Every finding on record at Florence Nursing and Rehabilitation CTR, LLC

Based on observation, interviews, and review of Resident Identifier (RI) #3's medical record, the facility failed to ensure Employee Identifier (EI) #5, the Licensed Practical Nurse (LPN) Treatment Nurse did not place wound supplies on the resident's mattress without a barrier; did not wipe drainage from below the wound bed back into the wound bed; and change gloves after cleaning RI #3's wound before applying a clean dressing. These deficient practices affected RI #3, one of one resident observed for wound care. Findings include: RI #3 was admitted to the facility on [DATE]. RI #3's physician order [REDACTED]. During wound care observation on 9/16/2020 at 10:19 AM, EI #5, the LPN Treatment Nurse placed 4x4s and a bordered dressing on RI #3's mattress without a barrier. EI #5 was observed to wipe bloody drainage from below RI #3's wound bed with a moistened 4x4 back into the wound bed. While still wearing the same gloves worn to clean RI #3's wound, EI #5 placed the aquacle and bordered dressing on RI #3's wound, without changing her gloves. In an interview on 9/16/2020 at 10:43 AM, EI #5, the LPN Treatment Nurse was asked when she should wash or sanitize her hands during wound care. EI #5 replied, when she removed the dirty dressing, she should remove her gloves wash her hands and put new gloves on. When asked how the resident's wound should be cleaned, EI #5 stated counter clock wise one time. When asked should she clean drainage from below the wound bed upward into the wound bed, EI #5 said no. When asked why not, EI #5 replied, because it would contaminate the wound and cause infection. EI #5 was asked did she clean bloody drainage from the below RI #3's wound into the wound bed. EI #5 answered yes. EI #5 was asked should she place wound supplies on the resident's mattress and she said no. When asked if she placed RI #3's wound supplies on the resident's mattress, EI #5 said yes. During an interview on 9/17/2020 at 8:45 PM, EI #3, the Infection Control Preventionist was asked when should a nurse change gloves and wash her hands during wound care. EI #3 replied, anytime going from a dirty to a clean area or getting anything else like supplies. When asked should a nurse wipe drainage from below the wound bed back into the wound bed when cleaning the wound, EI #3 answered no. EI #3 was asked should a nurse change gloves after cleaning a wound before applying a clean dressing. EI #3 replied, yes. When asked should a nurse place supplies for wound care on a mattress without a barrier, EI #3 answered no. When asked what the concern was with these things, EI #3 replied infection in the wound that could cause the wound to worsen.

Based on observation, interviews, and review of FUNDAMENTALS OF NURSING NINTH EDITION, the facility failed to ensure Employee Identifier (EI) #4, a Registered Nurse (RN): 1) did not pick up a pill with her bare hands and administer to Resident Identifier (RI) #2; 2) washed or sanitized her hands before she put gloves on to place a topical medication on RI #2's bilateral knees; 3) removed her gloves and sanitized her hands before she picked up RI #2's throw (blanket) and placed on the resident's knees; and 4) sanitized (cleaned) the pulse oximeter before and after use. These deficient practices affected RI #2, one of one resident observed for medication administration. Findings include: Page 445 of Chapter 29 titled Infection Prevention and Control of FUNDAMENTALS OF NURSING NINTH EDITION documented . Modes of Transmission . The major route of transmission of pathogens identified in the health care setting is the unwashed hands of the health care worker. Equipment used within the environment often becomes a source for the transmission of pathogens . Page 458 of Unit V Foundations for Nursing Practice of FUNDAMENTALS OF NURSING NINTH EDITION documented . Hand Hygiene. The most effective basic technique in preventing and controlling the transmission of infection is hand hygiene . The use of alcohol-based hand hygiene practices, protect health care workers hands, and reduce the transmission of pathogens to patients and personnel in health care settings . During medication pass observation on 9/16/2020 at 9:41 AM, EI #4, a RN opened and poured RI #2's by mouth medications into a cup. One of the pills dropped onto the medication cart and EI #4 picked up the pill with her bare hands and placed it back into the medication cup and administered it to RI #2. After EI #4 administered RI #2's inhaler and by mouth medications, EI #4 put gloves on, without washing or sanitizing her hands, and placed topical gel on RI #2's bilateral knees. While wearing the same gloves that had residue from the topical gel, EI #4 picked up RI #2's throw (blanket) and placed it over the resident's knees. Also noted, EI #4 removed from the medication cart to pulse oximeter to check RI #2's oxygen saturation. EI #4 did not clean the pulse oximeter before use. After RI #2's oxygen saturation was checked, EI #4 placed the pulse oximeter back into the medication cart without cleaning it. In an interview on 9/16/2020 at 3:11 PM, EI #4, a RN acknowledged she should wash or sanitize her hands when she removes gloves, before she put another pair of gloves on and in between residents. When asked what the concern was with handling PO (by mouth) medications with bare hands, EI #4 said contamination. EI #4 was asked if she picked up a pill from the top of medication cart and placed it in RI #2's cup of medications with her hands for administration. EI #4 replied, she did. When asked should she have, EI #4 said no. When asked why not, EI #4 replied obviously it's a contamination issue. EI #4 was asked what she should do with her gloves after administration of topical medications. EI #4 answered, remove the gloves and wash my hands. When asked if she removed her gloves and washed her hands after she applied topical gel on RI #2's bilateral knees before she picked up a throw and placed on the resident's knees, EI #4 replied, she did not. EI #4 was asked what the concern was with placing a resident's throw on their legs while wearing gloves used to administer topical medication. EI #4 stated, there might be some residue on the glove and it would get on the throw and the resident may put it somewhere it doesn't need to be and it's unsanitary. EI #4 acknowledged the pulse oximeter should be sanitized (cleaned) before and after use. When asked if she sanitized the pulse oximeter before and after use when she assessed RI #2's oxygen saturation, EI #4 said she did not. On 9/17/2020 at 8:45 PM, an interview was conducted with EI #3, the Infection Control Preventionist. EI #3 was asked should a nurse pick up a pill from the top of the medication cart with her hand hands and administer the pill to the resident. EI #3 said, absolutely not. When asked should a nurse wear gloves used for administration of topical gel to pick up a resident's throw and place it on their knees, EI #3 replied, no. EI #3 acknowledged the pulse oximeter should be cleaned before and after use.

Based on observations, interview, review of a facility policy titled, Labeling and Dating Foods (Date Marking), Cleaning Instructions: Ice Machine and Equipment, Cleaning Instructions: Slicer, and review of the (YEAR) U.S. (United States) Public Health Service Food Code, the facility failed to ensure: 1. outdated food was not stored in the walk-in cooler; 2. the ice machine was clean and free of a build-up of black substance; and 3. the meat slicer was clean and free from food particles between uses. These failures had the potential to affect 135 of 135 residents who received meals from the kitchen. Findings Include: 1)The facility policy titled, Labeling and Dating Foods (Date Marking), dated (YEAR), . Prepared food or opened food items should be discarded when: The food item is leftover for more than 3 days . A record review of the (YEAR) Food Codeby United State Public Health Service (USPHS), and the Food and Drug Administration (FDA) included the following: 3-501-17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (B) .(G) of this section, refrigerated, READY-TO-EAT-TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and packaged by a FOOD PR[NAME]ESSING PLANT shall be clearly marked (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use by-by date on FOOD SAFETY. A review of the (YEAR) U.S. Public Health Service Food Code revealed: . 3-5 LIMITATION OF GROWTH OF ORGANISMS OF PUBLIC HEALTH CONCERN . 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . (B) . FOOD prepared and PACKAGED by a FOOD PR[NAME]ESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES . On 01/12/20 at 12:17 p.m., the surveyor and Employee Identifier (EI) #4, Dietary Cook, observed the following food items in the walk-in-cooler: - four heads of cabbage with black leaves on the outer layer with a discard date of 12/25/19 and - prepared fruit cobbler covered and labeled with a discard date of 1/10/20. On 01/12/20 at 12:17 a.m., an interview was conducted with EI #4, the Dietary Cook. EI #4 was asked what was the discard date on the four heads of cabbage. EI #4 stated 12/25/19. EI #4 was asked what was the discard date on the prepared fruit cobbler. EI #4 stated 01/10/20. EI #4 was then asked should these out dated food items be in the walk-in cooler. EI #4 stated no. EI #4 was then asked what was the potential harm in having outdated food items in the walk in cooler. EI #4 stated it could possibly be served to the resident and make someone ill. On 01/14/20 at 10:42 a.m., an interview was conducted with Employee Identifier (EI) #5, Certified Dietary Manager (CDM). Surveyor went over the items observed on 1/12/20 by surveyor and cook in the walk in cooler with the CDM: - four heads of cabbage with black leaves on the outer layer with a discard date of 12/25/19 and - prepared fruit cobbler covered and labeled with a discard date of 1/10/20. EI #5 was asked should these food items be in the walk in cooler. EI #5 stated no; they should have been discarded. EI #5 was asked what was the potential harm in having these items in the walk in cooler. EI #5 stated if it had been used it could have caused a resident to become sick. 2) A review of the facility policy titled Cleaning Instructions: Ice Machine and Equipment, dated (YEAR), documented: Guideline: Ice machine and equipment will be kept clean . 3. Wash inside . On 01/12/20 at 12:55 p.m., during the initial kitchen tour, the surveyor and EI #5, CDM, observed the inside of the ice machine. A black substance inside the top right side of the ice machine was observed. The surveyor observed EI #5 use her bare hand to wipe black substance off the ice machine. EI #5 was asked what was the black substance on the ice machine. EI #5 stated it may be dirt. EI #5 was asked do you serve ice out of the machine to the residents. EI #5 stated yes. EI #5 was then asked what was the potential harm of the black substance being inside the ice machine. EI #5 stated it could get into the ice and be served to the resident. 3) A review of the facility policy titled Cleaning Instructions: Slicer, dated (YEAR), documented: Guideline: Slicer will be cleaned and sanitized after each use . On 01/12/20 at 01:01 p.m., during the initial kitchen tour, the surveyor and EI #5, CDM, observed the meat slicer covered with a plastic wrap. Surveyor asked EI #5 if the meat slicer was clean. EI #5 stated yes. The Surveyor then asked EI #5 to remove the plastic wrap covering. Surveyor and EI #5 observed a food particle (a piece of meat) on the slicer near the blade and food debris on the top inner side of meat slicer. Surveyor pointed to the item/substance on the meat slicer and asked EI #5 what it looked like. EI #5 stated it was a piece of meat. EI # 5 was then asked should the piece of meat be there. EI #5 stated no. EI #5 was then asked if the meat slicer was clean. EI #5 stated no. EI #5 was asked what was the potential harm in the piece of meat being left there and the meat slicer not being cleaned properly. EI #5 stated it could make someone sick. EI #5 was asked what was your policy regarding cleaning and sanitizing the meat slicer. EI #5 stated the policy was to clean and sanitize after each use.

Based on observation, interviews, medical review, and a facility document titled Hand Hygiene in Healthcare Settings, the facility failed to ensure: 1. a Licensed Practical Nurse (LPN), Employee Identifier (EI) #1, washed or sanitized her hands after she gave Resident Identifier (RI) #87's oral medication, and prior to administering (RI) #87's eye drop medication, and 2. a Registered Nurse (RN), EI #2, did not wash or sanitize her hands after she removed her gloves from giving RI #110's oral medications, and prior to opening RI #110's door, and placing RI #110's inhalation medications in the medication cart drawer. This affected two of six residents observed during medication pass and two of six nurses observed during medication pass. Findings Include: A review of a facility document titled Hand Hygiene in Healthcare Settings, with last reviewed date of 4/29/2019, revealed . When to Perform Hand Hygiene . After touching a patient or a patient's immediate environment . Immediately after glove removal . 1. RI #87 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 01/13/2020 at 8:40 a.m., the surveyor observed EI #1, a LPN, during the medication administration pass. EI #1 gave RI #87's oral medications with her gloved hands. EI #1 did not remove her gloves and wash or sanitize her hands, prior to administering an eye drop medication to RI #87's right and left eye. On 01/13/2020 at 2:39 p.m., an interview was conducted with EI #1, LPN. EI #1 was asked what did you do after you gave RI #87's oral medications with your gloved hands during the medication pass. EI #1 stated she administered RI #87's eye drop medication with the same gloves and did not wash or sanitize her hands prior to giving RI #87 the eye drop medications, but she should have. EI #1 was asked what would be the concern in not washing or sanitizing your hands after you gave RI #87's oral medication with both gloved hands, and prior to administered RI #87's eye drop medication. EI #1 stated this could cause an infection to the residents. On 01/13/2020 at 5:43 p.m., an interview was conducted with EI #3, Infection Control Preventionist, Registered Nurse. EI #3 was asked what would be the concern if a licensed nurse did not wash or sanitize her hands after she gave RI #87's oral medication with both gloved hands, and prior to administering RI #87's eye drop medication. EI #3 stated there could be bacteria on the licensed nurse's gloves or her hands. EI #3 stated this could have transferred germs to RI #87 and could cause an infection to RI #87. 2. RI #110 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 01/13/2020 at 9:00 a.m., the surveyor observed EI #2, RN, during medication administration pass. EI #2 removed her gloves after she administered RI #110's inhalation, nasal, and oral medications. EI #2 did not wash or sanitize her hands prior to leaving RI #110's room. EI #2 left RI #110's room, closed the door with both ungloved hands, opened the medication cart drawer with both ungloved hands, and placed RI #87's inhalation and nasal medication in the medication drawer. On 01/13/2020 at 2:15 p.m., an interview was conducted with EI #2, RN. EI #2 was asked what did you do after you gave RI #110's oral medications and removed your gloves. EI #2 stated she opened RI #110's door without washing or using hand sanitizer before leaving RI #110's room. EI #2 stated she went to the medication cart, opened the drawer to the medication cart, and placed RI #110's inhalation medication in the drawer. EI #2 stated she signed out RI #110's medication that was given on the computer using the keyboard with her ungloved hands. EI #2 was asked what she should have done after she gave RI #110's oral medications, prior to leaving the room. EI #2 stated she should have washed or sanitized her hands before she left RI #110's room. EI #2 was asked what would be the concern in not washing or sanitizing your hands after you removed your gloves from giving RI #110's oral medications and prior to opening RI #110's door and placing RI #110's inhalation medications in the medication cart drawer. EI #2 stated it could cause cross contamination between residents. EI #2 stated this could cause an infection to a resident. On 01/13/2020 at 5:43 p.m., an interview was conducted with EI #3, Infection Control Preventionist, RN. EI #3 was asked what would be the concern if a licensed nurse did not wash or sanitize her hands after she removed her gloves from giving RI #110's oral medications, and prior to opening RI #110's door, and placing RI #110's inhalation medications in the medication cart drawer. EI #3 stated if the licensed nursed picked up any bacteria from RI #87's room, this could have transferred germs to the medication cart. EI #3 stated this could cause an infection to other residents.

Based on observations, interviews, and review of a facility policy titled, Labeling and Dating Foods, the facility failed to ensure: 1. no outdated hot dog buns were on open shelving in the facility kitchen; 2. no outdated lettuce and sweet and sour sauce were stored in kitchen walk-in cooler and 3. no outdated bacon bits were stored in a facility unit nourishment room refrigerator. These failures had the potential to affect 127 of 127 residents receiving meals from dietary and one of one unit refrigerator observed with outdated bacon bits. Findings Include: 1. The facility's policy titled, Labeling and Dating Food,' (YEAR) Edition documented: . Procedure . 4. Prepared food or opened food items should be discarded when: . the food item is leftover for more than 3 days . the food item is older than the expiration date. On 10/22/18 at 3:45 PM, during the initial tour of facility kitchen with the Employee Identifier (EI) #2, Certified Dietary Manager (CDM) and EI # 3, the Kitchen Manager, the following observations were made: A package of hot dog buns was stored on an open shelving. The package had a use by date of 9/30/18 and and expiration date of 10/18/18. In the walk in cooler, heads of lettuce were in a box with a received date of 10/10/18. Two of three heads of lettuce in the box were noted with brown leaves, with moisture noted in the bag. Also, in the cooler was a clear container of sweet and sour sauce, labeled with a discard date of 10/20/18. On 10/23/18 at 09:00 AM, observations of the facility nourishment refrigerators, located on the units, were conducted with EI #3. In one of the refrigerators a package of ready made bacon bits was found with a use by date of 10/9/18. On 10/24/18 at 9:45 AM, an interview was conducted with EI #2, CDM. EI #2 was asked how should hot dog buns be stored, used and discarded. EI #2 stated, employees had placed an incorrect use by date on the sticker. EI #2 was asked when should have the hot dog buns with a use by date of 10/18/18 and an expiration date of 9/30/18 been discarded. EI #2 stated, they should have already been discarded. EI #2 was asked what was the potential harm, or risk of not discarding hot dog buns by use by/ expiration date. EI #2 stated, bacteria can grow on them. EI #2 was asked how long after lettuce is delivered should it be discarded if not used. EI #2 stated, seven days. EI #2 was asked when should lettuce that was delivered and received on 10/10/18 been discarded. EI #2 stated, 10/17/18. EI #2 was asked when should leftover sweet and sour sauce in the cooler be stored, used and discarded. EI #2 stated, should be discarded within 3 days. EI #2 was asked when left over sweet and sour sauce with a use by date of 10/20/18 should be discarded. EI #2 stated, that day. EI #2 was asked what was the potential harm, or risk of not discarding the sweet and sour sauce by the use by/ expiration date. EI #2 stated, bacteria can grow and get sour. EI #2 was asked how should bacon bits in the nourishment refrigerator on the unit be stored, used and discarded. EI #2 stated, should be labeled and dated and used within 3 days. EI #2 was asked what was the potential harm or risk of not discarding the bacon bits by use by/ expiration date. EI #2 stated, bacteria can grow. On 10/24/18 at 10:15 AM, an interview was conducted with EI #3. EI #3 was asked how should hot dog buns be stored, used and discarded. EI #3 stated, staff should check expiration date. EI #3 was asked when should have the hot dog buns with a use by date of 10/18/18 and an expiration date of 9/30/18 been discarded. EI #3 stated, on 9/30/18. EI #3 was asked what was the potential harm, or risk of not discarding hot dog buns by use by/ expiration date. EI #3 stated, taste would not have been palatable and they could have made someone sick. EI #3 was asked how should lettuce be stored, used and discarded. EI #3 stated, should have been discarded a week after the received date. EI #3 was asked how long after lettuce is delivered should it be discarded, if not used. EI #3 stated, one week. EI #3 was asked when should lettuce that was delivered and received on 10/10/18 have been discarded. EI #3 stated, 10/17/18. EI #3 was asked what was the potential harm, or risk of not discarding lettuce by use by/ expiration date. EI #3 stated, could cause harm, make someone sick. EI #3 was asked when should leftover sweet and sour sauce in the cooler be stored, used and discarded. EI #3 stated, sweet and sour sauce is cooled and stored in sealed and discarded after three days. EI #3 was asked when left over sweet and sour sauce with, a use by date of 10/20/18,should be discarded. EI #3 stated, 10/20/18. EI #3 was asked what was the potential harm, or risk of not discarding the sweet and sour sauce by use by/ expiration date. EI #3 stated, it would have been soured. EI #3 was asked how should bacon bits in the nourishment refrigerator on the unit be stored, used and discarded. EI #3 stated, if it was an employee's it should have been in the employee refrigerator, it should have been discarded on the expiration date regardless. EI #3 was asked what was the potential harm, or risk of not discarding the bacon bits by use by/ expiration date. EI #3 stated, could make someone sick.

Based on interview, medical record review and review of a facility policy titled, COMPREHENSIVE PERSON CENTERED CARE PLANS, the facility failed to ensure: 1. Resident Identifier (RI) #112's baseline care plans addressed smoking and 2. RI #186's baseline care plans addressed the use of a foley catheter and antipsychotic medications. This affected RI #112 and RI #186, two of 25 sampled residents. Findings Include: A review of a facility policy titled, COMPREHENSIVE PERSON CENTERED CARE PLANS, with a history date of 3/18, documented: POLICY: Each resident will have a person centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. Baseline Care Plan - initial plan of care to be used upon admission . PR[NAME]EDURE: .3. A Baseline Care Plan is to be developed within 48 hours. Develop initial goals based upon admission orders [REDACTED]. 1.) RI #112 was admitted to the facility on [DATE]. A review of RI #112's medical record revealed a document titled, Baseline Care Plan, dated 10/1/18, did not reflect RI #112 being a smoker. A review of RI #112's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/28/18, documented: . Section J1300: Current tobacco use 1.Yes . On 10/24/18 at 5:20 p.m., an interview was conducted with Employee Identifier (EI) #1, Director of Nursing (DON). EI #1 was asked, what was the purpose of baseline care plans. EI #1 said, to provide the staff an initial care guide on providing care for the residents. EI #1 was asked who was responsible for initiating the baseline care plans. EI #1 stated the admitting nurse initiates and all other disciplines add anything pertinent to their discipline. EI #1 was asked what were some things that should be addressed on baseline care plans. EI #1 replied, medication and any additional needs like if they have a foley (catheter), wound, how they transfer, if they are a smoker and anything that would address their care to be provided. EI #1 was asked did RI #112's baseline care plan address him/her being a smoker. EI #1 said, no. EI #1 was asked should the care plan address his/her smoking. EI #1 replied, yes. EI #1 was asked what was the concern with smoking not being addressed on the baseline care plan. EI #1 answered, to ensure he/she was going out safely and not having problems and was following the smoking policy. 2.) RI #186 was admitted to the facility on [DATE]. A review of RI #186's medical record revealed a document titled, Baseline Care Plan, dated 10/18/18, did not reflect RI #186's use of a foley catheter and [MEDICAL CONDITION] medications. On 10/24/18 at 5:20 p.m., during an interview with EI #1, DON, the surveyor asked EI #1 was RI #186 admitted with a foley catheter. EI #1 replied yes, it is documented in the admission note. EI #1 was asked, did RI #186's baseline care plans address the use of his/her foley catheter. EI #1 said, it was updated 10/24/18 to include the foley catheter. EI #1 was asked, should it have been addressed prior to 10/24/18. EI #1 said, if the resident was admitted with the catheter it should have been. EI #1 was asked what was the concern with not having a plan of care for the catheter. EI #1 replied, risk of infection. EI #1 was asked, was RI #186's [MEDICAL CONDITION] medications addressed on his baseline careplans. EI #1 stated, not until it was updated 10/24/18. EI #1 was asked should those have been addressed prior to 10/24/18. EI #1 said, yes. EI #1 was asked what was the concern with antipsychotic medications not being careplanned. EI #1 answered, not knowing to monitor the behaviors, effectiveness and any side effects.

Based on interview and medical record review, the facility failed to obtain physician orders [REDACTED].#186's foley catheter and foley catheter care after admission to the facility on [DATE]. This affected RI #186, one of three residents sampled with catheters. Findings Include: RI #186 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. A review of RI #186's medical record revealed no orders for a foley catheter or cath care until 10/23/18, seven days after admission to the facility. On 10/24/18 at 5:20 p.m., an interview was conducted with Employee Identifier (EI) #1, Director of Nursing (DON). EI #1 was asked, was RI #186 admitted with a catheter. EI #1 stated, yes it was documented in the admission note. EI #1 was asked, was there an order for [REDACTED].#1 was asked, when was the order written. EI #1 replied, 10/23/18. EI #1 was asked, what orders should be obtained when a resident was admitted with a catheter. EI #1 answered, an order with size of catheter and bulb size, how often to change, one for the bag and one for care. EI #1 was asked, what was the concern with catheter care not being ordered. EI #1 replied, risk of infection.

Based on interview and medical record review, the facility failed to ensure Resident Identifier (RI) #186's medical record contained an appropriate medical [DIAGNOSES REDACTED]. The facility further failed to ensure catheter care was provided for RI #186 on 10/16, 10/17, 10/18, 10/19, 10/20 and 10/22/18. This affected RI #186, one of three residents sampled with catheters. Findings Include: RI #186 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. A review of RI #186's medical record revealed no [DIAGNOSES REDACTED]. Further review of the medical record revealed, no documentation of catheter care being provided on 10/16, 10/17, 10/18, 10/19, 10/20 and 10/22/18. On 10/24/18 at 5:20 p.m., an interview was conducted with Employee Identifier (EI) #1, Director of Nursing (DON). EI #1 was asked, what was the [DIAGNOSES REDACTED]. EI #1 said, there was no [DIAGNOSES REDACTED]. EI #1 said she would rather see a [DIAGNOSES REDACTED]. EI #1 was asked, how often should catheter care be provided for a resident. EI #1 said, every shift and as needed. EI #1 was asked, was there documentation that RI #186's catheter care was provided since admission. EI #1 stated, she saw documentation on 10/21/18 at 12:41 a.m., 10/23/18 at 9:47 p.m. and 10/24/18 at 12:04 a.m., 12:31 p.m. and 5:03 p.m. EI #1 was asked, what was the concern with catheter care not being performed. EI #1 answered, risk of infection.

Based on observations, record review of The 2013 Food Code, Food & Nutritional Services' policy/procedure manual and staff interviews, the facility failed to assure: 1. holding temperature of hot foods were maintained at 135 degrees or above when served from the trayline, 2. the tea urn spigot was cleaned every 24 hours and 3. utensils (flatware) were cleaned and air dried to prevent cross-contamination and food-borne illness. The above practices posed the potential for food contamination and compromised food safety. This had the potential to affect all 141 residents on the diet list who received food from dining services. Findings include: 1. The 2013 Food Code by the United States Public Health (USPH) and the Food and Drug Administration (FDA) included the following: 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under ¶ (B) and in ¶ (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57oC (135oF) or above . On 1/24/18 at 11:00 AM, an observation was made of hot holding temperatures on the trayline in the kitchen prior to plating for the noon meal service. Temperatures of 119 degrees Fahrenheit (F) were identified for four items; two meats and pureed vegetables. Poor technique was observed to be used by the Food Service Worker (FSW). Scoops remained in foods during testing and the thermometer was placed next to the side of the serving container and not in the middle. The FSW was identified as being in training and was not monitored by staff during performance of the assigned task. An observation on 1/24/2018 at 12:00 PM, food served from a steamtable in the resident dining room. A record review of the temperature log documented by staff revealed 145 degrees F. At 12:20 PM. four of 14 residents had not been served. Fried Steak on the steamtable measured at 120 F. The Certified Dietary Manager (CDM), Employee Identifier (EI) #2, was interviewed on 1/25/2018 at 8:45 AM related to hot holding food temperatures. EI #2 was asked, why the holding temperature on the tray line was not at 135 degrees F. EI #2 gave said it was probably due to the use of the oven, not the steamer for holding and a failure to monitor the end of cooking time. EI # 2 was asked, what were the risk factors. EI #2 said, a potential for bacterial growth and food borne illness. 2. The 2013 Food Code by the United States Public Health (USPH) and the Food and Drug Administration (FDA) included the following: Cleaning of Equipment and Utensils .Frequency 4-602.11 Equipment Food-Contact Surfaces and Utensils. (E)(2) At least every 24 hours for iced tea dispensers . On 1/24/2018 at 9:35 AM the CDM, EI #2, was requested to disassemble tea urn spigot. The technique observed would not expose all parts. When taken apart, the spigot plunger was observed with a brown build-up encircling the internal plunger. An interview with EI #2 revealed there was a risk for potential bacterial growth. EI #2 was asked, why the spigot was not clean. EI #2 said, it was because the spigot was not completely disassembled. On 1/25/2018 at 8:48 AM, EI # 2 said the facility had no established policy/procedure describing how to disassemble the tea urn spigot for cleaning. 3. The 2013 Food Code by the United States Public Health (USPH) and the Food and Drug Administration (FDA) included the following: Drying 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or . On 1/24/2018 at 9:30 AM Flatware was observed on the trayline. Three spoons were taken from a cylinder and fanned out. Three were wet and not air dried. Two spoons contained food debris. EI #2 was asked about the risks. EI #2 stated there was a potential for bacterial growth. EI #2 said, the problem was probably due to there being too many items in the cylinder.

Based on observation and interviews, the facility failed to ensure RI (Resident Identifier) #109's pillowcase was free of a brown colored substance. This was observed on 01/24/2018. This affected one of 28 sampled residents whose bed linens were observed. Findings Include: RI #109 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. On 01/24/2018, during a Resident Council meeting, RI #109 stated his/her bed was never made and his/her pillowcase had dried blood on it for two weeks. On 01/24/2018 at 4:08 p.m., the surveyor went to RI #109's room and with permission observed a brown substance on the pillowcase. On 01/24/2018 at 4:15 p.m., RN (Registered Nurse) Unit manager, EI (Employee Identifier) #4 observed RI #109's pillowcase. EI #4 was asked did RI #109's bed linens and pillowcase look clean. EI #4 said RI #109's pillowcase did not look clean. EI #4 was asked who was responsible for ensuring resident's bed linens were clean as well as pillowcases. EI #4 said CNA's (Certified Nursing Assistants) were responsible. On 01/25/2018 at 7:42 a.m., an interview was conducted with EI #5, CNA. EI #5 was asked if she was familiar with RI #109. EI #5 said yes. EI #5 was asked how often was RI #109's bed linens changed and his/her bed made. EI #5 explained she usually changed RI #109's bed linens and pillowcases on the resident's shower days. EI #5 explained she provided care to RI #109 on 01/23/2018. EI #5 explained she had changed RI #109's bed linens on 01/23/2018, but did not change his/her pillowcase on that date. On 01/25/2018 at 8:09 a.m., an interview was conducted with EI #6, CNA. EI #6 was asked if she was familiar with RI #109. EI #5 said yes. EI #6 explained she provided care to RI #109 on 01/24/2018. EI #5 was asked on 01/24/2018 did she change RI #109's pillowcase. EI #5 said she could not recall.

Based on a review of a facility policy titled, Smoking Policy, and a facility document titled, SMOKING SAFETY EVALUATION, record reviews and interviews, the facility failed to complete a smoking evaluation on RI (Resident Identifier) #95, a resident identified as a smoker. This affected one of two sampled residents identified as smokers. Findings Include: RI #95 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #95's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/02/2017, revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15, which indicated RI #95 was cognitively intact. Further review of RI #95's MDS revealed the resident was assessed as a current tobacco user. A review of a facility policy titled, Smoking Policy with a revised date of 01/2017, revealed the following: .Procedure: 1 .all residents who wish to smoke will be assessed upon admission and as necessary to determine whether the resident is able to smoke safely. A review of RI #95's Care Plan with an onset date of 12/04/2017 revealed the following: .Problem/Need . Problem Onset: 12/04/2017 Potential for injury d/t (due to) cigarette smoking . Approaches . Complete smoking assessment . A review of a facility document titled, SMOKING SAFETY EVALUATION with a date of 11/25/2017 revealed RI #95 was evaluated as a none smoker. RI #95 did not receive another smoking safety evaluation until 01/25/2018. An interview was conducted with RI # 95 on 01/23/2018 at 4:09 p.m. RI #95 was asked about his/her smoking. RI #95 stated he/she smoked occasionally. On 01/25/2018 at 11:46 a.m., an interview was conducted with EI (Employee Identifier) # 3, RN (Registered Nurse) Unit Manager. EI #3 was asked when was RI #95 identified as a smoker. EI #3 stated she was made aware on 01/25/2018. EI #3 was asked who was responsible for completing a smoking evaluation on residents who smoke. EI #3 said any of the nurses. EI #3 was asked when RI #95's care plan was developed to reflect his/her smoking should there have been communication for the nurse to complete a smoking evaluation. EI #3 said yes. On 01/25/2018 at 1:57 p.m., an interview was conducted with EI #1, DON (Director of Nursing). EI #1 was asked was EI #95 a smoker. EI #1 said yes. EI #1 was asked when was RI #95 identified as a smoker. EI #1 explained RI #95 was identified as a smoker when his/her MDS was completed on 12/02/2017. EI #1 was asked, did RI #95 have an accurate smoking assessment prior to the assessment completed on 01/25/2018. EI #1 said no. EI #1 was asked why RI #95 did not receive a smoking evaluation prior to 01/25/2018. EI #1 explained there may have been a breakdown in communication. EI #1 was asked should RI # 95 have received an updated smoking evaluation prior to 01/25/2018. EI #1 said yes. EI #1 was asked what was the potential harm of a resident who smoked not to receive a smoking evaluation. EI #1 explained the resident could sustain an injury.

Based on observations, interviews and review of facility policies titled, HAND WASHING, NASAL INHALATION ADMINISTRATION PR(NAME)EDURES and STANDARD PRECAUTIONS and review of POTTER AND PERRY, FUNDAMENTALS OF NURSING, NINTH EDITION, the facility failed to ensure a licensed nurse: 1. changed gloves and washed her hands after administration of nasal spray and before administration of an inhaler to Resident Identifier (RI) #72, 2. cleaned RI #72's nasal spray container after contact with resident's nares and 3. washed her hands after cleaning RI #72's nebulizer reservoir and removing her gloves and before obtaining RI #72's vital signs. The facility further failed to ensure a Certified Nursing Assistant: 1. did not place clean gloves on an unclean counter for use during incontinence care and catheter care for RI #93, 2. washed her hands when removing gloves and before applying clean gloves during incontinence care for RI #93 and 3. washed her hands after providing incontinence care and removing gloves before picking up a clean sheet for RI #93. These deficient practices affected one of four licensed nurses observed during medication pass observations and two of 27 sampled residents. Findings Include: A review of a facility policy titled, HAND WASHING, dated 8/17 revealed: POLICY: Staff will use proper hand washing technique to prevent the spread of infection. A review of a facility policy titled, NASAL INHALATION ADMINISTRATION PR(NAME)EDURES dated 8/16 documented: . 4. Clean inhaler . 5. Wash hands . A review of a facility policy titled, STANDARD PRECAUTIONS dated 10/09 revealed: POLICY: Standard Precautions will be utilized to provide a primary strategy for the prevention of healthcare-associated infectious (HAI) agents among patients and healthcare personnel. .Standard Precautions applies to: .b. All body fluids, secretions and excretions . d. Mucous membranes . PR(NAME)EDURE: .2. Wash hands .after contact with .body fluids,secretions, excretions, .immediately after removing gloves .If hands move from a contaminated site to clean body site during care, wash hands .Wash hands before direct contact with patients. A review of POTTER AND PERRY, FUNDAMENTALS OF NURSING, NINTH EDITION, CHAPTER 32, Medication Administration, BOX 32-16 PR(NAME)EDURAL GUIDELINES, Administering Nasal Medications, documented: 16. Administer nasal spray: .18. Wipe tip of bottle with clean, dry tissue and replace the cap, .remove and dispose of gloves and perform hand hygiene. 1.) RI #72 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 01/23/18 at 4:12 p.m., during observation of medication pass for RI #72, Employee Identifier (EI) #7, a Licensed Practical Nurse (LPN) was observed and the following was not done: 1. change gloves and wash her hands after administration of nasal spray and before administration of an inhaler to RI #72, 2. clean RI #72's nasal spray container after contact with resident's nares before recapping and 3. wash her hands after cleaning RI #72's nebulizer reservoir and removing her gloves and before obtaining RI #72's vital signs. On 01/23/18 at 5:51 p.m., an interview was conducted with EI #7, a LPN. EI #7 was asked, when should she wash her hands during administration of a nasal spray and an inhalation medication. EI #7 said, before and after contact with the resident. EI #7 was asked, did she change gloves and wash her hands after she administered the nasal spray for RI #72, prior to administration of RI #72's inhaler. EI #7 answered, no. EI #7 was asked, did she clean the nasal inhaler container after administering it to the resident. EI #7 responded, no. The surveyor asked EI #7, what was the concern with not removing her gloves and washing her hands and not cleaning the nasal inhaler container. EI #7 replied, Infection Control. EI #7 was asked, after she cleaned the nebulizer reservoir, did she wash her hands when she removed her gloves and before obtaining RI #72's vital signs. EI #7 said, no. The surveyor asked EI #7, what was the concern with not washing her hands after she cleaned the reservoir and removed her gloves. EI #7 answered, Infection Control. 2.) RI #93 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 01/25/18 at 10:50 a.m., during an observation of incontinence care and catheter care for RI #93, EI #8, CNA: 1. placed clean gloves on an unclean counter, 2. did not wash her hands when removing gloves and before applying clean gloves during incontinence care and 3. did not wash her hands after providing incontinence care and removing gloves before picking up a clean sheet. On 01/25/18 at 3:15 p.m., an interview was conducted with EI #8. EI #8 was asked, what type of surface should gloves be placed on. EI #8 replied, on a clean surface. EI #8 was asked, where did she place the gloves she used during incontinence care and catheter care for RI #93. EI #8 said, on the counter by the sink. EI #8 was asked, was the counter by the sink cleaned prior to her placing the gloves there. EI #8 said, no. The surveyor asked, what was the concern with placing clean gloves on an unclean surface. EI #8 answered, Infection Control. EI #8 was asked, did she wash her hands after getting the perineal spray from the nightstand and removing her gloves. EI #8 said, no. EI #8 was asked, did she pick up a clean sheet after providing incontinence care for RI #93 without washing her hands. EI #8 answered, yes. EI #8 was asked, what was the concern of obtaining potentially contaminated items from a nightstand and of picking up a clean sheet after performing incontinence care without washing her hands. EI #8 said, Infection Control.

Based on observation, interview and record review the facility failed to ensure adequate kitchen staff present to provide the residents with standard dining ware for the dinner meal on 10/17/16. As evidenced by residents were served the Dinner meal using Styrofoam plates and bowls. This affected 135 residents receiving meals from the kitchen. Findings Included: A review of the facility Dietary staffing for Monday, October 17, 2016 Evening Shift revealed four staff scheduled. Only three staff available. A brief interview with Employee Identifier #3, Dietary Manager revealed the fourth dietary aide on the list did not come in to work for the evening shift. On 10/17/16 from 5:00 p.m. until 6:00 p.m., during the initial tour of the facility residents were observed in the dining room and in their rooms eating the Dinner meal. The meal was served in styrofoam take out plates and styrofoam bowls. On 10/17/16 at 5:05 p.m. during the initial tour of the kitchen, dirty dishes were observed stacked in the dishwashing area. On 10/19/16 at 1:50 p.m. an interview was conducted with EI #3, Dietary Manager. She was asked if the dishwasher was broke on 10/17/16; she replied no. EI #3 was asked if she could explain why during the supper meal on 10/17/16 residents were eating from take out styrofoam plates. EI #3 replied they had an employee that quit late in the day and she allowed staff to use the styrofoam plates. She went on to add, they were short staffed and she did not want them being late getting off work due to washing dishes. EI #3 replied it was to give the kitchen staff a break. EI #3 was asked how many staff scheduled on 10/17/16 evening shift; she replied four. When asked how many worked on 10/17/16 evening shift; she replied three. EI #3 was asked what was done if staff called in for the shift. EI #3 replied typically they have someone come in but those were on vacation. On 10/19/16 at 4:20 p.m. in an interview with EI #3, Dietary Manager, she was asked if three staff members were able to meet the needs of the residents. EI #3 replied she thought they were. She was then asked why the staff did not serve the meal on dishes. EI #3 stated, I was trying to be nice they had a rough day and I was trying to make it easier for them.

Based on observation, interview and record review the facility failed to ensure 1) Foods stored in the double refrigerator were discarded by the discard date and properly sealed; also frozen foods in the walk-in freezer were properly resealed after being opened to prevent cross-contamination and food-borne illness; and 2) The stove hood vent was free of an accumulation of a gray dust-like substance. This was observed on 10/17/16 during the initial tour of the kitchen and on 10/18/16 during tray line observation. This had the potential to affect 135 residents receiving meals from the kitchen. Findings include: 1) A review of the 2013 Food and Drug Administration's 3-501.17 . (B) revealed: .refrigerated, READY-TO EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on PREMISES, sold or discarded . On 10/17/2016 at 5:05 pm during the initial tour of the kitchen the following items were observed: chocolate cake partially covered with a discard date of 10/14/2016, ham stored in a plastic container with a discard date of 10/13/16, a carton of grated parmesan cheese with a discard date of 10/13/16 and a bottle of lemon juice with a discard date of 8/30/16 were stored in the double refrigerator. Also in the walk-in freezer observed were: two open boxes of frozen biscuits, an open plastic bag of frozen Parker Rolls, a plastic bag of frozen cookie dough and a plastic bag of frozen squash. On 10/19/2016 at 1:50 p.m. an interview was conducted with the (Dietary Manager), DM, Employee Identifier (EI) #3. EI #3 was asked should the out of date foods have been stored in the refrigerator. EI #3 replied no. EI #3 was asked why were they stored in the refrigerator. EI #3 said they were not checked over the weekend. EI #3 was asked who was responsible for making sure foods were not stored in the refrigerator. EI #3 replied the cook was supposed to check the cooler. EI #3 was further asked should frozen foods not sealed properly and exposed be stored in the walk-in freezer. EI #3 replied no. 2) A review of the Food and Drug Administration's 2009 Food Code revealed: 4-601.11 Equipment, Food -Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment food-contact surfaces, and utensils shall be clean to sight and touch . (C) Non-food-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris . On 10/18/2016 at 11:05 a.m. the hood vents over the stove was observed to have an accumulation of a gray dust-like substance covering the vents. EI #3 was asked if she could describe what was on the hood vent. EI #3 replied she saw dust on it.

Based on observation, interview and record review the facility failed to ensure a Certified Nursing Assistant (CNA) cleaned Resident Identifier (RI) #11's labia and failed to wipe the buttocks in a front to back direction during the provision of incontinent care. This was observed on 10/18/16 and affected one of two residents observed for incontinent care. Findings Included: A review of a facility form titled INCONTINENT CARE COMPETENCY AUDIT revealed PROCEDURE . 8. Remove .a.Utilize a downward motion . b. Use one gloved hand to stabilize and separate labia. Utilize clean wipe to clean wash side of the labia & then the center . RI #11 was readmitted to the facility 10/07/13 with [DIAGNOSES REDACTED]. A review of RI #11's most recent Minimum Data Set (MDS) with an Assessment Reference Date of 9/05/2016 revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview and RI #11 had memory problems. Further review of the MDS revealed RI #11 was totally dependant for toilet use. On 10/18/16 at 10:05 a.m. Employee Identifier (EI) #2, CNA was observed providing incontinent care for RI #11. EI #2 cleaned RI #11's buttocks area by wiping in a back to front direction. EI #2 then cleaned RI #11's perineal area without separating the labia and wiping down each side then down the center. On 10/19/16 at 10:00 a.m. an interview was conducted with EI #2. EI #2 was asked how was she trained to wipe the buttocks area during the provision of incontinent care; she replied from the butt up to the back. EI #2 was asked to describe how she wiped; she replied I went from the waist to the bottom. EI #2 was asked if that was the correct way. EI #2 replied no. EI #2 was asked how was she trained to wipe the front area of a resident. EI #2 replied wipe each side then down the center. EI #2 was asked if she should separate the labia and wipe; she replied yes. EI #2 was then asked what could the harm be in not wiping a resident correctly during incontinent care. EI #2 replied the resident could get a urinary tract infection and contamination. On 10/19/16 at 2:30 p.m. an interview was conducted with EI #1, Assistant Director of Nursing. EI #1 was asked how was staff trained to perform incontinent care. EI #1 replied wipe front to back, and separate the labia and wipe down each side then down the center. EI #1 was asked if staff was to separate the labia during pericare; she replied yes. EI #1 was asked what would the potential for harm be in not wiping correctly. EI #1 replied the resident could get a urinary tract infection.

Based on observation, record review and interview, the facility failed to ensure heating unit vents in Room Locator's (RL) #1 and 2 were in good repair. A knob on the heating unit was not missing in RL #1 and a dresser drawer facing was present in. This affected three rooms of 24 rooms on the 100 hall. Findings include: The facility's Job Description for the Director of Environmental Services dated 8/01/2012 documented the following: .General Description . The Director is accountable for the upkeep of the grounds, facility and equipment in a safe manner . Essential Duties .4 equipment are properly maintained for resident comfort and convenience . On the initial tour of the facility on 01/12/16 at 2:00 PM, heating unit vents were noted to be broken in RL #1 and #2, a knob was missing off the heating unit in RL #2, and the facing of one dresser drawer was missing in RL #3. On 01/13/16 at 8:05 AM, the surveyor observed the vent of the heating unit was broken in RL #1 and #2, a control knob was missing from the heating unit in RL#2 and the facing of one dresser drawer was missing in RL #3. In an interview on 01/13/16 at 12:05 PM, Employee Identifier (EI) #1, the Maintenance Director,was asked to describe the heating unit in RL #2. EI #1 stated the cover on the air conditioning/heating unit was busted. EI #1 was asked to describe the air conditioning/heating unit, as well as the dresser drawer in RL#1. EI #1 stated the vent was broken on the air conditioning/heating unit and the face of the drawer was pulled off. EI #1 was asked to describe the air conditioning/heating unit in RL #3. EI #1 replied the control knob was missing from the air conditioning. EI #1 was asked who is responsible for ensuring repairs are done. EI #1 affirmed he was responsible for ensuring repairs were done. EI #1 was asked what would be the potential harm to a resident with vents being broken. on the heating unit. EI #1 stated the a possible skin tear to a resident.

Based on interviews and record review the facility failed to ensure two of seven narcotic destruction records for the month of March 2015 contained the needed three (3) signatures. This was found in one (1) of 12 months of narcotic destruction sheets reviewed. Findings include: A facility policy titled Medication Destruction, dated 12/13 documented: . Responsibility: All Licensed Nursing Personnel / Director of Nursing Service . CONTROLLED MEDICATIONS . 4. Medication destruction occurs only in the presence of two licensed nurses and/or a licensed nurse and a pharmacist or as required by state regulation. 5. The following information is entered on the Medication Destruction Record - Controlled Medication sheet . h. The signatures of the persons conducting the disposal of the medication . 6. Medication Destruction Records will be stored in binders, non- controlled drugs separated from controlled drugs, in reverse chronological order. These will be kept by the Director of Nursing Service in the Director of Nurses office. On 1/14/16 at 11:30 a.m., during the Medication Room Observation with Employee Identifier (EI) #6, a Registered Nurse (RN), EI #6 revealed the facility's Record of Medication of Controlled Medications required 3 signatures and the Non - Controlled required 2 signatures on the sheets. Also, EI #6 revealed the method of destruction was by flushing the medications. On 1/14/16 at 2:15 p.m., the surveyors conducted an interview with the Administrator/Exective Director, EI #3. The surveyor asked EI #3 who can sign the medication destruction sheets. EI #3 said, the pharmacist and 2 RN's (Registered Nurses). A review of the facility's medication destruction records for March 2015 revealed two of 7 sheets did not contain the required three (3) signatures on the RECORD OF MEDICATION DESTRUCTION for March 23, 2015. The first medication destruction sheet listed: Lorazepam (Ativan) 0.5 mg (milligrams) (Quantity) - 4, Lorazepam 0.5 mg Quantity - 60, Morphine Sulfate 100 mg / 5ml (milliliters) Quantity - 29.75 ml. The only signature was that of the pharmacist. The form did not have the two required witness signatures. The second medication destruction sheet dated for March 23, 2015 listed: Diazepam (Valium) 10 mg - Quantity -12, Clonazepam (Klonopin) 0.5 mg, Quantity - 32, Tramadol, Quantity 47, Oxycodon-APAP (Oxycodone and Acetaminophen), Quantity - 17, Zolpidem (Ambien) Tartrate, Quantity - 9. These medications were destroyed due to the resident(s) having expired or were discharged from the facility. The form was signed only by the Pharmacist and one witness.

Based on observation, interviews and record review the facility failed to ensure a Certified Nursing Assistant (CNA), Employee Identifier (EI) #4 changed gloves and washed hands before placing a clean brief during incontinence care on Resident Identifier (RI) #5. This affected RI #5, one of one resident observed for incontinent care. Findings include: A review of a facility policy titled, INCONTINENT CARE dated 7/12 revealed: .PROCEDURE .16. Remove gloves and discardWash hands. 17. Place a dry brief on the resident RI #5 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #5's most recent Annual Minimum Date Set (MDS) with an Assessment Reference Date (ARD) of 10/26/15 revealed the resident was severely cognitively impaired for daily decision making. The MDS further revealed the resident required extensive assistance with Activities of Daily Living (ADL). The MDS also revealed the resident was always incontinent of bowel and bladder. On 01/14/16 at 9:55 PM, EI #4 and EI #5, CNA's were observed performing incontinent care for RI #5. EI #4 removed the resident's brief and EI #4 wiped RI #5's frontal pubic area and across top of pubic area and discarded wash cloth. EI #4 washed RI #5's left groin area and EI #4 washed the resident's right groin area. RI #5 was turned on left side and EI #4 wiped downward on the resident's buttocks and then wiped upward on the rectal area. EI #4 touched and placed a brief on RI #5 without changing her gloves or washing her hands. On 01/14/16 at 11:15 AM, an interview was conducted with EI #4. EI #4 was asked when should you change gloves and wash hands during incontinence care. EI #4 said when going from dirty to clean and before applying a clean brief. EI #4 was asked if she changed her gloves and washed her hands before applying a clean brief to RI #5. EI #4 said she did not. EI #4 was asked what is the potential harm in not changing gloves and washing hands. EI #4 said cross contamination.

Based on observation, record review and interview, the facility failed to ensure the tile floor was intact around a sewer drain in the central hall of the facility. This had the potential to affect 143 residents living in the facility. Findings include: The facility's Job Description for the Director of Environmental Services dated 08/01/2012 documents the following: .General Description Under the director of the Executive Director, the Director of Environmental Services is responsible to plan and direct the activities of the maintenance . The Director is accountable for the upkeep of the grounds, facility and equipment .Essential Duties .4. equipment are properly maintained .Standard Requirements . 3 implements specific procedures and programs for: . and safety . report/or correct unsafe working conditions, equipment repair and maintenance needs . On 01/12/16 at 2:50 PM, during the initial tour, the surveyor observed three large missing tiles around the area of an exposed sewer drain in the central area of the 100 hallway. There was no caution sign posted. On 01/13/16 at 8:15 AM, the surveyor observed residents and staff walking and staff pushing residents in their wheelchairs on the area around the exposed sewer drain in the central hall. There was no caution sign posted. On 01/13/16 at 12:05 PM an interview was conducted with Employee Identifier (EI) #1, the Maintenance Supervisor. EI #1 was asked how long had the the tile around the drain been missing. EI #1 said about a month or so. EI #1 was asked do residents walk on the hallway where the tile is missing. EI #1 said, Yes. EI #1 was asked was there a caution sign posted where the tile was missing. EI #1 said, No. EI #1 was asked what is the potential harm to a resident or staff walking on the hallway where tile is missing. EI #1 said, A trip hazard due to the floor not being completely leveled.

Based on record review and interviews, the facility failed to implement it's policy titled "SURVEILLANCE FOR HEALTHCARE ASSOCIATED INFECTIONS" when multiple residents were diagnosed with [REDACTED]. This deficient practice affected Resident Identifier (RI) #35, RI #40, RI #42 and RI #53, four of 33 sampled residents reviewed for skin issues, with the potential to affect the remaining residents who reside in the facility. Findings include: 1) The facility's policy with a subject of "SURVEILLANCE FOR HEALTHCARE ASSOCIATED INFECTIONS" dated November 2012, documented "POLICY: Surveillance for Healthcare Associated Infections will be completed to calculate baseline rates, detect outbreaks, track progress, and to determine trends to help prevent the development or spread of infection (HAI). DEFINITION: ... Healthcare Associated Infections (HAI), as defined by the CDC Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Setting 2007", refers to an infection that develops in a patient who is cared fro in any setting where healthcare is delivered ... RESPONSIBILITY: Director of Nursing / Infection Control Designee / Licensed Nurses PROCEDURE: ... 3. Complete the Monthly Infection Control Surveillance Log utilizing a new form each month ... Complete the date as indicated: a. Identifying the information, i.e. name, nursing unit; b. admitted ; c. Infection Onset Date; d. Infection site; e. Symptoms or related diagnosis; ... h. Record antibiotics or other treatment used; ... k. Record other interventions; l. Date infection resolved ... 5. Utilize CDC's Definitions of Infection for Surveillance in Long Term Care ... ." The "Definitions of Infection for Surveillance in Long-term Care Facilities" with a copyright date of 1996, documented " ... Skin infection ... Scabies The resident must have both (a) a maculopapular and/or itching rash and (b) either physician [DIAGNOSES REDACTED]. Because staff members in some long-term institutions may not have sufficient training to be able to make these diagnoses, and because there is no simple measure of the experience required, "[DIAGNOSES REDACTED]. However, the experience of the observer is recognized as more important than the particular qualification ... ." RI #40, who resided in a private room on the 300 hall, was admitted to the facility on [DATE]. On 5/23/14, RI #40 was examined in a local dermatology office. The dermatologist's report documented " ... Chief Complaint: rash Location: diffuse full body Duration: 2 Months Quality: itching Severity: chronic Associated signs and symptoms: itchy ... Review of Systems: ... Integumentary: Patient states positive for rash, pigment changes, thinning hair, bruising, itching, scars ... Physical Exam ... Oriented to person, place and time. Integumentary: The following body areas were examined and significant findings are noted below: head, neck, chest, abdomen, back, right upper extremity, left upper extremity, right lower extremity, left lower extremity, diffuse full body: there are discrete, small, slightly elevated vesicles (fluid filled sacs) with linear burrows Medical Decision Making Impression: Scabies ... Medications Prescribed This Visit ... [MEDICATION NAME] ... ." Although, the local dermatologist documented on 5/23/14, RI #40 had a diffuse full body rash for approximately two months, the facility's "Weekly Skin Audit" dated 5/2/14, 5/9/14 and 5/16/14 indicated RI #40 had a normal skin condition and no rash was present. According to the manufacturer information, " ... [MEDICATION NAME] ([MEDICATION NAME]) 5% Cream is a topical scabicidal agent for the treatment of [REDACTED]." The facility's "Infection Log" for the period 5/1/14 thru 5/31/14 indicated seven residents were treated in the facility during this time frame for a skin infection; however, RI #40, who was diagnosed by a local dermatologist with a scabies infection, was not included in the facility's May 2014 Infection Log. The facility's "Infection Log" for the period 6/1/14 thru 6/30/14 indicated six residents were treated in the facility during this timeframe for a skin infection; however, none of the residents were identified as RI #40. In an interview on 1/16/15 at 10:15 AM, EI #3, the ICN (Infection Control Nurse) was asked, would the Infection Control Book ("Infection Log") reflect the tracking of Scabies. EI #3 stated no because RI #40's case was not a confirmed case (diagnosis). According to an article published by the Centers for Disease Control and Prevention titled "Scabies Frequently Asked Questions (FAQs) updated 11/2/10, " ... Scabies is an infestation of the skin by the human itch mite ... The most common symptoms of scabies are intense itching and a pimple-like skin rash. The scabies mite usually is spread by direct, prolonged, skin-to-skin contact with a person who has scabies ... Institutions such as nursing home, extended-care facilities, and prisons are often sites of scabies outbreaks ... [DIAGNOSES REDACTED]. Whenever possible, the [DIAGNOSES REDACTED]. This can be done by carefully removing a mite from the end of its burrow using the tip of a needle or by obtaining skin scraping to examine under a microscope for mites, eggs, or mite fecal matter. It is important to remember that a person can still be infested even if mites, eggs, or fecal matter cannot be found; typically fewer then 10-15 mites may be present on an infested person who is otherwise healthy ... ." 2) RI # 35 was readmitted to the facility on [DATE]. During the month of March 2014, RI #35 resided in a semi-private room on the 100 hall in the facility. On 3/21/14 9:50 AM, the facility received a verbal order from EI #5, the CRNP, for RI #35 that documented "[MEDICATION NAME] Cream 5% Apply from hairline to feet. Leave on 12 hours. Then shower. May repeat x1 ... ." RI #35's March 2014 "Medication Administration Record (MAR)" indicated [MEDICATION NAME] Cream was applied to RI #35 on 3/21/14 and 3/28/14. RI #42 was admitted to the facility on [DATE]. During the month of March 2014, RI #42 resided in a private room on the 300 hall in the facility. RI #42's "PHYSICIAN'S TELEPHONE ORDERS" dated 3/20/14 7:00 PM, documented "[MEDICATION NAME] ([MEDICATION NAME]) 5% cream apply at bedtime from head to toe wash off in 12 hrs (hours) repeat x1 in one week Dx (diagnosis) rash ... ." RI #42's March 2014 "Medication Administration Record (MAR)" indicated [MEDICATION NAME] ([MEDICATION NAME]) Cream was applied to RI #42 on 3/20/14. RI #53 was admitted to the facility on [DATE]. During the month of March 2014, RI #53 resided in a semi-private room on the 200 hall in the facility. On 3/24/14 4:50 PM, the facility received a verbal order from EI #5, the CRNP, for RI #53 which documented "[MEDICATION NAME] Cream 5% apply from hairline to soles of feet. Leave on 12 hours then wash off. Repeat in 7 days ... ." RI #53's March 2014 "PRN (as needed) Medication Record" indicated [MEDICATION NAME] Cream was applied to RI #53 on 3/25/14. In an interview on 1/13/15 at 3:30 PM, EI #5, the CRNP stated if she ordered [MEDICATION NAME] cream for a resident, it appeared to her the resident had scabies. In an interview with EI #7, the facility's Medical Director (MD) on 1/14/15 at 8:45 AM, stated that as a physician or nurse practitioner, you treat what you see. EI #7 further stated that he didn't wait for test results to treat a patient. During an interview on 1/15/15 at 8:20 AM, EI #3, the Infection Control Nurse (ICN) stated the facility follows the CDC guidelines. When asked what was the harm in not following (monitoring) residents with skin issues, to include scabies, EI #3 stated, infection, spreading to others. EI #3 was asked, if not following (monitoring) residents with scabies could lead to an outbreak. EI #3 replied yes; it could lead to harm others. In an interview on 1/15/15 at 6:30 PM, EI #5, the CRNP acknowledged she ordered [MEDICATION NAME] Cream, when she suspected the resident had a scabies infection. EI #5 also added that a resident with scabies would itch first, then a few days later a rash would develop. During an interview on 1/16/15 at 11:15 AM, EI #1, the Director of Nursing (DON) acknowledged the facility completed tracking of residents with skin issues for the month of May 2014. When asked, if tracking was done for any other months, when residents were ordered [MEDICATION NAME] Cream, EI #1 said no, just May 2014. The facility's "Infection Log" for the period 3/1/14 thru 3/31/14 indicated three residents were treated in the facility during this timeframe for a skin infection; however, none of the residents treated with the scabicide cream ([MEDICATION NAME]) in March 2014, RI #35, RI #42 or RI #53, were documented on the March Infection Control Log. The log did indicate RI #42 was treated for [REDACTED]. The facility's "Infection Log" for the period 4/1/14 thru 4/30/14 indicated 10 residents were treated in the facility during this timeframe for a skin infection; however, none of the residents treated with the scabicide cream ([MEDICATION NAME]) in March 2014, RI #35, RI #42 or RI #53, were documented on the April 2014 Infection Control Log. The log did indicate RI #42 was treated for [REDACTED]. On 12/18/14, the local health department sent information to the facility to include: " ... SCABIES CONTROL MEASURES ... Treatment failure leading to persistent scabies infestations may result from any of the following: ... *Failure to identify and treat all scabies cases (including patients, health care workers, volunteers, family, and visitors) ... *Ineffective environment cleaning ... *Lack of surveillance for additional scabies cases after treatment ... ." This deficiency was cited as a result of the investigation of complaint/report number AL 547.

Based on record review and interviews, the facility failed to ensure Resident Identifier (RI) #2's geri chair was positioned in a manner to prevent a fall that resulted in a nondisplaced fracture of the cervical portion of the proximal right femur. This affected RI #2, one of seven sampled residents reviewed for falls. Findings include: RI #2 was admitted to the facility on [DATE]. RI #2's Quarterly Minimum Data Set with an assessment reference date of 7/31/14 indicated RI #2 required extensive physical assistance of two plus persons for transfers. RI #2's "Resident Incident Report" indicated on 10/18/14 at 11:46 AM, RI #2 was observed lying on the floor in front of a geri chair on his/her left side parallel to the night stand. The resident was lying with his/her feet toward the geri chair and head facing the doorway. Prior to the incident, the resident had been up in the geri chair and the geri chair was not reclined. RI #2 had a two centimeter reddened area to the head. X-ray obtained on 10/21/14 indicated the resident had a non-displaced fracture on the cervical portion of the proximal right femur. According to this report, the immediate action the facility took was to counsel the Certified Nursing Assistant (EI #2) for not reclining RI #2's geri chair. The "SUPERVISOR INVESTIGATION SUMMARY FORM" for RI #2's incident that occurred 10/18/14 signed by EI #1, the Director of Nursing (DON) and EI #3, a Registered Nurse (RN), documented " ... FOLLOW-UP ACTIONS: (RI #2) was assisted from bed into ... geri chair by C.N.A. (EI #2). Prior to leaving room (EI #2) failed to place (RI #2)'s geri chair into the reclined position. When another staff member came into the room she found (RI #2) on the floor in front of the chair laying (lying) on ... left side. A red raised area was noted to ... forehead ... (RI #2) complained of no other pain until later that afternoon. At that time (RI #2) stated (his/her) knee hurt. An x ray was obtained on 10/18/14 and was negative for injury. (RI #2's) pain medications were increased from prn (as needed) to scheduled in an effort to keep (RI #2) comfortable. (RI #2) was sent to (local hospital) on 10/21/14 for more x rays and it was found that (RI #2) had a nondisplaced fracture of the cervical portion of the proximal right femur ... (RI #2) was admitted , received surgical repair of the fracture ... ." RI #2's x-ray report indicated on 10/21/14, RI #2's right hip was x-rayed post fall, with " ... IMPRESSION: Nondisplaced fracture of the cervical portion of the proximal right femur ... ." In an interview on 11/19/14 at 8:52 AM, EI #2, the CNA acknowledged she was assigned to care for RI #2 on 10/18/14. When asked to explain what happened on 10/18/14, EI #2 stated after she was assisted by another staff member in getting RI #2 into the geri chair, she put RI #2's shoes on and in a hurry left out of the room and didn't recline RI #2's geri chair. According to EI #2, its procedure, if a resident is not eating, to recline the geri chair. When asked how did the positioning lead to RI #2's fall, EI #2 stated if she had reclined RI #2 back in the geri chair, the resident would not have leaned forward and fell . When asked what the harm was in not reclining RI #2's gerichair, EI #2 stated the resident fell . EI #2's "CATEGORY TWO VIOLATION EMPLOYEE CORRECTIVE COUNSELING MEMORANDUM" dated 10/20/14 and signed by EI #2, EI #'2 Supervisor, the Executive Director and Human Resource indicated EI #2 received a written warning for " ... (RI #2) was left in geri-chair upright, chair should be reclined after routine care and meals. Resident fell out of chair being left unattended in room, aide states she was in a hurry ... ." In an interview on 11/19/14 at 9:30 AM, EI #3, the RN stated the reason RI #2 fell out of the geri chair was because it was not reclined. During an interview on 11/19/14 at 2:30 PM, EI #1, the DON was asked did the CNA (EI #2) recline RI #2's geri chair when she left the room on 10/18/14. EI #1 said no. When asked what the harm was, EI #1 stated RI #2 fell and sustained a fracture.