asked what she observed in the bottom of the gray cart she stated, linen string, dust, dirt, and unknown white substance was on the bottom of the gray laundry cart. EI #8 stated, she was unable to clean the bottom of the gray laundry cart because she could not reach it. EI #8 stated, the risk of not sanitizing the whole gray laundry cart would be cross contamination. On 10/19/2023 at 8:44 AM, an interview with EI #7 laundry staff was conducted. EI #8 was asked what he saw on the bottom of the gray laundry cart. EI #7 replied, strings from linen, unknown liquid, dirt, and a leaf maybe. EI #7 was asked, what the ring of white substance was around the bottom sides of the gray laundry cart he used for the clean linen. EI #7 replied, he did not know but it had a chalky consistency. EI #7 stated, the risk of putting clean laundry in the gray laundry cart would be cross contamination. EI #7 stated, he did not consider that gray laundry cart to be clean. On 10/19/2023 at 9:30 AM, an interview with EI #4, the Nurse Supervisor /Registered Nurse (RN) for the 2nd floor was conducted. EI #4 stated, the CNAs put the dirty laundry in the gray laundry cart in the dirty laundry room on the first floor. EI #4 was asked who cleaned the gray laundry carts. EI #4 stated, she would have to find out, she did not know. EI #4 was asked what would be the risk of the gray laundry carts not being cleaned out and clean linen put in the cart. EI #4 stated, risk of infection control. On 10/19/2023 at 10:27 AM, a telephone interview with EI #3, the Infection Prevention Nurse/LPN was conducted. EI #3 was asked, what was the procedure for the laundry after it was placed in the dirty gray linen carts on the first floor. EI #3 replied, the laundry people who are contracted pick it up and take it to another facility, wash it, and bring back the clean laundry and linen. EI #3 also stated, the laundry staff was supposed to clean the gray laundry carts with a disinfectant. EI #3 stated, the laundry staff was not supposed to use the gray laundry carts, used for the dirty linen, for the clean linen. EI #3 stated, there should be a separate laundry cart for the clean linen. EI #3 stated, the gray laundry cart with the dirt, leaves, a wet substance, and the white chalky substance should not have been used to hold the clean laundry. EI #3 stated, the use of the dirty gray laundry cart would be cross contamination.

Based on an interview, review of the facility's narcotic Drug Disposition Records, and review of a facility policy titled, Medication - Disposition of Unused Drugs, the facility failed to ensure the required signatures were on four narcotic disposition sheets. This deficient practice affected four of twelve months of narcotic disposition records reviewed. Findings include: Review of a facility policy titled, Medication - Disposition of Unused Drugs, with a revised date of 03/31/2022, revealed the following: Policy To properly dispose of unused drugs and ensure accountability. The Pharmacy Consultant and Director of Nursing (DON) shall dispose of unused drugs monthly. Procedure . 3. Controlled Drugs . b. Controlled drugs shall be destroyed by the DON, the pharmacist and a witness monthly. 21055 On 10/19/2023 at 3:00 PM, the surveyors reviewed the narcotic drug disposition records from January 2022 to October 2023. On 10/19/2023 at 3:08 PM, an interview was conducted with Employee Identifier (EI) #2, the DON (Director of Nursing). When asked how many signatures were required on the narcotic disposition sheet, EI #2 said three, the pharmacist, hers, and another nurses. EI #2 said it would be responsibility of herself, EI #12, the ADON (Assistant Director of Nursing), and the pharmacist to ensure the correct signatures were on the sheets. EI #2 said there should be three signatures on the sheets to make sure what was there was verified. EI #2 said looking at the 12/16/2022 and 06/15/2023, disposition of unused drug narcotic sheets, there was only one signature on the sheets. EI #2 said looking at the 09/11/2023 and 10/14/2023, narcotic Drug Disposition Records, there were only two signatures on the sheets. When asked did the narcotic drug disposition sheets have the required signatures, EI #2 said no.

Based on observations, interviews, and review of a facility policy titled Preventative Maintenance Program, the facility failed to ensure there was not a missing blind in Room Locator (RL) #1; and the blinds in RL #'s 3-6 did not have pieces missing from the slats; and remained in good repair. This deficient practice affected RL #1 and RL #'s 3-6, five of 59 resident's rooms observed at the facility. Findings include: Review of a facility policy titled Preventative Maintenance Program, with an effective date of 08/13/2020, revealed the following: Policy A Preventive Maintenance Program shall be . implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Procedure . 5. The Maintenance Director and the Administrator shall complete a round each month to visualize . for any items that need repair . 1) On 10/17/2023 at 10:37 AM, the surveyor observed the blinds in Room Locator (RL) #3 to have two missing pieces on the left side of the blind and two missing pieces on the right side of the blind. Resident Identifier (RI) #68 said he/she did not know how long the blinds had been missing pieces. On 10/18//2023 at 8:07 AM, the slats on the blinds remained in the same condition in RL #3. On 10/19/2023 at 8:15 AM, the surveyor conducted an interview with Employee Identifier (EI) #12, the Maintenance Assistant. When asked how he was made aware of repairs that his department needed to complete, EI #12 said he would get a notification on his phone or through the computer TELS (Team Electronic Library System) system concerning work orders that needed to be completed. EI #12 said the nurse puts the needed repair in TELS, and if he was walking down the halls and someone tells him something needs to be done he will put it in TELS himself. EI #12 said his department was always walking around, and if they saw something that needed to be done, they would do it then. On 10/19/2023 at 8:32 AM, the surveyor asked EI #12 how he would describe the blinds in RL #3. EI #12 said there were broken pieces on the blinds. EI #12 said the blinds were not in good repair. EI #12 said he was not aware the blinds had broken pieces. 2) On 10/19/2023 at 8:36 AM, EI #12 was asked how he would you describe the blinds in RL #5. EI #12 said there was a broken piece on the blind. EI #12 said the blind was not in good repair and he had not been made aware the blind was broken. 29671 3) On 10/17/2023 at 5:00 PM, broken blinds were observed in RL #4 on both windows. On 10/19/2023 at 8:37 AM, when asked how he would you describe the blinds in RL #4, EI #12 said there was a broken piece on the blind. EI #12 said the blinds were not in good repair. EI #1 said he was not aware of the blinds being broken. On 10/19/2023 at 10:53 AM, the broken blinds were again observed in RL #4. The blinds were unable to close and cover the window. Resident Identifier (RI) #70 reported that the blinds had been broken for at least a year and that the staff was aware of the issue but had not replaced them. 4) On 10/17/2023 at 3:30 PM, broken blinds were observed in RL #6 on both windows. On 10/19/2023 at 2:33 PM, the broken blinds were again observed in RL #6. RI #74 and RI #41, who reside in RL #6, reported that the blinds had been broken for a while. 48195 5) On 10/18/2023 at 8:29 AM, the resident in RL #1 was observed sitting on the sofa, dressed, interacting and talking with staff present in the room. The right blind above the sofa was missing. On 10/19/2023 at 8:25 AM, the resident in RL #1 was observed sitting on the sofa eating breakfast. The right blind remained missing on the large window above the sofa. On 10/19/2023 at 8:26 AM, EI #12 was asked how he would describe the blinds in RL #1. EI #12 said there was a missing blind on the right side of window. EI #12 said he was not aware of the missing blind. EI #12 said there should be a blind on the right side of the window to keep anyone from looking into the resident's room. On 10/19/2023 at 8:38 AM, EI #12 was asked how should the blinds in the resident's room look. EI #12 said, they should be in good working order with no broken slats.

Based on interview, resident record review, and review of a facility policy titled, Comprehensive Care Plan, the facility failed to ensure Resident Identifier (RI) #83 had a care plan developed for the use of insulin. This deficient practice affected RI #83, one of 21 residents whose plans of care were reviewed. Findings include: Review of a facility policy titled Comprehensive Care Plan, with a revised dated of 10/24/2022, revealed the following: Purpose It is the policy of this facility to develop and implement a comprehensive person- centered care plan for each resident, . that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs that are identified in the resident's comprehensive assessment . Policy Explanation and Compliance Guidelines: . 2. The comprehensive care plan will be developed within 7 days after the completion of the comprehensive MDS (Minimum Data Set) assessment . 3. The comprehensive care plan will describe, at a minimum the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychological well-being. RI #83 was admitted to the facility on [DATE] and readmitted on [DATE], and had diagnosis of Type II Diabetes Mellitus. RI #83's September 2023 physician orders revealed RI #83 had an order dated 09/14/2023 for blood glucose monitoring and Humalog insulin was to be administered per sliding scale. A review of RI #83's September 2023 eMAR (electronic Medication Administration Record) revealed RI #83's blood glucose levels were being monitored and insulin was being administered per sliding scale. RI #83's admission MDS assessment, with an Assessment Reference Date (ARD) of 09/20/2023, also revealed RI #83 received insulin during the assessment period. RI #83's October 2023 Order Summary Report (Physician's Orders) also revealed RI #83 had orders for Blood Glucose Monitoring before meals and at bedtime; and Humalog insulin was to be administered per sliding scale. A review of RI #83's October 2023 eMAR revealed RI #83's blood glucose levels were being monitored and insulin was being administered per sliding scale. RI #83's significant change Minimum Data Set assessment, with an ARD of 10/08/2023, also revealed RI #83 received insulin during the assessment period. On 10/19/2023 at 10:58 AM, the surveyor conducted an interview with Employee Identifier (EI) #11, the ADON (Assistant Director of Nursing)/MDS Coordinator. When asked, about a resident receiving insulin and having a care plan for the insulin usage, EI #11 said, usually the resident would have a diabetic care plan that addressed the use of the insulin. EI #11 said, looking at RI #83's physician orders and eMAR, RI #83 had a physician order for insulin and RI #83's eMARs indicted RI #83 had received insulin doses. EI #11 said RI #83 should have a diabetic care plan, and she did not see one. When asked why it would be important for RI #83 to have a care plan for insulin usage, EI #11 said so the nurses knew how to care for RI #83's diabetes and to monitor for interventions on the care plan.

Based on observations, record reviews, interviews and review of a facility policy titled, Nebulizer Treatment-Hand Held Aerosol, the facility failed to ensure the Licensed Practical Nurse (LPN) remained with Resident Identifier (RI) #69 for the duration of his/her nebulizer treatment to ensure complete and accurate administration of the medication. This affected one of six residents observed during medication administration observations. Findings Include: A review of a facility policy titled, Nebulizer Treatment-Hand Held Aerosol, with a revised date of 01/18/2019, revealed the following: . Policy Aerosol nebulizer treatment shall be administered by the Licensed Nurse . Procedure 1. n. Observe resident during the procedure for any change in condition. RI #69 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of RI #69's (MONTH) 2019 Medication Administration Record [REDACTED]. On 4/4/2019 at 9:27 AM, an observation was made of Employee Identifier (EI) #1, LPN, setting up a nebulizer treatment with medications for RI #69. EI #1 placed the medication in the nebulizer chamber and placed the nebulizer mask on RI #69's face and left RI #69 unattended at 9:29 AM. EI #1 stated she would return in a minute. EI #1 went to another resident's room and administered medications before returning to RI #69's room at 9:39 AM. The nebulizer was still running when she returned. On 04/04/19 at 02:32 PM, EI #1 LPN, was asked who administered nebulizer treatments in the facility. EI #1 said, the LPN or charge nurse. EI #1 was asked what the policy was for administration of nebulizer medications. EI #1 said, put medicine inside the mask and apply to the face and stay with the resident. EI #1 was asked if she stayed in the room with RI #69 during the entire medication administration. EI #1 said, no, she went out and then came back to the room. When asked what the potential harm was in a resident receiving nebulizer medications/breathing treatment without a nurse present, EI #1 replied, they could take the mask off and not get all the medication they needed or they may not breathe in correctly and get the proper treatment. On 4/4/2019 at 3:03 PM, EI #2, Registered Nurse (RN), was asked who administered nebulizer treatments in the facility. EI #2 said, the charge nurse assigned to resident or the medication cart for the day. EI #2 was asked about the facility policy for administration of nebulizer medications. EI #2, said, to obtain respirations and assess the resident during the treatment. EI #2 was asked what was the potential harm in a resident receiving nebulizer medications/breathing treatment without a nurse present. EI #2 replied, there could be a change in their vital signs that could lead to a change in breathing. EI #2 said the nurse should not start a nebulizer treatment and then leave the resident's room.

Based on interviews, review of Resident Identifier (RI) # 1's medical record, and review of a facility policy titled Medication - Administration, the facility failed to ensure Resident Identifier (RI) #1's [MEDICATION NAME] was administered as ordered by the physician. This affected one of three sampled residents reviewed for administration of medications. Findings include: Review of the facility policy titled Medication - Administration, revised 1/13/16, revealed the following: . Purpose Medications shall be administered in a timely manner and as prescribed by the resident's attending physician or the facility's Health Care Practitioner. Policy Medications shall be given as ordered by a physician . RI #1 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of RI #1's written PHYSICIAN'S ORDERS revealed an order dated 8/01/18 for [MEDICATION NAME] 20 mg/mL (milligrams per milliliter) give 0.5 mL sublingually at 8:00 AM, 2:00 PM, 8:00 PM, and 2:00 AM routinely for pain. Review of RI #1's (MONTH) (YEAR) MAR (Medication Administration Record) indicated Employee Identifier (EI) #1, Registered Nurse (RN) , had initialed off the 8:00 AM scheduled dose of routine [MEDICATION NAME]; however, his initials were circled. On the back side of the MAR, the NOTES section indicated the 8/04/18 8:00 AM dose of [MEDICATION NAME] was held. EI #1, RN Supervisor, was interviewed on 9/06/18 at 6:35 PM. EI #1 was provided a copy of RI #1's MAR for his review. EI #1 admitted he had not administered RI #1's 8:00 AM routine dose of [MEDICATION NAME]. On 9/07/18 at 1:23 PM, EI #13, the Director of Nursing, confirmed RI #1 had not received his/her 8:00 AM scheduled dose of [MEDICATION NAME] on 8/04/18. EI #13 said the potential harm in not following the physician's order was increased pain.

Based on interviews, review of Resident Identifier (RI) #1's medical record, and review of the facility policy titled Medication - Administration, the facility failed to ensure the nurse notified the physician that RI #1's 8:00 AM scheduled dose of [MEDICATION NAME] for 8/4/2018 was not administered as ordered. This affected one of three sampled residents who were reviewed for the administration of medications as ordered by the physician. Findings include: Review of the facility's policy titled Medication - Administration, revised 1/13/16, revealed the following: . Procedure . 3. Should a dosage seem excessive considering the resident's age and medical condition, or a medication order seems to be unrelated to the resident's current [DIAGNOSES REDACTED]. director for further instructions. RI #1 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of RI #1's written PHYSICIAN'S ORDERS revealed an order dated 8/01/18 for [MEDICATION NAME] 20 mg/mL (milligrams per milliliter) give 0.5 mL sublingually at 8:00 AM, 2:00 PM, 8:00 PM, and 2:00 AM routinely for pain. There was also a second order dated 8/01/18 for [MEDICATION NAME] 20 mg/mL 1mL sublingually every one hour as needed for pain or shortness of breath. These orders were both verbal orders given by Employee Identifier (EI) #14, the facility's Medical Director. Review of RI #1's (MONTH) (YEAR) MAR (Medication Administration Record) indicated EI #1, Registered Nurse (RN) , had initialed off the 8:00 AM scheduled dose of routine [MEDICATION NAME]; however, his initials were circled. On the back side of the MAR, the NOTES section indicated the 8/04/18 8:00 AM dose of [MEDICATION NAME] was held for sedation. EI #1 entered a Departmental Note for RI #1 on 8/4/18 at 5:15 PM; however, there was no reference to the held 8:00 AM dose or indication the physician had been notified. EI #1, RN Supervisor, was interviewed on 9/06/18 at 6:35 PM. EI #1 was provided a copy of RI #1's MAR for his review. EI #1 admitted he had not administered RI #1's 8:00 AM routine dose, but said he had not given it because he felt it could end RI #1's life. When asked if he had contacted the physician about his concerns with the order, EI #1 said he had not, but apparently it was policy to do so. EI #1 said he should have notified the physician. EI #14, the facility's Medical Director and the prescribing physician, was interviewed on 9/07/18 at 11:52 AM. EI #14 said RI #1 did have orders for routine [MEDICATION NAME]. When asked if EI #1 had contacted him regarding RI #1's condition and the need to hold a scheduled dose of [MEDICATION NAME] on 8/4/18, EI #14 said no.

Based on interview, review of a facility policy titled Voting and review of an untitled facility document and a facility document titled (YEAR) Voting, the facility failed to ensure Resident Identifier (RI) #54 was allowed to vote in the (MONTH) 12, (YEAR), Special Election for United State Senator. This affected one of 20 registered voters in the facility. Findings Include: A review of a policy with a revised date of 05/17/16 documented the following: .Purpose To ensure that each resident is able to exercise his or her rights as a citizen or resident of the United States .Any resident registered to vote in this county/city will be able to vote during any election he or she chooses. A resident admitted to this facility who is not a registered voter will be given the opportunity to register .Responsibility The Director of Social Services and/or Designee is responsible for determining if a resident is/is not a registered voter and/or elects to register to vote upon admission and for contacting and scheduling the Registrar's Office for registration and/or voting purposes . A review of an untitled and undated document, provided by the facility, revealed RI #54 was a registered voter. A review of a document provided by the facility titled (YEAR) Voting, revealed 14 residents voted in the (MONTH) 12, (YEAR), Special Election. A review of an untitled and undated document, provided by the facility, revealed the following: Deadline to register to vote in General: (MONTH) 27, (YEAR) .General Election: (MONTH) 12, (YEAR) . RI # 54 was admitted to the facility on [DATE]. A review of RI #54's most recent Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/15/2018 documented a Brief Interview of Mental Status Score (BIMS) of 15, which indicated RI # 54 was cognitively intact. On 04/11/18 at 10:06 a.m. during the Resident Council meeting, RI #54 stated he/she wanted to vote in (MONTH) (YEAR) Special Election for United State Senator, but was unable to vote. An interview was conducted on 4/11/18 at 1:56 p.m. with Employee Identifier (EI) #5, Admission Coordinator. EI #5 was asked if RI #54 was a registered voter. EI #5 responded yes. EI #5 was asked if RI #54 was able to vote in the (MONTH) 12, (YEAR) Special Election for United State Senator. EI #5 stated no. EI #5 was asked why RI #54 was unable to vote. EI #5 responded because he/she was registered in a different county and we did not get the paperwork for a change of address completed in time. EI # 5 further stated the cut off date to register to vote was (MONTH) 27, (YEAR). EI # 5 was asked how many registered voters were allowed to vote in the (MONTH) 12, (YEAR) Special Election. EI #5 stated 14. EI #5 was asked if RI #54 should have been allowed to vote in the special election. EI #5 stated yes, if the paperwork had been completed. EI #5 was asked why the paperwork was not completed in time for RI #54 to vote. EI #5 stated it should have been completed, but it was dropped. EI #5 further stated residents should be allowed to vote because it is their right.

Based on observation, interview, medical record review and review of a facility policy titled, Restraint Free Environment, the facility failed to provide medical justification for the use of seatbelt for Resident Identifier (RI) #39. The facility further failed to ensure a restraint assessment was performed when the restraint was ordered for RI #39 on 10/05/17. These deficient practices affected RI #39, one of one residents sampled for the use of restraints. Findings Include: A review of a facility policy titled, Restraint Free Environment, with a revised date of 01/09/18 documented: Policy Each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints .and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. .Compliance Guidelines .4. When the use of a restraint is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. Procedure .5. Before a resident is restrained, the facility will determine the presence of a specific medical symptom (e.g.indication of a physical or psychological condition) that would require the use of restraints, and; a. How the use of restraints would treat the medical symptom; b. Protect the resident's safety; .6. Medical symptoms warranting the use of restraints should be documented in the resident's medical record, ongoing assessments and care plans. .13. For such identified residents, the facility will assess and care plan the need for restraint use on a systematic and ongoing basis. RI #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #39's (MONTH) (YEAR) physician's orders [REDACTED].> .Order date 10/05/17 RESIDENT IS TO HAVE SELF RELEASING ALARM TO WHEELCHAIR AT ALL TIMES FOR SAFETY WHEN IN WHEELCHAIR . A review of RI #39's Quarterly Minimum Data Set ((MDS) dated [DATE], documented severe cognitive impairment and use of a trunk restraint daily. On 04/12/18 at 10:05 a.m., RI #39 was observed by the surveyor sitting in the hallway with a seatbelt in place. The surveyor asked RI #39 if he/she could release the seatbelt. RI #39 held up a baby doll to the surveyor in response to the question. On 04/12/18 at 10:25 a.m., an interview was conducted with Employee Identifier (EI) #2, Licensed Practical Nurse (LPN)/Restorative Nurse. EI #2 was asked did RI #39 have a restraint. EI #2 said yes a self releasing alarm seatbelt. EI #2 was asked if RI #39 could release the seatbelt on command. EI #2 replied no. EI #2 was asked how long had RI #39 had the seatbelt. After looking at RI #39's medical record, EI #2 answered since 10/05/17. EI #2 was asked was there a Restraint Assessment done when the restraint was put in place. EI #2 said no but there was one done today. EI #2 was asked what was the concern with RI #39 not being assessed for the restraint. EI #2 answered we could have missed a skin issue and his/her safety. EI #2 was asked how would she know this was the least restrictive device. EI #2 said therapy should have looked at him/her. EI #2 was asked did therapy look at RI #39 to determine if it was the least restrictive restraint. EI #2 looked at RI #39's chart and stated no they did not. EI #2 was asked why was the restraint implemented. EI #2 said the family wanted it after a fall.

Based on observations, interviews, medical record reviews and review of a facility policy titled, Comprehensive Care Plans, the facility failed to ensure a care plan was developed for: 1. a seatbelt alarm for Resident Identifier (RI) #39 and 2. an indwelling catheter for RI #35. This affected RI #39 and RI #35, two of 19 sampled residents reviewed for care plans. Findings Include: A review of a facility policy titled, Care Plan - Comprehensive, with a revised date of 11/28/17, documented: .5. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. .7. Staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made . 1.) RI #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #39's Care Plans was conducted with no Care Plan for Restraints found in RI #39's medical record. A review of RI #39's Quarterly Minimum Data Set ((MDS) dated [DATE], documented severe cognitive impairment and use of a trunk restraint daily. On 04/12/18 at 10:05 a.m., RI #39 was observed by the surveyor sitting in the hallway with a seatbelt in place. The surveyor asked RI #39 if he/she could release the seatbelt. RI #39 held up a baby doll to the surveyor in response to the question. On 04/12/18 at 10:25 a.m., an interview was conducted with Employee Identifier (EI) #2, Licensed Practical Nurse (LPN)/Restorative Nurse. EI #2 was asked did RI #39 have a restraint. EI #2 said yes a self releasing alarm seatbelt. EI #2 was asked if RI #39 could release the seatbelt on command. EI #2 replied no. EI #2 was asked how long had RI #39 had the seatbelt. After looking at RI #39's medical record, EI #2 answered since 10/05/17. EI #2 was asked was the restraint on RI #39's Care Plan. EI #2 said no she just did not do one. EI #2 was asked what was the concern with RI #39 not having a Restraint Care Plan. EI #2 replied the Certified Nursing Assistants (CNAs) would not know to release it and check his/her skin. 2.) Resident Identifier(RI) #35 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 04/10/2018 at 2:56 p.m., a review of RI #35's (MONTH) (YEAR) Physician order [REDACTED].Indwelling Urinary Catheter .Change as needed for occlusion .change urinary catheter drainage bag and tubing every 14 days and as needed .irrigate catheter .as needed for occlusion . On 04/10/2018 at 02:57 p.m., a review of RI #35's five Day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) dated 03/05/2018 revealed: RI#35 had an indwelling catheter. On 04/11/2018 at 05:00 p.m., a review of RI#35's current care plans revealed no care plan addressing a Urinary Catheter. On 04/11/2018 at 5:50 p.m. an interview was conducted with Employee Identifier (EI) #2, a Licensed Practical Nurse/Restorative Nurse. EI#2 was asked who was responsible for initiating care plans for RI #35. EI #2 replied she was. EI#2 was asked what date was the physician order [REDACTED].#2 replied on 02/26/2018. EI#2 was asked when should the Care Plan be implemented, if a resident has an order for [REDACTED].#2 stated on 02/26/2018. EI#2 was asked if the facility had a policy on initiating care plans. EI#2 stated yes. EI#2 was asked if the policy was followed. EI#2 stated no. EI#2 was asked why should a resident's care plan be updated after receiving a physician order [REDACTED].

Based on observation, interview, medical record review and review of Potter and Perry, Fundamentals of Nursing, Ninth Edition, the facility failed to ensure a Licensed Nurse followed a physician's orders [REDACTED].#76 to rinse his/her mouth after inhaler administration. This affected RI #76, one of six residents observed during medication administration observation. Findings Include: A review of Potter and Perry, Fundamentals of Nursing, Ninth Edition, Chapter 23, Legal Implications in Nursing Practice, page 311, revealed: .Health Care Providers' Orders .Nurses follow health care providers' orders unless they believe that the orders are in error . RI #76 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #76's physician's orders [REDACTED]. .[MEDICATION NAME] Handihaler Give one inhalation daily, rinse mouth with water after use . On 04/11/18 at 7:52 a.m., Employee Identifier (EI) #3, Licensed Practical Nurse (LPN), was observed during medication administration for RI #76. EI #3 was observed administering an inhaler to RI #76. EI #3 did not instruct RI #76 to rinse his/her mouth with water after administration of his/her inhaler. On 04/12/18 at 7:43 a.m., an interview was conducted with EI #3. EI #3 was asked did she instruct RI #76 to rinse his/her mouth after administration of his/her inhaler. EI #3 said no she did not. EI #3 was asked did RI #76's physician's orders [REDACTED]. EI #3 reviewed RI #76's physician's orders [REDACTED]. EI #3 was asked was the physician's orders [REDACTED].#3 replied no. EI #3 was asked why was it important to follow the physician's orders [REDACTED]. EI #3 answered because the medication can cause problems if it is not rinsed out of the mouth.

Based on observation, interview, and review of the Food Code (YEAR), the facility failed to ensure: 1. six orange juice containers and three cranberry juice containers, observed in the second floor nourishment room refrigerator, were dated. This was observed on [DATE] and affected one of two nourishment rooms in the facility. Findings Include: A review of The Food Code (YEAR) revealed: XXX,[DATE].18 Ready-to-Eat . (A) A Food .shall be discarded if . (2) Is in a container or PACKAGE that does not bare a date or day . 1.) On [DATE] at 08:10 a.m., the surveyor observed six orange juice containers and three cranberry juice containers, in the second floor nourishment room refrigerator, that were not dated. On [DATE] at 08:32 a.m., an interview was conducted with Employee Identifier (EI) #1, Registered Dietitian. EI #1 was asked, did the juice containers in the second floor nourishment room refrigerator have a use by date on the juices. EI #1 replied no. EI #1 was asked if facility had a policy for use by dates on food/drink items in the refrigerator. EI #1 replied no. 9. EI #1 was asked, why should you have a use by date on food/drink items placed in a refrigerator. EI#1 replied, so staff can dispose of expired items and to ensure residents do not receive an expired item.

Based on observation, interview, medical record review and review of a facility policy titled, Nebulizer Treatment - Hand Held Aerosol, the facility failed to ensure a Licensed Nurse rinsed the mouthpiece, nebulizer and tubing with tap water after administration of Resident Identifier (RI) #17's nebulizer treatment. This deficient practice affected RI #17, one of six residents, and Employee Identifier (EI) #3, one of four nurses, observed during medication administration observation. Findings Include: A review of a facility policy titled, Nebulizer Treatment - Hand Held Aerosol with a revised date of 02/01/15 documented: Procedure: .19. Clean equipment used in aerosol nebulizer treatment as follows: .b. Rinse the mouthpiece, nebulizer and tubing with tap water after each treatment. c. Leave nebulizer system in clean area to dry thoroughly before reuse. RI #17 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 04/11/18 at 3:11 p.m., EI #3, LPN, was observed during administration of a nebulizer treatment for [REDACTED]. EI #3 was observed pouring the remaining liquid from RI #17's reservoir. EI #3 then placed the items in a plastic bag without rinsing or drying them. On 04/12/18 at 7:43 a.m., an interview was conducted with EI #3. EI #3 was asked, what should she do after administration of a nebulizer treatment. EI #3 said she should rinse and dry the reservoir and tubing and then store it in a plastic bag. EI #3 was asked did she rinse and dry RI #17's reservoir and tubing before she stored it in a plastic bag. EI #3 replied no she did not. EI #3 was asked what was the concern with placing the reservoir and tubing in the plastic bag without rinsing and drying it. EI #3 answered bacteria growth. EI #3 was asked what was the concern with bacteria. EI #3 said infection control. On 04/12/18 at 11:10 a.m., an interview was conducted with EI #4, LPN/Infection Control Coordinator. EI #4 was asked what should a nurse do after administering a nebulizer treatment. EI #4 said they should clean the nebulizer by rinsing it and drying it with a paper towel and storing it in a plastic bag. EI #4 was asked should a nurse store a nebulizer reservoir in a plastic bag that had not been rinsed or dried. EI #4 replied no. EI #4 was asked what was the concern with that. EI #4 answered bacteria growing in the damp environment of the plastic bag. EI #4 was asked what was the problem with bacteria. EI #4 said infection control.

Based on observations, interviews, medical record review, and review of the facility's policies titled, Perineal Care and Handwashing - Hand Hygiene, the facility failed to ensure a Certified Nursing Assistant (CNA), Employee Identifier (EI) #1, washed his hands and changed his gloves after wiping the buttocks of Resident Identifier (RI) #17 and RI #18 and before touching items in the room during incontinence care. This affected two of two residents sampled for incontinence care. The facility further failed to ensure a Registered Nurse (RN)/ Corporate Wound Consultant, Employee Identifier (EI) #2, washed her hands prior to exiting the room and after entering the room to assist with the wound care of RI #3. This affected one of two residents sampled for wound care. Findings Include: A facility policy titled, Perineal Care, with a revised date of 03/01/17, revealed: Purpose To cleanse the perineum and assist in preventing infection, skin irritation and odors. Procedure . 5. clean buttocks and peri-anal area last. refasten brief properly. 6. Remove soiled gloves and place in plastic bag, . Wash hands . and apply clean gloves. RI #17 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #18 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/28/17 at 9:40 a.m., a CNA, Employee Identifier (EI) #1, was observed touching the wipes package and other items in the room with soiled gloves after wiping the buttocks of RI #18 during incontinence care. On 11/28/17 at 9:54 a.m., a CNA, EI #1, was observed touching the wipes package and other items in the room with soiled gloves after wiping stool from the buttocks of RI #17 during incontinence care. An interview was conducted on 11/29/17 at 8:53 a.m. with EI #1. EI #1 was asked what should be done after wiping stool from the buttocks and before touching items in the room during incontinence care. EI #1 replied, Change gloves, sanitize hands. EI #1 was asked what was the potential for harm if items in the room were contaminated with soiled gloves after performing incontinence care. EI #1 replied, Infection, UTI (urinary tract infection). An interview was conducted on 11/30/17 at 9:48 a.m. with EI #3, Licensed Practical Nurse/ Infection Control Preventionist. EI #3 was asked what should a CNA do during incontinence care after wiping stool from the buttocks and before touching items in the room. EI #3 replied, Take off gloves, wash hands and put on clean gloves. EI #3 was asked what was the potential for harm in not washing hands and removing soiled gloves after wiping stool from the buttocks during incontinence care. EI #3 replied, Transferring germs to other objects, spreading germs throughout the facility. A facility policy titled, Handwashing - Hand Hygiene with a revised date of 03/01/17 revealed: Purpose To prevent the spread of infections. 5. Employees must wash their hands for at least twenty (20) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: k. Before and after changing a dressing; . RI #3 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/27/17 at 3:04 p.m., EI #2 was observed during wound care and did not wash her hands prior to exiting the room and after reentering the room to assist in the wound care of RI #3. An interview was conducted on 11/29/17 at 11:27 a.m. with EI #2. EI #2 was asked if she washed her hands before and after assisting in wound care on the previous day. EI #2 replied, No. When asked what was the potential for harm in not washing hands during wound care. EI #2 replied, Potential for infection. An interview was conducted on 11/30/17 at 9:48 a.m. with EI #3. EI #3 was asked should a nurse, participating in wound care, leave the room and return to the room without washing her hands. EI #3 replied, No. EI #3 was asked what was the potential for harm in not washing hands before leaving the room and upon returning to the room during wound care. EI #3 replied, Cross contamination.

Based on observation, interview and review of policies titled Food Preparationand Three Compartment Sink Dishwashing, the facility failed to ensure the following: 1. Food was covered prior to serving residents; and 2. Bowls were not stacked together to dry; and This was observed on 2/7/17 and 2/8/17, two of three days of the survey, and had the potential to affect all 90 residents receiving meals from the kitchen. Findings Include: A review of a policy titled Food Preparation, with a revised date of 12/01/13, documented the following: .C. Dessert Preparation . 2. Pies and Cakes or individual serving dishes are placed on trays and covered . A review of a policy titled Three Compartment Sink Dishwashing, with a revised date of 4/22/15, documented the following: .Purpose to ensure .dishes, washed by hand, are clean and sanitized .Procedure .9. Remove the items .Turn upside down or prop sideways . On 2/7/16 at 11:00 a.m. during the initial tour of the kitchen the following observations were made: 1. A tray of pudding was observed uncovered in the kitchen 2. Two large bowls were observed stacked on top of each other drying. On 2/8/16 the following observations were made in the kitchen: At 10:35 a.m. pie was observed uncovered on trays in individual bowls. At 10:45 a.m. two large bowls were observed stacked together by the sink drying. An interview was conducted with Employee Identifier (EI) # 9, Dietary Manager, on 2/8/17 at 3:30 p.m. EI # 9 was asked what is the potential harm of having uncovered food. EI # 9 replied something could possibly get in the food. EI # 9 was asked if bowls should be stacked together to dry. EI # 9 replied we normally place standing up to dry and they should have been stacked separate. EI # 9 was asked what is the harm of drying bowls stacked together. EI # 9 replied wet nesting.

Based on observations, interviews and review of facility policies titled, Finger Stick - Blood Glucose,Personal Protective Equipment - Gloves Usage, Handwashing - Hand Hygiene, the facility failed to ensure: 1) Employee Identifier (EI) #6, a Licensed Practical Nurse (LPN), did not place Resident Identifier (RI) #1's [MEDICATION NAME] Insulin pen and glucometer strip bottle on a soiled overbed table and then place the used glucometer machine in the medication cart without cleaning it. 2) Licensed staff did not place gloves and medications in her uniform pocket for use in providing care for RI #20. Further, the licensed staff member did not wash hands prior to putting on gloves; and 3) EI #3, Registered Nurse (RN)/Treatment Nurse washed her hands prior to gloving, after removing soiled gloves and between wound care dressing changes for RI #s 6 and 7. This affected three of eight medication observations and two of two wound care observations. Findings include: 1) A facility policy titled, Finger Stick - Blood Glucose, with a revision date of 02/01/2015 documented: Policy The purpose of this procedure is to guide the safe handling of blood sampling devices to prevent transmission of bloodborne diseases to residents and employees .General Guidelines .2. The meter should be disinfected using a disinfectant wipe after each use cleaning all surface areas of the meter .Procedure .2. Gather supplies, wash hands, put on gloves 3. Clean glucometer with disinfectant wipes .8. Disinfect meter after use using a disinfectant wipe .10. Remove gloves .11. Wash hands . RI #1 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #1's February Physician order [REDACTED]. On 02/07/2017 at 4:08 p.m., the surveyor observed EI #6, an LPN perform a finger stick (Glucometer check) and administer [MEDICATION NAME]to RI #1. She gathered supplies and entered RI #1's room. She placed the glucometer strip bottle and [MEDICATION NAME] pen on the unclean bedside table. EI #6 performed the finger stick, discarded the lancet and used strip. EI #6 administered the [MEDICATION NAME]to RI #1. She then placed the [MEDICATION NAME] pen and the glucometer strip bottle into her pocket, removed her gloves and washed her hands. EI #6 put the glucometer into the cart, then removed it to clean the glucometer. EI #6 also placed the [MEDICATION NAME] pen and glucometer strip bottle back into the medication cart. On 02/07/2017 at 4:55 p.m., the surveyor interviewed EI #6, the LPN who performed the finger stick and administered insulin to RI #1. EI #6 stated glucometer supplies should be placed on a barrier and she had not put the [MEDICATION NAME] pen or glucometer strip bottles on a barrier. EI #6 further stated the glucometer, strip bottle and [MEDICATION NAME] pen should have been wiped down or sanitized after use and prior to putting them in the medication cart in order to prevent the spread of germs. On 02/09/2017 at 09:00 a.m., the surveyor interviewed EI #8, Infection Control Nurse. EI #8 was asked where supplies should be placed while performing a finger stick (glucometer check). She stated on a paper towel on the overbed table. EI #8 further stated the glucometer should be cleaned before and after use to prevent contamination or spread of blood borne pathogens from one resident to another resident. 2) A facility policy titled, Personal Protective Equipment - Gloves Usage, with a revision date or 02/27/2013, documented: Policy Gloves must be worn when handling blood, body fluids, secretions, excretions, mucous membranes and/or non-intact skin. Purpose 1. To prevent the spread of infection;2. To protect hands from potentially infectious material; and 3. To prevent exposure to the infectious diseases from blood or body fluids. Procedure .8. Wash and dry hands thoroughly after removing gloves . A facility policy titled, Handwashing - Hand Hygiene, with a revision date of 02/01/2015 documented: .8. The use of gloves does not replace handwashing/hand hygiene . RI #20 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #20's Physician order [REDACTED]. On 02/08/2017 at 07:55 a.m., the surveyor observed EI #7, the LPN, administer the above medications to RI #20. EI #7 placed medications in a cup, placed her gloves in her pocket, and went to the resident's room. EI #7 administered some of the pills with applesauce and some with thickened water. EI #7 took gloves out of her pocket and put them on without sanitizing or washing her hands. EI #7 administered the nasal spray. She removed her gloves and washed her hands. EI #7 then removed another pair of gloves and the Refresh eye drops from her pocket, put on the gloves and administered the eye drops. On 02/08/2017 at 08:12 a.m., the surveyor interviewed EI #7 about RI #20's medication observation. EI #7 stated that hands should be washed before putting on gloves and after removing gloves due to the potential for spreading germs. EI #7 further stated that gloves should not be placed in her pocket due to infection control. On 02/09/2017 at 09:00 a.m., the surveyor interviewed EI #8, Infection Control Nurse. EI #8 stated hands should be washed before putting on gloves and after removing gloves to prevent the spread of infection. EI #8 was asked if gloves and eye drops should be placed in the nurses pocket prior to use and/or after use. She stated no because it contaminates from the resident to the nurse/uniform and on to other residents. 3) A facility policy titled, Dressings - Non-Sterile with a revision date of 02/01/2015 documented: Purpose To protect open wounds from contamination and absorb drainage. Procedure .3. Wash hands thoroughly before starting the procedure . 6. Put on gloves to remove the soiled dressing and expose the wound. Discard the soiled dressing in the plastic bag. Remove gloves and wash/sanitize hands. Put on clean gloves.15. Remove gloves and discard .16. Wash hands thoroughly after completing the procedure .Responsibility The Treatment Nurse (Designee) is responsible for the implementation of this policy and procedure . RI #6: RI #6 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 02/08/2017 at 11:28 a.m., the surveyor observed Employee Identifier (EI) #3, RN/Treatment Nurse, perform wound care to RI #6's four wounds. EI #3 gathered supplies, placed them on RI #6's nightstand then washed her hands. EI #3 removed the soiled dressing from RI #6's left hip, opened supplies, cleaned and measured the wound. EI #3 then got a pen from her pocket and wrote down the measurements. EI #3 got a sterile Q-tip to measure the depth of the wound, removed her gloves and wrote down the measurement then put on gloves. EI #3 did not wash or sanitize her hands after removing the dressing or removing her gloves. EI #3 then measured a second area to RI #6's left buttock and used the pen to write down the measurements. EI #3 removed her gloves and put on new gloves. EI #3 picked up scissors and cut the [MEDICATION NAME] silver dressing and applied it to the wound. EI #3 removed her gloves and got keys from her pocket and gave them to another staff member. EI #3 then put on new gloves. EI #3 applied the border gauze to the wounds and removed her gloves. EI #3 did not wash/sanitize her hands after cleaning the wound or after removing her gloves. EI #3 put on gloves and repositioned RI #6 to the left side. EI #3 removed the dressing to RI #6's right hip and coccyx wound. EI #3 removed her gloves and put on new gloves. EI #3 cleaned then measured the wound to RI #6's right hip, removed her gloves and put on new gloves. EI #3 applied the dressing to the wound. EI #3 removed her gloves, put on new gloves, and cleaned RI #6's coccyx wound. EI #3 removed her gloves, went to the roommates side of the room to get more gloves. EI #3 finally washed her hands. EI #3 put on gloves, measured the coccyx wound, removed her gloves, wrote down the measurements (placed the pen back into her pocket) and put her gloves on to finish the dressing change. EI #3 repositioned RI #6, removed her gloves, put the scissors in her pocket, gathered the supplies and left the room. EI #3 wheeled the treatment cart down the hall to the Soiled Utility to discard used supplies. EI #3 then sanitized her hands. On 02/08/2017 at 12:02 p.m., the surveyor interviewed EI #3, the RN/Treatment nurse. EI #3 stated the dressings had a small amount of drainage to each dressing. EI #3 stated hands should be washed before putting on gloves and after removing gloves to prevent infection. She further stated hands should be washed between wounds. EI #3 stated RI #6 had a total of 4 wounds that she had performed care to. EI #3 stated she had only washed her hands twice during the performance of the four wound cares. When asked what the potential for harm was in not washing her hands before putting on gloves and after removing gloves, EI #3 stated the spread of infection. On 02/09/2017 at 09:00 a.m., the surveyor interviewed EI #8, Infection Control Nurse. EI #8 stated hands should be washed prior to putting on gloves and after removing gloves to prevent the spread of infection and to remove any germs from your hands. EI #8 was asked when hands should be washed and gloves changed while performing wound care on a resident with multiple wounds. She stated hands should be washed after going from dirty to clean and between wounds to prevent contaminating one wound to another with bacteria. When asked if scissors should be placed in the nurses pocket prior to use and/or after use, EI #8 stated no because it contaminated from resident to the nurse/uniform and on to other residents. RI #7: RI #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. EI #3 was observed providing dressing changes for RI # 7's 5 wounds on 02/08/17 beginning at 8:00 a.m. EI #3 failed to wash her hands before donning clean gloves between each of RI #7's wounds. A follow-up interview via phone was conducted with EI #3, RN/Wound Care Nurse, on 02/09/17 at 9:00 a. m. EI #3 was asked if she had performed wound care for RI #7 on 02/08/17 at 8:00 a.m. She replied, yes. She was asked what the facilities policy was for washing hands and donning gloves between dressing changes. EI #3 stated, Wash and change gloves in between every dressing change and I am well aware I did not. EI #3 was asked why it was important to wash her hands and don clean gloves between each wound while providing wound care for a resident. She stated, Do not want to cross contaminate. An interview was conducted with EI #8, LPN/Infection Control Nurse, on 02/09/17, at 9:00 a.m. EI #8 was asked what should be done prior to putting gloves on and why. She replied, wash hands to prevent spread of infection and remove any germs from your hands before donning gloves. She was asked what should be done after removing gloves and why. EI #8 replied, wash hands to remove any bacteria once you have completed your task. EI #8 was asked when should hands be washed and gloved during wound care. She replied, anytime you go from dirty to clean. After touching dirty wash hands before you touch clean. EI #8 was asked what the potential for harm was for not washing hands when performing wound care. She replied, it could spread the infection from one site to another or spread infection to staff. EI #8 was asked when performing wound care on a resident with multiple wounds when should hands be washed and gloves changed and why. She replied, After going from dirty to clean between wounds to prevent contaminating one wound to another with bacteria.

Based on observation, interviews and review of facility policies titled, Dressings - Non-Sterile, the facility failed to ensure the RN (Registered Nurse)/Treatment Nurse provided wound care to Resident Identifier (RI) #6 and #7 in a manner that met professional standards as evidenced by not changing her gloves and washing her hands after removing soiled dressings or prior to cleaning the wounds. The RN/Treatment Nurse also failed to date and initial the new dressings. This affected two of two residents observed during wound care. The facility's Census and Conditions of Residents documented two residents with pressure ulcers. Findings include: A facility policy titled, Dressings - Non-Sterile, with a revision date of 02/01/2015, documented: Purpose To protect open wounds from contamination and absorb drainage. Procedure .3. Wash hands thoroughly before starting the procedure . 6. Put on gloves to remove the soiled dressing and expose the wound. Discard the soiled dressing in the plastic bag. Remove gloves and wash/sanitize hands. Put on clean gloves.9. Gently irrigate the wound .12. Apply the topical dressing . 14 . Date and initial the intact dressing . 15. Remove gloves and discard .16. Wash hands thoroughly after completing the procedure . Responsibility The Treatment Nurse (Designee) is responsible for the implementation of this policy and procedure . 1) RI #6 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 02/08/2017 at 11:28 a.m., the surveyor observed Employee Identifier (EI) #3, RN/Treatment Nurse, perform wound care to RI #6's four wounds. EI #3 gathered supplies, placed them on RI #6's nightstand, then washed her hands. EI #3 removed the soiled dressing from RI #6's left hip, opened supplies, cleaned the wound, touched RI #6's buttocks, got measuring tape and measured the wound. EI #3 then got a pen from her pocket and wrote down the measurements. EI #3 got a sterile Q-tip to measure the depth of the wound, removed her gloves and wrote down the measurement then put on gloves. EI #3 did not wash or sanitize her hands after removing the dressing or removing her gloves. EI #3 then measured a second area to RI #6's left buttock and used the pen to write down the measurements. EI #3 removed her gloves and put on new gloves. EI #3 picked up scissors and cut the [MEDICATION NAME] silver dressing and applied it to the wounds. EI #3 removed her gloves and got keys from her pocket and gave them to another staff member. EI #3 then put on new gloves. EI #3 applied the border gauze to the wounds and removed her gloves. EI #3 did not wash/sanitize her hands after cleaning the wound or after removing her gloves nor did she date and initial the new dressing. EI #3 then put on gloves and repositioned RI #6 to the left side. EI #3 moved RI #6's catheter tubing out of the way and removed the dressing to RI #6's right hip and coccyx wound. EI #3 removed her gloves and put on new gloves. EI #3 cleaned then measured the wound to RI #6's right hip, removed her gloves and put on new gloves. EI #3 opened supplies, got the scissors and cut the [MEDICATION NAME] dressing. EI #3 applied the dressing to the wound. EI #3 removed her gloves, put on new gloves, and cleaned RI #6's coccyx wound. EI #3 removed her gloves, went to the roommates side of the room to get more gloves. EI #3 finally washed her hands. EI #3 put on gloves, measured the coccyx wound, removed her gloves, wrote down the measurements (placed the pen back into her pocket) and put her gloves on to finish the dressing change. EI #3 did not date or initial the new dressings. EI #3 repositioned RI #6, removed her gloves, put the scissors in her pocket, gathered the supplies and left the room. EI #3 wheeled the treatment cart down the hall to the Soiled Utility to discard used supplies. EI #3 then sanitized her hands. On 02/08/2017 at 12:02 p.m., the surveyor interviewed EI #3, the RN/Treatment nurse. EI #3 stated the dressings had a small amount of drainage to each dressing. EI #3 stated hands should be washed before putting on gloves and after removing gloves to prevent infection. She further stated hands should be washed between wounds. EI #3 stated RI #6 had a total of 4 wounds that she had performed care to. EI #3 stated she had only washed her hands twice during the performance of the four wound cares. When asked what the potential for harm was in not washing her hands after removing the soiled dressings and before putting on the clean dressings, EI #3 stated the spread of infection. 2) RI #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. EI #3, RN/Treatment Nurse, was observed providing dressing changes for RI #7's 5 wounds on 02/08/17 beginning at 8:00 a.m. EI #3 failed to wash her hands before donning clean gloves between each of RI #7's wounds. A follow-up interview via phone was conducted with EI #3, RN/Wound Care Nurse, on 02/09/17 at 9:00 a.m EI #3 was asked if she had performed wound care for RI #7 on 02/08/17 at 8:00 a.m She replied, yes. She was asked what the facility's policy was for washing hands and donning gloves between dressing changes. EI #3 stated, Wash and change gloves in between every dressing change and I am well aware I did not. EI #3 was asked why it was important to wash her hands and don clean gloves between each wound while providing wound care for a resident. She stated, Do not want to cross contaminate. An interview was conducted with EI #8, Licensed Practical Nurse/Infection Control, on 02/09/17, at 9:00 a.m. EI #8 was asked what should be done prior to putting gloves on and why. She replied, wash hands to prevent spread of infection and remove any germs from your hands before donning gloves. She was asked what should be done after removing gloves and why. EI #8 replied, wash hands to remove any bacteria once you have completed your task. EI #8 was asked when should hands be washed and gloved during wound care. She replied, anytime you go from dirty to clean. After touching dirty wash hands before you touch clean. EI #8 was asked what the potential for harm was for not washing hands when performing wound care. She replied, it could spread the infection from one site to another or spread infection to staff. EI #8 was asked when performing wound care on a resident with multiple wounds when should hands be washed and gloves changed and why. She replied, After going from dirty to clean between wounds to prevent contaminating one wound to another with bacteria.

Based on observation, review of a facility policy titled: Quality of Life - Dignity, and interviews, the facility failed to ensure staff Nurses closed entry doors or closed privacy curtains while administering medications, including insulin, to Resident Identifier (RI) #s 12, 13 and 14. This affected 3 of 8 residents observed during medication pass and two of four nurses. Findings Include: A facility policy titled: Quality of Life - Dignity . Resident Rights & Dignity ., with a revised date of 02/01/2015, documented the following: . Procedure . 9. Staff shall maintain an environment in which confidential clinical information is protected . 10. Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures 1) RI #12 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #12's PHYSICIAN ORDERS, dated February 2017, included orders for multiple oral medications and an order for [REDACTED].>During an observation on 02/08/17 at 8:45 a.m., Employee Identifier (EI) #2, Licensed Practical Nurse (LPN), was observed administering RI #12's oral medications and subcutaneous insulin. EI #2 failed to close the resident's door or privacy curtain while administering the medications. An interview was conducted with EI #2, LPN, on 02/08/17, at 3:15 p.m EI #2 was asked if she administered medications for RI #12. EI #2 replied, oral medications and Insulin injection. EI #2 was asked if she closed the resident's door or curtain to provide privacy. She stated,No ma'am. She was asked if she should have pulled the curtain or closed the door before administering medications. EI #2 stated, Yes ma'am. EI #2 was asked why should she have closed the door or curtain. She stated, To provide privacy and for HIPAA (Health Information Portability and Accountability Act) (Confidentiality) reasons. EI #2 was asked what the potential for harm was for the resident if insulin and medications were given without pulling the curtain or closing the door. EI #2 replied, invasion of HIPAA Rules and Regulations and exposing the residents to other residents and visitors. 2) RI #13 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #13's PHYSICIAN ORDERS, dated February 2017, documented an order for [REDACTED]. During an observation on 02/07/17, at 4:30 p.m., EI #1 was observed administering RI #13's medications per the PEG tube. She failed to close the resident's door or privacy curtain while administering the medications. 3) RI #14 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #14's PHYSICIAN ORDERS, dated February 2017, included orders for oral medications, as well as subcutaneous insulin. During an observation of medication administration on 02/07/17, at 4:00 p.m., EI #1, LPN, was observed administering RI #14's oral medication. EI #1 was also observed administering RI #14's subcutaneous insulin in the resident's abdomen. EI #1 failed to close the resident's door or privacy curtain while administering the medications. An interview was conducted with EI #1, LPN on 02/08/17, at 4:07 p.m. EI #1 was asked if she closed the door or curtain while administering medications on 02/07/17 to RI #s 13 and 14. She stated, No. EI #1 was asked if she should have closed the door or privacy curtain. She stated, Yes I should have. EI #1 was asked what right was potentially violated if the curtain or door was not closed. She stated, Privacy.

Based on observations, review of a facility policy titled: Quality of Life - Dignity, and interviews, the facility failed to ensure staff did not stand over Resident Identifier (RI) # 6 while feeding him/her. This was observed during the lunch meal on 02/08/17, and affected 1 of 3 sampled residents who were fed by staff. Furthermore, the facility failed to ensure staff knocked on the door before entering RI #s 7, 15 and 16's room. This was observed on 02/07/17, and affected 3 of 17 sampled residents. Findings Include: A facility Policy titled: Quality of Life - Dignity . Resident Rights & Dignity ., revised 02/01/2015 documented: . Policy Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Procedure 1. Residents shall be treated with dignity and respect at all times. 2. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth 6. Residents' private space and property shall be respected at all times. a. Staff will knock and request permission before entering residents' rooms 1) RI #6 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of Resident Identifier (RI) # 6's most recent Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/23/16 documented RI # 6 was totally dependent on staff for eating. On 2/8/17 at 12:00 p.m. RI # 6's lunch tray was delivered to his/her room. Employee Identifier (EI) # 10 set up and fed RI # 6 the lunch meal. During the meal, EI # 10 was observed standing over RI #6 while feeding him/her. EI #10 was observed reaching down to feed RI # 6. The meal was completed at 12:15 p.m. An interview was conducted with EI # 10, Certified Nursing Assistant, on 2/9/17 at 8:10 a.m. EI # 10 stated she fed RI # 6 lunch on 2/8/17. EI # 10 was asked if she stood while feeding RI # 6. EI # 10 replied yes because the chair had something in it. EI # 10 was asked why you should sit while feeding a resident. EI # 10 replied so you are at eye level. EI # 10 was asked what would be the issue with standing while feeding a resident. EI # 10 replied it could make the resident feel uncomfortable. 2) On 02/07/2017 at 3:57 p.m., Employee Identifier (EI) #4 and 5, Certified Nursing Assistants (CNAs), were observed entering RI #15's room. They failed to knock on the door before entering. At 4:03 p.m. EI #s 4 and 5 entered RI #7's room. They failed to knock on the door before entering. At 4:09 p.m. EI #s 4 and 5 were observed entering RI #16's room. They failed to knock on the door before entering the room. An interview was conducted with RI #7 on 02/08/17 at 3:50 p.m He/She was asked if staff knocked before entering his/her room. RI #7 replied, no not always. RI #7 was then asked how that made him/her feel. RI #7 said he/she had not really thought about it but knew they were supposed to because he/she was a Certified Nursing Assistant. An interview was conducted with EI #4 on 02/08/17 at 5:00 p.m. She was asked if she provided care for RI #s 7, 15 and 16. EI #4 stated, Yes. EI #4 was asked if she should have knocked before entering these residents' rooms. She stated, Yes. EI #4 was asked why she failed to knock on their doors before entering. She stated, I guess I might have forgot. EI #4 was asked what right was potentially violated if she failed to knock on the resident's entry door. She stated, Privacy and Dignity. EI #4 was asked what the facility's policy was related to knocking on resident's doors. She stated, To always knock and introduce yourself, wash your hands and explain what your going to do. An interview was conducted with EI #5 on 02/08/17 at 5:08 p.m She was asked if she provided care for RI #s 7, 15 and 16. EI #5 stated, I think I did yes I did. EI #5 was asked if she should have knocked before entering these residents' rooms. She stated, Yes ma'am. EI #5 was asked why she failed to knock on their doors before entering. She stated, I was not thinking. EI #5 was asked what right was potentially violated if she failed to knock on the resident's entry door. She stated, Privacy and Dignity. EI #5 was asked what the facility's policy was related to knocking on resident's doors. She stated, To knock on door tell them who you are and what we are doing.