Every finding on record at Diversicare of Oneonta

Based on record reviews, interviews, facility document review, the Confirmation of Receipt of Online Incident Report, and facility policy titled Abuse, Neglect, Misappropriation, Exploitation Policy, the facility failed to ensure staff implemented the facility's abuse policies and procedures when: staff failed to identify an allegation of abuse, protect residents from further potential abuse, and immediately report an allegation of resident-to-resident sexual abuse on 01/14/2023 involving Resident #21 and Resident #2. Multiple staff (Registered Nurse (RN)#4, Certified Nursing Assistant (CNA) #2, Licensed Practical Nurse (LPN) #3, and CNA #37) became aware of the allegation, but no staff reported the incident to the Administrator for two days following the incident, during which time Resident #21 and Resident #2 continued to be roommates, with no measures implemented to prevent further potential abuse. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.12 (Freedom from Abuse, Neglect, and Exploitation) at a scope and severity of J. The IJ began on 01/14/2023 around 12:35 AM, when CNA #2 observed Resident #2 partially lying on Resident #21's bed. Resident #2 was wearing an unbuttoned shirt and no clothing or undergarments. Resident #2 was unfastening Resident #21's brief. CNA #2 observed Resident #2's upper body close to Resident #21's private area, Resident #2's hand at Resident #21's perineal area and thought Resident #2 was trying to penetrate Resident #21's private area. CNA #2 stated what she observed was sexual abuse; however, she did not take immediate action to protect residents from further potential abuse. CNA #2 reported the incident to LPN #3 who responded and observed Resident #2 sitting unclothed on Resident #21's bed. LPN #3 instructed Resident #2 to get back into his/her bed and did not take any further actions. The residents remained roommates without protective measures to prevent further abuse until 01/16/2023 when the incident was initially reported to the Administrator. This deficient practice placed Resident #2, one of two residents sampled for abuse, in immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment or death. On 07/22/2023 at 8:10 AM the Interim Administrator and Director of Nursing (DON) were provided a copy of the immediate jeopardy templates 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, at F607-Develop/Implement Abuse/Neglect, etc. Policies. The immediate jeopardy began on 01/14/2023 and continued until 01/20/2023, when the facility implemented corrective actions to correct the identified deficient practice and prevent recurrence; thus, immediate jeopardy past noncompliance was cited. Findings included: A review of the facility Abuse, Neglect, Misappropriation, Exploitation Policy, effective January 2019, revealed Purpose: To prohibit and prevent abuse . and to ensure reporting and investigation of alleged violations . Definitions: . Alleged Violation: A situation or occurrence that is observed or reported by team member . but has not yet been investigated . 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. Examine the resident . for any sign of injury, including a physical assessment or psychosocial assessment . If the suspected perpetrator is another resident/patient, the Administrator/Director of Nursing or designee shall separate the resident/patients so they do not have access to each other until the circumstances of the alleged incident can be determined and assessment completed and if applicable interventions put into place . 4. Prevention. Establish a safe environment: Team members are required to report incidents of suspected abuse, neglect, or misappropriation of property without fear of reprisal . 5. Identification If actual violation or alleged violation occurs the resident will be immediately assessed and removed from any potential harm . 7. Reporting/Response Alleged violations/violations will be reported to the Administrator, designee immediately . A review of Resident #21's Admission Record revealed the facility readmitted Resident #21 on 02/28/2019 diagnoses that included Adjustment Disorder with Depressed Mood, Alzheimer's Disease, and Dementia. A review of Resident #21's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/03/2023, revealed Resident #21 had a Brief Interview for Mental Status (BIMS) score of 4 (four) of 15, indicating the resident had severe cognitive impairment. The MDS also indicated Resident #21 required two-person assist for bed mobility and transfers. A review of Resident #2's Admission Record revealed the facility readmitted the resident on 04/20/2020 with diagnoses that included Major Depressive Disorder and Insomnia. A review of Resident #2's annual MDS, with an ARD of 08/05/2022, revealed Resident #2 had a BIMS score of 12 or 15, indicating the resident had moderate cognitive impairment. On 01/18/2023 Resident #2's BIMS was assessed to as 8 (eight) of 15 indicating a decline in cognitive ability since the previous assessment. A review of the Confirmation of Receipt of Online Incident Report from the Alabama Department of Public Health Online Incident Reporting System, revealed the facility notified the state survey agency of a sexual abuse allegation on 01/16/2023 at 12:08 PM. The report indicated on 01/14/2023 at 12:35 AM, Resident #2 was found straddling Resident #21 in their room, with Resident #2's shirt undone and Resident #21's brief undone. Per the report, the Administrator was made aware of the incident on 01/16/2023 at 10:30 AM by Certified Nursing Assistant (CNA) #1. During an interview on 07/18/2023 at 10:49 AM, LPN #32 reported that Resident #2 and Resident #21's beds were position parallel and about one and a half feet apart. LPN #32 added that it was just enough space between the beds where he could fit sideways. During a telephone interview on 07/13/2023 at 11:42 AM, CNA #2 stated she recalled the incident involving Resident #2 and Resident #21 but could not recall the exact time. CNA #2 stated she entered the residents' room to provide care to Resident #21 during her rounds, which she usually conducted around 12:30 AM, 2:00 AM, and 4:00 AM. CNA #2 stated she saw Resident #2 in the bed with Resident #21. According to CNA #2, Resident #2 was wearing only an unbuttoned shirt and was not wearing any bottoms, brief, or underwear. CNA #2 described that Resident #2's feet were in his/her bed, and Resident #2's chest was on the lower part of Resident #21's bed. Per CNA #2 when she entered the room, Resident #2's upper body was close to Resident #21's perineal area and Resident #2 was unfastening Resident #21's brief. CNA #2 indicated Resident #2 had his/her hand positioned at Resident #21's perineal and she thought Resident #2 was trying to penetrate Resident #21's private area. CNA #2 stated she left the room to notify LPN #3, the nurse on duty. CNA #2 reported that she found LPN #3 and reported to LPN #3 that she had a problem and did not know how to fix the situation. CNA #2 continued to tell LPN #3 that Resident #21 was in his/her bed with brief unfastened and Resident #2 was wearing an unbuttoned shirt and near Resident #21's perineal area. CNA #2 said the nurse went to the resident's room and she waited outside the room. CNA #2 reported she knew she should not have left the room, because there was sexual behavior going on and she should have yelled for help instead. CNA #2 stated she told the Administrator she knew she had done wrong, but her first instinct was to get the nurse because the situation was resident abuse. CNA #2 said had she known LPN #3 did not report the incident that she would have reported it herself. CNA #2 said what she witnessed was resident to resident sexual abuse and added she had always considered it to be sexual abuse. On 07/19/2023 during a follow-up interview, CNA #2 said she made the observation of Resident #2 in Resident #21's bed during her first round of the shift, after midnight. During a telephone interview on 06/29/2023 at 10:55 AM, LPN #3 stated she could not remember the date the incident occurred, but CNA #2 notified her that Resident #2 was sitting on Resident #21's bed, naked. LPN #3 stated she walked into Resident #21's and Resident #2's room and observed Resident #2 sitting, without clothes, on Resident #21's bed. LPN #3 stated she told Resident #2 to get back in his/her own bed and the resident did so. LPN #3 stated she did not report the incident to anyone. LPN #3 stated she did not separate the residents because Resident #2 put their clothes back on and got back in their own bed. LPN #3 stated she did not ask Resident #2 why they did not have any clothes on and just advised the resident that it was inappropriate. During an interview on 06/29/23 at 9:21 AM, RN #4 reported RN #27 told her about the incident on 01/15/2023. RN #4 said she did not report what she was told because it was over 48 hours after the incident and when she had walked on East wing it was the talk of the town. RN #4 said she thought it had been reported. During a telephone interview on 07/18/23 at 12:35 PM, CNA #37 reported that CNA #2 told her at the end of shift that Resident #2 crawled in bed with Resident #21. CNA #37 said she and CNA #2 talked about the incident that morning and the next night. CNA #37 added that everyone was talking about it. CNA #37 said she did not report the incident because she did not work on the unit in which the incident occurred. CNA #37 added, it was already being talked about all over the building, so she thought that it had been reported. During an interview on 06/29/2023 at 8:50 AM, CNA #1 stated she was the manager on duty the weekend of the incident and heard two nurses and a CNA talk about something that had occurred two days prior. CNA #1 could not recall the names of the nurses. CNA #1 stated the staff said a few days prior another CNA caught Resident #2 on top of Resident #21. According to CNA #1, the nurse told Resident #2 they were not supposed to be doing that, and Resident #2 got down off the bed. CNA #1 stated she heard the incident occurred Saturday (01/14/2023) or Sunday (01/15/2023), and she reported the incident to the Administrator on Monday (01/16/2023). During an interview on 06/30/2023 at 2:23 PM, the Administrator stated the incident occurred Friday night going into Saturday morning 01/14/2023, but she was not made aware of the allegation until 01/16/2023. According to the Administrator, CNA #1 reported to her that she overheard Resident #2 was on Resident #21 with no pants on and Resident #21's brief was not fastened. The Administrator stated staff should report it to her as soon as they see it, even if the staff did not witness the allegation because the staff may not know if the allegation had been reported. The Administrator stated through her interviews, she learned CNA #2 reported the incident to LPN #3, and by the time LPN #3 arrived at the residents' room, Resident #2 was on the side of Resident #21's bed. The Administrator stated staff should know how to protect the residents if they saw anything inappropriate. The Administrator stated CNA #2 was terminated because she should not have left Resident #21 and should have called for another CNA's assistance. According to the Administrator, LPN #3 was terminated because she failed to report the incident and she should have called the Administrator immediately. A review a Progressive Discipline Form, signed by CNA #2, their supervisor, and a witness indicated on 01/20/2023, the facility terminated the employment of CNA #2 for failure to report an instance of sexual abuse on the night of 01/13/2023 to the Administrator. A review a Progressive Discipline Form, signed by LPN #3, their supervisor, and a witness indicated on 01/20/2023, the facility terminated the employment of LPN #3 for failure to report an instance of sexual abuse on the night of 01/13/2023 to the Administrator. During a follow-up interview on 07/18/2023 at 2:21 PM, the Administrator stated CNA #2 told her that she was completing her rounds, and when she got to Resident #21's and Resident #2's room, she found Resident #2 on top of Resident #21's bed and Resident #21's shirt was undone. The Administrator stated it was determined CNA #2 left the residents' room to report the incident to LPN #3, which was a failure to protect the resident. When asked what interventions were implemented from the time the allegation occurred to the time the Administrator was notified, the Administrator stated, Absolutely nothing because the abuse coordinator was not notified. The Administrator stated at the time of the allegation, the residents should have been immediately separated and body assessments should have been completed, as well as notifications to the medical doctor, family, abuse coordinator, police, and state survey agency. The Administrator stated Resident #2 could have been sent out of the facility for an evaluation. The Administrator stated staff should have ensured all residents were protected by providing one-on-one supervision of Resident #2 until the resident could be sent out of the facility for an evaluation. This deficient practice was cited as a result of complaint/report #AL00043048. ************************************************************************************************************************************************************ Once the facility became aware of the allegation of abuse, the facility took the following corrective actions to correct the identified deficient practice: - Resident #21 was assessed for any injury by the Assistant Director of Nursing (ADON) on 01/16/2023, with no negative findings. - On 01/16/2023, Resident #21's room was changed, so that Resident #21 and Resident #2 no longer shared a room. - On 01/16/2023, statements were obtained from facility staff, and CNA #2 and LPN #3 were placed on administrative leave pending the outcome of the investigation. - On 01/18/2023, a behavioral health provider met with Resident #2 and Resident #21 to determine any signs and symptoms of distress related to the incident. - Mandatory in-service on the facility's abuse policy, with an emphasis on reporting and preventing abuse, was conducted with all facility staff from 01/16/2023 to 01/20/2023. No staff were allowed to work until the in-service was completed. - On 01/20/2023, the facility terminated CNA #2's and LPN #3's employment with the facility due to their failure to report an allegation of abuse to the Administrator. -On 01/20/2023 staff abuse in-service completed. -As part of the established quality assurance (QA) committee's practices, abuse investigations continued to be reviewed during the facility's routine QA meetings. *********************************************************************************************************************************************************** After review of documentation supporting the above corrective actions, including the facility's investigation file, in-service/education records, QA documentation, employee disciplinary forms, behavioral health visit notes, and staff interviews, the survey team verified the facility implemented corrective actions through 01/20/2023; thus, immediate jeopardy past non-compliance was cited.

Based on interviews, record review, and facility policy review, the facility failed to complete a new Preadmission Screening and Resident Review (PASARR) Level I after the resident was diagnosed with a new mental illness for one (Resident #80) of three residents reviewed for PASARR completion. Findings included: A review of the facility's undated policy titled, PASRR [PASARR] Requirements, revealed, .3. In the event a resident is discharged to a 'mental health or psychiatric hospital' and returns with a new mental illness diagnosis, a new PASRR must be completed prior to or immediately upon readmission. A review of Resident #80 Admission Record revealed the facility admitted Resident #80 on 10/29/2020 with diagnoses that included Depressive Disorders. Per the Admission Record, on 04/29/2022, the resident received a diagnosis of Paranoid Schizophrenia and on 05/04/2022, a diagnosis of Adjustment Disorder with Mixed Anxiety and Depressed Mood. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference date (ARD) of 04/13/2023, indicated Resident #80 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated was cognitively intact. The MDS indicated the resident had active diagnoses to include Anxiety Disorder, Depression, Schizophrenia, and Adjustment Disorder with Mixed Anxiety and Depressed Mood. A review of Resident #80's care plan, initiated on 11/16/2020 and revised on 07/13/2022, revealed the resident had a potential for drug related complications associated with the use of psychotropic medications - antianxiety medication, antidepressant medication, and antipsychotic medications. A review of Resident #80's medical record revealed a PASARR Level I Screening form dated 12/10/2020. In an interview on 06/30/2023 at 11:01 AM, Social Services (SS) said if a resident had a new mental diagnosis, she should complete and submit a new PASARR level I. SS confirmed Resident #80 had not had another PASARR Level I completed since 12/21/2020. SS said she was not aware Resident #80 had additional mental illness diagnoses and that another PASARR Level I was not completed, but it should have been. SS stated there was no current process to audit PASARRs completed prior to January 2023 when she began completing PASARR assessments. During an interview on 06/30/2023 at 2:01 PM, the Director of Nursing (DON) revealed she did know that when a resident had a new diagnosis or a change in their status, there should be a new PASARR level I completed. The DON agreed that a new Level I should have been completed at the time in April (2022) and May (2022) after Resident #80 had new mental illness diagnoses. In an interview on 06/30/2023 at 3:00 PM, the Administrator stated she was aware that a new PASARR Level I should be completed after a resident had a new mental illness diagnosis. The DON stated a new Level I should have been completed after Resident #80 had new mental illness diagnoses in April and May of 2022.

Based on interviews, record review, and facility policy review, the facility failed to ensure a level I Preadmission Screening and Resident Review (PASARR) was updated with a newly developed mental illness for one (Resident #14) of three residents reviewed for PASARRs. Findings included: A review of the facility undated policy titled, PASRR (Preadmission Screening and Resident Review) [PASARR] Requirements revealed, .Guidelines: In an effort of the Health Information Management Coordinator to obtain a completed record, all patients [residents] must have a Pre-Admission Screening and Resident Review prior to or immediately upon admission as required by Federal and/or a patient/resident specific review process as defined by local State guidelines. The PASRR is completed to determine provision of appropriate and needed serviced [sic] to individuals who have been diagnosed with MI/MR [mental illness/mental retardation]. Process: 1. Upon admission a PASRR must be completed timely for patients by qualified individuals . A review of Resident #14's Admission Record revealed the facility admitted the resident on 10/27/2022 with diagnoses that included Dementia without Behavioral Disturbance and Altered Mental Status. Per the Admission Record, on 11/01/2022, the resident received a diagnosis of Psychotic Disorder with Delusions. A review of Resident #14's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/26/2023, revealed Resident #14 had a Brief Interview for Mental Status (BIMS) score of seven (7), which indicated the resident had severe cognitive impairment. A review of Resident #14's care plan, initiated on 11/07/2022 and revised on 01/3/2023, indicated Resident #14 sometimes had behaviors due to their diagnosis of Psychotic Disorder with Delusions as evidenced by hallucinations of cats, dogs, and dirt on their ceiling. A review of Resident #14's State of Alabama Department of Mental Health PASRR Level I Screening & Results, dated 12/07/2022, indicated the resident did not have a current, suspected, or history of a major mental illness. During an interview on 06/30/2023 at 11:15 AM, Social Services acknowledged Resident #14's Level I PASARR was incorrect. During an interview on 06/30/2023 at 2:33 PM, the Director of Nursing said Resident #14's Psychotic Disorder should have been listed on the Level I form dated 12/07/2022 and the Level I should have been completed before 12/07/2022. During an interview on 06/30/2023 at 2:52 PM, the Administrator said a resident's PASARR should be completed before admission to the facility. Per the Administrator, if a PASARR was not accurately and timely completed accurately a resident might not receive the right level of care.

Based on interviews and record review, the facility failed to ensure treatment was provided per physician's orders for a resident who required their legs to be wrapped with a compression bandage daily due to edema for one (Resident #45) of 27 sampled residents. Findings included: A review of Resident #45's Admission Record revealed the facility admitted Resident #45 on 07/16/2022 with diagnoses that included Heart Failure, Weakness, and Type Two Diabetes Mellitus. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference date (ARD) of 06/16/2023, indicated Resident #45 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Resident #45 required limited assistance with dressing and personal hygiene. A review of Resident #45's physician's orders revealed an order dated 06/15/2023 for the resident to have both of their legs tightly wrapped with a compression bandage in the morning for edema and remove at bedtime. In an interview on 06/27/2023 at 9:54 AM, Resident #45 stated both of their legs should be wrapped daily with a compression bandage. The surveyor observed the resident's legs were not wrapped with a compression bandage. A review of a June 2023 Treatment Administration Record (TAR) revealed on 06/27/2023, Licensed Practical Nurse (LPN) #11 documented she wrapped both of Resident #45's legs with a compression bandage as directed on the TAR. On 06/28/2023 at 10:41 AM, the surveyor observed Resident #45 in their wheelchair in their room. Resident #45 did not have a compression bandage on either of their legs. Resident #45 stated no staff ever came in yesterday and wrapped their resident's legs and their legs had not been wrapped today. A review of the Progress Notes for the month of June 2023 revealed no documentation Resident #45 refused care or treatments. A review of Resident #45's comprehensive care plans revealed the resident was not care planned for noncompliance with care and/or treatments. An interview on 06/28/2023 at 12:53 PM with LPN #11 revealed physician orders for morning treatments were usually completed by her in the early morning between 7:00 AM and 8:00 AM. LPN #11 said she documented in the TAR right after the treatment was provided. LPN #11 said Resident #45 was noncompliant with having the wraps on their legs and would take them off. LPN #11 said she put the wraps on Resident #45's legs before breakfast yesterday (06/27/2023) before 7:00 AM. LPN #11 said she was going to put them on the resident's legs today, but the resident told her they were not ready get up yet. LPN #11 said she had not gone back into the resident's room today to try and put them on. She stated she did document on the TAR that the treatment of wrapping both resident's legs with a compression bandage was provided. LPN #11 confirmed that if a treatment was documented on the TAR, that meant the treatment had been provided. However, LPN #11 was unable to state why she documented the treatment was provided on the TAR when it was not provided. In an interview on 06/28/2023 at 1:19 PM, Certified Nursing Assistant (CNA) #39 stated Resident #45 was pretty compliant with care and was very sweet. She was not aware of any treatments the resident refused. CNA #39 said she had not seen the resident with their legs wrapped. During an interview on 06/28/2023 at 1:25 PM, Resident #45's roommate, who had a BIMS score of 15 per the quarterly MDS dated [DATE], stated no one came in their room today or yesterday to wrap Resident #45's legs. According to Resident #45's roommate, they had never seen Resident #45 refuse to allow staff to put the wraps on their legs, and they had never seen Resident #45 remove them. An interview on 06/29/2023 at 3:39 PM with the Administrator revealed the facility did not have a policy related to following physician orders. The Administrator stated it was a standard of practice. An interview on 06/30/2023 at 1:55 PM with the Director of Nursing (DON) revealed she expected nursing staff to provide treatments per the physician orders, and staff should not document a treatment was done until it was done. The DON stated LPN #11 should not have documented that treatment was provided on 06/28/2023 if it had not been provided. In a follow-up interview on 06/30/2023 at 3:08 PM with the Administrator revealed she expected nursing staff to complete treatment orders and to follow physician orders. The Administrator said there should be documentation that a treatment was provided only after it was completed. The Administrator said staff should document all refusals, and it should also be reflected on the resident's care plan. She said the physician should be made aware and that should be documented in progress notes. The Administrator said LPN #11 should not have documented the treatment was provided to Resident #45 on 06/28/2023 when it was not done.

Based on interviews, record review, and document review, the facility failed to ensure one (Resident #90) of one resident reviewed for vision/hearing was seen by the in-house optometrist as ordered by the physician. Findings included: A review of Resident #90's Admission Record revealed the facility admitted the resident on 03/17/2023 with a principal diagnosis of Parkinson's Disease. A review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/23/2023, revealed Resident #90 had a Brief Interview for Mental Status (BIMS) score of eight, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had adequate vision. A review of Resident #90's Order Summary Report indicated a physician's order dated 06/12/2023 for an Optometrist consult for right eye for in house MD [medical doctor]. A review of a document titled [Name] Final Appointment Listings in Alabama indicated an optometrist would be in the facility on 06/23/2023 to see 19 residents. Per the document, Resident #90 was not on the list to be seen by the optometrist. During an interview on 06/27/2023 at 9:22 AM, Resident #90 stated their right eye was blurry, and they could not see out of it. The resident stated the facility was supposed to send them to an eye doctor, but it had been three weeks and no appointment had been made. During an interview on 06/28/2023 at 11:03 AM, Licensed Practical Nurse (LPN) #5 acknowledged she received the physician's order dated 06/12/2023 for the resident to be seen by the optometrist. LPN #5 stated the physician wanted the resident to be seen by the in-house optometrist. LPN #5 stated the resident was placed on a list to see the in-house optometrist and Social Services (SS) had the list. During an interview on 06/28/2023 at 11:12 AM, SS stated the process for a resident to seen by the facility's in-house optometrist was for the resident's insurance to be approved first, and then the resident was added to the list for the next optometrist visit, which occurred every three months. SS stated staff would verbally tell her if a resident needed to be put on the list to be seen, but now the nurse placed a physician's order in the resident's electronic health record (EHR). SS stated there was a way to view a report of the orders placed in a resident's EHR, but she was used to being told of orders verbally. SS stated she was unaware Resident #90 needed to be seen by the optometrist. SS reviewed Resident #90's EHR and stated she saw the physician's order dated 06/12/2023 for an optometrist consultation. SS stated the in-house optometrist was scheduled on 06/23/2023, and Resident #90 was not on the list to be seen by the optometrist. In an interview on 06/29/2023 at 3:40 PM, the Administrator stated the facility did not have a policy related to vision. During an interview on 06/30/2023 at 1:37 PM, the Director of Nursing stated the request for Resident #90 to be seen by the in-house optometrist should have been communicated to the appropriate staff so the resident could have been seen by the optometrist on 06/23/2023. During an interview on 06/30/2023 at 2:23 PM, the Administrator stated that for a resident to be seen by the in-house optometrist, SS should be notified, and the resident would be added to the list. The Administrator stated if Resident #90 had a physician's order to be seen by the in-house optometrist prior to 06/23/2023, the optometrist should have seen Resident #90 on 06/23/2023.

Based on record review and interview, the facility failed to ensure the physician documented a clinical rationale for continuing a psychotropic medication ordered on an as-needed (PRN) basis beyond 14 days and failed to indicate a duration on the PRN order for one (Resident #63) of five residents reviewed for unnecessary medications. Findings included: A review of Resident #63's Admission Record indicated the facility admitted Resident #86 on 03/19/2021 with diagnoses that included Major Depressive Disorder, Panic Disorder, Anxiety Disorder, and Post-Traumatic Stress Disorder (PTSD). A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/01/2023, revealed Resident #63 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Further review of the MDS indicated the resident had Anxiety Disorder, Depression, Post-Traumatic Stress Disorder, and received antianxiety medication. A review of Resident #63's care plan, revised on 04/07/2023, indicated the resident had diagnoses that included PTSD, anxiety, major depressive disorder, and panic disorder. The care plan indicated Resident #63 got nervous and anxious if others knocked on the resident's door, due to it sounding like gun shots. Resident #63 was shot and was paralyzed from the neck down. The facility developed an intervention that directed staff to provide the resident with medications that helped the resident with their anxiety. A review of a Xanax audit for Resident #63 indicated an order for Xanax 1 mg tablet every eight hours as needed for anxiety with a start date of 11/07/2023 and a discontinued date of 01/26/2023 with a note indicating it was discontinued for Gradual Dose Reduction (GDR). Further review revealed, Xanax 1(one) mg every 24 hours PRN was ordered on 01/26/2023 and had an indefinite end date. A review of an Order Summary Report indicated Resident #63 had a physician's order for Xanax (an antianxiety, psychotropic medication) 1 (one) milligram (mg) tablet, take one tablet by mouth at bedtime. Resident #63 had an additional order for Xanax 1 mg tablet, take one tablet by mouth every 24 hours as needed, with a start date of 01/26/2023. A review of a Note to Attending Physician/Prescriber indicated that on 01/18/2023, the consultant pharmacist indicated the resident was prescribed Xanax 1 mg tablet and to take one tablet every eight hours as needed for anxiety, and PRN psychotropic drugs were limited to 14 days unless the attending physician deemed it appropriate for the PRN order to extend beyond the 14 days. The physician did not sign the form; however, there was a handwritten note at the bottom that indicated, Scheduled at bedtime on 1/26/23. A review of Resident #63's Medication Administration Record (MAR) from 01/01/2023 through 06/28/2023 revealed Resident #63 received the order for PRN Xanax every eight hours for 22 of 26 days in January 2023. The PRN Xanax order was changed from every eight hours to every 24 hours on 01/26/2023, and the resident did not receive any PRN Xanax from 01/26/2023 through 01/31/2023. Further review of the MAR revealed: - In February 2023, Resident #63 received the PRN Xanax for two of 28 days. - In March and April 2023, Resident #63 did not receive any PRN Xanax. - In May 2023, Resident #63 received PRN Xanax for one of 31 days. - In June 2023, Resident #63 received PRN Xanax for two of 28 days. During an interview on 06/30/2023 at 1:37 PM, the Director of Nursing (DON) stated a PRN psychotropic medication should be prescribed for a 14 day period and then re-evaluated at 14 days. The DON stated she could not state why the doctor had prescribed both scheduled Xanax and a PRN Xanax, but the resident had a lot of behaviors and the facility reviewed Resident #63's medications monthly. During an interview on 06/30/2023 at 2:23 PM, the Administrator stated a PRN psychotropic medication should be prescribed for 14 days. The Administrator stated she could not answer why Resident #63 was on a PRN Xanax as well as a routine Xanax. The Administrator indicated the facility did not have a policy related to PRN psychotropics.

Based on observation, medical record review, interviews, and review of a facility policy tilted Specific Medication Administration Procedures Administration Procedures For All Medications the facility failed to ensure Resident Identifier (RI) #20 was provided privacy during medication administration by a licensed nurse. This affected RI #20, one of four residents observed during medication administration, and one of four licensed nurses observed during medication administration. Findings Include: A review of a facility policy titled, Specific Medication Administration Procedures Administration Procedures For All Medications, with a date of 06/15, revealed, . Procedures: . 2. Provide privacy for resident during administration of medications, . RI #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/09/19 at 7:15 a.m., Employee Identifier (EI) #1, Licensed Practical Nurse (LPN), was observed during a medication administration for RI #20. After EI #1 entered RI #20's room, she left the door open and privacy curtain open for public view and visible for RI #20's roommate. The Surveyor observed one unknown person walking down the hallway and RI #20's roommate, RI #52, sitting in a wheelchair across the room in front of RI #20's bed. EI #1 began administering RI #20's oral medications with the door and privacy curtain open. On 12/09/19 at 07:38 a.m., the surveyor conducted an interview with EI #1, LPN. EI #1 was asked what should a nurse ensure was done prior to administering a medication to a resident. EI #1 stated close the resident's door and pull the privacy curtain. EI #1 was asked did you close the door and pull RI #20's privacy curtain after you entered the room to give RI #20's medication. EI #1 stated no she did not. EI #1 was asked why she had not closed the door and pulled RI #20's privacy curtain before administering the oral medications. EI #1 stated she forgot. EI #1 was asked what position was RI #20's door when you administered the oral medications. EI #1 stated the door was wide open for public view and the roommate was in the room sitting in a wheelchair in view or RI #20. EI #1 was asked should the privacy curtain have been pulled between RI #20 and RI #52. EI #1 stated yes. EI #1 was asked what would be the concern with a licensed nurse leaving a resident's door and curtain open during an oral medication administration. EI #1 stated privacy of the resident and their rights and staff could walk by. EI #1 was asked what does the facility policy say regarding giving oral medications and privacy. EI #1 stated the nurse should always provide privacy while administering medications. On 12/09/19 at 7:43 a.m., the surveyor conducted an interview with RI #20. RI #20 was asked when the nurse came into the room to administer oral medications without closing the door and pulling the privacy curtain, how did this make him/her feel. RI #20 stated she/he wanted privacy while receiving medications. RI #20 further stated the nurse should have pulled the privacy curtain and closed the door before giving medications.

Based on observation, interviews, a review of a document provided by the facility titled Perry.Potter Clinical Nursing Skills & Techniques 8th Edition, the facility failed to ensure a Licensed Practical Nurse (LPN) removed her gloves and washed her hands or used an alcohol-based hand rub between giving Resident Identifier (RI) #61's oral medications and a nebulizer breathing treatment. This affected RI #61, one of four residents observed during the medication pass, and one of four licensed nurses observed during the medication pass. Findings Include: A review of a document provided by the facility titled Perry.Potter Clinical Nursing Skills & Techniques 8th Edition, with a copyright date of 2014, revealed . Hand Hygiene . The most important and basic technique in preventing and controlling transmission of infections is hand hygiene . If hands are not visibly soiled, use an alcohol-based hand rub . a . after having direct contact with patients . f. After contact with inanimate objects (e.g., medical equipment) in the immediate vicinity of a patient . RI #61 was admitted to the facility on [DATE]. On 12/09/2019 at 11:15 a.m., the surveyor observed Employee Identifier (EI) #3, a Licensed Practical Nurse, during a medication pass. The surveyor observed EI #3 administer RI #61's oral medications. EI #3 did not remove her gloves, and wash her hands or use an alcohol-based hand rub after she gave RI #61's oral medications. After giving the oral medications, EI #3 picked up RI #61's nebulizer breathing machine from the top of the cabinet shelf, and proceeded to administer the nebulizer treatment. On 12/09/2019 at 2:30 p.m., an interview was conducted with EI #3, a Licensed Practical Nurse. EI #3 was asked what she should have done after she gave RI #61's oral medication. EI #3 stated she should have removed her gloves, and washed and dried her hands or used a hand sanitizer. EI #3 was asked what was the facility policy regarding hand hygiene after contact with a resident and touching an inanimate object (nebulizer breathing machine), and prior to administering an inhalation medication to a resident. EI #3 stated you should wash or dry your hands or use an alcohol based rub. EI #3 was asked if the facility policy was followed. EI #3 stated no. EI #3 was asked what would be the concern, as a licensed nurse, in not removing gloves and washing hands or using an alcohol-based hand rub after you gave RI #61's oral medications, and prior to picking up RI #61's nebulizer breathing machine to administer RI #61's inhalation medication. EI #3 stated it could potentially cause an infection to the resident. On 12/09/2019 at 2:41 p.m., an interview was conducted with EI #4, Infection Control Preventionist/Registered Nurse. EI #4 was asked what should a nurse have done between giving RI #61's oral medication and the nebulizer treatment. EI #4 stated after the nurse gave the oral medication to the resident, she should have removed her gloves and washed her hands. EI #4 was asked what was the facility policy regarding hand hygiene after contact with a resident and touching an inanimate object (nebulizer breathing machine), and prior to administering an inhalation medication. EI #4 stated you should wash your hands with soap and water for twenty seconds or use alcohol based hand gel. EI #4 was asked what would be the concern if a licensed nurse did not remove her gloves and wash her hands or use an alcohol-based hand rub after she gave RI #61's oral medications, and prior to picking up RI #61's nebulizer breathing machine to administer RI #61's inhalation medication. EI #4 stated it could potentially cause an infection to the resident.

Based on observation, interviews, record review and review of the facility's document titled, Peri Care Audit Tool, the facility failed to ensure peri-care was provided in a manner to prevent the potential for cross contamination when a staff wiped Resident Identifier (RI) #42 from the back to the front when providing incontinent care. This resident also has a history of urinary tract infections [MEDICAL CONDITION]. This affected one of two residents observed during incontinent care. A facility document titled, Peri Care Audit Tool, revealed, Action .3.wash front to back . RI #42 was admitted to the facility on [DATE]. A record review revealed, RI #42 had [DIAGNOSES REDACTED]. Peri Care was observed on RI #42 on at 10/24/18 at 7:19 PM, with Employee Identifier (RI) #3. EI #3 wiped back to front, in the perineal area. He then went to wash his hands and placed a brief on the resident. An interview with EI #3 was conducted on 10/24/18 at 7:50 PM. EI #3 was asked, which way should he wipe from when cleaning the buttock area. EI #3 replied, front to back. EI #3 was asked, which way did he wipe. EI #3 replied, from the back to front. EI #3 was asked, what was the potential for harm. EI #3 replied, infection. An interview on 10/25/18 at 10:03 AM, was conducted with EI #2. EI #2 was asked, when doing incontinence care, and wiping the back side, which way should staff wipe. EI #2 replied, front to back. EI #2 was asked, what was the potential for harm for wiping back to front. EI #2 replied, it could cause UTI's.

Based on observations, interviews, record review and review of a facility policy titled, Handwashing/Hand Hygiene, and a document titled, Peri Care Audit Tool , the facility failed to ensure: 1. Staff members did not turn the faucet off with their bare hands, and 2. Staff members wiped front to back while providing peri care. This had the potential to effect Resident Identifier (RI) #78, one of 6 residents observed during med pass and RI #42, one 2 residents observed during peri care. Findings include: A facility policy titled, Handwashing/Hand Hygiene, revised (MONTH) (YEAR), revealed Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation . Procedure . Washing Hands . 3. Dry hands thoroughly with paper towels and then turn off faucets with a clean dry paper towel. RI #78 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 1. A observation was made on 10/24/18 at 03:13 PM, of medication pass with Employee Identifier (EI) #1. EI #1 applied gloves and drew up insulin and administered to RI #78's abdomen. EI #1 then removed the gloves, washed his hands and turned the faucet off with his bare hands. EI#1 then put on gloves again, gave another medication injection in the left lower abdomen of RI #78, took the gloves off, washed his hands and turned the faucet off with his bare hands again. An interview with EI #1 on 10/24/18 at 4:08 PM. EI #1 was asked, how should he turn off the faucet after washing his hands. EI #1 replied, with a paper towel. EI #1 was asked, did he do that. EI #1 replied, no. EI #1 was asked, what was the potential for harm. EI#1 replied, bacteria and cross contamination. On 10/25/18 at 10:03 AM, an interview was conducted with EI #2, Infection Control Nurse. EI#2 was asked, how should staff turn off the faucet after washing their hands. EI #2 replied, with a new clean paper towel. EI #2 was asked, what was the potential for harm for turning off the faucet with bare hands. EI #2 replied, washing your hands was pointless. 2. A facility document titled, Peri Care Audit Tool, revealed, Action .3.wash front to back . RI #42 was admitted to the facility on [DATE]. A record review revealed, RI #42 had [DIAGNOSES REDACTED]. Peri Care was observed on RI #42 on 10/24/18 at 07:19 PM, with EI #3. EI #3 wiped the resident from the back area to front area (perineal area). He then went to wash his hands and placed a brief on the resident. An interview was conducted with EI #3 on 10/24/18 at 07:50 PM. EI #3 was asked, which way should he wipe from when cleaning the rear end, buttock area. EI #3 replied, front to back. EI #3 was asked, which way did he wipe. EI #3 replied, from the back to front. EI #3 was asked, what was the potential for harm. EI #3 replied, infection. An interview was conducted on 10/25/18 at 10:03 AM, with EI #2. EI #2 was asked, when doing incontinence care, and wiping the back side, which way should staff wipe. EI #2 replied, front to back. EI #2 was asked, what was the potential for harm for wiping back to front. EI #2 replied, it could cause UTI's.

Based on observations, interviews and record reviews of the facility policy/procedures titled, Tray Line and Meal Service Temperatures, Disposable Gloves, and Hand Washing Procedure, and a review of the facility's recipe # , the facility failed to: 1. assure cold foods (Tuna Salad) was maintained at 41 Degrees Fahrenheit (F) or below when served from the tray line. 2. prevent potential cross-contamination by assure a scoop used to measure a dry powder (thickener) was not stored atop the powder and in the can after use. 3. practice proper glove use to prevent potential cross-contamination. A food handler removed a contaminated disposal glove from her left hand, put on an oven mitt on this hand to remove an item from the oven, then placed the same contaminated disposal glove back on her left hand, and continued to serve food from the trayline The above practices posed the potential for food contamination and compromised food safety. This had the potential to affect all 109 residents receiving meal trays from dining services. Findings include: 1. Observation of the meal service tray line on 10/3/2017 at 5:40 PM revealed the entree was Tuna Sandwich. Staff documented the tray line temperature as 32 degrees F. (Fahrenheit). The Registered Dietitian (RD), present during this observation, checking the temperature of the Tuna Sandwich, and stated the temperature of the Tuna sandwich was 50 degrees F. The RD stated the Tuna Salad was only in the refrigerator for 30-40 minutes. A record review of facility policy titled Tray Line and Meal Service Temperatures, dated August 1, 2012, the the policy statement . All cold foods will be held at or below 41 degrees F . A review of the Recipe Number : titled: Tuna Salad Sandwich indicated CCP (Critical Control Point) -Maintain <(less than) 40 (degrees F.) . The cook, EI #5 was interviewed on 10/04/2017 at 5:25 PM. EI #5 was asked when did she take the Tuna Salad temperature. She responded the temperature was checked prior to plating. EI #5 was asked what was the temperature requirement for cold foods on the tray line. EI #5 said 41 degrees F. or lower. 2. An observation during the initial kitchen tour on 10/3/17 at 12:04 PM, was made of a can of thickener sitting on a counter with a blue measuring scoop stored inside. The RD, present during this observation, acknowledged seeing the scoop stored in the can of thickener. 3. EI #5, the PM (night cook) was observed on 10/03/2017 at 5:45 PM plating food on the tray line. During the process EI #5 stopped serving, removed her left disposable glove and donned a hot mitt on the left hand. EI #5 removed an item from the oven, removed the hot mitt and replaced the original disposable glove back on the left hand and continue to served food from on the trayline. EI #5 was observed not to wash her hands during this time. A record review of a Disposable Gloves Policy/Procedure (undated). When to change gloves listed After doing anything that would contaminate the gloves resulting in possible cross-contamination and After touching items, equipment . or soiled work areas. A second document titled Hand Washing Procedures with an effective date of August 1, 2012 under PR(NAME)EDURE . 3. Proper hand washing techniques will be used to eliminate the source of some of the bacteria in a food service department .

Based on observation, interviews, record review, review of Potter and Perry's Fundamentals of Nursing, the facility failed to ensure a Licensed Nurse, Employee Identifier (EI) #3, rotated Resident Identifier (RI) #16's [MEDICATION NAME] Patch, as ordered by the Physician, on 10/4/17, during the morning medication administration observation. This deficient practiced affected RI #16, one of one resident observed during the morning Medication Administration pass on 10/04/17, who received an [MEDICATION NAME]. Findings Include: A review of Potter and Perry's Fundamentals of Nursing, ninth edition, with a copyright date of 2017, Chapter 23, Legal Implications in Nursing Practice, page 311, documented: . Health Care Providers' Orders . Nurses follow health care providers' orders . RI #16 was originally admitted to the facility on [DATE] and readmitted on [DATE], with a [DIAGNOSES REDACTED]. RI #16's October 2017 Order Summary Report (Physician Orders) with a start date of 1/21/16, revealed RI #16 was to receive: the [MEDICATION NAME] Patch 24 Hour 9.5 MG/HR (Milligrams/Hours) (Rivastigmine) Apply 1 patch [MEDICATION NAME] (through the skin) one time a day related to MEMORY LOSS . Remove old patch with gloved hands and apply new patch . Rotate sites with each application . On 10/04/17 at 8:35 a.m., during the morning Medication Administration Observation, the surveyor observed EI #3, a Registered Nurse (RN) administer oral medications to RI #16. The RN, EI #3 removed the old [MEDICATION NAME] 9.5 MG/HR patch, that was on RI #16's right upper chest wall area, and discarded the patch. EI #3 applied a new [MEDICATION NAME] 9.5 MG/HR patch to the same area of RI #16 right upper chest wall. On 10/5/17 at 8:15 a.m., the surveyor conducted an interview with EI #3, the RN. The surveyor asked EI #3 when she removed RI #16's [MEDICATION NAME] where was it located. EI #3 said, the right upper wall. The surveyor asked EI #3 where did she placed the new [MEDICATION NAME]. EI #3 said, on the right upper chest wall. The surveyor asked EI #3 where should she had placed the new [MEDICATION NAME] on RI #16. EI #3 said, on the left chest wall to rotate the sites.

Based on observations, record review, and interviews, the facility failed to ensure Employee Identifier (EI) #2 did not touch a slice of bread with her bare hands while assisting Resident Identifier (RI) #10 with the lunch meal on 12/21/16. This affected one of 12 sampled residents observed during meal times. Findings Include: RI #10 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/21/16 at 1:35 p.m., during a meal observation, the surveyor observed EI #2, a Registered Nurse (RN), assist RI #10 with the noon meal. The surveyor observed EI #2 pick up a slice of bread. EI #2 touched the bread with her bare hands and placed a hamburger patty on the bread. While cutting the sandwich, EI #2's bare index finger also touched the sandwich. On 12/21/16 at 1:55 p.m., EI #2 was interviewed by the surveyor. EI #2 said the facility taught them to use gloves before touching a resident's food. EI #2 stated she should have put on a glove before she touched RI #10's food. An interview was held with EI #1, the Director of Nursing (DON) on 12/21/16 at 4:30 p.m. EI #1 stated staff knew not to touch resident's food and to always wear a glove.

Based on observations, record reviews and interviews, the facility failed to ensure: 1. A dietary worker cleaned a thermometer before taking the temperature of the spinach on 9/30/2015. 2. Three chocolate ice creams cups were frozen in the ice cream box. 3. Strawberries were placed in a Tupperware container with no open or used by date. 4. A container of cottage cheese had not expired by the use by date. 5. Spoons were not wet nesting in a cylinder. 6. A dietary worker reheated food to the correct temperature. This had the potential to affect 110 of 112 residents who receive meals from the kitchen. Findings Include: 1) A review of a facility policy titled, Food Thermometer Guidelines with an effective date of 02/12/2015 revealed the following: .3. Put only clean .Thermometer into a food item . On 9/30/2015 at 12:00 P.M., a dietary worker took a thermometer out of a glass of water and stuck it immediately into a pan of spinach. The thermometer had a large amount of a white substance on it. On 9/30/2015 at 1:35 P.M., an interview was conducted with EI (Employee Identifier) #3, Cook/Aide. EI #3 was asked, when taking the temperature of the Spinach did she wipe the thermometer. EI #3 replied, no ma'am. EI #3 was asked what was the white substance on the thermometer that she took the spinach temperature with. EI #3 replied chicken and dumpling. EI #3 was asked why did she not wipe the thermometer before taking the temperature of the spinach. EI #3 replied she was trying to get the food out on time. EI #3 was asked what was the potential harm when there was food on the thermometer and she used the thermometer to take the temperature of other foods. EI #3 replied bacteria. 2) A review of a facility policy titled, Storage of Frozen Foods with an effective date of 02/12/2015 revealed: . Ice Cream Freezers should be kept at an operation temperature to maintain frozen food . On 9/29/2015 at 10:20 A.M., the surveyor observed three ice cream cups that were not frozen solid in the ice cream box. The ice cream cups were four ounces. The surveyor pressed on one cup of ice cream and her finger went through the cup. On 9/30/2015 at 5:45 P.M., an interview was conducted with EI #4, Assistant Director of Dining Services . EI #4 was asked was if the ice cream in the ice cream box was soft. EI #4 replied yes. EI #4 was asked who was responsible for making sure ice cream was frozen in the ice cream box. EI #4 replied the one who was serving it should have checked it and everyone should check things before they use it. EI #4 was asked what should be done with soft ice cream. EI #4 replied it should be thrown away. EI #4 was asked what was the facility's policy on soft ice cream in the ice cream box. EI #4 replied she did not know. 3) A review of a facility's policy titled, Storage of Refrigerated Foods with an effective date of 02/12/2015 revealed the following: .Foods Storage . All items not stored in original container must be labeled and noted with use by date . The surveyor observed on 9/29/2015 at 10:20 AM, a Tupperware container with strawberries in it. There was no open by date or use by date on the container. On 10/1/2015 at 8:55 AM, an interview was conducted with EI #5, Director of Dining Services. EI #5 was asked where was the expired strawberries located. EI #5 replied in the freezer on the shelf. EI #5 was asked what was the open date and used by date on the container of strawberries. EI #5 replied it did not have anything on it and it did not have what it was. EI #5 was asked why was there no open and use by date on the strawberry container. EI #5 replied employees failed to put a label on it. EI #5 was asked who was responsible for labeling items. EI #5 replied the person who opened the item should have labeled the item with a use by date. EI #5 was asked what was the potential harm when food is not labeled. EI #5 replied it would not be safe to serve. EI #5 further stated, It causes you to have to throw the whole product away. 4) A review of a facility policy titled Storage of Refrigerated Foods with an effective date of 02/12/2015 revealed: .Monitor Expiration Dates Monitor all items daily for expiration dates or use by dates and discard all outdated items immediately . The surveyor observed on 9/29/2015 at 10:20 A.M., a medium container of cottage cheese with a best use by date of 9/27/2015. On 10/01/2015 at 8:47 A.M., an interview was conducted with EI #5. EI #5 was asked what was the best use by date on the cottage cheese in the refrigerator. EI #5 replied it was out of date 9/27/15. EI #5 was asked why was the cottage cheese still in the refrigerator. EI #5 replied they should have moved it out, instead of putting things in front of it. EI #5 was asked what was the facility's policy on expired food in the refrigerator. EI #5 replied it should be thrown away by the manufacturer's use by date. EI #5 was asked who was responsible for removing expired items out of the refrigerator. EI #5 replied cooks and aides or me when going through morning checks. EI #5 was asked when should expired items be moved out of the refrigerator. EI #5 replied throw it out on the expired date. EI #5 was asked what was the potential harm when residents received expired food. EI #5 replied food borne illness. EI #5 was asked where was the expired Cottage Cheese located. EI #5 replied in the refrigerator. 5) A review of a facility's policy titled, Dish Machine Use and Care with an effective date of 02/12/2015 revealed the following: .Cylinder Storage .2 Send flatware and empty cylinder through the dish machine 3 Allow to air-dry . On 9/30/2015 at 12:05 P.M., the surveyor observed seven spoons in a cylinder bin with water on them. EI # 6, Dietary Aide, wrapped some of the spoons in a napkin and placed them on the resident's tray. On 9/30/2015 at 1:42 P.M., an interview was conducted with EI #6. EI #6 was asked what was on the spoons that were being wrapped for the residents. EI #6 replied water. EI #6 was asked were spoons in the cylinder wet. EI #6 replied yes ma'am. EI #6 was asked did spoons go out to the residents wet. EI #6 replied yes. EI #6 was asked why were the spoons in the cylinder wet. EI #6 replied there were too many in the cylinder. EI #6 was asked who was responsible for making sure utensil were dry. EI #6 replied dietary aide. EI #6 was asked what was the potential harm when spoons are served to the residents wet. EI #6 replied they collect germs. On 9/30/2015 at 1:50 P.M., an interview was conducted with EI #4. EI #4 was asked what was on the spoons in the cylinder. EI #4 replied water. EI #4 was asked why were the spoons wet. EI #4 replied they did not let them air dry. EI #4 also said they were supposed to stay in the dish room until they were dry. EI #4 as asked who was responsible for making sure utensils were dry. EI #4 replied the aides on the clean side in the dish room. EI #4 was asked what was the potential harm when residents received wet utensils. EI #4 replied they could get bacteria. 6) A review of a facility policy titled, Infection Control - Holding and Serving with an effective date of 02/12/2015 revealed the following: .Reheat hot foods Reheat immediately to 165 degrees F (Fahrenheit) for 15 seconds any hot food that falls below 135 degree F . On 9/30/2015 at 11:35 A.M., the surveyor observed EI #3 take the temperature of the pureed peas and carrots. The first temperature of the peas and carrots was 120 degrees. The peas and carrots were placed in the oven for five minutes and taken out and placed back on the line. The temperature of the peas and carrots reached the temperature of 140 degrees F. On 9/30/15 at 1:35 P.M., an interview was conducted with EI #3. EI #3 was asked what was the temperature of the pureed peas and carrots when she took the temperature the first time. EI #3 replied 120 degrees and they were placed back in the oven. EI #3 was asked what was the second temperature of the peas and carrots. EI #3 replied 140 degrees. EI #3 was asked what should the temperature have been when the food was reheated. EI #3 said 140 degrees F. EI #3 was asked at what temperature should food be served. EI #3 replied 140 degrees. EI #3 was asked what was the potential harm when food was not reheated at the correct temperature. EI #3 replied bacteria.

Based on observations, interviews, and record review, the facility failed to ensure (Resident Identifier) RI #15 did not self-administer a nebulizer treatment during medication administration on 09/30/15. This affected one of two residents receiving nebulizer treatment during medication pass observations. Findings Include: RI #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #15's most recent Admission (Minimum Data Set) MDS with (Assessment Reference Date) ARD of 09/08/15 revealed the (Brief Interview of Mental Status) BIMS summary score was a 15 indicating the resident was cognitively intact. The MDS revealed RI #15 needed supervision with eating and needed limited assistance with bed mobility, locomotion on and off unit, dressing, toileting, and personal hygiene. RI #15's Order Summary Report form (Physician Orders), dated 09/01/15 revealed: .[MEDICATION NAME] Solution 0.5-2.5 (3) MG(milligrams)/3ML(milliliters) ([MEDICATION NAME]-[MEDICATION NAME]) 1 vial inhale orally via (by) nebulizer every 6 hours related to [MEDICAL CONDITION] . A review of the facility's policy titled, SELF-ADMINISTRATION BY RESIDENT with a date of 2007 revealed: .1. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability . 3. The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment . A review of RI #15's SELF-MEDICATION ASSESSMENT FORM, with a date of 09/01/15, revealed the SELF-MEDICATION ASSESSMENT FORM was not complete. The (Interdiscliplinary Team) IDT Members involved were not put on the form. Under the ASSESSMENT, #2, #3, and #4 were left blank. Also, the IDT DETERMINATION was left blank. The Resident did not sign or date the SELF-MEDICATION ASSESSMENT FORM. On 09/30/15 at 12:00 PM, (Employee Identifier) EI #2, a (Registered Nurse) RN medication nurse was observed setting up RI #15's Duo Nebulizer treatment. EI #2 handed the nebulizer treatment to the resident and exited the room with nebulizer medication treatment in progress. On 3/30/15 at 2:30 PM, an interview was conducted with EI #2. EI #2 was asked if there was a self administration form for RI #15. EI #2 said yes, and gave a copy of the form to the surveyor. EI #2 was asked if RI #15 was care planned for self-administration of nebulizer medication. EI #2 said no after looking through RI #15's care plans. EI #2 was asked if RI #15 verbalized that he/she wanted to self administer nebulizer medication treatment. EI #2 stated, No, not to me. EI #2 was asked what was the potential harm if a resident was not assessed correctly for self-administration of nebulizer medication. EI #2 said the resident may not get the adequate dose and may become short of breath, which could lead to respiratory distress. EI #2 was asked if there was a physician order [REDACTED].#2 said she did not see a written physician order [REDACTED]. EI #2 was asked what the facility's policy said about a resident self administering nebulizer medication. EI #2 verbalized that if the form was completely filled out, the medication nurse could put the nebulizer medication in the mask and let the resident do the rest. Also, the medication nurse could leave the room while the nebulizer medication treatment was in progress. EI #2 also verbalized if the self-administration form was not completely filled out or if the resident was assessed that he/she could not self-administer medication, then the medication nurse should stay in the resident's room until the nebulizer medication treatment was complete. On 3/30/15 at 5:20 PM, an interview was conducted with EI #1, the (Assistant Director of Nursing) ADON. EI #1 was asked what the facility's policy said about a resident self-administering medication. EI #1 said the policy stated that the IDT would meet and determine by their criteria if a resident was able to self-administer medication adequately. EI #1 was asked what was the potential harm if a resident was not properly assessed for self-administration of nebulizer medication. EI #1 said the resident could potentially not receive the full dose of medication and this could lead to a deterioration in his/her medical condition.

Based on observations and interview, the facility failed to ensure Room Locators (RL) #s 1, 2, 3, and 4 were kept in a clean and sanitary condition; as evidence by the following: 1) RL #1's bathroom floor with a black dirt like substance underneath the sink as well as the floor corners 2) RL #2's bathroom floor with black dirt like substance underneath the sink 3) RL #3's bathroom floor with a black dirt like substance behind the toilet and a black dirt like substance underneath the sink 4) RL #4's bathroom floor with an orange stain to the right of the toilet and the bathroom floor with a black dirt like substance in front of the bathroom sink This affected four of 30 rooms located on the west wing of the facility. Findings include: On 09/29/2015, 09/30/2015 and 10/01/2015 the following observations were made: 1) On 09/29/2015 at 11:25 AM, RL #1's bathroom floor had a black dirt like substance underneath the sink as well as the floor corners. On 09/30/2015 at 4:40 PM, RL #1's bathroom floor had a black dirt like substance underneath the sink as well as the floor corners. On 10/01/2015 at 9:18 AM, an observation was made again of RL #1's bathroom floor with the Housekeeping Supervisor, EI ( Employee Identifier) #12. On 10/01/2015 at 9:19 AM, an interview was conducted with EI #12. EI #12 was asked what did she see on RL #1's floor in the bathroom. EI #12 replied the floor looked dirty. 2) On 09/29/2015 at 10:43 AM, RL #2's bathroom floor had a black dirt like substance underneath the sink. On 09/30/2015 at 4:45 PM, RL #2's bathroom floor had a black dirt like substance underneath the sink. On 10/01/2015 at 9:01 AM, another observation was made of RL #2's bathroom floor with EI #12. On 10/01/2015 at 9:02 AM, an interview was conducted with EI #12. EI #12 was asked what did she see on RL #2's bathroom floor. EI #12 explained that she saw dirt behind the wheeled storage case positioned underneath the sink and that the corners of the floors looked like housekeeping staff did not sweep but just mopped and that staff was not scrubbing the floor. 3) On 9/29/2015 at 10:35 AM, RL #3's bathroom floor had a black dirt like substance behind the toilet and a black dirt like substance underneath the sink. On 09/30/2015 at 4:49 PM, RL #3's bathroom floor had a black dirt like substance behind the toilet and a black dirt like substance underneath the sink. On 10/01/2015 at 9:00 AM, an observation was made of RL #3's bathroom floor with EI #12. On 10/01/2015 at 9:16 AM, an interview was conducted with EI #12. EI #12 was asked what did she see on the floor in RL #3's bathroom floor and behind the toilet. EI #12 replied it looked like dirt. 4) On 10/01/2015 at 8:25 AM, an observation was made of RL #4's bathroom floor, with an orange stain to the right of the toilet and the bathroom floor with a black dirt like substance in front of the bathroom sink On 10/01/2015 at 9:20 AM, an observation was made of RL #4's bathroom floor with EI #12. On 10/01/2015 at 9:21 AM, an interview was conducted with EI #12. EI #12 was asked what did she see on RL #4's bathroom floor. EI #12 explained that the floor looked dirty. On 10/01/2015 at 9:25 AM, another interview was conducted with EI #12. EI #12 was asked who was responsible for ensuring that resident's rooms and bathrooms were cleaned. EI #12 stated she was and that residents' rooms should be cleaned twice a day. EI #12 was asked who monitored housekeeping staff to ensure housekeeping duties were completed. EI #12 replied that she was. EI #12 was asked, why should residents' bathroom floors be free of dirt. EI #12 explained that floors should be cleaned and disinfected to make the resident feel that they were in a clean environment. EI #12 was asked why did some of the resident bathroom floors have a black dirt like substance on them. EI #12 explained that she thought that staff was not sweeping and were not scrubbing the floors with the mops. EI #12 was asked what was the potential harm in residents' bathroom floors not being free of an accumulation of dirt. EI #12 replied germs and they could get sick.

Based on observation, record review and interviews the facility failed to ensure RI (Resident Identifier) #5, an incontinent resident was checked for incontinence or changed for four hours and fifty minutes on 09/30/2015. RI #5 was continuously observed from 9:00 AM to 1:50 PM, without being checked for incontinence or changed. This affected one of six sampled residents observed for checking for incontinence and changing. Findings Include: RI #5 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 07/01/2015 identified RI #5 as being severely impaired for daily decision making. The MDS also indicated RI #5 was totally dependent for ADL's (Activities of Daily Living). The MDS also indicated RI #5 was always incontinent of bladder and bowel. On 09/30/2015 a continuous observation was made of RI #5 from 9:00 AM until 1:50 PM. RI #5's brief was not checked or changed for urine or feces during this time. On 09/30/2015 at 2:45 PM, an interview was conducted with EI #10 CNA (Certified Nursing Assistant). EI #10 was asked how often was RI #5's brief suppose to be checked for urine/feces. EI #10 said every two hours and as needed. EI #10 was asked what type of care was provided to RI #5 from 9:00 AM to 1:50 PM. EI #10 said she checked the lap restraint. EI #10 was asked did she check RI #5's brief for urine/feces since 9:00 AM. EI #10 said yes she changed RI #5 that morning before the surveyor got there and after lunch. The surveyor showed the CNA documentation that the resident was continuously observed from 9:00 AM to 1:50 PM without being checked and changed for incontinence. EI #10 was asked what was the potential harm in an incontinent resident's brief not being checked for urine/feces in four hours and fifty minutes. EI #10 said UTI (Urinary Tract Infection) and skin breakdown. On 09/30/2015 at 5:20 PM, an interview was conducted with EI #8 RN (Registered Nurse) Unit Manager. EI #8 was asked how often should residents be checked for urine/feces. EI #8 said every two hours and as needed. EI #8 was asked was it an acceptable practice for this facility for an incontinent resident not to be checked for incontinence or changed from 9:00 AM to 1:50 PM. EI #8 said no. EI #8 was asked what was the potential harm in not checking or changing an incontinent resident for four hours and fifty minutes. EI #8 said infection, UTIs and skin breakdown. On 10/01/2015 at 10:20 AM, an interview was conducted with EI #9 RN, Infection Control. EI #9 was asked was it an acceptable practice of this facility for an incontinent resident not to be checked for incontinence or changed for four hours and fifty minutes. EI #9 said no. EI #9 was asked what was the potential harm in not checking or changing an incontinent resident for four hours and fifty minutes. EI #9 said infection, UTIs and skin breakdown.

Based on observation, interview and record review the facility failed to ensure RI (Resident Identifier) #5, an incontinent resident with a history of UTI (Urinary Tract Infection), was checked for incontinence or changed for four hours and fifty minutes on 09/30/2015. RI #5 was continuously observed from 9:00 AM to 1:50 PM without being checked for incontinence or changed. This affected one of four sampled residents with a history of UTI's. Findings Include: RI (Resident Identifier) #5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #5's quarterly MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 07/01/2015 revealed RI #5 was severely impaired for daily decision making. The MDS also revealed RI #5 was totally dependent for all ADL's (Activities of Daily Living). The MDS also revealed that RI #5 was always incontinent of bladder and bowel. A review of RI #5's laboratory results revealed: .Culture,Urine . Collected :11/26/2014 . >100,000 . Escherichia coli . A review of RI #5's laboratory results dated [DATE] revealed: .URINALYSIS . CULTURE . COLONY COUNT >100,000 ORGANISM [MEDICATION NAME] FAECALIS . On 09/30/2015 a continuous observation was made of RI #5 from 9:00 AM until 1:50 PM. RI #5's brief was not checked or changed for urine or feces during this time. On 09/30/2015 at 2:45 PM, an interview was conducted with EI #10 CNA (Certified Nursing Assistant). EI #10 was asked how often was RI #5's brief suppose to be checked for urine/feces. EI #10 said every two hours and as needed. EI #10 was asked what type of care was provided to RI #5 from 9:00 AM to 1:50 PM. EI #10 said she checked the lap restraint. EI #10 was asked did she check RI #5's brief for urine/feces since 9:00 AM. EI #10 said yes she changed RI #5 that morning before the surveyor got there and after lunch. The surveyor showed the CNA documentation that the resident was continuously observed from 9:00 AM to 1:50 PM without being checked and changed for incontinence. EI #10 was asked what was the potential harm in an incontinent resident's brief not being checked for urine/feces in four hours and fifty minutes. EI #10 said UTI (Urinary Tract Infection) and skin breakdown. On 09/30/2015 at 5:20 PM, an interview was conducted with EI #8 RN (Registered Nurse) Unit Manager. EI #8 was asked how often should residents be checked for urine/feces. EI #8 said every two hours and as needed. EI #8 was asked was it an acceptable practice for this facility for an incontinent resident not to be checked for incontinence or changed from 9:00 AM to 1:50 PM. EI #8 said no. EI #8 was asked what was the potential harm in not checking or changing an incontinent resident for four hours and fifty minutes. EI #8 said infection, UTIs and skin breakdown. On 10/01/2015 at 10:20 AM, an interview was conducted with EI #9 RN, Infection Control. EI #9 was asked was it an acceptable practice of this facility for an incontinent resident not to be checked for incontinence or changed for four hours and fifty minutes. EI #9 said no. EI #9 was asked what was the potential harm in not checking or changing an incontinent resident for four hours and fifty minutes. EI #9 said infection, UTIs and skin breakdown.

Based on record review and interview, the facility failed to ensure there were two signatures on the non-controlled drug destruction forms for May 2015. This affected one of six months of non-controlled drug destruction forms reviewed. Findings Include: A facility policy titled: Disposal of Medication with no date revealed the following: .4. Medications not listed in Schedules II,III,IV and V (non-controlled medications) shall be destroyed by the nursing care center in the presence of a pharmacist or nurse, and one other witness as per state regulation.a medication disposition log or form .and shall be retained as per federal privacy and state regulations. c. A non-controlled medication disposition log or form shall be used for documentation and shall be retained as per federal privacy and state regulations. The log shall contain the following information: .Signatures of the required witnesses . On 10/01/2015 at 11:47 AM, the non-controlled medications were reviewed. It revealed in May 2015 there was one witness signature on the forms. On 10/01/2015 at 12:20 PM, an interview was conducted with EI #11 RN (Registered Nurse) DON (Director of Nursing). EI #11 was asked how many signatures were supposed to be on the non-controlled drug destruction form. EI #11 said two. EI #11 was asked how many signatures were on the non-controlled destruction for 05/27/2015. EI #11 said one on the destruction sheet. EI #11 was asked why was there only one signature on the non-controlled destruction form. EI #11 said because the nurse signed the receipt for pick up and not the destruction form. EI #11 was asked what was the potential harm in having only one signature on the non-controlled destruction form. EI #11 said there would be only one person as a witness then there would be potential for diversion.

Based on record review,observation and interviews, the facility failed to ensure a licensed staff member washed or sanitized her hands in between two residents during medication administration on 09/29/2015. The facility further failed to ensure a licensed staff member did not touch a capsule with ungloved fingers before administering it to the resident during medication administration on 09/29/2015. This affected one of four residents observed during medication administration. Findings Include: A review of a facility policy titled, Handwashing/Hand Hygiene with a revised date of August 2014 revealed: .Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. 7. Use an alcohol-based hand rub containing at least 62% alcohol, or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: . b. Before and after direct contact with residents; c. Before preparing or handling medications; . A review of Potter and Perry's Fundamentals of Nursing Eighth Edition, Chapter 28, Infection Prevention and Control, page 419 revealed: .Change gloves and perform hand hygiene between tasks and procedures on the same patient, .Perform hand hygiene immediately to avoid transfer of microorganisms to other patients or environments. A review of a facility policy titled, Medication Administration dated 10/2007 revealed: .GENERAL GUIDELINES . Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices . 4.hands are washed with soap and water (gloves preferable) prior to handling tablets . 1.) RI (Resident Identifier) #9 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #9's quarterly MDS (Minimum Data Set) with an Assessment Reference Date (ARD) of 09/16/2015 revealed a BIMS (Brief Interview for Mental Status) score of 14 which indicated cognitively intact for daily decision making. On 09/29/2015 at 4:30 PM, EI (Employee Identifier) #7, RN (Registered Nurse) was observed during medication administration with RI #9. EI #7 did not sanitize or wash her hands before preparing RI #9's medication. EI #7 entered RI #9's room, administered the medication and exited the room. EI #7 did not sanitize or wash her hands before returning to the medication cart. EI #7 began preparing medication for another resident. On 09/30/2015 at 4:20 PM, an interview was conducted with EI #7. EI #7 was asked did she wash or sanitize her hands on 09/29/2015 with medication administration on RI #9. EI #7 said no. EI #7 was asked after administering RI #9's medication and exiting the room did she wash or sanitize her hands. EI #7 said no. EI #7 was asked what was the potential harm in not washing or sanitizing her hands between residents with medication administration. EI #7 said infection. On 09/30/2015 at 5:20 PM, an interview was conducted with EI #8 RN ,Unit Manager. EI #8 was asked what was the potential harm in not washing or sanitizing hands between residents during medication administration. EI #8 said infection. On 10/01/2015 at 10:20 AM, an interview was conducted with EI #9 RN, Infection Control. EI #9 was asked how are infections prevented in the facility. EI #9 said handwashing and isolation. EI #9 was asked how were infections controlled in the facility. EI #9 stated isolation and standard precautions. EI #9 was asked how were staff monitored to ensure they were washing their hands. EI #9 said staff were checked off on handwashing and observations were done with medication administration. EI #9 was asked what was the potential harm in not washing or sanitizing hands between residents with medication administration. EI #9 said the spread of infection. 2.) RI #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #24's quarterly MDS with an Assessment Reference Date of 07/03/2015 revealed a BIMS score of (6) six which indicated severely impaired cognition. On 09/29/2015 at 4:45 PM, an observation was made of EI #7 during medication administration. EI #7 picked the [MEDICATION NAME] capsule up with bare fingers out of the medication cup and pulled a piece of foil off of the capsule. EI #7 then entered RI #24's room, did not sanitize or wash her hands,then administered the medication. On 09/30/2015 at 4:20 PM, an interview was conducted with EI #7. EI #7 was asked did she wash or sanitize her hands on 09/29/2015 with medication administration with RI #24. EI #7 said no. EI #7 was asked should she have washed or sanitized her hands between residents. EI #7 said yes. EI #7 was asked did she touch the [MEDICATION NAME] capsule with ungloved fingers. EI #7 said yes. EI #7 was asked what was the potential harm in not sanitizing or washing hands between residents. EI #7 said infection. EI #7 was asked what was the potential harm in touching a capsule with bare fingers and then administering it to the resident. EI #7 said infection. On 09/30/2015 at 5:20 PM, an interview was conducted with EI #8. EI #8 was asked what was the potential harm in not washing or sanitizing hands between residents during medication administer. EI #8 said infection. EI #8 was asked should a capsule be picked up with ungloved fingers and then administered to a resident. EI #7 said no. EI #7 was asked what was the potential harm in picking a capsule up with ungloved fingers and then administer it to a resident. EI #8 said infection. On 10/01/2015 at 10:20 AM, an interview was conducted with EI #9. EI #9 was asked what was the policy on handwashing/sanitizing hands with medication administration. EI #9 said wash or sanitize hands in between residents. EI #9 was asked what was the potential harm in not washing or sanitizing hands between residents. EI #9 said spread of infection. EI #9 was asked should a capsule be picked up with bare fingers and then administered to a resident. EI #9 said no. EI #9 was asked what was the potential harm in touching and picking up a capsule with bare fingers and then administering it to a resident. EI #9 said infection.