Every finding on record at Everstead Health and Rehabilitation Center

Based on interviews, medical record reviews and a review of the facility policy titled, Comprehensive Care Plans, the facility failed to ensure the comprehensive person-centered care plan included a care plan with measurable objectives and timeframes for unresolved wounds for Resident Identifier (RI) #1 and RI #3. This affected RI #1 and RI #3 two of three residents sampled for pressure ulcer/injury. Findings include: A review of the facility policy titled, Comprehensive Care plans, with an implemented date of 7/27/22 revealed, .6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs . The objectives will be utilized to monitor the resident's progress. 1) RI #1 was admitted to the facility on [DATE] with diagnosis that included Type 2 Diabetes Mellitus with other Diabetic Ophthalmic Complication. A review of RI #1's Wound Assessment Report electronically signed by Employee Identifier (EI) #4, the Assistant Director of Nursing (ADON) dated 11/23/2022 revealed RI #1 had pressure injury identified to his/her left and right toe(s). A review of RI #1's care plans revealed no care plan was developed for the Pressure ulcer/injuries identified on 11/23/22 until 12/01/22. 2) RI #3 was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus with Unspecified Complications, Pressure Induced Deep Tissue Damage of Right Heel, and Pressure Induced Deep Tissue Damage of Left Heel. A review of RI #3's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed RI #3 was assessed as having two unhealed unstageable pressure ulcer/injuries. A review of RI #3's care plans revealed no care plan was developed for the Pressure ulcer/injuries identified on admission 9/29/22 until 11/07/22. An interview was conducted with EI #2, Nursing Supervisor, Staff Coordinator and she reported that she was training for MDS and care planning position. EI #2 reported that care plans were updated by the Interdisciplinary Team (IDT) and EI #6 who was part-time, interim MDS person while she was training. EI #2 reported when a wound was identified and when changes were made to wound care, the care plan should be updated within 24 hours to reflect what was going on with the resident. EI #2 reported that RI #1 had wounds identified on 11/23/22 and care plan not updated until 12/01/22. EI #2 reported RI #1 should have been care planned for active wounds within 24 hours of identification of the wounds. EI #2 reported the risk of RI #1 not having a care plan for active wounds was not having interventions in place to prevent infection and not knowing if goals were met. EI #2 reported the care plan policy was not followed when RI #1 developed wounds. EI #2 reported RI #3 had a wound identified on admission upon admission in September 2022 and no care plan for active wounds until 11/07/22. EI #2 reported that RI #3's care plan for active wounds should have been implemented within 24 hours of admission. An interview was conducted on 12/01/22 at 2:38 PM with EI #6 the interim Care Plan Coordinator. EI #6 reported that he had remote access to the facility's Electronic Health Record and was responsible for updating residents' care plans. EI #6 stated that care plan was updated when there was a change in a patient, annually, quarterly and according to the Resident Assessment Instrument guidelines. When asked, EI #6 reported that RI #1 had skin concerns identified on 11/23/22 and care planned 12/01/22. EI #6 reported that RI #1 should have been care planned for an active wound. When asked EI #6 reported that RI #3 had skin concerns and should have a care plan for active wounds but did not. EI #6 reported the risk of not care planning residents' active skin conditions or wounds was the wounds declining, mobility, contractures, and infections. An interview was conducted on 12/01/22 at 3:26 PM with EI #1, the Director of Nursing (DON). EI #1 reported EI #6, interim MDS Coordinator was responsible for developing the care plan related to newly identified wounds. EI #1 was asked when the care plan was implemented and updated for new skin concerns. EI #1 replied, within 24 hours. EI #1 stated she did not know why the process for the care plan was not followed for RI #1. On 12/1/22 at 5:08 PM a follow up interview was conducted with EI #1. EI #1 stated that RI #1 did not have a care plan for the wounds identified on 11/23/22. EI #1 was asked, how did RI #1's care plan include measurable objectives and timeframes to meet the resident's needs. EI #1 replied, RI #1 did not have a care plan for the wounds. EI #1 stated from the time the wound was found the care plan should have measurable objectives and timeframes to meet the residents needs. EI #1 stated the care plan was not put into place and therefore did not have measurable objectives. EI #1 reported that RI #3 had a care plan for active wounds implemented that was not implemented until 11/07/22.

Based on record review, interviews, a review of a facility policy titled MDS (Minimum Data Set) 3.0 Completion, the facility failed to ensure timely transmissions of MDS assessments to Centers for Medicare & Medicaid Services (CMS) for Resident Identifiers (RI) #1, RI #2, RI #3, RI #5, and RI #133. This affected five of 16 residents for whom MDS assessments were reviewed. Findings include: RI #1 was admitted to the facility on [DATE]. RI #1's quarterly MDS assessment with an Assessment Reference Date (ARD) of 8/13/2022 was signed as completed by the Registered Nurse (RN), Employee Identifier (EI) #3 on 8/26/2022. RI #2 was readmitted to the facility on [DATE]. RI #2's annual MDS assessment with an Assessment Reference Date of 8/17/2022 was signed as completed by the RN, EI #3 on 8/26/2022. RI #5 was admitted to the facility on [DATE]. RI #5's quarterly MDS assessment with an Assessment Reference Date of 8/11/2022 was signed as completed by the RN, EI #3 on 8/25/2022. A review of a facility report titled MDS Transmission Results Summary, that listed resident MDS assessment transmissions to CMS, revealed a transmission date of 9/18/2022 for RI #1's quarterly MDS assessment that should have been transmitted by 9/9/2022, a transmission date of 9/18/2022 for RI #2's annual MDS that should have been transmitted by 9/9/2022, and a transmission date of 9/18/2022 for RI #5's quarterly MDS that should have been transmitted by 9/8/2022. RI #3 was readmitted to the facility on [DATE]. RI #3's quarterly MDS assessment with an Assessment Reference Date of 8/13/2022 was signed as completed by the RN, EI #3 on 8/31/2022. RI #133 was admitted to the facility on [DATE]. RI #133's admission MDS assessment with an Assessment Reference Date of 8/18/2022 was signed as completed by the RN, EI #3 on 8/25/2022. Review of another facility report titled MDS Transmission Results Summary, that listed resident MDS assessment transmissions to CMS, revealed a transmission date of 9/18/22 for RI #3's quarterly MDS that should have been submitted by 9/14/2022 and a transmission date of 9/18/2022 for RI #133's admission MDS that should have been submitted by 9/8/2022. A review of a facility policy titled MDS 3.0 Completion with an implementation date of 9/19/2022 revealed: Policy: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. 7. Transmission Requirements: a. All assessments shall be transmitted to the designated CMS system . within 14 days of completion. On 9/21/2022 at 5:44 PM, an interview was conducted with EI #3, RN/Care Plan and MDS Director. When asked what issues the facility been experienced getting MDS assessments submitted timely, EI #3 said, she was told to do other things. EI #3 was asked if the administrator was aware the MDS assessments were transmitted late. EI #3 replied, the administrator was aware. EI #3 was asked, should the assessments have been transmitted on time. EI #3 replied, yes. On 9/21/2022 at 7:27 PM, an interview was conducted with EI #1, Administrator. EI #1 was asked when MDS assessments should be transmitted. EI #1 said, 14 days. When asked about the MDS assessments for RI #1, RI #2, RI #3, RI #5, and RI #133 that were transmitted late on 9/18/2022, EI #1 said, EI #3 had told her she was going to be late with some assessments. EI #1 was asked, what was the potential harm to residents when their annual, admit, or quarterly MDS assessments were not submitted timely. EI #1 replied, financial impact for the facility.

Based on observations, interviews, medical record reviews and review of a facility policy titled, Standard Precautions Infection Control, the facility failed to ensure staff performed hand hygiene and wore gloves before contact with blood and before contact with items potentially contaminated with blood. On 9/20/22 Employee Identifier (EI) #6, Environmental Services (ES) staff, was observed to clean blood from Resident Identifier (RI) #12's left lower leg with a Kleenex and not wearing gloves. Also on 9/20/22, EI #5, a Registered Nurse (RN), was observed cleaning a glucometer used to obtain RI #14's fingerstick blood sugar (FSBS) without wearing gloves or performing hand hygiene before continuing care tasks and administering injections. These deficient practices had the potential to affect RI #12, one of 16 sampled residents, and RI #14, one of five residents observed during medication pass observation. Findings include: A facility policy titled, Standard Precautions Infection Control, with a revision date of 6/10/22, documented: .Policy: All staff are to assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Therefore, all staff shall adhere to Standard Precautions to prevent the spread of infection. Policy Explanation and Compliance Guidelines: . 2. Using Personal Protective Equipment (PPE): a. All staff who have contact with residents and/or their environments must wear personal protective equipment as appropriate during resident care activities and at other times in which exposure to blood, body fluids, or potentially infectious materials is likely. RI #12 was readmitted to the facility on [DATE]. On 9/20/22 at 7:54 AM, the surveyor observed RI #12 at the nurse's station. RI #12 stated he/she bumped his/her leg in the bathroom, and it was bleeding. EI #6, ES staff, was observed getting a Kleenex and wiping blood off of RI #12's left lower leg without applying gloves and was holding the Kleenex with RI #12's blood in her bare hand. On 9/20/22 at 7:59 AM, an interview was conducted with EI #6, ES staff. When asked what she did when RI #12's leg was bleeding earlier, EI #6 said she cleaned the blood off. When asked how she cleaned the blood off, EI #6 said, with a Kleenex. When asked what was important to remember regarding handling blood, EI #6 said, wear gloves. EI #6 said she thought about it when she went to wash her hands, realized she did not have gloves on, and she should have been wearing them. When asked what the concern was with not wearing gloves when touching areas or items that contained blood, EI #6 said, cross contamination and infection control. EI #6 further stated that she knew she should have worn gloves. RI #14 was readmitted to the facility on [DATE]. On 9/20/22 at 11:23 AM during medication administration observation with EI #5, RN, the surveyor observed EI #5 obtain RI #14's fingerstick blood sugar (FSBS), return to the medication cart, clean the glucometer without wearing gloves, retrieve an alcohol wipe from medication cart drawer and return to RI #14's room, all without washing or sanitizing her hands. Once in RI #14's room, with unclean hands, EI #5, took gloves from a box on the wall, applied the gloves and administered an injection to RI #14. On 9/21/22 at 2:56 PM, an interview was conducted with EI #5, RN. When asked when she should wash her hands or change gloves during medication pass, EI #5 said before she started, if she touched any blood, body parts or contaminated items like a glucometer. When asked what she should do when cleaning a glucometer, EI #5 said she should glove her hands. EI #5 was asked if she wore gloves when she was cleaning the glucometer after she obtained RI #14's FSBS. EI #5 said no, she did not have on gloves. When asked what the concern was with her cleaning the glucometer without wearing gloves, EI #5 said, if there was any blood on it she could have been exposed to something and of course infection control. On 9/21/22 at 5:21 PM, an interview was conducted with EI #2, Director of Nursing/Infection Control Preventionist. When asked how should blood on a resident's leg be addressed, EI #2 said the nurse should don gloves, clean area with normal saline and gauze and then treat according to the injury. When asked should an ES worker wipe blood from a resident's leg with a Kleenex without wearing gloves, EI #2 said no, it could cause infection and exposure to germs for the resident and exposure to blood for the employee, which would be an infection control issue. EI #2 was asked if a nurse should clean a glucometer with her bare hands. EI #2 said no, again it would be infection control. EI #2 was asked about the concern with a nurse cleaning a glucometer without wearing gloves, then taking gloves out of a box on the wall without washing her hands and then administering an injection to RI #14. EI #2 stated, infection control risk for the nurse and the resident and contamination of gloves from reaching in the box with dirty hands. On September 18, 2022 a recertification survey in conjuction with a compliant investigation resulted in the following citations: Fed - F - 0640 - 483.20(f)(1)-(4) - Encoding/transmitting Resident Assessments S-S= E Fed - F - 0880 - 483.80(a)(1)(2)(4)(e)(f) - Infection Prevention & Control S-S= D IC deficiency (F880) cited during August 19, 2019 recertification survey. At this time SA rrccomends the following: 1) CMP as determined bt CMS. 2) DPNA effective November 18, 2022. 3)Termination of provider agreement effective March 1, 2023.

Based on observation, interviews, and review of a facility policy titled Safety During Food Storage, the facility failed to ensure that Employee Identifier (EI) #1, a dietary aide, discarded the following food items by the expiration/use by date: 1. one Chicken Salad in a plastic container that had an open date of [DATE] and a Use By Date of [DATE], and 2. one Peanut Butter and Jelly mixture in a plastic bowl that had a made date of [DATE] and a Use By Date of [DATE]. This had the potential to affect 37 of 45 residents in the facility that received meals from the kitchen. Findings Include: A review of a facility policy titled Safety During Food Storage, with no date, revealed: . II. Policy The following policy should be used regarding safety during food storage. III. Procedure . 2. The date the item was prepared shall count as Day 1. . 4. At the end of Day 3 staff should discard the unused item . All staff members are responsible for adhering to this policy and procedure . On [DATE] at 7:47 a.m., during the initial tour of the kitchen, the surveyor observed the following items in the inside refrigerator with EI #2, Assistant Director of Food and Nutritional Services: 1. one Chicken Salad in a plastic container that had an open date of [DATE] and a Use By Date of [DATE], and 2. one Peanut Butter and Jelly mixture in a plastic bowl that had a made date of [DATE] and a Use By Date of [DATE]. On [DATE] at 3:17 p.m., an interview was conducted with EI #2, Assistant Director of Food and Nutritional Services. EI #2 was asked on [DATE] at 7:47 a.m., what food items were observed in the refrigerator past their use by dates. EI #2 said Chicken Salad with a Use By Date of [DATE] and a Peanut Butter and Jelly mixture with a Use By Date of [DATE]. EI #2 further stated the items should have been discarded. EI #2 was asked who would have been responsible for ensuring the food items were discarded by the Use By Date on [DATE]. EI #2 stated EI #1, a Dietary Aide, would have been responsible for discarding any food in the refrigerator with expired use by dates. EI #2 stated that the food with expired use by dates could cause a food borne illness. [DATE] at 3:25 p.m., an interview was conducted with EI #1, dietary aide. EI #1 stated that on [DATE] she was supposed to check the open dates and use by dates of food items in the refrigerators, pull all leftovers that had an expired use by date, and put those items in the garbage can. EI #1 was asked if she removed all the food that had expired use by dates in the refrigerator. EI #1 stated no. EI #1 was asked why the chicken salad and peanut butter and jelly mixture were not discarded by their use by dates. EI #1 stated that she overlooked the food items. EI #1 was asked what was the facility policy on expired use by dates stored in a refrigerator. EI #1 stated that all food items should be discarded by the expired use by date. EI #1 was asked what was the potential harm to have food items in the refrigerator with expired use by dates. EI #1 stated the food items with an expired use by date could make people sick if they ate the items.

Based on observations, interviews, medical record review and review of facility policies titled, Hand Washing and Standard Precautions Infection Control, the facility failed to ensure a Registered Nurse: 1. did not pull Resident Identifier (RI) #45's privacy curtain with her bare hand and then apply gloves without washing hands, and did not move RI #45's overbed table while wearing gloves and then wear those same gloves to administer RI #45's insulin injection; and 2. did not place clean gloves on an unclean surface without a barrier for use in administering RI #22's eye drops. Further, the nurse did not wash hands or change gloves after RI #22 handed her a medication cup and water cup, prior to administering RI #22's nasal spray. This affected RI #45 and RI #22, two of four residents observed during medication pass observations and one of two nurses observed. Findings Included: A review of a facility policy titled, Hand Washing with a Date Implemented: 5/7/15, documented: .All facility personnel must wash their hands for 20 seconds under the following conditions: . 3. After handling contaminated objects. A review of a facility policy titled, Standard Precautions Infection Control with a Date Implemented: 11/15/2016, revealed: . 1. Hand Hygiene: a. During the delivery of patient care services, avoid unnecessary touching of surfaces in close proximity to the patient to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surfaces. 3. Using Gloves: . e. Remove gloves after contact with a patient and/or the surrounding environment (including medical equipment) using proper technique to prevent hand contamination. RI #45 was readmitted to the facility on [DATE]. On 08/19/19 at 7:43 a.m., during medication pass observation, Employee Identifier (EI) #3, Registered Nurse (RN), was observed pulling RI #45's privacy curtain with her bare hand. EI #3 then applied clean gloves, moved RI #45's overbed table, and while wearing those same gloves, administered RI #45's insulin injection. RI #22 was readmitted to the facility on [DATE]. On 08/19/19 at 8:00 a.m., during medication pass observation, EI #3, RN, was observed placing clean gloves on an overbed table without a barrier. She then applied these gloves to administer RI #22's eye drops. EI #3 was then observed taking a medication cup and water cup from RI #22 while wearing gloves, then wore those same gloves to administer RI #22's nasal spray. On 08/19/19 at 10:34 a.m., an interview was conducted with EI #3, RN. EI #3 was asked when should she wash her hands during medication administration. EI #3 said before and after she touched any contaminated objects. When asked if she washed her hands after pulling RI #45's privacy curtain before applying her gloves to give RI #45's insulin injection, EI #3 replied no, but she should have. EI #3 was asked when should she wash her hands and change gloves. EI #3 stated when gloves are dirty or after touching anything dirty before touching anything clean. EI #3 was asked if she changed her gloves and washed her hands after moving RI #45's overbed table while wearing her gloves before she administered RI #45's insulin injection. EI #3 said no. EI #3 was then asked where she placed the clean gloves she used to administer RI #22's eye drops prior to using them. EI #3 replied, on the bedside table without a barrier. EI #3 was asked what was the concern with placing items on an unclean surface without using a barrier. EI #3 stated, infection. EI #3 was asked did she take the medication cup and water cup from RI #22 while wearing gloves and then administer RI #22's nasal spray while wearing those same gloves. EI #3 said yes. EI #3 was asked what was the concern with handling items while wearing gloves and then administering medications while wearing those same gloves. EI #3 replied infection. When asked what was the concern with not washing her hands and changing gloves when potentially contaminated during administration of eye drops and nasal spray, EI #3 answered, spreading the infection to myself or another resident or if something was on the table, the spread of that infection to the resident. On 08/19/19 at 4:39 p.m., an interview was conducted with EI #4, RN/Infection Control Coordinator. EI #4 was asked, when should a nurse wash her hands during medication pass. EI #4 said before and after giving medications, after touching anything in the resident's room and before and after gloves. EI #4 was asked should a nurse wash her hands before applying gloves to administer an insulin injection after pulling a privacy curtain with her bare hand. EI #4 replied yes. EI #4 was asked should a nurse place clean gloves on an unclean surface without a barrier to be used during eye drop administration. EI #4 responded, no, they should always use a barrier before laying anything down. EI #4 was asked should a nurse change her gloves and wash her hands and apply clean gloves after a resident hands her a medication cup and water cup while she was wearing gloves. EI #4 said she should have changed her gloves and washed her hands and then applied clean gloves before giving the nasal spray. When asked what was the concern with these issues, EI #4 answered, infection control.

Based on observation, interview, record review and a review of a document titled, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure the MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 2/11/17 and 5/10/17, accurately reflected Resident Identifier (RI) #10's lower extremity impairment. This affected one of 11 residents whose MDS assessments were reviewed. Findings Include: A review of Center for Medicare & Medicaid Services (CMS)'s Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.14, dated October 2016, revealed: . CH (chapter) 3: MDS items (G) .section G0400 Functional Limitation in Range of Motion .Intent: The Intent of G0400 is to determine whether functional limitation in range of motion (ROM) interferes with the resident's activities of daily living or places him or her at risk of injury . RI #10 was admitted on [DATE], with [DIAGNOSES REDACTED]. On 6/20/17 at 5:00 p.m., during the initial tour, RI #10 was observed lying in bed with a trapeze device over the head of bed. RI #10 stated he/she had been at the facility for one year because he/she had a car accident three years ago and broke his/her neck and back. RI #10 stated he/she was paralyzed and had a wheelchair to get around. A review of RI #10's most recent Annual MDS with an ARD of 5/10/17 and Quarterly MDS with an ARD of 2/11/17, section G0400B both coded RI #10 a 0, no impairment of lower extremity. On 6/22/17 at 11:30 a.m., an interview with Employee Identifier (EI) #1, Restorative Licensed Practical Nurse (LPN) was conducted. EI #1 was asked, what was impairment. EI #1 said, not being able to use or having full ROM of that particular extremity. EI #1 was asked, did RI #10 have impairment of his/her lower extremities. EI #1 stated, yes he/she had paralysis of the lower extremities. EI #1 was asked, could RI #10 use his/her legs. EI #1 replied, no. EI #1 was asked, should it be coded as impairment on the MDS. EI #1 stated, yes, she could not walk. EI#1 was asked, what was the potential harm for coding no impairment on RI #10's MDS with ARD of 2/11/17 and 5/10/17. EI #1 stated, it looked like he/she was able to use the lower extremities when he/she could not.

Based on observation, interview and a dietary document titled, Diet Spreadsheet, the facility failed to ensure nine residents who received a pureed diet received pureed garlic bread with the lunch meal on 6/21/17. This affected nine of 47 residents who received meals from the kitchen. Findings Include: A review of a dietary document titled Diet Spreadsheet documented the following: .Day: 4 Wednesday .Lunch .Pureed .Pureed Garlic Bread #(number) 20 Dip . On 6/21/17 at 11:10 a.m. the surveyor entered the kitchen to observe the lunch tray line. The following items were observed on the tray line: regular beef tips, regular egg noodles, pureed beef tips, pureed noodles, pureed green beans, meat loaf, regular green beans, fried potatoes, chopped meat, pinto beans, pureed sweet potatoes and regular garlic bread. No pureed garlic bread was observed on the tray line. On 6/22/17 at 9:30 a.m., an interview was conducted with Employee Identifier (EI) #2, Dietary Aide. EI #2 was asked if she prepared pureed garlic bread for lunch on 6/21/17. EI #2 replied it was not garlic bread. EI #2 further stated she used loaf bread in the pureed beef tips. EI # 2 was asked why she did not prepare the garlic bread. EI #2 replied she thought the loaf bread should be used because they normally had rolls. EI #2 was asked if the menu called for pureed garlic bread. EI #2 replied yes. EI #2 was asked if the menu was followed for lunch on 6/21/17. EI # 2 replied the menu was followed except for the pureed garlic bread. On 6/22/17 at 9:40 a.m. an interview was conducted with EI #3, Dietary Manager. EI #3 was asked if residents receiving a pureed diet should have received pureed garlic bread for lunch on 6/21/17. EI #3 replied yes, if it was on the menu. EI #3 was asked if the menu was followed for the pureed garlic bread for lunch on 6/21/17. EI #3 replied no.

Based on observation, interview and record review the facility failed to ensure Employee Identifier's (EI)'s #1 and #3 provided incontinent care for Resident Identifier (RI) #2 in a manner to prevent cross contamination. During incontinent care, EI #1 and EI #3 touched RI #2's clean brief after touching his/her soiled brief. Also, EI #1 placed the soiled brief on RI #2's bed. This affected one of two sampled residents for observations of perineal care/catheter care. Findings Include: An undated facility policy titled: PERINEAL CARE BASIC RESPONSIBILITY: LICENSED NURSE AND NURSING ASSISTANT . PURPOSE 1. To cleanse the perineum. 2. To prevent infection and odor . PROCEDURE . 19. After pericare and before handling clean brief/pull-up or diaper remove dirty gloves and wash hands. RI #2 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #2's most recent Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/31/2016, documented: Section G: as needing Extensive Assistance with Toilet Use of Two + persons physical assist. Section H: 3. Always Incontinent of Urine and 2. Frequently Incontinent of Bowel. On 06/15/16 at 1:45 PM, the surveyor observed incontinent care for RI #2 along with EI #2, Infection Control Nurse for the facility. EI #1 performed the incontinent care with the assistance of EI #3. EI #1 and #3 touched RI #2's soiled brief. They failed to remove their soiled gloves and wash their hands and continued to touch the clean brief. On 06/16/16, at 2:50 PM, during a phone interview, EI #1 was asked if RI #2 was incontinent when she provided care for him/her on 06/14/16. EI #1 stated, Yes. EI #1 was asked where she placed RI #2's soiled brief after she removed it. EI #1 stated, On the bed. EI #1 was asked why she left the brief lying beside the resident and continued to place the clean brief on him/her. She stated, I don't know, I should have put it in the garbage. EI #1 was asked what she should have done after she touched the soiled brief and before she touched the clean brief. She stated, Washed my hands and put on clean gloves. EI #1 was asked why she touched the soiled brief and then touched the clean one. EI #1 stated, I don't know, I messed up so bad, I've worried about it all night. She was asked about the potential for harm when touching a resident's soiled brief, then touching the clean brief. EI #1 stated, They can get an infection. EI #1 was asked about the facility's policy for disposing of the soiled brief. She stated, Throw dirty away, remove gloves wash hands, put on clean gloves. On 06/16/16 at 2:05 PM, an interview was conducted with EI #3, the CNA who assisted EI #1 with RI #2's incontinent care. EI #3 was asked where EI #1 had placed RI #2's soiled brief during incontinent care. She replied, on the end of the bed. She was asked what EI #1 should have done with the soiled brief. EI #3 replied, discarded it in a bag in garbage. EI #3 was asked what EI #1 should have done before touching RI #2's clean brief. She replied, washed her hands and apply clean gloves. EI #3 was then asked why she touched RI #2's soiled brief and then touched the clean brief. She stated, the other CNA had mixed her up. EI #3 was asked about the facility's policy for disposing of the soiled brief. She replied, put in the trash, remove gloves, discard; wash hands and put clean gloves on. She was then asked what the potential for harm was if she touched the soiled brief and then touched the clean brief. EI #3 replied, infection/cross contamination. On 06/16/16, at 3:50 PM EI #4 Director of Nursing was asked what types of infections the facility was currently monitoring. She replied, UTI's (Urinary Tract Infections). EI #4 was asked if RI #2 had a history of [REDACTED]. She was asked if she was aware EI #1 and #3 had touched RI #2's soiled brief and then touched his/her clean brief while providing incontinent care. She replied, yes. EI #4 was asked what the potential for harm was if a CNA touches a clean brief after touching a soiled brief. She replied, cross contamination.

Based on observations, interviews and review of facility documents, the facility failed to ensure a licensed staff member pulled the privacy curtain far enough to provide privacy between RI (Resident Identifier) #16 and the roommate during wound care on 5/6/15.This affected one of one Resident that was observed during wound care. Findings Include: Review of the facility 's policy titled, " DRESSING CHANGE (CLEAN), " with no date, revealed the following: PURPOSE ...3.To prevent infection and the spread of infection ... GENEREAL RESIDENT RIGHTS GUIDELINES- ...Screen and drape resident for maximum privacy ... RI #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #16 's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) date of 3/27/15 revealed the resident had two Stage 2 pressure ulcers on admit and one Unstageable - deep tissue on admit. A review of RI #16 's " RISK FOR PRESSURE AREAS " Care Plan, with a Problem Onset date of 3/20/15, revealed also RI #16 was admitted with two Stage 2 pressure ulcers, one to right outer ankle and one to the right buttocks and one Unstageable Pressure area to right heel... A review of RI #16 's Physician order [REDACTED]. On 5/6/15 at 9:04 AM, EI ( Employee Identifier) #3 during the wound care observation on RI #16 half pulled the privacy curtain near door and half pulled the privacy curtain between RI #16 and the roommate, exposing RI #16 from waist down to roommate. On 5/6/15 at 11:02 AM, EI #3, the Treatment Nurse was interviewed and asked when performing a treatment on a resident what should be done when roommate is present. EI #3 stated the curtain closed. It was not closed enough. EI #3 was asked what did you do. EI #3 stated not close it completely. EI #3 was asked if it was an acceptable practice of this facility to not pull the privacy curtain between a resident and their roommate when performing wound care. EI #3 stated no it is practice to close it. EI #3 was asked what the potential harm was in not pulling the privacy curtain between resident and roommate during wound care. EI #3 stated exposure of the resident and privacy violation. On 5/6/15 at 11:08 AM, EI #1, the Director of Nursing was interviewed and asked what should be done to ensure complete privacy between a resident and their roommate when providing wound care. EI #1 stated the curtain should be pulled. EI #1 was asked if it was an acceptable practice of this facility for the privacy curtain between residents not to be pulled during wound care. EI #1 stated no. EI #1 was asked what the facility's policy on privacy was when a resident is receiving wound care. EI #1 stated in a semi private room pull the curtain and cover any private area not treating at the time. EI #1 was asked what the potential harm was in not completely providing privacy when performing wound care and not pulling the privacy curtain when the roommate was in the room. EI #1 stated it would be a dignity and privacy issue.

Based on record review and interviews, the facility failed to ensure Resident Identifier (RI) # 6's care plans was revised or updated to reflect interventions for a fall that occurred on 4/20/15. This affected one of six sampled resident reviewed for falls. Findings Include: Review of the facility's policy titled, "POLICY AND PROCEDURES FOR DOCUMENTATION AFTER FALLS," with no date revealed the following: "PURPOSE: For complete assessment and documentation after a resident falls PROCEDURE: ...Other things to document: ...5. Change in Care Plan to prevent reoccurrence ... Review of another facility policy titled, "ROUTED PROCEDURES: INCIDENT REPORTS/INVESTIGATION 7.) Charge Nurse is to...come up with an intervention that will potentially prevent this same type of incident from re-occurring AT THE TIME IT IS DISCOVERED. Charge Nurse must document the intervention ..." RI #6 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #6's MDS (Minimum Data Sheet) with an ARD (Assessment Reference Date) date of 2/05/2015 revealed the resident had a BIMS (Brief Interview for Mental Status) of 12 which indicated RI #6 was cognitively intact. A review of RI #6's "Risk for falls" Care plan, with no problem onset date, revealed no problem onset goal & target date or approaches which are interventions for the 4/20/15 fall to inform staff in order to prevent reoccurrence of the fall. On 5/6/15 4:28 PM, Employee Identifier (EI) #4, the Restorative Nurse was interviewed and asked to look through the Fall investigations and tell the surveyor when the last fall was for RI #6. EI #4 said according to these, 4/20/15 was her last one. EI #4 was asked to look at RI #6 Care Plan and show the surveyor where the care plan was updated to address the 4/20/15 fall. EI #4 stated it was not on there. EI #4 was asked what the facility policy was on updating care plans after each fall. EI #4 stated, "We update them with each fall when they occur." EI #4 was asked did you update this care plan. EI #4 stated, " No haven't updated it yet." EI #4 was asked what the potential harm was in not updating the care plan after each fall. EI #4 stated, "Staff or anyone may not be aware of interventions put into place. " On 5/6/15 at 5:39 PM, EI #4 was asked who was responsible for updating the falls care plan. EI #4 stated,"I am."

Based on observations, interviews and review of facility documents, the facility failed to ensure a licensed staff member washed or sanitized her hands after removing a dirty dressing and before touching and applying clean gloves and a clean dressing during wound care on 5/6/15. This affected RI #16, one of one residents observed during wound care. Findings Include: Potter and Perry " FUNDAMENTALS OF NURSING " Eighth Edition, copyright 2013, Chapter 28, Infection Prevention and Control, page 411 revealed the following: "...3. If hands are not visibly soiled ...use an alcohol-based waterless antiseptic agent for ... decontaminating hand ...b. After contact with ...wound dressings. Chapter 48, Skin Integrity and Wound Care, page 1217 revealed the following: ...4. Remove gloves, perform hand hygiene and apply clean or sterile gloves ... " RI #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #16's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 3/27/15 revealed the resident had two Stage 2 pressure ulcers and one Unstageable - deep tissue on admit. A review of RI #16's " RISK FOR PRESSURE AREAS " Care plan, with a problem onset date of 3/20/15, revealed: RI #16 was admitted with two Stage 2 pressure ulcers, one to right outer ankle and one to the right buttocks and one Unstageable Pressure area to right heel. A review of RI #16 's physician's orders [REDACTED]. On 5/6/15 at 9:06 AM, EI (Employee Identifier) #3, Treatment Nurse during the wound care performance on RI #16 was observed cutting the old dressing off RI #16's right heel, pulled off gloves, and re-applied clean gloves, then applied the Granulax to the abdominal pad and then applied the pad to RI #16's right heel and then wrapped with gauze and applied tape. On 5/6/15 at 11:02 AM, EI #3 was interviewed and asked when performing wound care and after touching and taking off an old dressing what should be done. EI #3 stated, "Rewash hand." EI #3 was asked what did you do. EI #3 stated, "Replied clean gloves." EI #3 was asked was it an acceptable practice of this facility to not wash hands after touching and removing the old wound dressing and gloves and before applying a clean pair of gloves and clean dressing. EI #3 stated, "Absolutely not." EI #3 was asked what was the potential harm in not washing your hands after taking off the old dressing and gloves and then applying clean gloves and clean dressing. EI #3 stated, "Risk of exposure and spreading germs." On 5/6/15 at 11:11 AM, EI #1 the Director of Nursing was interviewed and asked what should be done when taking off the old dressing and before applying clean gloves and touching and applying the clean dressing. EI #1 stated wash hands. EI #1 was asked was it an acceptable practice of this facility to not wash hands after taking off the dirty dressing and before applying clean gloves and a clean dressing. EI #1 stated, "no." EI #1 was asked what was the facility's policy on washing hands during wound care and when taking off an old dressing. EI #1 stated wash hands take off the old dressing, wash hands then apply clean gloves and dressing. EI #1 was asked what was the potential harm in not washing hands after taking off the old dressing and then applying clean gloves and touching and applying the clean dressing. EI #1 stated potential for infection.

Based on observations, record reviews, and interviews the facility failed to ensure a Certified Nursing Assistant (CNA) separated the labia and cleaned the vaginal area when performing incontinent care for Resident Identifier (RI) #7 a resident with a history of Urinary Tract Infection [MEDICAL CONDITION], on 5/6/15. The facility also failed to ensure a CNA changed the bath water or changed the wash cloth during the bath and perineal care of RI #5, a resident with a history of UTI, on 5/6/15. The facility further failed to ensure a CNA wiped RI #5's buttocks once with a disposable wipe discarding it during perineal care on 5/6/15. This affected RI #7 and RI #5, 2 of 2 sampled residents observed during perineal and incontinent care. Findings Include: A review of facility policy titled,"PERINEAL CARE" with no date revealed: "... PURPOSE 1. To cleanse the perineum. 2. To prevent infection and odor. ... PROCEDURE ... 11. ... Female perineal care ... d. ... separate the labia, with other hand wash from front to back. ..." RI #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #7's initial Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/3/15 revealed the resident had a Brief Interview of Mental Status (BIMS) score of 10 suggesting the resident's cognition was moderately impaired. The MDS revealed the resident required limited and extensive assistance with Activities of Daily Living (ADLs). The MDS also revealed the resident was frequently incontinent of bladder and bowel. A review of RI #7's Care Plan revealed: "...Problem Need Problem Onset: 03/20/2015 ... (Resident's Name) requires assist with ADL care due to: limited ROM (Range Of Motion), incontinennce secondary to alzheimers, unfamiliar environment, unsteady gait." RI #7's discharge summary from the hospital on [DATE] revealed RI #7 had been admitted to the hospital on [DATE] with complaint of severe back pain. During this hospitalization , RI #5 was treated for [REDACTED].#7 was placed on appropriate antibiotics. On 5/6/15 at 9:45 AM, Employee Identifier (EI) #6, a CNA(Certified Nursing Assistant) was observed performing incontinent care for RI #7. EI #6 removed RI #7's brief that was saturated with urine. RI #7 was helped to stand in the bathroom and EI #6 wiped each crease and down the outer labia with a clean wash cloth &(and) soap and changed corners on wash cloth after each wipe. EI #6 wiped front to back but was not observed separating the labia and cleaning the vaginal area. On 5/6/15 at 10:15 AM, an interview was conducted with EI #6. EI #6 was asked what does the facility's policy say about separating the labia during incontinent care. EI #6 answered to open the labia during incontinent care and clean the vaginal area. EI #6 was asked did you do this. EI #6 said "No". EI #6 was asked what was the potential harm if during incontinent care you do not separate or open the labia and clean the vaginal area well on RI #7. EI #6 said UTI or bacterial infection. On 5/7/15 at 9:30 AM, an interview was conducted with EI #1, the Director of Nursing (DON). EI #1 was asked what does the facility's policy say about separating the labia and cleaning the vaginal area during incontinent care. EI #1 answered to separate the labia and clean the vaginal area. EI #1 was asked if it was an acceptable practice for this facility for a CNA not to separate the labia and clean the vaginal area during incontinent care of a resident with urine in the brief. EI #1 said no. EI#1 was asked what was the potential harm if a CNA does not separate the labia and clean the vaginal area during incontinent care. EI #1 said potential for infection. A review of a facility policy titled, " CLEANSING BED BATH " with no date revealed: " ...Change water at least once during procedure ..." 2) RI #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #5's most recent Annual MDS with an ARD of 03/13/2015 revealed the resident was severely cognitively impaired for daily decision making. The MDS also revealed the resident required extensive assistance for toilet use and personal hygiene. The MDS further revealed the resident was always incontinent of bowel and bladder and had an active [DIAGNOSES REDACTED]. A review of RI #5 's urine culture report dated 12/09/2014 revealed: "...*CULTURE SOURCE URINE COLONY COUNT 50,000 ORGANISM PROVIDENCIA STUARTII ... " A review of RI #5 's urine culture report dated 03/09/2015 revealed: " ...*CULTURE SOURCE CATH URINE COLONY COUNT >100,000 ORGANISM ESCHERICHIA COLI On 5/6/15 at 10:25 AM, the surveyor observed EI #2, CNA, giving RI #5 a bed bath. EI #2 sanitized her hands and donned gloves. EI #2 placed water into a basin and placed it on EI #2's bedside table. EI #2 washed, rinsed and dried the resident's face and upper body. EI #2 washed, rinsed and dried the resident's thighs, legs and feet. EI #2 then washed, rinsed and dried the resident's perineal area and vagina with the same washcloth and same water that was used for washing the upper and lower body. EI #2 did not change gloves after cleaning the upper and lower body before cleaning the perineal area and the vagina. During perineal care, EI #2 was observed using a disposable wipe three times when cleaning the resident's buttocks before discarding it. On 5/6/15 at 10:55 AM, an interview was conducted with EI #2. EI #2 was asked how many times was she supposed to wipe with a disposable wipe. EI #2 said she was not really sure, but she was going to say just once. EI #2 was asked if she placed the wash cloth that she cleaned the resident's upper and lower body with in the same water and cleaned the resident's perineal area. EI #2 said yes. EI #2 was asked if she changed the water at all during the bath and perineal care. EI #2 said no, she did not change the water. EI #2 was asked if she should have changed the bath water after cleaning the resident's body and then cleaning her perineal area. EI #2 said yes, she probably should have. EI #2 was asked should she have used a clean wash cloth to perform the resident's perineal care. EI #2 said she probably should have used a different clean wash cloth or a disposable wipe. EI #2 was asked what was the potential harm in not changing the bath water after cleaning the upper and lower body and before cleaning the perineal area. EI #2 said UTI. EI #2 was asked what was the potential harm in using the same wash cloth to clean the body and perform perineal care. EI #2 said UTI. EI #2 was asked what was the potential harm in using a disposable wipe more than once. EI #2 said UTI. On 5/7/15 at 10:32 AM, an interview was conducted with EI #1, DON. EI #1 was asked if it was an acceptable practice of that facility for a CNA to give a resident a bed bath and not change the bath water at all during the whole process with perineal care included. EI #1 said no. EI #1 was asked if it was an acceptable practice of that facility for a CNA to give a resident a bed bath and use the same wash cloth for bathing the body and perineal care. EI #1 said no. EI #1 was asked if it was an acceptable practice of that facility for a CNA to wipe a resident's buttocks 3 times with the same wipe during perineal care. EI #1 said no. EI #1 was asked what was the potential harm if a CNA does not change the water in the basin when washing the body and performing perineal care. EI #1 said, "Infection." EI #1 was asked what was the potential harm if a CNA uses the same wash cloth to wash the resident's body and perform perineal care. EI #1 said , "Infection." EI #1 was asked what was the potential harm if a CNA uses a disposable wipe more than once to clean a resident's buttocks. EI #1 said, "Infection."

Based on observations, record reviews, and interviews, the facility failed to ensure a Certified Nursing Assistant (CNA) washed or sanitized her hands or changed her gloves after performing incontinent care and before applying a clean pull-up to Resident Identifier (RI) #7 on 5/6/15. The facility further failed to ensure a CNA changed her gloves when going from washing RI #5's upper and lower body to performing perineal care on 5/6/15. This affected 2 of 2 sampled residents observed during bathing and incontinent care. Findings Include: A review of facility policy titled, "Standard Precautions Infection Control" with copyright date 2014: "... Policy Explanation and Compliance Guidelines: ... e. Perform hand hygiene: ... ii. After contact with ... body fluids or excretions, ... 3. Using Gloves: ... h. Change gloves during patient care if the hands will move from a contaminated body-site (... perineal care) to a clean ..." RI #7 was admitted to the facility 3/20/15 with [DIAGNOSES REDACTED]. A review of RI #7's initial Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/3/15 revealed the resident had a Brief Interview of Mental Status (BIMS) score of 10 suggesting the resident's cognition was moderately impaired. The MDS revealed the resident required limited and extensive assistance with Activities of Daily Living (ADLs). The MDS also revealed the resident was frequently incontinent of bladder and bowel. RI #7's discharge summary from the hospital on [DATE] revealed RI #7 had been admitted to the hospital on [DATE] with complaint of severe back pain. During this hospitalization , RI #7 was treated for [REDACTED].#7 was placed on appropriate antibiotics. On 5/6/15 at 9:45 AM, Employee Identifier (EI) #6, a CNA was observed performing incontinent care for RI #7. EI #6 removed RI #7's brief that was saturated with urine. RI #7 was helped to stand in the bathroom and EI #6 began incontinent care and EI #6 was never observed to wash or sanitize her hands or change her gloves during incontinent care and before putting on RI #7's clean pull up. On 5/6/15 at 10:15 AM, an interview was conducted with EI #6. EI #6 was asked what the facility's policy said about washing or sanitizing hands when doing incontinent care. EI #6 said you only wash or sanitize hands before and after incontinent care. EI #6 was asked if she washed or sanitized her hands or changed her gloves prior to putting on the clean pull-up on RI #7. EI #6 said, "No". EI #6 was also asked what was the potential harm if you do not wash or sanitize hands and change gloves when going from dirty to clean. EI #6 said UTI or bacterial infection. On 5/7/15 at 9:30 AM, an interview was conducted with EI #1, the Director of Nursing (DON). EI #1 was asked when should hands be washed or sanitized and gloves changed during incontinent care. EI #1 said before and after incontinent care. She also said if the hands/gloves become dirty during the incontinent care, then the hands should be washed or sanitized and gloves changed. EI #1 was asked if it was an acceptable practice of the facility for a CNA to do incontinent care on a resident and then touch a clean brief or pull-up and apply it to the resident without washing or sanitizing hands or changing gloves. EI #1 said, "No". EI #1 was asked what was the potential harm if a CNA does not wash or sanitize their hands or change gloves after providing incontinent care and before applying a clean brief or pull-up to a resident. EI #1 said potential for cross contamination and infection. A review of Potter and Perry's "FUNDAMENTALS OF NURSING" EIGHTH EDITION, Copyright 2013, Chapter 28, Infection Prevention and Control, page 419 revealed: "...The CDC (Centers for Disease Control) notes that you need to wear clean gloves when touching...secretions...moist mucous membranes...Change gloves and perform hand hygiene between tasks and procedures on the same patient after contact with the material that contains a high concentration of microorganisms.... Chapter 39 Hygiene 801...o. Provide perineal hygiene. ...(a) Apply pair of clean gloves. ..." 2) RI #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #5's most recent Annual MDS with an ARD of 03/13/2015 revealed the resident was severely cognitively impaired for daily decision making. The MDS also revealed the resident required extensive assistance for toilet use and personal hygiene. The MDS further revealed the resident was always incontinent of bowel and bladder. On 5/6/15 at 10:25 AM, the surveyor observed EI #2, CNA, giving RI #5 a bed bath. EI #2 sanitized her hands and donned gloves. EI #2 placed water into a basin and placed it on EI #2's bedside table. EI #2 washed, rinsed and dried the resident's face and upper body. EI #2 washed, rinsed and dried the resident's thighs, legs and feet. EI #2 then washed, rinsed and dried the resident's perineal area and vagina with the same washcloth and same water that was used for washing the upper and lower body. EI #2 did not change gloves after cleaning the upper and lower body before cleaning the perineal area and the vagina. During perineal care, EI #2 was observed using a disposable wipe three times when cleaning the resident's buttocks before discarding it. On 5/6/15 at 10:55 AM, an interview was conducted with EI #2. EI #2 was asked if she had changed her gloves after washing RI #5's upper and lower body and before performing perineal care for the resident. EI #2 said no. EI #2 was asked if she should have changed gloves after cleaning RI #5's upper and lower body and before she performed perineal care for the resident. EI #2 said, "Yes." EI #2 was asked what was the potential harm in not changing gloves when going from bathing the upper and lower body to performing perineal care. EI #2 said,UTI. On 5/7/15 at 10:32 AM, an interview was conducted with EI #1, DON (Director of Nursing). EI #1 was asked if it was an acceptable practice of that facility for a CNA to give a resident a bed bath and not change gloves in between washing the resident's upper and lower body and performing perineal care. EI #1 said,"No." EI #1 was asked what was the potential harm if a CNA did not change gloves in between giving a bed bath and before performing perineal care. EI #1 said, "Definitely infection." On 5/7/15 at 10:40 AM, an interview was conducted with EI #5, LPN (Licensed Practical Nurse)/Infection Control Nurse. EI #5 was asked how infections were prevented in the facility. EI #5 said through hand washing, glove usage, in-services and education. EI #5 was asked how infections were controlled in the facility. EI #5 said if the resident required isolation, they would be isolated according to the doctor's order. EI #5 was asked if direct care staff were washing their hands and changing gloves according to facility protocol. EI #5 said yes. EI #5 was asked how direct care staff were monitored to ensure they were washing their hands and changing gloves according to facility protocol. EI #5 said the charge nurses monitored by conducting random check-offs on all shifts. EI #5 was asked what was the potential harm if a CNA gave a resident a bath and used the same wash cloth for bathing and perineal care, never changed the water between bathing and perineal care, used a disposable wipe more than one time when cleaning the buttocks and did not change gloves when going from bathing the body to perineal care. EI #5 said UTI, contamination and spreading infection. EI #5 was asked what was the potential harm if a CNA did not separate the labia and clean during perineal care. EI #5 said the resident would be at risk for infections, UTI's and breakdown. EI #5 was asked what was the potential harm if a CNA did not change gloves or wash or sanitize their hands after performing perineal care and before touching a clean brief. EI #5 said contaminating the clean area with dirty.

Based on observation, interview and record review, the facility failed to ensure RI (Resident Identifier) #4 received perineal care in a manner to prevent risk for urinary tract infections (UTIs). This affected one of two residents observed for incontinent care. Findings Include: A review of the facility's policy and procedure: "PERINEAL CARE" "...Purpose 1. To cleanse the perineum. 2. To prevent infection and odor ...Procedure ...11. d. Use one gloved hand to stabilize and separate the labia with the other wash from front to back." RI #4 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review or RI #4's most recent Quarterly Minimum Data Set with an assessment reference date of 05/08/14 documented RI #4 had both long and short term memory loss. RI #4 was assessed as always incontinent of bowel and bladder. On June 23, 2014 at 10:45 AM, an observation was made of perineal care to RI #4. EI (Employee Identifier) #1 wiped down the resident's groin on both sides using a clean wipe each time. EI #1 then wiped down the center of the perineal area two times, never separating the labia. EI #1 turned RI #4 onto her right side, and with a clean wipe, wiped RI #4 from her upper buttocks, down toward her anal area, times two using a clean wipe each time. On June 23, 2014 at 10:50 AM, EI #1 was asked how she was taught to do perineal care. EI #1 stated, wipe three times; each side (of the labia) and down the middle, and wipe front to back. EI #1 was asked did you wipe the labia each side then down the middle? EI #1 explained she thought she did. EI #1 was asked did you separate the labia? EI #1 stated she wiped the resident two times. EI #1 was asked how should you wipe the anal area? EI #1 stated, from her bottom up to her back, front to back. EI #1 was asked what would the harm be for this resident in not receiving proper perineal care. EI #1 stated she could get an infection. On June 23, 2014 at 3:00 PM, the Director of Nursing (EI #2) was asked what was the policy for providing perineal care? EI #2 stated of course to provide privacy; wash hands, put on gloves, then open the labia and wipe each side top to bottom, then down the middle. EI #2 was asked should the staff wipe the labia? EI #2 stated yes, they should wipe down each side, then down the middle. EI #2 was asked how should the staff clean the buttock/anal area? EI #2 stated front to back. EI #2 was asked why should the staff provide proper perineal care? EI #2 stated, to prevent urinary tract infections. EI #2 was asked what was the potential for harm in inadequately providing perineal care? EI #2 stated, infections.

Based on record review, observation and staff interviews, the facility failed to ensure the head of bed, for Resident Identifier (RI) #8's and Unsampled Resident Identifier number (URI #) 1, were elevated at all times while their enteral feeding was infusing. This deficient practice affected one sampled and one unsampled resident of six residents with continuous tube feedings. Findings include: The facility's policy titled, "POLICY AND PROCEDURE FOR ADMINISTERING FORMULA THROUGH A FEEDING TUBE" with no review or implementation date revealed the following, "... k. Ensure HOB (head of bed) is at least at 30-45 degree angle during feeds." Potter & Perry's, "Fundamentals of Nursing" 7th Edition, with a copyright date of 2009, page 1118, documented, "Administering Enteral Feedings via [MEDICATION NAME], Gastrostomy, or Jejunostomy Tubes ... STEPS ... 10. Place client in high-Fowler's position, or elevate head of bed at least 30 degrees ... RATIONALE Elevated head helps prevent aspiration ... ." On 09/07/2012 at 2:40 PM an interview was conducted with EI #5, Maintenance Director. EI #5 was asked when the head of the beds of tube feeders are lowered what elevation do the blocks provide. EI #5 stated, "10 degrees". EI #5 was asked what the elevation of the head of the bed should be for residents who received continuous tube feeding. EI #5 replied at least 30 degrees. On 09/07/2012 at 2:30 PM, Employee Identifier (EI) #4, the DON (Director of Nurses) was asked what are the staff instructed to do related to the position of the head of the bed of a resident that receives continuous tube feeding. EI #4 answered that the head of the bed should be elevated 30 to 45 degrees. EI #4 was asked when the staff provide incontinent care what have the CNA's been instructed to do. EI #4 replied that they were instructed to lower the head of the bed because the blocks are placed under the head of the bed of all tube feeders. EI #4 further stated that it was thought that the blocks would maintain the head of the bed at a 30 degree angle. EI #4 was asked how much elevation do the blocks actually provide. EI #4 said 10% (percent). EI #4 was asked if maintaining the head of the bed elevated 10% was adequate and she replied no. EI #4 was asked what can be caused by not maintaining the head of the bed elevated at least 30 degrees while a resident's tube feeding is infusing. EI #4 replied aspiration. RI #8 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 07/17/2012, identified RI #8 as having severely impaired cognitive skills for daily decision making with long and short term memory problems. RI #8 was assessed as being totally dependent on staff for eating, toilet use and personal hygiene. RI #8's, "physician's orders [REDACTED]." On 09/05/2012 at 10:10 AM, Employee Identifier (EI) #2, a Certified Nursing Assistant (CNA) was observed preparing RI #8 for incontinent care. EI #2 lowered RI #8's bed to a flat position while the tube feeding was infusing at 40 cc per hour. RI #8's bed remained in a flat position until EI #2 completed the incontinent care. EI #2 then raised the head of the bed to approximately 30 to 45 degree angle. On 09/07/2012 at 1:45 PM an interview was conducted with EI #2, CNA. EI #2 was asked if she had lowered RI #8's head of bed to a flat position while providing incontinent care. EI #2 replied yes. EI #2 stated that the tube feeding pump was still running. EI #2 was asked if she had been instructed to lower the head of the bed, of a resident receiving continuous tube feeding during incontinent care. EI #2 replied yes and that she always lowers the head of the bed because the blocks under the bed prevent the bed from being lowered to a flat position. EI #2 was asked what had she been instructed to do about lowering the head of the bed for a resident who received continuous tube feeding. EI #2 replied make sure the head of the bed was elevated 30 to 35 degrees. EI #2 was asked why should the bed be elevated 30 to 45 degrees during continuous tube feeding. EI #2 stated, "If we have them flat the food could go to their lungs." URI #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 07/16/2012, identified URI #1 as having severely impaired cognitive skills for daily decision making with long and short term memory problems. URI #1 was assessed as being totally dependent on staff for eating, toilet use and personal hygiene. URI #1's, "physician's orders [REDACTED]. " On 09/07/2012 at 9:30 AM, Employee Identifier (EI) #3, a Certified Nursing Assistant (CNA) was observed completing URI #1's ADLS (activities of daily living). URI #1's bed was in the flat position with the tube feeding infusing. URI #1's bed remained in the flat position while EI #3 waited on another CNA to bring the Hoyer lift. An interview was conducted with EI #3, a CNA, on 09/07/2012 at 2:10 PM. EI #3 was asked if she had provided a bath and incontinent care for URI #1 on 09/07/12. EI #3 replied yes. EI #3 was asked what position was the head of the bed during URI #1's ADL care. EI #3 replied that she had rolled the head of the bed down all the way. EI #3 was asked if URI #1's tube feeding was infusing during this time. EI #3 said yes. EI #3 was asked what URI #1's ADL sheet directed concerning positioning the head of bed. EI #3 replied to maintain URI #1's head of bed at least 30 to 45 degrees. EI #3 was asked if she had maintained URI #1's head of bed elevated at 30 to 45 degrees. EI #3 said that she thought she had because of the blocks. EI #3 was asked what can be caused by not maintaining the head of the bed at 30 to 45 degrees for a resident with a continuous tube feeding. EI #3 replied aspiration.

Based on observation, interviews and record reviews the facility failed to ensure a Resident Identifier (RI) #1's butterfly harness restraint was released every thirty minutes as care planned. This affected one of three residents sampled with restraints. Findings include: RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 07/28/12, identified RI #1 as having long and short term memory problems. RI #1 was assessed as requiring extensive assistance with all Activities of Daily Living (ADL). This MDS identified RI #1 as having a trunk restraint for in chair/out of bed. During this assessment period, the restraint was used daily. Facility document titled, "POLICY FOR PHYSICAL RESTRAINTS", with a date of 3/91 revealed,"...When physical restraints are used, their use shall be in accordance with physician orders, which shall include the type of restraint, specific purpose, and specific circumstances or time periods that the restraint is to be applied. In addition, the order will include how often it is to be released..." RI #1's physician's orders [REDACTED]. RELEASE & (AND) POSITION EVERY 2HRS, MONITOR EVERY 15 MINS (MINUTES) RELEASE EVERY 30 MIN..." RI #1's Care Plan with a date of 06/01/12 documented, "...Butterfly Chest Harness to be applied when (up) in w/c (wheelchair) for positioning/poor upper Body Control Release & Position Q (every) 2H (hour) Monitor Q15 min (minutes) Release Q30 min." On 09/05/12, RI #1 was observed continuously from 8:50 AM until 12:30 PM. During this time RI #1's trunk restraint was released a total of three times. RI #1's trunk restraint was not released every thirty minutes nor was it released for lunch while she was being fed by Employee Identifier (EI) #9, Licensed Practical Nurse, Treatment Nurse. EI #8, LPN Restorative, was asked in an interview on 9/05/12 at 11:20 AM if RI #1 could release her trunk restraint on command. EI #8 replied no. EI #8 was then asked how often the trunk restraint was to be released. EI #8 stated she believed it to be every 30 minutes. In an interview on 09/07/12 at 10:40 AM, with EI #7, Activities Director, was asked if RI #1's restraint had been released every thirty minutes on 09/05/12 while she attended activities. EI #7 stated no, that the nursing staff usually takes care of releasing the harness unless the resident needs to be repositioned. EI #6, Certified Nursing Assistant (CNA), was asked in an interview on 09/07/12 at 9:50 AM if she was assigned to care for RI #1 on 9/05/12. EI #6 stated that when she worked, she was always assigned to RI #1. EI #6 was asked how often RI #1's trunk restraint was to be released. EI #6 replied that the restraint was to be released every thirty minutes to an hour. EI #6 was then asked if she released RI #1's restraint every thirty minutes on 9/05/12. EI #6 answered no. An interview was conducted with EI #9, LPN Treatment Nurse, on 09/07/12 at 1:45 PM. EI #9 was asked if she had released RI #1's restraint while she fed her on 09/05/12. EI #9 stated that she did not but she was suppose to release the restraint during meals and every thirty minutes. EI #9 stated the reason for releasing the restraint was so that the resident could have freedom of movement and not be restricted while eating.