Every finding on record at Diversicare of Marion

Based on interviews, record review, review of the facility's abuse investigation, and review of the facility policy titled, Abuse, Neglect, Misappropriation, Exploitation Policy, the facility failed to ensure Employee Identifier (EI) #3, Social Service Director, implemented immediate protective measures in accordance with the facility's abuse policy upon witnessing EI #4, Certified Nursing Assistant (CNA) both verbally and physically abuse Resident Identifier (RI) #1 on 09/13/2022. On 9/13/2022 at approximately 12:50 PM, EI #3, the Social Services Director, was on the Memory Care Unit and heard a loud noise, described as the sound of a chair scraping against the floor. EI #3 turned and saw RI #1 rise up halfway to a standing position from his/her chair. She then observed EI #4, a Certified Nursing Assistant (CNA), rush towards the resident from the employee breakroom and place her hands on the resident's chest area and forcibly maneuver RI #1 back into the chair. EI #3 then witnessed EI #4 bend down to the resident's eye level and point her finger towards the resident's face and say, No, I'm tired of this[OBSCENITY] After witnessing the incident, EI #3 left the Memory Care Unit and allowed EI #4, the CNA witnessed to verbally and physically abuse RI #1, to remain on the unit with RI #1, as well as the 13 other residents residing on the Memory Care Unit at the time of this incident. This deficient practice placed RI #1, as well as the 13 other residents residing on the Memory Care Unit, in immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment, or death. On 10/20/2022 at 04:10 PM, the Administrator, Director of Nursing (DON), and Corporate Nurse were given a copy of the immediate jeopardy template and notified of the findings of substandard quality of care at the immediate jeopardy level in the area of Freedom from Abuse, Neglect and Exploitation, F607-Develop/Implement Abuse/Neglect Policies. Findings Include: A review of the facility's policy titled, Abuse, Neglect, Misappropriation, Exploitation Policy, with an effective date of January 2019, documented, Purpose: To prohibit and prevent abuse, neglect, exploitation, misappropriation of resident property and to ensure reporting and investigation of alleged violations (to include injuries of unknown source, mistreatment and involuntary seclusion) in accordance with Federal and State Laws. Definitions: Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical Abuse: Includes, but is not limited to, hitting, slapping, punching, biting, and kicking . Verbal Abuse: May be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. The following protocol has been established in the event of an allegation of abuse: 1. Protection First and foremost the resident/patient will be immediately assessed and removed from any potential harm. RI #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/26/2022 documented the resident had a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident was unable to complete the interview. This assessment also indicated RI #1 had both short-term and long-term memory problems. RI #1's Care Plan dated 09/16/2022 documented the resident's . safety is at risk and there is a potential for abuse due to: Decreased cognitive ability, inability to communicate, Need for total care, Wandering . A review of the facility's Alleged Abuse/Unusual Occurrence Result Summary, dated 09/19/2022, documented the following: . Date and Time of Incident/Allegation/Unusual Occurrence: 9/13/22, 12:50 pm . Investigation: . On 9/13/22 at 12:50 pm, a team member was on the Memory Care unit and witnessed (EI #4) C.N.A. sling (RI #1) a resident down in a chair after (RI #1) was attempting to get up. (EI #4) C.N.A. proceeded to point her finger at (RI #1) and curse (him/her) saying, no, I'm tired of this[OBSCENITY] (RI #1) started to cry. This allegation of Physical abuse is substantiated due to witness of the occurrence. In an interview on 10/18/2022 at 03:30 PM, EI #3, Social Services Director, reported she observed EI #1 sitting in a chair at the other end of the straight hallway of the Memory Care Unit. EI #3 stated she was getting ready to exit the unit when she heard a loud noise, described as the sound of a chair scooting back. She then observed EI #4 run out of the kitchen area at the other end of the hallway. According to EI #3, RI #1 was halfway up from the chair where he/she was sitting. EI #3 reported she then witnessed EI #4 grab RI #1 by the shirt and push RI #1 back into the chair. EI #3 said she then saw EI #4 point her right finger in the resident's face and scream, no, I'm tired of this[OBSCENITY] EI #3 stated RI #1 cried. EI #3 stated what she witnessed was abuse. When asked what actions she took after witnessing the abuse, EI #3 said, unfortunately, she did the wrong thing. EI #3 said she left RI #1 and EI #4 on the unit and went to report what she witnessed to EI #2, the DON. EI #3 stated she should have removed RI #1 from the situation and brought the resident with her when she reported the incident to EI #2. EI #3 stated she did not protect the resident because she left him/her in a hostile situation. EI #3 stated she received training prior to the incident on abuse and she knew she was to remove the resident from the situation. EI #3 stated she did not know why she did not do as she was trained. EI #3 stated she did not follow the facility's policy because she did not stop the situation and remove the resident from the abuse. EI #3 stated she should have removed the resident so the abuse could not continue. In an interview on 10/18/2022 at 04:30 PM, EI #2, DON, reported EI #3 came to her at 12:53 PM and reported she observed EI #4 come out of the kitchen area on the Memory Care Unit and grab RI #1 and sit him/her down hard. EI #3 told her EI #4 sat the resident in his/her chair, pointed her finger at the resident's face and said, no, I am about tired of this[OBSCENITY] EI #2 stated she then reported the incident to EI #1, the Administrator and Abuse Coordinator, and removed EI #4 from the unit. EI #2 stated RI #1 was alone with EI #4 between 12:53 PM and 01:00 PM. EI #2 stated EI #3 should have stopped the interaction, protected the resident from the incident, made sure the resident was safe and told EI #4 to get off the unit. EI #2 stated the facility's policy was not followed because EI #3 did not stop the abuse right then and remove EI #4 from the facility. In an interview on 10/19/2022 at 05:08 PM, EI #1, Administrator and Abuse Coordinator, reported EI #2, DON, reported to her that EI #3 reported she saw EI #4 walk up to RI #1, grab the resident by the shirt, sit the resident in his/her chair and said that she was tired of this[OBSCENITY] EI #1 said after EI #2, the DON made her aware of what happened, EI #2 went to the Memory Care Unit to remove EI #4. EI #1 stated when EI #2 got to the unit, EI #4 was removed and a body audit was completed on RI #1. EI #1 stated the facility's investigation substantiated the allegation of physical abuse based on the witness statement. EI #1 stated the facility also identified a concern about protection of RI #1 when EI #3 told EI #2 about the incident, while leaving RI #1 and EI #4 on the unit. EI #1 stated the facility's policy was not followed because EI #3 did not remove the resident or EI #4 from the area when she witnessed the abuse. EI #1 stated the policy was to remove the resident or the perpetrator. EI #1 stated the resident should have been immediately protected to prevent further abuse for the identified resident and other residents. EI #1 stated there were 14 residents on the Memory Care Unit at the time of the incident, including RI #1. This deficient practice was cited as a result of the investigation of complaint/report number AL 099. The facility took immediate action to correct the noncompliance by: 1. Suspended EI #4 on 09/13/2022 and removed her from the facility 09/13/2022 at 01:21 PM 2. Reported incident to ADPH (9/13/2022 at 1:52 PM) 3. Notifications to sponsor and physician made (9/13/2022) 4. Investigation was initiated (9/13/2022) 5. RI #1 was evaluated for negative outcome (9/13/2022) 6. 1:1 education to EI #3 on abuse policy (9/13/2022) 7. 1:1: education to EI #2 on abuse policy (09/13/2022) 8. Incident discussed at Daily Connect Meeting (09/14/2022) 9. EI #4 terminated (09/16/2022) 10. Investigation completed (09/19/2022) 11. Four step action plan created (09/20/2022) 12. Facility-wide education (started 09/13/2022 and completed 09/30/2022) 13. Audit of reportables from past three months to determine if resident was protected (09/19/2022) 14. QAPI Meeting to determine status and on-going monitoring (10/06/2022) After review of documentation supporting the above corrective actions, including inservice records, employee files, education records, and interviews with staff, the survey team verified the facility had implemented corrective actions from 09/13/2022 through 10/06/2022 and had an ongoing monitoring system in place; thus immediate jeopardy past noncompliance was cited.

Based on interviews, record review, review of the facility's abuse investigation, and review of the facility policy titled, Abuse, Neglect, Misappropriation, Exploitation Policy, the facility failed to protect Resident Identifier (RI) #1's right to be free from verbal and physical abuse. On 9/13/2022 at approximately 12:50 PM, Employee Identifier (EI) #3, the Social Services Director, was on the Memory Care Unit and heard a loud noise, described as the sound of a chair scraping against the floor. EI #3 turned and saw RI #1 rise up halfway to a standing position from his/her chair. She then observed EI #4, a Certified Nursing Assistant (CNA), rush towards the resident from the employee breakroom and place her hands on the resident's chest area and forcibly maneuver RI #1 back into the chair. EI #3 then witnessed EI #4 bend down to the resident's eye level and point her finger towards the resident's face and say, No, I'm tired of this[OBSCENITY] This deficient practice placed RI #1, one of 14 residents on the Memory Care Unit, in immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment, or death. On 10/20/2022 at 04:10 PM, the Administrator, Director of Nursing (DON), and Corporate Nurse were given a copy of the immediate jeopardy template and notified of the findings of substandard quality of care at the immediate jeopardy level in the area of Freedom from Abuse, Neglect and Exploitation, F600-Free from Abuse and Neglect. Findings Include: On 09/13/2022 at 1:52 PM, the State Survey Agency received an initial report from the facility regarding an allegation that EI #4, CNA, abused RI #1. This report indicated the facility's Social Services Director, EI #3, witnessed EI #4 sling RI #1 into a chair after he/she attempted to get up and then point her finger in RI #1's face and state, No, I'm tired of this[OBSCENITY] A review of the facility's policy titled, Abuse, Neglect, Misappropriation, Exploitation Policy, with an effective date of January 2019, documented, Purpose: To prohibit and prevent abuse, neglect, exploitation, misappropriation of resident property and to ensure reporting and investigation of alleged violations (to include injuries of unknown source, mistreatment and involuntary seclusion) in accordance with Federal and State Laws. Definitions: Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical Abuse: Includes, but is not limited to, hitting, slapping, punching, biting, and kicking . Verbal Abuse: May be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. RI #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/26/2022 documented the resident had a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident was unable to complete the interview. This assessment also indicated RI #1 had both short-term and long-term memory problems. RI #1's Care Plan dated 09/16/2022 documented the resident's . safety is at risk and there is a potential for abuse due to: Decreased cognitive ability, inability to communicate, Need for total care, Wandering . A review of the facility's Alleged Abuse/Unusual Occurrence Result Summary, dated 09/19/2022, documented the following: . Date and Time of Incident/Allegation/Unusual Occurrence: 9/13/22, 12:50 pm . Investigation: . On 9/13/22 at 12:50 pm, a team member was on the Memory Care unit and witnessed (EI #4) C.N.A. sling (RI #1) a resident down in a chair after (RI #1) was attempting to get up. (EI #4) C.N.A. proceeded to point her finger at (RI #1) and curse (him/her) saying, no, I'm tired of this[OBSCENITY] (RI #1) started to cry. This allegation of Physical abuse is substantiated due to witness of the occurrence. In an interview on 10/18/2022 at 12:16 PM, EI #4, CNA, reported she was taking her lunch break in the kitchen area on the Memory Care Unit hallway with the door open. She reported RI #1 was in and out of the kitchen area. EI #4 would tell RI #1 to sit in the chair in the hallway because the resident was over her food, and when EI #4 turned her back, RI #1 would put his/her hand in EI #4's food. EI #4 stated she kept sitting RI #1 down and the last time she sat the resident down, RI #1 killed over (as described by EI #4) like he/she was falling and RI #1 started to cry. EI #4 acknowledged she did put both her hands on the resident's shoulders when she told the resident to sit down. EI #4 denied pushing the resident or using force. EI #4 stated she did not remember pointing her finger in the resident's face. When asked if she had used a curse word when sitting RI #1 back down in the chair, EI #4 said she did not know. EI #4 stated she did remember stating she was tired the day this incident occurred. In an interview on 10/18/2022 at 03:30 PM, EI #3, Social Services Director, reported she observed EI #1 sitting in a chair at the other end of the straight hallway of Memory Care Unit. EI #3 stated she was getting ready to exit the unit when she heard a loud noise, described as the sound of a chair scooting back. She then observed EI #4 run out of the kitchen area at the other end of the hallway. According to EI #3, RI #1 was halfway up from the chair where he/she was sitting. EI #3 reported she then witnessed EI #4 grab RI #1 by the shirt and push RI #1 back into the chair. EI #3 said she then saw EI #4 point her right finger in the resident's face and scream, no, I'm tired of this[OBSCENITY] EI #3 stated RI #1 cried. EI #3 stated what she witnessed was abuse. EI #3 stated she reported the incident to EI #2, DON. In an interview on 10/18/2022 at 04:30 PM, EI #2, DON, reported EI #3 came to her at 12:53 PM and reported she observed EI #4 come out of the kitchen area on the Memory Care Unit and grab RI #1 and sit him/her down hard. EI #3 told her EI #4 sat the resident in his/her chair, pointed her finger at the resident's face and said, no, I am about tired of this[OBSCENITY] EI #2 stated she then reported the incident to EI #1, the Administrator and Abuse Coordinator, and removed EI #4 from the unit. On 10/19/2022 at 4:33 PM, an observation was made of the Memory Care Unit, with EI #1, the Administrator, and EI #3, the Social Services Director, both present. EI #3 demonstrated the spot she was standing when she witnessed the abuse of RI #1 by EI #4. The distance between her and what she witnessed was measured to be 65 feet. This observation confirmed EI #3 would have been able to see and hear the things she stated she witnessed from her point of view at the time the incident occurred. In an interview on 10/19/2022 at 05:08 PM, EI #1, the Administrator and Abuse Coordinator, said EI #2, the DON, reported to her that EI #3 reported she saw EI #4 walk up to RI #1, grab the resident by the shirt, sit the resident in his/her chair and said that she was tired of this[OBSCENITY] EI #1 told EI #2 that it was abuse and it needed to be reported. EI #1 stated the facility's investigation substantiated the allegation of physical abuse based on the witness statement. This deficient practice was cited as a result of the investigation of complaint/report number AL 099. The facility took immediate action to correct the noncompliance by: 1. Suspended EI #4 on 09/13/2022 and removed her from the facility 09/13/2022 at 01:21 PM 2. Reported incident to ADPH (9/13/2022 at 1:52 PM) 3. Notifications to sponsor and physician made (9/13/2022) 4. Investigation was initiated (9/13/2022) 5. RI #1 was evaluated for negative outcome (9/13/2022) 6. 1:1 education to EI #3 on abuse policy (9/13/2022) 7. 1:1: education to EI #2 on abuse policy (09/13/2022) 8. Incident discussed at Daily Connect Meeting (09/14/2022) 9. EI #4 terminated (09/16/2022) 10. Investigation completed (09/19/2022) 11. Four step action plan created (09/20/2022) 12. Facility-wide education (started 09/13/2022 and completed 09/30/2022) 13. Audit of reportables from past three months to determine if resident was protected (09/19/2022) 14. QAPI Meeting to determine status and on-going monitoring (10/06/2022) After review of documentation supporting the above corrective actions, including inservice records, employee files, education records, and interviews with staff, the survey team verified the facility had implemented corrective actions from 09/13/2022 through 10/06/2022 and had an ongoing monitoring system in place; thus immediate jeopardy past noncompliance was cited.

Based on interviews, record review, and review of a facility policy titled, Rights of Nursing Facility Residents, the facility failed to ensure Resident Identifier (RI) #56 was offered a bathing method other than bed baths to promote the resident's right to choose. This deficient practice affected RI #56, one of two sampled residents for choices. Findings include: Review of a facility policy titled, Rights of Nursing Facility Residents, dated 05/01/2012, revealed, . every nursing facility resident had the right . To receive all care necessary to have the highest possible level of health. RI #56 was admitted to the facility on [DATE]. RI #56 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an annual Minimum Data Set (MDS), dated [DATE], revealed RI #56 had a Brief Interview for Mental Status (BIMS) score of 7, indicating moderate cognitive impairment. The MDS indicated the resident considered it very important to be able to choose between a tub bath, shower, bed bath, or sponge bath. The MDS revealed the resident required limited assistance with transfers and was totally dependent on staff for bathing and personal hygiene. Review of a Bathing Task sheet, dated 08/02/2022 through 08/13/2022, revealed the resident received a full bed bath or partial bath each day except on 8/6/22. There was no evidence to indicate whirlpools, showers, or tub baths were provided for RI #56. During an interview on 08/13/2022 at 11:45 AM, RI #56 revealed he/she had not had a shower or bath since admission to the facility. RI #56 indicated he/she had been in the facility about a year, and no shower or bath had been offered. During an interview on 08/15/2022 at 3:13 PM, RI #56 denied ever refusing a shower and indicated that a shower had never been offered. During an interview on 08/15/2022 at 3:50 PM, Employee Identifier (EI) #2, the Director of Clinical Services (DCS), indicated EI #6, the CNA assigned to RI #56, admitted that she gave the resident a good bed bath but had not offered to shower RI #56. During an interview on 08/16/2022 at 12:47 PM, EI #6 stated the resident got a complete bed bath every other day. EI #6 stated she would have to have another CNA's assistance to transfer the RI #56 for a shower. EI #6 stated she had never asked for help to transfer the resident to a shower chair but indicated it would be possible for the RI #56 to have a shower. During a follow-up interview on 08/16/2022 at 1:15 PM, EI #2 revealed her expectation was for staff to offer RI #56 a shower. During an interview on 08/16/2022 at 1:26 PM, EI #1, the Administrator, indicated she expected a shower to be offered even if it might be refused.

Based on interview and record review, the facility failed to coordinate assessments with the Preadmission Screening and Resident Review (PASARR) program by failing to update a level I screen when a new [DIAGNOSES REDACTED].#30) of three (3) residents reviewed for PASARR out of 17 sampled residents. The findings include: Review of the medical record for Resident #30 revealed he/she was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED]. Review of the Level I PASARR Screening and Results document for Resident #30 revealed it was completed on 1/13/2020 by hospital staff prior to admission. This screen did not note a [DIAGNOSES REDACTED]. The document determined there was no need for a level II evaluation. Review of the medical record for Resident #30 revealed [DIAGNOSES REDACTED]. There was no updated level I PASARR completed after the [DIAGNOSES REDACTED].#30. As stated on the State of Alabama Department of Mental Health PASRR Level I Screen and Results for Mental Illness (MI)/Intellectual Disability (ID)/Related Condition (RC), [MEDICAL CONDITION] is listed as a qualifying [DIAGNOSES REDACTED]. On 4/6/21 at 2:00 p.m., an interview with the Social Services Director, he/she stated he/she was unaware of the [DIAGNOSES REDACTED].#30. He/She stated an updated level I PASARR should have been completed as required to determine if a resident would need a referral for level II services with a new [DIAGNOSES REDACTED]. On 4/8/21 at 10:30 a.m. during an interview with the Administrator, he/she stated the facility was aware there was a problem with the proper completion of PASARR referrals. He/She stated the Social Services Director needed some additional training on the proper procedure as he/she was new to the position. He/She stated the facility had not developed an improvement plan related to completion of PASARR but would be doing that in the near future which would include the education of the Social Services Director.

Based on interview and record review, the facility failed to complete a level II Pre-admission Screening and Record Review (PASARR) evaluation as required when a level I screening determined a level II to be necessary for one (1) (Resident #40) of three (3) reviewed for PASARR out of 17 sampled residents. The findings include: Review of the medical record for Resident #40 revealed he/she was admitted to the facility on [DATE] with a recent readmission date of [DATE]. [DIAGNOSES REDACTED]. Review of the PASARR file for Resident #40 revealed a level I PASARR was completed on 6/18/19, prior to admission and did not require a level II evaluation. On 1/24/2020 when Resident #40 was readmitted to the facility after a hospitalization , he/she was admitted to short term rehab which did not require a level I screen. When Resident #40 converted to long term care and had a serious mental health [DIAGNOSES REDACTED]. The level I screen, dated 5/18/2020, determined After a Quality Assurance Review, this Nursing Facility (NF) applicant requires a Level II Evaluation before admission in a Medicaid Certified NF to determine the need for NF services and eligibility. As a referral source (employee name) is responsible for completing an accurate level I screening based on the available medical records. A Level II evaluation is due to a short term to long term placement change and a serious mental health [DIAGNOSES REDACTED]. This is a Non-Medicaid recipient for long term care that must met 2 medical criteria. This NF applicant is currently in the nursing home. Evaluation Type: MI (Mental Illness); Partial Review PAS. Level II Due Date: 5/28/2020. However, there was no level II evaluation in Resident #40's medical record. On 4/6/21 at 2:00 p.m., during an interview with the Social Services Director, he/she stated he/she was unaware a level II PASARR had been recommended for Resident #40. He/She stated the level I was received by the front office and someone must have been placed the level I in the medical record without notifying him/her. He/She stated the level II evaluation should have been completed since the level I screen determined it was necessary. On 4/8/21 at 10:30 a.m. during an interview with the Administrator, he/she stated the facility was aware there was a problem with the proper completion of PASARR referrals. He/She stated the Social Services Director needed some additional training on the proper procedure as he/she was new to the position. He/She stated the facility had not developed an improvement plan related to completion of PASARR but would be doing that in the near future which would include the education of the Social Services Director.

Based on observation, record review, interview, and review of a facility policy titled, I.V. (Intravenous)insertion &routine care of I.V. site, the facility failed to ensure Resident Identifier (RI) #150's IV site was changed every 72 hours. Further, the facility failed to ensure RI #150's IV access site was dated, timed, and initialed. This affected one of one resident in the facility with IV access. Findings include: Review of a facility policy titled, I.V. insertion &routine care of I.V. site, dated 01/01/12, revealed: Policy: It is the policy of Perry County Nursing Home to initiate Intravenous therapy as the physician orders [REDACTED]. Procedure: Starting an I.V. . i.) Label the IV site with the date, time, and your initials. l.) . I.V. sites should be changed every 72 hours or PRN (as needed) complications . RI # 150 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of RI #150's (MONTH) 2019 Physician order [REDACTED]. RI #150's TREATMENT RECORD for (MONTH) 2019 documented the IV access site was to be changed every 72 hours, on 2/3/19, 2/6/19, 2/9/19, and 2/12/19. However, the only date initialed as having the site changed as ordered was 2/6/19. All other dates were blank. An observation was made on 02/11/19 at 4:33 p.m RI #150 was observed with an IV in the left hand, with gauze and tape around the IV site. There was no date or time of when the IV was inserted anywhere on the site. A second observation was made on 02/12/19 at 8:57 a.m An IV was observed in RI #150's left hand. The IV was visible under clear tape with a piece of gauze under the IV catheter. There was no date or time of insertion visualized on the site. A third observation was made on 02/13/19 at 3:23 p.m. An IV was observed in the top of the RI #150's left hand, with a piece of gauze under the catheter and clear tape on top of it. There was no date, time or initials documented. During an interview on 02/13/19 at 04:54 PM, with Employee Identifier (EI) # 3, Director of Nursing, the surveyor asked how often the facility's policy specified an IV site should be changed. EI # 3 replied, every 72 hours and as needed. EI # 3 also said RI #150 had a physician's orders [REDACTED]. When asked if the site was changed every 72 hours for RI #150, EI # 3 replied, according to the documentation, no. EI # 3 was asked, what is the potential concern of not changing the site every 72 hours. EI # 3 replied, infection. EI #3 further stated after inserting and taping an IV catheter down, the nurse should date, time, and initial the IV access site. When asked how staff would know the last time the IV access site was changed if it was not labeled with a date, time, and initials, EI #3 said refer to the Treatment Record.

Based on observation, interviews, and review of a facility policy titled, Medication Administration General Guidelines, the facility failed to ensure a licensed nurse washed her hands after putting Resident Identifier (RI) #11's medication and water cups in the garbage can, prior to putting on a pair of gloves for eye drop administration. Further, the gloves applied by the licensed nurse were stored in the left pocket of her uniform top. This deficient practice affected one of one resident observed receiving an eye drop medication and one of five licensed nurses observed during medication administration pass. Findings Include: A review of a facility policy titled, Medication Administration General Guidelines dated 2/07/2017, revealed, . 11 . Gloves should be applied after washing hands before administration of . ophthalmic . medications . RI #11 was admitted to the facility on [DATE] for the [DIAGNOSES REDACTED]. A review of RI #11's Physician order [REDACTED].[MEDICATION NAME] (Generic: Dorzolamide HCL/[MEDICATION NAME]) eye drops 22.3-6.8 solution one drop into left eye twice daily . On 2/13/19 at 8:11 a.m., the surveyor observed Employee Identifier (EI) #1, a Licensed Practical Nurse, during a medication administration pass. The surveyor observed EI #1 put a pair of gloves in the left pocket of her uniform top. After administering oral medications to RI #11, EI #1 threw the medication and water cup in the garbage can. She did not wash hands, and proceeded to apply the pair of gloves from her pocket. EI #1 then administered RI #11's eye drops. On 2/13/19 at 8:46 a.m., an interview was conducted with EI #1, a Licensed Practical Nurse. EI #1 was asked what did you do after giving RI #11's medication by mouth, prior to putting eye drop medication in RI #11's left eye. EI #1 stated she took the gloves out of her left pocket of the uniform and put the gloves on her hands without washing her hands first. EI #1 was asked why she had not washed her hands prior to putting on her gloves, after giving RI #11 the medication by mouth, and prior to putting eye drop medication in RI #11's left eye. EI #1 stated she forgot to wash her hands. EI #1 was asked what was the potential harm in not washing hands prior to putting on gloves after giving medication by mouth, and prior to putting eye drop medication in RI #11's left eye. EI #1 replied that it could transfer germs to the resident's eye. EI #1 was also asked why she put the gloves in the left pocket of her uniform top. EI #1 stated she just put them in her pocket without thinking. EI #1 was asked what was the potential harm in putting gloves in a uniform pocket. EI #1 stated it could cause an infection to a resident, due to contamination of the gloves in the uniform pocket. On 2/13/19 at 10:02 a.m., an interview was conducted with EI #2, a Registered Nurse and Infection Control Preventionist. EI #2 was asked what was the potential harm in a licensed nurse not washing hands, prior to putting on gloves after giving medication by mouth, and prior to putting eye drop medication in a resident's eye. EI #2 stated the licensed nurse could spread germs which could cause infection to the resident or herself. EI # 2 was asked what the facility's policy was on hand washing. EI #2 stated you should wash your hands before and after a procedure, and if hands become soiled or contaminated. EI #2 was asked what was the potential harm in a licensed nurse putting gloves in the pocket of their uniform top. EI #2 stated it could spread an infection to a resident.

Based on observations, record review, interviews, and review of facility policies titled Perineal Care and Blood Sugar Monitoring, and review of a document tilted Don't forget to WASH YOUR HANDS, the facility failed to ensure: 1) a Certified Nursing Assistant (CNA) washed hands when changing gloves during the provision of incontinent care for Resident Identifier (RI) #40; 2) licensed staff did not stack cups of medications for RI #s 20 and 28, one inside the other; 3) licensed staff did not place RI #39's used lancet on the surface of the table in the dining room; and 4) licensed staff washed hands between glove changes during [MEDICAL CONDITION] care for RI #28. These failures affected one of two incontinent care observations, two of two nurses observed during medication administration observations, three of nine residents observed during medication administration observations, and one of one [MEDICAL CONDITION] care observation. Findings include: 1) A Facility policy titled: Perineal Care with a revised date of 1/30/17 revealed: Policy: . to provide perineal care to . residents to cleanse the perineum and to prevent infection . Procedure: . 5. Wash hands and apply gloves. . 14. Remove soiled gloves, wash hands and put on clean gloves. . 16. Remove protective pad from under buttocks. 17. Remove soiled gloves, wash hands and put on clean gloves. RI #40 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 2/6/2018 revealed RI #40 was totally dependent on staff for personal hygiene and was always incontinent of bowel and bladder. A review of 3/2/2018 handwritten Physician's Orders revealed, RI #40 was to receive [MEDICATION NAME] (antibiotic) 100 milligrams (mg) twice daily by mouth for 7 days for a [DIAGNOSES REDACTED]. RI #40's Care Plan dated 9/20/2017 revealed: Bathroom Habits: . INCONTINENT OF . BOWEL AND BLADDER AT ALL TIMES . HISTORY OF URINARY INFECTION THAT INCREASE MY RISK . 1. STAFF WILL CHECK ME FOR INCONTINENCE . AND PROVIDE PROPER PERINEAL CARE . On 3/7/2018 at 8:45 AM, an observation was made of incontinent care for RI #40. Employee Identifier (EI) #1, CNA, entered RI #40's room and put on gloves without washing her hands. EI #1 prepared incontinent supplies on the resident's over bed table. Upon unsecuring RI #40's brief, it was observed to be soiled with urine and bowel movement (BM). EI #1 provided incontinent care to RI #40's front perineal area. EI #1 removed her gloves and donned new gloves, without washing her hands. RI #40 was turned to his/her left side and the rectal area and buttock area was cleaned. EI #1 folded and removed the soiled brief from under RI #40. EI #1 then continued cleaning the buttock area. The underpad was rolled under RI #40 and the resident was turned to the right side, and the soiled underpad was removed. EI #1 did not change her gloves or wash her hands before a clean underpad and brief was placed under RI #40. EI #1 applied a barrier ointment to a new disposable wipe and applied the ointment to RI #40's buttocks. EI #1 again removed her gloves and donned new gloves, without washing her hands. RI #40 was turned onto his/her back and the brief was secured. On 3/07/18 at approximately 9:13 AM, an interview was conducted with EI #1, CNA. EI #1 was asked what did the facility policy indicate about when hands should be washed and gloves changed when performing incontinent care. EI #1 said, after every glove change. EI #1 was asked did she wash her hands when she changed gloves during the incontinent care for RI #40. EI #1 said, no. When asked why she did not wash her hands before she began incontinent care and after she changed her gloves, EI #1 said, because RI #40's bowels kept moving. EI #1 was asked what was the potential harm to the resident when hands were not washed and gloves were not changed during the provision of incontinent care. EI #1 said, bacteria. After speaking with EI #1, the CNA that provided the care, the surveyor also interviewed EI #2, Licensed Practical Nurse/Infection Control. EI #2 was asked what did the facility policy indicate about when hands should be washed when providing incontinent care. EI #2 said, hands should have been washed at the beginning of care, any time gloves are visibly soiled, anytime gloves are removed, and when changing areas of care (cleaning the front area to cleaning the back area). When asked should a CNA have washed her hands upon entering a room to begin incontinent care, EI #2 said, yes. EI #2 was asked what was the potential harm to a resident when hands were not washed or gloves were not changed during incontinent care. EI #2 said, the spreading of bacteria. 2) On 3/07/18 at 8:00 AM, Employee Identifier (EI) #4, Licensed Practical Nurse (LPN) gave RI # 20 medications from stacked medication cups. A medication cup containing liquid medication was stacked on top of another cup containing pills. On 3/07/18 at 8:45 AM, EI #4 was again observed stacking medication cups for administration. EI #4 placed all of RI #28's medications in 7 different cups and stacked them one inside the other prior to crushing the medications. On 3/07/18 at 1:51 PM, EI #4 was asked why she stacked the medication cups containing medications for residents. EI #4 said she did not know. EI #4 said stacking medication cups could potentially be a concern for infection. When asked why stacking the medication cups could cause contamination, EI #4 explained it was because the cups had been on the surface of the medication cart. On 3/08/18 at 8:54 AM EI #2, LPN/ Infection Control Nurse, was asked what should be done to prevent infection when preparing medications and carrying medications to a resident's room. EI #2 said she had instructed staff that if they have multiple cups, they should carry them without stacking them. EI #2 said staff could use a rolling table to roll multiple medication cups to the bedside. When asked why nurses would stack medication cups of pills and liquid medication one inside the other to carry them into a resident's room, EI #2 said she did not know, because she had instructed them not to do that. EI #2 explained stacking medication cups containing pills and liquid medication was an infection control concern. 3) Review of the facility policy titled Blood Sugar Monitoring, dated 1/01/2012, revealed the following: . Procedure: . 5. Discard used lancet in red needle disposal container . On 3/07/18 at 4:25 PM, Employee Identifier (EI) #5, Licensed Practical Nurse (LPN) checked a fingerstick blood sugar for RI #39 in the dining room and placed the used lancet on the dining room table. On 3/07/18 at 6:00 PM, EI #5 was asked what the facility's policy was regarding infection control when performing finger stick blood sugars, including handling the lancet after use. EI #5 said the lancet should be placed in a sharps container. When asked why she placed the used lancet on the dining room table, EI #5 said she was using the dining room table like a work area. EI #5 said placing the used lancet on the table could have resulted in blood getting on the table. On 3/08/18 at 9:03 AM, EI #2, LPN/Infection Control Nurse, stated staff were supposed to dispose of used lancets in a sharps container. When asked why a nurse would place a used lancet on the dining room table after a fingerstick blood sugar, EI #2 said she did not know. EI #2 said a fingerstick blood sugar should preferably be performed in the resident's room. She further stated placing a used lancet on the dining room table potentially exposes everyone that comes through the dining room to bloodborne pathogens. 4) Review of an undated facility document titled Don't forget to WASH YOUR HANDS, revealed: . Remember to wash: . Before putting on gloves & (and) after taking gloves off . RI #28 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of RI #28's (MONTH) (YEAR) Physician Orders revealed an order for [REDACTED]. On 3/07/18 at 11:00 AM, Employee Identifier (EI) #4, Licensed Practical Nurse/LPN, was observed performing RI #28's [MEDICAL CONDITION] care. Before inserting the inner cannula, EI #4 washed hands and applied gloves. EI #4 then removed the new inner cannula, changed gloves without washing her hands, and then inserted another new cannula. When asked why she changed the inner cannula twice, EI #4 said because RI #28 coughed into it. EI #4 further explained when RI #28 coughs into the inner cannula he/she will often call her back down to change it, so she went ahead and changed it again. On 3/07/18 at 1:56 PM, EI #4 was asked what the facility's policy was for glove use and hand-washing during [MEDICAL CONDITION] care. EI #4 said you should wash hands before applying gloves, before starting the care, and anytime you remove gloves. When asked why she had changed gloves but not washed her hands when she changed RI #28's inner cannula the second time, EI #4 said she did not know. EI #4 said it was important to wash hands when changing gloves during [MEDICAL CONDITION] care to prevent infection. On 3/08/18 at 9:15 AM, EI #2, LPN/Infection Control Nurse, said staff should wash their hands when gloves become soiled and are removed during [MEDICAL CONDITION] care. When asked why the nurse removed an inner cannula, changed gloves, and inserted a new inner cannula without washing her hands, EI #2 said she did not know. EI #2 explained it was important to wash hands when changing gloves during [MEDICAL CONDITION] care to prevent the spread of infection and germs.

Based on observations, record review, interviews, and review of the facility policy titled Perineal Care the facility failed to ensure a Certified Nursing Assistant (CNA) did not change gloves without washing hands during the provision of incontinent care for Resident Identifier (RI) # 40, a resident with a history of Urinary Tract Infections (UTIs). Further, the CNA did not change gloves or wash hands prior to touching RI #40's clean brief. This affected RI #40, one of two residents observed for incontinent care. Findings include: A Facility policy titled: Perineal Care with a revised date of 1/30/17 revealed: Policy: . to provide perineal care to . residents to cleanse the perineum and to prevent infection . Procedure: . 5. Wash hands and apply gloves. 14. Remove soiled gloves, wash hands and put on clean gloves. 16. Remove protective pad from under buttocks. 17. Remove soiled gloves, wash hands and put on clean gloves. RI #40 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 2/6/2018 revealed RI #40 was totally dependent on staff for personal hygiene and was always incontinent of bowel and bladder. A review of 3/2/2018 handwritten Physician's Orders revealed, RI #40 was to receive [MEDICATION NAME] (antibiotic) 100 milligrams (mg) twice daily by mouth for 7 days for a [DIAGNOSES REDACTED]. RI #40's Care Plan dated 9/20/2017 revealed: Bathroom Habits: . INCONTINENT OF . BOWEL AND BLADDER AT ALL TIMES . HISTORY OF URINARY INFECTION THAT INCREASE MY RISK . 1. STAFF WILL CHECK ME FOR INCONTINENCE . AND PROVIDE PROPER PERINEAL CARE . On 3/7/2018 at 8:45 AM, an observation was made of incontinent care for RI #40. Employee Identifier (EI) #1, CNA, entered RI #40's room and put on gloves without washing her hands. EI #1 prepared incontinent supplies on the resident's over bed table. Upon unsecuring RI #40's brief, it was observed to be soiled with urine and bowel movement (BM). EI #1 provided incontinent care to RI #40's front perineal area. EI #1 removed her gloves and donned new gloves, without washing her hands. RI #40 was turned to his/her left side and the rectal area and buttock area was cleaned. EI #1 folded and removed the soiled brief from under RI #40. EI #1 then continued cleaning the buttock area. The underpad was rolled under RI #40 and the resident was turned to the right side, and the soiled underpad was removed. EI #1 did not change her gloves or wash her hands before a clean underpad and brief was placed under RI #40. EI #1 applied a barrier ointment to a new disposable wipe and applied the ointment to RI #40's buttocks. EI #1 again removed her gloves and donned new gloves, without washing her hands. RI #40 was turned onto his/her back and the brief was secured. On 3/07/18 at approximately 9:13 AM, an interview was conducted with EI #1, CNA. EI #1 was asked what did the facility policy indicate about when hands should be washed and gloves changed when performing incontinent care. EI #1 said, after every glove change. EI #1 was asked did she wash her hands when she changed gloves during the incontinent care for RI #40. EI #1 said, no. When asked why she did not wash her hands before she began incontinent care and after she changed her gloves, EI #1 said, because RI #40's bowels kept moving. EI #1 was asked what was the potential harm to the resident when hands were not washed and gloves were not changed during the provision of incontinent care. EI #1 said, bacteria. After speaking with EI #1, the CNA that provided the care, the surveyor also interviewed EI #2, Licensed Practical Nurse/Infection Control. EI #2 was asked what did the facility policy indicate about when hands should be washed when providing incontinent care. EI #2 said, hands should have been washed at the beginning of care, any time gloves are visibly soiled, anytime gloves are removed, and when changing areas of care (cleaning the front area to cleaning the back area). When asked should a CNA have washed her hands upon entering a room to begin incontinent care, EI #2 said, yes. EI #2 was asked what was the potential harm to a resident when hands were not washed or gloves were not changed during incontinent care. EI #2 said, the spreading of bacteria.

Based on review of the facility's controlled medication destruction records from 1/2017 through 3/2018, review of the facility policy titled Destroying Medication and interview, the facility failed to ensure the 4/2017 controlled medication destruction records were signed by the three required staff members as specified by facility policy. This was evident for one of 15 months of controlled medication destruction records reviewed. Findings include: Review of the facility's policy titled Destroying Medication, revised 3/12/15, revealed the following: Policy: It is the policy of Perry County Nursing Home to establish and follow proper guidelines for the destruction of medications. Procedure: . 3. All narcotic medications will be destroyed by flushing down the commode. The consulting pharmacist , the D.O.N. (Director of Nursing) or designee and a witness must be present at the time narcotic medication is destroyed and all will co-sign the destruction record for each narcotic medication destroyed . On 3/07/18 at 5:06 PM the Controlled Medication Destruction Records from 1/2017 through (MONTH) (YEAR) were reviewed. One of two pages from the 4/5/2017 Controlled Medication Destruction Records only contained two signatures. Medications included on this page included: [MEDICATION NAME]/[MEDICATION NAME], and [MEDICATION NAME]. Employee Identifier (EI) #3, Registered Nurse/DON, was interviewed on 3/07/18 at 5:17 PM. When asked what the facility's policy was regarding the destruction of controlled/narcotic medications, she stated the facility should have the pharmacist, the DON, and a witness present for the destruction of controlled/narcotic medications. EI #3 said all three of them should sign the destruction records, and further explained if there were multiple pages of narcotics to be destroyed that month, all three signatures should be on each page. When asked what the importance of having the correct number of signatures on narcotic destruction records was, EI #3 said it was important to verify the medications were actually destroyed. EI #3 reviewed a copy of the 4/2017 controlled medication destruction records and agreed the third signature was missing. She was unsure why they were missing a signature.

Based on observations, interviews, a review of Potter and Perry's Fundamentals of Nursing, a review of the facility's policies and procedures and record review, the facility failed to ensure: 1) CNAs (Certified Nursing Assistants) changed gloves and washed their hands after cleaning the perineal areas and prior to cleaning the buttocks of RI (Resident Identifier) #1 and #5; and 2) Licensed staff washed hands after removing their gloves during the medication pass observations for RI #4 and #7. These failures affected RI #s 1 and #5, two of three residents observed for incontinent care and RI #s 4 and #7, two of five residents observed during medication administration. Findings include: 1) Potter and Perry's FUNDAMENTALS OF NURSING, Eighth edition, copyright 2013, Chapter 39, pages 801 to 802 documented: .(2) .(a) Apply pair of clean gloves .(c) wash . majora . p. Remove soiled gloves and discard in trash; .q.(1) Perform hand hygiene and apply clean pair of gloves . (5) Clean buttocks and anus . (A)RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1's Quarterly Minimum Data Set (MDS) with a reference date of 12/27/2016 documented RI #1 was cognitively impaired, was always incontinent of bowel and bladder and was totally dependent on staff for toileting needs. On 01/24/2017 at 4:32 p.m., the surveyor observed Employee Identifiers (EI) #1 and #2, CNAs perform incontinent care on RI #1. Both CNAs began the care by washing their hands and putting on gloves. EI #1 then performed the perineal care to RI #1, EI #2 separated RI #1's labia so EI #1 could clean. EI #1 then removed the residents soiled brief which contained feces, cleaned RI #1's buttocks and applied a clean brief. Neither CNA removed their gloves or washed their hands after completing the care to RI #1's perineal area and before cleaning RI #1's buttocks. On 01/24/2017 at 4:47 p.m., the surveyor interviewed EI #1, the CNA who performed care to RI #1. EI #1 stated RI #1 had urine and feces in her brief. EI #1 stated after cleaning RI #1's perineal area and prior to cleaning RI #1's buttock, hands should be washed and gloves should be changed. EI #1 further stated she had not changed her gloves or washed her hands. EI #1 also stated before touching the clean brief, hands should be washed and gloves should be changed. She stated she had not done this. When asked what was the importance of washing hands and changing gloves during incontinent care, EI #1 stated germs and infection control. On 01/24/2017 at 5:22 p.m., the surveyor interviewed EI #2, the other CNA who provided care to RI #1. EI #2 stated gloves should be changed after wiping the residents front and before going to the back. EI #2 stated she had not washed her hands or changed her gloves during the incontinent care of RI #1. EI #2 also stated hands should be washed and gloves changed after providing the care and before touching the clean brief. When asked what was the importance of washing hands and changing gloves when providing incontinent care, EI #2 stated her gloves could be soiled and it would spread germs. On 01/26/2017 at 1:25 p.m., the surveyor interviewed EI #3, the Infection Control Nurse. EI #3 stated that hands should be washed before/after incontinent care and during as needed especially if the resident had had a bowel movement. EI #3 stated gloves should be changed and hands should be washed after cleaning the perineum and before cleaning the buttocks. When asked why it was important to change gloves and wash hands during incontinent care, EI #3 stated to prevent spreading germs. B) Potter and Perry's FUNDAMENTALS OF NURSING, Eighth edition, copyright 2013, Chapter 39, page 802 documented: .(3) Male patient (a) Apply pair of clean gloves .(d) Wash tip of penis . p. Remove soiled gloves and discard in trash; .q.(1) Perform hand hygiene and apply clean pair of gloves . (5) Clean buttocks and anus . RI #5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #5's Quarterly MDS with a reference date of 11/29/2016 documented RI #5 was cognitively impaired, was totally dependent on staff for toileting and was always incontinent of bowel and bladder. On 01/25/2017 at 09:50 a.m., the surveyor observed EI #4 and #5, CNAs provide incontinent care to RI #5. EI #4 performed the care while EI #5 assisted. EI #4 cleaned RI #5's perineal area, then cleaned RI #5's buttocks. She did not wash her hands or change her gloves after finishing with RI #5's front and before going to the buttocks. On 01/25/2017 at 10:30 a.m., the surveyor interviewed EI #4, the CNA who performed the perineal care on RI #5. EI #4 stated gloves should be changed and hands should be washed after cleaning RI #5's perineal area and she had not changed her gloves. When asked what the potential for harm was in not washing her hands and changing her gloves, EI #4 stated infection. On 01/26/2017 at 1:25 p.m., the surveyor interviewed EI #3, the Infection Control Nurse. EI #3 stated gloves should be changed and hands should be washed after cleaning the perineum and before cleaning the buttocks. When asked why it was important to change gloves and wash hands during incontinent care, EI #3 stated to prevent spreading germs 2) An undated facility document titled, Don't forget to WASH YOUR HANDS documented: Remember to wash: .Before putting on gloves & after taking gloves off . A facility policy dated 05/08/2012, titled, Glucometer testing, Cleaning & Monitoring Guidelines documented: . Disinfection of equipment: Note: Disinfecting of equipment must be done after each use of the glucometers, prior to storage of the device. 1. Wash hands 2. Put on non-sterile gloves. 3. Cleanse the glucometers using a facility approved disinfectant wipe . 6. Dispose of gloves and wash hands . A) RI #4 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #4's Significant Change MDS with a reference date of 12/19/2016 documented RI #4 was cognitively impaired and totally dependent on staff for all care. RI #4's Physician order [REDACTED].#5 required sliding scale insulin. On 01/25/2017 at 11:05 a.m., the surveyor observed EI #6, a Licensed Practical Nurse (LPN) cleaning a glucometer to be used to check RI #4's blood glucose level prior to administering sliding scale insulin. EI #6 washed her hands, placed a paper towel barrier and put on her gloves. EI #6 put sanitizer towels in a cup and removed her gloves. EI #6 then put on gloves without washing her hands. She then cleaned the glucometer, removed her right hand glove and replaced the glove after wiping off the glucometer. EI #6 then removed both gloves. EI #6 then put on another pair of gloves and gathered the lancet and strips. EI #6 removed her gloves. EI #6 then dropped the glucometer on the floor, removed her gloves and then washed her hands. EI #6 then started the procedure over and did not wash her hands or change her gloves throughout the second process. After checking RI #4's blood sugar, EI #6 began to prepare the sliding scale insulin for RI #4. EI #6 removed her gloves and put on new gloves, then drew up the insulin to be administered to RI #6. On 01/25/2017 at 11:35 a.m., the surveyor interviewed EI #6. EI #6 stated hands should be washed prior to putting on gloves, after removing gloves and during the cleaning of the glucometer. EI #6 stated she had removed her gloves a lot of times but had not washed her hands every time she removed them. When asked why it was important to wash her hands before putting on gloves and after removing gloves, EI #6 stated to prevent transfer of bacteria. EI #6 was asked how many times she had changed her gloves during the preparation of RI #4's insulin. She stated a whole lot of times and further stated she had not washed her hands each time. On 01/26/2017 at 1:25 p.m., the surveyor interviewed EI #3, the Infection Control Nurse. EI #3 was asked when hands should be washed during medication administration. EI #3 stated before putting on gloves and after removing gloves. EI #3 stated the importance of washing hands before and after gloving was to prevent the spread of infection. B) RI #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #7's January 2017 Physician order [REDACTED]. On 01/25/2017 at 08:15 a.m., the surveyor observed EI #7, an LPN prepare and administer the above listed medications to RI #7. EI #7 washed her hands prior to the eye drop administration. Administered the eye drops, removed her gloves, went to the medication cart and signed off the medications without washing her hands. EI #7 then put on her gloves and cleaned the syringe used to draw up the [MEDICATION NAME]. EI #7 then removed her gloves, placed the syringe into a carton and placed the carton into the medication cart. EI #7 then washed her hands. On 01/25/2017 at 08:40 a.m., the surveyor interviewed EI #7 about the medication pass to RI #7. EI #7 stated hands should be washed prior to putting on gloves as well as after removing gloves. When EI #7 was asked when had she washed her hands during the medication administration to RI #7, she said before and after. EI #7 stated the purpose of hand washing and wearing gloves was for infection control. When asked what the potential for harm was in not washing her hands before putting on gloves and after removing her gloves during medication administration, EI #7 stated infection. On 01/26/2017 at 1:25 p.m., the surveyor interviewed EI #3, the Infection Control Nurse. EI #3 was asked when hands should be washed during medication administration. EI #3 stated before putting on gloves and after removing gloves. EI #3 stated the importance of washing hands before and after gloving was to prevent the spread of infection.

Based on observation, interviews and record review, the facility failed to ensure a dependent resident with a history of urinary tract infections (UTIs) was checked and changed every two hours as ordered. This affected Resident Identifier (RI) #6, one of six residents observed for repositioning and toileting. Findings included: The facility's General Guidelines for Nursing Assistant Duties (revised 01/01/12) directs Certified Nursing Assistants (CNAs) as follows: .11. Assist the residents to bathroom as necessary before placing in wheelchairs. All bed bound or wheelchair residents are to be checked frequently and taken to the bathroom at least every two hours as requested or as indicated according to that resident's individual needs. 12. Turn and reposition all bed and chair residents at least every two hours or as indicated according to that resident's individual needs. RI #6 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most current quarterly review Minimum Data Set with an assessment reference date of 10/20/15, identified this resident as severely impaired in cognition, totally dependent for toileting needs, always incontinent of bowel and unrated for urinary continence due to the presence of a catheter. The resident was considered to be at risk for the development of a pressure sore. physician's orders [REDACTED].Incontinent of Stool, Check and change, clean properly upon arising, during routine personal care, after meals at HS (hour of sleep) and as needed. physician's orders [REDACTED]. The lab results revealed the presence of escherichia (e.) coli (greater than 100,000 colony forming units per milliliter), for which an antibiotic was ordered. Previous tests revealed the presence of another UTI on 08/20/15, also due to e. coli). Again, antibiotic therapy was given. Care plan interventions related to RI #6's history of falls (dated 05/21/15) directed staff to check on me every hour when I am in my room alone. On 12/16/15, the surveyor observed RI #6 from 9:40 AM until 1:15 PM. Throughout this time the resident remained seated in his/her wheelchair, without a position change or check of incontinence status. At 1:12 PM (after 3.5 hours of observation), a surveyor alerted the Charge Nurse of RI #6's need for an incontinence check. The responsible CNA, Employee Identifier (EI) #5 was contacted to provide the needed care. On 12/16/15 at 1:15 PM, the CNA assisted RI #6 back into bed and found the resident to be soiled with bowel movement. Incontinence care was provided. The surveyor asked EI #5 at 1:30 PM, what time she had gotten the resident up in the wheelchair that morning. EI #5 responded it was before breakfast (around 7:00 AM). EI #5 affirmed the resident should have been checked and changed every two hours; a UTI could result. On 12/16/15 at at 1:35 PM, the surveyor asked EI #5 why she had not repositioned or checked the resident since (before) 9:40 AM. EI #5 explained she took care of residents on another hall also, and had been checking on them. On 12/17/15 at 8:45 AM, the surveyor asked the Director of Nursing (EI #1) how often staff were supposed to check and change residents. EI #1 explained the normal routine was every two hours or as needed. When asked the potential harm of allowing RI #6 to sit in a soiled brief, EI #1 explained the resident already had a UTI and he/she could develop skin breakdown.

Based on observations, record review and interviews the facility failed to ensure that Resident Identifier (RI) #3 was provided a sectional plate during the evening meal on 12/15/15. This affected one of six residents for whom meal observations were made. Findings include: RI #3 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) with a reference date of 11/09/15 indicated that RI #3 was impaired in range of motion on both sides, with set up help for eating. A review of the Physican's Order dated 11/02/15 indicated RI #3 was to eat all meals out of a sectional plate. A review of RI #3's Care Plan for Dining/Nutrition/Hydration dated 06/11/15, indicated RI #3 was to have a sectional plate for all meals. On 12/15/15 at 5:20 PM, RI #3 was observed eating the evening meal without a sectional plate. On 12/16/15 at 3:45 PM, Employee Identifier (EI) #3, a Licensed Practical Nurse (LPN) was asked if RI #3 had a sectional plate with his evening meal on 12/15/15. EI #3 replied, No. When asked if RI #3 was supposed to have a divided plate with all meals, EI #3 replied, Yes. On 12/17/15 at 12:00 PM, an interview with EI #2/Dietary Manager was conducted. EI #2 was asked who was responsible for ensuring that the correct adaptive equipment got on the resident's meal tray. EI #2 replied, the dietary staff. EI #2 was asked what the potential for harm was if the resident did not get the adaptive equipment. EI #2 replied, They might not be able to eat or feed themselves to promote their independence. On 12/17/1 at 12:30 PM an interview was conducted with EI #4, the Activity Assistant. EI #4 was asked if RI #3 had a sectional plate during the evening meal. EI #4 replied he did not. When asked if RI #3's meal tray card indicated that RI #3 was supposed to have a sectional plate, EI #4 replied; it did. When asked what was the potential for harm to the resident, EI #4 replied, It will be difficult for the resident to get the food to their mouth.

Based on observations, record reviews and interviews the facility failed to ensure the actual hours worked were documented on the daily Nurse Staffing and Resident Census form on 3 of 3 days of the survey. This had the potential to affect all 53 residents residing in the facility. Findings included: The facility policy titled, Nurse Staffing and Resident Census with a date of 09/03/15 stated the following: Policy: It is the policy of Perry County Nursing Home that, the nurse staffing and resident census information, be accurately completed and posted as required, per the state and federal regulations. Procedure: .4. The total hours worked will be calculated, after the shift has been completed. On 12/15/15 the surveyor observed the facility's Nurse Staffing and Resident Census form did not have the hours worked documented for the Registered Nurse (RN), Licensed Practical Nurse (LPN) and the Certified Nursing Assistant (CNA) on it. On 12/16/15 the surveyor also observed the facility's Nurse Staffing and Resident Census form did not have the hours worked documented on it for the RNs LPNs and the CNAs. On 12/17/15 the surveyor again observed that the facility's Nurse Staffing and Resident Census form did not have the hours work documented for the RNs, LPNs and the CNAs. On 12/17/15 at 11:00 AM, an interview was conducted with EI #1, RN/Director of Nursing (DON). When asked if she was responsible for filling out the nurse staffing and census form, EI #1 said Yes. EI #1 was asked if the nurse staffing and resident census form for 12/15/15, 12/16/15 and 12/17/15 had the actual hours worked documented on them, and EI #1 said, No, they do not.

Based on observations, interviews and document reviews, the facility failed to ensure: 1) Dietary staff were aware of parameters required for calibrating thermometers when checking temperatures on the meal tray line. 2) Dietary staff were aware of the type of dish machine utilized by the facility, and the parameters required to ensure proper functioning of the dish machine. This had the potential to affect 49 residents that were served meals from the kitchen. Findings include: 1) A review of the facility's undated policy entitled, "Policy and Procedure for Calibrating Digital thermometer and cleaning the thermometer," revealed, "POLICY: It is the policy to Calibrate or recalibrate the food thermometer before each meal to 32 degrees by manufacture directions. PROCEDURE: ...5. If the temperature reading is 32 degrees the thermometer is accurately calibrated. If necessary to adjust the thermometer do so by small amounts by turning the calibration screw to the right to decrease the reading and turn to the left to increase the reading. ..." During the lunch tray line observation on 12/03/2014 at 11:05 AM, EI #5, the Dietary Supervisor, was observed to calibrate the digital thermometer after checking the temperature of the milk. The thermometer read 31.4 degrees F (Fahrenheit). EI #5 informed the surveyor, "Anything less than 32 degrees is good." On 12/04/2014 at 2:10 PM, an interview was conducted with EI #5. EI #5 was asked what the facility's policy was on calibrating thermometers. EI #5 replied, "We're supposed to calibrate them with every meal." E #5 was asked how calibration of the thermometer should be done. EI #5 stated, "... We calibrate it to 32 degrees. I've been told if it gets below 32 degrees, like 31 degrees, it's calibrated ..." EI #5 was asked what should be done if the thermometer reads less than 32 degrees F during calibration. EI #5 stated, "Nothing, because it's calibrated." EI #5 was asked what the potential harm was of not calibrating the thermometer to 32 degrees F. EI #5 stated, "You don't have the accurate temperature of the food." EI #8, the Dietary Manager was interviewed on 12/04/2014 at 2:58 PM. EI #8 was asked what the facility's policy was on calibrating thermometers. EI #8 stated, "They're supposed to be calibrated before each meal." EI #8 was asked how calibration of the thermometer should be done. EI #8 replied, "... If it registers 32 degrees, it's calibrated. If it's not, there's a button to push to get it higher or lower." EI #8 was asked what should be done if during calibration, the thermometer read less than 32 degrees F. EI #8 responded, "Turn it up with (a) screwdriver to get it to 32 degrees." EI #8 was asked what the potential harm was of not calibrating the thermometer to 32 degrees F. EI #8 replied, "The food would not be the right temperature and could make someone sick if not (the) right temperature." 2) A review of the facility's undated policy titled, "POLICY AND PROCEDURE FOR WASHING AND SANITIZING DISHES," revealed, "Procedure for washing and sanitizing dishes. ...The dishes are washed at 125 degrees for 56 seconds. The dishes are sanitized chemically with sanitizing solution CL(Chlorine). The strength of the solution should be tested three times a day at the start of the wash cycle on the first load of dishes ran for that meal. Test the dishes on the clean side after running through the machine. The solution strip should read 50 ppm (Parts Per Million)..." On 12/03/2014 at 9:03 AM, EI #6, a Dietary Aide, was observed to perform dish washing in the dirty dish washing area. The surveyor asked EI #6 what type of dish machine was used, and what were the parameters required of the machine. EI #6 stated, "High temp(temperature) machine. Wash at 130 degrees and rinse at 100 degrees." An interview was conducted with EI #6 on 12/04/2014 at 1:21 PM. EI #6 was asked what type of dish machine did the facility use. EI #6 stated, "It's a low (temp machine). Yesterday I wasn't thinking ..." EI #6 was asked how did staff monitor and document the proper functioning of the dish machine." EI #6 replied, "You have to keep monitoring it. You monitor the gauge with temperature. Just keep turning it on until it's the right temperature. By it being low (temp), it goes up and down." EI #6 was asked how often the sanitizing solution was tested . EI #6 stated, "We test it three times a day." EI #6 was asked how had she tested the solution during the observation on 12/03/2014. EI #6 replied, "I tested it with the strips after you left. We have a log book and it's documented in there." EI #6 was asked what the results were when she tested the sanitizing solution. EI #6 stated, "When I tested it, it was normal. PPMs is unknown." EI #6 was asked what the potential harm was of not testing the solution in the dish machine. EI #6 replied, "Anything could happen like the dishes won't be sanitized or the water not correct. If wrong, you're supposed to notify your supervisor." During the interview on 12/04/2014 at 2:58 PM, EI #8, the Dietary Manager, was asked what type of dish machine the facility used. EI #8 stated, "Low temp. 125 degrees for washing. Rinsing with a sanitizing solution." EI #8 was asked how did staff monitor and document the proper functioning of the dish machine. EI #8 replied, "Everyday, 3 times a day. They document the temps and PPMs. They should test at (the) beginning of the wash cycle and the first sanitizing cycle. This should be done after running one time." EI #8 was asked how often the sanitizing solution was to be tested . EI #8 stated, "tested three times a day when you start washing dishes." The surveyor shared the dishwashing observation done on 12/03/2014 of the PPMs not being checked with EI #6. EI #8 was asked what the potential harm was of not testing the solution in the dish machine. EI #8 replied, "If it wasn't correct, everybody could be sick."

Based on observations, interviews, and document reviews, the facility failed to ensure: 1) Dietary staff had hair and facial hair appropriately covered while working in the kitchen. This was observed on 2 of 3 survey days. 2) Dietary staff did not wear earrings, necklaces, bracelets, and a watch while working in the kitchen. The jewelry worn by staff was observed on 2 of 3 survey days. 3) A trash can was observed uncovered in the dish washing area while no staff was present. This was observed on 1 of 3 survey days. 4) A food tray cart was sanitized with an appropriate cleaning agent before being returned to the clean kitchen area. This was observed on 1 of 3 survey days. 5) Water was not dumped from a glass and allowed to air dry, after removal from the dish machine. This was observed on 1 of 3 survey days. 6) A crate with clean glasses was not placed on the handwashing sink and water was allowed to drip onto them. This was observed on 1 of 3 survey days. 7) A food item which was not at 135 degrees F (Fahrenheit) on the lunch tray line was not re-heated more than one time prior to being served to residents. This was observed on 1 of 3 survey days. 8) The vent hood over the stove was not observed with a build-up of a grayish, black/brown substance, observed on 2 of 3 survey days. These deficient practices had the potential to affect 49 residents served meals from the kitchen. Findings include: 1) A review of the "Food Code U. S. (United States) Public Health Services 2013," revealed, "Hair Restraints 2-402.11 Effectiveness. (A) ... FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. ..." During the tour of the kitchen on 12/02/2014 at 10:55 AM, the following were observed in the kitchen: EI (Employee Identifier) #5, the Dietary Supervisor, was observed with the left back portion of her hair uncovered by the hair net. EI #1, a Cook, was observed with the entire back portion of her hair uncovered by the hair net. EI #2, a Cook, was observed with the back of her hair uncovered by the hair net. EI #4, a Dietary Aide, was observed with a mustache, and not wearing a beard guard. EI #5 informed the surveyor, "(He's) not working with us today. He just took the trash out for us." On 12/03/2014 at 10:32 AM, EI #11, a Maintenance Worker, entered the kitchen to adjust the air temperature. EI #11 had a mustache and beard and was not wearing a beard guard. On 12/03/2014 at 10:39 AM, EI #4, was observed in the kitchen with a mustache, and not wearing a beard guard. EI #4 was sorting and placing utensils in sleeves, and folding napkins for residents trays. On 12/03/2014 at 10:44 AM, EI #1 was observed in the kitchen, again with the entire back portion of her hair uncovered by the hair net. On 12/04/2014 at 2:00 PM, an interview was conducted with EI #1. EI #1 was asked what the facility's policy was on hair coverings in the kitchen. EI #1 stated, "All the hair should be covered." EI #1 was asked why, and she replied, "Because the hair can get in the food. Like loose hair." EI #1 was asked what the potential harm was of all hair not being covered appropriately while in the kitchen area. EI #1 replied, "It can fall into whatever you're fixing, like tea or juice. If the resident eats it, it may make them sick." During the interview on 12/04/2014 at 2:10 PM, EI #5, the Dietary Supervisor, was asked what the facility's policy was on hair coverings in the kitchen. EI #5 replied, "Your hair is supposed to be under a net." EI #5 was asked what the facility's policy was on facial hair coverings while in the kitchen. EI #5 stated, "Trimmed; I'm guessing. (EI #4) is the only guy, so, neat and trimmed." EI #5 was asked if all hair should be covered while in the kitchen, and she replied, "Yes. Because there is a chance of hair falling into food." An interview was conducted with EI #8, the Dietary Manager, on 12/04/2014 at 2:58 PM. EI #8 was asked what the facility's policy was on hair coverings in the kitchen. EI #8 stated, "They have to wear hair nets at all times while in the kitchen, and all hair has to be covered." EI #8 was asked what the facility's policy was on facial hair coverings while in the kitchen. EI #8 replied, "I've never had anyone with facial hair in the kitchen, but it would have to be covered also." EI #8 was asked if all hair should be covered while in the kitchen, and she replied, "Yes, because it could break off or fall out and into food." 2) A review of the "Food Code U. S. Public Health Services 2013," revealed, "Jewelry 2-303.11 Prohibition. Except for a plain ring such as a wedding band, ... FOOD EMPLOYEES may not wear jewelry including medical information jewelry on their arms and hands ..." During the tour of the facility on 12/02/2014 at 10:55 AM, the following were observed in the kitchen: EI #5, the Dietary Supervisor, was observed wearing silver, heart shaped earrings that were approximately 1.5 cm (centimeters) in size, in both ears, and uncovered by her hair net. EI #5 was also wearing a watch with a black band on her left wrist. EI #1, a Cook, was observed wearing 3 silver earrings of different sizes in both ears, uncovered by her hair net, and a silver necklace with a cross. EI #2, a Cook, was observed with silver hoop earrings that were approximately 1.5 cm in size, in both ears. EI #3, a Cook/ Dietary Aide, was observed wearing black studs in both ears, uncovered by her hair net, and a silver bracelet on her right wrist. On 12/03/2014 at 8:15 AM, the following were observed in the kitchen: EI #2 was observed with silver hoop earrings, approximately 1.5 cm in size, in both ears, and uncovered by her hair net. EI #5 was observed with silver, heart-shaped earrings approximately 1.5 cm, in both ears, and uncovered by her hair net. On 12/03/2014 at 9:03 AM, EI #6, a Dietary Aide was observed in the kitchen with silver hoop earrings, approximately 1 cm in size, in both ears, and not covered by her hair net. On 12/03/2014 at 10:44 AM, EI #1 was observed in the kitchen with 3 silver earrings of different sizes, in both ears, and uncovered by the hair net. EI #1 was also wearing a silver necklace with a cross. On 12/04/2014 at 12:55 PM, an interview was conducted with EI #2, a Cook. EI #2 was asked what the facility's policy was on jewelry in the kitchen. EI #2 stated, "We're not supposed to wear rings and necklaces. We can wear studs or small earrings ..." EI #2 was asked what the potential harm was of earrings being worn in the kitchen, and uncovered. EI #2 replied, "They could come loose and fall in the food. This could harm the patient, if they got it." EI #2 was asked what the potential harm was of watches and bracelets being worn in the kitchen. EI #2 stated, "It could get in the food or touch the food. Food could get in them and cause contamination." EI #2 was asked what the potential harm was of necklaces being worn in the kitchen, and she replied, "If you bend over, it could touch the food, and that's a no-no." During the interview on 12/04/2014 at 2:10 PM, EI #5 was asked what the facility's policy was on jewelry in the kitchen. EI #5 stated, "We're not supposed to wear jewelry. We've been told the only thing we can wear is a wedding band." EI #5 was asked what the potential harm was of earrings being worn in the kitchen, and uncovered. EI #5 replied, "They carry germs and there's a chance of them falling in the food." EI #5 was asked what the potential harm was of watches and bracelets being worn in the kitchen. EI #5 stated, "They carry germs." EI #5 was asked what the potential harm was of necklaces being worn in the kitchen, and she replied, "Germs. They can come off and fall in the food." 3) A review of the "Food Code U. S. Public Health Services 2013," revealed, "5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: (A) Inside the FOOD ESTABLISHMENT if the receptacles and units: (1) Contain FOOD residue and are not in continuous use; or ..." During the tour of the kitchen on 12/02/2014 at 10:55 AM, a trash can was observed uncovered, with trash inside, in the dish washing area. There was no staff present in this area at the time. During the interview on 12/04/2014 at 2:10 PM, EI #5, the Dietary Supervisor, was asked what the facility's policy was on trash cans uncovered and unattended in the kitchen. EI #5 stated, "All trash cans have to be covered at all times. They're supposed to have a lid on at all times." EI #5 was asked what the potential harm was of trash cans being uncovered in the kitchen area and no staff present. EI #5 stated, "I don't know, but can find out ..." During the interview on 12/04/2014 at 2:58 PM, EI #8, the Dietary Manager, was asked what the facility's policy was on trash cans uncovered and unattended in the kitchen. EI #8 replied, "They are supposed to be covered at all times." EI #8 was asked what the potential harm was of trash cans being uncovered in the kitchen area and no staff present. EI #8 replied, "Could cause flies, in the summer time." 4) A review of the facility's policy dated 1/7/2013 and titled, "Policy: Cleaning Food Carts," revealed, "Policy: It is the policy of the dietary department to clean all food carts before bringing them into the food service area. Procedure: Each food cart should be cleaned and sanitized after each meal with bleach and water before bringing the food cart into the kitchen." On 12/03/2014 at 9:10 AM, EI #6, a Dietary Aide, was observed in the dirty dish washing area. After all meal trays were removed from the rolling tray cart, EI #6 was passed a clean dry dish towel, by EI #2, a Cook. EI #6 wet the dish cloth in plain water and wiped each shelf on the cart. EI #6 did not use any type of sanitizing or disinfectant cleaner to clean the rack. EI #6 then took the cart into the kitchen area and informed the surveyor, "(The cart was) Ready to be used." An interview was conducted with EI #6 on 12/04/2014 at 1:21 PM. EI #6 was asked how food carts should be cleaned or sanitized. EI #6 replied, "You should wash them down using a cleaner or soap and water, then take them into the kitchen." EI #6 was asked what the potential harm was of wiping the carts with plain water. EI #6 replied, "That's not sanitizing." The surveyor shared the observation of 12/03/2014 with EI #6. EI #6 was asked how she had cleaned the food cart on 12/03/2014 during the observation. EI #6 stated, "I knew I had done the wrong thing, because I was nervous with you watching me, and just didn't think just right." During the interview on 12/04/2014 at 2:10 PM, EI #5, the Dietary Supervisor, was asked how food carts should be cleaned or sanitized. EI #5 stated, "They should be cleaned and sanitized before brought back into the kitchen. They are to be cleaned with warm soap, water and bleach." EI #5 was asked what the potential harm was of wiping the carts with plain water. EI #5 replied, "There could still be germs left on the cart." During the interview on 12/04/2014 at 2:58 PM, EI #8, Dietary Manager, was asked how food carts should be cleaned or sanitized. EI #8 replied, "They are to be washed down with Chlorox water." EI #8 was asked what the potential harm was of wiping the carts with plain water. EI #8 stated, "Infection control problem." 5) A review of the 2013 Food Code U.S. Public Health Services revealed, "CLEANING OF EQUIPMENT AND UTENSILS ... 4-602.11 Equipment Food-Contact Surfaces and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES AND UTENSILS shall be cleaned: ... (5) At any time during the operation when contamination may have occurred. ..." During the dishwashing observation on 12/03/2014 at 9:10 AM, a rack with glasses were placed in the dish machine with the drinking ends down. When the glasses were removed from the dish machine, 1 glass was observed with the drinking end upright. EI #2, a Cook, removed the glasses and dumped the water from the upright glass. EI #2 placed the glass with others, and left it to air dry. The glass was not re-run through the dish machine. On 12/03/2014 at 9:37 AM, the surveyor asked EI #2 what should be done with glasses or bowls with water in them when they come from the dish machine. EI #2 stated, "When we have glasses, or bowls (with water in them), water is poured out and they are left to air dry. We then place them on the different racks." An interview was conducted with EI #2 on 12/04/2014 at 12:55 PM. EI #2 was asked what should be done if glasses, cups or bowls had water in them from the dish machine. EI #2 stated, "My opinion is they should be sent back through the dish machine. We have poured the water out and put them on the shelves to air dry." EI #2 was asked if it was appropriate to dump the water out of the glasses, cups or bowls and allow them to air dry. EI #2 stated, "I don't think so ... That glass or bowl could have some sanitizer in it." EI #2 was asked what the potential harm was of not re-washing glasses, bowls or cups with water inside of them after coming out of the dish machine. EI #2 replied, "(They) Could be contaminated, because you don't know what's in the water in the glass or bowl." During the interview with EI #5, Dietary Supervisor, on 12/04/2014 at 2:10 PM, EI #5 was asked what should be done if glasses, cups or bowls had water in them from the dish machine. EI #5 stated, "They should be sent back through the dish machine." EI #5 was asked if it was appropriate to dump the water out of the glasses, cups or bowls and allow them to air dry. EI #5 replied, "No. Because that water could have germs or chlorine still in them. Dumping them could leave them still contaminated." EI #5 was asked what the potential harm was of not re-washing glasses, bowls or cups with water inside of them after coming out of the dish machine. EI #5 responded, "Contamination." During the interview with EI #8, the Dietary Manager, on 12/04/2014 at 2:58 PM, EI #8 was asked what should be done if glasses, cups or bowls had water in them from the dish machine. EI #8 stated, "The water emptied and they should be run back through the dish machine." EI #8 was asked if it was appropriate to dump the water out of the glasses, cups or bowls and allow them to air dry. EI #8 stated, "No ma'am. They should be sent back through to get the soap or sanitizing solution out." EI #8 was asked what the potential harm was of not re-washing glasses, bowls or cups with water inside of them after coming out of the dish machine. EI #8 stated, "Could make somebody sick." 6) A review of the 2013 US Public Health Service Food Code, Chapter 5, Section 5-205.11 "Using a Handwashing Sink," revealed: "(A) A HANDWASHING SINK shall be maintained so that it is accessible at all times for EMPLOYEE use. (B) A HANDWASHING SINK may not be used for purposes other than handwashing... " A review of the facility's Policy and Procedure titled, "STORING DISHES," with a date of 1/24/2014, revealed: "POLICY: It is the policy of the dietary department to store cleans (clean) dishes on open rack for air drying. PROCEDURE: The dishes are taking (taken) from the clean dish line after coming out of the dish machine. The dishes are then stored on a slotted cart for air drying ..." On 12/03/2014 at 10:30 AM, a crate with clean glasses was observed sitting on a hand washing sink in the kitchen. The drinking ends were turned down, and water was observed dripping from the sink's faucet, onto one of the glasses. During the interview on 12/04/2014 at 2:10 PM, EI #5, the Dietary Supervisor, was asked if it was appropriate to place a crate with clean glasses on the hand washing sink and allow water to drip onto them. EI #5 replied, "No. Because clean glasses should not be on the sink where you wash your hands at. Water dripping onto the clean glass would contaminate the glasses and the sink would, too." During the interview with EI #8, the Dietary Manager, on 12/04/2014 at 2:58 PM, EI #8 was asked if it was appropriate to place a crate with clean glasses on the hand washing sink and allow water to drip onto them. EI #8 responded, "No ma'am." EI #8 was asked why not, and she replied, "Contamination." 7) A review of the 2013 Food Code by the United States Public Health Service (USPHS) and the Food and Drug Administration (FDA) included the following: "... 3-403.11 Reheating for Hot Holding. (A) ... TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the FOOD reach a temperature of at least ... (165 {degree} F) for 15 seconds ... 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) ... TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At ... (135 {degree} F) or above ... ." During the lunch tray line observation on 12/04/2014 at 10:32 AM, the salisbury steaks were observed to be 124 degrees F. EI #5, the Dietary Supervisor, informed the surveyor, "(The salisbury steaks) Gotta go back in (the) oven." The meat was replaced in the oven. At 10:39 AM, the salisbury steaks were observed to be 143 degrees F. EI #5 informed the surveyor, "Supposed to be at least 165 degrees. Gonna put it back in." The meat was again placed in the oven. At 10:44 AM, the salisbury steaks registered 151 degrees F. EI #5 informed the surveyor, "Gotta get it right before I can serve it." EI #5 added some water to the pan with the meat, and informed the surveyor she added water, "To add some steam." The salisbury steaks were again placed into the oven. At 10:51 AM, the salisbury steaks registered 167 degrees F. The salisbury steaks were then placed back onto the tray line to be served to the residents. During the interview with EI #5 on 12/04/2014 at 2:10 PM, EI #5 was asked what the facility's policy was on re-heating a hot food item if it was less than 135 degrees on the tray line. EI #5 stated, "It's supposed to be 165 degrees." EI #5 was asked how many times could staff re-heat a food item if it was less than 135 degrees F, on the initial testing. EI #5 replied, "I'm not sure. I thought you could re-heat (it) until it gets to 165 degrees." EI #5 was asked what the potential harm was of re-heating a food item more than one time. EI #5 replied, "It must be because of contamination." EI #5 was asked how many times had she re-heated the salisbury steaks during the observation on 12/03/14, and she replied, "3 times." During the interview with EI #8 on 12/04/2014 at 2:58 PM, EI #8 was asked what the facility's policy was on re-heating a hot food item if it was less than 135 degrees on the tray line. EI #8 replied, "We don't have a policy. They re-heat to 165 degrees for 15 seconds." EI #8 was asked how many times staff could re-heat a food item if it was less than 135 degrees F, on the initial testing. EI #8 stated, "We can only re-heat once. After that, it's to be thrown out." EI #8 was asked what the potential harm was of re-heating a food item more than one time. EI #8 responded, "The food wouldn't be good. It would be dried out." 8) A review of the U.S. Public Health Service 2013 Food Code, Chapter 6, Section 6-501.14 "Cleaning Ventilation Systems, Nuisance and Discharge Prohibition," revealed: "(A) Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt, and other material. ..." During the tour of the kitchen on 12/02/2014 at 10:55 AM, the vent hood over the stove was observed with small amounts of grayish, black/brown substances. EI #5, the Dietary Supervisor, informed the surveyor that maintenance cleaned the vent hood, and that it was cleaned last week. On 12/03/2014 at 8:25 AM, the vent hood was observed with a grayish/black substance on the slats. On 12/03/2014 at 2:10 PM, EI #7, the Maintenance Supervisor, was in the kitchen. EI #7 informed the surveyor, "That is a little grease and it comes right off." EI #7 went on to inform the surveyor, "(The) Vent hood (is) cleaned once a month. We clean them the first week in every month and haven't got to them yet." On 12/04/2014 at 10:54 AM, an interview was conducted with EI #7. EI #7 was asked who was responsible for maintaining the vent hood over the stove in the kitchen. EI #7 replied, "We (my department) clean them monthly, and (Named Company) comes in semi-annually to clean them. They service them and do the heavy cleaning above what we do. Me and (EI #11), my helper, clean them the first of each month." EI #7 was asked when the vent hood was cleaned last. EI #7 replied, "(EI #11) cleaned it yesterday, but before that it was during the first week of November." EI #7 was asked what condition the vent hood was observed to be in on 12/03/2014 at 2:10 PM. EI #7 replied, "It wasn't heavy, but mild grease. We'd call that 3 ? week old grease. ..." EI #7 was asked what the potential harm was of the grayish/black/brown substances on the vent hood over the stove. EI #7 stated, "Nothing. It's in the filter itself. The filters are not deteriorating. They are in good working condition." During the interview on 12/04/2014 at 2:10 PM, EI #5, the Dietary Supervisor, was asked who was responsible for maintaining the vent hood over the stove in the kitchen. EI #5 stated, "Maintenance." EI #5 was asked when the vent hood was cleaned last, and by whom. EI #5 stated, "Maintenance once a month. He will clean it if the supervisor observes it needs it, but at least once a month." EI #5 was asked when the vent hood was cleaned last. EI #5 responded, "Last month (November) by maintenance." EI #5 was asked what the potential harm was of the grayish/black/brown substances on the vent hood over the stove. EI #5 replied, "Contamination." During the interview on 12/04/2014 at 2:58 PM, EI #8, the Dietary Manager, was asked who was responsible for maintaining the vent hood over the stove in the kitchen. EI #8 replied, "Maintenance." EI #8 was asked what the potential harm was of the grayish/black/brown substances on the vent hood over the stove. EI #8 stated, "It could flake off and into the foods you're cooking."

Based on an observation, interviews, and record reviews, the facility failed to ensure a CNA (Certified Nursing Assistant) provided incontinence care in a manner to prevent the potential for cross contamination. This affected RI (Resident Identifier) #8, one of one resident observed for incontinence care. Findings include: A review of Potter - Perry Fundamentals of Nursing, 7th Edition with a copyright date of 2009, Chapter 39, page 877, revealed, "SKILL 39-2 PERINEAL CARE: STEPS 1. Identify clients at risk for developing infection of genitalia, urinary tract, or reproductive tract ... 3. Apply clean gloves, and assess genitalia for signs of inflammation, skin breakdown, or infection ...Discard gloves. Perform hand hygiene. ... 9. Apply clean gloves. 10. If fecal material is present, enclose in a fold of underpad or toilet tissue, and remove with disposable wipes or tissue. Cleanse buttocks and anus, washing front to back ... Cleanse rinse, and dry area thoroughly. If needed, place an absorbent pad under client's buttocks. Remove and discard underpad, and replace with clean one. 11. If gloves are soiled, perform hand hygiene and then apply new pair of gloves." A review of RI #8's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of an Admission MDS (Minimum Data Set) for RI #8, with an Assessment Reference Date of 11/27/2014, revealed RI #8 was coded as having short term and long term memory problems and was severely impaired for cognitive skills for daily decision making. RI #8 was coded as being totally dependent on staff for all ADLs (Activities of Daily Living) such as bed mobility, transfers, dressing, eating, toilet use, personal hygiene, and bathing. RI #8 was coded as being always incontinent of bladder and bowel function. On 12/3/2014 at 11:10 AM, the surveyor observed incontinence care provided to RI #8 during the wound care observation. The surveyor observed EI (Employee Identifier) #10, CNA, assisting the Treatment Nurse with wound care. EI #10 was holding RI #8 on the side when she stated RI #8 was wet. EI #10 went to the closet and obtained a clean adult brief and personal wipes. EI #10 then pulled the wet brief off and wiped RI #8's bottom from back to front two times. EI #10 then turned the resident onto the back after placing a clean brief under the resident. EI #10 wiped the front of the perineal area with 3 [MEDICAL CONDITION] with different disposable wipes from back to front. EI #10 did not open the front of the labia to clean the front of RI #8's perineal area. EI #10 positioned RI #8 on the right side and pulled the covers up over the resident. EI #10 failed to change gloves or wash hands prior to positioning the resident after providing incontinence care. On 12/3/2014 at 2:00 PM, an interview was conducted with EI #10. EI #10 was asked when should hand washing be performed during incontinence care. EI #10 stated, "Before, after, anytime you are giving care in between. Also, change gloves when they are visibly soiled." EI #10 was asked when did she wash her hands and change her gloves while providing incontinence care for RI #8. EI #10 stated she knew she changed gloves after she finished turning RI #8. EI #10 also stated, after she finished and got the resident comfortable she washed her hands and changed gloves. EI #10 was asked what direction should be used to wipe when cleaning a resident. EI #10 stated from front to back. EI #10 was asked what direction did she wipe when cleaning RI #8. EI #10 stated from back to front. EI #10 also stated that she had realized it during care. EI #10 was asked what the concern was when residents were wiped from back to front during incontinence care. EI #10 stated Urinary Tract Infection. On 12/4/2014 at 1:50 PM, an interview was conducted with EI #13 (Director of Nursing). EI #13 was asked when should staff wash their hands and change their gloves during incontinence care. EI #13 stated before donning gloves and taking them off. EI #13 stated at any time staff came into contact with soiled items, they were to wash their hands, donn gloves and restart the process. EI #13 stated, for example, if they have to go into a closet they can't use those same gloves. EI #13 stated staff could not wash hands or change gloves too many times. EI #13 was asked what the concern was regarding staff not changing gloves or washing hands during incontinence care. EI #13 stated contamination and infection control. EI #13 was asked which direction staff should wipe during incontinence care. EI #13 was asked what the concern was regarding the observation of RI #8's incontinence care provided by EI #10. EI #13 stated cross contamination, infection, and Urinary Tract Infections.

Based on observations, interviews and record reviews, the facility failed to ensure: 1) A Licensed Practical Nurse (LPN) did not drop supplements on the floor and then administer them to RI (Resident Identifier) #5. 2) An LPN washed or sanitized her hands between residents during the medication pass. These deficiencies had the potential to affect RI #s 5, RI #9 and RI #14, three of eight residents observed during medication pass. Findings include: A review of the facility's policy titled: "Hand Washing," with a revised date of 01/01/14, revealed the following: "Policy: It is the policy of (the name of the facility), for its employees to thoroughly cleanse their hands ...to provide medical asepsis in an effort to control infection and reduce the transmission of organisms from: resident to resident, nursing staff to resident and/or resident to nursing staff. ..." A review of Potter / Perry, "FUNDAMENTALS OF NURSING," Seventh Edition, Chapter 34, Infection, Prevention and Control, page 655, documented: "The CDC (Centers for Disease Control and Prevention) ... recommends the following: 1. Wash hands with water and either a non-antimicrobial or antimicrobial soap... 2. ... a. After contact with a client's intact skin... c. After contact with body fluids or excretions... d. When moving from a contaminated to a clean body site during patient care e. After contact with inanimate objects (including medical equipment) in the immediate area of the client... h. After removing gloves..." 1. A review of RI #5's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #'5's Quarterly MDS (Minimum Data Set), with the ARD (Assessment Reference Date) of 11/11/14, revealed RI #5 had an BIMS (Brief Interview for Mental Status) score of 7 out of 15 possible points. This score indicated RI #5 had severe cognitive impairment. RI #5 required extensive assistance for all activities of daily living. A medication pass observation for RI #5 was done on 12/3/14 at 8:45 AM with EI (Employee Identifier) #12. EI #12 dropped a container of [MEDICATION NAME] and a package of [MEDICATION NAME] Powder onto the floor. EI #12 picked the items up off of the floor and put them into her uniform pocket. EI #12 entered RI #5's room and put the two items, along with other medications, on top of the resident's bedside table. EI #12 washed her hands and applied gloves and then gave the [MEDICATION NAME] via [DEVICE]. After administering other items via tube, EI #12 preceded to mix the [MEDICATION NAME] Powder with water. The package of [MEDICATION NAME] Powder that was dropped onto the floor, touched the inside of the cup when the powder was poured into the cup. EI #12 gave RI #5 the mixture to drink. 2. A review of RI #9's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #9's admission orders [REDACTED]. A review of RI #14's medical record revealed RI #14 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #14's Quarterly MDS, with an ARD of 10/07/14, revealed RI #14 had a BIMS score of 6 out of a possible 15 points. This score indicated RI #14 had severe cognitive impairment. RI #14 required extensive to total assistance for all activities of daily living. On 12/03/14 from 9:35 AM to 9:50 AM, the surveyor observed a medication pass with EI #9. EI #9 administered medications via Gastrostomy tube to RI #9. EI #9 washed her hands and then pulled the trash with her bare hands. EI #9 left RI #9's room and put the bag of trash in a container. EI #9 did not wash her hands or use a sanitizer. EI #9 documented on the MAR (Medication Administration Record) then pushed the medication cart to another hall. EI #9 went into the dining room and then pushed RI #14, who was in a wheelchair, into another room. EI #9 obtained a medication patch out of the medication cart. EI #9 applied gloves, but did not wash her hands. EI #9 applied the patch to RI #14's right upper chest, removed the gloves, then pushed RI #14 back to the dining room. EI #9 used alcohol gel, then documented on the MAR. On 12/03/14 at 2:45 PM, the surveyor interviewed EI #9. EI #9 was asked when should hands be washed during medication pass. EI #9 stated, "Any time, before putting on gloves, taking off gloves, dealing with body fluid, doing dressings, and so on." The surveyor asked EI #9 when did she wash her hands after she pulled the trash from RI #9's room. EI #9 stated, "I don't remember, to be honest." The surveyor shared the above observation with EI #9, and then asked what the concern was. EI #9 stated, "Infection control between patients." An interview was conducted with EI #13, the Director of Nursing of the facility. The surveyor shared the above observation regarding the lack of hand washing during the two medication pass observations. EI #13 was asked what the concern was. EI #13 stated, "Infection control."

Based on observations, interviews, and record review, the facility failed to: 1) ensure new interventions were implemented following Resident Identifier (RI) #'7's fall on 08/27/2013. On 09/06/2013, RI #7 sustained a fall which resulted in a laceration requiring an emergency room (ER) visit and staples to his head; 2) implement planned interventions, to include not to leave the resident in his room alone in his chair, resulting in RI #7 sustaining a fall with laceration to his forehead on 09/27/2013 and to keep RI #7's bed in the lowest position at all times; 3) ensure direct caregivers were aware of interventions in place for the prevention of falls for RI #7; The facility further failed to ensure RI #8, a resident at risk for falls, wore non-skid socks as care planned. These failures affected 2 of 8 residents sampled for falls. Findings Include: 1) RI (Resident Identifier) #7 was admitted to the facility on [DATE] and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of RI #7's "Resident Admission Care Plan" dated 8/2/13 revealed the following: "... Strip alarm at all times. Fall precautions due to multiple falls while at home..." The Fall Risk Assessments dated 8/2/2013 and 8/5/2013 indicated RI #7 was at moderate risk for falls. The Fall Risk Assessments dated 8/6/2013, 8/7/2013, 8/19/2013, 8/28/2013, 9/9/2013, and 9/30/2013 indicated RI #7 was at high risk for falls. Review of RI #7's admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 08/09/2013, revealed RI #7 scored a 7 out of 15 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. Further review revealed RI #7 required one person physical assistance with bed mobility, transfers, walking in his room and the corridor, and locomotion. Further review of RI #7's admission assessment revealed RI #7 was not steady when moving from a seated to standing position, walking, turning around while walking, or for surface to surface transfers. RI #7 was only able to stabilize with staff assistance. This assessment also indicated RI #7 had sustained 2 or more falls without injury and 1 fall with minor injuries since his admission, re-entry, or prior assessment. Review of RI #7's care plans revealed the following: "... admitted [DATE]... CP (care plan) Date: 8/21/2013... Safety: I fell at home several times and hurt myself as a result of falling. I had to come here for therapy so that I could get stronger. My balance is not as good as it used to be and I cannot stand or walk without someone helping me. I will try to get up on my own and not wait for help. I have fallen several times since I have been here and I have an alarm in place that let the staff know I am getting up on my own without help... Since I have had several falls in the past I could fall again..." RI #7 sustained a fall on 8/27/13. Review of the "Resident Incident Report" for RI #7's fall on 8/27/13 revealed he was found on the floor of his room with no injuries noted. His alarm was on but not sounding. The following interventions were implemented after this fall: make sure alarm is intact and working properly and continue to monitor for 72 hours for any signs of injuries. These approaches were a continuation of previous care plan interventions. During an interview on 1/16/14 at 4:35 PM, Employee Identifier (EI) #5, the MDS/Care Plan Coordinator, stated they had implemented the following after RI #7's fall on 8/27/13: monitor for 72 hours for injuries, monitor the alarm, and body audit for 72 hours. EI #5 then stated none of those interventions would prevent a fall. She then explained although the body audit was new, it was not in her opinion, an intervention for falls. During an interview on 1/17/14 at 11:25 AM, EI #13, the Risk Management Coordinator/QA (Quality Assurance) Nurse, stated staff were instructed to make sure RI #7's alarm was intact and working properly after his fall on 8/27/2013. EI #13 further stated that was not a new intervention. RI #7 sustained another fall on 9/6/13. Review of the "Resident Incident Report" for RI #7's fall on 9/6/13 revealed RI #7 was found on the floor of his room with a laceration to the back of his head. RI #7 was assessed and an order was received to send him to the emergency room for treatment and evaluation, where he received staples to close the laceration. Following their investigation of the fall, the facility implemented the following corrective action: staff not to leave resident in chair while alone in room and eat in Restorative Dining Room. Review of the notes from the emergency room following RI #7's fall on 9/6/2013 revealed a CT (Computed Tomography) of his brain had been performed at the emergency room and did not indicate an intracranial hemorrhage. RI #7 was diagnosed with [REDACTED]. During an interview on 1/17/14 at 11:25 AM, EI #13, the Risk Management Coordinator/QA Nurse, stated for RI #7's fall on 9/6/13, they had implemented the following: Restorative Dining Room for meals, instructed staff not to leave resident up in his chair alone in his room, and up to nurse's station after his family leaves. RI #7 sustained another fall on 9/27/13 after being left alone in his room in his chair. Review of the "Resident Incident Report" for RI #7's fall on 9/27/13 revealed RI #7 was found on the floor of his room with a hematoma and laceration to his head after being left alone in his room in his chair. The CNA (Certified Nursing Assistant) at the time of the fall stated RI #7 was seated in his chair when she left the room to get a towel, and upon her return to the room she found him on the floor. An order was obtained to transfer RI #7 to the emergency room for treatment and evaluation. On 9/27/2013 at 6:20 AM, prior to RI #7's fall, the nurse documented in the Nurses's Notes that RI #7 was up in his recliner in his room. At 7:25 AM the nurse documented she was called to RI #7's room by the CNA to report RI #7 had been found on the floor with the alarm sounding. Upon RI #7's return from the emergency room at 11:15 AM, steri-strips were applied to the laceration to his forehead. The Medical Director documented the following in the Progress Notes upon notification of RI #7's fall on 9/27/2013: " ... 0755 (7:55 AM)... nurse called & reported the (RI #7's name) had fallen & lacerated his scalp... LPN (Licensed Practical Nurse) reported CNA had just left room after preparing his breakfast. He had been in his chair. CNA heard alarm & found him on floor after falling from his chair..." During an interview on 1/18/14 at 6:50 PM, the surveyor and EI #5, the MDS/Care Plan Coordinator, discussed RI #7's falls that occurred on 9/6/13 and 9/27/13. EI #5 stated the corrective action following RI #7's fall on 9/6/13 was not to leave resident alone in his room. The surveyor then asked EI #5 if RI #7 had been alone at the time of his fall on 9/27/13. EI #5 explained RI #7 was alone in his recliner. She then stated, "They did not follow his care plan." RI #7 was discharged from the facility on 9/30/2013 and was readmitted to the facility 10/11/2013. Review of RI #7's current Minimum Data Set (MDS) Assessment, a quarterly assessment, with an Assessment Reference Date (ARD) of 10/26/2013 revealed RI #7 had scored an 8 out of 15 on the BIMS, indicating moderate cognitive impairment. Further review revealed RI #7 required one person physical assistance with bed mobility, transfers, walking in the corridor, and locomotion. This MDS indicated RI #7 had not walked in his room during the 7 days prior to the assessment. Further review of RI #7's quarterly MDS revealed he was not steady when moving from a seated to standing position, walking, turning around while walking, or for surface to surface transfers. RI #7 was only able to stabilize with staff assistance. On 11/9/2013 RI #7's safety care plan was updated to include an approach to leave his bed in the lowest position at all times when alone. During the initial tour of the facility on 01/14/2014 beginning at 10:12 AM, the surveyor observed RI #7 in his room in his wheel chair with a chair alarm in place. The surveyor also noted an alarm on RI #7's bed; however, his bed was in the raised (not in the lowest position off of the floor) position. On 1/14/2014 the surveyor observed RI #7 continuously from 1:25 PM until 1:37 PM and the following observations were made: At 1:25 PM, RI #7 was noted in his room in his bed. RI #7's eyes were closed at this time and appeared to be sleeping. The surveyor observed an alarm on RI #7's bed; however, his bed was in the raised position. At 1:30 PM staff knocked on the door to RI #7's room and entered. The staff asked RI #7 how he was doing. RI #7 asked the staff what time it was, and the staff replied, "It's about 1:30 (PM)." Staff exited the room. The door remained open and the bed was in the raised position. The surveyor asked what care the staff had provided, and she stated she was just checking on him because she heard him "moving around a little." At 1:35 PM another staff member entered RI #7's room and shut the door and immediately exited. When asked what care she had provided, the staff member stated she was looking to see if RI #7's wife had been in yet, because she normally leaves her a paper. At 1:36 PM housekeeping was observed using a dust mop in RI #7's room. Upon her exiting, the door remained open and RI #7's bed was still in the raised position. At 1:37 PM, 3 staff members (CNA, RN {Registered Nurse}, and Maintenance Staff) entered RI #7's room. The surveyor knocked and entered the room once staff stated it was okay. RI #7 was observed in his bed with his eyes closed. He appeared to be sleeping. His bed was in the raised position. When asked what they were doing, one staff member stated they were "trying to fix this control." When asked if it was a control for the TV, staff stated, "No the bed." Staff indicated they were unable to get the bed to lower. Staff further commented, "We're not sure how to lower the bed down." Maybe that's as low as it goes." At this time, the resident was still in the raised bed with his eyes closed. The maintenance staff was under the bed working. The CNA was looking through drawers trying to locate a crank to lower the bed. The RN stated, "I think we have to lower the whole bed to lower it." The CNA then exited the room and brought back a crank. The bed was then lowered to the lowest position by the RN with the resident still in the bed. An interview was conducted on 1/14/14 at 1:45 PM with EI #16, the CNA caring for RI #7. When questioned regarding RI #7's bed position, EI #16 stated, "He usually tries to get out of it. If he's awake he tries to get up. It is normally low." When asked what position RI #7's bed should be in, EI #16 stated, "Low like that," pointing to the bed staff had just lowered. When asked if she knew who had raised RI #7's bed, EI #16 said she couldn't say but thought it had probably been raised when they changed the linens on Monday (1/13/14) and they had forgotten to lower it. When asked if she knew when RI #7's bed had been raised, EI #16 said, "It's been up all day..." An interview was conducted with EI #17, the CNA assigned to RI #7 at the time of the interview, on 1/17/14 at 10:20 AM. When asked what interventions/approaches were currently in place for RI #7 in regards to his falls, EI #17 stated she makes sure his alarm is on at all times, moves his wheel chair because he will try to get up, and she will redirect him or sit and talk with him. When asked how she knows what should be done for RI #7, EI #17 stated, "You can tell because of the way he is acting. I've been working with him a while. I just observe him." She further explained her approaches depend on RI #7's mood for any given day. When asked if there were any certain interventions on RI #7's falls care plan that should be implemented every day, EI #17 stated, "I haven't seen anything. In the ADL (Activities of Daily Living) book it has what he used to do, his likes and dislikes." When asked how she is notified if any interventions had been changed or added, EI #17 said she checks the 24 Hour Report Log. She also stated the 24 Hour Report Log is what she uses to determine what she should be doing for RI #7. The surveyor asked EI #17 to pull the 24 Hour Report Log for RI #7 and show her what should be done for RI #7. EI #17 pulled the report and said it was not showing anything, only indicating a skin tear for RI #7. The surveyor then asked if RI #7's bed should be in any certain position. EI #17 explained she puts the head of RI #7's bed down and his feet up, because he rests better. EI #17 then explained she makes rounds every two hours but she generally has RI #7 sitting up at the nurse's station during the day. When asked if any new instructions are provided to CNAs after a resident has a fall, EI #17 said the nurses do an incident report that is not seen by the CNAs. EI #17 again stated she goes by the 24 Hour Report or by what other CNAs tell her. An interview was conducted with EI #18, a CNA, on 1/17/14 at 10:35 AM. When asked what interventions were currently in place for RI #7 in regards to his falls, EI #18 explained he used to be an insurance salesman, so she would get him a pen and let him write quotes to occupy his time. She also stated he likes the newspaper and talking about his family. EI #18 also explained RI #7's alarm should always be under him, but stated, "Most of the time when you hear the alarm it's too late when you get there." When asked how she determines what intervention/ approaches are in place, EI #18 stated, "It depends on his day. It's not the same every day." When asked how she is notified if any interventions have been changed or added, EI #18 stated she would check the 24 Hour Report Log and the ADL book. She then stated she checks the 24 Hour Report Log daily but only checks the ADL book for his care plans when she is trying to figure out something new to try and to see if there is something new she has not tried. The surveyor then asked EI #18 how she knew what should be done on a daily basis to prevent RI #7 from falling. EI #18 explained she gets him up and keeps him calm and then tries whatever "maneuver" she thinks may work that day based on his mood. She then said, if that does not work, she goes to the ADL book to see if anything else had been added she had not tried yet. EI #6, the DON (Director of Nursing), was interviewed on 1/18/14 at 8:36 AM. When asked how caregivers know what fall interventions are in place for residents, EI #6 stated the temporary care plans, the actual care plans, and the care plan meetings. She further stated the information could be found in the ADL books. EI #6 also explained the charge nurses were in charge of putting new interventions in place after every fall. When asked how charge nurses are trained to determine what interventions will work best for each fall, EI #6 explained the nurses get with the CNAs for ideas and will also call the families to get ideas. When asked why it was important to update the care plan, EI #6 stated so that new interventions can be added and anyone can look at it. When asked what potential harm could occur if the care plans were not updated, EI #6 explained that if care plans aren't updated, staff won't know what to do and there is the potential for more falls. A follow-up interview was conducted with EI #5, the Care Plan Coordinator, on 1/18/14 at 8:40 AM. During the interview, EI #5 confirmed that RI #7's bed should be in the low position at all times. When asked why it was important to update care plans with new interventions after each fall, EI #5 stated, "So staff know what to do to prevent further falls." When asked what potential harm could occur if care plans were not updated with new interventions after each fall, EI #5 explained, "A resident could have further falls." She then stated care plans need to be updated so staff know how to care for the residents. When asked how staff knew, on a day to day basis, which interventions should be in place, EI #5 explained she had started discontinuing the temporary care plans and the information was in the ADL books. When asked how staff knew which interventions were correct prior to her recent changes, EI #5 stated, "They didn't. There was confusion." She also stated that if care plans are not followed there is the potential for further falls. 2) RI (Resident Identifier) #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of RI #8's Quarterly MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 11/13/13 revealed the resident was cognitively intact and was independent with transfers, walking in room and corridor and required a one person physical assist for dressing. The resident was occasionally incontinent of bladder and always continent of bowel. The assessment also identified RI #8 has had no falls since prior assessment. The facility "...Falls at Risk Profile and Falls Protocol " form documented the resident was assessed on 11/13/13 as at "Low Risk for Falls". The facility "Incident Report" form for the fall on 12/25/13 documented RI #8 was found on floor with no injury noted. New interventions implemented included for the resident to wear skid free socks when walking around room. A review of the facility "Incident/Accident Follow-up Form" for RI #8's fall, dated 12/30/13 and signed by EI #13, the Risk Management Coordinator/QA (Quality Assurance) Nurse revealed the following: Corrective Action: "... Encourage resident to wear skid free socks when ambulating around room..." During the initial tour of the facility begun at 10:12 AM on 1/14/14, RI #8 was observed in his room seated on the side of his bed. He had on a pair of socks (not non-skid) without shoes. Two pairs of shoes were noted beside RI #8's bed. On 1/14/14 at 1:20 PM the surveyor observed RI #8 in his room in bed. RI #8 then sat up on the side of his bed. His socks were noted to be gray and were not non-skid. On 1/14/14 at 1:34 PM the surveyor observed RI #8 ambulate to the doorway of his room without shoes or non-skid socks on to request additional food and drink from EI #6, the DON (Director of Nursing). On 1/14/14 RI #8's completed his dinner meal at 5:20 PM. Upon finishing his meal, RI #8 was observed to take his tray to the cart in the hallway. RI #8 did not have on shoes or non-skid socks. On 1/15/14 at 4:15 PM, RI #8 was observed in his room sitting on the side of his bed. He did not have on shoes or non-skid socks. The resident was observed to ambulate to the door of his room. An interview was conducted with EI #11, the CNA (Certified Nursing Assistant) caring for RI #8 on 1/15/14 at 4:45 PM. When asked if RI #8 had had any falls, EI #11 stated he had not. When asked if RI #8 was able to dress himself, EI #11 said they hand him clothes and help him. When asked if RI #8 had any interventions in place to prevent falls, EI #11 said his chair and oxygen tank should be kept out of his walk way because he stumbles when he gets up. The surveyor then asked how CNAs knew what interventions were in place for residents. She stated she looked at the ADL (Activities of Daily Living) book. When asked to look in the ADL book and tell the surveyor what should be in place for RI #8, EI #11 stated RI #8 had a fall on 12/25/13 when she was not there. She said after 12/25/13 there was an intervention on the "Temporary Care Plan" for RI #8 to wear non-skid socks. She stated this would be a continuous intervention to keep him safe. EI #11 also explained that if RI #8 was seen without non-skid socks on, he should be encouraged to put some on. The surveyor then asked if RI #8 was currently wearing non-skid socks. EI #11 stated, "I don't know." At 4:50 PM, EI #11 entered RI #8's room and verified he did not have non-skid socks on. When asked why it was important to make sure RI #8 had non-skid socks on, EI #11 stated to keep him from falling or slipping again. An interview was conducted with EI #5, the Care Plan Coordinator on 1/18/14 at 8:40 AM. During the interview EI #5 stated skid free socks had been added to RI #8's care plan on 12/25/13. She further stated that the skid free socks could be effective to keep RI #8 from sliding when ambulating. When asked if RI #8 should have non-skid socks on, EI #5 said he should. EI #5 said that RI #8 could fall again if staff did not follow his falls care plan.

Based on observations, interviews and record review, the facility failed to ensure Resident Identifier (RI) #7, a resident with a 10.6 percent weight loss in one month, was assessed by the Registered Dietitian for his nutritional needs and recommendations to prevent further weight loss. The facility identified RI #7's significant weight loss on 10/17/2013; however, his high calorie diet was not implemented until 11/6/2013 (3 weeks later). The facility further failed to ensure RI #8 received two health shakes after each meal as indicated by his care plan and then failed to increase health shakes as recommended by the Certified Dietary Manager (CDM). This affected two of three residents sampled for nutritional concerns. Findings Include: 1) RI (Resident Identifier) #7 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of RI #7's Initial MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/9/2013 revealed RI #7 required limited one person physical assist with eating. When RI #7 was readmitted to the facility on [DATE] his diet orders were for a regular diet with chopped meats. On 10/14/2013 the CDM documented RI #7 weighed 151 pounds at readmission, indicating a 9.6 percent loss in 30 days, and was receiving a regular diet with chopped meats. The CDM further documented RI #7 was in the hospital from 9/30/2013 until 10/11/2013. On 10/17/2013 the "Roundtable Meeting Minutes" indicated the Interdisciplinary Team had discussed RI #7's 14 pound weight loss (from 165 pounds to 151 pounds) and had recommended implementing a high calorie diet. However, RI #7's October 2013 orders did not reflect any changes to dietary orders; nor, did his nutritional care plan reflect the recommendation of a high calorie diet from this 10/17/2013 meeting. Review of RI #7's Quarterly MDS assessment with an ARD of 10/26/2013 revealed RI #7 required limited one person physical assist for eating. It further revealed RI #7 had experienced a weight loss not prescribed by a physician. During the "Roundtable Meeting " on 11/6/2013 staff discussed RI #7's additional 13 pound weight loss in one week: 153 pounds on 10/23/2013 to 140 pounds on 10/30/2013. Again staff recommended to restart RI #7's high calorie diet. In addition, the Roundtable Committee recommended adding a health shake at night and obtaining labs as ordered. On 11/6/2013 an order was obtained for [MEDICATION NAME] and [MEDICATION NAME] levels due to [MEDICAL CONDITION] and weight loss. An order was also written to continue high calorie foods on all meal trays and for a health shake at bedtime for weight loss. RI #7's nutritional care plan was updated on 11/6/2013 to reflect these orders. RI #7's [MEDICATION NAME] was 3.4 (flagged Low) on 11/8/2013, below the normal range of 3.5-4.8. His [MEDICATION NAME] was 12 (flagged Low) on 12/10/2013, below the normal range of 20-40. On 11/13/2013 the CDM documented in the Dietary Progress Notes that EI #5, the MDS/Care Plan Coordinator, had contacted her on 11/6/2013 for a recommendation to address RI #7's 13 pound weight loss. RI #7 was started on high calorie foods and a health shake at bedtime to promote weight gain. A telephone interview was conducted with EI #3, the Registered Dietitian, on 1/18/14 at 11:40 AM. During the interview, EI #3 stated any significant changes in weight are brought to her attention on a monthly basis. When asked if she was familiar with RI #7, EI #3 stated she was not. The surveyor then provided some basic information regarding RI #7's weight loss and asked at what point she should have assessed him. EI #3 stated weights are tracked on a 30, 90, 120, and 180 day basis and indicated RI #7's weight loss should have been flagged so she would know to assess him. She also stated she should have assessed RI #7 upon any return from a hospital stay as well. When asked how she would be notified of the need to assess a resident due to a significant weight loss, EI #3 stated that EI #2, the CDM, would call her, but was unsure if there was a policy in place on how/when to contact her. When asked what involvement she had in suggesting supplements, EI #3 explained supplements were generally started by EI #2 and then she (EI #3) reviewed them. An interview was conducted with EI #5, the MDS/Care Plan Coordinator on 1/18/2014 at 4:30 PM. During the interview, EI #5 provided a general outline of RI #7's weight loss and the approaches initiated by the facility. EI #5 explained RI #7 had weighed 170 pounds upon his admission on 8/2/2013. EI #5 stated RI #7's weight for 11/6/13 was 135 pounds (an additional 5 pound loss), and explained when the weight loss was discovered, she contacted EI #2, the CDM. EI #5 was under the impression RI #7 had already been on high calorie foods. When asked if the dietitian had been consulted regarding RI #7's weight loss, EI #5 stated she did not know. EI #5 did state RI #7's weight loss would be considered a significant loss. EI #5 referred the surveyor to EI #2, the CDM, to determine if the dietitian should have assessed RI #7. EI #2, the CDM, was interviewed on 1/19/2014 at 8:55 AM. When asked if the dietitian had assessed RI #7 at any point after her initial assessment on 8/30/2013, EI #2 stated, "I had him on my list for her to see and it was marked off. There aren't anymore (Dietitian Assessments). I don't know what happened. I don't know why he fell through." When asked if there were certain triggers requiring a Dietitian Assessment, EI #2 stated anyone with a significant weight loss would be put on the list for her to see. When asked when RI #7's high calorie foods had been started, EI #2 explained he had been on them prior to 9/30/2013 when he went to the hospital. She then stated upon his return, RI #7's diet order was for regular with chopped meats and high calorie foods were not ordered until 11/6/2013. EI #2 then explained RI #7 was on weekly weights upon his return in October. When asked how the weekly weights were used, EI #2 explained everyone gets copies of weekly weight on Wednesdays of each week and any problems noted would be discussed on Thursday in the weekly Roundtable Meeting. EI #2 then stated RI #7's weight loss should have been addressed in the weekly Roundtable meetings. When asked if the Registered Dietitian had assessed RI #7 due to his significant weight loss, EI #2 stated she had not. When asked why it is important for the dietician to review/assess residents experiencing weight loss, EI #2 said, "To make sure their needs are being met and we are putting in interventions that would prevent further weight loss." On 1/19/2014 at 12:40 PM, EI #2, the CDM, verified RI #7 had not been receiving high calorie foods upon his return from the hospital on [DATE]. She stated from 10/11/2013 to 11/6/2013, RI #7 had been receiving a regular diet with chopped meats. EI #6, the Director of Nursing, was interviewed on 1/19/2014 at 2:40 PM. During the interview, the surveyor asked EI #6 to explain what was discussed during the Roundtable Meetings concerning RI #7's weight loss. EI #6 stated they had identified RI #7 as having a weight loss of 14 pounds on 10/17/13. When asked what approaches they had put in place upon identifying RI #7's significant weight loss, EI #6 stated he was already on a high calorie diet. When asked if RI #7 should have been on a high calorie diet as of 10/17/2013, EI #6 stated if he wasn't already on it, it should have been ordered that day. When asked when RI #7 should have been receiving the high calorie diet, EI #6 stated he should have been on it since his readmission of 10/11/2013. EI #6 then stated they had again discussed RI #7's weight loss during their Roundtable Meeting on 11/6/2013. She said at that time they had noted a 13 pound weight loss in one week. She said they had restarted his high calorie diet. The surveyor then asked why RI #7's high calorie diet had not been restarted until 11/6/2013 since during the meeting on 10/17/2013, they had indicated he should be on the high calorie diet. EI #6 stated, "That is a discrepancy." EI #6 again stated RI #7's high calorie diet should have been in place prior to 11/6/2013. As of the end of the survey, the Registered Dietitian had not assessed RI #7's nutritional needs in relation to his significant weight loss. 2) RI (Resident Identifier) #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #8's medical record revealed a Dietary Note dated 2/27/2013 by EI #2, the CDM. EI #2 documented RI #8 was at risk for weight loss due to the resident's decreased meal intake. RI #8 preferred to drink health shakes rather than eat his meals because that is what he liked. RI #8 received 8-10 health shakes a day. The Registered Dietitian assessed RI #8 on 4/26/2013. At the time of her assessment, RI #8 weighed 151 pounds. The Registered Dietitian documented that RI #8's nutritional needs were not being met due to refusing meals, but indicated the meals, snacks, and health shakes combined were adequate. On 11/12/2013, EI #2, the CDM, documented the following for RI #8: "NUTRITIONAL ASSESSMENT... Weight 144 # (pounds)... Meal Consumption % (percent) eaten (average x last 7 day) 25%... Supplements... Healthshakes x3 w/meals (times three with meals).. Progress Note... At Risk for: wt (weight) loss... calorie needs not met with current intake & (and) supplements... Summary: Res (resident) has no appetite, loves Healthshakes and Choc. (chocolate) candy... Recommendation: Health shake on meal tray x3 (times 3)..." Review of RI #8's most recent Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/13/2013 revealed he scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating he was cognitively intact. Further review also revealed RI #8 could eat independently and required no staff assistance. RI #8's current care plan (reviewed 11/20/13) for Nutrition/Hydration included the following nutritional approaches: " .... I like to get 2 Health shakes after meals and at bedtimes some days I drink 8-10 health shakes. I like them and had rather drink them than eat..." A review of RI #8's "Physician Orders" for January 2014 revealed the following: "...Date 5/01/13 (of order)...Time Code HS (hour of sleep)... Health shake ii (two) carton po (cartons by mouth) after each meal...", an order to offer a Regular Health Shake if 50% or less of a meal was eaten and a Regular with chopped meat no added salt diet. A review of RI #8's January 2014 "MEDICATION ADMINISTRATION RECORD" included an order for [REDACTED]. Facility staff were only recording health shakes for RI #8 at 8:00 PM. On 1/14/2014, the surveyor observed RI #8's dinner meal. RI #8 completed his meal at 5:20 PM. Upon completing his meal, RI #8 placed his tray on the cart in the hallway. No shakes were observed on his tray. RI #8 completed approximately 50% of his meal. A continuous observation was made from 5:20 PM until 5:35 PM following his supper meal. RI #8 did not receive his Health Shakes during this time. At 5:35 PM, the surveyor asked RI #8 if he ever received his health shakes after he finished his dinner meal. RI #8 stated he sometimes gets them but not all the time. When asked when they normally give him his shakes, RI #8 explained, "It varies but its normally later if I get them." On 1/15/2014, the surveyor observed RI #8's dinner meal. At 5:20 PM, RI #8 walked to his doorway to notify staff he was done. RI #8 completed approximately 50% of his meal. Staff entered to take his tray but did not take him his Health Shakes. A continuous observation was made from 5:20 PM until 5:55 PM and health shakes were not delivered to RI #8 during that time. An interview was conducted with EI (Employee Identifier) #5, the MDS/Care Plan Coordinator, on 1/18/2014 at 4:30 PM. During the interview, EI #5 stated RI #8 should be receiving two health shakes after each meal. She further stated the two health shakes after each meal had been implemented on 5/1/2013. When asked what potential harm could occur if staff were not giving RI #8 the two health shakes after each meal as indicated on his care plan, EI #5 stated he could lose more weight. An interview was conducted with EI #2, the CDM (Certified Dietary Manager), on 1/19/2014 at 8:55 AM. During the interview, the surveyor asked if RI #8 had any weight loss concerns. EI #2 stated RI #8's weight had been up and down, but he had not had any significant weight loss. EI #2 further stated RI #8's intakes had decreased because he loves the health shakes and that is all he wants. When asked how many shakes RI #8 should be receiving each day, EI #2 said he should be getting 8 to 10 shakes per day and any more he may request. When asked what impact it could have on RI #8 if he was not receiving his shakes with every meal, EI #2 stated, "He would lose weight." EI #2 explained that RI #8's bedtime shakes are on his snack list, but further explained the others would be provided by nursing staff. EI #2 then stated she had recommended three health shakes with each meal on 11/12/2013. When asked if there was any documentation on follow-up to her recommendation, EI #2 said no. When asked what the procedure was for obtaining orders based off of her recommendations, EI #2 said she puts a sticky note on the chart and the nurses get the order. When asked if that should have occurred on 11/12/2013 for her recommendation of three shakes with each meal, EI #2 said it should. EI #2 then reviewed RI #8's chart and stated, "It was never followed up on." EI #2 then explained if RI #8 had been receiving the two shakes as ordered, she might not have needed to recommend increasing to three. An interview was conducted with EI #6, the DON (Director of Nursing), on 1/19/2014 at 2:40 PM. During the interview EI #6 stated she wasn't sure what had happened regarding RI #8's health shakes. EI #6 stated he should have been receiving one at bedtime and two behind meals. She further stated RI #8 was only getting the one at bedtime. When asked the process for getting orders on any supplement recommendations, EI #6 stated they give them to the doctor to review. When asked about the recommendation for 3 shakes with each meal, EI #6 stated an order should have been written for the three shakes with each meal.