Every finding on record at Fair Haven

Based on interviews, record review, the facility's investigation and a facility policy titled, Assessing Falls and Their Causes, the facility failed to ensure Resident Identifier (RI) #1, a resident who sustained a fracture hip after a fall, was assessed by a nurse before being moved. This affected RI #1; one out of five residents sampled for accidents. Findings Include: A review of the facility's policy titled, Assessing Falls and Their Causes, revised 03/2018, documented, Purpose The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. Steps in the Procedure After a Fall: 1. If a resident has just fallen, or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities. 4. If an assessment rules out significant injury, help the resident to a comfortable sitting, lying, or standing position, . RI #1 was admitted to the facility on [DATE]. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's Investigation Summary documented that RI #1 complained of pain on the morning of 06/05/2022, one day after RI #1's fall. Employee Identifier (EI) #3, Licensed Practical Nurse (LPN), assessed RI #1 and found the resident's right leg appeared shorter than the left leg. The resident's family member reported to EI #3 that the resident told him/her that the resident had fallen. EI #3 requested an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was sent to the hospital. The facility's investigation into the resident's injury revealed that on 06/04/2022, EI #4, Certified Nursing Assistant (CNA), was preparing to move the resident from the bed to the wheelchair, using a sit-to-stand lift. While the resident was sitting on the side of the bed, but before the lift was in place, the resident became rigid and slid off the edge of the bed onto the floor. The radiology interpretation for Vuepoint Diagnostics dated 06/05/2022, revealed Acute Intertrochanteric Fracture of the right hip. In a telephone interview on 08/03/2022 at 4:46PM, EI #4, CNA, reported she was assisting RI #1 with getting up and dressed on 06/04/2022. EI #4 reported the resident locked up and slid down to the floor. EI #4 stated she made EI #3 aware and EI #3 said, Okay. EI #4 stated she waited on the nurse but after about 30 minutes she got another CNA (which could not be verified) and they moved the resident to the recliner. EI #4 stated she was wrong to move the resident but she did not want to leave the resident on the floor. EI #4 stated a resident was to be moved after a fall only after the resident had been assessed by the nurse. EI #4 stated the concern in moving a resident after a fall without an assessment was she could have broken the resident's bones or caused more damage. In an interview on 08/02/2022 at 5:57 PM, EI #3, LPN, reported she did not know RI #1 fell on [DATE]. EI #3 stated EI #4 never told her the resident fell . EI #3 stated she did not assess the resident on 06/04/2022. EI #3 stated she did not have notice RI #1 was in pain on 06/04/2022 but knew RI #1 complained of pain on 06/05/2022. EI #3 stated if she was notified a resident fell , the resident would stay on the floor and she would assess the resident by talking to the resident and taking vital signs. EI #3 stated further injury could occur or the injury could become more severe if a resident was moved after a fall before being assessed. In an interview on 08/04/2022 at 1:54PM, EI #2, Director of Nursing (DON), reported the investigation regarding RI #1's injury on 06/05/2022 revealed EI #4, CNA, said RI #1 fell on [DATE]. EI #3, LPN, reported she was not notified of anything on 06/04/2022. EI #2 stated if RI #1 had fallen, the CNA should have notified the nurse and the resident stayed on the floor until the nurse assessed the resident. EI #2 said that did not happen. EI #2 stated the resident was to be moved after the nurse assessed the resident and said it was okay to move the resident. EI #2 reported that EI #3 assessed the resident on 06/05/2022 but not on 06/04/2022 because she was not notified of the fall. EI #2 stated staff could cause further injury if a resident was moved after a fall without an assessment first. EI #2 stated if there was a fall, then the facility's policy was not followed. This deficiency was cited as a result of the investigation of AL 936.

Based on interviews, a review of a facility policy titled, . COVID 19-STAFF VACCINATION POLICY, and the facility's COVID -19 Staff Vaccination Status for Providers form, the facility failed to ensure staff either had all does of a multi-dose COVID 19 vaccine, a one dose COVID -19 vaccine, or been granted an exemption before being allowed to provide care or service to residents. The facilities vaccination rate was 81.29 %. This deficient practice affected nine of 365 employees employed by the facility. Findings included: A review of the facility's policy titled, COVID-19 STAFF VACCINATION POLICY, with a date of 01/14/22 revealed: Policy As a Condition of Participation in the Medicare and Medicaid programs, the Centers for Medicare and Medicaid Services (CMS) requires that all staff . be vaccinated to reduce the risk of transmitting COVID-19. Staff . who have received the first dose of a two-dose COVID-19 vaccine or a one-dose COVID-19 vaccine by February 14, 2022 and the final dose of a primary vaccination series by March 15, 2022, prior to providing any care, treatment, or other services for the facility and/or its residents, are considered to have met the individual vaccination requirements. Guidelines It is required that all staff . in the facility receive the designated COVID-19 vaccination or provide evidence of vaccine receipt or exemption. A review of the facility's, COVID-19 Staff Vaccination Status for Providers form with a run date of 4/8/22, revealed, out of 365 employees, 280 employees were completely vaccinated, 19 had been granted exemptions and no employees were identified as having a temporarily delayed vaccination, resulting in a 81.92% vaccination rate. On 04/08/22 at 11:41 AM an interview was conducted with Employee Identifier (EI) #1, Registered Nurse, Infection Preventionist. EI #1 was asked what her responsibilities were when it came to staff vaccinations. EI #1 said her responsibilities were to make sure employees were vaccinated, keep a spread sheet with all the vaccination statuses, and to provide education about the vaccination. EI #1 was asked how many staff, including contract staff does the facility employ. EI #1 said 365. EI #1 was asked how many staff were partially vaccinated. EI #1 was asked how many staff were completely/fully vaccinated. EI #1 said 280. EI #1 was asked how many staff had exemptions. EI #1 said 19. EI #1 was asked how many staff had pending exemptions. EI #1 said zero. EI #1 was asked how many staff were unvaccinated. EI #1 said 9. EI #1 was asked what type of additional precautions the unvaccinated staff were required to follow. EI #1 said they are required to wear a N95 mask and be tested twice a week. EI #1 was asked how many residents had been diagnosed with COVID -19 in the past four weeks. EI #1 said no residents tested positive in the month of March. EI #1 was asked what the harm of employees not being vaccinated. EI #1 said they could have a higher chance of contracting COVID and come to work asymptotic and spread it to other staff and residents. On 04/08/22 at 4:14 PM a follow-up interview was conducted with EI #1. Registered Nurse, Infection Preventionist, EI #1 was asked what the plan was to get the 9 unvaccinated employees vaccinated. EI # 1 said telling them they have to be vaccinated or have an exemption. EI #1 was ask what she was doing to get employees to get the second dose since the facility was in the 60 day plus period. EI #1 said calling the household leaders and getting a list of employees that require the second dose that are working. She stated she planned to show up physically on their shift and give them their 2nd dose.

Based on interviews, record review, and review of a facility policy titled Resident Participation - Assessment/Care Plans the facility failed to ensure Resident Identifier (RI) #1 and RI # 2's sponsors were notified of quarterly care plan meetings and further failed to ensure RI #4 was invited to participate in his/her care plan meetings. This affected three of five residents sampled for care plan meetings. Findings Include: A facility policy titled Resident Participation - Assessment/Care Plans with a revised date of December 2016 revealed: Policy Statement The resident and his or her representative are encouraged to participate in the resident's assessment and in the development and implementation of the resident's care plan. Policy Interpretation and Implementation 1. The resident and his or her legal representative are encouraged to attend and participate in the resident's assessment and in the development of the resident's person-centered care plan. 2. Spouses and other members of the family may participate in the .development of the person-centered care plan . 3. The resident/representative's right to participate in the development and implementation of his or her care plan includes the right to: a. Participate in the planning process. 4. The care planning process will: a. Facilitate the inclusion of the resident and/or representative . 7. A seven (7) day advance notice of the care planning conference is provided to the resident and his or her representative. Such notice is made by mail or telephone. 8. The Social Services Director or designee is responsible for notifying the resident/representative and for maintaining records of such notices. RI #1 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] On 12/19/21 at 10:25 PM an interview was conducted with RI #1's family. RI #1's family was asked how often they attend care plan meetings. RI #1's family indicated they had not had a care plan meeting since 2019. RI #1's family was asked if they would like to attend care plan meetings. RI #1's family replied, yes. RI #2 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/21/21 at 11:27 AM an interview was conducted with RI #2's family. RI #2's family was asked when they had been invited to a care plan meeting. RI #2's family stated they had not been to a meeting. RI #2's family was asked if they would like to be involved in a care plan meeting every quarter. RI #2's family replied, yes, depending on what time it was, so they could be involved and be able to listen to what the facility has to say and to discuss RI #2's care. RI #4 was originally admitted to the facility on [DATE] and readmitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] On 12/21/21 at 8:20 PM an interview was conducted with RI #4. RI #4 reported that someone had mentioned a care plan meeting to him/her once before and he/she agreed to participate, but no one ever got around to having the meeting with him/her. RI #4 reported that he/she was interested in participating in the care plan meetings but could not recall ever having a care plan meeting. On 12/20/21 at 11:00 AM an interview was conducted with Employee Identifier (EI) #3, Household Leader (HHL) for RI #1 and RI #2's building. EI #3 reported she was the Social Worker Designee for the building. EI #3 was asked how often care plan meetings were scheduled and she replied quarterly unless requested sooner by the family or resident. EI #3 was asked, how care plan meeting attendance was recorded or documented. EI #3 replied, EI #9 usually put it in a nursing note. On 12/21/21 at 10:50 AM a second interview was conducted with EI #3. EI #3 was asked, why it was important to involve the residents and sponsors in care plan meetings. EI #3 replied, to keep them informed of any changes, let them know what care was being provided, let them know if anything was going on with the resident, and let them know what activities were available. On 12/20/21 at 4:45 PM an interview was conducted with EI #9, Clinical Leader. EI #9 was asked how often care plan meetings were scheduled with sponsors and/or residents. EI #9 replied, meetings were scheduled when residents were newly admitted and the meeting was held within the first few days, and then quarterly or for significant changes. EI #9 reported that a sign-in sheet was signed when the meeting was completed. EI #9 explained for about the last year, the admissions office and Director of Nursing (DON) had been setting up the care plan meetings. EI #9 reported that the care plan meeting was supposed to be documented on a form, printed and placed on the chart and she documented the care plan meeting in the nurses' notes, but did not document who attended. EI #9 reported that EI #3 had a sign in sheet for attendees to sign in on. On 12/21/21 at 4:40 PM a record review was completed for RI #1, 2, and 4. No records were found regarding correspondence with residents and/or sponsors about scheduled care plan meetings; nor was there any documentation to indicate the residents or their sponsors had attended the care plan meetings. On 12/21/21 at 5:40 PM an interview was conducted with EI #2, DON. EI #2 was asked, how were residents and sponsors notified of care plan meetings. EI #2 replied, the sponsors should be called by the HHL about a week before the meeting. EI #2 was asked, how frequently should sponsors be invited to care plan meetings. EI #2 replied, once a quarter for long-term care residents. EI #2 was asked how care plan attendance should be documented. EI #2 replied, it should be several different ways, but a progress note of some sort.

Based on observation, interviews, and review of a facility policy titled Cleaning and Disinfection of Resident-Care Items and Equipment the facility failed to ensure Employee Identifier (EI) #12 did not measure Resident Identifier (RI) #10's vital signs with a blood pressure cuff, thermometer, and oximeter and then, without cleaning or disinfecting the equipment, proceed to enter RI #11's room to measure vitals with the same equipment. This had the potential to affect one of three total residents who were observed to have vital signs measured. Findings Include: A facility policy titled Cleaning and Disinfection of Resident-Care Items and Equipment with a revised date of October 2018 revealed: Policy Statement Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC (Centers for Disease Control and Prevention) recommendations for disinfection and the OSHA (Occupational Safety and Health Administration) Bloodborne Pathogens Standard. Policy Interpretation and Implementation 1. The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in resident care. c. Non-critical . items are those that come in contact with intact skin but not mucous membranes. (1) Non-critical items include . blood pressure cuffs, . (2) Most non-critical reusable items can be decontaminated where they are used . d. Reusable items are cleaned and disinfected or sterilized between residents ( .durable medical equipment). 3. Durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident. 4. Reusable resident care equipment will be decontaminated and/or sterilized between residents . RI #10 was admitted to the facility on [DATE]. RI #11 was admitted on [DATE] and readmitted on [DATE]. On 12/21/21 at 10:11 AM the surveyor observed EI #12, Certified Nursing Assistant (CNA) enter RI #10's room wearing gloves and carrying vital sign equipment that included pulse oximeter, blood pressure cuff, and skin thermometer. EI #12 placed the blood pressure cuff over RI #10's clothes on the right arm. After she measured the vital signs, EI #12 removed gloves and washed her hands. EI #12 exited the room and did not clean, wipe, or in any way clean or disinfect the blood pressure cuff, thermometer, or pulse oximeter. On 12/21/21 at 10:14 AM EI #12 knocked on RI #11's door and began to enter by stepping both feet in the door while carrying the same, uncleaned vital sign equipment in her hands. At that time, EI #12 was asked what she was going in RI #11's room to do and she stated to check his/her vitals. On 12/21/21 at 10:15 AM an interview was conducted with EI #12. EI #12 was asked, when did she clean the blood pressure cuff, thermometer, and/or oximeter that she was using to measure residents' vital signs. EI #12 replied, she did not, she worked with a staffing agency and was just helping out today and no one provided her with anything to clean the equipment. EI #12 reported that she checked all the resident's vitals and had not cleaned the equipment because she was not provided anything to clean with. On 12/21/21 at 4:45 PM an interview was conducted with EI #13, Registered Nurse/Infection Preventionist. EI #13 was asked, what was the facility's policy or process for cleaning re-usable resident equipment like blood pressure cuff, thermometer, and pulse oximeter. EI #13 reported, the equipment should be cleaned with purple top (Sani cloth) or Cavi Wipes after each resident's use. EI #13 was asked, what was the potential harm to residents when a staff member did not clean the vital sign equipment between resident use. EI #13 replied, the potential to spread germs to other people. On 12/21/21 at 5:40 PM an interview was conducted with EI #1, RN/Director of Nursing. EI #1 was asked, what was the facility's process and policy for cleaning re-usable resident equipment like blood pressure cuff, thermometer, pulse oximeter. EI #1 replied, the equipment should be cleaned after each resident's use. EI #1 was asked, what was the concern with a staff member measuring a resident's vitals and then without cleaning the equipment, entering another resident's room to assess vitals. EI #1 replied, the potential to spread germs.

Based on observation, interviews and facility policies tilted Garbage & Refuse and Insect and Rodent Control the facility failed to ensure the dumpster/area outside the kitchen was free of debris and pests. This had the potential to effect residents in the main Long Term Care building one of three buildings. Findings Include: A review of a policy titled Garbage & Refuse with a revised date of 12/28/2012 documented the following: .To prevent the spread of bacteria .Garbage and refuse containers should be free from cracks or leaks and covered when not in use.Procedure: 1) Garbage should be disposed of in refuse containers which have . lids. 2) When the refuse container is full, plastic liners should be tied securely before transferring the garbage to the dumpster. 3) Refuse containers should be emptied throughout the day to avoid over filling the container 4) Refuse containers should be emptied at the end of the last shift.7) The Dietary Department is responsible for the daily monitoring of these areas . A review of a policy titled Insect and Rodent Control with an effective date of 2/1/2002 documented the following: .To prevent the spread of bacteria that may cause food borne illnesses.e. Garbage should be disposed of according to policy . On 6/16/21 at 10:33AM the surveyor and Employee Identifier (EI) # 5, Registered Dietician (RD) toured outside area to include facility dumpster and courtyard by loading dock near kitchen. Observed the following items in the courtyard by loading dock near kitchen: Two bins of trash with no cover with flies around the open trash, discarded boxes, numerous pieces of paper, banana peels on the ground near the bins of uncovered trash, one open green bin near kitchen door with bagged laundry and trash in the bin to include cans and paper products, flies around the open green bin, four broken chairs near the door of the building, one old broken wheelchair, old mops and brooms near building, two old mattresses near building and numerous flies near the discarded items in the courtyard area. On 6/16/21 at 10:48AM surveyor walked back toward kitchen with EI #5. Observed Trash bin/compacter doors open. Observed numerous flies flying near compacter. Observed loose trash in the trash/bin/dumpster/compacter. On 6/16/21 at 3:00PM completed an interview with EI # 6, Environmental Director. EI # 6 was asked what was the process of disposing trash. EI # 6 stated two employees picked the trash up throughout the building and takes it to the dumpster near the kitchen. EI # 6 was asked about the discarded furniture in the courtyard area. EI # 6 stated they were going to be donated but were forgotten about. EI # 6 was asked what was the harm of having trash and discarded furniture next to the building and near the kitchen. EI # 6 stated a potential for bugs. EI # 6 was asked what was the potential harm of flies being around uncovered garbage. EI # 6 stated health concerns. EI # 6 was asked if a bin with bagged dirty laundry and trash should be outside the kitchen door. EI # 6 stated no, it should not be near the door due to a potential for bugs. EI # 6 was asked if the area observed on 6/16/21 was clean and free of debris. EI # 6 stated no. EI # 6 further stated it should be clean and free of debris. EI # 6 was asked why it should be clean and free of debris. EI # 6 stated residents and family could see it and health concerns. An interview was completed with EI # 5 on 6/16/21 at 4:18PM. EI # 5 was asked if the area outside the kitchen was clean and free of debris this morning. EI # 5 stated no not this morning. EI # 5 was asked what was the potential harm of trash and discarded furniture near the building. EI # 5 stated potential for pests coming in the building. EI # 5 was asked what was the potential harm of multiple files near the kitchen door and around the facility dumpster. EI # 5 stated they could come in the building. EI # 5 was asked if there was loose trash in the compacter/dumpster during the morning tour. EI # 5 stated yes. EI # 5 was asked if she observed the flies near the dumpster/compacter. EI # 5 stated yes. EI # 5 was asked if the doors to the dumpster/compacter were closed this morning during the tour. EI # 5 stated no, not when we went back in the kitchen. EI # 5 was asked if there was loose trash in the dumpster/compacter during the tour on 6/16/21. EI # 5 stated yes. EI # 5 was asked what can be done to control flies. EI # 5 stated trash needed to be bagged, covered, and disposed of as quickly as possible. EI # 5 was asked why there was trash in the bin with bagged dirty linen. EI # 5 stated no it should not be in there. EI # 5 was asked what was the negative outcome of trash being in the bin with the bagged dirty linen. EI # 5 stated pests and rodents could come in the kitchen.

Based on record review, interviews and a facility policy titled Comprehensive Care Planning-Person Centered the facility failed to ensure a Person Centered Care Plan was developed for the use of anticoagulant (AC) medication for Resident Identifier (RI) # 97. This affected 1 of 2 residents sampled for AC medication Findings Include: Review of a policy titled Comprehensive Care Planning-Person Centered with an approved date of 1/15/2018 documented: .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. RI # 97 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI # 97's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .Order Date 4/26/21 Start Date 4/26/21 . A review of RI # 97's admission minimum data set (MDS) with an Assessment Reference Date (ARD) of 5/01/2021 Section N documented the use of AC medication. On 6/17/21 at 3:55PM a review of RI # 97's care plans revealed no care plan for AC medication On 6/17/21 at 5:15PM an interview was completed with Employee Identifier (EI) # 8, Licensed Practical Nurse (LPN), (MDS). EI # 8 was asked if RI # 97 currently took AC medication. EI # 8 responded yes [MEDICATION(S)]. EI # 8 was asked if RI # 97 was taking AC medication upon admission. RI # 97 stated yes. EI # 8 was asked if RI # 97 had a current care plan for the use of AC medication. EI # 8 stated no. EI # 8 further stated that RI # 97 should have a care plan for the use of AC medication. EI # 8 was asked who was responsible for ensuring the care plan was completed. EI # 8 stated the clinical leader on each unit. EI # 8 was asked what would be a negative outcome of not having a care plan for the use of AC medication. EI # 8 stated the staff may not know what to monitor. On 6/17/21 at 5:23PM an interview was conducted with EI # 9, LPN, Clinical Leader. EI # 9 was asked if RI # 97 had a care plan for AC medication. EI # 9 stated no. EI # 9 was asked why RI # 97 did not have a care plan for the use of AC medication. EI # 9 stated it was overlooked. EI # 9 was asked if RI # 97 had been receiving AC medication. EI # 9 stated yes. EI # 9 was asked what would be a potential negative outcome of not having a care plan for the use of AC medication. EI # 9 stated staff would be unaware of life sustaining medication and not know what to watch for.

Based on observation, interviews, record review, and a review of Potter and Perry, Fundamentals of Nursing, the facility failed to ensure: A licensed staff washed her hands and changed gloves after cleaning the wound and before applying the new dressing to the wound for Resident Identifier (RI) #132. This affected RI #132, one of one opportunities of wound care observation. RI #132 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] RI #132 Physicians Orders dated 5/4/21 revealed: . Clean and dry, apply skin prep to peri-wound per facility protocol. Apply [MEDICATION(S)] calcium alginate sheet to wound bed. Cover with bordered adhesive foam dressing and change QOD and PRN on sacrum wound . Findings Include: A review of Potter and Perry Fundamentals of Nursing, ninth edition, chapter 48, page 1225 revealed . Implementation 1. Perform hand hygiene. Open sterile packages and topical solution containers as necessary. 2. Remove bed linen and patient's gown as necessary to expose ulcer and surrounding skin. Keep remaining parts covered and apply clean gloves. 3. Clean ulcer thoroughly with normal saline or cleaning agent. 4. Remove gloves, perform hand hygiene and apply clean or sterile gloves. 5. Apply topical agents as prescribed: . On 6/16/21 at 2:17 PM, Employee Identifier (EI) #4 Licensed Practical Nurse (LPN), was observed performing wound care. EI #4 introduced herself to the RI #132 and then washed her hands with soap and water at the sink. EI #4 donned gloves and put supplies on bedside table. There was no bandage on RI #132. EI #4 stated the appearance of the wound, small area to coccyx, area about 1 cm long x 0.5 cm width, no drainage noted and pale in color. EI #4 cleaned the wound and surrounding area with wound cleanser soaked gauze, then threw away the gauze. EI #4 then soaked another 4x4 gauze with wound cleanser and cleaned the area and then threw away the gauze in the trash. EI #4 then dried the wound with 4x4 gauze and threw it in the trash. EI #4 with the same gloves she cleaned the wound with, opened skin prep and applied skin prep around wound and threw the skin prep in the trash can. EI #4 opened the [MEDICATION(S)] and applied [MEDICATION(S)] to the wound. EI #4 applied dated and initialed [MEDICATION(S)] bandage over the wound. On 6/16/21 at 2:30 PM an interview with EI #4 was conducted. EI #4 was asked, when were you supposed to change gloves during a wound dressing. EI #4 replied, wash your hands before you start to apply gloves, change your gloves if sterile dressing and apply sterile field. EI #4 was asked, when were you supposed to wash your hands during dressing change. EI #4 replied, she hoped she did not have to wash her hands because she had gloves on. EI #4 was asked, when did you wash your hands during the wound dressing. EI #4 replied, she washed her hands after entering the room and before she put her gloves on. EI #4 was asked, what was the policy on washing your hands when changing a wound dressing. EI #4 replied, if your gloves get soiled then you would change them, but since there was no drainage, no blood she proceeded to clean the area and dress the area. EI #4 was asked, what could happen if you do not change your gloves during wound care. EI #4 replied, she could re-introduce bacteria or infection. On 6/17/21 at 3:49 PM an interview was conducted with EI #3, Infection Control Nurse. EI #3 was asked, when were you supposed to wash your hands during dressing change. EI #3 replied, before gathering supplies, after gathering the supplies, after positioning the resident, after cleaning the wound, and after the wound care. EI #3 was asked, when should you change your gloves during a dressing change. EI #3 replied, before gathering equipment and after entering the room, after gathering the supplies, after positioning the resident, after cleaning the wound, and after the wound care. EI #3 was asked, what was the policy on hand hygiene during dressing change. EI #3 replied, after positioning resident, after removing soiled dressing, after labeling the new dressing, after you clean and apply the new dressing. EI #3 was asked, what was the risk of not washing your hands during a dressing change. EI #3 replied, cross contamination and possible infection. EI #3 was asked, what was the risk of not changing your gloves during a dressing change. EI #3 replied, cross contamination and possible infection. EI #3 was asked, when were gloves indicated during dressing change. EI #3 replied, all the time during the dressing change. On 6/16/21 at 3:55 PM a follow up interview was conducted with EI #4. EI #4 was asked when did she change her gloves during the dressing change on the RI #132. EI #4 replied, at the beginning, I should have changed them after I cleaned the wound. EI #4 was asked, did you change your gloves before getting the new dressing to place on the wound on RI #132. EI #4 replied, no she did not. EI #4 was asked, what was the harm of not washing your hands during wound care. EI #4 replied, reintroducing contaminants to the wound.

Based on interview and review of Resident Identifier (RI) #2's medical record, the facility's policy titled Visitation Policy for Alabama Skilled Nursing Facilities, . in Response to COVID-19, a document titled, Can't Wait To See You!, the Fair Haven Retirement Community Grievance Form, the ASSOCIATE COUNSELING REPORT, In Service Educational Record, an email from RI #2's responsible party, a statement from Employee Identifier (EI) #2, a Certified Nursing Assistant (CNA) and the cdc.gov/coronavirus website, the facility failed to ensure staff wore the recommended personal protective equipment (PPE), a facemask, when they transported RI #2 to and away from a family visit on 12/19/2020. This deficient practice affected RI #2, one of nine sampled residents. Findings include: RI #2 was admitted to the facility on [DATE]. The facility's policy titled, Visitation Policy for Alabama Skilled Nursing Facilities, . in Response to COVID-19 revised 10/1/2020, documented . Policy Interpretation and Implementation . Regardless of how visits are conducted, there are certain core principles and best practices that reduce the risk of COVID-19 transmission and these core principles shall be adhered to at all times. Core Principles of COVID-19 Infection Prevention . Face covering or mask (covering the mouth and nose) . A facility document titled, Can't Wait To See You! revealed a family visit was scheduled for RI #2 on 12/19/2020 at 9:30AM. During a telephone interview on 12/29/2020 at 3:31 PM, RI #2's responsible party stated neither staff that transported RI #2 to the family visit and the staff that transported RI #2 away from the visit, wore a face covering (facemask). According to the Fair Haven Retirement Community Grievance Form dated 12/21/2020 regarding RI #2, documented . Resident's son was here on 12-19-20 for a plexiglass visit and CNA who brought his (mom/dad) out for visit did not have a mask on, his (mom/dad) didn't have a mask on and the Employee who brought (him/her) back in to the facility did not have a mask on . On 12/19/2020 at 4:12 PM, RI #2's responsible party sent an email to EI #4, the Clinical Leader and EI #1, the facility's Administrator which read . Dear Nurse (EI #4): . 1. I visited (RI #2) today at 10 am. Neither the One staff person that brought (RI #2) in for the plexiglas visit nor the 2nd person who took (him/her) back inside 1L had masks (on their faces or around their necks, or elsewhere that I saw) . Neither did (RI #2) have a mask . During an interview on 12/30/2020 at 5:43 PM, EI #4, the Clinical Leader stated she became aware of the incident (staff not wearing a mask) when she received an email from RI #2's son. According to EI #4, she called the nurse to ask who took RI #2 out and who brought the resident back in from the visit. EI #4 stated she was told EI #2, a CNA, took the resident out and EI #5, a CNA, brought the resident back in. In an interview on 12/30/2020 at 4:59 PM, EI #3, a Household Leader, stated she became aware of the incident (staff not wearing a mask) when EI #4 (Clinical Leader) informed her (EI #3) that RI #2's son had sent an email. EI #3 stated she called the Administrator (EI #1) on 12/21/2020, then talked with staff and got statements. When asked what was determined from the staff statements, EI #3 stated it was determined EI #2 (CNA) did not wear her face mask properly. EI #3 explained that EI #2 (CNA) had the mask on but the CNA's nose was not covered. A statement from EI #2, a CNA, dated 12/21/2020 documented Statement regarding incident on 12/19/20, Not wearing mask during family visitation: . My mask was mouth covered . On 12/31/2020 at 9:06 AM, EI #2, a CNA returned a telephone call, from 12/30/2020, to the State Surveyor. During the telephone call/interview, EI #2, a CNA acknowledged her face mask only covered her mouth; that it had been taken from her nose so that she could breath. According to the cdc.gov/coronavirus Facemask Do's and Don'ts For Healthcare Personnel . When wearing a facemask, don't do the following: DON'T wear your facemask under your nose or mouth . The ASSOCIATE COUNSELING REPORT signed by EI #2, a CNA on 12/29/2020, indicated the CNA received a written warning for (EI #2) failed to wear appropriate PPE on 12/19/20 while taking resident out to a plexi-glass visit. The report further documented (EI #2) has been counseled on the PPE policy and has been informed any other issues will result in further disciplinary action and or leading up to termination. In a telephone interview on 12/30/2020 at 5:24 PM, EI #5, a CNA stated RI #2 did not have a mask on when she (EI #5) saw the resident. EI #5 stated she wore a facemask. The In Service Educational Record dated 12/21/2020, indicated EI #2 and EI #5 received Infection Control education from EI #7, the Infection Control Preventionist. The record documented Masks (N95) be worn while on household. Residents that are out of their rooms must also have on a mask. Residents that are having visitation via window visit must still follow all indoor protocols, wear a mask and social distance from others. Staff must follow their guidelines outside while supervising window visits. During an interview on 12/30/2020 at 7:01 PM, EI #1, the facility's Administrator stated he determined from RI #2's responsible party statement the aides (EI #2 and EI #5) violated the facility's visitation policy; however, he was not 100% sure of the second aide, EI #5. This deficiency was cited as a result of the investigation of complaint/report number AL 798.

Based on interviews, record review and review of a facility policy titled Change in a Resident's Condition or Status the facility failed to contact Resident Identifier (RI) # 1's resident representative/sponsor upon identification of a wound to his/her sacrum area on 8/19/2020. This affected one of three sampled residents reviewed for notification of change. Findings Include: Review of a facility policy titled Change in a Resident's Condition or Status, revised May 2017, revealed: Policy Statement Our facility shall promptly notify the .representative (sponsor) of changes in the resident's medical . condition and/or status . Policy Interpretation and Implementation . 4. a nurse will notify the resident's representative when: .b. There is a significant change in the resident's physical .status . 5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical . status . RI # 1 was admitted to the facility on [DATE]. RI #1's nurse's notes included a noted dated 8/19/2020, signed by Employee Identifier (EI) #1, Licensed Practical Nurse (LPN) that documented the following: 8/19/20 Nurse made aware of open area to resident's sacrum. Nurse went into resident's room, assessed the wd (wound), slough, measured the wd. MD (Medical Doctor) notified, hospice notified. Wd care orders received . There were no notes that indicated RI #1's sponsor was informed upon the identification of the new wound or upon receiving new orders for treatment. RI # 1's physician's orders [REDACTED]. On 9/17/2020 at 3:14 p.m., an interview was conducted with RI #1's responsible party/sponsor. When asked about the wound to RI #1's coccyx area, RI #1's sponsor said she did not know when it first occurred. RI #1's sponsor stated that she had a problem with the facility not calling her regarding RI #1's wound. When asked if the facility had called when the wound was identified on 8/19/2020, RI #1's sponsor stated the facility did not call her when they identified the wound. An interview was completed with EI # 1, LPN, on 9/17/2020 at 7:05 p.m. EI # 1 stated she was the nurse working with RI #1 on 8/19/2020 when the wound was identified. When asked if she had contacted RI #1's sponsor to inform them about the wound, EI #1 said no, but she should have. EI #1 was asked what the potential negative outcome was of not notifying a resident's sponsor or family of changes. EI #1 stated the sponsor or family not knowing about the change. On 9/17/2020 at 7:17 p.m., an interview was conducted with EI #2, Registered Nurse/Director of Nursing. EI #2 was asked who was responsible for notifying a resident's family when there was a change in condition. EI #2 replied, the primary nurse or the supervisor. EI #2 was asked who was responsible for notifying RI #1's sponsor or family on 8/19/2020 upon identification of a wound to his/her coccyx. EI #2 replied, the primary nurse who was assigned to the resident. EI #2 was asked when family members should be notified. EI #2 said immediately. EI #2 was asked why it was important that the sponsor or family members be notified when there was a change in condition. EI #2 replied, because they have decision making power involving care when there was a significant change. EI #2 was asked what family member was notified on 8/19/2020 when RI #1's wound was identified. EI #2 replied, they were not notified on 8/19/2020.

Based on record review, interview and review of a facility policy titled Abuse and Crime Investigation and Reporting, the facility failed to report an allegation of abuse involving Resident Identifier (RI) # 188 within two hours of staff being made aware of the incident. This affected one of four Facility Reported Incidents reviewed during the survey. Findings Include: A review of a facility policy titled Abuse and Crime Investigation and Reporting, dated 11/28/17, documented the following: . Reporting 1. All ALLEGED violations involving abuse .will be reported .to .a. The State Agency responsible for surveying/licensing the facility .2. SUSPECTED abuse .will be reported within two hours . On 8/22/19 at 12:03 PM, the State Agency received an initial report from the facility regarding an incident involving RI #188. The report indicated Employee Identifier (EI) #1, Administrator/Abuse Coordinator, received a text message on 8/22/19 at 8:26 AM from an unknown source containing a photo of RI #188's nude body. His/her body was exposed, except for the genital area, which was covered by a towel. An interview was conducted with EI # 1, Administrator/Abuse Coordinator, on 1/30/20 at 9:53 AM. EI # 1 was asked when the incident occurred involving RI # 188. EI # 1 stated 8/22/19 at 8:26 AM. EI # 1 was asked when the incident was reported to the state agency. EI # 1 stated 8/22/19 at 12:03 PM. EI # 1 was asked if it was reported within two hours. EI # 1 stated no, we were trying to find out what happened and missed the two hour reporting time. EI # 1 was asked if the incident should have been reported within two hours. EI # 1 stated yes. EI # 1 was asked what would be a possible negative outcome of not reporting abuse within two hours. EI # 1 stated non-compliance with the two hour reporting rule.

Based on interview, medical record review and review of a facility policy titled, Discharge Summary and Plan, the facility failed to ensure a discharge summary was completed for Resident Identifier (RI) #242, a resident who discharged from the facility on 10/31/19. This affected one of three residents sampled for discharge. Finding Include: A review of a policy titled Discharge Summary and Plan, with a revised date of (MONTH) (YEAR), revealed: .When a resident's discharge is anticipated, a discharge summary .will be developed to assist the resident to adjust to his/her new living environment .The discharge summary will include a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of the discharge . RI #242 was admitted to the facility on [DATE] and discharged to another facility on 10/31/19. RI # 242's Skilled Charting notes included a note on 10/31/19 that documented RI #242 would be transferring that day to another local facility. A review of RI #242's Discharge Minimum Data Set (MDS) documented RI # 242 was discharged from the facility on 10/31/19 to an inpatient rehabilitation facility. RI #242's medical record did not contain a discharge summary. On 1/30/20 at 8:21 PM, an interview was conducted with Employee Identifier (EI) #10, Registered Nurse/Director of Nursing. The Surveyor asked EI #10 if a discharge summary was completed when RI # 242 transferred to another facility. EI #10 said no I don't see anything in the medical record. EI # 10 was asked why a discharge summary was not completed when RI # 242 transferred to another facility. EI # 10 stated he did not know, that it could have been missed. EI # 10 was asked why a discharge summary should be completed when a resident leaves the facility. EI # 10 stated to be able to communicate information to the new provider. EI # 10 was asked what would be the negative outcome of not completing a discharge summary. EI # 10 stated information may not be readily available which would slow down the admission process.

Based on observations, interviews, medical record review, and review of the facility policy titled, Fingernails/Toenails, Care of' the facility failed to ensure a brown substance was not under Resident Identifier (RI) #120's finger nails. This was observed on 01/29/20 and 01/30/20, two of three days of the survey. This deficient practice affected RI #120, one of six residents sampled for Activities of Daily Living (ADL) care. Findings Include: A facility policy titled, Fingernails/Toenails, Care of, revised (MONTH) (YEAR), revealed, .The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. . General Guidelines 1. Nail care includes daily cleaning and regular trimming. . Steps in the Procedure . 4. Allow the . hand .to soak in . warm soapy water for approximately five (5) minutes . 10. remove the dirt from around and under each nail with an orange stick . RI #120 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #120's Significant Change in Status Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 12/17/19, revealed RI #120 had both short and long term memory problems and severely impaired daily decision making skills. The MDS also indicated RI #120 required total care for personal hygiene and bathing. A review of RI #120's care plan documented the following: . Focus . The resident has an ADL self-care performance deficit related to Alzheimer's . Date initiated: 09/11/2017 . (RI #120) will have all . needs met . bathing/showering: Check nail length and trim and clean on bath day and as necessary . On 01/29/20 at 4:10 PM, during a phone interview, a family member of RI #120 stated staff were not cleaning or clipping toenails and fingernails. On 01/29/20 at 4:54 PM, Employee Identifier (EI) #8, Licensed Practical Nurse, accompanied the surveyor to RI #120's room to observe RI # 120's fingernails. The Surveyor observed brown substance underneath the nail beds on the left and right hand ring finger and thumb. The Surveyor asked EI #8, what does that look like underneath the nails. EI #8 stated it looked like dirt. After leaving RI #120's room, an interview was conducted with EI #8. EI #8 was asked should there be dirt underneath the finger nails. EI #8 stated no it should not be there. EI #8 was then asked why should it not be there. EI #8 stated nail beds should be clean that it could be stool or anything. EI #8 was asked how often do you clean nails. EI #8 said the Certified Nursing Assistants (CNAs) do that. On 01/30/20 at 10:06 AM, EI #9, a CNA, was asked what kind of care she had provided for RI #120 that day. EI #9 stated she gave the resident a bed bath, got him/her dressed and put him/her in the geri-chair. On 01/30/20 at 02:26 PM, while EI #9 was providing incontinent care to RI #120, the Surveyor observed light brown substance underneath the ring finger and the middle finger on both hands. EI #9 was asked what it looked like underneath RI #120's fingernails. EI #9 stated dirt under the ring finger and the middle finger on both hands. After leaving RI #120's room, EI #9 was asked should dirt be there. EI #9 stated no. EI #9 was then asked why should that not be there. EI #9 stated it could cause some type of infection. EI #9 was asked do you clean underneath RI #120's finger nails. EI #9 said she clipped them about a week prior. EI #9 was then asked how she cleaned the finger nails. EI #9 stated she washed them with a wash cloth and soap and water during baths. EI # 9 was then asked if she used anything to clean underneath RI #120's fingernails. EI #9 said she did not. An interview was conducted on 01/30/20 at 7:35 PM with EI #7, Clinical Leader. EI #7 was asked what the protocol was for cleaning nails. EI #7 stated that it was a part of bathing and should be done everyday.

Based on observation, interview, and review of a facility policy titled Storage of Medications, the facility failed to ensure that a stock bottle of expired Vitamin C (Citrus) 500 MG (milligram) was not left on a medication cart. This deficient practice was observed one of six medication carts selected for review. Findings Include: A facility policy titled Storage of Medications, revised (MONTH) 2007, stated . The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals . On [DATE] at 9:52 AM, the surveyor conducted a medication cart review of the medication cart on the 6200 hall (2nd floor) of Building K, the Rehabilitation Building, with Employee Identifier (EI) #2, a Licensed Practical Nurse (LPN). There was a stock bottle of Vitamin C 500 milligrams with an expiration date of ,[DATE], observed on the medication cart. In an interview with EI #2, LPN, on [DATE] at 09:57 AM, when asked what was the expiration date on the Vitamin C 500 milligram bottle, EI #2 replied (MONTH) 2019. The surveyor asked was it past due. EI #2 replied yes. EI #2 was asked who was responsible for ensuring expired items were removed from the medication cart. EI #2 replied each nurse was suppose to check the expiration dates at the beginning of every shift. EI #2 further stated it was her responsibility, she just missed it.

The facility failed to ensure a licensed nurse washed her hands or used hand sanitizer after taking Resident Identifier (RI) #148's blood pressure, prior to putting on gloves to administer RI #148's oral medications. Further, the licensed nurse did not wash her hands or use hand sanitizer between administering RI #148's oral medication and administering RI #148's inhalation medication. This affected one of nine residents observed during medication administration pass and one of four nurses during medication administration pass. Findings Include: A review of a facility policy titled Handwashing/Hand Hygiene, with a revised date of (MONTH) (YEAR), revealed This facility considers hand hygiene the primary means to prevent the spread of infections . 7. Use an alcohol-based hand . or alternatively, soap . water for the following situations . c. Before preparing or handling medications . l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident . After removing gloves . RI #148 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 01/29/2020 at 9:00 AM, the surveyor observed Employee Identifier (EI) # 5, a Registered Nurse, during medication administration pass. EI #5 placed a blood pressure cuff, from an automatic blood pressure machine, on RI #148's upper left arm with both ungloved hands. After taking RI #148's blood pressure, EI #5 did not wash her hands or use hand sanitizer. She then put on a pair of gloves to administer RI #148's oral medications. After EI #5 gave RI #148's oral medications, she removed her gloves, but did not wash her hands or use hand sanitizer prior to putting on another pair of gloves to administer RI #148's inhalation medication. On 01/29/2020 at 9:15 AM, an interview was conducted with EI #5. EI #5 was asked what she should have done after she took RI #148's blood pressure, prior to administering RI #148's oral medications. EI #5 stated she should have washed her hands or used hand sanitizer. EI #5 was asked what she should have done after giving RI #148's oral medication, prior to putting on another pair of gloves to administer RI #148's inhalation medication. EI #5 stated she should have washed her hands or used hand sanitizer. EI #5 was asked what would be the concern if a licensed nurse did not wash their hands after taking RI #148's blood pressure, and prior to putting on gloves to administer RI #148's oral medications. EI #5 stated she could transfer an infection to the resident or herself. EI #5 was asked what would be the concern if a licensed nurse did not wash her hands after she gave RI #148's oral medication, prior to putting on another pair of gloves to administer RI #148's inhalation medication. EI #5 stated it could transfer an infection to the resident or herself. On 1/29/20 at 1:28 PM, an interview was conducted with EI #4, a Infection Control Preventionist/Registered Nurse. EI #4 was asked what should a licensed nurse do after after she took RI #148's blood pressure, prior to putting gloves on to administer RI #148's oral medications. EI #4 stated she should have provided hand hygiene, either by hand washing or using a hand sanitizer. EI #4 was asked what should a licensed nurse do after she gave RI #148's oral medication, prior to putting on another pair of gloves to administer RI #148's inhalation medication. EI #4 stated she should have provided hand hygiene, either by hand washing or using a hand sanitizer. EI # 4 was asked what would be the concern if a licensed nurse did not wash their hands or use a hand sanitizer after she took RI #148's blood pressure, prior to putting gloves on to administer RI #148's oral medications. EI #4 stated this could be a risk of spreading germs from one person to another person. EI #4 was asked what would be the concern if a licensed nurse did not wash their hands after she gave RI #148's oral medication, prior to putting on another pair of gloves to administer RI #148's inhalation medication. EI #4 stated this could be a risk of spreading germs from one person to another person.

Based on record review, interview and review of a facility policy titled Weight Assessment and Intervention, the facility failed to ensure Resident Indentifier (RI) # 1 was weighed weekly for 4 weeks upon his/her admission to the facility on [DATE]. This affected 1 of 3 residents sampled for nutritional concerns. Findings Include: A review of a policy titled Weight Assessment and Intervention documented: Policy Statement The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. Policy Interpretation and Implementation Weight Assessment . 2. Weights will be recorded in each unit's Weight Record chart or notebook and in the individual's medical record . RI # 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI # 1's Admit Orders, signed by the physician on 4/8/19, included an order for [REDACTED]. A review of a document tilted Weight Summary documented a weight of 204 pounds on 4/10/19. An entry for 4/19/19 was struck through with a note that indicated . Incorrect Documentation . There were no other weights recorded for RI #1. A review of RI # 1's (MONTH) 2019 Medication Administration Record (MAR) documented Weekly weights x 4 wks 4/5 .; however, no weights were documented on the MAR. An interview was completed with Employee Identifier (EI) # 3, Licensed Practical Nurse (LPN) on 5/8/19 at 11:30 AM. EI # 3 stated she was familiar with RI # 1. EI # 1 was asked who was responsible for resident weights. EI # 3 stated Certified Nursing Assistants are responsible, they are supposed to get a weight upon admission and every Monday. EI # 3 was unsure as to why RI # 1's weights were not documented. EI # 3 was asked what is the potential negative outcome of not completing weekly weights. EI # 3 stated possible weight loss or gain, and they would not know how to treat the resident. An interview was completed with EI # 2, Registered Nurse (RN), on 5/9/19 at 3:45 PM. EI # 2 stated the first weight recorded for RI # 1 after admission on 4/5/19 was on 4/10/19. EI # 2 further stated RI # 1 was weighed on 4/19/19 but it was a wheel chair weight and was dashed out. EI # 2 stated the correct weight from 4/19 is unknown. EI # 2 was asked if RI # 1 was weighed weekly. EI # 2 stated RI # 1 was only weighed twice and the second weight recorded was not correct. EI # 2 was asked what was the possible negative outcome of not weighing residents according to facility policy of physician's orders [REDACTED].# 2 stated you would not know if a resident had weight loss. An interview was completed with EI # 1, Administrator, on 5/9/19 at 5:20 PM. EI #1 was asked why RI # 1's weights were not documented. EI # 1 stated she was not sure. EI # 1 was asked if RI # 1 had an order for [REDACTED]. EI # 1 stated yes, that was standard. EI # 1 was asked if the order was followed. EI # 1 stated it was only documented on 4/10/19 and 4/19/19. EI # 1 was asked what is the potential harm of not doing weekly weights. EI # 1 stated it is good practice and you wouldn't have a complete picture of the resident.

Based on observations, interviews, facility records, a facility document titled, Reporting Communicable Disease, a facility policy titled Reportable Diseases and guidance from the Alabama Department of Public Health Infectious Diseases and Outbreaks Division, the facility failed to ensure: 1) an outbreak of a Norovirus on Unit L1 was reported to the appropriate governmental agencies within the required specific time frame. Resident Identifiers (RI) #4, #9, and #74 were tested and confirmed positive but were not reported timely. This deficient practice affected three residents on unit L1, but had the potential to affect all 22 residents residing on the unit. 2) The facility further failed to ensure a licensed staff did not take RI # 114's medication and place it on the bedside table without a barrier and return them back to the medication cart; and 3) another licensed staff did not drop the artificial tears box on the floor, pick it up and then place eyes drops in RI #80 eyes. These deficient practices affected 2 of 7 residents and 2 of 4 nurses observed during medication pass. Findings include: 1) A facility document titled, Reporting Communicable Diseases with a revised date (MONTH) 2014, was reviewed. Included in the document was The purpose of this procedure is to guide reporting of suspected and confirmed communicable diseases to the appropriate governmental agency or authority. General Guidelines 2. The Infection Preventionist is responsible for notifying the local, district, . of confirmed cases of state - specific reportable diseases. The facility policy titled Reportable Diseases with a revised date (MONTH) (YEAR), was reviewed. The policy interpretations and implementation included, 1. Should any resident . suspected or diagnosed as having a reportable communicable /infectious disease according to State-specific criteria, such information shall be promptly reported to appropriate local and /or state health department officials. The Alabama Department of Public Health Infectious Disease and Outbreaks Division specify's that notifiable disease reporters must report 'Outbreaks of any kind' and 'Cases of potential public health importance' to the division within 24 hours, . An outbreak is defined as two or more similarly ill persons who . have a common exposure. A review of a facility document titled, Summary of L1 virus revealed the first confirmed case of Norovirus was 2/25/19. Documented on 2/28/19 were three residents who were affected with [MEDICAL CONDITION], RI #4, #9 and #74. Reviews of laboratory services reports provided to the facility for RI #4, #9 and #74 were conducted, along with reviews of the emails that were submitted to the Public Health reporting the outbreak. The reports revealed: RI #4's results was reported on 3/4/19 at 7:50 AM, however the Public Health was not notified until 3/4/19 at 2:12 PM. RI #9's results was reported on 3/1/19 at 8:46 AM, but was not reported to Public Health until 3/4/19 at 2:32 PM. RI #74's results was reported on 2/25/19 at 8:31 AM, however was not reported to Public Health until 3/1/19 at 5:36 PM. All results tested positive for the Norovirus. On 3/6/19 at 9:30 AM, an interview was conducted with Employee Identifier (EI) #3, Registered Nurse Clinical Leader on L1 Unit. EI #3 was asked if there was a recent outbreak of [MEDICAL CONDITION] of any kind. EI #3 replied yes they had an outbreak of Norovirus. When asked how many cases, EI #3 replied three were positive. EI #3 was asked when it started. She reported that heavy diarrhea started on 2/19/19 and residents were tested on [DATE] with results on 2/25/19 and reported to the Health Department on 3/1/19. EI #3 was asked who she notified about the outbreak. She replied she notified the Medical Doctor and he gave standing orders. She reported she also notified the families that were affected, the three residents that tested positive. EI #3 was asked if she made other residents or other families and/or visitors aware that there was an outbreak. She replied no, and that was what the Health Department said, she should have posted signs. 2) On 3/05/19 at 4:20 PM, a medication pass was observed with EI #6, Licensed Practical Nurse (LPN) and RI #114. After preparing the medications to be administered, EI #6 entered the resident's room and placed the medications on the bedside table, without a barrier. On 3/5/19 at 4:32 PM, EI #6 was interviewed. She was asked after entering RI #114's room did she place the medications on the bedside tablet without something under it (to separate it from the table), then bring the meds out of the room, return them to the cart, go and obtain a syringe, go back to the cart and retrieve the meds and then return to the resident's room. She replied she did. When asked what that was a potential for, EI #6 replied contamination. 3) RI #80 was admitted to the facility on [DATE]. A review of RI #80 medications included Artificial Tears Drops. On 3/06/19 at 8:11 AM, EI #5 was observed for medication pass with RI #80. The medications EI #5 prepared included artificial eye drops. After EI #5 prepared the medications she entered the residents room and dropped the box containing the eye drop bottle on the floor. She proceeded to place the other medications on the bedside table. EI #5 then picked the box with the eye drops from the floor and placed it on the bedside table (without wiping the box or the bottle). After she administered the oral meds to the resident and washed her hands, she then administered eye drops to the resident's left eye then the right eye. On 3/06/19 at 8:26 AM, EI #5 was interviewed. EI #5 was asked what should she have done with the eye tears. She said she should have thrown it away. EI #5 was asked what this was a potential for. She replied spread infection. On 3/07/19 at 5:01 PM, EI #3 Clinical Nurse Leader and Infection Preventionist was interviewed. EI #3 was informed that the nurse dropped the box containing the nasal spray on the floor as she entered the resident's room. She later picked the box containing the artificial tears up off the floor, washed her hands and then administered the eye drops to each of RI #80 eyes. EI #3 was asked what was the procedure when med, even inside in the container, has been dropped on the floor. EI #3 replied if it dropped on the floor and the content does not come out of the container, then just wipe them both off, but the best thing would be just to order/get another. When asked what are the concerns with the above issue, if the process she gave was not followed, EI #3 said the nurse would need re-education/ re-training.

Based on record review, interview and a facility policy titled, Resident Assessment Instrument, the facility failed to ensure an anticoagulation medication for Resident Identifier (RI) #23 did not continued to be coded on the 11/30/18 Minimal Data Set (MDS), when the medication was discontinued on 10/4/18. This affected one of 40 residents for MDS review. Findings Include: A review of a facility policy titled, Resident Assessment Instrument revised (MONTH) 2010, revealed: . Policy Interpretation and Implementation . 7. All persons who have completed any portion of the MDS Resident Assessment Form . attesting to the accuracy of such information. RI #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a physician's orders [REDACTED]. 7/18/18 Admit medications: [REDACTED]. BID (twice a day) . A review of a physician's orders [REDACTED]. 6. DC (Discontinue) . Eliquis . A review of a Quarterly MDS with an Assessment Reference Date of 11/30/18 revealed Section N . N0410. Medications Received . Anticoagulant Enter Days 7 . , indicating the resident received an anticoagulation medication for 7 days. On 3/06/19 at 5:24 PM, an interview was conducted with Employee Identifier (EI) # 4, [NAME][NAME] Licensed Practical Nurse, Clinical Leader. EI #4 was asked who was responsible for coding medications on the MDS. EI #4 replied, the Clinical Leaders, usually the one on the unit. EI #4 was asked who coded the quarterly MDS dated [DATE] for RI #23. EI #4 replied, she did, she was filling in for another Clinical Leader. EI #4 was asked if RI #23 was currently receiving an anticoagulation medication. EI #4 replied, no, she was receiving Eliquis which was discontinued on 10/4/18. EI #4 was asked to review the 11/30/18 quarterly MDS and then was asked if the anticoagulation medication was coded. EI #4 replied, yes. EI #4 was asked should the anticoagulation medication have been coded. EI #4 replied, no. EI #4 was asked why should it have not been coded. EI #4 replied, because it was discontinued on 10/4/18. EI #4 was asked if the 11/30/18 MDS would be an accurate assessment with the coding of anticoagulation medication. EI #4 replied, no. EI #4 was asked what was the risks of an inaccurate coding of an MDS assessment. EI #4 replied, it could send a red flag because it says the resident was receiving anticoagulation medication when they were not.

Based on observation, interviews, medical record review, and a review of Fundamentals of Nursing Ninth Edition, the facility failed to ensure the medication nurse did not leave medications on RI #140's bedside table while she went into the bathroom to wash her hands. While Employee Identifier (EI) #5 was in the bathroom, the resident administered nasal spray to self. This deficient practice affected 1 of four nurses observed during medication pass. Findings Include: A review of the Fundamentals of Nursing Ninth Edition Potter/Perry text page 657 Chapter 32- Medication Administration revealed: . l. Do not leave medications unattended. Nurse is responsible for safekeeping of drugs. RI #140 was admitted to the facility on [DATE]. On 3/6/19 at 8:11 AM, EI #5 was observed for medication administration. Among the medications prepared by EI #5 was (Fluicasone) [MEDICATION NAME] Nasal Spray. After EI #5 entered the room and set the medications down on the beside table, she then went into the bathroom and washed her hands. While she was in the bathroom RI #140 picked up the nasal spray and self-administered, then placed the spray back onto the bedside table. On 3/6/19 at 8:26 AM, EI #5 was interviewed. She was asked did she leave the room while meds were still in room. She replied yes she did, she went to wash her hands. EI #5 was asked what did this have issues for. EI #5 replied the resident could have taken more than he/she was suppose to.

Based on record review, interviews and the Centers for Medicare &(and) Medicaid Services, Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to accurately code Resident Identifier (RI) #93's 01/05/2018, Significant Change Minimum Data Set (MDS) Assessment for hospice. This affected one of eight sampled residents receiving hospice services. Findings Include: A review of the Centers for Medicare & Medicaid Services, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated (MONTH) (YEAR), revealed: .page O-4 . O0100K, Hospice care Code residents identified as being in a hospice program for terminally ill persons . RI #93 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #93's physician's orders [REDACTED]. On 02/15/18 at 2:50 p.m., during a review of RI #93's Significant Change in Status Assessment, with an ARD (Assessment Reference Date) of 01/05/18, the surveyor noted RI #93 was not coded for hospice. 02/15/18 at 4:04 p.m., an interview was conducted with Employee Identifier (EI) #5, MDS Coordinator. EI #5 was asked did RI #93 have an order for [REDACTED].#5 was asked when did hospice services begin for RI #93. EI #5 replied, (MONTH) 10, (YEAR). EI #5 was asked why was a significant change assessment done in (MONTH) (YEAR). EI #5 said RI #93 had a change in mood and decline in weight. When asked was RI #93 coded for hospice on the MDS with an ARD of 01/05/18, EI #5 replied no, he/she was not. When asked why RI #93 was not coded for hospice on the MDS with an ARD 01/05/18, EI #5 replied she did not know, because another nurse, EI #6, RN (Registered Nurse) MDS Coordinator, was responsible for coding the O section (the section for special treatments, procedures and programs). On 02/15/18 at 4:23 p.m., an interview was conducted with EI #6. EI #6 was asked who was responsible for completing the O Section of the MDS for RI #93. EI #6 replied the Clinical Coordinator for that section of the facility, the Dementia Unit. EI #6 was asked should RI #93 have been coded for hospice services on the Significant Change MDS dated [DATE]. EI #6 replied yes. EI #6 was asked why RI #93's Significant Change MDS with an ARD of 01/05/18 was not coded for hospice. EI #6 replied she did not know, she was helping the Clinical Coordinator on the Dementia Unit and she guessed, she just missed it. When asked why it was important to have the MDS coded accurately, EI #6 replied, the MDS was the picture of the resident and reflected the care and services they were receiving.

Based on observation, interview, record review, a review of Potter and Perry's FUNDAMENTALS OF NURSING, and a review of the facility's policies titled, Handwashing/Hand Hygiene and Handling and Storing Laboratory Specimens, the facility failed to ensure: 1. a licensed nurse did not return the Kleenex box and medication cup to the medication cart after being placed on Resident Identifier (RI) #83's uncleaned over bedside table, 2. a licensed nurse did not turn the water faucet off with bare hands during medication administration and 3. blood specimens were not stored in the refrigerator designated for medications. This had the potential to affect all residents receiving medications from the medication cart on the West Unit and residents receiving medications from the second floor medication refrigerator in the Rehabilitation Center. Findings Include: A review of Potter and Perry's, FUNDAMENTALS OF NURSING, Chapter 29, page 445, revealed: . Equipment used in the environment . often becomes a source for the transmission of pathogens. Modes of Transmission .Vehicles Contaminated Items . A review of the facility's policy titled, Handwashing/Hand Hygiene, with a revised dated of (MONTH) (YEAR), revealed: Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. Washing Hands . 3. Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel. RI #83 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/14/18 at 8:37 a.m., Employee Identifier (EI) #7, LPN (Licensed Practical Nurse) was observed during medication administration. EI #7 returned the Kleenex box and medication cup to the medication cart after being placed on the over RI #83's uncleaned bedside table. EI #7 turned the water faucet off with bare hands after washing her hands. An interview was conducted on 2/14/18 at 8:58 a.m. with EI #7. EI #7 was asked if the Kleenex box and the medication cup should have been returned to the medication cart after it had been place on RI #83's uncleaned bedside table. EI #7 replied, no. EI #7 was asked if the water faucet should be turned off with bare hands after washing her hands. EI#7 replied, not with bare hands, do it with a paper towel. EI #7 said she thought she did. EI #7 was asked what was the potential for harm. EI #7 replied, the spread of germs. A review of the facility's policy titled, Handling and Storing Laboratory Specimens, with an approved date of 01/01/10 revealed: . Policy: Laboratory specimens will be handled and stored in a manner that meets the standards of OSHA (Occupational Safety and Health Administration) and ensures the safety of employees and residents. 3. When necessary, lab specimens will be stored in a refrigerator designated and labeled only for biological specimens maintained at a temperature range of 35.6 degrees F (Fahrenheit) - 50 degrees F. On 2/15/18 at 4:44 p.m., the surveyor was accompanied by EI #8, LPN, to the second floor of the Rehabilitation Center medication room. A vial of blood was observed in the medication refrigerator, labeled with an unsampled resident's name on it. EI #8 explained that the third floor of the Rehabilitation Center had a refrigerator designated for laboratory specimens and that the vial of blood should not be in the medication refrigerator on the second floor.

Based on record review and interviews the facility failed to ensure RI (Resident Identifier) #3's pressure ulcer received treatment in a timely manner upon return to the facility. The facility further failed to ensure RI #3 was assessed in a timely manner. This affected RI #3, a sampled resident whose chart was reviewed for pressure ulcers. The facility also failed to ensure RI #12, an incontinent resident who was at risk for pressure ulcers, was checked for incontinence or changed in a timely manner. RI #12 was continuously observed from 8:00 AM to 11:00 AM on 10/21/2015 without being checked for incontinence or changed. This affected RI #12, one of eight sampled residents who were observed for checking for incontinence and changing. Findings Include: The facility had no policies or procedures pertaining to pressure ulcers. 1) RI #3 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #3's Significant change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 06/10/2015, revealed the resident had a Stage 3 pressure ulcer present upon admission. A review of RI #3's ADMISSION EVALUATION AND INTERIM CARE form with a date of 06/08/2015 revealed: .Unstageable pressure area to sacrum 6 cm (centimeters) x(by) 5.5 cm. A review of a facility document titled, (Name of Facility) NOTE DEPARTMENT OF MEDICINE . with a date of service on 06/01/2015, revealed: .PHYSICAL EXAMINATION . SKIN: Warm and dry. We have deferred exam of his/her sacrum until we can examine it with the nurse.PLAN: . The patient did have an unstageable ulcer on his/her buttocks. We will come back and evaluate that. A review of a facility document titled (Name of Facility) DEPARTMENT OF MEDICINE . with a date of service on 06/10/2015 revealed: .HISTORY OF PRESENT ILLNESS: .This wound was initially unstageable and closed. At some point it opened. The nurse supervisor evaluated the wound on June 8th and noted that at that point it was open. She noted that there was drainage that saturated the dressing. The wound bed still had some blackened areas. She measured it at 5.5 cm x 4.5 cm x 0.8 cm. She noted that there was a foul odor.ASSESSMENT: . 1. Sacral ulcer, likely Stage II to III. A review of a facility document titled INTERDISCIPLINARY NOTES revealed: 05/30/2015 at 12:50 Resident returned to facility via stretcher .Skin W/D (warm and dry) to touch . 05/31/2015 with no time documented .skin W/D to touch .dsg (dressing) on back side dry intact. 06/08/2015 3p .Drsg changed to sacral wound. Drainage saturated dressing. Wound bed still has some blackened areas noted in wound bed.Wound measurements 5.5 x 4.5 x 0.8 . 06/09/2015 9:20 pm Resident noted c (with) temp(temperature) 102.6.Dr. (doctor) notified about unpleasant smell & (and) appearance to residents wound (Bed sore) antibiotic started . A facility document titled TREATMENT RECORD with a date of 06/05/2015, 06/08/2015 and 06/09/2015 documented: CLEAN area to sacrum with NS (Normal Saline) dry, apply [MEDICATION NAME] gel/paste to area cover with [MEDICATION NAME] Q(every) 3 days PRN (as necessary) . A facility document titled WEEKLY PRESSURE ULCER QI (Quality Improvement) LOG dated 06/09/2015 revealed: .RI #3's . Site sacrum . Size (cm) L (Length) x W (Width) 11 x 10, Depth (cm) 5.0 . Odor: y (yes), Drainage: Lg (Large) . A review of RI #3's physician's orders [REDACTED]. Dry. Apply [MEDICATION NAME] gel/paste to area cover c [MEDICATION NAME] q 3 days . A review of RI #3's physician's orders [REDACTED]. Pro-stat 30 ml (milliliters) p.o. (by mouth) q day. 2. Juven 1 pk (pack) daily BID (twice daily). A review of RI #3's physician's orders [REDACTED]. A review of RI #3's physician's orders [REDACTED].gauze in santyl pack wound, cover with [MEDICATION NAME] . 4) [MEDICATION NAME] 1g (gram) IV (intravenous) daily x 2 days . A review of RI #3's physician's orders [REDACTED]. Admit to Alacare Hospice .Wound care for sacrum: cleanse with wound cleanser.Pack wound with 0.125% (percent) dakins solution moisten gauze. secure with paper tape. Wound care to be done daily and PRN soiling . (Name of Facility) staff to provide wound care when Hospice staff not present. A review of RI #3's MEDICATION RECORD revealed the [MEDICATION NAME] and [MEDICATION NAME] were documented as given per Physician order. A review of RI #3's care plan with a date of 06/21/2015 revealed: Problems/situation Potential for .pressure ulcers . Goal Resident will: no avoidable skin breakdown or pressure areas within next 90 days . On 10/22/2015 at 11:05 AM, a phone interview was conducted with EI (Employee Identifier) #9 LPN (Licensed Practical Nurse). EI #9 was asked did RI #3 have any skin issues. EI #9 said yes, this was the resident that came from the hospital with an area on the backside and lower part of the back. On 10/27/2015 at 3:48 PM, an interview was conducted with EI #11, CNA (Certified Nursing Assistant). EI #11 was asked did she remember RI #3. EI #11 said yes. EI #11 was asked what type of care did she provide to RI #3. EI #11 said pericare and basic hygiene care. EI #11 was asked to describe any skin issues she remembered. EI #11 said in June and July RI #3 had skin issues, discoloration of his/her feet. RI #3 went to the hospital and when RI #3 came back there was a fist size hole between the lower part of his/her back in the middle of the buttocks. EI #11 was asked to describe the fist size hole. EI #11 said it looked like dead skin and eventually they had to scrape it off. EI #11 said Hospice came and did the wound care and their nurses did too. EI #11 stated it never healed, it continued to spread. EI #11 was asked did she remember how RI #3's skin looked before going to the hospital. EI #11 said yes RI #3 had loose skin but no red areas or thin skin. On 10/28/2015 at 8:40 AM, a phone interview was conducted with EI #10 LPN. EI #10 was asked if she recalled RI #3. EI #10 said yes. EI #10 was asked was there any skin issues prior to RI #3 being discharged to the hospital on [DATE]. EI #10 said I can't remember if she had any pressure sores before she was discharged to the hospital. EI #10 was asked did she conduct skin assessments on RI #3 after his/her return to the nursing home. EI #10 said no, she did not conduct any skin assessments, but she sign off for any CNA's who would give the showers. On 10/28/2015 at 1:00 PM, an interview was conducted with EI #22 M.D. (Medical Doctor). EI #22 was asked did RI #3 have any pressure sores before discharge on 05/22/2015. EI #22 said not to her knowledge. EI #22 was asked when RI #3 was readmitted did she have any pressure sores. EI #22 said upon readmission the resident had a pressure sore. EI #22 was asked where was the pressure sore. EI #22 said the sacrum. EI #22 said she did not assess it on 06/01/2015. EI #22 further stated on 06/09/2015 RI #3 spiked a fever and that was when she did a further assessment. EI #22 was asked where was the pressure sore to the sacrum acquired. EI #22 said I believe at the hospital. On 10/29/2015 at 1:23 PM, a phone interview was conducted with EI #21 LPN, Charge Nurse. EI #21 was asked did she remember RI #3. EI #21 said yes ma'am. EI #21 was asked when did the wound develop. EI #21 said the end of May was when she saw it. EI #21 was asked where was the wound. EI #21 said on the sacrum. EI #21 was asked what did the wound look like. EI #21 said it was a big area she had to pack with Dakins. EI #21 said it was pinkish around the edges and pink on the inside with a small amount of slough. EI #21 was asked did the wound have an odor. EI #21 said sometimes most wounds will have an odor. EI #21 was asked what was the wound staged at. EI #21 said she did not know and she said the doctor and treatment nurse did the staging. On 10/29/2015 at 2:15 PM, an interview was conducted with EI #1 RN (Registered Nurse) DON (Director of Nursing). EI #1 was asked did she remember RI #3. EI #1 said yes. EI #1 said she was told RI #3 was readmitted with a unstageable pressure ulcer to the coccyx. EI #1 was asked what was RI #3's skin condition upon discharge to the hospital on [DATE]. EI #1 said there were no open areas that she was aware of. EI #1 was asked was she aware of the wound being infected. EI #1 said the doctor (EI #22) had discussed the wound with the interdisciplinary team but she did not remember the date. EI #1 was asked to review the WEEKLY PRESSURE ULCER QI LOG and compare those measurements to the measurements documented on the admission evaluation. EI #1 was asked why was the wound measuring much larger. EI #1 said the larger area was necrotic on the border of the wound and on the inside, the smaller area started opening from that area. EI #1 was asked if RI #3 was readmitted with a pressure, why was care not initiated or documented. EI #1 said the nurse failed to complete the admission assessment and failed to document wound care. On 10/29/2015 at 5:40 PM, a phone interview was conducted with EI #9, LPN. EI #9 was asked when she said RI #3 had an area to the backside what did she mean. EI #9 said RI #3 had a pressure sore on her sacrum. EI #9 was asked to describe what the pressure to RI #3's sacrum looked like. EI #9 said it was a hole, it had an odor and it was packed with some kind of gauze. EI #9 was asked how large was the area. EI #9 said it was bigger than a half dollar and it was big enough to stick her fingers in to get the dressing it was packed with. EI # 9 was asked how many fingers would she say. EI #9 said two fingers. EI #9 was asked when did she identify the area. EI #9 said the same day, 05/30/2015, the day the resident came in. EI #9 was asked did she treat the area on 05/30/2015. EI #9 said yes, she repacked it with a wet to dry dressing. EI #9 was asked where was it documented. EI #9 said it would be documented on the chart. EI #9 was asked if the dressing change was not documented, was it done. EI # 9 said yes it was done. EI #9 was asked was there a physician order [REDACTED].#9 said she could not put that soiled dressing back in there, the decubitus did have an odor. EI #9 was asked did she report the odor to anyone. EI #9 said yes, everybody could smell it. EI #9 was asked did she do a treatment note for changing the dressing. EI #9 said no I did not. On 10/30/2015 at 7:30 AM, an interview was conducted with EI #12, CNA. EI #12 was asked was she familiar with RI #3. EI #12 said yes. EI #12 was asked was she RI #3's CNA. EI #12 said yes. EI #12 was asked did she observe any skin issues before RI #3 was admitted to the hospital. EI #12 said no. EI #12 was asked did she observe any skin issues when RI #3 was readmitted to the facility. EI #12 said yes. EI #12 was asked to describe what she observed. EI #12 said the pressure sore was the size of a quarter on the sacrum, it did not have an odor at first but RI #3 had constant bowel movements and eventually the pressure started to have an odor. EI #12 was asked did she report the odor to a nurse. EI #12 said yes. EI #12 was asked who did she report it to. EI #12 said she thought it was EI #10 LPN. On 10/30/2015 at 8:45 AM, an interview was conducted with EI #8. EI #8 was asked upon RI #3's readmission on 05/30/2015 if the resident had a pressure ulcer. EI #8 said she did not see the wound until 06/08/2015. EI #8 was asked what did the wound look like. EI #8 said the wound had a film over it on 06/08/2015 and that was the first time she looked at it. EI #8 said the documentation that was done on the WEEKLY PRESSURE ULCER QI LOG was done by her. EI #8 was asked was the wound larger from 06/08/2015 to 06/09/2015. EI #8 said yes. EI #8 was asked to describe what the wound looked like on 06/09/2015. EI #8 said it had slough and still had a film over it. EI #8 further stated they had applied Medi-Honey on 06/08/2015 and it had started [MEDICATION NAME] the wound. There was no odor at that time. On 10/30/2015 at 9:10 AM, an interview was conducted with EI #23 LPN Unit Manager/Wound Consultant. EI #23 was shown the physician's orders [REDACTED]. EI #23 was asked was that her signature. EI #23 said yes and she assessed the wound that same day. EI #23 was asked to describe what the wound looked like. EI #23 said she remembered slough and no odor. EI #23 said she applied a [MEDICATION NAME] and [MEDICATION NAME] to the wound and it was smaller than the [MEDICATION NAME]. EI #23 was asked what size was the [MEDICATION NAME] that was applied. EI #23 said it was 4x4. EI #23 was asked was the pressure ulcer acquired in the facility. EI #23 said no. EI #23 was asked when was the first treatment done on the wound. EI #23 said according to documentation the treatment was done on 06/05/2015. EI #23 was asked should the wound have been treated before 06/05/2015. EI #23 said yes. On 10/30/2015 at 9:50 AM, an interview was conducted with EI #1. EI #1 was asked if there was any treatment done to RI #3's wound from 05/30/2015 until 06/05/2015. EI #1 said the documentation did not reflect any treatment done until 06/05/2015. EI #1 was asked why was no treatment done from 05/30/2015 to 06/05/2015. EI #1 said the documentation did not reflect treatment was done until 06/05/2015. EI #1 was asked if the pressure ulcer was avoidable. EI #1 said no. EI #1 was asked why was it not avoidable. EI #1 said RI #3 was nutritionally compromised. This deficiency was cited as a result of the investigation of complaint/report #AL 539. A review of a facility policy titled, Resident Rounds with a date of 12/07/2012 revealed: Policy: A. The nursing staff will complete resident rounds every two hours to ensure resident needs are met . 2) RI #12 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #12's most recent Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 9/05/2015 revealed the resident had severely impaired cognitive skills for daily decision making. The MDS further revealed the resident required extensive assistance from staff for toilet use and personal hygiene. The MDS also revealed the resident was always incontinent of bowel and bladder. The MDS also revealed the resident was at risk of developing pressure ulcers. On 10/21/2015 from 8:00 AM to 11:00 AM, RI #12 was continuously observed by the surveyor without being checked for incontinence or changed. On 10/21/15 at 11:00 AM, when RI #12's brief was removed by EI(Employee Identifier) #17, Hospice CNA (Certified Nursing Assistant), it was observed to have been saturated with urine and the resident had redness present to both sides of the buttocks. On 10/22/15 at 10:19 AM, an interview was conducted with EI #16, CNA. EI #16 was asked if he was assigned to RI #12 on 10/21/2015. EI #16 said he was. EI #16 was asked if RI #12 was incontinent of bowel and bladder. EI #16 said at one time the resident was not, but now the resident was frequently incontinent. EI #16 was asked how often RI #12 was supposed to be checked for incontinence and changed. EI #16 said, Every two hours. EI #16 was asked why the resident was not checked for incontinence or changed from 8:00 AM to 11:00 AM. EI #16 said,I really have no reason. EI #16 was asked if he checked RI #12 for incontinence or changed the resident within a two hour period from 8:00 AM to 11:00 AM on 10/21/2015. EI #16 replied, No. EI #16 was asked to describe RI #12's brief when EI #17 removed the brief in the shower room. EI #16 said, It was soiled with urine. EI #16 was asked what was the potential harm when an incontinent resident who was at risk of pressure ulcers was not checked for incontinence or changed for three hours. EI #16 said, Skin breakdown, agitation, irritability; it could be a potential for UTI (Urinary Tract Infection). On 10/22/15 at 10:43 AM, an interview was conducted with EI #14, RN (Registered Nurse)/Unit Manager 2 North. EI #14 was asked how often should an incontinent resident be checked for incontinence or changed. EI #14 said, Every two hours and as needed. Sometimes if they are a heavy wetter, we encourage them to check hourly. EI #14 was asked if RI #12 was incontinent. EI #14 said, Yes, always, both bowel and bladder. EI #14 was asked if RI #12 was at risk for pressure ulcers. EI #14 said, Absolutely yes. EI #14 was asked if she could tell the surveyor why RI #12 was not checked or changed from 8:00 AM to 11:00 AM on 10/21/2015. EI #14 said, The CNA should have checked him, it's a protocol they should follow, everyone should be checked every two hours and as needed. EI #14 was asked if it was an acceptable practice of that facility for an incontinent resident who was at risk of pressure ulcers not to be checked for incontinence or changed for three hours. EI #14 said, No, they have to be checked at least every two hours. EI #14 was asked what was the potential harm if an incontinent resident who was at risk of pressure ulcers was not checked for incontinence or changed for three hours. EI #14 said, They could have a recurrence of UTI and redness on the bottom. That redness could escalate to open skin. They need to be kept dry at all times to prevent pressure ulcers. This deficiency was cited as a result of the investigation of complaint/report #AL 435.

Based on interviews and record reviews, the facility failed to ensure Resident Identifier (RI) #1 was provided supervision on 02/16/13. On 02/16/13 during the 3:00 PM to 11:00 PM shift, Employee Identifier (EI) #1, a Certified Nursing Assistant (CNA) was sitting in RI #1's room because the resident was agitated and was observed scooting to the end of the bed and trying to get out of bed. When the CNA (EI #1) left RI #1's room to go on break, she informed the Licensed Practical Nurse (LPN)/Charge Nurse (EI #2), who failed to monitor and/or supervise RI #1 in the CNA's absence. When EI #1 returned from break, she found RI #1 on the floor. RI #1 complained of left leg pain; an x-ray was completed which revealed a fractured left femur. This deficient practice affected RI #1, one of three residents sampled for falls. Findings include: Resident Identifier (RI) #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1's MDS (Minimum Data Set) Significant Change in Status Assessment, with an assessment reference date of 01/30/2013, identified RI #1 as severely impaired in her cognitive skills for daily decision making and with short and long term memory problems. RI #1 was assessed as being totally dependent on staff for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, personal hygiene and bathing. The resident was also at risk for falls. According to RI #1's "Incident/Accident Report" completed by Employee Identifier (EI) #2, a Licensed Practical Nurse (LPN), documented on 02/16/13 at 7:45 PM, " ... CNA (Certified Nursing Assistant) called me (EI #2) to resident (RI #1) room upon entering found resident sitting on the floor by her bed 'states' I fell out of my bed.' Complains of pain Left Leg. ..." The report also documented the resident's condition before the accident/incident as "confused". A review of RI #1's Interdisciplinary Notes dated 2/16/13, documented, " 7:45 PM Upon entering resident room, resident sitting on the floor next to her bed. She stated, 'I fell out of bed my bed.'...Complaining of pain on left lower extremity." On 02/16/13, the resident's left tibia/fibula (lower leg), pelvis and femur (thigh bone) were x-rayed. The report results indicated a fracture involving the neck of the left femur with displacement. RI #1's "Interdisciplinary Notes" dated 02/17/13 8:00 AM documented, " ... c/o (complained of) pain in lower legs & feet. Night nurse reported giving PRN (as needed) pain med (medication) @ (at) 2AM & 6AM. Resident stated, "I'm hurting ... ." On 03/20/13 at 4:30 PM, the surveyor conducted an interview with EI #3, a CNA working on 02/16/13 on the 3:00 PM to 11:00 PM shift. According to EI #3, EI #1 was assigned to care for RI #1. EI #3 stated EI #1 was sitting with RI #1 in her room because RI #1 was restless. EI #3 stated EI #1 left RI #1's room for something and when she returned to the room she screamed out and said RI #1 had fallen. EI #3 stated when she got to RI #1's room she observed RI #1 on the floor at the end of the bed. On 03/20/13 at 6:15 PM, the surveyor conducted an interview with EI #1, the CNA assigned to RI #1 on 02/16/13. EI #1 stated after she checked on her other residents, she noticed RI #1 was trying to get out of bed, scooting to the end of the bed and agitated. When asked why EI #1 was sitting in the room with RI #1, she stated because RI #1 kept trying to get out of bed. EI #1 then stated she left RI #1's room to go on break and when she returned from break she observed the call light for RI #1's room on and when she entered the room she saw RI #1 on the floor. EI #1 was asked did she report to anyone that she was going on break and she said she told the Charge Nurse, EI #2. On 03/21/13 at 9:05 AM, the surveyor conducted an interview with EI #2, the LPN/Charge Nurse assigned to care for RI #1 on 02/16/13. EI #2 stated RI #1 had been confused and EI #1 (CNA) had been in RI #1's room watching her. EI #2 stated EI #1 left RI #1's room around 7:30 PM. EI #2 stated when EI #1 returned to RI #1's room around 7:45 PM, RI #1 was on the floor. EI #2 acknowledged she was aware that EI #1 had left RI #1's room. The surveyor asked EI #2 did she check on RI #1 while EI #1 was out of the room. EI #2 stated no and explained that she was in the middle of something. On 03/21/13 at 4:40 PM, the surveyor conducted an interview with EI #5, the Director of Nursing (DON). The surveyor asked EI #5, since RI #1 was agitated on 02/16/13 on the 3:00 PM to 11:00 PM shift, what would she have expected her staff to do when RI #1 was trying to get out of bed. EI #5 stated she would have expected her staff to assess the resident for pain, offer to get RI #1 up in a Geri-chair and take her to the common area or check the physician's orders [REDACTED].#1's agitation. This deficiency was cited as a result of the investigation of complaint/report number AL 604.

Based on observations, interviews, and record reviews, the facility failed to ensure Resident Identifier (RI) #5 was adequately supervised on 11/30/12 when she was in a rock-n-go chair. RI #5 sustained a fall that resulted in a laceration to her forehead, which required emergency medical treatment. The facility further failed to ensure the proper lift was used when transferring RI #3 and failed to ensure RI #9's floor mat was in place as care planned. These deficient practices affected RI #3, RI #5 and RI #9, three of 10 residents reviewed for falls. Findings include: 1) RI #5 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #5's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 08/31/12, identified RI #5 as having a BIMS (Brief Interview for Mental Status) score of 3, indicating RI #5 had severely impaired cognition. RI #5 was assessed as needing total assistance with all ADL's (Activities of Daily Living) with the assistance of one. RI #5's balance during transitions and walking was coded as not steady, only able to stabilize with staff assistance with moving from seated to standing position, moving on and off toilet and with surface-to-surface transfers. RI #5's functional limitation in range of motion was coded as having impairment on both sides to her lower extremities. RI #5 was coded as having one fall with injury (except major) during this assessment period. RI #5's fall care plan documents: "Date 9-28-12, PROBLEM/CONCERN Resident is very high risk to fall (secondary to) her impaired mobility, impaired cognition, restlessness and HX (history) of falls w (with)/ DX (diagnosis) of advanced Dementia ... Had an Actual fall on 9-27-12 @ (at) 4:55 pm She was found on the floor mat besides her bed. No injury. 10-15-12 Resident was found on the floor next to bed. No injury. 10-16-12 Resident found on the floor next to bed. No injury noted. 10-30-12 Resident was found on the mat next to bed c (with) her head and shoulder touching the floor. Neuro checks started ... 11-13-12 Resident was found on blue mat beside low bed ... 11-30-12 Resident was found in the floor in front of Rock N Go sustained skin tear/laceration on top of forehead sent to hospital for suturing. Approaches: ... (9) When out of bed to Rock N Go Keep Res (Resident) in an area visible to everybody (added 11-14-12) ... Check chair alarm for proper placement lock Rock N Go's wheel when not moving around (added 11-30-12) ..." INTERDISCIPLINARY NOTES for RI #5 documents: "10/31/13 3 pm Pt (patient) in Geri chair, yelling out. Attempting to get out of Geri chair, requiring constant monitoring by staff ... Hematoma remains on Lt (left) forehead. Neuro (checks) in progress. 11-30-12 4:30 p Called to DR (Dining Room) per (by) (name of EI #25, House Supervisor) - who found Resident lying on floor on her right side c Blood noted around her head. Cleaned area to find laceration to Forehead - Stopped bleeding. 911 called. Resident moaning - could not tell where her pain was ... 11-30-14 4:45 p Ambulance here to transfer Resident to (name of hospital) for sutures to forehead and eval (evaluation for possible other injuries." Emergency Department notes for RI #5 from (name of hospital RI #5 transferred to) dated 11/30/12 at 18:35 (6:35 PM) documents: "... History of Present Illness Pt (Patient is a 87 yowf (year old white female) with a hx of progressive dementia who presents after falling out of her wheelchair at the nursing home ... Pt is non ambulatory ... Physical Examination ... Head: ... pt has a 0.5 inch linear laceration to the forehead ... Medical Decision Making ... Rationale: ... Pt laceration was closed at bedside ... Procedure Laceration Repair: Location: forehead... Length: 3 cm (centimeters) ... Layers: SINGLE-LAYER closure. Description of Closure: The wound was closed using a 5-0 fast absorbing gut ... Medical Emergency: Yes ... COMPUTER TOMOGRAPHY ... Indication: Closed head injury ..." An INTERDISCIPLINARY NOTE for RI #5 documents: 11-30-12 10 p Returned to (name of Nursing Home). Awake - Has sutures in Forehead ..." On 12/06/12 at 7:33 AM, the surveyor conducted an interview with EI #25, the RN (Registered Nurse) supervisor working on 11/30/12. The surveyor asked EI #25 what happened to RI #5 on 11/30/12. EI #25 stated she didn't see the occurrence. EI #25 stated when she went to the bathroom to wash her hands there were a few residents in the dining room and EI #24 (a CNA) was in the dining room with the residents. EI #25 stated when she came out of the bathroom she heard RI #5 say 'somebody help me.' EI #25 stated she looked down and RI #5 was on the floor bleeding from her forehead. EI #25 stated RI #5 had fallen from her Rock N Go chair. EI #25 stated RI #5 tries to stand up all the time but she couldn't. EI #25 stated as a result of RI #5 falling she sustained a laceration to her forehead. EI #25 stated RI #5 was sent out of the facility to get the laceration sutured. The surveyor asked EI #25 who was assigned to care for RI #5 at the time. EI # 25 stated EI #24 (a CNA). EI #25 stated someone (a staff member) was assigned to be in the dining room but she did not know who that would have been. The surveyor asked EI #25 did RI #5 require supervision. EI #25 stated yes. EI #25 stated it would have been the responsibility of the CNA to provide supervision to RI #25 while she was in the dining room. On 12/06/12 at 4:35 PM, the surveyor conducted an interview with EI #24, a CNA. The surveyor asked EI #24 what RI #5 was doing at the time of her fall. EI #24 stated RI #5 was in her chair in the dining room on 11/30/12. EI #24 stated there were about eight other residents in the dining room. EI #24 stated the call lights started going off so she left to answer one of them. EI #24 stated she didn't know who was the last person (staff) in the dining room but she was gone about 10-15 minutes. EI #24 stated when she got back to the dining room she heard RI #5 hollering for help. EI #24 stated she observed RI #5 on the floor with her head face down and she was bleeding. EI #24 stated there wasn't any staff in the dining room when she got back. The surveyor asked EI #24 did RI #5 require supervision. EI #24 stated yes. EI #24 stated RI #5 has had a lot of falls and she was a fall risk. On 12/06/12 at 6:50 PM, the surveyor conducted an interview with EI #5, the facility's DON (Director Of Nursing). The surveyor asked EI #5 what had the facility done to prevent a reoccurrence of RI #5 falling out of her Rock N Go chair. EI #5 stated nothing that she was aware of. The surveyor asked EI #5 had the facility conducted inservices with staff on fall preventive measures since RI #5's fall on 11/30/12. EI #5 stated staff had not been inserviced since RI #5's fall. EI #5 stated she was not sure if staff had increased their frequency in monitoring RI #5 either. The surveyor asked EI #5 was RI #5 supervised by staff on 11/30/12. EI #5 stated she could not answer that question. The surveyor asked EI #5 did RI #5 require supervision. EI #5 said, "Yes she does." 2) RI #3 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #3's most recent Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/16/12 was reviewed. RI #3 was assessed as having long and short term memory problems with severe impairment for daily decision making. Section J 1900-B indicated RI #3 had 2 falls with injuries (except major) since admission or prior assessment. An interview was conducted with Employee Identifier (EI) #15, Unit Manager for B wing on 12/05/12 at 3:05 PM. The surveyor asked EI #15 if she was aware of the fall for RI #3 on 10/15/12 and 10/18/12. EI #15 said she was not aware of the fall for RI #3 on 10/15/12 but that she was aware of RI #3's fall on 11/18/12. EI #15 was asked what type of lift was documented in RI #3's care plan, to be used for transfers, at the time of RI #3's fall on 11/18/12. EI #15 said, the Marissa lift and not the stand up lift. The surveyor asked EI #15 why was the stand up lift used instead of the Marissa Lift. EI #15 stated, the Certified Nursing Assistant (CNA) said she did not know that she was suppose to use the Marissa Lift for RI #3 when transferring. EI #15 was asked if RI #3 was a one or two person assist with transfers. EI #15 stated, two person. She was asked if two people assisted with RI #3's transfer during his fall on 11/18/12. EI #15 stated, "It does not appear to have been two people according to the report." The surveyor asked EI #15 what was the facility's policy regarding use of mechanical lifts. EI #15 said there should always be two people assisting with the transfer. During an interview with EI #11, CNA on 12/6/12 at 8:40 AM, the surveyor asked EI #11 if she provided assistance with a transfer for RI #3 on 11/18/12. She stated she did. EI #11 was asked who assisted her with the transfer for RI #3. The CNA said no one. She was asked how did she know how to provide care for RI #3. EI #11 said she should look at the care guide/resident status sheet. The surveyor asked EI #11 how many people are required to provide transfer assistance for RI #3. She said two people with the Marissa Lift. She was asked if she used RI #3's care guide on 11/18/12 when he had a fall. EI #11 replied, "No ma'am." She was asked why not. She said because she thought he, (RI #3) could stand up with the stand up lift and that she made a mistake. The surveyor asked EI #11 if she received any inservice after the incident with RI #3's fall. She said she did not. 3) Resident Identifier(RI) #9 was readmitted to the facility on 04/04/2012, with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date of 04/11/2012, revealed RI #9's cognitive skills were severely impaired with short and long term memory problems. The MDS indicated RI #9 was totally dependent on staff for bed mobility, transfer, dressing, eating, toileting and personal hygiene. The MDS further indicated that RI #9 was at risk for falls. A review of RI #9's "CARE PLAN - FALLS" dated 11/5/12 revealed: "At Risk for Falls ... Approach ... low bed (with) mat" hand written on the care plan. On 12/04/12 at 4:00 PM, 12/05/12 at 12:00 PM, and 12/06/12 at 8:00 AM, no floor mat was observed at RI #9's bed side. An interview was conducted with EI #5, Registered Nurse (RN), Director of Nurses on 12/06/2012 at 3:15 PM. EI #5 was asked if RI #9 had a low bed with mat and she replied no, not at this time. An interview was conducted with EI #6, RN, Unit Manager, on 12/06/2012 at 6:00 PM. EI #6 stated when RI #9 fell on [DATE] she added a low bed with a mat. EI #6 said that she did put the mat in place and that it should still be used. EI #6 was asked if a mat had been used at RI #9's bed side in the last three days and she replied no, but she said it should have been.