Every finding on record at Estelline Nursing and Care Center

Based on observation, interview, and policy review, the provider failed to follow standard food safety practices for one of one cook (D) who did not submerge a cutting board into the hot water sanitation sink for the required amount of time to achieve proper sanitation, for one of one cook (C) who wiped food off her hand with an anti-slip mat and did not perform hand hygiene before continuing to serve food, and for one of one cook (D) who did not perform hand hygiene after putting soiled trash into the trash can.Findings include:1. Observation on 6/25/26 at 11:06 a.m. in the kitchen revealed cook D was handwashing a cutting board in the three-compartment sink. After she washed and rinsed the cutting board, she submerged one end of the cutting board into the hot water sanitation sink for less than one second, turned the cutting board around and submerged the other end of it into the hot water sanitation sink for less than one second. She then placed the cutting board behind the water faucet and leaned it up against the wall behind the hot water sanitation sink to air dry.2. Observation on 6/25/26 from 11:09 a.m. to 11:24 a.m. in the kitchen revealed cook C was plating resident's food for lunch. The menu was barbeque ribs, a baked potato with sour cream, lettuce salad, and mint chip ice cream. There were two green anti-slip mats on the serving line that cook C would place the plates on. Several times throughout the observation, cook C would grab the small plastic serving cups of sour cream to place on the plates, and she would get sour cream on her fingers. Rather than washing her hands, she would wipe the sour cream onto the green anti-slip mat. There were several times throughout the observation when bits of baked potato fell off a plate, and she used her bare hands to grab them and place them back in the serving bin of baked potatoes.3. Interview on 6/25/26 at 12:14 p.m. with cook C revealed that if her hands were soiled, she was supposed to wash her hands in the handwashing sink. She confirmed that she caught herself using the green anti-slip mat to wipe off the sour cream and other food items from her hands, and she should have washed her hands instead.4. Observation on 6/25/26 at 12:18 p.m. in the kitchen revealed cook D washed her hands in the handwashing sink and used paper towels to dry her hands. She placed the paper towels in the trash can and pushed the paper towels down a bit into the trash can. Her hands came into contact with other items in the trash can. She did not perform hand hygiene after that. She proceeded to the clean dish area and started to put away clean dishes.5. Interview on 6/25/26 at 12:20 p.m. with cook D revealed that she confirmed she pushed the paper towels down into the trash can, did not perform hand hygiene, and then handled clean plates with her potentially soiled hands.When asked about her process for handwashing dishes in the three-compartment sink, she explained that she first scraped excess food off the dish or food prep equipment, washed it with warm soapy water, rinsed it under running water, and placed it in the hot water sanitation sink. The hot water in the third compartment needed to be at 180 degrees Fahrenheit, and the dishes were supposed to be submerged under the hot water for at least 30 seconds. She confirmed she did not submerge the cutting board in the hot water sanitation sink for at least 30 seconds, and she had already put the cutting board away with the other clean cutting boards.6. Interview on 6/25/26 at 12:30 p.m. with dietary supervisor B revealed that the dietary staff should know what to do in regard to washing dishes in the three-compartment sink as she had trained the dietary staff several times on the proper procedures. There was a clock on the wall above the three-compartment sink so staff could time how long the dishes were submerged in the hot water sanitation sink. The dishes were supposed to be submerged for at least 30 seconds.7. Review of the provider's July 2025 Hand Hygiene policy revealed that it was more specific to healthcare personnel rather than food service workers. The policy read, All personnel will follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. The policy described when to use soap and water for hand hygiene, particularly when hands are visibly dirty or contaminated.8. Review of the provider's August 2022 Using the Three Compartment Sink for All Dishes When Dishwasher is Out of Order policy revealed that dishes were to be sanitized in the third sink for 30 seconds. The hot water was to be between 171 to 180 degrees Fahrenheit.9. Review of the provider's December 2023 What To Do if Dishwasher is Out of Order policy revealed that All pots, pans, silverware or any non-disposable ware will be washed, rinsed, and sanitized in 3-compartment sink at 171 degrees [Fahrenheit] for 30 seconds.

Based on observation, interview, record review, and policy review, the provider failed to ensure that staff were able to verify the dishwasher rinse cycle temperature to confirm that the dishes were sanitized at the proper temperature. Failure to ensure that increased the potential risk of foodborne illnesses for the entire resident population who received meals prepared in the kitchen. Findings include: 1. Observation on [DATE] at 8:30 a.m. in the kitchen revealed: *The dishwasher rinse cycle temperature gauge was not working. *The [DATE] Dishwasher Temp Log documented a breakfast rinse temperature on [DATE] of 192 degrees Fahrenheit. Observation on [DATE] at 12:15 p.m. of the dishwasher in the kitchen revealed that the rinse cycle temperature gauge was not working through two full washing and rinsing cycles. Interview at that time with dietary aide (DA) G and F revealed: *DA G was not aware that the temperature gauge was not working. When asked how he was measuring the temperature of the dishwasher rinse cycle, he shrugged his shoulders and pointed to DA F. *DA F was not aware that the dishwasher rinse temperature gauge was not working. -She stated that the food service supervisor had given her the Dishwasher Temperature Sensor Labels that morning. Staff were using them to measure dishwasher temperatures. -She demonstrated how staff use the sensor labels by placing them on a dish and running it through the dishwasher. -She explained that there were three temperature boxes on the label for 160, 170, and 180 degrees Fahrenheit. If the temperature box turned black after the full dishwasher wash and rinse cycle, that corresponding temperature was achieved. *Upon closer inspection of the Dishwasher Temperature Sensor Labels, it was noted that they expired on [DATE]. Observation and interview on [DATE] at 2:15 p.m. in the kitchen with DA G and cook E revealed: *The dishwasher rinse temperature gauge was still not functioning after observing three full wash and rinse cycles. *DA G was again asked how he measured the dishwasher temperatures. He pointed to the gauges and stated that he documented the temperatures from the gauges onto the Dishwasher Temp Log once per meal. *The rinse temperatures on the Dishwasher Temp Log were recorded as follows: -[DATE] breakfast, 192 degrees Fahrenheit. -[DATE] lunch, 188 degrees Fahrenheit. -[DATE] supper, 190 degrees Fahrenheit. -[DATE] breakfast, 190 degrees Fahrenheit. -[DATE] lunch, 180 degrees Fahrenheit. *He was unable to explain what process would have been required if the rinse temperature gauge was not functioning. *He was not aware of the sensor labels that were to have been used secondary to the rinse temperature gauge. *Cook E was not aware that the rinse temperature gauge was not working and stated that she did not usually wash the dishes. Interview on [DATE] at 2:22 p.m. with food service supervisor (FSS) D revealed: *She was not aware that the dishwasher rinse temperature gauge was broken and the sensor labels had expired. *She explained that the dishwasher servicing company had sent those labels last year and the dishwasher was last serviced in [DATE]. 2. IMMEDIATE JEOPARDY Interviews with dietary staff throughout the survey indicated that no one was aware that the dishwasher rinse cycle temperature gauge was not functioning, the staff somehow were still recording the rinse temperatures on the Dishwasher Temp Log. At least two dietary staff interviewed were unaware of the secondary sensor labels. The staff that were aware of the temperature sensor labels were not aware that they were expired. Staff were not aware of any process to follow when the rinse temperature gauge was not functioning. At the time of the survey, staff could not accurately verify the final rinse temperature of the dishwasher to ensure proper sanitation due to the non-functioning rinse gauge and the expired sensor labels. IMMEDIATE JEOPARDY NOTICE Notice of immediate jeopardy was given verbally and in writing on [DATE] at 3:05 p.m. to administrator A and FSS D. They were asked for an immediate removal plan. Interview at that time with administrator A and FSS D about the rinse gauge revealed: *FSS D said, no one can tell me when it wasn't working, when referring to the broken rinse gauge. -She also indicated that staff might have been guessing what they think the temp should be when they wrote the temperatures on the Dishwasher Temp Log. *DA F had told FSS D that the gauge had been working on [DATE]. *Other staff had told her that when the rinse gauge was not working on previous occasions, they would flick the gauge which sometimes made it work again. IMMEDIATE JEOPARDY REMOVAL PLAN On [DATE] at 5:29 p.m., administrator A provided the survey team with a final written immediate jeopardy removal plan. The removal plan had been approved by the survey team on [DATE] at 6:27 p.m. with guidance from the long-term care advisor for the South Dakota Department of Health. The provider gave the following acceptable immediate jeopardy removal plan on [DATE] at 5:29 p.m.: *On [DATE] at 4:08 p.m. our facility did the following to ensure safety/compliance . 1. The [dishwasher servicing company] technician was called at 3:15 p.m. about the faulty gauge and he said that he will be here right away on the morning of [DATE] to change out the gauge with a new one. 2. We will be serving supper and breakfast on paper plates and plastic silverware to ensure sanitation until the gauge is fixed in the morning. 3. All prep items to include: pots/pans/other to be washed in the 3 bin sink at the proper regulated temperatures. Those temperatures will be logged and dated by the dietary staff each time they use it. 4. We took [a] meat thermometer and placed [it] in the dishwasher during the rinse cycle and it temped out at 180 degrees. 5. Dietary staff were instructed to notify Certified Dietary Manager right away if there is a faulty piece of equipment so proper safety/protocols can be implemented to ensure safety. 6. New test strips have been ordered today when we found out ours were expired. 7. Certified Dietary Manager provided all dietary staff with the following education: foodborne illnesses, how it is caused, how to prevent food born illnesses, and the importance of sanitizing food contact surfaces. All Dietary staff will sign and date that they have read the education prior to working their shift. Observation and interview on [DATE] at 8:15 a.m. with administrator A and the dishwasher company's technician I in the kitchen revealed: *Dishwasher technician I was installing the new rinse temperature gauge. *Administrator A was stressing that there was no potential for harm at all because the temperature of the rinse cycle was just fine. *Administrator A questioned why the surveyors had not informed him that the rinse gauge was not working. *Surveyors questioned why staff decided to flick the gauge to make it work again temporarily rather than informing management that the gauge was malfunctioning. *After administrator A had left the kitchen at 8:20 a.m., dishwasher technician I stated, I can understand your concern, when mentioning the rinse gauge malfunctioning. The immediate jeopardy was removed on [DATE] at 12:30 p.m. after verification that the provider had implemented their removal plan. After the removal of the immediate jeopardy, the scope and severity of the citation level was F. 46453 3. Review of an electronic communication sent by administrator A to the survey team on [DATE] at 5:29 p.m. revealed: *Administrator A denied that any of [the] residents were negatively affected by this practice. 4. Review of the provider's documentation on when the dishwasher was last serviced revealed: *Dishwasher technician I visited the facility on [DATE]. *He noted the rinse temperature of the dishwasher was at 184 degrees Fahrenheit.

Based on observation, interview, record review, and policy review, the provider failed to follow Centers for Disease Control and Prevention (CDC) guidelines related to the coronavirus (COVID-19) pandemic by failing to: *Provide infection control practices for the care of five of five sampled residents (1, 2, 3, 4, and 5). *Perform hand hygiene and change gloves when entering and exiting residents' rooms for five of five sampled residents (1, 2, 3, 4, and 5). *Extend and/or reuse personal protective equipment (PPE) according to national guidelines. *Close all doors to rooms of residents who had tested positive for COVID-19. These failures have a potential to expose all residents, staff, and visiting essential personnel to COVID-19, a [MEDICAL CONDITION] infection that could lead to serious harm or death. NOTICE: On 12/7/20 at 1:08 p.m. an Immediate Jeopardy was identified after the Centers for Medicare and Medicaid Services (CMS) Regional Office review of the 11/18/20 Focused Infection Control Survey Form CMS-2567. The facility failed to implement CMS and CDC recommended practices to prepare for COVID-19. On 12/7/20 at 4:57 p.m. a copy of the immediate jeopardy template was emailed to the provider for review during the discussion. Notice of immediate jeopardy was given verbally, via telephone to the administrator, and director of nursing (DON). Specifically, the provider failed to ensure: *CDC guidelines were followed for proper PPE usage to prevent the spread of COVID-19. *Staff performed hand hygiene, changed into new gloves/gowns when entering COVID-19 positive resident room. *Staff removed and discarded gowns/gloves and performed hand hygiene before entering a COVID-19 negative resident room. *Face shields/goggles worn into a COVID-19 positive resident room were not worn into a COVID-19 negative resident room. *Face shield/goggles were disinfected after leaving a COVID-19 positive resident room. *PPE stations were in the North and East hallway for staff use that included an area for disinfection of eye protection. *Separate stations for staff to put on and remove PPE on the North and East hallway to prevent cross-contamination. On 12/7/20 at 4:57 p.m. the administrator was asked for an immediate removal plan to ensure all deficient practices were addressed and corrected. PLAN: On 12/8/20 at 5:03 p.m. the administrator provided the surveyor with an email that included the final written removal plan. That removal plan was accepted by the surveyor on 12/8/20 at 5:42 p.m. The Immediate Jeopardy was removed on 12/11/20 at 11:58 a.m. after the removal plan implementation was verified during an onsite visit by the surveyor. After removal of the Immediate Jeopardy, the scope/severity of this citation is level F. The facility provided the following acceptable removal plan on 12/8/20: Response to F880: What: 'Use of Personal Protective Equipment' and 'Hand Hygiene' policies were reviewed and updated. Pandemic Plan has been reviewed and updated. The reviewed and updated policies will be made immediately available to all staff and they will be thoroughly discussed on December 10, 2020 at the mandatory All Staff meeting. Infection Control nurse will perform QA audits. Who: Administration, Infection Control Nurse, and QA team will monitor. When: Education will be provided this week to all staff. It will be provided upon hire, at quarterly all staff meetings (next meeting December 10, 2020) and as needed throughout the course of the year. How: Pandemic Plan reviewed and updated. Staff assignments will be made based upon infections in the facility to prevent cross contamination. (Applies to the following) 1. Reviewed and updated PPE and Hand Hygiene policies. Will review information at mandatory all staff meeting scheduled for December 10, 2020. Infection Control nurse will do QA audit on random sample of 20% of staff across all shifts and departments. Outcome of audit will be reported to administration weekly and to QA team monthly and quarterly. QA team will determine changes in schedule based on outcome of audits. 2. Reviewed and updated PPE policies. Will review information at mandatory all staff meeting scheduled for December 10, 2020. Infection Control nurse will do QA audit on random sample of 20% of staff across all shifts. Outcome of audit will be reported to administration weekly and to QA team monthly and quarterly. QA team will determine changes in schedule based on outcome of audits. 3. Reviewed and updated PPE policy. Will review information at mandatory all staff meeting scheduled for December 10, 2020. Infection Control nurse will do QA audit on random sample of 20% of staff across all shifts. Outcome of audit will be reported to administration weekly and to QA team monthly and quarterly. QA team will determine changes in schedule based on outcome of audits. 4. Reviewed and updated PPE policy. Will review information at mandatory all staff meeting scheduled for December 10, 2020. Infection Control nurse will do QA audit on random sample of 20% of staff across all shifts. Outcome of audit will be reported to administration weekly and to QA team monthly and quarterly. QA team will determine changes in schedule based on outcome of audits. 5. In the case of widespread infections in the facility, isolation carts will be placed down each wing and there will be availability to disinfect equipment. We will also continue to utilize current PPE supply boxes, which are located throughout the building. 6. In the case of widespread infections in the facility, isolation carts will be placed down each wing and there will be availability to disinfect equipment. We will also continue to utilize current PPE supply boxes, which are located throughout the building. Findings include: 1. Interview on 11/18/20 at 10:05 a.m. with administrator A and infection control registered nurse B revealed the facility had: *Twenty-three total residents that had tested positive for COVID-19. *Not designated a COVID-19 unit due to the large number of positive cases. *Residents who tested positive for COVID-19 on 11/11/20 and 11/13/20 were moved to a designated area. *Sixteen residents that tested positive for COVID-19 on 11/16/20 were not moved out of their rooms. -Administrator A suspected the increased numbers of COVID-19 positive residents happened as a result of moving residents the week before. *COVID-19 positive resident rooms next to COVID-19 negative resident rooms. *All the doors to the resident rooms were open due to many of the residents having a cognitive impairment. -They had concerns if the doors were closed the residents would be more at risk of falling. *Marked all COVID-19 positive resident doors with an X in blue masking tape. *All staff wear N95 masks with goggles or a face shield and a plastic disposable gown. -It had been their practice to reuse the N95 masks until they were soiled or wet to conserve the supply of N95 masks. *All staff fit tested . 2. Observation and interview on 11/18/20 at 11:53 a.m. with licensed practical nurse C revealed: *Her standing in front of the nurses station wearing a disposable gown, face shield, and N95 mask. *She had concerns regarding PPE availability and its reuse. *They wore disposable gowns. *The practice was to continue to reuse N95 masks until they were soiled or wet. *She would have liked to change the PPE more frequently but did what she was instructed to do. 3. Observation on 11/18/20 at 11:55 a.m. of the north hallway revealed: *Staff wearing disposable gowns, gloves, N95 masks, and goggles or face shield. *Various staff distributing meal trays to the resident rooms. *An unidentified staff member took a tray from the dietary cart with gloved hands and carried the tray into resident 1 and resident 2's shared room and placed the tray on a bedside stand. -The room door had a blue X with masking tape that indicated it was a positive COVID-19 room. -No hand hygiene was performed by the staff prior to entering or exiting the room. *The staff member went to the dietary cart, took another tray, and entered resident 3 and 4's shared room. -Those two residents were negative for COVID-19. -She placed the meal tray on a bedside stand in the room. *The same staff member took a meal tray into resident 5's room and placed it on the bedside table. -The room door had a blue X with masking tape that indicated it was a positive COVID-19 room. *Other staff members were observed entering COVID-19 positive and negative rooms without performing hand hygiene or changing PPE between rooms. -Staff had not disinfected their face shields or goggles after exiting the rooms or prior to entering new rooms. *There was a PPE station set-up in front of the nurses station for staff to obtain clean PPE. -No staff were observed to go to the station for new PPE. *No staff were observed gathering clean PPE from this station. *All doors were open to the resident rooms *Residents were not wearing masks in their rooms. 4. Interview on 11/18/20 at 12:15 p.m. with administrator A and infection control registered nurse B revealed: *Acknowledgement staff were not changing gowns between resident rooms. *Staff put on a clean disposable gown at the beginning of their shift. *They thought it was appropriate to use the same PPE between positive residents and negative residents. *They thought they had followed the right procedure for the situation. -Confirmed their expectation of staff to perform hand hygiene and change gloves between resident rooms. *They had not anticipated so many COVID-19 positive residents at the same time. Review of the provider's 3/27/20 Universal Mask policy revealed: *All employees will be expected to wear procedural/surgical face masks at all times. The exception to this would include those health care professionals wearing N95 respirators while providing care for presumed COVID-19 (rule out) or known COVID-19 positive patients. Masks are to be worn whenever on (facility name) property. Staff are also allowed to take off masks to eat and drink on premises in a location where they can maintain six-foot distance. Masks are to be re-worn until visibly torn, soiled, or saturated. During COVID outbreak, all staff working on the floor must wear appropriate PPE including mask N95 (after being fit tested ), goggles or face shields, gown and gloves. Review of the provider's April 2020 Standard Body Substance Isolation policy revealed: *Wash hands after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn. Wash hands or use alcohol-based solution immediately after gloves are removed, between resident contacts, and when otherwise indicated to avoid transfer of microorganisms to other residents or environments. *Wear clean, non-sterile gloves when touching blood, body fluids, secretions, excretions, and contaminated items. Put on clean gloves just before touching mucous membranes and non-intact skin. Change gloves between tasks and procedures on the same resident; use proper hand hygiene to avoid transfer or (of) microorganisms to other residents or environments. Do not reuse gloves. *Wear a mask and eye protection or a face shield to protect mucous membranes of the eyes, nose, and mouth during procedures and resident care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, and excretions. *Wear a clean, non-sterile gown to protect skin and to prevent soiling of clothing during procedures and resident care activities that are likely to generate splashes or sprays of blood, body secretions, or excretions. Remove a soiled gown as promptly as possible and use proper hand hygiene to avoid transfer of microorganisms to other residents or environments. Do not reuse gowns. Review of the provider's March 2020 Pandemic Emergency Plan revealed: *In the event of a pandemic, we will follow guidance from the CDC (Centers for Disease Control and Prevention) and DOH (department of health) related to isolation precautions. *Supplies and trash disposal bins will also be positioned near the door of rooms in isolation. General infection control supplies such as tissues, hand sanitizer, and facemasks would be placed in common areas with no touch receptacles available. Staff will be dedicated to specific residents to prevent cross contamination. Review of CDC's COVID-19 guidance for nursing homes, Responding to Coronavirus (COVID-19) in Nursing Homes, www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html, accessed on 11/19/20 revealed: *Facilities that have already identified cases of COVID-19 among residents but have not developed a COVID-19 care unit, should work to create one unless the proportion of residents with COVID-19 makes this impossible (e.g (for example)., the majority of residents in the facility are already infected). Ideally the unit should be physically separated from other rooms or units housing residents without confirmed COVID-19. Depending on facility capacity (e.g., staffing, supplies) to care for affected residents, the COVID-19 care unit could be a separate floor, wing, or cluster of rooms. Assign dedicated HCP (health care professional) to work only on the COVID-19 care unit. At a minimum this should include the primary nursing assistants (NAs) and nurses assigned to care for these residents. HCP (health care professional) working on the COVID-19 care unit should ideally have a restroom, break room, and work area that are separate from HCP working in other areas of the facility. Place signage at the entrance to the COVID-19 care unit that instructs HCP (health care professional) they must wear eye protection and an N95 or higher-level respirator (or facemask if a respirator is not available) at all times while on the unit. Gowns and gloves should be added when entering resident rooms. Ensure that HCP (health care professional) have been trained on infection prevention measures, including the use of and steps to properly put on and remove recommended personal protective equipment (PPE). *If the resident is confirmed to have COVID-19, regardless of symptoms, they should be transferred to the designated COVID-19 care unit. Increase monitoring of ill residents, including assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam, to at least 3 times daily to identify and quickly manage serious infections. Consider increasing monitoring of asymptomatic residents from daily to every shift to more rapidly detect any residents with new symptoms.

Based on observation, record review, interview, and policy review, the provider failed to ensure a bowel management program had been followed and interventions were implemented for one of one sampled resident (2) who had a [DIAGNOSES REDACTED]. 1. Observation and interview on 1/24/17 at 2:05 p.m. with resident 2 revealed: *She had been lying on the bed in her room. *She grimaced when asked how she was and stated Okay. *She stated her stomach was cramping. *It would cramp up when she had not had a bowel movement for a few days. *She stated it had started to cramp earlier, and she went to the bathroom. *She had a large bowel movement. *She sometimes had diarrhea, but if she had not had a bowel movement in a few days she would usually go a lot. *She was not going to attend the BINGO activity as she was waiting for the cramping to stop, and it made her tired. *She stated the nurses were aware of the situation. Review of resident 2's 11/28/16 Minimum Data Set assessment revealed: *Her Brief Interview for Mental Status score was a fifteen. -A score of thirteen to fifteen meant her mental ability was intact. *She was independent with bathrooming. Review of resident 2's medical record revealed she had been admitted on [DATE]. She had a [DIAGNOSES REDACTED]. Interview on 1/25/17 at 9:15 a.m. with resident 2 revealed: *The nurses would ask her if she had a bowel movement, and she would tell them yes or no. *They had not asked everyday. *If they had not asked one day she would tell them the next time they asked. *Cramping usually occurred when she had not had a bowel movement in three to four days. *She stated It is no fun. *She had missed activities because of the cramping. Review of resident 2's 12/1/16 through 12/31/16 bowel movement records revealed: *She had gone four days before having a bowel movement from 12/3/16 to 12/6/16 and from 12/17/16 through 12/20/16. *There had been three other times she had gone three days before having a bowel movement. Review of resident 2's December 2016 Medication Administration Record [REDACTED] *[MEDICATION NAME] capsule give one capsule two times a day started on 10/22/16. *[MEDICATION NAME] HCI 50 milligram (mg) give 0.5 tablet three times a day started on 7/29/16 and as needed (PRN) started on 8/16/16. *[MEDICATION NAME] suppository 10 mg PRN for constipation. *[MEDICATION NAME] capsule 100 mg, one capsule PRN for constipation. *[MEDICATION NAME] powder PRN for constipation. *She had not received the [MEDICATION NAME] suppository or the [MEDICATION NAME] capsule. *She had received the [MEDICATION NAME] powder on 12/8/16, 12/9/16, and 12/10/16. -Those dates had not correlated with the above dates where she had gone four days before having a bowel movement. Review of resident 2's 1/1/17 through 1/24/17 bowel movement records revealed: *She had gone five days before having a bowel movement from 1/7/17 to 1/11/17. *She had gone four days before having a bowel movement from 1/17/17 to 1/20/17. Review of resident 2's January 2017 MAR indicated [REDACTED] *She had the same orders as the above December 2016 MAR. *She had not received the [MEDICATION NAME] suppository. *She had received the [MEDICATION NAME] powder on 1/9/17, 1/10/17, and 1/18/17. *She had received the [MEDICATION NAME] capsule on 1/10/17, 1/19/17, and 1/23/17. Review of the 1/15/16 physician's standing orders revealed for constipation they were to give milk of magnesia and the a Fleets enema or [MEDICATION NAME] suppository. Interview on 1/25/17 at 1:20 p.m. with the administrator and director of nursing regarding resident 2 revealed: *Four and five days was a long time to go without having a bowel movement. *Nurses would determine what PRN medication to use if a resident had not had a bowel movement in two or three days. *She had sometimes refused medication. -Her refusing had not been documented. *She had been on a [MEDICATION NAME]. -The physician had discontinued it, because she thought she was on too many pills. *He felt that was the best medication to get rid of. *They had asked her about adding fiber, but she had not wanted to. *She did not like prune juice. -There had been no other nutritional interventions attempted. *There had been no documentation they had provided education to her regarding not taking medications, going off the [MEDICATION NAME], or how nutritional interventions could have helped. *There had been no documentation they had implemented individualized interventions for her knowing her history and diagnosis. Review of the provider's April 2016 Bowel Movement Monitoring and Procedures policy revealed: *CNA's (certified nursing assistants) record BM's (bowel movements) in the E chart. *Nurses will check E (electronic) chart each shift for residents on day 2 or day 3. *Nurses will make a list to pass between shifts. *Nurses will determine what action is needed. *Attempts will be made to regulate resident's bowels with dietary measures. If that fails, physician will be notified for medication additions or changes. *Nurses will utilize standing orders where applicable. *Medication changes will be addressed with the physician as needed.

Based on record review, and interview, the provider failed to ensure one of three sampled residents (1) who received an antipsychotic medication had an appropriately documented indication for its use. Findings include: 1. Review of resident 1's 5/25/16 significant change Minimum Data Set (MDS) assessment revealed: *He was admitted on [DATE]. *His Brief Interview for Mental Status (BIMS) score was ten indicating moderate cognitive impairment. *He exhibited no acute cognitive changes or [MEDICAL CONDITION]. *He exhibited no [MEDICAL CONDITION] or behaviors except wandering. Observation of resident 1 in his room on 1/23/17 at 4:15 p.m. revealed: *He was alert and confused to place and time. He stated his wife was somewhere, but then said I don't know where she is. *He was attempting to move the television and stand. But he seemed to have some word find issues and was unable to accurately describe what he was attempting to do. *It was sparsely decorated. *There were no personal items that might have made it homelike and recognizable. *His room was unusually cold, and he made reference to the temperature saying And that thing pointing to the heat register as if he had tried to adjust the room temperature. Review of resident 1's 1/13/17 physician's orders [REDACTED]. *[MEDICATION NAME] 10 milligrams (mg), one tablet two times a day for memory related to unspecified dementia with behavioral disturbance, started on 12/30/16. *Quetiapine [MEDICATION NAME] tablet 100 mg, one tablet three times a day for unspecified dementia with behavioral disturbance, started on 6/29/16. *[MEDICATION NAME] HCl tablet 50 mg, 1.5 tablet one time a day for mood, started on 8/4/16. *[MEDICATION NAME] HCl tablet 150 mg, one tablet at bedtime for unspecified dementia with behavioral disturbance, started on 9/17/16. Review of resident 1's psychoactive medication monitoring for the following revealed: *April 2016: -He received quetiapine [MEDICATION NAME] tablet 25 mg, three times a day. -[MEDICATION NAME] HCl 50 mg tablet, one time a day. -The behaviors he exhibited were wandering, looking for his wife, and attempting to leave the building, thinking someone was in his bathroom so he slept in his chair, sleeplessness and urinating in inappropriate place. *May 2016: -The behaviors he exhibited were wandering, was edgy, being upset with his wife, and going into other residents' rooms. *June 2016: -He was exit seeking, pacing, wandering, restless, went into other residents' room, and taking other residents' items. -He was now receiving [MEDICATION NAME] 50 mg at bedtime. *July 2016: -The behaviors he exhibited were wandering, restless, going into other residents' rooms, having verbal outbursts, getting angry when he was told he could not be in the nursing station, and exit seeking. -He had two episodes of hallucinating. -The quetiapine [MEDICATION NAME] medication had been increased to 100 mg every morning and 150 mg every evening. *August 2016: -He was resistant to medications once, and wandered into other residents' rooms once but was easily redirected. -He received [MEDICATION NAME] 75 mg everyday. *September 2016: -He wandered into other residents' rooms, used another resident's bathroom, attempted to crawl into another residents' bed, and was hallucinating once,talking to others. *October 2016: -He wandered two days, one day had an angry affect most of the day, and refused lunch once. *November and December 2016: several instances of wandering. *There was no documentation of the resident threatening other residents, potentially hurting himself or others, or verified consistent indicators of a [MEDICAL CONDITION]. Review of resident 1's physician's progress notes or communication revealed: *4/18/16 fax sent to physician: Resident has had an increase in wandering, exit seeking and paranoid behaviors. Most behaviors have been at night, but also occasional during the day. He had one instance of asking a nurses Do you want to fight? When she was attempting to redirect him, overall he has been directable and cooperative. We have utilized his PRN (as needed) [MEDICATION NAME], but have not seen any consistency in the PRN effectiveness. -The physician ordered quetiapine 100 mg BID (twice a day) scheduled. *6/20/16 fax sent to physician: Resident is still wandering alot at night. He even tried to elope. Seem to be a problem mostly at noc (night). -The physician ordered Trazadone 50 mg every evening. 6/29/16 fax sent to physician: Resident has been wandering more frequently at all hours of the day. Resident has also become harder to redirect, he has ben becoming more agitated when staff try to redirect. -The physician ordered Iincrease the [MEDICATION NAME] to 100 mg every morning and 150 mg every hours of sleep. If this is not helpful may change to 100 mg three times a day. *7/7/16: Physician visit progress note: He has problems with behaviors that start about 3 p.m. per nursing. He has some inappropriate sexual behavior and is harder to redirect the later it gets. Will treat a component of anxiety by increasing [MEDICATION NAME] to 75 mg qday (every day) and try to assist with sleep by increasing [MEDICATION NAME] to 100 mg at HS. -Increased [MEDICATION NAME] to 75 mg every day. -Increased [MEDICATION NAME] to 100 mg every evening. -Signed by his physician. *8/11/16, physician visit progress note: Dementia, Alzheimer's type with behavior dsiturbance. Will continue his current psychiatric medications which are controlling behaviors and improving his quality of life. *9/15/16 physician progress notes [REDACTED]. He does have issues with wandering, a little bit of agitation occasionally when he has to be redirected. He has some inconsistent sleep quality at times. He is on multiple medication, He is going to be seen by psychiatric services that come here. -The behavior issues are not severe but needing some attention. -Alsheimer's dementia with agitation and behavior issues. -Will increase [MEDICATION NAME] to 150 at HS. Will have psychiatric services recommend any additional changes. Will continue [MEDICATION NAME] for the dementia component. Review of resident 1's mental health consults revealed: *9/19/16: He has been wandering and staying up later at night. No disruptive behaviors reported today which in the past included wandering, resisting cares, inappropriate interactions with female residents, and agitation. -No medication changes. *12/5/16: No disruptive behaviors reported today which in the past included wandering, resisting care, inappropriate interactions with female residents, and agitation. Interview on 1/24/17 at 1:45 p.m. with registered nurse (RN) A regarding resident 1 revealed: *He was pleasantly confused, usually quite pleasant. *They rarely had any issues with him. *He was never combative. -She had never heard that. *He wandered. -It was not aimless wandering, but he would follow the nurse sometimes right into another resident's room. -He was easily redirected. Review of resident 1's 4/14/16 care plan revealed: *It had been reviewed and was current. *He exhibited wandering related to [MEDICAL CONDITION]. Staff were to: 'Distract him by offering pleasant diversions, the bathroom, structured activities, food, conversation, television, book. -Staff may attempt to have him watch car shows on TV, encourage him to assemble nuts and bolts in activity office, try 1:1 visits, and offer snacks. -His preferred activities were looking through local newspapers, spending time with animals, watching TV or listening to the radio, and spending time outside. -He liked to visit with his wife. *He had impaired cognitive function or impaired thought processes related to [DIAGNOSES REDACTED]. -They were to provide him with a homelike environment. *He used [MEDICAL CONDITION] medications related to [DIAGNOSES REDACTED]. *The care plan did not address: -The behaviors he exhibited to warrant the use of the medications. -How they were monitoring their use. -Any consideration or schedule for a gradual dose reduction. -What they were doing to help him be more familiar with his environment and making it homelike. -Enhancing their structure later in the day when the behaviors were likely to increase. Interview on 1/24/17 at 2:30 p.m. with the director of nursing (DON) and review of resident 1's progress notes revealed: *There were many instances documented when the resident was wandering. -She confirmed the primary behavior he exhibited was wandering. *There had been a couple times when they documented he had hallucinated. *The behaviors had not presented a danger to himself or others. *She agreed he wandered a lot, but that was not necessarily an appropriate reason for the use of an antipsychotic medication. *They did not have a policy that addressed antipsychotic medications or gradual dose reductions. Further interview on 1/25/17 at 8:00 a.m. with the DON regarding resident 1 revealed: *There was no documentation to support that diversional activity had been implemented as a means to manage the behaviors before the medications were changed or increased. *She was unable to find additional documentation to support they had exhausted non-medicinal means to manage the wandering before they had started or increased the antipsychotic medication. *She had spoken to their consulting pharmacist, and she had confirmed they did not have any of the above policies. Interview on 1/25/17 at 10:00 a.m. with the social services director revealed: *She agreed the resident's room was sparsely decorated and not homelike. -She agreed if he recognized items from his home in his room it might have prevented him from wandering. -She recalled talking to his wife about bringing items in to make it more homelike. --She had declined. *They had at one time put a racing cap near his door to help him find his room. -They had not continued that when he kept taking it down. *They did not have a policy on behavior management. Interview on 1/25/17 at 10:50 a.m. with resident 1's wife revealed: *She worried the resident's behavior was a problem for staff. *She did not recall staff talking to her about personalizing his room as a benefit for himto assist in adjusting and feeling at home in the facility.

Based on record review, interview, and policy review, the provider failed to ensure the accuracy of Minimum Data Set (MDS) assessments for 5 of 13 sampled residents (1, 2, 4, 6, and 9) related to mood and toileting programs. Findings include: 1. Review of resident 6's 10/26/15 MDS assessment revealed she: *Had been admitted on [DATE]. *Scored a 4 on the Brief Interview for Mental Status (BIMS) assessment (a measure of memory and mental decline). -A score of 0 to 7 revealed severe mental impairment. *Had not exhibited any signs of a mood problem or anxiety including sleep issues. *Was frequently incontinent (loss of bladder control) but had an individualized toileting program. Review of resident 6's October 2015 psycho-active (mood altering) medication monitoring record revealed she was anxious thirteen out of thirty-one days. Her behaviors included yelling, whimpering, calling out, crying out due to nightmares, and resisting care. Interview on 11/23/15 at 1:50 p.m. with registered nurse (RN) B regarding resident 6 revealed: *She frequently was awake during the night and was very anxious. *Staff would get the resident up due to the anxiousness during the night and bring her out to the nursing station. *It was not uncommon for the resident to be up out of bed when the day shift came on duty. *She received medications to help with the anxiety. Interview on 11/25/15 at 9:00 a.m. with the social services director regarding resident 6 revealed: *The resident had verbally denied any mood or sleep issues when she had been interviewed for the MDS assessment. *She confirmed the resident had scored a 4 on the BIMS assessment that indicated severe mental impairment. -She understood she was still to interview a resident if they could speak no matter how confused they were. -She did not think the resident was as confused as her BIMS assessment revealed. -She confirmed the resident had scored a 3 on her initial BIMS assessment in August. *She was aware the resident was frequently awake during the middle of the night, and due to anxiety she was gotten up out of bed. Review of resident 6's 8/20/15 care plan revealed she was frequently bladder incontinent. The plan had not addressed an individual toileting schedule. Interview on 11/24/15 at 10:50 a.m. with certified nursing assistant (CNA) B regarding resident 6 revealed: *She was very verbal and anxious at times. *She was always nervous if she did not know where her roommate was at. *A lot of times when she came on duty the resident had already been gotten up during the night because of her anxiety. *Sometimes she would tell staff if she needed to go to the bathroom. -Otherwise they would take her every two to three hours if she had not asked. -There was not actually a set schedule for toileting her. -There were too many residents to have a set toileting schedule. *She was frequently incontinent. Interview on 11/24/15 at 12:20 p.m. with CNA A regarding resident 6 revealed: *She was toileted every two hours and was on a toileting schedule. *She could usually tell staff when she had to go to the bathroom. *She could tell if a resident was on a toileting program by looking where they documented toileting in the electronic medical record system. -If there was a box around their name they were on a two hour toileting plan. *She was unsure why the resident was incontinent so often if she could tell staff when she had to go to the bathroom and was on an individualized toileting program. Review of resident 6's 10/26/15 through 11/24/15 toileting documentation revealed: *On 10/26/15 staff attempted to toilet her eight times. -She refused twice. -She was incontinent three times. *On 10/31/15 staff attempted to toilet her six times. -She refused once and was incontinent three times. *On 11/8/15 staff attempted to toilet her six times. -She refused once and was incontinent once. *On 11/18/15 staff attempted to toilet her five times. -She refused once and was incontinent three times. *The number of times staff attempted to toilet her on any day ranged from five to eight times. Interview on 11/24/15 at 4:00 p.m. with the director of nursing (DON) regarding resident 6 revealed: *They could not provide additional information to support the resident's toileting program was more individualized than every two hours. *She confirmed resident 6 was frequently incontinent. *The resident was very anxious a lot of the time and was frequently awake and verbal during the night. -The MDS assessment had not been completed accurately for the resident's mood. 2. Review of resident 1's 7/13/15 MDS assessment revealed: *He was on a urinary toileting program that had resulted in decreased wetness. *He was frequently incontinent of urine. *His BIMS assessment showed he had moderate cognitive impairment (difficulty with the thought process). Review of resident 1's 9/21/15 MDS assessment revealed: *He was on a urinary toileting program that had resulted in decreased wetness. *He was occasionally incontinent of urine. *His BIMS assessment showed moderate cognitive impairment. 3. Review of resident 9's 6/15/15 MDS assessment revealed: *He was on a urinary toileting program that had resulted in decreased wetness. *He was frequently incontinent of urine. *His BIMS assessment showed severe cognitive impairment. Review of resident 9's 9/14/15 MDS assessment revealed: *He was on a urinary toileting program that had resulted in decreased wetness. *He was frequently incontinent of urine. *His BIMS assessment showed severe cognitive impairment. 4. Interview on 11/24/15 at 1:30 p.m. with the DON and the MDS nurse regarding the toileting program for residents 1 and 9 revealed: *All residents were started on a toileting program on admission. *The residents were reassessed with [REDACTED]. -Information was obtained through interview and review of documentation by nursing staff. *The care plans had not listed individualized time frames when residents were to be toileted. -General time frames of night rounds, upon rising in the morning, after breakfast and dinner, mid-afternoon, and after supper were noted on each care plan. *They verbalized residents 1 and 9 would both have been appropriate for a toileting program as they could make their needs known. Interview on 11/24/15 at 4:45 p.m. with licensed practical nurse G regarding residents 1 and 9 revealed: *Resident 1 would likely be able to make his needs known due to a recent medication change that had decreased his level of confusion. *Resident 9 was too advanced with his dementia to state when he had to use the bathroom. Interview on 11/25/15 at 9:20 a.m. with CNA E regarding the toileting program for residents 1 and 9 revealed: *Resident 1 had some intermittent periods of increased confusion but was sometimes able to make his needs known. *Resident 9 was not able to effectively make his needs known due to his advanced stage of dementia. 5. Review of resident 2's 9/14/15 MDS assessment revealed: *A BIMS assessment score of severely impaired. *She needed extensive assistance of two to toilet her. *She was frequently incontinent of bladder and bowel and wore a brief. *She was on a toileting program. Review of resident 2's 11/24/15 care plan revealed: *She requires extensive assist(ance) by two staff for toileting. She will refuse at times. *Assist to bathroom at these times: check on night rounds, when she first gets up, after breakfast and dinner, mid-afternoon, after supper, (and) at bedtime. *No individualized toileting program. Review of resident 2's medical record revealed: *A [DIAGNOSES REDACTED]. *A Bowel and Bladder Elimination checklist from the last fourteen days showed most days she had been incontinent. For one time period she was marked as continent. *A 6/23/15 progress note She continues to have an occasional continent episode but there is not really a pattern to it. *No assessment had been found to determine if she was appropriate for a toileting program nor to show there was an individualized toileting program. 6. Review of resident 4's 9/21/15 MDS assessment revealed: *A BIMS assessment score of two that was severely impaired. *She needed extensive assistance of two to toilet her. *She was frequently incontinent of bladder and wore a brief. *She was on a toileting program. Review of resident 4's 11/24/15 care plan revealed: *She requires extensive assistance of one to two staff for toileting. *Assist to bathroom at these times: Check on night rounds, when she first gets up, after breakfast and dinner, mid-afternoon, after supper, and at bedtime. *No individualized toileting program. Review of resident 4's medical record revealed: *A [DIAGNOSES REDACTED]. *A Bowel and Bladder Elimination checklist from the last fourteen days showed half the time she had been incontinent and half the time not. *A 9/21/15 progress note She is frequently incontinent of urine with some control present during the day but still no pattern noted. *No assessment had been found to determine if she was appropriate for a toileting program nor to show there was an individualized toileting program. 7. Interview on 11/24/15 at 10:00 a.m. with RN C revealed there were no assessments done for individualized toileting programs. Interview on 11/24/15 at 10:05 a.m. with CNA D regarding residents 2 and 4 revealed: *She was familiar with both residents. *There were no specific times residents 2 or 4 were toileted. It was done when they get up, between meals and after lunch. *It was not specific for the residents. *Resident 2 can voice when she needs the bathroom. Interview on 11/24/15 at 1:30 p.m. with the DON and the MDS nurse regarding the toileting programs for residents 2 and 4 revealed: *All residents were started on a toileting program on admission. *The residents were reassessed with [REDACTED]. -Information was obtained through interview and review of documentation by nursing staff. *The care plans had not listed individualized time frames when residents were to be toileted. -General time frames of night rounds, upon rising in the morning, after breakfast and dinner, mid-afternoon, and after supper were noted on each care plan. *Resident 4 would have been appropriate for a toileting program as she could generally make her needs known. *Resident 2 would not have been appropriate for a toileting program. *They were unsure why individualized times were necessary with a toileting program. 8. Review of the provider's March 2014 Bowel and Bladder training policy revealed If the resident is incontinent, will review the bowel and bladder charting, interview direct care staff, and interview resident, if appropriate, to determine whether or not resident would benefit from scheduled toileting. If the resident is not appropriate for a bowel and bladder program, they will be checked routinely.

Based on record review and interview, the provider failed to ensure one of one sampled resident (14) had a discharge summary completed at the time of her transfer to another skilled nursing facility (SNF). Findings include: 1. Review of resident 14's closed (no longer at facility) medical record revealed she had been transferred to another SNF on 7/24/15. A discharge summary had not been completed at the time of her transfer. Interview on 11/25/15 at 9:30 a.m. with the director of nurses revealed she: *Confirmed resident 14's closed record did not have a discharge summary. *Was unaware a discharge summary was required when a resident was transferred to another SNF. -They had not been doing that. *They did not have a policy on discharge summaries.

Based on record review, policy review, and interview, the provider failed to assess and care plan self-administration of medication for two of nine sampled residents (2 and 7). Findings include: 1. Review of resident 2's medical record revealed: *A physician's orders [REDACTED]. *The October 2014 treatment administration record had stated, "nursing to evaluate appropriateness every day shift every monday." *There had not been a self-administration assessment available. *Self-administration had not been addressed on her care plan. 2. Review of resident 7's complete medical record revealed: *A 9/1/14 physician's orders [REDACTED]. *No assessment had been completed to ensure the resident had been safe to self-administer her medications. *There was no mention of self-administration of medication on her 8/23/14 care plan. 3. Interview on 10/8/14 at 12:20 p.m. with the director of nursing revealed she agreed self-administration of medication should have been assessed, documented, and added to the care plan. Review of the provider's reviewed and revised August 2014 Monitoring and Recording Medications Which Are Self-Administered policy revealed "The decision that a resident has the ability to self-administer medications is placed on the resident's care plan. The above decision is subject to periodic re-evaluation by the interdisciplinary care team should there be a change in the resident's status."

Based on observation, interview, record review, and policy review, the provider failed to ensure care plans reflected the residents' current status for 6 of 13 sampled residents (1, 2, 7, 11, 12, and 13). Findings include: 1. Observation on 10/6/14 at 4:15 p.m. revealed resident 12 had been sitting in his recliner with a towel laying on his right ankle. His pant leg had been pulled up to his knee. An open area was noted on that exposed leg approximately two inches long by one-half inch wide. It was draining a clear colored liquid and all of the exposed skin had a bright red rash. Observation on 10/7/14 at 12:55 p.m. during personal care revealed resident 12 had a bright red rash on the abdomen, pelvic area, and both legs. Interview with the resident at that time indicated the leg had been causing him pain, and the rash itched "terrible." Review of resident 12's medical record revealed a 10/3/14 nurses progress note revealed the [DIAGNOSES REDACTED]. A nurses note on 10/6/14 at 2:00 p.m. indicated the resident had been allergic to the [MEDICATION NAME] (antibiotic) he had been on, and it was to have been added to his list of allergies [REDACTED]. *The undated wound documentation sheet revealed an entry dated 10/2 (no year) by nurse "RN" that stated resident 12 had "2 dime sized blisters on R (right) shin with no drainage and the treatment was to have been [MEDICATION NAME] (brand name wound dressing) to areas." The undated temporary care plan revealed: *allergies [REDACTED]." It did not list [MEDICATION NAME]. *He had an infection "10/7 [MEDICAL CONDITION]" it did not indicate where the [MEDICAL CONDITION] had been. It also stated he had been put on "10/ Keflex (antibiotic) 500 mg PO (oral) TID (three times a day) X (times) 10 days." *There had been no indication he had been on [MEDICATION NAME] for the [MEDICAL CONDITION], and that it had been determined he had been allergic to that medication. Review of the revised 8/7/14 comprehensive care plan revealed: *allergies [REDACTED]." It did not list [MEDICATION NAME]. *A focus area of "At risk for skin breakdown." *The goal had been "Intact skin, free of redness, blisters or discoloration." *There had been no documentation about the open area on the right lower leg or the rash on the body. 2. Review of resident 13's medical record revealed she had been admitted on [DATE] with a wound on her right foot and developed a wound on her left inner buttock after admission. Review of the undated wound documentation sheet indicated: *On "9/19 (no year)" an open area on the "left inner buttock by coccyx (tail bone)." -It had been a stage two (blister or shallow crater) ulcer (open area). *The wound had been documented as "healed" on "9/28 (no year)." Review of the undated temporary care plan indicated [DIAGNOSES REDACTED]. *"R (right) foot ST (soft tissue) infection." *"[MEDICAL CONDITION]." *"Abscess SP(status [REDACTED]. *"DM (diabetes mellitus)-insulin dependent." *She had a "R (right) foot ulcer with a wound vac (vacuum)." *It did not indicate an open area on the left inner buttock. Review of the 9/25/14 care plan revealed: *A focus area "__ (resident name) has a stage two pressure ulcer on the left inner buttock." *According to the wound documentation sheet that area was currently healed. Interview on 10/8/14 at 9:45 a.m. with the director of nursing confirmed she would have expected the temporary or the comprehensive care plans to reflect the current status of the residents. 3. Review of resident 1's complete medical record revealed: *An 8/28/14 care plan revealed: -A problem area of a stage II ulcer on his right coccyx area. -A goal he would have no skin breakdown by 11/26/14. -Multiple interventions related to skin breakdown. *A wound documentation form revealed his pressure ulcer had been documented as healed on 9/16/14. *His care plan had not been updated to reflect his healed stage II ulcer. 4. Review of resident 11's complete medical record revealed: *She had been admitted on [DATE]. *She had a peripherally inserted central catheter (PICC) line (intravenous access) in her right arm. *A temporary care plan with no interventions on how to care for her PICC line. 5. Review of resident 7's complete medical record revealed: *A 9/1/14 physician's orders [REDACTED]. *There was no mention of self-administration of medication on her care plan. Refer to F176, finding 2. 6. Review of resident 2's complete medical record revealed: *A physician's orders [REDACTED]. *Self-administration of nebulizer after nurse set-up had not been included in the care plan. Refer to F176, finding 1. 7. Review of the revised July 2013 Resident Overall Plan Of Care (OPC) policy revealed: *"All care plans are to be reviewed and pertinent changes made as the resident's condition changes or as goals and objectives have been made." *An accurate face page should be complete. *The care plan should be reviewed and revised as required.

Based on observation, interview, and policy review, the provider failed to ensure: *Ready-to-eat foods were handled in a sanitary manner by two of two cooks (H and I) for two of two observed meal services. *Dry goods were stored in a sanitary manner in the kitchen. Findings include: 1. Observation on 10/7/14 at 11:10 a.m. of the lunch meal service revealed cook H: *Used her ungloved hand to hold baked potato halves while she buttered them. *She then put a glove on her left hand after touching a few potatoes and used that gloved hand to hold the rest of the potatoes to butter them throughout the service. *She also touched plates, trays, utensils, the steam table top and metal counter top with that gloved hand throughout the service. *Other dietary staff had touched the same metal counter top after being in the dining room and not washing or sanitizing their hands when they re-entered the kitchen. Observation on 10/7/14 at 5:10 p.m. of the supper meal service revealed cook I: *Used her gloved hands to place saltine crackers on residents' plates. *She also touched plates, bowls, the steam table top, metal counter top with those same gloves. *She opened the refrigerator to remove a piece of cheese in a baggie with those same gloves. *She used an oven mitt to remove a pan from the oven while wearing those same gloves. *She removed a bun from a bag for a resident's sandwich with those same gloves. *She had not put on new gloves or washed or sanitized her hands throughout the service after performing any of the above activities. 2. Observation on 10/7/14 during the supper meal service revealed a large bin with bags of sugar stored under the kitchen counter. There was a scoop stored in one of the open sugar bags. 3. Interview on 10/8/14 at 8:15 a.m. with the dietary manager revealed the staff had been trying to implement the use of tongs more than gloves. They had been unsure of the best way to handle ready-to-eat foods. The scoop should not have been stored in the bag of sugar. She agreed the cooks should not have left the immediate serving area and returned without washing their hands and putting on new gloves. Review of the revised March 2012 dietary policies revealed food should not be touched directly with hands, and tongs or gloves should be used to serve ready-to-eat foods. There had not been instructions on when to replace gloves. There had not been instructions on where to store scoops for dry goods.

Based on observation, interview, and policy review, the provider failed to ensure: *Appropriate hand hygeine and glove use by two of two observed nurses registered nurse (RN) (A) and licensed practical nurse (LPN) (B) while administering medication and checking blood sugar. *A blood glucose (sugar) meter had been disinfected after each use by two of two observed nurses (RN) (A) and (LPN) (B). *A barrier had been used when bringing the blood glucose kit into multiple residents' rooms by two of two observed nurses (RN) (A) and (LPN) (B). Findings include: 1. Observation on 10/7/14 at 9:20 a.m. with RN A while she prepared to administer eye drops to resident 16 revealed she: *Put her gloves on. *Locked her medication cart. *Knocked on the resident's door. *Administered the resident's eye drops. 2. Observation on 10/7/14 at 10:50 a.m. with RN A while she checked resident 13's blood sugar revealed she: *Put gloves on and had not performed hand hygeine. *Set her blood sugar testing supply container on the resident's bedside table. *Had not used a barrier underneath of the container. *Checked the resident's blood sugar. *Wiped the blood glucose meter with a Super Sani-cloth wipe with those same soiled gloves on. *Immediately put the blood glucose meter in its case. *Removed her soiled gloves. *Sanitized her hands. *Obtained supplies including insulin and a syringe out of her medication cart. *Drew up the insulin dose. *Put gloves on and had not washed or sanitized her hands. *Administered the dose of insulin. *Removed her gloves. *Documented the medication administration in the resident's medication administration record. 3. Observation on 10/7/14 at 4:55 p.m. with LPN B while she checked resident 17's blood sugar revealed she: *Put gloves on. *Knocked on the resident's door. *Carried the blood glucose container into the resident's room. *Set her blood sugar testing supply container on the resident's bedside table. *Had not used a barrier underneath the container. *Opened the resident's bathroom door. *Turned on the faucet and wetted a cotton ball. *Checked the resident's blood sugar. *Wiped the blood glucose meter with a Super Sani-Cloth wipe with those same soiled gloves on. *Immediately put the blood glucose meter into its case. 4. Review of the Super Sani-Cloth manufacturer's label revealed: *All blood and body fluids must be thoroughly cleaned from surfaces and objects before disinfection by the germicidal wipe. Open and unfold the first germicidal wipe to remove heavy soil. Use a second germicidal wipe to thoroughly wet the surface. Allow to remain wet two minutes, let air dry. Interview on 10/8/14 at 12:20 p.m. with the director of nursing revealed she agreed: *Appropriate hand hygiene and glove use should have been done. *A barrier should have been used when transporting the blood glucose supply container between residents' rooms. *The blood glucose meter should have been properly disinfected according to the manufacturer's label after each use. Review of the provider's July 2012 Hand Hygiene policy revealed: *When to have used waterless antiseptic: -Before resident care. -Between resident contact. -After touching environmental surfaces or equipment near residents. -After contact with potential contaminated surfaces and objections in all other locations. -After removing gloves. -After contact with body fluids. Review of the provider's reviewed and revised September 2013 Care of Assure Platinum (blood glucose meter) policy revealed it had not addressed the specific procedure to disinfect the device. It did state to clean it by using a "Purple Top PDI Sani-Cloth.

Based on observation, interview, record review, and policy review, the provider failed to ensure security and accountability was maintained for government controlled and highly diverted (stolen) medications (schedule III) for 8 of 14 sampled and random residents (2, 3, 13, 14, 15, 16, 17, and 18) reviewed who received as needed (PRN) schedule III medications. Findings include: 1. Review on 8/28/13 at 10:30 a.m. of schedule III medications from two of two medication carts revealed the following information: a. Resident 2 had a blister pack (pre-formed plastic packaging) for PRN alprazolam (for anxiety) 0.5 milligrams (mg). *The blister pack containing thirty tablets had been issued on 1/21/13. *Five of the tablets had been removed from the blister seals. *Review of resident 2's January 2013 through August 2013 medication administration records (MARs) revealed three tablets had been documented as given. *Two tablets had not been accounted for. b. Resident 3 had a blister pack for PRN Lorazepam (for anxiety) 1 mg. *The blister pack containing thirty tablets had been issued on 4/30/13. *Twenty-one of the tablets had been removed from the blister seals. *Review of resident 3's April 2013 through August 2013 MARs revealed thirteen tablets had been documented as given. *Eight tablets had not been accounted for. c.Resident 13 had a blister pack for PRN Lorazepam 0.5 mg. *The blister pack containing thirty tablets had been issued on 5/21/13. *Five tablets had been removed from the blister seals. *Review of resident 14's May 2013 through August 2013 MARs revealed three tablets had been documented as given. *Two tablets had not been accounted for. d. Resident 14 had a blister pack for PRN Lorazepam 0.5 mg. *The blister pack containing thirty tablets had been issued on 11/30/2012. *Twenty-three tablets had been removed from the blister seals. *Review of resident 15's November 2012 through August 2013 MARs revealed eighteen tablets had been documented as given. *Five tablets had not been accounted for. e. Resident 15 had a blister pack for PRN hydrocodone-APAP (for pain) 5-325 mg. *The blister pack containing thirty tablets had been issued on 7/11/13. *Fourteen tablets had been removed from the blister seals. *Review of resident 15's July 2013 and August 2013 MARs revealed thirteen tablets had been documented as given. *One tablet had not been accounted for. f. Resident 16 had a blister pack for PRN hydrocodone-APAP 5-325 mg. *The blister pack containing thirty tablets had been issued on 2/20/13. *Five tablets had been removed from the blister seals. *Review of resident 17's February 2013 through August 2013 MARs revealed three tablets had been documented as given. *Two tablets had not been accounted for. g. Resident 17 had a blister pack for PRN Alprazolam 0.25 mg. *The blister pack containing thirty tablets had been issued on 6/27/2013. *Eleven tablets had been removed from the blister seals. *Review of resident 17's June 2013 through August 2013 MARs revealed four tablets had been documented as given. *Seven tablets had not been accounted for. h. Resident 18 had a blister pack for PRN hydrocodone-APAP 5-325 mg. *The blister pack containing twenty tablets had been issued on 4/16/13. *Seven tablets had been removed from their blister seals. *Review of resident 18's April 2013 through August 2013 MARs revealed one tablet had been documented as given. *Six tablets had not been accounted for. i. Interview on 8/28/13 at 11:00 a.m. with the assistant director of nursing (ADON) revealed the previous DON used a book in her office to account for schedule III medications on a monthly basis. The ADON had been unsure how the tracking system had worked. Interview on 8/28/13 at 1:05 p.m. with the director of nursing, ADON, and administrator revealed: *They had been unable to locate documentation for the missing schedule III medications. *The previous DON had developed a system for accountability of the schedule III medication, but they had been unable to understand the system. *They had contacted their consultant pharmacist and would institute a policy to count all PRN schedule III medications every shift beginning 8/28/13. *They had already contacted the local law enforcement, and the law enforcement had been in contact with the division of criminal investigation. *They had contacted the Department of Health to report the missing medication. Review of Patricia A. Potter and Ann Griffin Perry, Fundamentals of Nursing, 6 th edition, Mosby, St. Louis, Mo, 2005, revealed: *Page 907: -"All controlled substances are handled according to strict procedures that account for each medication." -"Medications should be charted immediately after administration." *Page 828: -"Discrepancies in narcotic counts are reported immediately." -"A special inventory record is used each time a narcotic is dispensed and provides an accurate ongoing count of narcotics used and remaining."

Based on observation, interview, policy review, and manufacture recommendations, the provider failed to ensure appropriate sanitary practices were followed for: *The cleaning and disinfecting of the whirlpool tub between residents use in one of one whirlpool room (200 Hall). *Multiple use resident care equipment (nail clippers, scissors, tweezers, nail files, hair brush, manicure stick, and razor) in one of one whirlpool room (200 Hall). Findings include: 1. Observation on 8/27/13 at 1:40 p.m. in the whirlpool room on the 200 hall (room [ROOM NUMBER]) with CNA A revealed the Century whirlpool tub disinfectant was Penner Classic Whirlpool Disinfectant Cleaner. Interview at the above time with certified nursing assistant (CNA) A revealed the Penner Classic Whirlpool Disinfectant Cleaner disinfectant time used on the whirlpool tub between residents was two to five minutes. 2. Observation at the same time and at the same location as above revealed: *In a plastic cart with four pull-out shelves there were: -Three nail clippers, three scissors, two tweezers, and two nail files in a cream-colored plastic container. -There were visible nail clippings, hair, and multiple tan and brown specks on the bottom of the container. -Two nail files and a manicure stick next to an antiperspirant container, several hair shampoo bottles, a mouthwash bottle, a small white hair brush, one package mouth sponge swabs, and several cotton tipped sticks in a gray-colored plastic container. -There was visible gray and white hair on the hair brush, nail clippings, hair, and multiple tan and brown specks on the bottom of the container. *A Remington razor was opened and multiple, short, gray and white hairs were present. Interview at the above time with CNA A revealed: *The nail clippers, scissors, tweezers, nail files, brush, and the razor were to have been disinfected with the same disinfectant cleaner used to clean the whirlpool tub after each use. *Visible nail clippings, hair, and multiple tan and brown specks were on the bottom of both plastic containers containing the above listed items. *Visible gray and white hair was on the hair brush. *The razor was opened and multiple, short, gray and white hairs were present. *She was unsure why the mouth sponge swabs and cotton tipped sticks were in the cart. Interview on 8/28/13 at 10:15 a.m. with the director of nursing confirmed: *The whirlpool tub should have been properly cleaned and disinfected after each resident's use. *Resident care items including nail clippers, scissors, tweezers, nail files, the brush, and the razor should have been cleaned after each use. Review of the provider's February 1995 Cleaning of the Century Bathing System policy revealed: *Cleaner disinfectant was diluted according to directions and used between residents use. *Allow sufficient time for thorough chemical action. Review of the provider's June 2011 Cleaning of Equipment for Personal Cares in Bath Area revealed: *To provide personal care in bath area with disinfected equipment. *"Personal items (i.e... combs, nail clippers) will be soaked in diluted disinfectant after use." Review of the provider's manufacture instructions label for the Penner Classic Whirlpool Disinfectant Cleaner to be used as a disinfectant was to allow it to remain wet for ten minutes. Association for Professionals in Infection Control and Epidemiology, Inc. (APIC), APIC Text of Infection Control and Epidemiology, 3rd Ed., APIC, Washington, DC, 2009, p.100-2, revealed: *The key to cleaning and disinfecting environmental surfaces was physically removing visible dirt, organic material, and debris thereby removing microorganisms. *The cleaning of environmental surfaces needed frequent cleaning because of the high degree of handling and the risk of cross-contamination of infection. *Frequently touched items needed to be cleaned after each resident use.

Based on observation, record review, interview, and policy review, the provider failed to maintain dignity during two of two meals for one of four sampled residents (4) needing assistance to eat. Findings include: 1. Observation on 8/27/13 from 10:50 a.m. through 11:45 a.m. of resident 4 revealed: *At 10:50 a.m. he was placed at the table by a staff member. *There were a total of five residents at the table who needed to have assistance eating. *The activity Chow Time Chatter took place from 11:30 a.m. through 11:45 a.m. *At 11:45 a.m. four residents had received their meals. *Certified nursing assistant (CNA) B was sitting next to him but was assisting the resident to his left. *CNA C was assisting two other residents at the same table. *A random staff member was feeding the fourth resident to his right. *He had not received his meal and staff had not spoken to him during that observation. Interview on 8/27/13 at 11:55 a.m. with CNA B and C regarding resident 4 revealed he had not gotten his meal, because they were waiting for another staff member to come assist him. Observation on 8/27/13 at 12:00 noon regarding resident 4 revealed: *He had gotten his meal, and staff had started to assist him. *He had been at the table for an hour and ten minutes before he had gotten his meal. *The other four residents at the table had received their meals fifteen minutes before he had gotten his. Observation on 8/27/13 from 5:15 p.m. through 6:00 p.m. of resident 4 revealed: *At 5:15 p.m. he had his meal and was being assisted by registered nurse (RN) D. *RN D got up three times during the observation and left him while he was still eating. Interview on 8/28/13 at 6:00 p.m. with resident 4 revealed he: *Had made eye contact when spoken to. *Replied "yeah" when asked if he was done with his meal. *Had not said any other words other than "yeah." Review of resident 4's 7/1/13 Minimum Data Set assessment revealed: *He needed extensive assistance of one staff member to eat. *He was sometimes able to make himself understood. *He was sometimes able to understand others. *His attention, orientation, and ability to recall things were severally impaired. Review of resident 4's 7/5/13 care plan revealed: *Staff were to "set up and assist with eating as needed; usually extensive assist of one." *To have met his activities of daily living he was to have an "extensive to total assist of one with eating." Interview on 8/28/13 at 2:00 p.m. with assistant director of nursing (ADON) and the director of nursing (DON) revealed: *Lunch was served starting at 11:15 a.m. *They had known resident 4 needed staff to assist him with his meals. *They had not known resident 4 had waited an hour and ten minutes at lunchtime before he had gotten his meal. *They had not been able to state what their expectation was regarding how long residents should have to wait to get their meals. *CNA B was allergic to hand sanitizer which was why she had only been assisting one resident at lunchtime. *They were not sure why the other staff at the table who had only been assisting one other resident had not helped resident 4. Review of the provider's May 2012 Serving Meals in Dining Room policy revealed meals were to have been served rapidly to keep the hot foods hot and the cold foods cold. A policy on dignity was requested from the DON and she referred to the admission packet for that information. Review of the admission packet revealed no dignity policy in the contents.

Based on observation, record review, interview, and policy review, the provider failed to ensure care plans had been revised for 2 of 12 sampled residents (5 and 6) to reflect the current resident's status. Findings include: 1. Resident 5 had been admitted on [DATE]. *He had a [DIAGNOSES REDACTED]. *He had been started on an antidepressant medication on 7/2/13. *The care plan dated 6/27/13 did not reflect any issues of depression. 2. Resident 6 had been admitted on [DATE] The 7/2/13 care plan had stated: *"His dad is now a resident of this facility. His parents assist with health care decisions." *The charting within the medical record indicated his father had passed away on 7/17/13. *The care plan dated 7/2/13 did not reflect: -His father had passed away. -To monitor or assess the grieving process. 3. Interview on 8/28/13 at 10:27 a.m. with the director of nursing (DON) confirmed she would have expected the care plans to have been updated within fourteen days of the status change using the resident assessment index (RAI) process. The provider did not produce a care plan or care plan revision policy prior to exiting.

Based on record review, interview, and policy review, the provider failed to ensure the appropriate care and interventions were provided to prevent a fecal impaction for one of twelve sampled residents (5). Findings include: 1. Review of resident 5's May 2011 bowel and bladder form revealed she did not have a documented bowel movement (BM) from 5/14/11 to 5/18/11. Review of the resident's May 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] *Senna-S (stool softener) one tablet. *Milk of Magnesia (stool softener) one ounce twice daily. *[MEDICATION NAME] suppository. She did not have medications ordered on a routine basis for prevention of constipation. Review of that same MAR indicated [REDACTED] *[MEDICATION NAME]. *[MEDICATION NAME]. *[MEDICATION NAME]. Review of resident 5's PRN (as needed) notes/medication information revealed she had received: *Senna-S on 5/13/11 that had resulted in a BM. *Senna-S on 5/14/11, 5/16/11, 5/17/11, and 5/18/11 with no BM results. *[MEDICATION NAME] suppository on 5/18/11 with no BM results. Review of the resident's 5/18/11 nurse's notes revealed she had a large amount of dark, hard stool manually removed from her rectum. Those notes stated the physician would be notified on her next rounds which would have been five days later. Review of the provider's "hall books" revealed each resident had their BMs monitored on a daily basis for one week at a time. Those monitoring sheets were discarded weekly and were not maintained within individual resident's records. Review of the provider's revised February 2010 BM monitoring and procedures policy revealed: *The purpose was to ensure residents were having routine bowel movements. *Certified nursing assistants were to record BMs on the front sheet of the "hall books." *Day nurses were to have decided what actions needed to have been taken based on each resident's individual circumstances. *Attempts would have been made to regulate residents' bowels with prunes or special foods. Review of resident 5's February 2009 physician's protocols revealed for constipation residents were to have: *Milk of Magnesia one ounce at bedtime. That could have been repeated in the morning. *Soap suds enema, fleets enema, or [MEDICATION NAME] suppository could have been used for soft stool impactions. Review of resident 5's 5/23/11 physician's progress notes revealed she had to be "manually disimpacted on at least one occasion" due to constipation. Those notes indicated the staff was requesting a daily medication to prevent constipation. Interview at 4:00 p.m. on 8/16/11 with the director of nursing revealed the bowel and bladder monitoring form retained in the resident's charts might not be considered accurate. She stated the "hall books" were considered to have been more accurate. She stated those records were discarded on a weekly basis. She confirmed the documentation in the 5/18/11 nurse's notes indicated resident 5 had to have hard stool manually removed. She could not confirm the provider's policies or resident 5's physician's orders [REDACTED]. Interview at 11:05 a.m. on 8/17/11 with the Minimum Data Set coordinator confirmed she had documented the 5/18/11 manual removal of hard stool from resident 5. She confirmed the documentation did not indicate all options per policy and orders were instituted to prevent that fecal impaction from occurring. Review of resident 5's 5/23/11 physician's orders [REDACTED].