Every finding on record at Diversicare of Lanett

Based on interviews, medical record review and review of Resident Assessment Instrument (RAI) Manual Chapter 4, the facility failed to implement Resident Identifier (RI) #1's s care plan for two- person assist with Mechanical lift. This affected Resident Identifier (RI) #1, one of three residents for whom care plans were reviewed. Findings include: A review of the RAI Manual Chapter 4 October 2019 revealed . Chapter 4 Care Area Assessment Process and Care Planning . 4.7 . The care plan is driven not only by identified resident issues and/or conditions but also by a resident's unique characteristics, strengths and needs. Develops and implements a intradisciplinary care plan based on the assessment information gathered throughout the RAI process, with necessary monitoring and follow up .Provides information regarding how the causes and risks associated with issues and or conditions can be addressed to provide for a resident's highest practicable level of well-being (care planning). RI #1 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis to include Lack of Coordination, Muscle Wasting and Atrophy, Other Reduced Mobility, Muscle Weakness and Poly Neuropathy. RI #1's Lift Transfer Evaluation dated 06/27/2022, documented total lift required, two team members required. RI #1's care plan for impaired physical functioning due to self care and mobility impairments . documented, Interventions Transfer assistance of 2 person assist with mechanical left . An interview was conducted with Employee Identifier (EI) #3, Certified Nursing Assistant (CNA) on 12/07/2022 at 1:57 PM. EI #3 stated one or two people could be used to transfer RI #1 when using the mechanical lift. EI #3 admitted on [DATE] when she was preparing RI #1 for an outing, she transferred resident without assistance. An interview was conducted with EI #2, Director of Nursing (DON) on 12/07/2022 at 2:06 PM. EI #2 stated RI #1 is care plan for a two person assist when transferring with the mechanical lift. EI #2 admitted RI #1's care plan was not followed when EI #3 did not have assistance in transferring RI #1 on 10/28/2022. EI #2 stated the concern of not following the transfer care plan is safety. An interview was conducted with EI #1, Administrator/Abuse Coordinator on 12/07/2022 at 2:30 PM. EI #1 admitted that RI #1's care plan was not followed when EI #1 transferred RI #1 without assistance on 10/28/2022. EI #1 stated the concern of RI #1 not being transferred properly is staff not following the policy and safety. This deficiency was cited as a result of the investigation of complaint number AL00042382.

Based on observations, interviews, and review of the facility's policies and documents, the facility failed to store, prepare, distribute, and serve food in a sanitary and safe manner. This deficient practice had the potential to affect all 58 residents who receive their meals from the dietary department. Findings include: Review of the facility's policy titled, Dry Food, effective 01/01/17, revealed, 1 .The floors, walls, shelves, and equipment in the storeroom with be kept clean and in good repair .3. Ceilings will be constructed in such a manner as to protect the food from leaking pipes, heat, and contamination 5. Food will be labeled as to content and date. Review of the facility's policy titled, Equipment Cleaning Schedules, effective 08/12/12, revealed, All equipment will be identified for cleaning. The frequency and position assigned item should be designated on the schedule. The policy listed different equipment found in the facility's kitchen and the frequency in which it should be cleaned. 1. Observations during the initial kitchen tour with the Employee Identifier (EI) #3, Dietary Manager, on 04/18/21 at 7:15 PM revealed the following concerns: a. On the bottom shelf of the cart containing the iced tea dispenser was a unknown substance with a can of coffee, a bottle of EcoLab Cleaner Grease Cutter, a spatula, and a clear bag containing a white cloth with brown stains sitting on top of the substance. b. The eye wash sink located next to the hand wash sink had brown residue with paper towel pieces in the bowl of the eye wash sink. c. Freezer Unit 1 had a brown substance on the floor of the unit as well as the following containers of food that are undated: two bags of French toast, two bags of Salisbury steaks, one bag of meatballs, one bag of omelets, one bag of frozen cookies, one bag of cinnamon rolls, one bag of fish sticks, one bag of chicken patties, one bag of ravioli, one bag of pancakes, and one bag of chicken [NAME]. The bags were clear, so the contents were visible. EI#3 verified the contents during the initial kitchen tour. d. Refrigerator Unit 2 contained two 16-ounce containers of ham base in a box of fresh garlic, a container of diced tomatoes that was unlabeled and undated, seven 16-ounce containers of ham base and one 16-ounce container of beef base in a box of celery and fresh vegetables, one bag of shredded cheese that was undated and one block of cheese that had been opened and rewrapped with no date or label. e. The bottom shelf the kitchen food prep table contained a brown sticky like substance with containers of imitation vanilla flavor, season salt, and teriyaki vinegar stored on top of the substance. f. On 04/18/21 at 7:20 PM, the air conditioner (AC) unit located inside the kitchen next to the kitchen's prep sink had a dust filled filter that would blow once the unit came on. The AC unit was in use during the tour of the kitchen. The duct working in the kitchen had black substance on them along with all the AC vents in the kitchen. g. The walls of the kitchen had a brown sticky coating on them in what appeared to be uncleaned splatters. 2. Observation of the kitchen's dry food storage room on 04/18/21 at 7:20 PM revealed four large kitchen tiles (two feet by four feet) were missing with pink insulation falling from the ceiling. The insulation had a black substance on it. There was a white tarp with brown stains covering the refrigeration unit and falling onto the dry storage of packages of condiment packets and boxes of thickened liquids being stored on the storage shelf. During an interview at the time of observation, EI#3 stated that the ceiling had been in disrepair since November 2020, starting with a leak. EI#3 went on to state that in January 2021 the ceiling started to fall from a crack in the roof. During a follow up observation on 04/19/21 at 8:49 AM revealed the window in the dining room where dirty dishes are passed through still had splatters on the wall. The shelving unit still had the same concerns as observed on 04/18/21. The ceiling tiles in the dry food storage had been replaced and the items stored on the shelf were removed. During a follow up interview and observation with EI#3 on 04/19/21 at 2:44 PM, the surveyor confirmed all the condiments found on the storage shelf in the dry food storage with the white tarp on top were in use until 04/18/21. On 04/19/21 at 2:44 PM, observation of the dish washing room, revealed the AC unit had black substance surrounding the vent blowing over what EI#3 identified as cleaned items. The food prep cart was dirty with debris on the shelf containing clean cooking pans. Further interview on 04/19/21 at 3:09 PM, EI#3 stated the kitchen had not been deep cleaned for several weeks and that the facility had not been keeping up with a cleaning schedule. EI#3 had no cleaning logs for review. Review of a written timeline provided by the Maintenance Director, EI#21, regarding the ceiling concerns, revealed: IN APPROXIMATELY NOVEMBER, (EI#3, Dietary Manager) REPORTED TO ME (EI#21), THAT THERE WAS SOME DRIPPING FROM THE CEILING TLES IN THE RESTROOM IN THE KITCHEN. I DON'T HAVE THE EXACT DATE, BUT I DO RECALL GOING ON THE ROOF AND SEALING ONE TEAR THAT I IDENTIFIED. DURING THE MONTHS OF OVEMBER AND DECEMBER, THERE WAS NOT MUCH RAIN AND THIS ISSUE WAS NOT BROUGHT UP AGAIN. ON 1/22/2021 - RECEIVED A WORK ORDER THAT THERE WS A LEAK IN THE RESTROOM IN THE KITCHEN. THE DRY STORAGE AREA WAS NOT ACCECTED AT THIS TIME. 1/27/2021 - MAINTENANCE SUPERVOROR GOT ON ROOF AND BLEW OFF PUDDLES OF WATER AND SEALED OFF ALL IDENTIFIED TEARS WITH COOL SEAL. COOL SEAL WAS ON PREMISES FROM PRIOR SUPERVISOR, DIDN'T PURCHASE ANY AT THIS TIME. 2/17/2021 - HEAVY RAIN. CEILING LEAKING AGAIN. MAINTENANCE SUPERVISOR PATCHED ROOF AGAIN WITH [NAME] 587 DURA-BRITE WHITE .THE DRY STORAGE AREA WAS NOT AFFECTED AT THIS TIME. LEAKS WERE NOTED IN THE RESTROOM, DRY STORAGE AREA, AND SMALL STORAGE ROOM. 3/3/2021 - HEAVY RAIN NOTED LEAKS. CEILING TILE IN DRY STORAGE AREA COLLAPSED. MAINTENANCE PATCHED AND SEAL SEVERAL AREAS ON THE ROOF. RAIN CONTINUED AND MAINTENANCE SUPERVIOSR CONTINUED TO SEAL AREAS ON ROOF ON 3/19/2021 AND 4/9/2021. ON 3/3/2021 MAINTENANCE SUPV. (SUPERVISOR) CLEANED UP THE AREA WHERE THE CEILING HAD COLLAPSED AND PLACED A PLASTIC TARP UNDER THE AFFECTED AREA AND ON TOP OF HTE FREEZER. TARP ALSO COVERED THE TOP SHELF LOCATED TO THE LEFT OF THE FREEZER. 4/16/2021 - ROOF IS STILL LEAKING. PLACED PLASTIC TARP ON ROOF. 4/19/2021 - REGIONAL ENVIRONMENTAL SPECIALIST CONTRACTING A ROOFER TO COME LOOK AT ROOF. PATCH KIT TO BE ORDERED FROM TROPICAL ROOFING PRODUCTS BY MAINTENANCE SUPERVISOR. CEILING IN DR STORAGE AREA, RESTROOM, AND STORAGE ROOM WAS REPLACED. ALL HANGING INSULATION WAS REMOVED AND DISCARDED. NO MOLD WAS NOTED ON TEH INSULATION OR THE CONCRETE CEILING. This document was signed by EI #21. During an interview on 04/20/ 21 at 9:10 AM, EI#1 stated that EI#21, the Maintenance Supervisor, did not contact a roofer until 04/19/21. During the Quality Assurance Program interview on 04/22/21 at 5:15 PM, EI#1 stated there was a little blurb made regarding the roof around October/November of 2020 but that the QA committee thought the roof was fixed.

Based on observation, staff interview, and policy review, the facility failed to store a liquid topical medication in a locked compartment away from residents with dementia who independently use the toilet in one of three shower rooms. The dementia unit has 14 out of 15 residents who can independently use the toilet in the shower room on the unit. Findings include: Review of the facility policy titled 6.3 Storage and Expiration of medications, Biologicals, Syringes and Needles, revised 10/31/16, revealed Procedure . 3.3 Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by resident and visitors. During an observation of the dementia care unit on 04/18/21 at 7:30 PM, a gray rolling cart containing resident care supplies was observed in the unlocked shower room. A bin on the top and to the side of the cart contained resident care items and a bottle of liquid medication, [MEDICATION(S)] (a potent steroid medication used to treat scalp and skin conditions). The prescription label indicated the medication was for Resident Identifier (RI) #30. Further observation on 04/19/21 at 11:30 AM revealed RI #22 independently using the toilet in the shower room. No staff were present. Review of RI #22's electronic medical record (EMR) admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/20/20 revealed a Brief Interview for Mental Status (BIMS) score of one out of 15, indicating RI#22 has severe cognitive impairment and is independent but requires cueing for toileting. During an interview on 04/20/21 at 2:30 PM, Employee Identifier (EI) #9, Licensed Practical Nurse (LPN), confirmed the shower room is not secured and residents are able to use the toilet in the shower room without staff assistance. EI #9, also confirmed the rolling cart is occasionally stored in the shower room for staff to access the resident care supplies stored on the cart. EI #9 stated the cart was currently in the clean utility room. During an observation of the gray rolling cart in the utility room on 04/20/21 at 2:30 PM, with EI #9 revealed the same bottle of liquid prescription medication, [MEDICATION(S)], for RI #30 in the bin on the cart. EI #9 stated that should not be there. During an interview on 04/22/21 at 4:30 PM, EI #2, interim Director of Nursing (DON), confirmed medications are to be secured at all times and confirmed medications are not to be stored on a cart in a resident care area. Review of the medication list, provided by EI# 2 on 04/22/21 at 4:30 PM revealed the liquid medication, [MEDICATION(S)], for RI #30 had been discontinued on 10/08/20 and stated RI #30 was no longer receiving the liquid medication.

Based on record review, policy review, and interview, the facility failed to ensure administration or declination of pneumococcal and influenza immunizations for two (Resident Identifier (RI) #12 and RI #59) of the five residents sampled for immunizations. This failure created an increased risk for the residents to contract pneumonia and influenza. Findings include: Review of the facility's policy, Pneumonia Vaccination Policy (Patients and Residents), effective 11/28/16, indicated, Policy statement Pneumococcal vaccination is offered to all patients and residents that meet the eligibility criteria in accordance with current best practice clinical guidelines such as those from the CDC. Procedure 1. Assessment of Eligibility and Information Gathering .If no documentation of prior dose(s) of pneumococcal vaccine is available then appropriate pneumococcal vaccination will be offered to those that meet eligibility criteria unless medically contraindicated or declined by the patient/resident or responsible party .3. Documentation . The immunization will be documented in the patient/resident health record 4. Pneumococcal Vaccination Selection and Timing of Administration Series .The center will maintain a log of vaccination administration dates including future pneumococcal vaccination due dates and monitor and administer at the recommended intervals . A review of the facility's policy, Influenza Vaccination Policy (Patients and Residents), effective 11/01/16, indicated, Policy Statement: For the health and safety of all patients and residents on an annual basis based on the risk presented to patients and residents through routine direct exposure .Procedure .6. Center will obtain and document patient/resident/responsible party consent or declination for flu vaccination using Patient/Resident Declination/Authorization Form. 7. Center will document the administration of the influenza vaccination in the patient/resident's medical record . Review of RI#12's Profile tab, located in the electronic medical record (EMR), revealed he was admitted to the facility on [DATE]. Review of the Immuno tab, located in the EMR, indicated documentation that on 12/22/20 RI#12 consented to receive the influenza vaccination. Further review of the EMR, indicated there was no documentation that RI#12 received or declined the influenza vaccination during the year 2020. Review of RI#59's Profile tab, located in the EMR, revealed she was admitted to the facility on [DATE]. Review of the Immuno tab, located in the EMR, indicated there was no documentation that RI#59 had been offered or received a pneumococcal vaccine once age eligible. Also, under the Immuno tab, it was indicated there was no documentation that RI#59 was offered/received or declined the influenza vaccination during the year 2020. During an interview on 04/19/21 at 9:15 AM, Employee Identifier (EI)#1, the Administrator, stated that due to the facility having a COVID outbreak during November and December of 2020, which interrupted their usual vaccination period, their Pneumococcal and Flu vaccination rates were lower than in past years. During an interview on 04/22/21 at 3:15 PM with EI#2, the interim Director of Nursing (DON), stated he did not know why there was no documentation in the EMR of the administration or declination of the pneumococcal vaccination for RI#59 and the influenza vaccinations for RI#59 and RI#12.

Based on observation, record review, and interview, the facility failed to post the nurse staffing data on a daily basis at the beginning of each shift. This failure can result in residents and visitors not having accurate staffing information. Findings include: Observation and record review on 04/18/21 at 7:10 PM revealed the Daily Nurse Staffing Form posted in the entrance of the East Hall was dated 04/14/21 and contained staffing documentation for first shift (7:00 AM -3:00 PM) only. No additional documentation was recorded on the form. The East Hall is the main hall where nurse staffing is posted for all residents and visitors. During an interview on 04/18/21 at 7:10 PM Employee Identifier (EI) #1, the Administrator, verified that the staffing was not up to date. During an interview on 04/22/21 at 11:22 AM, EI#1 stated, I have never seen a policy regarding staff posting but I know it supposed to be posted daily.

Based on interviews, resident record review, review of the facility's Investigation Report, and review of the policy titled Medication Administration Controlled Substances, the facility failed to maintain an account of all controlled medications and reconcile controlled medications at each shift change with a physical inventory. On 11/29/2020, Employee Identifier (EI) #2, Licensed Practical Nurse (LPN), noticed two cards of [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) 5/325 milligrams (mg) belonging to Resident Identifier (RI) #1 were missing from the controlled drug inventory without a record of the disposition of the medication. This affected RI #1, one of three residents reviewed for pharmacy services, but had the potential to affect all 32 residents in the facility with orders for narcotic medications. Findings include: Review of a facility Investigation Report revealed on 11/29/2019, the facility reported to the State Agency that RI #1 had 100 tablets of [MEDICATION NAME] 5/325mg (one card with 60 tablets and one card with 40 tablets) missing from the controlled drug inventory. The facility's investigation contained an Investigation Template that documented the facility was unable to determine what occurred and when the medication was removed from the cart, as there was inconsistencies in the narcotic record count dating back as far as 11/19/2019, ten days prior to staff realizing RI #1's [MEDICATION NAME] tablets were missing. Review of the facility policy titled Medication Administration Controlled Substances, dated November 2017 revealed the following procedures related to accounting for narcotic medications: [REDACTED] . PROCEDURES . 2. The Director of Nursing and the Consultant Pharmacist establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation, and determine that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. 7. At each shift change, a physical inventory of controlled medication, as defined by state regulation, is conducted by two licensed clinicians, and is documented on an audit record. RI #1 was originally admitted to the facility on [DATE]. A pharmacy shipping manifest indicated 100 tablets of [MEDICATION NAME] 5/325 were delivered to the facility for RI #1 on 11/13/2019. Review of facility forms titled CONTROLLED DRUG COUNT, revealed two cards of [MEDICATION NAME] 5/325 for RI #1 were added to the narcotic drug inventory on 11/13/2019, for a total of 24 medication cards in the medication cart. However, in reviewing the Controlled Drug Count Records from 11/13/2020 through 11/29/2020, the following discrepancies were noted: On 11/14/2020, one card was removed from the cart inventory, leaving a total of 23 cards on the cart. On 11/15/2020, two cards were added, bringing the total to 25 total cards. The next shift on 11/15/2020 documented four cards were removed from the cart, leaving 21 total cards. The next documented count was not dated, but indicated five cards of medication had been added to the cart, which should have totaled to 26 medication cards. However, the nurses that documented the count, listed 25. There was no documentation indicating why there was a discrepancy or that anyone had been notified to look into the concern. Then, on 11/16/2020, two more cards were added to the cart, and the nurses documented a count of 28, which according to the entries, is the number that should have been present, but was inaccurate based on the previous number recorded by the nurses. On the next shift on 11/16/2020, four cards were removed from the cart, leaving a total of 24 cards. The 11PM-7AM shift documented there were 28 cards on the cart at change of shift, but there were no entries indicating any medications had been delivered or why the count was higher than the previous one. On 11/17/2020, one card was removed and the number of cards was recorded as 27. The card count remained at 27 until the 3PM-11PM shift on 11/18/2020, when the nurses documented there were 28 cards present, but there was no entry indicating any medications had been delivered or that anyone was notified of the discrepancy. On 11/18/2020, the 11PM-7AM shift documented one card was removed, and a total card count of 27. Then on 11/19/2020, the 7AM-3PM shift documented three cards were added and a card count of 30 was documented. The 11/19/2020 3PM-11PM shift documented a card count of 28 without any documentation medication cards had been removed or anyone was notified of the count discrepancy. On 11/20/2020, the 3PM-11PM shift documented one card was added to the cart, for a total of 29 cards. Then the 11/20/2020 3PM-11PM shift documented two cards were removed, for a total of 27 cards. On 11/21/2020, the 3PM-11PM shift documented one card was removed, and the 11PM-7AM shift documented three cards were added, for a total of 29 cards. On 11/22/2020, five cards were removed, leaving a total of 24 cards on the cart. On 11/22/2020, the 11PM-7AM shift documented a card count of 28, but there was no documentation of any medications added to the cart or of anyone being notified of the count discrepancy. On 11/23/2020, one card was removed, and two others added, leaving a total documented card count of 29. However, on 11/24/2020, the card count was recorded as 28, again with no documentation any medications had been removed or that anyone had been notified of the count discrepancy. On 11/25/2020, two cards were removed, leaving 26 cards on the cart. On 11/26/2020, three cards were added to the cart, for a total count of 29. The documented count remained 29 until 11/28/2020 when the 3PM-11PM shift documented four medications were sent with a resident while out of the facility with family. However, the card count recorded at that time was 24, instead of 25. There was no documentation as to why there was a discrepancy or if anyone was notified. Then on the 7AM-3PM shift on 11/29/2020, the Director of Nursing (DON), EI # 1, signed off on the Controlled Drug Count when she was informed of the missing cards of RI #1's [MEDICATION NAME]. EI #2, a Licensed Practical Nurse (LPN) who signed off on the Controlled Drug Count records, was interviewed on 7/21/2020 at 1:12 PM. When asked what she could tell the surveyor about RI #1's missing [MEDICATION NAME], EI #2 said she had not been working that day, and when she came back to work the medication was gone. EI #2 said RI #1 had been out to the hospital two different times and she was unsure if the medications had been removed from the cart because the resident went to the hospital. EI #2 said after reviewing the Controlled Drug Count sheet and not seeing a note anyone had removed them from the cart, she notified the DON (EI #1) RI #1's [MEDICATION NAME] were missing. EI #2 said she had worked 11PM to 7AM that day and had not noticed when they did the counts at the start of her shift the medications were not there, but had noticed later in her shift. EI #2 was asked who did the counts with her at shift change, and EI #2 said it had been EI #3, an LPN. When asked how they had performed the count, EI #2 said that EI #3 was calling out numbers. EI #2 said later, when she realized RI #1's [MEDICATION NAME] medication cards were missing from the cart, she checked the Controlled Drug Count sheet and the numbers were right, but there was nothing recorded indicating RI #1's cards had been removed. When asked how the card count was correct if RI #1's cards had been removed without anyone noting it, EI #2 said someone adjusted the numbers to make them correct. EI #2 said on 11/28/2020 the count went from 29 to 24, and the logs just did not look right. EI #3, LPN, was interviewed on 7/21/2020 at 2:15 PM. When asked about RI #1's missing medications, EI #3 said he usually worked 3PM-11PM and the nurse assigned was not someone he was familiar with. He said when they were counting the cards, he noticed two of the cards were turned backwards, and he turned them back around, and counted. EI #3 said he could not say whose cards had been turned around, but their count matched what was on the Controlled Drug Count sheet. EI #3 said there were some discrepancies in the logs, but he had not noticed them at that time. EI #4, a Registered Nurse (RN), was interviewed on 7/21/2020 at 2:45 PM. When EI #4 was asked what she could tell the surveyor about RI #1's missing medications, EI #4 said she did not know what happened, one day the medications were there and then they were missing. EI #4 said there were days where nurses did not count the narcotics when changing shifts. She said she could not pinpoint what days, but they did that if someone was running late. When asked what nurses should have done with the controlled medications at shift change, EI #4 said they were supposed to go through the cart and verify the counts of medications that were present, and if any discrepancies were noted, they should notify the supervisor or DON. EI #4 said nursing staff should not have been doing what they were doing. When asked why it was important to check the controlled medication counts per protocol, EI #4 said to make sure the medications were accounted for. EI #4 further stated they would change the count on the Controlled Drug Record to match what was actually present in the cart. EI #4 said as nurses, they were not doing what they were supposed to do. EI #5, LPN, was interviewed on 7/21/2020 at 4:25 PM. When asked what she could tell the surveyor about RI #1's missing medications, EI #5 said she had been called to the office about the missing medication cards, but she had not been working that week. EI #5 said she had not realized the importance of the Controlled Drug Count sheets. She further stated she was aware of some of the nurses not even counting the medications at shift change. EI #1, the DON, was interviewed on 7/23/2020 at 8:45 AM. When asked what happened with RI #1's missing medications in November 2019, EI #1 said EI #2 had contacted her and told her the medication was missing. EI #1 said she went into the facility to investigate what happened, but by looking at the Controlled Drug Count records, she could not tell when the medication went missing. When asked why she was unable to pinpoint when the medication went missing, EI #1 said some of the counts on the sheets had been changed. EI #1 said she discovered the nurses were just changing numbers to make the counts match and some were not even counting at all. When asked what nursing staff should have been doing, EI #1 said they should have been recording any activity, such as additions or subtractions, on the form to verify count numbers. EI #1 said any time nurses exchanged keys for the medication carts, there should be a physical medication reconciliation to verify the medication counts, before the keys are exchanged. When asked why staff were not doing that, EI #1 said they were haphazard and not taking their Controlled Drug Count seriously. EI #1 explained the purpose of the Controlled Drug Count with the exchange of keys to the medication carts was accountability and acknowledging what the medication inventory is at the time you either take possession of or relinquish the keys to the medication cart. EI #1 further stated accountability and inventory correctness was important to make sure medications are being administered correctly and that no one takes any medication out of the inventory that should not be. On 7/23/2020 at 1:43 PM the facility's Pharmacy Consultant was interviewed. When asked why the nurses were not counting controlled medications at each shift change or exchange of keys to the cart, EI #7 said, she was not aware of that. When asked why they were changing numbers on the CONTROLLED DRUG COUNT sheets without documentation of addition or subtraction of the cards, some times just changing numbers to reflect what was on hand, EI #7 said, she was not aware of that either. When asked what the concern was if nurses were not counting narcotics and just exchanging keys to the medication carts, EI #7 said, there was a danger of diversion of medication, and someone taking something or giving the wrong medication, and it was part of regulation. When asked about the importance of accounting for and maintaining all controlled medication in facility, EI #7 said, it was federal law, all narcotics had to be tracked and accounted for and every person touching the medications should be responsible and prevent diversion. ************ The surveyor determined current compliance of this deficient practice by reviewing and verifying the following actions taken by the facility: 1. The facility's Investigation Template documented the following Actions taken post investigation: . * Education on controlled drug count process and accountability revisions * Re-education on returning medications to pharmacy *DNS (Director of Nursing Services)/Designee will audit controlled drug count process 3x (times)/ (per) weekly x 2 weeks, then 2x/weekly x 2 weeks, then weekly for 3 months and as needed * Remaining discontinued medication was removed from active inventory and secured for proper destruction . Review of the facility's inservice logs verified nursing staff was inserviced on Controlled Medication Count and Accountability, as well as Returning Controlled Medications to Pharmacy, beginning on 12/06/2019 and completed by 12/22/2019. Review of monitoring tools from December 2019 through the end of March 2020 revealed monitoring was in place as specified in the facility's Actions post investigation, including monitoring for two nurses performing medication count according to guidelines, two signatures present, correct card count and documentation of any changes, and all add-ons and subtractions witnessed. 2. The facility provided disciplinary actions taken against EI #4 and EI #5, as well as other nursing staff, related to the investigation of RI #1's missing medication, for failing to perform an actual count during controlled drug counts. These disciplinary actions were administered on 12/06/2020. 3. The facility also provided QAPI (Quality Assurance and Process Improvement) documentation from their December 2019 meeting where RI #1's missing medications were discussed. This documentation indicated the facility determined the causal factor/root cause of this incident to be licensed nursing noncompliance. The QAPI committee identified a trend with nurses not following nursing guidelines, pharmacy guidelines, or facility policies on controlled drugs, and developed a plan to address the concerns consisting of disciplinary actions, education, strict supervision, and monitoring by nursing leadership.

Based on interviews, resident record review and review of a facility policy titled Medication Administration Controlled Substances, the facility failed to ensure licensed staff documented the removal of Resident Identifier (RI) #1's controlled medication from inventory and/or the administration of the medication in RI #1's medical record. This affected one of three residents for whom medical records were reviewed. Findings include: Review of the facility policy titled Medication Administration Controlled Substances, dated November 2017, revealed the following: Controlled Medications are substances that have an accepted medical use (medications which fall under U.S. Drug Enforcement Agency (DEA) Schedules II-V), have a potential for abuse, . These medications are subject to special handling, storage, disposal, and record keeping at the nursing care center, in accordance with federal and state laws and regulations. PROCEDURES . 4. When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record when removing dose from controlled storage: . a. Date and time of administration b. Amount administered c. Signature of the nurse administering the dose 5. Administer the controlled medication and document dose administration on the MAR (Medication Administration Record) . RI #1 was originally admitted to the facility on [DATE]. Review of RI #1's CONTROLLED DRUG RECORD documents and Medication Administration Records revealed the following PRN (as needed) medications were not documented as administered on the MAR: On 10/8/2019 at 2:30 AM and 10/30/2019 at 7:00 AM, Employee Identifier (EI) #4, Registered Nurse (RN), signed out RI #1's [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) 5/325 milligrams (mg) from the Controlled Drug Record without documentation on the MAR to show the medication was administered. On 12/12/2019 at 12:30 AM, EI #4 signed out [MEDICATION NAME]/[MEDICATION NAME] from RI #1's Controlled Drug Record without documentation on the MAR to show the medication was administered. During an interview with EI #4, RN, on 7/22/2020 at 4:15 PM, EI #4 was asked what the facility policy was for administration of narcotics/controlled medications. EI #4 said she was supposed to sign out the medication on the Controlled Drug Record, then initial the MAR after administering the medication. EI #4 was asked why RI #1's [MEDICATION NAME] 5/325 was signed out on the Controlled Drug Record on 10/8/19 at 2:30 AM and 10/30/10 at 7:00 AM and [MEDICATION NAME]/[MEDICATION NAME] on 12/12/19 at 12:30 AM, without any documentation on the MAR she had administered the medications. EI #4 said she pulled it from inventory and recorded it on the Controlled Drug Record, but forgot to go back and sign the MAR when the medication was administered. When asked why it would be important to initial the medication on the MAR, EI #4 said, it would give the doctor an idea of the pain management and effectiveness. Further review of RI #1's CONTROLLED DRUG RECORD documents and Medication Administration Records revealed the following PRN medications were not documented on the MAR as administered: EI #5, Licensed Practical Nurse (LPN), signed out [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) 5/325 milligrams (mg) on 10/16/2019 at 11:00 PM and 11/11/2019 without documentation on the MAR that the medication was administered. EI #5 signed out [MEDICATION NAME] on 12/12/2019 at 6:00 PM without documentation on the MAR the medication was administered. On 7/22/2020 at 4:55 PM, EI #5, LPN, was asked what the facility policy was for administration of narcotics/controlled medications. EI #5 said when you pull the medication from the medication cart, it should be documented on the Controlled Drug Record, and once the medication is administered, sign the MAR to indicate it was given. When asked why RI #1's [MEDICATION NAME]/[MEDICATION NAME] was signed out on the Controlled Drug Record on 12/12/19 at 6:00 PM, and the [MEDICATION NAME] 5/325 mg on 10/16/19 at 11:00 PM, but there were no initials on the MAR to indicate she had administered those medications, EI #5 said, it should have been signed on the MAR. When asked what should have been done, EI #5 said, when she pulled the medication from the inventory she should have signed it out on the Controlled Drug Record, and once administered, documented on the MAR the medication was given. When asked why it would be important to initial the medication on the MAR, EI #5 said, so it would not be given too close together and be sure it was effective. Further review of RI #1's CONTROLLED DRUG RECORD documents and Medication Administration Records revealed the following PRN medication was documented on the MAR as given, but there was no record of the medication being pulled from the narcotic inventory: On 10/13/2019 at 5:30 PM, EI #3, LPN, documented on RI #1's MAR that he had administered [MEDICATION NAME]-[MEDICATION NAME] 5/325 milligrams; however, the Controlled Drug Record had no documentation the medication had been removed from inventory. On 7/23/2020 at 8:10 AM, EI #3, LPN, was asked what the facility policy was for administration of narcotics/controlled medications. EI #3 said the medication should be signed out on the Controlled Drug Record, and once administered, document on the MAR. When asked why he documented on the MAR RI #1's [MEDICATION NAME] was given at 5:30 PM on 10/13/19, but there was not any signed out on the Controlled Drug Record at that time, EI #3 said, it was an oversight. When asked why it was important for documentation to match on the Controlled Drug Record and the MAR, EI #3 said for a complete record of administration of medication, it was extremely important for it to match. When asked how it could affect the resident if it did not match, EI #3 said, they could run out of medication early or orders could be missed.

Based on observation, interview, review of the facility form titled Blood Glucose Monitoring Audit, and review of Potter and Perry FUNDAMENTALS OF NURSING, the facility failed to ensure: 1) an LPN (Licensed Practical Nurse), EI (Employee Identifier) #6, cleaned the used glucometer after the resident's blood was tested , before testing was done on the next resident. This affected RI (Resident Identifier) #64, #53, and #66, three of four residents observed during finger stick blood sugar checks; 2) EI #5, an LPN, did not stack medication cups in a manner that contaminated the medications in the bottom cup; and 3) EI #5, LPN, washed her hands before donning gloves to administer eye drops to RI #12. These failures affected four of six residents and two of three nurses observed during medication administration. Findings include: 1.) The facility's Blood Glucose Monitoring Audit, documented: . 13. Cleans glucometer with Glucorwipe after use. On 03/15/2018 at 2:45 PM, EI #6 entered RI #53's room with the glucometer, placed the glucometer on the resident's overbed table and checked the resident's blood sugar. EI #6 exited the room and placed the contaminated glucometer in the medication cart without cleaning it. EI #6 proceeded to RI #66's room with the used glucometer from the medication cart and checked RI #66's blood sugar. EI #6 then returned to the medication cart and placed the used glucometer inside the cart without cleaning the glucometer. EI #6 entered RI #64's room with the used glucometer from the cart and placed the glucometer on the overbed table and checked RI #64's blood sugar. EI #6 exited the room, and without cleaning the glucometer, placed the contaminated glucometer back in the medication cart. EI #6 was interviewed on 3/15/2018 at 3:00 PM. EI #6 was asked when he cleaned the glucometer. EI #6 stated every second time. EI #6 was asked what the facility's policy was for cleaning the glucometer. EI #6 first stated it was every shift, then corrected himself and said after every resident. When asked why it was important to clean it after each use, EI #6 stated to keep from spreading infection. On 3/15/2018 at 5:30 PM, EI #3, the DON (Director of Nurses) was asked what the facility's policy was for cleaning the glucometer. EI #3 stated after every use. When asked what was the potential harm of not cleaning it after each use, she stated that it could spread infection from one resident to another. 2) On 03/14/2018 at 8:30 AM, EI #5, LPN, was observed administering medications. EI #5 placed two plastic medication cups on top of the medication cart. EI #5 proceeded to place medications in each cup and stacked the medication cups, one inside the other on top of the medications. EI #5 entered RI #12's room and administered the oral medications. EI #5 returned to the medication cart, and was asked what was the harm of stacking medication cups which had been on top of the medication cart. EI #5 stated it would be an infection control issue. 3) A review of Potter and Perry, Eighth edition, Unit 5, page 616, revealed the following: . Administering Ophthalmic medications: [REDACTED] Implementation . 2. Perform hand hygiene. Hand hygiene reduces transfer of microorganisms . On 03/14/2018 at 8:30 AM, EI #5, LPN, was observed administering medications. EI #5 entered RI #12's room and administered the oral medications. Then, without washing her hands, EI #5 donned gloves and administered eye drops to RI #12. EI #5 returned to the medication cart, and was asked what she should do before donning gloves to administer eye drops. EI #5 said, wash your hands. EI #5 admitted she forgot to do that.

Based on observation, interviews and review of the facility policy Controlled Medication Storage, the facility failed to ensure licensed staff accurately reconciled narcotic counts on the Secure Unit, West Unit, and East Unit, three of three units in the facility. Findings include: A review of the facility policy entitled Controlled Medication Storage, dated 09/2008 specified the following procedure: .7. At each shift change or when keys are rendered, a physical inventory of all Schedule II controlled medications is conducted by two licensed nurses or per state regulation and is documented on the controlled substances count report. 1) An observation was made on 3/9/17 at 1:45 PM, which revealed blank spaces for nurse signatures on the Secure Unit Controlled Drug . Sheet Count dated 2/28/17 (11-7); 3/1/17 (11-7); 3/3/17 (11-7); 3/4/17 (11/7), 3/5/17, (3-11) and (11-7); and 3/7/17 (11-7). The emergency narcotic box sheet on the west unit revealed missing signatures for 2/18/17 (3-11); 2/19/17 )3-11); 2/20/17 (3-11); 2/22/17 (3-7) and (7-11) ;2/27/17 (3-11); 3/03/17 (3-11); 3/3/17 (11-7); 3/4/17 (3-11); and 3/4/17 (11-7); 3/5/17 (3-11); 3/6/17 (7-3); 3/6/17 (11-7); 3/8/17 (3-11); 3/8/17 (11-7); 3/9/17 (7-3). 2) The east medication cart Controlled Drug Sheet Count was observed on 3/9/17 at 2:10 PM by the surveyor, and revealed blank spaces for the nurse signature accountability records dated 2/24/17 (11-7); 2/25/17 (3-7); 2/25/17 (7-7); 2/26/17 (7-7); 2/27/17 (11-7); and 2/28/17 (7-3). 3) On 3/9/17 at 2:10 PM, the west medication cart accountability records were reviewed and revealed the following dates unaccounted: 3/3/17 (3 p-11 p, 11 p-7a); 3/4/17 (3-11 p & 11 p-7a); 3/5/17 (3 p-11 p); 3/6/17 (7a-3 p & 11 p-7a); 3/7/17 (8 p - 7a). An interview was conducted with the Director of Nursing (EI #2) on 3/9/17 at 2:30 PM. The surveyor asked what was the deficient practice of having blank time slots when signing the narcotic control sheets? EI #2 stated, The nurse verifying the count or signing off failed to acknowledge the count or verifying the count by not signing the control, narcotic sheet. The surveyor asked EI #2 what was the importance of signing out with 2 signatures for controlled medication? EI #2 stated, Verifying there is no missing drugs/medication and verifies the count is correct when receiving keys that the count is correct. The surveyor asked who was responsible for signing out for the controlled drug count signature sheet? EI #2 stated, Two licensed nurses. The surveyor asked when did the Licensed staff count and sign the controlled drug sheet? EI #2 stated, Before and at the end of each shift,t and anytime the keys are passed to another nurse. Each nurse must sign the controlled verification sheet. Each nurse conducting the count must sign.

Based on a review of the training records of six randomly selected staff and an interview with the Administrator, the facility failed the ensure three of six Certified Nursing Assistants (CNAs) had received their 12 hours of continuing education, including training in Dementia Management and Abuse Prevention, over the past 12 month period. This deficient practice affected Employee Identifiers (EI) #9, #10, and #11. Findings included: In response to the surveyor's request, the Administrator (Employee Identifier/EI #7) provided (on 03/09/17) documentation of continuing education provided over the past 12 months to the CNAs employed by the facility. Three of six randomly selected CNAs lacked sufficient (12)continuing education hours. Training in dementia management and/or resident abuse prevention was also lacking: a) EI #9 received a total of 4.83 hours of training, with no training in dementia management. b) EI #10 received a total of 1.0 hours of training, with no training in dementia management or abuse. c) EI #11 received an unknown number of training hours, which excluded dementia management, as required. On 03/09/17 at 3:34 p.m., the Administrator (EI #7) verified that EI #10 and EI #11 both worked on an as needed basis. EI #10 had been unable to attend training and had not worked due to a family emergency. EI #7 further stated they would be hiring a Clinical Trainer.

Based on observation, interview, record review and facility policies, the facility failed to ensure the staff did not contaminate the wound by allowing the opened wound to come in contact with the bed sheets, after the wound care was completed. This affected Resident Identifier (RI) #3, one of three residents observed during wound care. Findings include: RI #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS with an assessment reference date of 11/09/2016, determined RI #3 was dependent for all Activities of Daily Living. On 03/08/2017 at 2:40 PM, EI #1 was observed providing wound care for RI #3. EI #1 used her scissors to cut away the dressing from the first wound. Without cleaning the soiled scissors, EI #1 cut away the dressing from the second wound. Again, without cleaning the scissors, EI #1 cut a piece of sterile gauze, allowing it to drop into the Dakins solution. EI #1 then placed the gauze onto the open wound. After cleaning the bloody, draining wound, the open, uncovered wound was allowed to come into contact with the resident's bed sheet, leaving a bloody residue on the sheet. The wound was not re-cleaned. EI #1 was interviewed regarding the care of RI #3 on 03/09/2017 at 1:30 PM. EI #1 was asked what was the potential harm in allowing an open draining wound to touch the bed sheet, and what should be done. EI #1 stated it was cross contamination of the wound and the sheet. The wound should have been re-dressed.

Based on observation, interviews, record review and the facility's Medication Administration policy review, the facility failed to ensure staff flushed a percutaneous endoscopic gastrostomy (PEG) tube, before administering medication through the tube. This affected Resident Identifier (RI) #18, one of one resident observed during medication pass with a PEG tube. Findings Include: The facility policy, Medication Administration dated 12/12, related to ENTERAL TUBES specifies the following guideline: .9. Enteral tubes are flushed before administering medications and after all medications have been administered with at least 15 cc (cubic centimeters) of water. RI #18 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an assessment reference date of 04/25/2016, assessed RI #18 with a feeding tube, nasogastric or abdominal (PEG). Employee Identifier (EI) #3, a Licensed Practical Nurse, was observed administering medication through the PEG tube, to RI #18, without first flushing the PEG tube. On 03/09/2017 at 2:30 PM, EI #3 was interviewed. EI #3 was asked what was the facility policy for administering medications through a PEG tube. EI #3 stated it was to check placement, flush the tube, administer the medications, then flush again. When asked why it was important to flush a PEG tube before medications were given, EI #3 stated it was to make sure there was no residual feeding in the tube to mix with the medications, and to ensure there would be no adverse reactions.

The facility failed to ensure a staff member washed their hands after administering a oral medication, before donning gloves to administer eye drops to RI (Resident Identifier) #19. This affected one of one residents observed during the medication administration of eye drops. Findings Included: The facility's policy dated 12/12, General Guidelines Policy and Procedures, Medication Preparation states: .11. Hands are washed with soap and water and gloves applied before administration of ophthalmic, Otic, .Hands are washed with soap and water again after administration. During the medication pass observation on 03/07/2017 at 3:20 PM, the Licensed Practical Nurse, Employer Identifier (EI) #4 was observed administering oral medication and eye drops to RI #19. EI #4 entered RI #19's room, closed the curtain and without washing hands, administered the oral medication. Without washing her hands, EI #4 then donned gloves and administered drops to both of RI #19's eyes. EI #4 was interviewed on 03/09/07 at 3:30 PM. When asked what was the facility's procedure for administering eye drops, EI #4 stated to wash hands before and after, and to be sure gloves were worn. When asked why this was important, RI #4 stated for infection control. When asked what was the potential harm to the resident, RI #4 stated, an eye infection because hands were always dirty.

Based on closed record review, interviews, and a review of standards from Fundamentals of Nursing by Potter and Perry, the facility failed to ensure one of three discharged residents' medical records were completely documented, verbal and phone orders were not co-signed by the physician and/or Certified Registered Nurse Practioner (CRNP), and entries were consistently dated. These deficient practices included Resident Identifier (RI) #16, one of three closed records reviewed. Findings included: The Nursing textbook, Fundamentals of Nursing, 9th edition (copyright 2017), by P.A. Potter and A.G. Perry specifies in the chapter related to Professional Standards in Nursing Practice, for Telephone Orders, page 367: Telephone orders (TOs) occur when a health care provider gives therapeutic orders over the phone to a registered nurse. Verbal orders (VOs) occur when a health care provider gives therapeutic orders to a registered nurse while they are standing in proximity to one another. TOs and VOs usually occur at night or during emergencies; they should be used only when absolutely necessary and not for the sake of convenience.After you have taken the order, read it back using the 'read-back' process and document that you did this to provide evidence that the information received (such as call-back instructions and/or therapeutic orders) was verified with the provider.The health care provider later verifies the TO .legally by signing it within a set time (e.g., 24 hours) as set by hospital policy. Potter and Perry likewise direct as nursing protocol, the need of current documentation, on page 362: Timely entries are essential in a patient's ongoing care. Delays in documentation lead to unsafe patient care. RI #16 was admitted to the facility on [DATE]. The following verbal and/or telephone orders were written by licensed nursing staff, but not co-signed by the physician or Certified Registered Nurse Practitioner (CRNP), or consistently timed: [DATE] at 11:00 a.m.: Medication order change by CRNP (neither VO or TO specified); [DATE] (untimed): TO treatment order change, by MD; [DATE] at 11:00 a.m.: VO with medication changes, by MD. RI #16 died on [DATE], with physician's orders [REDACTED]. P/O .MD's name/LPN name. The order was not signed by the Medical Doctor (MD) from whom the order was received. The last Physician's Progress Note referred to events and observations made by the physician on [DATE] (two days before RI #16 expired). Appearance is reportedly normal for this pleasant, cooperative patient. Eyes and pupils normal for this patient, hearing normal . cardiac exam normal heart sounds . This documentation was signed by the physician on [DATE]. On [DATE] at 3:25 p.m., the Director of Nursing (Employee Identifier/EI #2) and Nursing Home Administrator (EI #7) were interviewed. EI #2 and EI#7 stated they used guidelines specified by Potter and Perry in regarding to telephone orders/ verbal orders. EI #2 and #7 affirmed RI #16 had expired on [DATE]. When asked about the signing off of TOs after written, EI #2 and EI #7 explained the physician would sign the orders monthly, when he came into the facility. EI #2 and EI #7 explained they had closed the chart before the MD had signed the orders. When asked about the lack of the physician's co-signature, on physician's verbal orders dated [DATE], EI #2 and EI #7 affirmed the physician should have signed the orders, and explained there had not been a medical record person (for reviews) for quite some time. On [DATE] at 4:40 p.m., the surveyor asked the Physician (EI #8) how often he signed off TOs. EI #8 stated the TOs were sometimes faxed to him, sometimes the CRNP would sign the orders, there were many ways to sign off the orders.

Based on observation, interview, and a review of Potter and Perry, Fundamentals of Nursing, Ninth Edition, (copyright 2017) the facility failed to ensure medications were removed from the current medication supply or identified as medications awaiting destruction. This affected one of two 2 medication rooms in which stock medications were stored. Findings include: Fundamentals of Nursing, Potter/Perry Ninth Edition, page 656: Skill 32-1 Administering Oral Medications, .f. Check expiration date on each medication, one at a time. Return outdated drug to pharmacy. Medications used past their expiration date may lose strength, be inactive or harm patient. On 03/09/2017 at 1:45 PM during medication room inspection, the surveyor observed medications in the Diabetic Emergency Box as follows: Dextrose 50%, 25 gms 50 ML: 2 syringes with an expiration date of 1 May, 2015; InstaGlucose 1 container with an expiration date of 1/2013; and Insta Glucose 1 container with an expiration date of 6/2008. Employee Identifier (EI) #6 (a Licensed Practical Nurse) was asked by the surveyor, whose was responsible for pulling expired drugs from the medication room. EI #6 stated, Nurses. The surveyor asked when staff checked for expired drugs. EI #6 stated, On a daily basis, and match back, when meds need to be reordered. The surveyor asked what was the deficient practice for having expired drugs in the medication room? EI #6 explained they were no longer effective. EI #6 was asked who used the Diabetic Emergency Box? EI #6 stated they did not use the medications in the box; instead they got their emergency medications from the Skilled Nursing Medication Room. EI #6 also explained they had a glucagon kit in the Medication Cart.

Based on observation, interview and a review of the facility's Daily Nurse Staffing Forms, the facility failed to ensure staffing numbers were posted prior to each shift. This was observed on 3/7/17 - 3/9/17, three of three days of the survey. This deficient practice had the potential to affect all residents. Findings include: On 03/07/17 at 10:25 a.m., during the initial tour of the facility, the survey staff observed the facility's Daily Nurse Staffing Form posted by the employee time clock. The form included the 24 hour staffing of all 3 nursing shifts, as follows on 03/07/2017: Day Shift RN 1 Evening RN -- Night RN -- LPN 3 LPN 3 LPN 3 CNA 10 CNA 8 CNA 4 On 03/08/17 at 12:00 a.m., the surveyor observed the staffing posted for all 3 shifts. Day Shift RN 1 Evening RN -- Night RN -- LPN 3 LPN 3 LPN 3 CNA 10 CNA 7 CNA 4 On 03/09/17 at 7:30 a.m., the surveyor observed the staffing posted for all 3 shifts. Day Shift RN 2 Evening RN -- Night RN -- LPN 3 LPN 3 LPN 3 CNA 9 CNA 7 CNA 4 On 03/09/17 at 1:25 PM, the Director of Nursing (EI #2) was interviewed. The surveyor requested a staffing posting policy. EI #2 stated the facility did not have a staffing policy; they followed the guidelines and posted the staffing daily, making adjustments each shift. EI #2 explained if there were changes in the staffing, they would address the changes.

Based on observation, record review and interview the facility failed to ensure: 1) The top of the vent hood over the stove range was free from an accumulation of a dust-like substance and 2) The lid on the thickening product was placed back on the the container after use and was not left sitting on a shelf near the steam table. Findings Include: A review of the facility's policy tiled, Cleaning Exhaust Hoods not dated revealed the following: . Daily Exhaust Hood Maintenance . Wipe hood exterior with a solution of warm water and detergent daily Potential Fire Hazard . Keep hoods free of grease and dust at all times. On 2/3/2016 at 5:15 PM central time the vent hood over the stove range was observed to have a dust-like substance covering the front of the hood directly over the stove. On 2/4/2016 at 4:40 PM central time an interview was conducted with the Dietary Manager (DM), Employee Indentifier (EI) #5. EI #5 was asked who was responsible for making sure the vent hood over the stove was clean and free of dust like substance. EI #5 said he was. EI #5 was asked how often was the vent hood supposed to be cleaned. EI #5 said quarterly. EI #5 was asked who was responsible for cleaning the vent hood. EI #5 said he had a company who cleaned it. EI #5 was asked why on 2/3/2016 at 5:15 PM was the vent hood covered in a dust like substance. EI #5 said the company that cleaned it did not clean it. EI #5 was asked what was the facility's policy on cleaning the vent hood over the stove. EI #5 said they have a company come in to clean it and make sure it was working right. EI #5 was asked what was the potential harm in the vent hood over the stove having a dust-like substance on it. EI #5 said the dust could have fallen in the food. A review of the facility's policy titled Storing Dry Food, with no date revealed the following: . Most dry good items will remain safe as long as storage methods assure no cross-contamination . On 2/3/2016 at 5:15 PM a container of thickening product was observed opened with the lid sitting on a shelf near the steam table containing food items. On 2/4/2016 at 4:50 PM an interview was conducted with the Dietary Manager EI #5. EI #5 was asked how should the thickening product be stored after it's use. EI #5 said it should have been re-covered everytime it was opened and used. EI #5 was asked why was the lid on the container not placed back on it after it was used . EI #5 said they were running behind trying to get food out on the tray line and forgot to put it back on. EI #5 was asked who was responsible for making sure the lid on the container was placed back on it after use. EI #5 said they all were. EI #5 was asked what was the facility's policy on storage of thickening products. EI #5 said place it in a container, cover it at all times and make sure it is out of harm's way. EI #5 was asked what was the potential harm in having a container of thickening product with out a lid on it. EI #5 said it could get contaminated.

Based on interview and record review, the facility failed to ensure the sponsor of Resident Identifier (RI) #8 was notified when a pressure ulcer to the resident's left trochanter was identified on 12/01/2015. The sponsor was not aware of the area until she took the resident to the wound clinic on 12/04/2015. This affected 1 of 10 sampled residents reviewed for change in condition. Findings include: The facility's guideline statement in the policy and procedure for Notification of Change in Resident Health Status, effective date 11/12/2014, documented, To ensure that proper notifications are made when a resident has a change in health status. Further documentation stated, . The center will . notify the resident's legal representative . when there is: . (B) . significant change in the resident's physical, . status (i.e. deterioration in health . clinical complications.) Criteria: . Clinical complications are such things as development of a stage 2 pressure sore when no ulcers were previously present at stage 2 or higher, . Appropriate notification time: immediate. RI # 8 was readmitted back to the facility on [DATE]. [DIAGNOSES REDACTED]. On 12/01/2015, RI #8 was identified with an in - house acquired unstageable pressure ulcer to the left trochanter (hip area) measuring 3.3 centimeters (cm) by 3.9 cm with 0 depth. A review of RI #8's Significant Change Minimum Data Set (MDS) assessment, date 01/22/2016, identified the resident with short and long term memory deficit and severely impaired in daily decision making skills. The MDS also identified RI #8 with three unstageable pressure ulcers. The Significant Change MDS was submitted due to the resident being placed on hospice. On 02/03/2016 at 2:55 PM central time, a family interview was conducted with RI #8's family member/ legal representative. The family member informed the surveyor she was not made aware, by the facility, of the pressure ulcer on the resident's left hip. The family member said she was not aware until she saw it on 12/04/2015 when she took the resident to the wound clinic. On 02/04/2016 at 10:30 AM central time, an interview was conducted with Employee Identifier (EI) #1, Director of Nursing. EI #1 was informed of the concern the family member had of not being notified of the pressure ulcer to the resident's left hip. EI #1 was asked the purpose for the notification of resident change in conditions. She said it was to let family know what was going on with the resident and what the facility was doing to make the situation better. EI #1 said they notified if the area was healing or getting worse, when referring to pressure ulcers. EI #1 was asked to review the nurses progress notes for documentation of family notification for the pressure ulcer identified on 12/01/2015. EI #1 said the sponsor was not notified at the time the left trochanter was identified.

Based on observation, interview and record review, the facility failed to ensure a CNA (Certified Nursing Assistant) provided incontinence care for RI (Resident Identifier) #5 and RI # 2, two residents with a history of urinary tract infections, in a manner to prevent a Urinary Tract Infections. This affected two of two residents observed during incontinence care. A review of the facility's Perineal Care policy dated 12/07/2015, reveals: Procedure details: . f. Use one gloved hand to stabilize and separate the labia, with the other hand wash from front to back . 1) RI # 5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The current Significant Change MDS with a assessment reference date of 01/13/2016, revealed the facility was unable to assess the resident's cognitive status for decision making. RI #5 was assessed for being incontinent of bowel and bladder and dependent for all activities of daily living. On 02/02/2016, at 9:00 AM central time, EI # 2, a CNA, was observed providing incontinence care for RI # 5. EI # 2 failed to separate the labia and clean RI # 5 thoroughly. After washing across the labia, EI # 2, without washing her hands, changed her gloves and continued to provide incontinence care. On 02/04/2016 at 2:00 PM central time, EI #2 was interviewed. EI # 2 was asked when was the last inservice on incontinence care. EI # 2 stated it was in January 2016. EI #2 was asked if they had been instructed to separate the labia when providing incontinence care for a female resident. She stated that was included in the inservice. When asked why it was important to do this for a female resident, EI # 2 stated it was to prevent urinary tract infections. 2) RI # 2 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of RI #2's Annual Minimum (MDS) data set [DATE] revealed RI #2's Brief Interview for Mental Status, summary score of 06 indicating severe impairment. RI #2 was assessed for being incontinent of bowel and bladder and required extensive assistance with all activities of daily living. RI #2's Careplan initiated 10/27/2014, with a revision date of 1/22/2016, revealed RI #2 was careplaned for potential for Urinary Tract Infections due to a history of Urinary Tract Infections. On 02/03/2016 at 6:00 PM central time, a CNA EI # 3 was observed providing incontinence care for RI #2. EI # 3 transferred RI # 2 onto the bed and removed her pants and brief. The brief was noted to be saturated with urine with a moderate amount of loose bowel movement in the brief and on RI #2. Without separating the labia, EI 3 wiped across the genital area. RI # 2 was positioned to the right side and EI # 3 cleaned the buttocks and rectal area. A clean brief was placed under RI # 2. EI # 3 removed her gloves and without washing her hands donned clean gloves and applied cream to RI # 2's buttocks. EI # 3 removed her gloves and without washing her hands left the room to obtain more supplies and then returned. When EI # 3 started to fasten the brief, the surveyor asked if she had finished cleaning RI # 2. EI #3 stated she had. The surveyor then asked EI #3 to clean the resident's genital area again. When EI #3 wiped across the labia there was smears of stool on the cloth. The surveyor then asked EI # 3 to separate the labia and clean the resident again. When EI # 3 did this, there was smears of stool on the cloth. EI# 3 wiped the area three times before the resident was thoroughly cleaned, stool being on two of the three cloths. On 02/04/2016 at 2:15 PM central time, EI # 3 was interviewed. When asked if she knew the importance of separating the labia on a female resident during incontinence care, she stated it was to prevent urinary tract infections. EI # 3 was asked what was on the cloth after she cleaned RI # 2. She stated it was bowel movement. EI # 3 was asked why she failed to wash her hands after cleaning RI # 2 before leaving the room for more supplies. EI # 3 stated she washed them at the nurses station before coming back to the room. The DON (Director of Nursing) EI #1, was interviewed on 02/04/2016 at 2:30 PM central time. When EI # 1 was asked how often they had inservices on infection control and incontinence care, she stated it was done frequently. EI # 1 was asked how they monitored the CNA providing incontinence care. EI #1 stated the Director of Clinical Education did it randomly until she left several weeks ago.

Based on observation, interview and record review, the facility failed to ensure the RN (Registered Nurse) washed her hands when going from a soiled area to a clean area and when changing her gloves during the provision of wound care. This affected RI (Resident Identifier) #8 and RI #5, two of two residents observed during wound treatments. Findings include: 1) RI # 8 was readmitted back to the facility on [DATE]. [DIAGNOSES REDACTED]. On 12/01/2015, RI #8 was identified with an in - house acquired unstageable pressure ulcer to the left trochanter (hip area). On 02/03/2016 at 10:40 AM central time, an RN, EI (Employee Identifier) #4 was observed providing wound care to RI #8. EI # 4 donned gloves and cleaned the purulent drainage from the wound to RI # 8's left hip. Without washing her hands, EI # 4 donned new gloves, applied the [MEDICATION NAME] powder, changed gloves and applied the dressing. EI #4 cleaned both areas to RI # 8's foot without changing gloves or washing hands between dressings. 2) RI # 5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's Significant Change MDS, reference date 01/13/2016, identified the resident with three Stage II pressure ulcers. On 02/03/2016 at 11:20 AM, EI #4 was observed providing wound care for RI # 5. EI # 4 removed the dressing from RI # 5's left hip. Without washing her hands, EI # 4 changed her gloves and applied the ointment to a clean dressing. The dressing was then applied to the left hip of RI # 5. The dressing was then removed from RI #5's right foot. EI #4 then cleaned the area and applied a clean dressing without washing her hands after changing her gloves. EI #4 cleaned the area to RI # 5's coccyx and without washing her hands changed gloves and applied the clean dressing. EI # 4 was interviewed on 02/04/2016 at 1:35 pm central time. EI # 4 was asked what was the protocol for changing gloves and washing hands during wound care. EI #4 stated before starting, after removing a soiled dressing and in between, if they get soiled. When EI # 4 was asked why she would change gloves and wash hands between cleaning a wound and putting a clean dressing on, she replied to prevent contamination of the clean dressing. When asked what she should have done after cleaning RI # 5's coccyx area before applying the dressing, EI #4 stated she should have washed her hands.