Every finding on record at Diversicare of Winfield

Based on interviews and review of Resident Identifier (RI) #202's medical record, the facility's policy titled Abuse, Neglect, Misappropriation, Exploitation Policy and the facility's investigation file, the facility failed to ensure Employee Identifier (EI) #7, a Nurse Aide (NA) did not mentally abuse RI #202 on 2/21/2021. This deficient practice affected RI #202; one of four residents reviewed for abuse. Findings include: The facility's policy titled, Abuse, Neglect, Misappropriation, Exploitation Policy dated January 2019, documented Purpose: To prohibit and prevent abuse . Definitions: Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . It includes . mental abuse . 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 . Mental Abuse: is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation . On 2/22/2021, the facility reported an allegation of mental abuse to the State Survey Agency. According to the report, (RI #202) reported on 02/22/2021 at 12:45pm that yesterday nurse aide (EI #7) made comments about (his/her) (spouse) seeing another (man/woman). Resident stated it upset (him/her) and (he/she) was unable to sleep last night, but was feeling much better at the time. (He/She) stated it embarrassed (him/her). The facility's investigation summary signed by EI #1, the facility's Administrator, documented (RI #202) stated the day before at the resident smoke break that (EI #7) Nurse Aide saw (his/her) (spouse) and best friend come to the facility. (RI #202) said (EI #7) stated to (him/her) Are you sure they aren't f ing. (RI #202) said she (EI #7) embarrassed (him/her) in front of the other residents and (he/she) could not sleep because of the comment she (EI #7)made. (EI #7) was interviewed and stated that she did ask (RI #202) if (his/her) (spouse) was sleeping with (his/her) best friend. I asked (EI #7) if she used the word sleeping and she admitted that no she used the f word. She stated that she was just joking with (RI #202) and later apologized. I am substantiating abuse in this matter. (EI #7) will be terminated . RI #202 was admitted to the facility on [DATE]. In an interview on 6/2/2021 at 9:07 AM, RI #202 was asked what happened involving EI #7 on 2/21/2021. RI #202 stated, We were all in the front lobby because we were going to go out and smoke and my (spouse) pulled up out front to bring me some clothes and one of my good friends rode with (spouse). Out of the blue (EI #7), one of the aide, said out loud, Are they [OBSCENITY] ing?, and I said no and left. When asked how the resident felt about what EI #7 said, RI #202 said It embarrassed me in front of the friends that I had made in the facility because I didn't want them to think something like that was going on. According to RI #202, the resident could not sleep night, but after that he/she shrugged it off because he/she knew it wasn't true. In a telephone interview on 6/3/2021 at 9:38 AM, EI #7, a NA was asked what she could recall about an incident that occurred on 2/21/2021 with RI #202. EI #7 stated she doesn't know why she said it, it was stupid thing to say and she now knows that she should not have said it. During an interview on 6/3/2021 at 5:00 PM, EI #1, the Administrator was asked about the incident between RI #202 and EI #7. EI #1 stated they were at the front door and RI #202's spouse came to the facility. EI #7 looked at RI #202 and asked the resident how long has your spouse been [OBSCENITY] ing your friend. RI #202 didn't respond, but was embarrassed. EI #7 stated she knew it embarrassed RI #202 and later apologized. The resident didn't report it to anyone when it occurred, but finally told someone the next day. When asked if she felt occurred was abuse, EI #1 said yes mental abuse due it embarrassing the resident. ************************* Once the facility became aware of the allegation of mental abuse, the following corrective actions were taken: EI #7 was suspended and not allowed back to work pending the investigation findings. EI #7's employment with the facility was terminated on 3/1/2021. The facility timely reported the allegation and the subsequent findings to the State Survey Agency, the facility's Medical Director and RI #202's representative. RI #202 was assessed by the licensed nursing staff. Beginning 2/23/2021 until 3/14/2021, the facility conducted staff in-service regarding Diversicare Service Standards How to Talk to a Resident ************************* After review of the facility's investigation file, in-service/education records, staff and resident interviews, the facility implemented corrective actions from 2/22/2021 to 3/14/2021; thus past noncompliance was cited. This deficiency was cited as a result of the investigation of complaint/report number AL 258.

Based on observations, interviews and review of Potter and Perry Clinical Nursing Skills and Techniques, the facility failed to ensure: 1.) a licensed nurse administering medications washed her hands or used hand sanitizer between each resident during medication administration, this affected Resident Identifier (RI) #81 and RI #95, and 2.) a licensed nurse did not place gloves and a plastic bag containing RI #87's nasal spray on a potentially contaminated surface without a barrier prior to applying the gloves to administer RI #87's nasal spray and placing the plastic bag back into the medication cart. These deficient practices affected three of seven residents observed during medication administration. Findings include: 1.) A review of Potter and Perry Clinical Nursing Skills and Techniques, 8th Edition, Chapter 7, pages 168 and 169 revealed, .Hand Hygiene .The most important and basic technique in preventing and controlling transmission of infection is hand hygiene. Hand hygiene is a general term that applies to handwashing, . antiseptic hand rub, . Follow these guidelines for hand hygiene .: 1. Wash hands with either plain soap and water or an antibacterial soap and water when hands are visibly dirty, . 3. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in the following clinical situations: a. Before and after having direct contact with patients. f. After contact with inanimate objects . in the immediate vicinity of the patient . On 6/2/21 at 4:53 PM, during observation of medication administration with Employee Identifier (EI) #5, a Registered Nurse (RN), the surveyor entered RI #81's room with EI #5. The surveyor observed RI #81 standing up in front of a wheelchair. EI #5 touched the wheelchair and RI #81's right arm to assist RI #81 to sit in the wheelchair. When RI #81 was sitting, EI #5 administered medications and held a cup of water for RI #81 to drink from. EI #5 placed the cup of water on RI #81's bedside table and returned to the medication cart and threw the medication cup out at the medication cart. EI #5 did not wash her hands or cleanse hands with hand sanitizer. EI #5 then touched her pen, touched the computer mouse, unlocked the medication cart and prepared medications for RI #95 by dispensing medications into a medication cup. EI #5 then poured RI #95 a cup of water, touching the paper cup, water pitcher and a wrapped straw. EI #5 unwrapped the straw and touched the center of the straw and put the straw in the cup of water for RI #95. EI #5 and the surveyor entered RI #95's room. EI #5 placed the medication cup containing medications on the bedside table. Touching the bedside table EI #5 moved the table out of the way, elevated the head of the bed by using the remote attached to the bed rail. Touching RI #95's medication cup EI #5 administered the medications, touched the cup of water, held the straw with her bare hands, gave RI #95 a drink of water, lowered the head of the bed using the bed remote, returned to the medication cart, touched her pen, touched the computer mouse, all without washing her hands or using hand sanitizer. On 6/2/21 at 5:04 PM, an interview was conducted with EI #5. EI #5 was asked, when she finished giving medications to RI #81, what did she forget to do. EI #5 replied, she did not know. EI #5 was asked, when did she wash her hands or use hand sanitizer. EI #5 replied, she used hand sanitizer before she gave medications to RI #81 and that she washed her hands after every third resident. EI #5 was asked, how often did she wash her hands during medication administration. EI #5 replied, it depended on if she was wearing gloves and she would wash her hands after removing gloves. EI #5 was asked, when should she use hand sanitizer during medication administration. EI #5 replied, she would use hand sanitizer after every third resident or if she came in contact with a surface they had touched, like a water cup or medication cup. EI #5 was asked, when did RI #81 have contact with the water cup or medication cup. EI #5 replied, RI #81's lips touched the top of cup but she had touched the bottom of the cup. EI #5 was asked, how she handled RI #95's cup. EI #5 replied, she held the cup and straw and held the bottom of the cup. EI #5 was asked, when was handwashing indicated. EI #5 replied, before starting her shift, anytime she came in contact with something contaminated, after every third resident, if visibly soiled, before eating and after using the restroom. EI #5 was asked, what did she touch in RI #81's room that was contaminated. EI #5 replied, the wheelchair. EI #5 was asked, what did she touch that was contaminated in RI #95's room. EI #5 replied, she moved the bedside table and touched the bed control. EI #5 was asked when should she have washed her hands or used hand sanitizer. EI #5 replied, after RI #81 and before RI #95 and then after RI #95. On 6/3/21 at 8:36 AM, an interview was conducted with EI #3, the Infection Preventionist/Clinical Educator. EI #3 was asked, when was hand hygiene indicated. EI #3 replied, when coming into the building, before entering a resident room, anytime hands were visibly soiled, after touching something contaminated and after providing care. EI #3 was asked, when should a nurse perform hand hygiene during medication administration. EI #3 replied, before entering the room and after administering medications. EI #3 was asked, when should a nurse perform hand hygiene between every third resident during medication administration. EI #3 replied, as long as they don't touch anything and use hand sanitizer in between each resident. EI #3 was asked, why would a nurse not perform hand hygiene between each resident during medication administration. EI #3 replied, they should use hand sanitizer between each resident. EI #3 was asked, when are hands considered contaminated. EI #3 replied, if visibly soiled or if anything in a resident's room or a resident is touched. EI #3 was asked, what should nurses do when their hands become contaminated. EI #3 replied, wash their hands. EI #3 was asked, what should nurses use to sanitized their hands with between residents during medication observation. EI #3 replied, hand sanitizer. EI #3 was asked, what was the risk to the residents when contaminated hands were not cleansed between residents. EI #3 replied, cross contamination and spread of infection. 2.) A review of POTTER AND PERRY, FUNDAMENTALS OF NURSING, NINTH EDITION, UNIT V Foundations for Nursing Practice, CHAPTER 32 Medication Administration, page 632, documented: . Correct Administration.Use aseptic technique and proper procedures when handling and giving medications . On 6/3/21 at 8:00 AM during medication administration, EI #6, a Licensed Practical Nurse (LPN), was observed placing gloves and a plastic bag containing nasal spray on RI #87's overbed table, a potentially contaminated surface, next to RI #87's breakfast tray. EI #6 picked the gloves up off the table and applied them to administer RI #87's nasal spray. She placed the nasal spray back into the plastic bag, returned to the medication cart and placed the nasal spray in the bottom drawer without wiping off the plastic bag. In an interview on 6/3/21 at 3:37 PM, EI #6, LPN, was asked what was important when she used gloves to administer medications. EI #6 stated to place a barrier on the table before laying the gloves down. EI #6 was asked where she placed her gloves when she entered RI #87's room. EI #6 said on RI #87's bedside table. EI #6 was asked if she placed a barrier before she put the gloves on the table. EI #6 replied no. EI #6 was asked should she have placed a barrier. EI #6 said yes. EI #6 was asked where she placed RI #87's nasal spray. EI #6 stated, on RI #87's table in a plastic bag. EI #6 was asked what was the concern with placing items to be used during medication administration on a potentially contaminated surface prior to use. EI #6 said it contaminated the items and she may transfer viruses or bacteria to the resident. EI #6 was asked what she did when she took the nasal spray back to the medication cart. EI #6 stated, placed it in the bottom drawer. EI #6 was asked if she wiped the bag off before she placed it back in the drawer. EI #6 said no. EI #6 was asked should she have wiped off the bag. EI #6 stated yes, because it had been on the bedside table. EI #6 was asked what was the concern with those things. EI #6 said, infection control. On 6/3/21 at 4:03 PM an interview was conducted with EI #1, Registered Nurse (RN)/Administrator. EI #1 was asked where should gloves be placed prior to use during medication administration. EI #1 said there should be a barrier put down and the gloves placed on the barrier. EI #1 was asked should gloves be laid on an overbed table without a barrier prior to applying them to administer nasal spray. EI #1 replied no. EI #1 was asked why not. EI #1 said, cross-contamination. EI #1 was asked should a plastic bag containing nasal spray be placed on an overbed table without a barrier and then returned to the medication cart. EI #1 said no. EI #1 was asked why. EI #1 stated the bag should be cleaned with a bleach wipe first or the bag should be changed. EI #1 was asked why. EI #1 said, to avoid cross-contamination to other items in the medication drawer. EI #1 was asked what was the concern with those things occurring during medication administration. EI #1 stated, infection control.

Based on observation, interviews, record review, and review of a facility policy titled, Daily Clinical Start-Up Process, the facility failed to ensure an order for [REDACTED]. This affected RI #98, one of two residents for whom catheter admission orders [REDACTED] Findings Include: A review of a facility policy titled, Daily Clinical Start-Up Process, dated (MONTH) 2019, revealed the following: . Purpose . Ensure communication to physicians . is in place . Ensure documentation is thorough and reflective of care delivered . Items to review daily: . All new admission and re-admission documentation is reviewed including: Physician orders [REDACTED]. RI #98 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of RI #98's baseline care plan, dated 12/4/19, revealed the following: . 7. Special Treatments/Procedures g. Catheter . Resident admitted . from home .Foley cath (catheter) . intact . A review of RI # 98's comprehensive care plan, dated 12/12/19, revealed the following: . I have a Foley cath r/t (related to) bladder neck obstruction . However, review of RI #98's physician's orders [REDACTED].#98. On 2/5/20 at 4:00 PM, the surveyor observed RI #98 with a catheter. On 2/5/20 at 4:59 PM, an interview was conducted with Employee Identifier (EI) #2, Registered Nurse (RN), Director of Nursing (DON). EI #2 was asked if RI #98 had a catheter. EI #2 stated yes. EI #2 was asked if RI #98 had a physician's orders [REDACTED].#2 replied that she did not see a current order. EI #2 was asked if RI #98 was admitted to the facility with a catheter. EI #2 replied yes, RI #98 was admitted on [DATE] and readmitted on [DATE] with a Foley catheter. When asked why there was not an order for [REDACTED].#2 was asked what was the potential negative outcome of not having an order for [REDACTED].

Based on observation, interviews, review of the (YEAR) Food Code and the facility policy Dietary Food Handling the facility failed to ensure staff dispensed ice without bare hand contact. This had the potential to affect all 111 residents for whom meals were prepared and served. Further, based on the facility policy Use & Storage of Food from Outside Sources, staff failed to ensure food stored in the nursing pantry refrigerators were labeled with name of owner and date. This affected one of two nursing pantry refrigerators. Findings included: 1) The (YEAR) FOOD CODE of the United States Food and Drug Administration mandates under regulation 3-301.11 Preventing Contamination from Hands as follows: .(B) FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands . The facility policy, Dietary Food Handling dated 01/01/17 states: 'It is the policy of this center to provide guidelines for the safe preparation, handling and storage of perishable foods . The procedure mandates: .3. Foods should be prepared and served with clean tongs, scoops . or other suitable implements so as to avoid manual contact of prepared foods with hands. On 05/09/18 at 11:35 AM, the Cook (Employee Identifier), EI #13 was observed scooping ice into trays of beverage glasses for the lunch tray line. EI #13 used one hand to scoop the ice, and cupped the other ungloved hand around the glasses to guide ice into the glasses--touching the ice with her bare hand. On 05/10/18 at 8:49 AM, the surveyor explained the above observation and asked the Certified Dietary Manager, EI #7 and her assistant, EI #8, to explain how staff were to dispense ice into the beverage glasses. EI #8 stated the Cook did not normally dispense ice. EI #7 additionally explained it was typical for staff to not wear gloves. The surveyor explained that EI #13 had used her bare hand to guide ice into glasses and asked what harm may that pose. EI #8 replied, touching ice. 2) The facility policy, Use & Storage of Food from Outside Sources (effective 11/01/16), stated: Under limited circumstances, food may be brought into the Center from outside sources. Due to the potential for foodborne illness or interference with nutritional treatment, family members and/or visitors who bring food in from the outside will be educated on safe food handling practices . The procedures included: .2. Foods or beverages brought in from the outside will be labeled with the resident's name, room number and dated by nursing with the current date the item(s) was brought to the Center for storage. On 05/10/18 at 9:25 AM, the surveyor, accompanied by a Registered Nurse (EI #6) from the East Nursing Unit checked the pantry refrigerator at the East Nursing Station. The freezer compartment contained two packages of frozen pork sausage, neither of which were labeled with the owner's name or date. Also included in the freezer was a hand mitt with frozen interior pad and two additional nylon mitt covers. All were unlabeled. EI #6 did not know what the mitt was used for. EI #6 contacted the Rehabilitation Department, and was told the mitt was a therapeutic tool, but because it had not been used in a long time, to discard the mitt. The East pantry refrigerator contained one (unopened) package of wieners and an unopened package of (8) hot dog buns. The refrigerator also contained a 32 oz bottle of punch flavored Gatorade, three 10-oz bottles of Special K Protein Shakes and two 4-oz containers of Activia yogurt. None of these items were labeled with the owner's name. The surveyor asked EI #6 whether the items belonged to any of the residents or to the staff. EI #6 did not know, but stated the staff had their own refrigerator in the break room. On 05/10/18 at 7:20 PM, the above concerns were discussed with the Nursing Home Administrator, EI #1. EI #1 explained the staff had cleaned out their refrigerator in the break room, and transferred their food into the residents' pantry refrigerator. The buns and wieners were the staff's, as were the two packages of frozen sausage.

Based on observations, interviews, medical records, and review of a facility policy titled, Infection Control Guide and a facility document titled, Clean Dressing Change, the facility failed to ensure: 1. a staff member applied Personal Protection Equipment upon entering the room of Resident Identifier (RI) #11, a resident for whom Contact Isolation Precautions were clearly identified, 2. a licensed nurse did not place gloves on top of a paper towel dispenser while washing her hands and use those gloves to administer nasal spray for RI #60, and 3. a licensed nurse washed her hands and applied clean gloves after removing a soiled dressing before cleaning RI #78's wound, re-cleaned a wound after it came in contact with a brief before applying a clean dressing for RI #78 and did not reposition covers, pillows and reapply a heel boot wearing the same gloves worn during wound care for RI #78. These deficient practices affected RI #11, 1 of 1 resident reveiwed for contact isolation precautions, RI #60, 1 of 3 residents observed for medication administration and RI #78, 1 of 1 resident observed for wound care. Findings Include: A review of a facility policy titled, Infection Control Guide, with no date, revealed: .Contact .Scabies .Gloves required upon entering room, change gloves after contact .Gown required if clothing may come into contact with .environmental surfaces . RI #11 was admitted to the facility on [DATE]. On 5/08/18 at 05:04 PM, a review of the physician orders [REDACTED]. A review of RI #11's care plan, dated 05/08/2018, revealed: Resident tested positive for scabies .Isolation Precautions to be observed . On 05/09/18 at 8:53 a.m., Employee Identifier (EI) #10, a Certified Nursing Assistant, was observed entering RI #11's room without applying gloves or a gown. EI #10 exited the room with RI #11's food tray and placed it on the food cart. On 05/09/18 at 8:55 a.m., an interview was conducted with EI #10. EI #10 was asked, what does the sign on RI #11's door say/mean. EI #10 stated, see nurse before entering the room because the resident is on contact isolation precautions. EI #10 was asked when a resident is on contact isolation precautions, what kind of Personal Protected Equipment should a staff member put on before entering a resident room. EI#10 stated gloves, a gown and face mask. EI #1 was asked if any Personal Protected Equipment was put on before entering RI#11's room. E I#10 stated no. EI #10 was asked what item did she bring out of the room without having on Personal Protected Equipment. EI#10 replied RI #11's breakfast tray. EI #10 was asked why should she wear Personal Protected Equipment before entering RI #11's room. EI #10 stated to prevent spreading of contact diseases when a resident is on contact isolation precautions. On 05/10/18 at 9:15 am., an interview was conducted with EI #3, Registered Nurse, Assistant Director of Nursing and Interim Infection Control. EI #3 was asked what kind of isolation was RI #11 on. EI #3 stated contact isolation precautions due to scabies. EI #3 was asked, according to the facility's policy, what kind of precautions should a staff member take when entering a resident's room with contact isolation precautions. EI #3 stated, to see the nurse to see what kind of precautions the resident is on, and dress appropriately using the Protected Personal Equipment, when entering the resident's room. EI #3 was asked why should staff dress appropriately with Protected Personal Equipment when entering a resident room with contact isolation precautions. EI #3 replied to keep the infection to the room and have no staff members or other residents contact the infection. 2.) RI #60 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 05/09/18 at 8:29 a.m., during medication pass observation for RI #60, EI #14, LPN, was observed placing gloves on top of a paper towel dispenser while washing her hands. She then picked up the gloves and applied them to administer nasal spray for RI #60. On 05/09/18 at 3:24 p.m., an interview was conducted with EI #14. EI #14 was asked should gloves be placed on top of the paper towel dispenser while she was washing her hands. EI #14 said no. EI #14 was asked what was the concern with placing gloves on the paper towel dispenser and then using those gloves to administer RI #60's nasal spray. EI #14 answered infection control. 3.) RI #78 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a facility document titled, Clean Dressing Change, with no date, documented: .8 Remove soiled dressing . 9 Dispose of gloves in plastic bag 10 wash hands and put on second pair of gloves . 16 Remove gloves and discard in to plastic bag 17 Wash hands 18 Assist resident to a comfortable position . On 05/09/18 at 8:56 a.m., wound care was observed for RI #78. Employee Identifier (EI) 11, Licensed Practical Nurse (LPN)/Treatment Nurse, was observed cleaning a wound on RI #78's right buttock. While EI #11 applied medication to RI #78's dressing, RI #78 laid back onto her/his brief. EI #11 applied the clean dressing without cleaning the wound that had been in contact with the soiled brief. EI #11 was then observed pulling up RI #78's covers, rearranging pillows and replacing RI #78's wedge wearing the same gloves worn during wound care. During this same observation, EI #11 was observed providing wound care to RI #78's right outer ankle. EI #11 removed a soiled dressing from RI #78's right outer ankle and cleaned the wound wearing the same gloves used to remove the soiled dressing. After completing wound care, EI #11 was observed reapplying RI #78's right heel boot wearing the same gloves she wore during during wound care. On 05/09/18 at 03:04 p.m., an interview was conducted with EI #11. EI #11 was asked did RI #78's right buttock come into contact with her/his brief after she had cleaned the wound. EI #11 said yes. EI #11 was asked did she re-clean the wound after that contact before she applied the clean dressing. EI #11 replied no. EI #11 was asked did she wash her hands and change her gloves after she removed the soiled dressings during wound care for RI #78. EI #11 answered she thought she did but apparently she did not. EI #11 was asked if she reapplied RI #78's heel protector wearing the same gloves she wore during wound care. EI #11 said yes. EI #11 was asked what was the concern with not changing her gloves and washing her hands when providing wound care. EI #11 answered spreading germs and bacteria to whatever she was touching. EI #11 was asked what was the concern with spreading germs and bacteria. EI #11 said being spread around to other places and infection control. 05/10/18 at 3:03 p.m., an interview was conducted with EI #3, RN/ADON/Interim Infection Control Coordinator. EI #3 was asked when should nurses wash their hands during wound care. EI #3 said when they enter the room, after they remove the soiled dressing and before they leave the room. EI #3 was asked if a resident lays back down on their brief should the wound be re-cleaned before the clean dressing is applied. EI #3 replied yes. EI #3 was asked should a nurse adjust covers, reposition pillows and reapply a heel boot wearing the same gloves she wore during wound care. EI #3 said no. EI #3 was asked should a nurse place gloves on top of a paper towel dispenser while washing her hands and then apply those same gloves to administer nasal spray. EI #3 replied no. EI #3 was asked what was the concern with these issues. EI #3 answered infection control.

Based on observation, interviews,a facility document titled Temperature Log and review of a facility policy titled, Use & Storage of Food from Outside Sources, the facility failed to ensure the temperatures on the West Station Medication Room Refrigerator were routinely monitored. This affected one of two medication room refrigerators. Findings Include: A review of a facility policy titled, Use & Storage of Food from Outside Sources, with effective date of 11/01/2016, documented: .PR[NAME]EDURE . 6. All refrigeration units .to monitor temperatures. All units must be maintained at internal temperatures that are deemed safe . On 05/09/18 at 10:34 a.m., the surveyor observed, with Employee Identifier (EI) #9, a licensed nurse, that the temperatures on the Refrigerator Medication Room Log, in the West Station Medication Room, were not routinely documented. When the facility temperature log was reviewed, the following dates were missing daily temperature recordings in (MONTH) (YEAR): 1,2,3,4,5,9,10,11,14,15,18,19,20,21,22,23,24,25,26,27,28,29,30. On 05/09/18 at 11:25 a.m., an interview was conducted with EI #4, a Registered Nurse and Unit Manager on West Station. EI #4 was asked when should the temperature for the refrigerators in the West Nursing Station Medication Room be checked and recorded. EI #4 stated on the 11 p.m. - 7a.m. shift daily. EI #4 was asked why should you record the temperatures daily for the medication room refrigerators. EI #4 stated, to make sure the temperatures are in the correct range. On 05/09/18 at 1:50 p.m., an interview was conducted with EI #9. E #9 was asked when should the temperature logs be recorded. EI #9 replied that it should be done daily. EI #9 was asked what dates were not logged in April, (YEAR) on the West Station Medication Room Refrigerator daily temperature log. EI #9 stated (MONTH) 1,2,3,4,5,9,10,11,14,15,18,19,20,21,22,23,24,25,26,27,28,29,30.

Based on interview, documents titled Alabama Department of Public Health Online Incident Reporting System and Investigation Template and a facility policy titled Abuse Policy, the facility failed to ensure Resident Identifier (RI) #18 was free from physical abuse on 5/3/18. This affected RI #18 one of three residents reviewed for abuse concerns. Findings Include: RI #18 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of RI #18's most recent Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/20/18, documented severely impaired cognitive skills for daily decision making. A review of a policy titled Abuse Policy with an effective date of (MONTH) (YEAR) documented the following: .Abuse means the willful .infliction of injury . with resulting physical harm, pain or mental anguish .Physical abuse includes hitting, slapping, punching and kicking . Policy Statement It is the policy of the center to take appropriate steps to prevent the occurrence of abuse . A review of a document tilted Alabama Department of Public Health Online Reporting System documented: .Incident Type .Physical Abuse .Employee Identifier (EI) 12, Certified Nursing Assistant (CNA) reported RI #18 hit her with his/her shoe. RI #18 was noted to have a bruise and a skin tear to his/her right lower arm . A review of a facility document titled Investigation Template documented: . (RI #18, resident's name) was noted to have a 3 skin tear to right forearm and a 1.5 skin tear to right hand. (RI #18, resident's name) was also noted to have a bruise on right forearm around skin tear .Investigation Summary: .substantiating abuse in the matter . (EI #12, staff's name) will be terminated . A telephone interview was conducted with EI #12, CNA on 5/10/18 at 4:39 p.m. EI #12 stated she went into RI #18's room on 5/3/18 around 9:00 p.m. EI # 12 stated she attempted to change RI #18 and he/she became combative and hit her with a shoe. EI #12 stated she then left the room and told EI #9, Licensed Practical Nurse (LPN). EI # 12 was asked if she hit RI #18 after he/she became combative and hit her with a shoe. EI #12 stated no, as soon as it happened she left the room. EI #12 further stated she never saw a skin tear on RI #18. An interview was conducted with EI # 9, LPN on 5/10/18 at 6:40 p.m. EI # 9 stated on 5/3/18 EI #12 came to the desk and told her RI #18 hit her with a shoe. EI #9 stated EI #12 then went outside in the smoking area. EI #9 stated she went to RI #18's room and found he/she laying on his/her right side. There were no sheets on the bed and RI #18 had blood on his/her shirt. EI #9 stated she got a sheet and covered RI #18 up. EI #9 stated she then went and told EI # 12 not to come back into the building. EI #9 stated she then called EI #1, Administrator and she arrived at the facility within 10 minutes. An interview was conducted with EI #1 on 5/10/18 at 7:24 p.m. EI #1 stated she received a phone call on 5/3/18 between 9:00 p.m. and 9:30 p.m. EI #1 stated EI #12 was outside in the smoking area when she arrived at the facility. EI #1 stated she suspended EI #12 and sent her to the emergency room for treatment to her eye. EI #1 stated she then assessed RI #18 and there was blood on his/her shirt. RI #18 told EI #1 that a man had twisted his/her arm. EI #1 stated she then called the police and they came to the facility and took a report. EI #1 was asked if she was able to substantiate abuse. EI #1 stated yes, based on the fact RI #12 did not give a truthful statement. EI #1 stated the skin tear was present and visible. EI #1 further stated she believed RI #18's account of what happened. EI #1 was asked if RI #18 was kept free from abuse. EI #1 stated no. On 5/10/18 at 7:51 p.m. the Surveyor and EI # 1 went into RI #18's room. A bandage was observed on his/her right forearm. RI #18 was asked about the skin tear. RI #18 stated his/her arm was twisted but no further information was given. RI #18 was confused and could not hold a conversation.

Based on record review and interview, the facility failed to initiate a Significant Change in Status Minimum Data Set (MDS) Assessment after the decline in two areas: the use of an indwelling urinary catheter and the worsening of a pressure ulcer. This affected Resident Identifier (RI) #78, one of 23 residents for whom MDS assessments were reviewed. Findings Include: Resident Identifier (RI) #78 was admitted to the facility on [DATE], and discharged on [DATE]. On 03/21/18, RI #78 was readmitted to the facility with [DIAGNOSES REDACTED]. RI #78 also had orders for a foley catheter and bedrest for healing of a Stage 3 pressure ulcer, that had worsened from a Stage 2. A review of RI #78's (MONTH) (YEAR) Order Summary Report revealed: .#16 Foley Cath (catheter) to bedside drainage due pressure ulcer .Bed rest to wound heals .Clean wound to r (right) buttock with NS (normal saline) and apply [MEDICATION NAME] Calcium alginate dsg (dressing) to cover wound bed and cover with secondary dsg . A review of the RI #78's prior Quarterly MDS with an assessment reference date of 01/10/2018, revealed in section H, the resident was frequently incontinent of bowel and bladder and used no appliances. The M section of the MDS also revealed the resident had one Stage 2 pressure ulcer. A review of the most recent Quarterly MDS with an assessment reference date of 04/10/2018, revealed in section H, the resident was frequently incontinent of bowel and bladder and used no appliances. Also in Section M on the MDS, the resident was coded as having one Stage 3 pressure ulcer that was coded on the previous Quarterly assessment at a lesser stage, Stage 2. Employee identifier (EI) #6, Registered Nurse (RN) MDS Coordinator, was interviewed on 05/10/2018, at 3:29 p.m. and was asked if a significant change assessment had been completed when RI #78 was readmitted from the hospital with orders for a foley catheter and bedrest until wound heals on 03/21/2018. EI # 6 replied no. EI #6 was asked when should a significant change have been completed. EI #6 said 14 days after readmission would have been (MONTH) 3rd. EI #6 was asked was the Significant Change in Status Assessment missed. EI #6 answered yes.

Based on observation, medical record review and interview the facility failed to ensure: 1. a care plan was implemented for contact isolation precautions for Resident Identifier (RI) # 11, 2. a care plan was developed for oxygen use for RI # 24 and 3. a care plan was developed for Activities of Daily Living care for RI # 78. This affected RI # 11, 24 and 78, three of 23 residents reviewed for care plans. Findings Include: 1) RI #11 was admitted to the facility on [DATE]. On 5/08/18 at 5:04 p.m., a review of the physician orders [REDACTED]. A review of RI #11's care plan, dated 05/08/2018, revealed: . Isolation Precautions to be observed . On 05/09/18 at 8:53 a.m., Employee Identifier (EI) #10, a Certified Nursing Assistant, was observed entering RI # 11's room without applying gloves or a gown. On 05/09/18 at 8:55 a.m., an interview was conducted with EI #10. EI #10 was asked when a resident is on contact isolation precautions, what kind of Personal Protected Equipment should a staff member put on before entering a resident room. EI #10 stated gloves, a gown and face mask. EI#1 was asked if any Personal Protected Equipment was put on before entering RI #11's room. EI #10 stated no. On 05/10/18 at 09:45 a.m., an interview was conducted with EI #3, a Registered Nurse, Assistant Director of Nursing and Interim Infection Control. EI #3 was asked did RI #11 have a care plan for contact isolation precautions. EI #3 stated yes. EI #3 was asked if a staff member enters a resident room, that is on contact isolation precautions, without wearing personal protected equipment, would they be following a care plan that stated isolation precautions to be observed. EI #3 stated no. 2) RI #24 was readmitted to the facility on [DATE]. On 5/10/18 at 3:20 p.m. the Surveyor reviewed the care plan for RI # 24. No care plan for oxygen was found. A review of RI # 24's physician's orders [REDACTED].O2 @ 3L/M (millilter) via NC (nasal canal) every shift .Start Date 3/19/18 . On 5/10/18 at 5:34 p.m. an interview was conducted with Employee Identifier (EI) #6, Registered Nurse (RN). EI #6 confirmed RI #24 had an order for [REDACTED].#6 reviewed RI #24's care plans and stated there was no oxygen care plan. EI #6 further stated there should be an oxygen care plan and it was an oversight. EI #6 stated the problem with RI #24 not having an oxygen care plan would be staff not knowing how to care for his/her oxygen needs. 3.) RI #78 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #78's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed RI #78 Brief Interview for Mental Status (BIMS) score of 03, indicating severe cognitive impairment. The MDS also assessed RI #78 as requiring total care for personal hygiene and bathing. A review of RI #78's care plans revealed no care plan for Activities of Daily Living (ADLs). On 05/09/18 at 8:56 a.m., during wound care observation, RI #78's toenails were observed to be long, thick with jagged edges on bilateral feet. On 05/10/18 at 3:29 p.m., an interview was conducted with Employee Identifier (EI) #6, Registered Nurse (RN)/ MDS Coordinator. EI #6 was asked if RI #78 had an ADL care plan. EI #6 answered no. It must have been an oversight. He/she should have one.

Based on observations, interviews and medical record review, the facility failed to ensure toenail care was provided for Resident Identifier (RI) #78, a dependent resident. This deficient practice affected RI #78, one of one resident sampled for Activities of Daily Living (ADLs) care. Findings Include: RI #78 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #78's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed RI #78 Brief Interview for Mental Status (BIMS) score of 03, indicating severe cognitive impairment. The MDS also indicated RI #78 required total care for personal hygiene and bathing. A review of RI # 78's care plans revealed no care plan for the care of the resident's toenails. On 05/09/18 at 8:56 a.m., during wound care observation, RI #78's toenails were observed to be long, thick with jagged edges on his/her bilateral feet. On 05/10/18 at 4:37 p.m., EI #5, RN/East Unit Manager, accompanied the surveyor to RI #78's room to observe RI # 78's toenails. After leaving RI #78's room, an interview was conducted with EI #5. EI #5 was asked where was nail care documented. EI #5 replied she did not think it was documented anywhere. EI #5 was asked how often should nail care be provided. EI #5 said staff should look at them daily and be cut at least weekly. EI #5 was asked did it look like RI #78's toenails have been trimmed. EI #5 said no it really did not.

Based on observation, interviews and review of a facility document titled, Clean Dressing Change, the facility failed to ensure a Licensed Nurse cleaned RI #78's wound after the resident laid back on his/her brief before applying a clean dressing to the wound . This affected RI #78, one of one residents observed for wound care. Findings include: RI #78 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a facility document titled, Clean Dressing Change, with no date, documented: .8 Remove soiled dressing .9 Dispose of gloves in plastic bag 10 wash hands and put on second pair of gloves .16 Remove gloves and discard in to plastic bag 17 Wash hands 18 Assist resident to a comfortable position . On 05/09/18 at 8:56 a.m., wound care was observed for RI #78. Employee Identifier (EI) 11, Licensed Practical Nurse (LPN)/Treatment Nurse, was observed cleaning a wound on RI #78's right buttock. While EI #11 applied medication to RI #78's dressing, RI #78 laid back onto her/his brief. EI #11 applied the clean dressing without cleaning the wound that had been in contact with the brief. During this same observation, EI #11 was observed providing wound care to RI #78's right outer ankle. EI #11 removed a soiled dressing from RI #78's right outer ankle and cleaned the wound wearing the same gloves used to remove the soiled dressing. On 05/09/18 at 03:04 p.m., an interview was conducted with EI #11. EI #11 was asked did RI #78's right buttock come into contact with her/his brief after she had cleaned the wound. EI #11 said yes. EI #11 was asked did she re-clean the wound after that contact before she applied the clean dressing. EI #11 replied no. EI #11 was asked did she wash her hands and change her gloves after she removed the soiled dressings during wound care for RI #78. EI #11 answered she thought she did but apparently she did not. EI #11 was asked what was the concern with not changing her gloves and washing her hands when providing wound care. EI #11 answered spreading germs and bacteria to whatever she was touching.

Based on interviews, medical record review, review of a facility policy titled, Notification of Patient/Resident Change and review of a facility document titled, physician's orders [REDACTED].#24's responsible party when he was transferred out of the facility to the hospital on [DATE]. This affected RI #24, one of three residents sampled for notification of transfer/discharge from the facility. Findings Include: On 08/11/17, the State Agency received a complaint that RI #24's responsible party was not notified of his/her transfer to the hospital on [DATE]. Review of a facility policy titled, Notification of Patient/Resident Change, with an effective date of 11/01/16 documented: The center will . notify the patient/resident's legal representative or an interested family member when there is: .(D) A decision to transfer or discharge the resident from the center Criteria: Appropriate notification time, immediate . RI #24 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a facility document titled, physician's orders [REDACTED]. 7/31/17 D/C (Discharge) to . (hospital) behaviors PO (Phone order) . Review of RI #24's Progress Notes for 07/31/17, revealed no documentation RI #24's family/responsible party was notified of the discharge to the hospital. On 9/7/17 at 1:07 p.m. in an interview with Employee Identifier (EI) #1, a Licensed Practical Nurse (LPN), the surveyor asked, did she talk to the family about RI #24 being sent out of the facility on 7/31/17. EI #1 said, No Ma'am. On 9/7/17 at 1:47 p.m. in an interview with EI #2, Registered Nurse (RN)/DON (Director of Nursing), the surveyor asked, did she take the order to discharge RI #24 to the hospital. EI #2 replied, I didn't actually take the order. I put the order in the computer . EI #2 said she thought EI #3, LPN/Medical Records, took the order since she was the one that wrote it. EI #2 was asked, did she contact the family about RI #24 being discharged . EI #2 stated, I didn't. On 9/7/17 at 2:08 p.m. in an interview with EI #3, LPN/Medical Records, the surveyor asked, did she write the order to discharge RI #24. EI #3 answered, Yes. EI #3 was asked, did she talk to the family about RI #24 being discharged . EI #3 said, No Ma'am. When asked what should occur when a resident was discharged , EI #3 said call the family. On 9/7/17 at 2:25 p.m. in an interview with EI #4, Administrator, the surveyor asked, when did she become aware RI #24's family was not notified of his/her discharge on 7/31/17. EI #4 answered, on the second of August. The surveyor determined current facility compliance by: 1) Review and verification of the facility's Action Plan, dated 08/03/2017, as outlined in general terms below: - Checked the documentation for all residents in the hospital at the present time for documentation of family notification; Designated Team Member: Medical Records; completed by 08/04/2017 - Education to the Nursing Department of appropriate documentation of notifying family for change of condition and transfers from center; Designated Team Member: Administrator/Director of Nursing/Assistant Director of Nursing; completed by 08/10/2017 for regular staff and PRN (as needed) staff to complete as scheduled - Documentation of notification of family regarding change of condition or transfers will be monitored daily in clinical start up; Responsible Party: Director of Nursing/Assistant Director of Nursing/Unit Managers - Documentation to be monitored and reviewed by the Administrator 5 times a week for one month, 3 times a week for a month, then monthly for 3 months; Responsible Party: Administrator - Any resident identified without proper documentation on transfer or change of condition, family will be notified immediately and nurse will be retrained; Responsible Party: Director of Nursing/ Assistant Director of Nursing/Unit Manager 2) Review of the facility's audit dated 08/03/2017. This audit included documentation of notifications for all hospital discharges. 3) Review of training documentation, dated 08/02/2017, related to the need for staff to review and ensure appropriate documentation and notifications for change of condition and transfers during the clinical start up meetings. 4) Review of training documentation for the Nursing Department, dated 08/02/2017, related to change of condition and the need to notify the resident's sponsor of any change of care. 5) Review of monitoring logs for change of condition or transfers and notification of responsible party/family and the physician.

Based on interview and review of the facility's education training records for Employee Identifier (EI) #s 7-11, the facility failed to ensure CNAs (Certified Nursing Assistant) received at least 12 hours of education per year including education related to Abuse Prevention and Dementia. This affected five of five CNAs reviewed for training records and had the potential to affect 20 of 63 resident rooms for whom those CNAs were assigned to provide care. Findings Include: A review of the facility's employee listing of CNAs revealed EI #7's hire date was 1/11/2008. EI #7's education training certificates from 01/11/2016-01/11/2017 documented five hours of continuing education hours, and did not include documentation of Dementia training. A review of the facility's employee listing of CNAs revealed EI #8's hire date was 3/7/2016. EI #8's education training certificates from 03/07/2016 through 03/07/2017 documented 0.25 hours of continuing education hours, and did not include documentation of Abuse Prevention or Dementia training. A review of the facility's employee listing of CNAs revealed EI #9's hire date was 4/21/2015. EI #9's education training certificates from 04/21/2016 through 04/21/2017 documented 2.5 hours of continuing education hours, and did not include documentation of Abuse Prevention training. A review of the facility's employee listing of CNAs revealed EI #10's hire date was 4/4/2005. EI #10's education training certificates from 04/04/2016 through 04/04/2017 documented 3.25 hours of continuing education hours, and did not include documentation of Abuse Prevention training. A review of the facility's employee listing on CNAs revealed EI #11's hire date was 2/2/1998. EI #11's education training certificates from 02/02/2016 though 02/02/2017 documented two hours of continuing education hours, and did not include documentation of Dementia or Abuse Prevention training. On 6/28/2017 at 8:49 a.m., an interview was conducted with EI #6, Director of Clinical Education. EI #6 reviewed the records the facility provided for EI #s 7-11 and agreed they did not have the required hours, nor did they all have abuse and/or dementia training. EI #6 was asked how many hours of training CNAs were required to have each year. EI #6 stated, 12 hours. EI #6 said mandated topics included Abuse, Neglect and Dementia. When asked why it was important to ensure CNAs received education, EI #6 replied, because residents need to have proper care and harm could result if procedures were not properly followed.

Based on interview and record review, the facility failed to ensure RI (Resident Identifier) #7's alteration in elimination care plan was followed. This care plan listed an approach to evaluate RI #7 for time and frequency of elimination. This affected one of 20 residents for whom care plans were reviewed. Findings Include: RI #7 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of RI #7's medical records revealed the last bowel and bladder assessment was completed 10/11/2016, prior to the urinary catheter removal. Review of RI #7's plan of care with a focus area of Alteration in elimination of bowel and bladder ., with an initiation date of 2/22/2017 and a revised date of 5/12/2017, revealed an intervention as follows: . Evaluate frequency/timing of incontinence episodes . RI #7's quarterly MDS (Minimum Data Set) assessment with an Assessment Reference Date (ARD) of 5/11/2017, revealed RI #7 was always incontinent of bowel and bladder and required extensive staff assistance with toilet use and hygiene. The assessment also indicated a toileting program was not used to manage RI #7's bowel and bladder incontinence after removal of an indwelling catheter. RI #7's Annual MDS assessment with an ARD of 6/2/2017, revealed RI #7 was always incontinent of bowel and bladder and required extensive staff assistance with toilet use and hygiene. The assessment also indicated a toileting program was not used to manage RI #7's bowel and bladder incontinence after removal of an indwelling catheter. On 6/28/2017 at 5:25 p.m., EI #2, DNS (Director of Nursing Services), was asked why care plan interventions were not followed for evaluating the frequency/timing of incontinent episodes for RI #7's. EI #2 replied, that was a generic care plan. When asked why it was important to follow care plan interventions, EI #2 said, a care plan should reflect the resident's needs.

Based on interview and record review, the facility failed to ensure: 1. RI (Resident Identifier) #7 was tracked to determine bowel and bladder patterns, after removal of a urinary catheter, for the development and implementation of a plan of care that included approaches individualized for RI #7; and 2. A care plan was developed to address RI #16's order for isolation precautions. These deficient practices affected RI #7, one of three residents tracked for bowel and bladder elimination and RI #16, one of three residents observed for isolation precautions. Findings Include: 1. RI #7 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of RI #7's records revealed bowel and bladder assessment forms dated 10/11/2016, that documented the use of an indwelling bladder catheter. There were no bowel and bladder assessments documented for RI #7 after the removal of the indwelling catheter. RI #7's quarterly MDS (Minimum Data Set) assessment with an Assessment Reference Date (ARD) of 5/11/2017, revealed RI #7 was always incontinent of bowel and bladder and required extensive staff assistance with toilet use and hygiene. The assessment also indicated a toileting program was not used to manage RI #7's bowel and bladder incontinence after removal of an indwelling catheter. RI #7's Annual MDS assessment with an ARD of 6/2/2017 revealed RI #7 was always incontinent of bowel and bladder and required extensive staff assistance with toilet use and hygiene. The assessment also indicated a toileting program was not used to manage RI #7's bowel and bladder incontinence after removal of an indwelling catheter. RI #7's care plans were reviewed and there were no individualized interventions or approaches documented to address RI #7's bowel and bladder incontinence. On 6/28/2017 at 9:50 a.m. EI (Employee Identifier) #2, DNS (Director of Nursing Services) said, RI #7 was always incontinent of bowel and bladder and used to have a catheter, but not currently. EI #2 said, if RI #7 had been tracked for bowel and bladder the facility would have known what times RI #7 was voiding in order to develop a plan of care with an established schedule for RI #7. When asked what the purpose of a toileting schedule was, EI #2 said, to prevent an incontinent episode. 2. RI #16 was admitted to the facility on [DATE]. On 06/17/2017, a physician's orders [REDACTED].#16's tracheotomy site at the base of the neck. Review of RI #16's lab reports, indicated on 06/20/2017 at 10:30 a.m., [MEDICAL CONDITION] (MRSA) was identified as the result of RI #16's tracheotomy site culture. On 06/21/2017, an order was written to place RI #16 on contact isolation. However, review of RI #16's comprehensive care plans revealed there was not a care plan addressing RI #16's need for contact isolation. During an interview with EI #2, the Director of Nursing, on 06/28/2017 at 5:40 p.m., EI #2 was asked how RI #16's care plans addressed the need for contact isolation. After reviewing RI #16's care plans and care guide, EI #2 said she did not see where it was addressed. EI #2 said the order for contact isolation was written on 06/21/2017, and a care plan should have been developed right then. EI #2 said it was important to develop care plans addressing isolation precautions so staff know what they should do.

Based on observation, interview, record review and review of a form provided by the facility titled, Alabama Your Resident Rights and Protections Under State and Federal Law, the facility failed to ensure RI (Resident Identifier) #7 was provided privacy during incontinent care on 6/26/2017, when staff left the room four times during care leaving RI #7 uncovered and exposed. This affected one of three residents observed during incontinent care. Findings Include: Review of an undated form provided by the facility titled, Alabama Your Resident Rights and Protections Under State and Federal Law revealed: . Privacy. You have a right to personal privacy, including privacy in accommodations . RI #7 was readmitted to the facility on [DATE]. On 6/26/2017 at 7:00 p.m., EI (Employee Identifier) #3, CNA (Certified Nursing Assistant), provided incontinent care for RI #7 and left the room four times during care, leaving RI #7's perineum exposed and uncovered. RI #7's privacy curtain was only pulled half way across the entrance to the room. One of the four times EI #3 left the room, RI #7's door did not shut leaving RI #7's perineum exposed to the hallway. The incontinent care EI #3 provided took place from 7:00 p.m. until 7:45 p.m. leaving RI #7's perineum uncovered for 45 minutes. On 6/27/2017 at 7:05 p.m. EI #3 was asked how she protected a resident's privacy during incontinent care. EI #3 said, close the curtain and make sure the door was shut. EI #3 said, to cover the exposed resident when leaving the room. EI #3 said she left the room multiple times without covering the resident because she was nervous. EI #3 stated she should have provided privacy for RI #7 out of respect for the resident.

Based on record reviews, interviews with Employee Identifier (EI) #1, a Social Services Director and review of a facility policy titled, PASRR Requirements, the facility failed to ensure Level II PASRR (Pre-Admission Screen and Resident Review) evaluations were completed as required on two residents. This deficient practice affected Resident Identifier (RI) #8 and RI #16, two of 20 sampled residents for whom the PASRR was reviewed. Findings Include: A facility policy titled, PASRR Requirements, with no date, documented: Guidelines: . all patients 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 . Process: . 4. Each center should follow PASRR and Level II State specific requirements . 1. RI #8 was originally admitted to the facility on [DATE] and readmitted [DATE], with [DIAGNOSES REDACTED]. RI #8's PASRR Level I Screening & (and) Results for Mental Illness (MI) / Intellectual Disability (ID) / Related Conditions (RC) form dated 01/03/2017, documented RI #8's [DIAGNOSES REDACTED]. .NOT AN OBRA (Omnibus Budget Reconciliation Act) PASRR LEVEL I DETERMINATION **MAY REQUIRE A LEVEL II** . Review of a letter addressed to the facility dated January 20, 2017, from the State Project Director revealed the following: .Re: (Name of Resident) A categorical review was completed on the above named individual to determine their need for admission/continued stay . Based on this review, this individual is Approved for a categorical admission of 120 days beginning 01/10/17 and ending 05/09/17. Please be advised of the following: . (2) if the status changes to long term and/or rehab stops, a significant change Level I Screening submission is required within 14 days and the level of care criteria must be met. RI #8's OBRA PASRR LEVEL I DETERMINATION FOR CONTINUED RESIDENCY IN A MEDICAID CERTIFIED NURSING FACILITY form was resubmitted on 06/27/2017; 35 days after it was due to be resubmitted. On 06/28/2017 at 2:39 p.m. in an interview with EI #1, Social Services Director, the surveyor asked if a Level II was required when RI #8 was admitted . EI #1 said, Yes. EI #1 was asked, when should have RI #8's Level I Screening been resubmitted. EI #1 answered, 05/09/17. EI #1 was asked, when was her/his Level I resubmitted. EI #1 replied, 06/27/17, when you asked me about it. EI #1 was asked, was the Level I out of compliance. EI #1 said, Yes. 2. RI #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #16's PASRR Level I Screening & (and) Results for Mental Illness (MI) / Intellectual Disability (ID) / Related Conditions (RC) form dated 03/31/2017, documented RI #16's [DIAGNOSES REDACTED]. .NOT AN OBRA PASRR LEVEL I DETERMINATION **MAY REQUIRE A LEVEL II** . A VALID LEVEL I DETERMINATION WILL BE FAXED . RI #16's OBRA PASRR LEVEL I CATEGORICAL DETERMINATION FOR NF (Nursing Facility) CONVALESCENT CARE ADMISSION ONLY documented: . This Level I Screening and Determination is valid only with written PT (Physical Therapy) /OT (Occupational Therapy) NF orders . Review of RI #16's Physician order [REDACTED]. . Pt (patient) d/cd (discharged ) from OT (Occupational Therapy) to NSG (nursing) c (with) FMP (Functional Maintenance Plan) . RI #16's PASRR Level I Screening and Results for Mental Illness (MI) / Intellectual Disability (ID) / Related Condition (RC) form was resubmitted on 06/28/2017; nine days after it was due to be resubmitted. On 06/28/17 at 4:09 p.m., the surveyor asked EI #1 if RI #16's Level I had been resubmitted after his/her Occupational Therapy ended on 06/05/17. EI #1 stated, it was on her desk. The surveyor asked, was it resubmitted. EI #1 said, no, but she was going to and would give the surveyor a copy when she got it done. The surveyor asked EI #1, was RI #16's Level I in compliance. EI #1 said, no.

Based on observation, interview, record review, and review of the facility Peri Care Audit Tool, the facility failed to ensure a CNA (Certified Nursing Assistant) provided incontinent care to RI (Resident Identifier) #7, a resident with a history of UTI (Urinary Tract Infection) in a manner to prevent cross contamination. Specifically the CNA cleaned RI #7 with disposable wipes multiple times with the wipes in the same position and wiped from the back to the front of the perineum, and changed gloves without washing hands or performing hand hygiene. The facility also failed to ensure RI #7 received bowel and bladder assessment and tracking to maintain or improve bowel and bladder continence status. This affected one of three residents observed for incontinent care. Findings Include: Review of an undated facility Form titled, Peri Care Audit Tool revealed the following: . 3. Removes soiled brief, wash front to back, changes side of cloth or disposable wipe with each swipe. RI #7 was admitted to the facility on [DATE] and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of RI #7's records revealed bowel and bladder assessment forms dated 10/11/2016, that documented the use of an indwelling bladder catheter. There were no bowel and bladder assessments documented for RI #7 after 10/11/2016, or after RI #7's indwelling catheter was removed. Review of RI #7's Final Laboratory report with a urine collection date of 2/21/2017, revealed bacterial growth as follows: . > (greater than) 100,000 CFU/ML (Colony Forming Unit/milliliter)[MEDICAL CONDITIONS] . RI #7's quarterly MDS (Minimum Data Set) assessment with an Assessment Reference Date (ARD) of 5/11/2017, revealed RI #7 was always incontinent of bowel and bladder and required extensive staff assistance with toilet use and hygiene. The assessment also indicated a toileting program was not used to manage RI #7's bowel and bladder incontinence after removal of an indwelling catheter. RI #7's Annual MDS assessment with an ARD of 6/2/2017, revealed RI #7 was always incontinent of bowel and bladder and required extensive staff assistance with toilet use and hygiene. The assessment also indicated a toileting program was not used to manage RI #7's bowel and bladder incontinence after removal of an indwelling catheter. On 6/26/2017 at 7:00 p.m. EI #3, CNA (Certified Nursing Assistant) provided incontinent care to RI #7. EI #3 used disposable wipes with visible stool and/or in the same position four to ten times each to clean RI #7's groin and perineum. After changing gloves without washing her hands, EI #3 continued to use disposable wipes. EI #3 placed the used, disposable wipes that contained stool next to RI #7's buttocks on the soiled brief instead of in the bag at the foot of the bed. EI #3 continued to clean stool from RI #7's buttocks and perineum, used three different disposable wipes soiled with stool seven times each while using the wipes to wash from the back to front of the perineum. EI #3 continued to use disposable wipes to clean stool from RI #7's buttocks, wiping from the back to the front two to three times for each disposable wipe. EI #3 cleaned stool from RI #7's buttocks with a wash cloth, changed gloves, placed the soiled linen and trash bags on the floor, changed gloves again, and without hand hygiene, placed the clean sheet, draw sheet and brief on the bed with RI #7. EI #3 left and reentered RI #7's room, regloved without hand hygiene, and continued to clean stool from RI #7. EI #3 left the room and returned with a clean sheet and ointment, gloved without hand hygiene, applied ointment to the front of the perineum, changed gloves without hand hygiene, applied ointment to the buttocks, again changed gloves without hand hygiene and fastened a clean brief on RI #7. On 6/27/2017 at 7:00 p.m., EI #3 was asked how she was trained to clean residents during incontinent care. EI #3 said, to clean the sides, the middle, and the buttocks. EI #3 said, she should wash her hands and change her gloves when she touched a resident and let go of a resident. EI #3 said she used disposable wipes multiple times in the same position and did not wash her hands when she changed soiled gloves because she was nervous. When asked why she wiped from the back to the front, EI #3 replied, it was a mistake. When asked what the potential harm was in cleaning the perineum from the back to the front EI #3 said, it could push stool farther to the front. When asked what the potential for harm was in wiping multiple times with wipes and using the same portion of wipe, EI #3 replied, it could cause infection. EI #3 said, changing soiled gloves without hand hygiene could cause contamination.

Based on observation, interview and review of the facility policy titled, Dry Storage, the facility failed to ensure that spices were maintained with lids intact to prevent potential contamination. This affected eight of greater than 25 large canisters of spices stored in the dry storage area. Findings Include: Review of the facility policy titled, Dry Storage, dated 08/01/2012, revealed the following: POLICY It is the policy of this facility to store, prepare and serve food that is stored in accordance with federal, state, and local sanitary codes . PROCEDURE .7. Containers with tight-fitting covers will be used . During the initial tour of the kitchen on 6/26/2017 at 6:20 p.m., eight of greater than 25 spice bottles were observed with open plastic lids, exposing the contents to potential contaminants. Employee Identifier (EI) #4, the Dietary Manager, was interviewed on 6/28/2017 at 10:00 a.m. EI #4 said that spices should be stored with lids closed to prevent potential contamination.

Based on interviews, review of facility drug destruction records, and review of the facility policy titled, CONTROLLED MEDICATIONS - DISPOSAL, the facility failed to ensure that three signatures were obtained for the destruction of controlled medications. This affected four of 11 months of drug destruction records reviewed. Findings Include: Review of the facility policy titled CONTROLLED MEDICATIONS - DISPOSAL, dated 10/01/2003, revealed the following: Policy Medications included . as controlled substances are subject to special handling, storage, disposal, and record keeping . 3. Controlled medications remaining in the facility . are disposed of in the facility, as directed by state laws, regulations . Review of the facility's drug destruction records from July 2016 to June 2017, revealed three signatures were not present on the destruction records for narcotics in November 2016 or in February, March, and April of 2017. Specifically, the following was noted: 1. November 2016 - The sheet dated 11/04/2016, indicated Norco, Ultram, Ativan, Fentanyl, and Morphine (all controlled substances) were destroyed; the signature section included the signatures of the Consultant Pharmacist and the first witness, and did not document the second witness signature. 2. February 2017 - The sheet dated 02/10/2017, indicated Ultram, Norco, Morphine and Ativan were destroyed; the signature section included the signatures of the Consultant Pharmacist and the first witness, and did not document the second witness signature. 3. March 2017 - The sheet dated 03/20/2017, indicated Ultram, Ativan, Norco, Morphine, and Percocet (all controlled substances) had been destroyed; the signature section did not have documentation of the Consultant Pharmacist or the two witnesses. 4. April 2017 - The sheet dated 04/24/2017, indicated Lomotil, Ultram, Ativan, and Ultracet (all controlled substances) had been destroyed; the signature section included the Consultant Pharmacist signature and did not have documentation for the two witness signatures. Employee Identifier (EI) #2, the Director of Nursing, was interviewed on 6/28/2017 at 5:30 p.m. EI #2 said there were three signatures required for destruction of controlled medications, including the pharmacist and two nurses. EI #2 said three signatures were proof that controlled medicines were destroyed and reduced the chance of drug diversion.