Every finding on record at Eastern Shore Rehabilitation and Health Center

Based on interview, record review, and review of facility policy, the facility failed to ensure each resident's right to determine their advance directives for four (Resident Identifier (RI) #11, RI #26, RI #50, and RI #116) of seven residents reviewed for advance directives. Expressed wishes for No Code or Do Not Resuscitate (DNR) status were not followed up on to assure that the facility had all documentation and that required forms were complete and notarized, if required, to validate that this was the resident's current request per their code status. The failure to assure that all needed documentation regarding advance directives was obtained creates the potential for the resident to receive services which are not requested or per their informed preference. Findings include: The facility's Do Not Resuscitate Orders Policy dated 03/2019 indicated, When the resident is competent, the Do-Not-Resuscitate order must be reached by the resident and his physician. When the resident is incompetent, the decision must be reached by appropriate surrogate (spouse, children, parents, etc.), or legal representative, and the physician . If the resident has a declaration pursuant to the Alabama Natural Death Act, a copy of this declaration shall, if available, be made part of the resident's medical record . In the event that the resident is discharged from, and subsequently readmitted to, the facility, and the resident desires to have a Do-not-Resuscitate order, a new order should be obtained from the resident's physician. 1. RI #11 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. RI #11's Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/24/20, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 11/15, indicating mild to moderate cognitive impairment. Review of RI #11's Power of Attorney document, dated 01/15/21 and found in the resident's paper clinical record under the Advance Directive Tab, indicated, that to the statement, I want to have life sustaining treatment if I am terminally ill or injured, the answer initialed by the resident was No. To the statement, I want to have life-sustaining treatment if I am permanently unconscious, the answer initialed by the resident was No. Hospital discharge documentation, dated 02/17/21 which was provided to the survey team on 03/25/21 at approximately 4:00 PM, indicated RI #11 had a Full Code order in place in the hospital. physician's orders [REDACTED].>Further review of physician's orders [REDACTED]. The facility was unable to provide the resident's Advance Directive Acknowledgement Form, routinely completed upon admission and kept in the Admissions Office, prior to the survey exit date of 03/26/21. The surveyor was unable to interview RI #11 regarding their wishes related to their Advance Directives due to their decline in mental status. During an interview with RI #11's family member/responsible party on 03/24/21 at 3:50 PM, she stated she was the resident's co-responsible party per the resident's Medical Proxy. She indicated she lived locally and visited the resident frequently, and stated, She (RI #11) has never wished to be full code, and it would surprise me if she wanted that now. She further stated the facility had reached out to her that morning to request that she bring in another copy of the resident's Advance Directive, as the copy they had was not signed by a Notary, and that this was the requirement for the facility to implement a DNR order for the resident. The resident's family member indicated the copy of the Advance Directive originally provided to the facility had not been notarized, but the facility had not reached out to the family prior to 03/24/21 to indicate they would need the form notarized in order to implement a DNR order. During an interview with Employee Identifier (EI) #4, the Assistant Director of Nursing (ADON), on 03/25/21 at 9:01 AM, she indicated she had just spoken with RI #11's son/co-proxy, and that he indicated he wanted RI #11 to remain DNR until he could have a conversation with the resident to see if her wishes regarding her Code Status had recently changed. EI #4 stated that the resident's son had confirmed that RI #11 had always wished to be a DNR status. 2. RI #26 was admitted to the facility on [DATE] with diagnoses, according to the undated Face Sheet found in the EMR under the Demographics Tab, including dissection of unspecified site of aorta and [MEDICAL CONDITION]. RI #26's most recent MDS, a comprehensive Annual Assessment with an ARD of 12/16/20, indicated the resident had a BIMS of 3/15, indicating severe cognitive impairment. physician's orders [REDACTED].>RI #26's Advanced Directive Care Plan dated 12/05/17 also indicated, Problem: (Resident) and/or family request DNR order to be in effect; and Respect end of life decisions and provide emotional support. The resident's Advance Directive Acknowledgement Form, dated 08/23/16 and kept in the Admissions Office, was reviewed, and indicated none of the following boxes were checked regarding the resident's Advance Directive Status: Advance Directive in existence was blank, Advance Directive not in existence was blank, and Copy of Advance Directive Provided to the facility was blank. The facility was unable to provide an Advance Directive or any other documentation to the survey team, prior to facility exit on 03/26/21, to indicate the resident or her responsible party had been informed about the process related to her DNR status, or that she or her responsible party had chosen the DNR status vs Full Code Status. The surveyor was unable to interview RI #26 regarding their wishes related to their Advance Directives due to their decline in mental status. 3. RI #50 was re-admitted to the facility on [DATE] with diagnoses, according to the undated Face Sheet found in the EMR under the Demographics Tab, including COVID-19 and unspecified Dementia. RI #50's most recent MDS, a comprehensive Admission Assessment with an ARD of 01/21/21, indicated the resident had a BIMS of 13/15, indicating the resident was cognitively intact. physician's orders [REDACTED].>However, RI #50's Advanced Directive Care Plan dated 10/27/20 with a resolution date of 01/15/21 indicated, Problem: (Resident) and/or family request DNR order to be in effect; and Respect end of life decisions and provide emotional support. The resident's Advance Directive Acknowledgement Form, dated 01/15/21 and kept in the Admissions Office, indicated none of the following boxes were checked regarding the resident's Advance Directive Status: Advance Directive in existence was blank, Advance Directive not in existence was blank, Portable Do Not Resuscitate (DNR) Order in existence was blank, and Copy of Advance Directive Provided to the facility was blank. The surveyor was unable to interview the resident related to Code Status due to confusion the resident was experiencing throughout the survey period. 4. RI #116 was admitted to the facility on [DATE] with diagnoses, according to the undated Face Sheet, found in the EMR under the Demographics Tab, including [MEDICAL CONDITION] infarction ([MEDICAL CONDITION]). RI #116's MDS was not complete as of the date of the survey due to her recent admission to the facility and was not available for review. The resident's Comprehensive Admission Assessment, dated 03/10/21 and found in the EMR under the Assessment Tab, indicated the resident was cognitively intact. physician's orders [REDACTED].>However, the resident's Advance Directive Acknowledgement Form, dated 01/15/21 and kept in the Admissions Office, indicated Portable Do Not Resuscitate (DNR) Order Provided to Facility. RI #116's Portable DNR Order could not be located in the resident's record, nor was the facility able to provide the order to the survey team prior to the survey exit date of 03/26/21. During an interview conducted with RI #116 on 03/25/21 at 4:27 PM, she stated, We have a living will. I'm not going to do anything to myself, but when God thinks it's time, I believe it's time. During an interview with EI #5, a Licensed Practical Nurse (LPN)/Treatment Nurse, on 03/24/21 at 12:11 PM, she indicated she was typically responsible for resident admission/re-admission paperwork, and that any time a resident was sent out to the hospital and then readmitted to the facility, a new code order was obtained to match the hospital order. She indicated both RI #11 and RI #50 had both recently been readmitted to the facility from the hospital, and that their hospital orders must have indicated their current code status. During an interview with EI #4 on 03/25/21 at 10:30 AM, she stated the facility process was that code status was to be reviewed with residents and their responsible parties upon admission and the Advance Directive Acknowledgement Form was to be filled out. The form was to be discussed and then the resident/responsible party was to fill it out to indicate whether or not an Advance Directive/Portable DNR was in existence. She indicated if an Advance Directive or Portable DNR was in existence, staff should follow up to ensure the forms were provided to the facility in a timely manner. She further stated orders for residents returning from the hospital were based on hospital code status. She stated that if the Advance Directive Acknowledgement Form indicated a resident had an Advance Directive or Portable DNR Form, and the resident's ordered code status was Full Code, this meant the facility had not obtained a copy of those documents. She stated it was Admissions and Social Services (SS) responsibility to follow up on any missing documentation related to code status in a timely manner. During an interview with EI #6, a Corporate Admissions Coordinator, on 03/25/21 at 3:26 PM, she stated she was currently helping the facility while they were trying to fill their facility admission position. She stated she would go over the Admission Packet, including the Advance Directive Acknowledgement Form with residents and their responsible parties at the time of admission to the facility. She stated that sometimes residents/responsible parties would check the box indicating an Advance Directive was in place but would not have the actual document in hand at the time of admission. She stated, We let them know that we have to have the documentation in hand, and until we do they (the resident) will be a Full Code. If a resident says they don't have anything (an Advance Directive) in place, we offer assistance to fill out/give information on portable DNR. The social worker would need to then follow up regarding the DNR paperwork. Information (related to Code Status) is also passed off to the nurses. If I expect additional paperwork to be delivered (by the family), I pass that to the staff. The facility staff should absolutely follow up (related to Code Status paperwork/forms). During a follow up interview with EI #4 on 03/26/21 at 9:49 AM, she indicated SS should be discussing Code Status with residents and families upon admission/ re-admission. She stated, If someone indicates there is a DNR order, she (SS) should get a copy. If she can't get a copy at admission, then she needs to follow up. During an interview with EI # 8, a Registered Nurse, on 03/26/21 at 10:06 AM, she stated each nurses' station had a book with copies of each resident's Code Order. She stated if a resident were to code, she would go to the book to find the copy of the resident's code order. She indicated she could, additionally, log into the computer to look at a code order if needed, but that it was quicker to look in the book. The surveyor verified the code books were at each nurses' station, and included the current code orders for RI #11, RI #26, RI #50, and RI #116. During an interview with EI #10, an LPN, on 03/26/21 at 10:15 AM, she indicated if a resident were to code, she would go to the Code Status Book or the EMR to find the resident's current Code Orders. During an interview with EI #12, Social Services staff, on 03/26/21 at 1:50 PM, she stated, Code status is a clinical thing for us. Full Code or DNR that is between patient and physician and family. We would go to the nurse manager (for decisions related to Code Status) here. It is not social services. It (Code Status) is something nursing follows up on. If an issue related to Code Status was brought to my attention, I would get that issue to the clinical team. Nothing has been brought to my attention (related to any concerns about Code Status). If someone comes into the facility and they don't have an advanced directive, we have advanced directive forms in the office, and we can get those and go over them with a resident. We do have that information on advanced directives available.

Based on observation, interview, and record review, the facility failed to ensure one (Resident Identifier (RI) #12) of one sampled residents reviewed for range of motion received care and services to prevent potential further decline in his range of motion. RI #12's right-hand splint was not applied routinely per his plan of care. Findings include: Review of RI #12's undated Face Sheet, found in the Electronic Medical Record (EMR) under the Demographics Tab, revealed RI #12 was a long-term resident with [DIAGNOSES REDACTED]. RI #12's Functional Management Program, dated 01/14/19, read, Splint: Right hand/wrist. Wear 6 hours per day. RI #12's current Contracture Care Plan, found in the resident's EMR under the Care Plan Tab and dated 06/08/19, read, Problem: (Resident) has the use of a splint to his right hand; and Approaches: Apply splint to right hand mon - fri (Monday through Friday) in the AM (morning) and remove in the evening or as tolerated. RI #12's current Physician Orders, found in the resident's EMR under the Orders Tab and dated March 2021, indicated no order for splints. RI #12 was observed on 03/23/21 at 10:30 AM, 12:00 PM, and 2:50 PM. The resident was lying in bed on his back with the head of his bed elevated approximately 30 degrees. The resident's right hand was observed to be severely contracted, with his fingers tightly curled into the palm of his hand. No splinting device was observed on RI #12's right hand during any of the indicated observations. RI #12 was observed in bed on 03/24/21 at 10:15 AM and 3:15 PM. The resident was not wearing his right-hand splint during either observation. During an interview with Employee Identifier (EI) #11, a Licensed Practical Nurse, on 03/25/21 at 11:01 AM, she indicated RI #12 was to wear a brace on his right hand during the day and either nursing or the restorative aide was to apply it. She further stated, I was here yesterday, and I know I didn't put it on then. During an interview with EI #7, a Restorative Certified Nursing Assistant, on 03/25/21 at 11:21 AM, she confirmed RI #12 was to wear a brace on his right hand during the day. She stated, I have a Functional Maintenance Plan for it (the brace). Usually I put it (the brace) on. I didn't put it on yesterday or the day before because I was on the halls doing weights and didn't have time. The brace should be on (RI #12's hand) for four to six hours per day, five days per week. I normally put it on in the morning and take it off before I leave work for the day. During an interview with EI #4, the Assistant Director of Nursing, on 03/25/21 at 3:53 PM, she indicated RI #12 had been sent out to the hospital from 06/03/19 through 06/08/19 and that when he returned to the facility, the order for his splint had dropped out of the EMR system. She confirmed RI #12 needed the splint and stated she put a new order in for it on that date, after surveyor intervention. Review of a Telephone Order, provided to the survey team on 03/25/21 at approximately 4:30 PM and dated 03/25/21, read Nursing/Restorative Aide to apply right hand splint Monday through Friday. Apply in AM and remove at 2:00 PM. May remove sooner if not tolerated. During an additional interview with EI #4 on 03/26/21 at 9:43 AM, she stated there was no facility policy related to splinting/contracture management.

Based on interview, record review, review of the facility's grievance log, and review of facility policy, the facility failed to ensure the grievance process was followed consistently for two (Resident Identifier (RI) # 37 and RI # 59) of two residents reviewed for grievances. The facility failed to keep a record of grievances, take prompt action, and investigate, and inform the complainant of the results of the investigation regarding grievances in such area as staff language and/or missing clothes. Findings included: A review of a facility policy titled, Resident Grievances, with an effective date of 03/2018, revealed, The resident has a right to voice grievances without discrimination or reprisal. The facility will make prompt efforts to resolve grievances and will keep the resident appropriately apprised of its progress towards resolution .The facility Grievance Official is the Director of Social Services or designee. That person shall be responsible for .1. Overseeing the grievance process, receiving, tracking and working with individual departments .issuing written grievance decisions to the resident .4. Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concern(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as result of the grievance, and the date the written decision was issued. 1. Review of an admission Minimum Data Set (MDS), dated [DATE], revealed RI #37 was admitted to the facility on [DATE]. Per this MDS, RI #37 was cognitively intact. During an initial interview on 03/23/21 at 1:45 PM, RI #37 stated that last week sometime, while providing care, staff were insulting to her. She was asked if she had told someone about this. She stated she had spoken to the Administrator about it but had not heard anything back in response to her complaint. She further stated that whatever he said must have worked, as for one day they were nice, but then they went back to being insulting again. A review of the grievance log book for 2021 revealed that for the month of January, there were three grievances. For the months of February and March 2021, there was zero evidence of any grievances. In an interview on 03/24/21 at 3:50 PM, Employee Identifier (EI) #1, the Administrator, stated that RI #37 had spoken to him about her concern, and he felt her concerns did not rise to the level of abuse, so it was not investigated. EI #1was asked if he had logged the incident in the grievance book. He stated no, he just handled the concern verbally. 2. Review of a quarterly MDS with an Assessment Reference Date (ARD) of 02/21/21 revealed staff assessed RI #59 as moderately impaired in cognition. In a family interview on 03/23/21 at 11:41 AM, when asked if RI#59 had any missing personal items, the family member stated there had been missing clothes. He was asked if he had reported the missing clothing and if the facility investigated the concern. He stated the facility did look for them; however, nothing had been found or reported back to him. He further stated the facility did not have a good system in place and therefore, he had stopped buying clothes for RI #59. In an interview on 03/25/21 at 8:41 AM, EI #3, the Social Services staff, was asked if grievances were documented when there were missing items. She stated that she would let the resident decide if their concern was a grievance or not. EI #3 was asked if there was any documentation of investigation or follow through. EI #3 did not answer the question. When asked how grievances were tracked if there was no documentation, EI #3 acknowledged that it would be difficult to track then if there was no documentation. In a follow-up interview on 03/26/21 at 11:53 AM, EI #1 was asked about the facility's grievance process. He stated that grievances were mostly verbal and that they would be looked into by the staff person who had received the complaint. EI #1 was shown the grievance log for 2021, which listed a total of three grievances for the year. He stated that there was an obvious process, as in 2020 there were numerous documented entries; however, he agreed that the whole grievance process needed to be reviewed and updated to include documentation, tracking/trending, and documentation that the resident and/or family members had been informed and the issue resolved.

Based on observations, interviews, and a facility policy titled Policy: Catheters, Urinary: Catheterization, Condom Catheter, Catheter Care and Urinary Drainage Bag the facility failed to ensure: 1. Resident Identifier (RI) #1's urinary catheter bag and tubing was not on the floor. 2. RI #2 did not have a urinary catheter in place for 19 days without a physician's orders [REDACTED]. This affected two of four residents with a urinary catheter. Findings Include: 1. A facility policy titled Policy: Catheters, Urinary: Catheterization, Condom Catheter, Catheter Care and Urinary Drainage Bag with an effective date of 11/2016 revealed: . STANDARD: . PROCESS FOR CATHETER CARE: 1. Indwelling Catheter Care . b) . drainage bag lower than the bladder but off the floor . RI #1 was admitted to the facility on [DATE] and re-admitted on [DATE] and had [DIAGNOSES REDACTED]. A review of physician's orders [REDACTED]. On 12/14/20 at 4:12 PM, an observation was made of RI #1's urinary catheter tubing on the floor while Employee Identifier (EI) #3, Licensed Practical Nurse (LPN) was in the room. On 12/14/20 at 4:25 PM an observation was made of EI #3, LPN and a Certified Nursing Assistant (CNA) providing care to RI #1. The bed was raised, and the urinary catheter tubing was raised off the floor. At 4:35 PM RI #1's bed was lowered, and the urinary catheter tubing and urinary drainage bag was lowered to the floor. EI #3's right lower leg touched the urinary catheter tubing and drainage bag. EI #3 and the CNA exited the room at 4:40 PM. At 4:45 PM EI #3 returned to RI #1's room and EI #3's right upper shoe and bedside table wheel touched the urinary catheter tubing. The catheter urinary catheter tubing and drainage bag remained on the floor. On 12/14/20 at 5:00 PM RI #1's urinary catheter tubing and drainage bag observed to be in same position and the drainage bag noted to be partially under the bed rail of RI #1's bed. On 12/14/20 at 5:20 PM EI #4, CNA was observed entering RI #1's room to deliver meal tray. RI #1's urinary catheter tubing and drainage bag remained on the floor. On 12/14/20 at 5:35 PM an interview was conducted with EI #3, LPN. RI #3 was asked, where was RI #1's catheter bag and tubing. EI #3 replied, on the floor. EI #3 was asked, who was responsible to ensure catheter tubing and drainage bag were not on the floor. EI #3 replied, all staff, CNAs and nurses. EI #3 was asked, when should a catheter bag and tubing be on the floor. EI #3 replied, never. EI #3 was asked, what was the facility's policy regarding catheter bag and tubing. EI #3 replied, the bag and tubing should not be on the floor and below the bladder. On 12/15/20 at 8:35 AM an observation was made of EI #1's urinary catheter tubing touching the floor. On 12/16/20 at 12:20 PM an interview was conducted with EI #1, Registered Nurse (RN), Director of Nursing (DON). EI #1 was asked, what was the facility's policy regarding a urinary catheter tubing and/or drainage bag being on the floor. EI #1 replied, it was not to be on the floor; the bag and tubing should be below the level of the bladder, but off the floor. EI #1 was asked, who was responsible to ensure urinary catheter drainage bags and tubing were not kept on the floor. EI #1 replied, all nursing staff - CNAs and nurses. EI #1 was asked, why should a urinary catheter bag and/or tubing not be kept on the floor. EI #1 replied, to reduce the risk of infection. EI #1 was asked, when should a urinary catheter bag and/or tubing be on the floor. EI #1 replied, it should not. EI #1 was asked, what was the potential harm when a resident's urinary catheter bag is on the floor. EI #1 replied, increased risk of infection. 2. A facility policy titled Policy: Catheters, Urinary: Catheterization, Condom Catheter, Catheter Care and Urinary Drainage Bag with an effective date of 11/2016 revealed: . STANDARD: A physician's orders [REDACTED]. A resident who enters a facility with an indwelling catheter . is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary. RI #2 was admitted to the facility on [DATE] and re-admitted on [DATE]. A document titled ADMIT BODY AUDIT dated 11/27/20 indicated RI #2 had a urinary catheter. A document titled DISCHARGE SUMMARY from the discharging hospital with a print date of 11/27/2020 revealed .Discharge Summary . Treatments . Urinary Catheter - Indwelling . On 12/15/20 at 9:15 AM an observation was made of EI #2's urinary drainage bag and tubing. On 12/15/20 at 4:00 PM an interview was conducted with EI #2, RN, Assistant Director of Nursing. EI #2 was asked, did RI #2 have a physician's orders [REDACTED].#2 replied, no. EI #2 was asked, what was RI #2's [DIAGNOSES REDACTED].#2 replied, Urinary Tract Infection [MEDICAL CONDITION], so he/she did not have a qualifying diagnosis. EI #2 was asked, when should a resident have a urinary catheter for over 2 weeks without a physician's orders [REDACTED]. EI #2 was asked, when should a resident have a urinary catheter without a qualifying diagnosis. EI #2 replied, they should not. EI #2 was asked, why did RI #2 have a urinary catheter. EI #2 replied, she did not know. EI #2 was asked, when was the urinary catheter inserted. EI #2 replied, RI #2 was sent to the hospital on [DATE] and he/she returned on 11/27/20 with the urinary catheter. EI #2 was asked, who was responsible to ensure resident's with a urinary catheter had a qualifying diagnosis, physician's orders [REDACTED].#2 replied, the unit manager on the unit and the staff member who completed the Minimum Data Set reviewed the chart for items that required a care plan. EI #2 was asked, why has RI #2's urinary catheter not been removed. EI #2 replied, it would be removed today when the physician was notified. On 12/16/20 at 12:20 PM an interview was conducted with EI #1, RN, DON. EI #1 was asked, how long did RI #2 have a urinary catheter without a physician's orders [REDACTED]. EI #1 was asked, how long did RI #2 have a urinary catheter without a clinical indication for use. EI #1 replied, 19 days. EI #1 was asked, when RI #2 was re-admitted on [DATE] did he/she have a urinary catheter. EI #1 replied, yes. EI #1 was asked, when was RI #2 assessed for removal of the urinary catheter. EI #1 replied, last night, 12/15/20. EI #1 was asked, when was clinical indications for use of urinary catheter identified and documented. EI #1 replied, 12/15/20. EI #1 was asked, who was responsible to ensure resident returning to the facility with a catheter have proper clinical indications for use identified and documented as soon as possible. EI #1 replied, she was, the DON. EI #1 was asked, what was the facility's policy to ensure residents readmitted to the facility with a urinary catheter have a clinical indication for use and physician's orders [REDACTED]. EI #1 was asked, what was the potential harm to a resident when a urinary catheter remains in place for over 15 days without a clinical indication. EI #1 replied, increase risk of infection.

Based on record review, interviews and a review of a facility policy titled Resident Assessment Instrument the facility failed to ensure RI # 4, 5 and 6's Minimum Data Set (MDS) assessments were transmitted within the 14 days required time frame. This affected 3 of 3 residents whose assessments were not transmitted timely. Findings Include: A review if a facility policy titled, Resident Assessment Instrument (RAI) with an effective date of ,[DATE], revealed: PURPOSE: Residents are assessed, based on a comprehensive assessment process, in order to ensure they receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices. Tracking Records and Discharge Assessments . b) Death in the facility tracking record c) Discharge Assessment. A review of the Resident Assessment task of the survey process system revealed RI #4, #5 and #6's MDS were over 120 days old. On [DATE] at 9:00 a.m., Employee Identifier (EI) #5, Registered Nurse was interviewed. EI #5 stated that RI #4 was admitted to the facility on [DATE] and expired on [DATE]. EI #5 said RI #4's assessment was closed but not submitted. EI #5 said RI #5 came to the facility [DATE] and was discharged on [DATE]. She reported RI #5's assessment should have been closed and submitted. EI #5 reported RI #6 was admitted to the facility [DATE] and was discharged on [DATE]. EI #5 said RI #6's assessment was completed but not submitted. On [DATE] at 9:43 am, an interview was conducted with EI #6, the MDS Supervisor. EI #6 was asked who was responsible for transmitting resident data to the CMS (Centers for Medicare & Medicaid Service) system. EI #6 replied, she was or EI #5. EI #6 was asked who was responsible for transmitting RI #4, #5, and #6's data to CMS. EI #6 replied, she was. EI #6 was asked why was RI #4, #5, and #6's data not transmitted to CMS. EI #6 replied, because it did not show up on the transmit list due to be completed, but not closed. EI #6 was asked why was it important to transmitted data to CMS. EI #6 replied, CMS kept a record of the assessment data that they send to them and it was for reimbursement purpose. EI #6 was asked when should they transmit resident data to CMS. EI #6 replied, transmit weekly, but should be transmitted 14 days of the completion date. EI #6 was aked what did the facility policy say regarding transmitting resident data to CMS. EI #6 replied, to transmit accurate assessment in timely. EI #6 was asked where was it documented that RI #4, #5 and #6's data was transmitted to CMS. EI #6 replied, it was not documented that it was transmitted. EI #6 was asked why she was not alerted to transmit RI #4, #5 and #6's data to CMS. EI #6 replyed, they were not closed to pull over to her transmit list.

Based on record review, interview and a facility policy titled, Resident Assessment Instrument, the facility failed to ensure Resident Identifier ( RI ) #18's most current Minimum Data Set (MDS) assessment was coded for Hospice. This affected 1 of 19 sampled residents whose MDS' were reviewed. Finding include: A review of a facility policy titled, Resident Assessment with an effective date of 3/2018 revealed . Process: b) The individual interdisciplinary team . members responsible for the following sections of the Minimum Data Set . Nursing . O . RI #18 was readmitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. A review of RI #18's (MONTH) 9, (YEAR) MDS was not coded for Hospice in section O k. Hospice care. On 1/30/19 at 2:20, an interview was conducted with Employee Identifier (EI) Registered Nurse, #5. EI #5 was asked when did she check the Hospice box on RI # 18's (MONTH) 9, (YEAR) MDS . EI #5 replied, that day, (MONTH) 30. EI #5 was asked why was she late checking the box. EI #5 replied, it was an error in reporting it on the MDS. EI #5 was asked who was responsible for coding section O of the MDS'. EI #5 replied, she was. EI #5 was asked when should the O section be complete on the MDS. EI #5 replied, no later than 14 days of the ARD (Assessment Reference Date). EI #5 was asked why should the MDS be accurate. EI #5 replied, to get an accurate picture of the patient. EI #5 was asked what was the process for coding the MDS when a resident has a change. EI #5 replied, if a resident came on or off hospice that was a significant change, or if they had a change in two areas such as ADL (Activity of Daily Living), weight loss or pressure ulcer. EI #5 was asked how was she made aware when a resident was placed on hospice. EI #5 replied, normally the unit manage would let her know there was a hospice consult, when someone had move to hospice. EI #5 was asked what was the potential harm to the resident when the MDS was not coded accurately. EI #5 replied, it reflects on their care and they may not get the care if not coded correctly. EI #5 was asked when was the resident discharged from hospice. EI #5 replied, she continues to be on hospice.

Based on observation, interview, record review, review of the Potter / Perry Ninth Edition Fundamental of Nursing text and the facility policy titled, Dressings, Clean (Wound Care), the facility failed to ensure: 1. a Certified Nursing Assistant (CNA) did not place a clean brief and cloth pad under Resident Identifier (RI) #7 with the same soiled gloves worn during the provision of RI #7's care. The CNA further failed to wash his hands between glove changes while performing the incontinent care for RI #7; and 2. a licensed staff did not clean RI #7's wound on the right heel, and with the same soiled gloves placed the clean treatment on the heel. Also, during the care of the sacral wound, the nurse cleaned the wound and with the same soiled gloves on, applied the clean treatment to the wound. This affected one of one resident observed for incontinent care and affected one of 2 residents observed for wound care. Findings Include: 1. A review of Potter / Perry Ninth Edition Fundamental of Nursing was conducted. The text, Chapter 29 Infection Prevention and Control, page 458, addressed hand hygiene. The text revealed, . the most effective basic technique in preventing and controlling the transmission of infection is hand hygiene. The recommended hand hygiene guidelines included, . 3. * When moving from a contaminated to a clean body site during care . * After removing gloves. RI #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/29/19 at 9:50 AM, two CNAs were observed performing incontinent care for RI #7. Employee Identifier (EI) #3, CNA was observed to loosen the brief of RI #7, while EI #4, CNA removed the gown from the resident and placed the soiled gown in RI #7's bedside chair. After EI #3 cleaned bowel movement (BM) from RI #7's buttocks she placed a clean brief and another clean pad under RI #7, wearing the same soiled gloves. EI #3 handed the soiled pad to EI #4 and she placed it in the bedside chair with the gown. EI #3 then placed and secured a clean brief wearing the same soiled gloves. EI #3 then changed his gloves without washing his hands. EI #3 cleaned RI #7's face and hands with a clean wipe then put on a clean gown. On 1/29/19 at 10:10 AM an interview was conducted with EI #3. EI #3 was asked what were they to do regarding when to wash hands during incontinent care. EI #3 replied, he should wash his hands before and after care and in between glove changes. EI #3 was asked if he washed his hands when he changed gloves. EI #3 replied, no. EI #3 was asked what was the harm in not washing hands with a glove change. EI #3 replied, he could spread germs. EI #3 was asked what were they to do regarding changing gloves while performing incontinent care. EI #3 replied, he should change gloves after cleaning a resident. EI #3 was asked if the resident had a bowel movement. EI #3 replied, yes. EI #3 was asked if he placed a clean brief and a clean pad under RI #7 with the same gloves he cleaned the bowel movement. EI #3 replied, yes ma'am I did. EI #7 was asked when should he have washed his hands. EI #3 replied, after he cleaned RI #7 and before he placed the clean things. EI #3 was asked what was the risk of cleaning the resident with BM then placing the clean brief and cloth pad with same gloves. EI #3 replied, passing germs. On 1/29/19 at 10:20 AM, an interview was conducted with EI #4, CNA. EI #4 was observed placing the soiled gown and soiled cloth pad, removed from RI #7, in the bedside chair. EI #4 was asked where were they to place soiled gowns and pads when removed from a resident. EI #4 replied, in a plastic bag. EI #4 was asked where did she put the gown and pad. EI #4 replied, in the chair next to the bed. EI #4 was asked what was the harm in putting the gown and soiled pad in the chair. EI #4 replied, spreading germs, then someone may sit in the chair. 2. A review of a facility policy titled Dressings, Clean (Wound Care) with an effective date of 3/2018 revealed: PURPOSE: To provide guidelines for the care of wounds and soiled dressings, to decrease the potential for nosocomial infection. PR[NAME]ESS: .4. Wash hands and put on clean gloves 5. Remove the existing dressing 6. Pull your glove off the hand and over the dressing; discard . 7. Wash hands and put on clean gloves 8. Cleanse the wound as ordered . 10. Wash hands and put on clean gloves 11. Apply treatment as ordered . A review of RI #7's (MONTH) 2019 Physician order [REDACTED].EVERY OTHER DAY .CLEAN RIGHT HEEL WITH NORMAL SALINE .EVERY OTHER DAY . CLEAN SACRUM .DAILY . On 1/30/19 at 10:10 AM, the surveyor observed wound care for RI #7, performed by EI #2, Treatment/Registered Nurse (RN). After set up the supplies EI #2 provided cleaning and treatment to RI #7's left heel. EI #2 cleaned the wound then patted the wound dry, wearing the same soiled gloves. EI #2 then applied the treatment and outer covering to the heel wound, wearing the same soiled gloves. EI #2 then provided cleaning and treatment to the resident's sacral area. After cleaning the area, she patted the area dry, wearing the same soiled gloves. She then applied the treatment and outer covering, wearing the same soiled gloves. EI #2 then removed her gloves and washed her hands. On 1/30/19 at 11:07 AM, an interview was conducted with EI #2. EI #2 was asked what was the policy on washing hands during wound care. EI #2 replied, it does not say, but you wash hands before starting, after removing soiled dressing and after completing the care. EI #2 was asked when should she wash her hands during wound care. EI #2 replied, you wash your hands if gloves were visibly soiled. EI #2 was asked when a wound was cleaned was it a clean area or a dirt area. EI #2 replied, if your hands were not visibly soiled, it would be clean. EI #2 was asked if she washed her hands when she cleaned the wounds before placing the treatment. EI #2 replied, no. EI #2 was asked what would the potential for harm be in not washing her hands after cleaning the wounds before applying the ordered treatment. EI #2 replied, you could re-contaminate the wounds. On 1/30/19 at 3:08 PM, an interview was conducted with EI #1, Director of Nursing. EI #1 was asked what was the policy on providing incontinent care. EI #1 replied, wash hands, put on gloves, clean the resident, after cleaning remove gloves and wash hands and put on clean gloves and place clean brief and pads. EI #1 was asked when should a CNA clean BM from a resident, then with the same gloves place a clean brief and clean cloth pad. EI #1 replied, they should not. EI #1 was asked what was the policy on washing hands with glove changing. EI #1 replied, they were supposed to wash their hands everytime they remove their gloves. EI #1 was asked what was the potential for harm if a CNA performed incontinent care on a resident, then with the same gloves place a clean brief and pad. EI #1 replied, there was the potential for cross contamination. EI #1 was asked what was the policy on washing hands and changing gloves during wound care. EI #1 replied, the staff was to change gloves and wash hands after removing the soiled dressing and after cleaning the wound. EI #1 was asked when should a nurse clean a resident's wounds, then with the same gloves place the clean treatment. EI #1 replied, they should not. EI #1 was asked what was the harm in a nurse having on the same gloves she cleaned a wound with to place the clean treatment. EI #1 replied, cross contamination.

Based on record review, review of a facility policy titled, Care Plans - Person Centered, and interviews, the facility failed to ensure a plan of care was developed for a resident with a [DIAGNOSES REDACTED]. This affected RI (Resident Identifier) #5, one of twenty-five resident whose care plans were reviewed. Findings Include: A review of the facility policy titled, Policy: Care Plans - Person Centered, with an effective date of 10/17, revealed: . PURPOSE: Person centered care plans are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals for the resident that include measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in comprehensive assessment. A review of the medical record revealed RI #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders for RI #5 revealed: . [MEDICATION NAME] 100 MG (Milligrams) GIVE ONE (1) TABLET BY MOUTH ONCE DAILY AT BEDTIME DX (DIAGNOSIS): DEPRESSION . A review of the Admission MDS (Minimum Data Set) assessment for RI #5 dated 11/14/17, revealed a [DIAGNOSES REDACTED]. A review of the care plans for RI #5 revealed no problem, goal, or interventions for the [DIAGNOSES REDACTED]. During an interview on 02/15/18 at 2:45 PM, EI (Employee Identifier) #3, a Certified Nursing Assistant (CNA), was asked what she used to guide the care and monitoring of residents. EI #3 answered the print-outs from the care plan. EI #3 was asked what did the care plan indicate to monitor for, related to the [DIAGNOSES REDACTED].#5. EI #3 answered that she did not remember it saying anything about Depression. EI #3 was asked if the care plan did not address Depression, how would staff know to monitor for signs and symptoms of Depression. EI #3 answered she usually monitored for anything that might be a concern, but if it was not in the care plan, she would ask the nurse. During an interview on 02/15/18 at 2:54 PM, EI #2, a Licensed Practical Nurse (LPN), was asked if the Admission MDS assessment had a [DIAGNOSES REDACTED]. EI #2 was asked what did the care plan include for the [DIAGNOSES REDACTED].#2 replied nothing. EI #2 was asked what was the purpose of the plan of care and she answered it gave staff an idea of what was going on and how to treat it. EI #2 said it was a plan for their care, goals to work toward and it kept everybody on the same page. EI #2 was asked if it should address the [DIAGNOSES REDACTED].#5 and she answered yes. EI #2 was asked why. EI #2 answered because Depression can cause so many other things, a goal of what to watch for to prevent things from happening or worsening was needed. During an interview on 02/15/18 at 3:15 PM, EI #1, the Care Plan Coordinator, was asked what was the purpose of the plan of care. EI #1 answered it guided staff in the care of the residents. EI #1 was asked what was the facility policy regarding developing a plan of care that correlated with a resident's needs and diagnoses. EI #1 answered staff added care plans to go along with their [DIAGNOSES REDACTED]. EI #1 was asked what did the plan of care indicate for RI #5's [DIAGNOSES REDACTED].#1 answered that it just told staff to assist RI #5 to talk about his/her feelings and talk to RI #5 about his/her work history and if weather permitted, see if RI #5 wanted to go outside. EI #1 was asked if the initial/admission MDS included a [DIAGNOSES REDACTED]. EI #1 was asked if the plan of care should include interventions and/or guidance for monitoring related to a [DIAGNOSES REDACTED].

Based on observations, record reviews, and interviews, the facility failed to ensure an LPN (Licensed Practical Nurse washed her hands and changed gloves during wound care and did not touch the wound with the outer package of the gauze dressing while measuring the wound, without re-cleaning the wound. This affected RI (Resident Identifier) #6, one of three sampled residents observed for wound care. Findings Include: A review of Potter - Perry Fundamentals of Nursing 7th Edition, Chapter 34, page 655, Infection Prevention and Control, revealed: .The CDC (Center for Disease Control) recommends the following: 1. Wash hands with a non-antimicrobial soap or antimicrobial soap and water when hands are visibly soiled. 2. If hands are not visibly soiled, use an alcohol-based waterless antiseptic agent for routinely decontaminating hands in all other clinical situations: . e. After contact with inanimate objects (including medical equipment) in the immediate care of the client. h. After removing gloves. A review of Potter - Perry Fundamentals of Nursing 7th Edition, Chapter 48, page 1315, Skin Integrity and Wound Care, revealed: SKILL 48-3 Applying Dry and Moist Dressings . STEPS . 1. Perform hand hygiene . 9. Put on clean, disposable gloves, and remove tape, bandage, or ties. 11. With gloved hand carefully remove gauze dressing . 13. Fold dressing . With small dressing, remove gloves inside out over dressing . Dispose of gloves and soiled dressing in a disposable bag. Perform hand hygiene. Rationale .Reduces transmission of microorganisms. Prevents contact of hands with material on gloves. 14. Open sterile dressing tray or individually wrapped sterile supplies. Rationale .Sterile dressings remain sterile while on or within sterile surface. Preparation of supplies prevents break in technique during dressing change. 15. a. Pour ordered solution into sterile irrigation container. b. Apply clean gloves. 16. Apply dressing: A. Dry dressing (1) Apply sterile gloves. Rationale .Allows handling of sterile supplies without contamination. (2) Inspect wound . (3) Cleanse wound with solution: a. Clean from least-contaminated area to most-contaminated area . (4) Dry area. (5) Apply sterile dry dressing covering wound. (6) Apply [MEDICATION NAME] dressing if indicated. A review of RI #6's medical record revealed the resident was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #6's Quarterly MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 10/05/16, revealed RI #6 had a BIMS score of 13 out of a possible 15 points. This score indicated RI #6 was cognitively intact. RI #6 was coded as requiring extensive assistance for ADLs (Activities of Daily Living). RI #6 was always continent of bowel and was frequently incontinent of urine. On 12/07/16 at 10:00 a.m., EI (Employee Identifier)#1, an LPN, was observed performing wound care for RI #6. EI #1 was not observed to wash her hands or use alcohol gel prior to setting up the supplies for RI #6's wound care. The set up included a gel wound product, vials of sterile saline, packages of sterile gauze, and foam dressings. The supplies were set up with bare hands. EI #1 washed her hands and applied gloves. She pulled the blanket back and removed the old dressing from RI #6's left ankle. EI #1 did not wash her hands or change her gloves. EI #1 squirted the wound with sterile normal saline and cleaned the wound with a gauze dressing from inner to outer. EI #1 repeated the process. EI #1 washed her hands and changed gloves. She measured the wound by placing the outer package of the gauze dressing on the wound bed. EI #1 did not re-clean the wound, wash her hands or change her gloves. EI #1 applied the wound gel with on the right heel with a cotton tip applicator, covered and dated the wound's dressing. EI #1 washed her hands and applied gloves. RI #6's wound on the right heel did not have a dressing. EI #1 measured the wound. EI #1 did not wash her hands or change her gloves. She cleaned and dressed the wound. EI #1 then washed her hands and turned off the faucet with her bare hand. EI #1 applied gloves and dressed the wound. On 12/8/16 at 10:45 a.m., an interview was conducted with EI #1, an LPN. EI #1 was asked how she provided wound care for RI #6. EI #1 stated she had all of the supplies and informed the resident what she was going to do after entering the room. EI #1 stated she washed her hands and removed the old dressing after she gloved up. EI #1 stated she washed her hands and donned clean gloves, put the medicine on, washed her hands and donned clean gloves again. EI #1 stated she placed clean gloves on to proceed continue wound on the other foot. EI #1 stated she then disposed of the red bag. EI #1 was asked how the faucet should be turned off during hand washing. EI #1 stated after she dried her hands, she had used the paper towel. EI #1 was asked had she used the paper towel each time to turn off the faucet. EI #1 replied yes. The surveyor shared with EI #1 the observation of her turning off the faucet with her bare hand. EI #1 stated she did not remember that, but if the surveyor saw her she must have done it. The surveyor discussed the above observation of the wound care with EI #1 and asked her what was the concern. EI #1 stated the potential for the spread of infection. On 12/8/16 at 3:50 p.m. an interview was conducted with EI #2, the DON (Director of Nursing). The surveyor shared the above observation of wound care with EI #2 and asked what the concern was. EI #2 stated infection prevention was the concern. EI #2 was asked how a nurse should clean a wound. EI #2 stated she should wash her hands, apply gloves, and clean the wound from the clean to the dirty area.

Based on an observation, interviews, and a record reviews, the facility failed to ensure, the destruction of a Fentanyl 25 mcg (micrograms)/hr (hour) patch was witnessed by a second nurse in the facility. This had the potential to affect one of one nurses observed for the destruction of a controlled substance. Findings include: A review of a Facility Policy and Procedure titled, Disposal of Medications, Syringes and Needles Disposal of Medications dated 12/12 revealed: 5.4 DISPOSAL OF MEDICATIONS(:) POLICY . 2. Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances (or those classified as such by state regulation) are subject to special handling, storage, disposal, and record keeping in the nursing care center in accordance with federal and state laws and regulations. 3. Methods of disposition of pharmaceutical hazardous and non-hazardous waste are consistent with applicable state and federal requirements, local ordinances, and standards of practice. The nursing care center will use an approved vendor for pharmaceutical waste disposal needs. PROCEDURES . 2. b. For the State of Alabama, these controlled substances shall be disposed of by the nursing care center in the presence of appropriately titled professionals (check appropriate line): · Licensed nurse employed by the nursing care center and a pharmacist · Two licensed nurses employed by the nursing care center . A review of RI #20's medical record revealed the resident was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #20's Quarterly MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 11/10/16, revealed RI #20 had a BIMS score of 14 out of a possible 15 points. This score indicated RI #20 was cognitively intact. RI #20 was coded as requiring total assistance for ADLs (Activities of Daily Living). A review of the physician's orders [REDACTED]. .Duragesic 25 mcg /HR Fentanyl 25 MCG/HR PATCH APPLY ONE (1) PATCH EVERY 72 HOURS, USE ALTERNATE SITES ON TRUNK OF BODY. DX (Diagnoses) PAIN. On 12/7/16 at 8:40 a.m., a medication pass observation was made for RI (Resident Identifier) #20 by EI #1, an LPN. EI #1 removed the used Fentanyl patch from RI #20 and applied the new patch. EI #1 cut the used patch and placed it in a sharps container, used alcohol gel, and documented on the Medication Administration Record. EI #1 did not get a second nurse to witness the destruction of the used Fentanyl patch. On 12/8/16 at 10:45 a.m., an interview was conducted with EI #1, an LPN. EI #1 was asked how was she instructed to waste a narcotic patch. EI #1 stated they always lock the patches in the cart until they have another nurse to witness the destruction. EI #1 stated she did not do that on 12/7/2016. EI #1 stated she thought the surveyor wanted to see the entire process so she went on and cut it up into strips and put it in the sharps container. EI #1 was asked if a second nurse should have witnessed the destruction of the Fentanyl patch. EI #1 stated yes. EI #1 was asked what the concern was if a second nurse did not witness the drug destruction of a narcotic. EI #1 stated you do not know where the Fentanyl patch could have gone if a second nurse does not witness the destruction. On 12/8/16 at 3:50 p.m., an interview was conducted with EI #2, DON (Director of Nursing). EI #2 was asked how a nurse should dispose of a narcotic patch. EI #2 stated the patch should be folded in half with a second nurse in the facility and dispose of it in the sharps container. EI #2 was asked what the concern was when a second nurse did not witness the destruction of a narcotic. EI #2 stated the narcotic was not properly disposed of. EI #2 also stated there was a potential for diversion. EI #2 stated that was not the case and there was no concern for diversion but she should have had another nurse witness the destruction.

Based on record reviews and interviews, the facility failed to ensure staff notified the Physician and sponsor of a change in condition, as evidenced by the resident vomiting AM medications and dark emesis on 10/9/15. This affected RI (Resident Identifier) #1, one of six residents sampled for notification. Findings include: A review of a facility policy titled, Change in a Resident's Condition or Status, with a revision date of February 2014, revealed, . Policy Statement Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's physical/emotional/mental condition; . A review of a job description for Licensed Practical Nurse/Registered Nurse with a revision date of 1/1/2015 revealed, . Notify the resident's attending physician and next-of-kin when there is a change in the resident's condition. A review of the medical record revealed RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Admission MDS (Minimum Data Set), assessment dated [DATE], revealed RI #1 required moderate to maximum assistance with most ADLs (Activities of Daily Living). The resident was coded as occasionally incontinent of bowel and bladder. The resident was assessed with [REDACTED]. This score indicated RI #1 was cognitively intact for daily decision making skills. A review of the Nurses notes for RI #1, dated 10/9/15, revealed, . Out of bed at this time, CNA (Certified Nursing Assistant) reported episode of vomiting, upon this Nurse assessment, Patient noted sitting on toilet, Emesis Dark in color noted to Basin, . Scheduled for discharged today. Will monitor/continue plan of care. A review of RI #1's medical record produced no evidence of notification of the physician or sponsor regarding the resident's episode of dark colored emesis and vomiting medications on 10/10/16. An interview was conducted with EI (Employee Identifier) #3, an LPN (Licensed Practical Nurse), on 5/5/16 at 5:33 PM. EI #3 was asked if she had assessed RI #1 on 10/9/15 (date of discharge from the facility). She answered yes. EI #3 was asked if RI #1 had voiced any complaints during the assessment. She answered during the first part of her shift no, but then RI #1 vomited. EI #3 was asked if she had administered RI #1's medications on the morning of 10/09/15 and she answered yes. EI #3 listed the medications she had given to RI #1 as Aspirin 81 mg (milligrams), Calcium 600 mg, Lactobacillus, [MEDICATION NAME], [MEDICATION NAME] 7.5 mg, multivitamin, and vitamin E 400 units. EI #3 was asked if RI #1 complained of nausea and vomiting at that time and she answered later on RI #1 complained. EI #3 was asked when and where did RI #1 vomit. She answered he/she was in the bathroom, about eight o'clock AM. EI #3 was asked who saw the emesis. She answered the CNA and she had seen it. EI #3 was asked what the emesis looked like and she answered dark in color. EI #3 was asked what the resident said about the vomiting. She answered RI #1 felt like she had taken her medicines too fast and didn't feel like he/she was going to vomit again. EI #3 added the resident did want to lay down right afterwards. EI #3 was asked if the resident had vomited up medications. She answered there were a few pills in the emesis. EI #3 was asked what the pills were and how many were there. She answered she didn't know. EI #3 was asked if she had notified the physician of RI #1 vomiting up morning medications. She answered she couldn't remember. EI #3 was asked if there was documentation of the physician being notified and she answered no. EI #3 was asked why the physician was not notified and she answered normally if they have a second episode, they notify the physician. EI #3 was asked if the physician was notified about the medications being vomited and the color of the emesis. She answered she was monitoring for another episode. EI #3 was asked if the sponsor had been notified of the resident vomiting up medications and dark emesis. EI #3 answered it was not documented. She thought she told the sponsor when they came in, but RI #1 had not vomited any more. EI #3 was asked should the episode have been reported to the physician. She answered yes. EI #3 was asked when did RI #1 have a change in condition. She answered at 8 o'clock AM.

Based on record reviews and interviews, the facility failed to ensure an order for [REDACTED].#2, one of six sampled residents. The facility also failed to ensure a flow sheet in the medical record was accurate and complete. This affected RI #2, one of six sampled residents. Findings include: A review of POTTER AND PERRY FUNDAMENTALS OF NURSING Chapter 35 Medication Administration Page 706 - 707, revealed, . Standards . Professional standards, such as the American Nurses Association's Nursing: Scope of Nursing Practice . To prevent medication errors, follow the six rights of medication administration consistently . The six rights of medication administration include the following: 1. The right medication 2. The right dose 3. The right client 4. The right route 5. The right time 6. The right documentation . A review of the medical record for RI #2 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The review of a written Physician order [REDACTED]. An interview was conducted on 5/5/16 at 7:00 PM with EI (Employee Identifier) #6, an LPN (Licensed Practical Nurse). EI #6 was asked the five rights of a medication order. EI #6 stated,Patient, time, route, name of drug, dose. The surveyor showed the [MEDICATION NAME] order for RI #2 dated 4/29/16 to EI #6 and asked if there was anything wrong with the order. EI #6 stated, Yes, the current dose of [MEDICATION NAME], what is the current dose EI #6 was asked what she would do if she saw an order like this during medication pass. EI #6 stated, I would call and clarify or when the chart is checked, they would catch it. An interview was conducted on 5/5/16 at 7:45 PM with EI #2, the DON (Director of Nursing). EI #2 was asked the five rights of a medication order. EI #2 stated, Drug, patient, route, dose, form, and time. EI #2 was shown the [MEDICATION NAME] order for RI #2 dated 4/29/16. EI #2 was asked what was missing from the order. EI #2 said they were just continuing an order that was already there. EI #2 was asked what she would do if she came across this order during medication pass. EI #2 said she would clarify the order. On 5/5/16 a review of RI #2's PT/INR/[MEDICATION NAME] ([MEDICATION NAME]) FLOWSHEET dated 3/18/16 to 5/13/16, revealed: Blank spaces under notification of change for dates 4/25/16, 4/27/16, and 4/29/16. These were dates changes were made. Two blank spaces under MD notified on 4/18/16 and 4/29/16. A blank space under current dose on 4/25/16 and 4/29/16. A blank space under PT results on 4/25/16 and 5/13/16. INR results of 3.0 on 4/29/16 (Report from the lab dated 4/29/16, indicates the final result of the INR to be 2.2), INR results for 5/13/16 of 2.2 (the flowsheet was reviewed on 5/3/16). On 5/5/16 at 7:00 PM an interview was conducted with EI #6, an LPN. EI #6 was shown the flow sheet and asked what INR result was charted on the flow sheet on 4/29/16 for RI #2. EI #6 stated, 3.0. EI #6 was asked what result was indicated on the lab sheet for RI #2 from the outside lab that analyzed the blood. EI #6 stated, 2.2 EI #6 was asked how she would know which was correct. EI #6 stated she didn't know. There was a lab sheet with 3.0 on it that she was going by. When asked to read the date and the results under the entry for 4/29/16 for RI #2, EI #6 stated, Today is the fifth, May fifth. (The entry under the 4/29/16 entry was dated for 5/13/16.) EI #6 was asked if the latest entry was drawn without an order. EI #6 stated yes, it was drawn without an order if it was drawn, that day, because May 13th isn't here yet. On 5/5/16 at 7:45 PM, an interview was conducted with EI #2, the DON. EI #2 was asked to look at the flow sheet for RI #2 and tell the surveyor what the concerns were with the flowsheet. EI #2 stated, It looks like they just wrote the wrong numbers. She is new to long term care and doesn't know long term care. I see we obviously have a flow sheet inservice coming up.

Based on record reviews and interviews, the facility failed to ensure a lab test was not drawn without a physician's order. This affected RI (Resident Identifier) #1, one of six sampled residents. Findings include: A review of the Potter and Perry's Fundamentals of Nursing 7th EDITION with a copyright date of 2009 revealed, . Chapter 18 . Types of Interventions . Physician-initiated interventions are dependent nursing interventions, or actions that require an order from a physician or another health care professional. As the nurse, you intervene by carrying out the independent provider's written and/or verbal orders. Administering a medication, implementing an invasive procedure, changing a dressing, and preparing a client for diagnostic tests are examples of physician-initiated interventions. A review of the medical record revealed RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Admission MDS (Minimum Data Set), assessment dated [DATE], revealed RI #1 required moderate to maximum assistance with most ADLs (Activities of Daily Living). The resident was coded as occasionally incontinent. The resident was assessed with [REDACTED]. This score indicated RI #1 was cognitively intact for daily decision making skills. A review of the medical record revealed a basic metabolic panel lab test was performed for RI #1 with no coinciding physician's order. An interview was conducted with EI (Employee Identifier) #3, an LPN (Licensed Practical Nurse), on 5/5/16 at 5:33 PM. EI #3 was asked where was the order for the basic metabolic panel lab test drawn for RI #1 on 9/14/15. She answered there wasn't one. EI #3 was asked what was the facility's policy on lab draws without a physician's order. She answered they don't draw it. An interview was conducted with EI #2, the DON (Director of Nursing), on 5/5/16 at 7:11 PM. EI #2 was asked where was the order for the basic metabolic panel lab test drawn for RI #1 on 9/14/15. She answered she didn't find it. EI #2 was asked what was the facility's policy on lab draws without a physician's order. She answered they were supposed to have a physician's order.

Based on record reviews and interviews, the facility failed to ensure instructions for medications on discharge were current with physicians orders. This affected RI (Resident Identifier) #1, one of two closed records reviewed. Findings include: A review of the Potter and Perry's Fundamentals of Nursing 7th EDITION with a copyright date of 2009 revealed, . Chapter 35 . BOX 35 - 7 Process for Medication Reconciliation 1. Verify: Obtain a current list of the client's medications. 2. Clarify: Make sure the list of medications, dosages, and frequencies is accurate; clarify the list with as many people as necessary . to ensure the list is accurate. 3. Reconcile: Compare new medication orders with the current list; investigate any discrepancies with the client's health care provider. 4. Transmit: Communicate the updated and verified list to caregivers and the client as appropriate. A review of a job description for Licensed Practical Nurse/Registered Nurse with a revision date of 1/1/2015 revealed, . Review the resident's chart for specific treatments, medication orders, diets, etc. (et cetera), as necessary. A review of the medical record revealed RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Admission MDS (Minimum Data Set,) assessment dated [DATE], revealed RI #1 required moderate to maximum assistance with most ADLs (Activities of Daily Living). The resident was coded as occasionally incontinent. The resident was assessed with [REDACTED]. This score indicated RI #1 was cognitively intact for daily decision making skills. A review of the discharge medication instructions dated 10/9/15, for RI #1 signed by EI (Employee Identifier) #3, the discharging LPN, (Licensed Practical Nurse), revealed, . [MEDICATION NAME] 3 MG (Milligrams) TABLET GIVE 1 TABLET BY MOUTH ONCE A DAY . A review of the MAR (Medication Administration Record) for RI #1 revealed a start date of 10/8/15 for . [MEDICATION NAME] (generic for [MEDICATION NAME]) 2 mg on Tues (Tuesday) Thursday Sat (Saturday) Sunday AFib ([MEDICAL CONDITION] Fibrillation) . [MEDICATION NAME] 3 mg on M (Monday)/Wed (Wednesday)/Friday AFib . A review of a physician's orders [REDACTED]. 1. Give [MEDICATION NAME] 3 mg on Mon (Monday)/Wed/Friday 2. Give [MEDICATION NAME] 2 mg on Tues Thursday Sat Sund (Sunday) . An interview was conducted with EI #3 on 5/5/16 at 5:33 PM. EI #3 was asked who provided the discharge instructions to the resident and the sponsor of RI #1. She answered she did. EI #3 was asked what were the discharge instructions in regards to the [MEDICATION NAME] at the time of discharge. She answered (reading from a copy of the discharge instructions given to the sponsor. The list was signed by the sponsor and EI #3.) [MEDICATION NAME] 3 mg 1 tablet by mouth once a day. EI #3 was asked what the physician's orders [REDACTED]. She observed the physician's orders [REDACTED]. EI #3 was asked if there was a discrepancy in the instructions given to the sponsor and the current physician's orders [REDACTED]. She answered yes. EI #3 was asked what system was in place to ensure discharge instructions were correct with physician's orders [REDACTED]. EI #3 was asked who verified the accuracy of the discharge medication instructions. She answered the nurses. EI #3 was asked if RI #1's discharge medication instructions were verified with the physician's orders [REDACTED]. EI #3 was asked how was the count on the [MEDICATION NAME]. She answered she didn't remember but she believed she matched the medication to the discharge instructions. EI #3 was asked if she would have seen that the order/dose was incorrect if she had counted the [MEDICATION NAME] like the other medications, would she have seen the discharge medication instructions were incorrect. She answered, I believe I would have. EI #3 was asked why it was important to verify discharge instructions. She answered, Accuracy. An interview was conducted with EI #2, the DON (Director of Nursing), on 5/5/16 at 7:11 PM. EI #2 was asked what were the discharge instructions in regards to the [MEDICATION NAME] at the time of discharge. She answered [MEDICATION NAME] 3 mg, 1 tablet by mouth, once a day. EI #2 was asked what the physician's orders [REDACTED]. She reviewed the physician's orders [REDACTED]. Two mg on Tuesday, Thursday, Saturday, and Sunday. EI #2 was asked why there was a discrepancy in the instructions given compared to the physician's current order at the time of discharge. She answered she didn't know. EI #2 was asked what system was in place to ensure discharge medication instructions were correct with physician's orders [REDACTED].#2 was asked who verifies the discharge medication instructions. She answered the Nurse. EI #2 was asked when those discharge instructions were verified. She answered prior to discharge. EI #2 was asked why was it important to verify discharge instructions. She answered to prevent errors.

Based on observations, interviews, and record reviews, the facility failed to ensure: 1. A resident's care plan was followed regarding Multi Podus boots to be in use for RI (Resident Identifier) #11. 2. A resident's care plan was followed regarding toe nails being trimmed for RI #7. This affected RI #s 11 and 7, two of eighteen residents whose care plans were reviewed. Findings include: A review of the facility document titled, Using the Care Plan, with a revision date of August 2006, revealed, Highlights Policy Statement The care plan shall be used in developing the resident's daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident. 4. Changes in the resident's condition must be reported to the MDS Assessment Coordinator so that a review of the resident's assessment and care plan can be made. A review of the facility document titled, Certified Nursing Assistant . Job Description, with a revision date of 1/1/2015, revealed, . Personal Nursing Care Functions . Assist residents with nail care (i. e. {id est/that is} clipping, trimming, and cleaning the finger or toenails). (Note: Does not include diabetic residents.). Perform restorative and rehabilitative procedures, as instructed. 1. A review of RI #11's medical record revealed the resident was admitted [DATE] with [DIAGNOSES REDACTED]. A review of the Quarterly MDS (Minimum Data Set) assessment with an ARD (Assessment Review Date) of 9/9/15, indicated RI #11 was totally dependent on staff for assistance with all ADLs (Activities of Daily Living) including transferring. The resident was coded to have contractures of upper and lower extremities. RI #11 was coded as having short and long term memory problems and was severly impaired for cognitive skills of daily decision making. A review of RI #11's Plan of Care, dated 04/01/2015, revealed, RI #11 had been evaluated by Physical Therapy. It was written on the care plan on 9/10/2015, Patient to be up 5-7 days a week; Placement of Multi Podus Boots; observe for proper positioning frequently . A review of the document Functional Maintenance Plan revealed a program start date of 08/21/2015 with a frequency of 5-7 times per week. . Patient receives stretching/PROM (Passive Range of Motion) of both ankles prior to placement of Multi Podus Boots. An observation was made on 9/30/2015 at 8:16 AM of RI #11 in a Broda chair without Multi Podus Boots on the lower extremities. An observation was made on 10/01/2015 at 8:26 AM of RI #11 up in a Broda chair in the common area by the nursing station. RI #11 was observed without Multi Podus Boots on. An observation was made on 10/01/2015 at 12:21 PM of RI #11 sitting in a Broda chair. RI #11 was being fed by a staff member. RI #11 did not have Multi Podus Boots on. A brief interview was conducted at this time with the CNA (Certified Nursing Assistant) feeding RI #11. The CNA was asked about RI #11 having Multi Podus Boots. The CNA said (RI #11's name) had them at one time but she had not seen them in a while. An interview was conducted on 10/1/2015 at 3:41 PM with EI (Employee Identifier) #9, an LPN (Licensed Practical Nurse). EI #9 was asked if she knew RI #11 was suppose to be wearing Multi Podus Boots. EI #9 replied those were on hold right now because they were not fitting good and another Physical Therapy evaluation had been requested. EI #9 was ask if she knew when the Multi Podus Boots were ordered and how often was RI #11 supposed to be wearing the Multi Podus Boots. EI #9 replied the request for the Multi Podus Boots to be placed on hold and another Physical Therapy evaluation was made at a planning meeting. EI #9 was asked if the nurse writes orders for the doctor to hold the Multi Podus Boots and the Physical Therapy evaluation. EI #9 stated the nurses write orders on everything so they have a paper trail. EI #9 was asked what would be done with the care plan at the time orders were written. EI #9 replied usually when orders were written the care plan coordinator gets a copy and transfers the orders to the care plan. EI #9 was asked if she knew the care plan for RI #11 still showed the Multi Podus Boots were to be worn by RI #11. EI #9 replied no she didn't. EI #9 was asked who puts on the Multi Podus Boots. EI #9 replied usually 11-7 shift does because RI #11 was usually an early riser. EI #9 was asked if the Multi Podus Boots were discontinued. EI #9 replied, no they were placed on hold. EI #9 was asked what RI #11's care plan said to do about the Multi Podus Boots. EI #9 replied she really didn't know. An interview was conducted on 10/01/2015 at 4:36 PM with a EI #10, a CNA. EI #10 was asked if she provided care for RI #11. EI #10 replied yes she did. EI #10 was asked to explain what type of care she provided RI #11. EI #10 replied total assistance. RI #11 was a two person assist at all times. While in the Broda chair, staff keep the Multi Podus Boots on RI #11 and take them off when RI #11 goes to bed. EI #10 was asked if anyone told her not to use the Multi Podus Boots because they were not fitting correctly. EI #10 replied no, they were still using them as directed by the Nurse. EI #10 said she had been putting the Multi Podus Boots on RI #11. EI #10 was asked, Where the Multi Podus Boots are right now. EI #10 replied she couldn't tell the surveyor where the Multi Podus Boots were. EI #10 was asked if she had put the Multi Podus Boots on RI #11. EI #10 replied yes I have. EI #10 was asked if the Multi Podus Boots were discontinued. EI #10 replied she had not been told not to put them on the resident. An interviewed was conducted on 10/01/2015 at 5:10 PM, with EI #12, the MDS Coordinator. EI #12 was asked if she was familiar with RI #11. EI #12 replied some what, it has been a long time since I did RI #11's assessment. EI #12 was asked if she developed and updated care plans. EI #12 replied yes. EI #12 was asked how did she know when to update and revise a care plan. EI #12 replied we get yellow slips from nursing which is a carbon copy of the orders written. EI #12 was asked if she knew that the Multi Podus Boots for RI #11 were placed on hold last week. EI #12 replied no, I didn't know. EI #12 stated, If restorative program is written, recommendations we do not require a doctors order. EI #12 was asked who decided to place the Multi Podus Boots on hold. EI #12 replied it was a Nursing judgement to prevent the potential for skin break down. EI #12 was asked who would be responsible for updating the care plan. EI #12 replied it would still be MDS Coordinator's responsibility. EI #12 was asked if MDS had revised or updated the care plan for RI #11 related to the Multi Podus Boots being placed on hold. EI #12 replied the last time the care plan was revised was when the Multi Podus Boots were added to the care plan but not when they were placed on hold. EI #12 was asked if the care plan was being followed. EI #12 replied no. 2. A review of the facility document titled, Care of Fingernails/Toenails with a revision date of October 2010, revealed, . Purpose The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. General Guidelines 1. Nail care includes cleaning and regular trimming. A review of the medical record revealed RI #7 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the Admission MDS assessment dated [DATE], indicated RI #7 was totally dependent on staff for assistance in transferring. The MDS also indicated RI #7 required 2 person assistance with personal hygiene. A review of the initial Plan of Care dated 9/18/2015, revealed, RI #7 had Self care deficit as related to: Impaired mobility Decreased strength Decreased functional ability . Approach Assess patient ADL Upon admission Assist patient as needed to meet ADL needs while impaired . An observation was made on 9/29/2015 at 8:45 AM of RI #7 in bed with noticeably long toe nails. Eight of the ten toe nails were long and two were jagged and appeared to be broken off. An observation was made on 9/30/2015 at 9:49 AM of RI #7's toenails during a wound care observation. There was no change in the condition of the toenails from the previous observation on 9/29/2015. A brief interview was conducted following wound care for RI #7 on 9/30/15 at 9:49 AM. EI #5, an LPN, was asked what she noticed about RI #7's toes. She answered, His nails could use a trim. EI #5 was asked who was responsible for trimming the toe nails of residents that cannot perform that task for themselves. She answered, The Nurse or the CNA. If they are diabetic, the Nurse. An interview was conducted on 10/1/2015 at 2:57 PM with EI #4, a CNA. EI #4 was asked what ADL assistance RI #7 was care planned for. She answered, . ADL, (RI #7) needs 2 person assistance with lifting, transferring/mobility. EI #4 was asked if RI #7 was care planned for assistance with ADLs that they could not perform. She answered, That (RI #7) can't perform, yes Ma'am. EI #4 was asked if RI #7 could clip their own toenails. She answered, No Ma'am. EI #4 was asked if a resident was care planned to be assisted with ADLs they cannot perform, who should assist with clipping toe nails. She answered, The CNA or my Nurse or Charge Nurse. If they have a Dr's order for Podiatrist (then the Dr. would). EI #4 was asked why. She answered, Due to infections, can cause irritation to the skin if they get too long. EI #4 was asked what was the facility's policy regarding following the Plan of Care. She answered, They expect me to give care according to the Plan of Care. A second interview was conducted on 10/1/2015 at 3:22 PM with EI #5. EI #5 was asked what ADL assistance RI #7 was care planned for. She answered, One person assist. EI #5 was asked if RI #7 could clip their own toenails. She answered, No. EI #5 was asked if a resident was care planned to be assisted with ADLs they could not perform, who should assist with clipping toe nails. She answered, The CNAs can as long as the resident is not diabetic. EI #5 was asked why. She answered, Regular hygiene, just basic care. EI #5 was asked what was the importance of providing ADL assistance to match the resident's needs. She answered, Care correlates with their health needs. EI #5 was asked what was the facility's policy regarding following the Plan of Care. She answered, They expect us to use that as a guide for care. A brief interview was conducted with EI #6, LPN/Unit Manager, on 10/1/2015 at 4:30 PM. EI #6 was asked if there was any reason why RI #7 should not have their toenails trimmed. She answered, Not that I'm aware of.

Based on observations, record reviews, and interviews the facility failed to ensure: 1) A CNA (Certified Nursing Assistant) provided pericare in a manner to prevent the potential for cross contamination for RI (Resident Identifier) #4. 2) The CNA washed her hands after cleaning stool and moving to the perineal area. This affected RI #4, one of three residents observed for pericare. 3) A resident received assistance with meals as indicated by the resident's assessment. This affected RI #4, one of twelve residents observed for meals. Findings Include: 1) and 2) A review of the facility policy titled, Incontinent Care, with a revision date of October 2010, revealed, Purpose The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritations, and to observe the resident's skin condition. Steps in the Procedure . 7.e. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. A review of the medical record revealed RI #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a Quarterly MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 7/3/2015, revealed RI #4 had a BIMS (Brief Interview for Mental Status) score of 6 out of a possible 15. This score indicated RI #4 was severely impaired for daily decision making skills. RI #4 required extensive two person assist with bed mobility and transfers. RI #4 required extensive one person assist with dressing, eating and hygiene. RI #4 was totally dependent for toileting and bathing. RI #4 was always incontinent of bowel and bladder requiring the use of adult briefs. An observation was made on 9/30/2015 at 10:45 AM. The surveyor observed EI (Employee Identifier) #1, a CNA (Certified Nursing Assistant), knock and enter RI #4's room with supplies. The surveyor knocked and entered RI #4's room. The privacy curtain between the two beds had been pulled. The window blinds were open. EI #1 had gloves on and was gathering water basins. EI #2, a CNA, came in to assist. After placing supplies on the bedside table, EI #1 went into the bathroom to wash her hands. EI #1 donned gloves, wet a washcloth and cleaned RI #4's face. After cleaning RI #4's chest and arms, EI #1 turned RI #4 to the left side. When the brief was pulled down, a small amount of brown, pasty stool was observed on the brief. The brief was not wet. EI #1 added body wash to one of the basins of water. EI #1 wet a washcloth and wiped the resident between the buttocks from front to back in an upward motion. The washcloth was discarded. EI #1 folded and pulled the brief from underneath the resident and discarded the brief. EI #1 changed her gloves without washing her hands. EI #1 then turned RI #4 to the back. EI #1 wet a washcloth and cleaned down the center of the perineal area twice, folding the washcloth with each wipe. EI #1 wiped the left and right groin in a downward motion, changing the position of the cloth each time. The washcloth was discarded and gloves were changed. RI #4 was turned to the left side. EI #1 obtained a new wet washcloth and wiped between RI #4's buttocks front to back in an upward motion three times. With each wipe, EI #1 either changed the position of the cloth or obtained a new cloth. EI #1 obtained a clean wet washcloth and wiped the right and left buttock, one time each, in a circular motion and then discarded the washcloth. A clean brief was placed under RI #4. RI #4 was turned to the right side, the brief was pulled through and then fastened. RI #4 was placed in a fresh gown and covered with a blanket. An interview was conducted with EI #3, the LPN (Licensed Practical Nurse)/Infection Control Nurse of the facility, on 10/1/15 at 4:05 PM. EI #3 was asked when should a staff member wash their hands while providing incontinence care for a resident, especially when stool was present. EI #3 stated, They should wash their hands before they begin. We teach to use a basin, one with soapy and one with clean water. We teach to wipe front to back. We teach not to use the same wash cloth. I tell them to get a whole bunch of wash cloths. If they use a clean wash cloth they don't have to worry about finding a clean side of the wash cloth. Before rinsing with the clean water, we teach them to wash their hands and change gloves. They then wash their hands when they are finished with the procedure. The surveyor asked EI #3 when should a staff member change gloves during incontinence care. EI #3 stated, I would say as stated above, and or if the gloves are visibly soiled. The surveyor shared the observation of the incontinence care for RI #4 on 9/30/15, and then asked what was the concern when a staff member did not wash their hands during incontinence care when stool was involved. EI #3 stated, I would say contamination, especially when cleaning from back to front. I would say when gloves are changed, definitely wash your hands. When going from back to front, I definitely see a concern going from the back to the front . A phone interview was conducted with EI #1 on 10/1/2015 at 4:30 PM. EI #1 was asked when a staff member should wash their hands while providing incontinence care for a resident especially when stool was present. EI #1 stated, Before you start, after wiping, change gloves and wash your hands, put more gloves on. EI #1 also stated every time per wipe, and indicated she messed up on also. EI #1 was asked what was the concern when a staff member did not wash their hands during incontinence care when stool was present. EI #1 stated contamination and infection. An interview was conducted on 10/01/2015 at 4:50 PM with EI #8, the DON (Director of Nursing.) EI #8 was asked when a staff member should wash their hands while providing incontinence care for a resident when stool was present. EI #8 stated the hands should be washed before the procedure was started, after they clean the stool, before they proceed to another area and when the procedure was completed. EI #8 was asked what the concern was when a staff member did not wash their hands during incontinence care when stool was present. EI #8 responded infection. 3) A review of the facility policy titled, Certified Nursing Assistant, with a revision date of 1/1/2015, revealed, Job Description . Food Service Functions . Serve food trays. Assist with feeding as indicated (i. e. {such as}, cutting foods, feeding, assist in dining room supervision, etc. (etcetera) RI #4's Quarterly MDS, with an ARD of 7/3/2015, indicated RI #4 required extensive one person assist with eating. A review of the care plan with a focus on DEHYDRATION, with the last review date of 7/2/2015, revealed, . Interventions . Monitor intake to ensure at least 75% of meal taken . A review of the care plan with a focus on NUTRITION with the last review date of 7/2/2015 revealed . Interventions . Provide supplements as ordered. Encourage adequate po (by mouth) intake . Set up meal trays and assist with meals as needed. A review of the care plan with a focus on ADLs (Activities of Daily Living) with the last review date of 07/02/2015 revealed . Interventions . Feeding - Independent with tray set up; Allow resident time to complete meal. She eats slow.- Ext (Extensive assistance) x (times)1 (staff member) at times to complete meal . A review of RI #4's medical record revealed a document titled, Safe Swallowing Precautions, dated 12/19/2012. The following precautions were listed, Sit in most upright position for all oral intake . Take small bites and sips . Alternate bites of solids with sips of liquid . Sit in most upright position for 30 minutes following meals. A review of the most recent Registered Dietician note on the chart was the entry in the Nutritional Progress Notes, dated 7/10/2015. RI #4's weight was documented as 127.5 lbs, which was noted to be gradually trending downward. RI #4's weight on 4/1/2015 was 135 lbs. RI #4's weight on 10/01/2015 was 124.0 pounds. On 9/29/2015 at 12:20 PM, an observation was made of lunch being taken into RI #4's room. The tray was placed on the over bed table which was already across the resident in the bed. At 9/29/2015 at 1:10 PM, the surveyor knocked and entered RI #4's room. The surveyor asked if RI #4 was going to finish lunch. RI #4 stated, I'm still working on it. The food on the tray appeared to not had been touched. On 9/29/2015 at 1:20 PM, the surveyor observed RI #4 sitting in bed with lunch tray on over bed table. RI #4 was not eating. RI #4's eyes were closed. No one else was in the room. On 9/29/2015 at 1:21 PM, EI (Employee Identifier) #2, a CNA (Certified Nursing Assistant), entered the room and asked if RI #4 was through eating. The CNA then stated, You want me to help you? At that time another CNA, EI #13, entered the room and asked for assistance in another room. The two CNAs pulled RI #4 up in the bed and then walked out of the room. On 9/29/2015 at 1:30 PM, the surveyor observed RI #4 push the over bed table with the tray on it away from her. A observation was made on 9/30/2015 at 8:20 AM of RI #4. RI #4 was lying in bed with eyes closed and the upper body leaning to the right. RI #4 was wearing oxygen per nasal cannula. A breakfast tray was observed to be on the over bed table which was pulled across the resident. No food on the tray had been eaten. At 8:35 AM on 9/30/2015, EI #2 entered RI #4's room and asked if the resident was going to wake up and eat. EI #2 then left the room and returned 5 minutes later with a mighty shake. RI #4 drank the shake with EI #2 assisting. The tray was removed from the room. At 8:15 AM on 10/1/2015, an observation was made of RI #4. The resident was lying in the bed with eyes closed. The breakfast tray was on the over bed table which was across RI #4. None of the food had been eaten. At 8:23 AM on 10/1/2015, EI #7, a Restorative CNA, was observed to be at RI #4's bedside. When the surveyor entered the room, EI #7 left the room to get her name badge. RI #4 was lying in the bed holding a glass of orange juice with the glass leaning against the over bed table. On 10/1/2015 at 8:30 AM, the surveyor observed a medication pass for RI #4. EI #8, an LPN (Licensed Practical Nurse), had to hold a cup of water to RI #4's mouth and coax RI #4 to take all of her medication. EI #8 did not cue or assist the resident with breakfast meal. At 9:20 AM on 10/1/2015, the surveyor observed EI #7 remove EI #4's breakfast tray from the room. EI #7 showed the tray to the surveyor and RI #4 had not eaten anything. An interview was conducted with EI #12, MDS/Care Plan Coordinator, on 10/1/2015, at 5:05 PM. EI #12 was asked who was responsible for developing the care plans for the residents. EI #12 stated that she was responsible for the skilled patients and another employee was responsible for the long term care residents. EI #12 was asked how often the care plans were updated or revised. EI #12 stated a bare minimum of quarterly, although usually more often as needed. EI #12 was asked how RI #4 should have been care planned if the MDS, with an ARD of 7/3/2015, was coded extensive assistance with one person for eating. EI #12 stated it depends, sometimes a resident can feed themselves and sometimes they require assistance. The MDS was coded based on the highest level of assistance required at least 3 times in the seven day look back period. EI #12 was asked how RI #4 was coded. After looking at the medical record, EI #12 stated that RI #4 was coded as independent with tray set up. Extensive assistance was for someone who may need assistance at the end of the meal, to finish their meal.

Based on record reviews, observation, and interview, the facility failed to ensure a CNA (Certified Nursing Assistant) closed the blinds prior to performing perineal care for RI (Resident Identifier) #4. This affected RI #4, one of three residents observed for perineal care. Findings Include: A review of the facility policy titled, Quality of Life - Dignity, with a revision date of November 2010, revealed, Highlights Policy Statement Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. 10. Staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. A review of the medical record revealed RI #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Quarterly MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 7/3/2015, revealed RI #4 had a BIMS (Brief Interview for Mental Status) score of 6 out of a possible 15. This score indicated RI #4 was severely impaired for daily decision making skills. An observation was made on 9/30/2015 at 10:55 AM. The surveyor observed EI (Employee Identifier) #1, a CNA, knock and enter RI #4's room with supplies. The surveyor knocked and entered RI #4's room. The privacy curtain between the beds had been pulled. RI #4 was in the bed by the window. The window blinds were open. EI #1 had gloves on and was gathering water basins. EI #2, a CNA, came in to assist. After placing supplies on the bedside table, EI #s 1 and 2 proceeded to provide peri-care for RI #4. The window blinds remained open throughout the provision of care. There was a patio to the right of RI #4's window in view of RI #4's bed. A telephone interview was conducted with EI #1 on 10/1/2015 at 4:35 PM. EI #1 was asked how privacy was provided for a resident during a procedure. EI #1 stated the curtain was pulled and the door was closed. If peri-care was being done, the resident should be covered with a towel. EI #1 was asked how she provided privacy for RI #4 during peri-care on 9/30/2015. EI #1 stated that she had pulled the curtain and placed a towel over RI #4. EI #1 was asked why it was important to provide privacy for a resident during a procedure. EI #1 stated because a resident does not want their room-mate or anyone else to come in and see them. EI #1 was asked if the patio was visible from RI #4's room. EI #1 stated that it was and that she must not have closed the blinds. EI #1 was asked if she had closed the blinds in RI #4's room prior to providing peri-care and she responded that she didn't think so. An interview was conducted with EI #8, DON (Director of Nursing), on 10/1/2015 at 4:50 PM. EI #8 was asked how should a resident's privacy be maintained during a procedure. EI #8 stated the privacy curtains should be pulled and the door should be closed. Make sure the resident can't be seen during the procedure. EI #8 was asked why it was important to provide privacy for a resident during a procedure. EI #8 responded to maintain the resident's dignity.

Based on record reviews and interview, the facility failed to ensure the care plan for RI #4 was revised to reflect the most recent MDS (Minimum Data Set) assessment. This affected RI (Resident Identifier) #4, one of eighteen residents whose care plans were reviewed. Findings Include: A review of the medical record revealed RI #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a Quarterly MDS, with an ARD (Assessment Reference Date) of 7/3/2015, revealed RI #4 had a BIMS (Brief Interview for Mental Status) score of 6 out of a possible 15. This indicated RI #4 was severely impaired for daily decision making skills. RI #4 required extensive two person assistance with bed mobility and transfers. RI #4 required extensive one person assistance with dressing, eating and hygiene. RI #4 was totally dependent for toileting and bathing. RI #4 was always incontinent of bowel and bladder, requiring the use of adult briefs. A review of a Significant Change MDS, with an ARD of 9/30/2014, revealed RI #4 had a BIMS score of 5 out of a possible 15. This indicated that RI #4 was severely impaired for daily decision making skills. RI #4 required extensive two person assistance with bed mobility. RI #4 was totally dependent on staff for dressing, toileting and bathing assistance. RI #4 was coded as requiring supervision and one person assist with eating. RI #4 was always incontinent of bowel and bladder, requiring adult briefs. RI #4's medical record revealed a document titled, Safe Swallowing Precautions, dated 12/19/2012. The following precautions were listed, Sit in most upright position for all oral intake . Take small bites and sips . Alternate bites of solids with sips of liquid . Sit in most upright position for 30 minutes following meals. A review of the most recent Registered Dietician note on the chart was the entry in the Nutritional Progress Notes, dated 7/10/2015. RI #4's weight was documented as 127.5 lbs (pounds), which was noted to be gradually trending downward. RI #4's weight on 4/1/2015 was 135 lbs. RI #4's weight on 10/01/15 was 124.0 pounds. A review of the care plan with a focus on DEHYDRATION, with the last review date of 7/2/2015, revealed, . Interventions . Monitor intake to ensure at least 75% of meal taken . A review of the care plan with a focus on NUTRITION, with the last review date of 7/2/2015, revealed, . Interventions . Provide supplements as ordered. Encourage adequate po (by mouth) intake . Set up meal trays and assist with meals as needed. A review of the care plan with a focus on ADLs (Activities of Daily Living), with the last review date of 07/02/2015, revealed, . Interventions . Feeding - Independent with tray set up; Allow resident time to complete meal. She eats slow.- Ext (Extensive assistance) x (times)1 (staff member) at times to complete meal . An interview was conducted with EI #12, MDS/Care Plan Coordinator, on 10/1/2015, at 5:05 PM. EI #12 was asked who was responsible for developing the care plans for the residents. EI #12 stated that she was responsible for the skilled patients and another employee was responsible for the long term care residents. EI #12 was asked how often the care plans were updated or revised. EI #12 stated a bare minimum of quarterly, although usually more often as needed. EI #12 was asked how RI #4 should have been care planned if the MDS, with an ARD of 7/3/2015, was coded extensive assistance with one person for eating. EI #12 stated it depends, sometimes a resident can feed themselves and sometimes they require assistance. The MDS was coded based on the highest level of assistance required at least 3 times in the seven day look back period. EI #12 was asked how RI #4 was coded. After looking at the medical record, EI #12 stated that RI #4 was coded as independent with tray set up. Extensive assistance was for someone who may need assistance at the end of the meal, to finish their meal.

Based on observations, interviews and review of documents, the facility failed to ensure: 1) A Dietary staff member had all hair covered while working in the kitchen, as observed on 1 of 3 survey days; 2) Dietary staff members did not work in the kitchen with earrings and watches uncovered. This was observed on 1 of 3 survey days. 3) Milk was not observed with ice covering it, on 2 of 3 survey days. These deficient practices had the potential to affect 91 residents served meals from the kitchen. Findings include: 1) A review of the facility's policy dated 2008, and titled, "Employee Hygiene and Sanitary Practices," revealed, "... 11. Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, ..." A review of the U.S. (United States) Public Health Services Food Code, 2013 edition, revealed, "... Hair Restraints 2-402.11 (A) Except as ..., FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep thier hair from contacting exposed FOOD; ..." On 10/22/2014 at 7:50 AM, EI (Employee Identifier) #4, a Dietary Aide, was observed in the kitchen with hair at both temporal areas and at the nape of her neck uncovered by the hair net. An interview was conducted with EI #7, a Cook, on 10/23/2014 at 1:45 PM. EI #7 was asked what the facility's policy was on hair coverings in the kitchen. EI #7 replied, "We can have hair nets or bonnets. All hair should be covered." EI #7 was asked why all hair should be covered and she stated, "Less possibility of hair falling out and into food." On 10/23/2014 at 2:32 PM, an interview was conducted with EI #1, the Dietary Manager. EI #1 was asked what the facility's policy was on hair coverings in the kitchen. EI #1 stated, "Hair nets should be worn when in the kitchen and beard restraints on facial hair." EI #1 was asked why all hair should be covered while in the kitchen. EI #1 responded, "To prevent hair from falling and contaminating food." 2) A review of the 2013 U.S. (United States) Public Health Service Food Code revealed, "... Jewelry 2-303.11 Prohibition. Except for a plain ring such as a wedding band, ... FOOD EMPLOYEES may not wear jewelry including medical information jewelry on their arms and hands. ..." On 10/22/2014 at 5:52 AM, the following was observed, in the kitchen: a) EI #6, Dietary Assistant, was observed with silver/white stud earrings, approximately ? (one-half) cm (centimeter), in both ears, and uncovered. b) EI #5, Dietary Assistant, was observed with silver studs approximately ? (one-fourth) cm in both ears, and uncovered. c) EI #4 was observed with 2 silver studs, of different sizes of approximately ? and ? cms, in the left ear, and 1 silver stud, approximately ? cm in the right ear, uncovered. d) EI #3, Cook, was observed with 3 silver studs of different sizes in the left ear, and 4 silver studs in the right ear, all uncovered, and ranging in sizes of 1/4, 1/3 (one -third) and 1/2 cms. e) EI #7, was observed with 2 silver studs in both ears, different sizes of approximately ? and ? cm, all uncovered. On 10/22/2014 at 6:35 AM, EI #1 was observed in the kitchen with a silver and gold watch on her left wrist, and a gold, diamond type earring in the right ear, uncovered by her bonnet. On 10/22/2014 at 7:00 AM, EI #2, Assistant Dietary Manager, was observed in the kitchen with pearl-like studs of approximately ? cm, in both ears, and uncovered. EI #2 was also observed wearing a black watch on her right wrist. During an interview on 10/23/2014 at 1:45 PM, EI #7 was asked what the facility's policy was on jewelry in the kitchen. EI #7 stated, "You can wear studs and nothing dangling, and a wedding band." EI #7 was asked what the potential harm was of wearing earrings uncovered in the kitchen. EI #7 stated, "Them falling out." EI #7 was asked what the potential harm was of wearing watches in the kitchen. EI #7 replied, "Harm would be if the band came a loose, the watch could fall in food and possibly contaminate it." EI #7 was asked if it was appropriate to wear watches while working in the kitchen. EI #7 stated, "No. Because you are constantly washing your hands and dealing with food, and there's the possibility of germs and bacteria on the watch band and skin." During an interview on 10/23/2014 at 2:32 PM, EI #1 was asked what the facility's policy was on jewelry in the kitchen. EI #1 stated, "Limited jewelry. Watch, stud earrings and preferably a band that doesn't have a set in it." EI #1 was asked if it was appropriate to wear watches while working in the kitchen. EI #1 stated, "Yes. We've never said they couldn't be, but they should be removed to wash your hands appropriately." EI #1 was asked if it was appropriate to wear earrings uncovered while working in the kitchen, and she replied, "Yes. Studs are ok. Hoop earrings are not to be worn." EI #1 was asked what the potential harm was of wearing watches in the kitchen. EI #1 replied, "Bacteria could get under your watch." EI #1 was asked what the potential harm was of earrings uncovered in the kitchen. EI #1 replied, "As far as the stud earrings, I guess they could come off. There would be the potential of falling into food. ..." 3) A review of the 2013 U.S. Public Health Food Code, revealed, "... 3-303.12 Storage or Display of Food in Contact with Water or ice. (A) PACKAGED FOOD may not be stored in direct contact with ice or water if the FOOD is subject to the entry of water because of the nature of its packaging, wrapping, or container or its positioning in the ice or water. ..." During a tour of the kitchen on 10/21/2014 at 10:50 AM, milk was observed in the walk-in cooler, in a cooler with ice covering it. EI #1 informed the surveyor the milk was, "Prepared for (the) dining room." On 10/22/2014 at 8:42 AM, the last food cart was taken to the fourth floor. On this cart, milk was observed in a cooler with some ice frozen over, and covering the milk. During the interview on 10/23/2014 at 2:32 PM, EI #1 was asked why the milk was observed with ice covering it on Tuesday (10/21/14) during the tour, and Wednesday (10/22/14) when the test trays were done. EI #1 stated, "The milk is put on ice to maintain temp of below 41 degrees." EI #1 was asked if it was appropriate to have ice covering milk prior to serving. EI #1 stated, "Some ice does end up on the top of the cartons. The actual drinking edges are concealed. Therefore, I would think it would be appropriate. We try to set it in the ice so that all the carton is surrounded by the ice to keep it cold."

Based on observations, interviews and record reviews, the facility failed to ensure the privacy curtain was pulled completely around the bed for RI (Resident Identifier) #10 during perineal care. This was observed on 1 of 16 sampled residents. Based on the facility's policy titled, "Quality of Life - Dignity", with the revised date of 2010, revealed: "... Policy Statement Each resident shall ... 10. Staff shall promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. ..." RI #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/14/2013 at 12:45 PM, an observation was made of perineal care for RI #10, a resident located in a bed by the door. EI (Employee Identifier) #1, a CNA (Certified Nursing Assistant) pulled the privacy curtain between the two beds, and half-way around the foot of the bed for RI #10. The curtain was open, and RI #10 was exposed to anyone entering the door. EI #2 (a CNA) entered the room and began perineal care for RI #10. During perineal care, EI #2 called for the nurse to come to assess the wound dressing of RI #10. At 12:54 PM, EI #3 an RN (Registered Nurse), knocked and entered RI #10's room. After removing the old dressing, EI #3 washed his hands and left the room to gather supplies. A few minutes later, EI #3 returned to RI #10's room with supplies. After completing the dressing change, EI #3 washed and dried his hands, then pulled privacy curtain completely around RI #10's bed, as he was leaving the room with the surveyor. An interview was conducted with EI #3 on 11/14/2013 at 3:25 PM. EI #3 was asked what was the facility's policy on privacy during perineal care and wound treatments. EI #3 stated, "Privacy. Pull the drapes. Shut the door". EI #3 was asked about the potential negative outcomes if privacy was not ensured. EI #3 stated, "Dignity issue". EI #3 was asked if privacy was provided with wound and perineal care for RI #10 during care on 11/14/2013 at 12:54 PM, when he came into the room. EI #3 stated, "The curtain was pulled around the bed, the door was shut, when we were leaving, the curtain was pulled as a wrap around closing." On 11/15/2013 at 4:05 PM, an interview was conducted with EI #1. EI #1 was asked what was the facility's policy on privacy when providing care. EI #1 stated, "Pull privacy curtain." EI #1 was asked if the privacy curtain should be pulled around a resident's bed between the bed and the door, and why or why not. EI #1 stated, "Yes. Because if someone comes in the door you could see them if curtain not pulled." EI #1 was asked if the curtain was pulled completely around the bed during perineal care for RI #10, on 11/14/13 at 12:45 PM, and why or why not. EI #1 stated, "No. The other CNA didn't pull it all the way around". On 11/15/2013 at 5:40 PM, an interview was conducted with EI #5 the DON (Director of Nursing). EI #5 was asked about the potential negative outcome if privacy was not ensured during perineal or wound care. EI #5 stated, "Dignity, absolutely".