Every finding on record at Goodwater Healthcare Center

Based on observations, record review, and interviews, the facility failed to ensure a system was in place to assess residents to determine if side rail use was appropriate, as well determine the residents' risk of entrapment. Further, no alternative approaches were attempted prior to using the side rails, and no informed consent was obtained from either the residents or their representatives prior to utilizing side rails. These failures affected Resident Identifier (RI) #s 13 and 28, two of seven sampled residents reviewed for side rail use, and had the potential to affect all 33 residents with orders and/or careplans in place for side rail use. The facility provided a Census List identifying 33 residents that utilized side rails out of total facility census of 62. Findings include: 1) RI #13 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #13's admission Nursing Assessment, dated 02/10/2017, indicated RI #13 should have 1/2 (half) side rails up times two for turning and positioning. The assessment made no reference to any alternatives attempted prior to side rail use. RI #13's (MONTH) (YEAR) Physician order [REDACTED]. RI #13's most recent Annual Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 02/11/2018, documented RI #13 had both short and long term memory impairment and had severely impaired daily decision making skills. This assessment also indicated RI #13 was totally dependent on two plus people for bed mobility. RI #13's fall care plan, last reviewed 2/12/2018, included an approach to use 1/2 side rails as ordered for positioning. On 3/14/2018 at 4:03 PM, RI #13 was observed in bed with side rails up times two. 2) RI #28 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #28's (MONTH) (YEAR) Physician order [REDACTED]. RI #28's quarterly MDS Assessment, with an ARD of 02/21/2018, documented RI #28 had both short and long term memory problems and severely impaired daily decision making skills. This assessment also indicated RI #28 was totally dependent on one person for bed mobility. RI #28's fall care plan, last reviewed 2/22/2018, included an approach to use 1/2 side rails up times two for turning and positioning. This approach was dated 10/31/2016. On 03/13/2018 at 4:05 PM, RI #28 was observed in bed with 1/2 side rails up times two; however RI #28 was unable to answer questions or demonstrate if he/she was able to utilize side rails for turning and positioning in the bed. On 3/14/2018 at 10:09 AM, RI #28 was again observed in bed with 1/2 side rails up times two. On 03/15/18 at 6:27 PM, Employee Identifier (EI) #6, Licensed Practical Nurse (LPN)/Restorative Nurse, discussed RI #28's order to use 1/2 side rails for turning and positioning in bed, and explained that at one point RI #28 could use the side rails because his/her cognition was much better. However, EI #6 said RI #28 could no longer use the side rails for turning and positioning in the bed. EI #6 further explained RI #28 does wiggle back and forth and is top heavy and leans to the side, which could possibly put the resident at risk for entrapment. On 3/14/2017 at 11:10 AM, the surveyor asked EI #4, the Director of Nursing (DON), if the facility did side rail assessments and where to locate that information in the residents' charts. EI #4 responded that maintenance checked the side rails. The surveyor then asked about a resident assessment, and EI #4 said she did not think the facility did side rail assessments on the residents. When asked for the facility's policy related to side rail use, EI #4 said she would check, but did not think the facility had one. EI #4 explained the facility used side rails for turning and repositioning. On 3/14/2018 at 2:17 PM, EI #4, the DON, returned and stated the facility did not do side rail assessments. When asked if she was able to locate a facility policy, EI #4 said there was not a policy addressing side rails. On 03/15/18 at 6:27 PM, EI #6, Licensed Practical Nurse (LPN)/Restorative Nurse, was interviewed. When asked if she had any involvement in assessing residents for the use of side rails, EI #6 stated she did. The surveyor asked EI #6 to explain the facility's process for evaluating residents for the need for side rails, as well as entrapment risk. EI #6 explained she did not have any documentation of resident assessments for side rails, only an inservice addressing the need to check side rails and mattresses on admission, monthly and with any room changes. EI #6 said during these checks, they basically just looks at the resident in the bed and looks at the side rails. EI #6 further clarified that when doing this, they do not pull residents' charts to review that information, and to her knowledge that had never been done. The surveyor asked if any of the following factors were considered when assessing residents for the use/need for side rails: diagnoses, resident's size and weight, sleep patterns, medications, interventions, presence of [MEDICAL CONDITION], ability to safely toilet, cognition, communication, mobility, fall risk, and any alternatives attempted prior to side rail use. EI #6 responded none of the preceding items were things she considered when evaluating for side rails. When asked how residents' risk of entrapment was assessed, EI #6 stated she has never assessed residents for entrapment risk. The surveyor then questioned EI #6 regarding the use of any alternatives prior to using side rails. EI #6 explained it was typical that side rails were implemented upon admission, and no alternatives were attempted prior to utilizing the side rails. EI #6 also stated she does not get informed consent for the use of side rails. When asked why it would be important to assess each resident and the factors discussed above when determining the need for side rails, EI #6 stated because there are certain times side rails can cause more harm by being up. EI #6 then stated the same applied to the importance of assessing for entrapment risk. On 3/15/18 at 7:01 PM, EI #4, DON, was asked how residents were assessed to determine if they required the use of side rails. EI #4 said side rails were listed on the admission Nursing Assessment. The surveyor then questioned EI #4 regarding alternatives attempted prior to use of side rails, if the admission Nursing Assessment included them. EI #4 said the admission Nursing Assessment was completed within 24 hours of admission, so they did not really have time to do alternatives before using the side rails. When asked how they determined the appropriate size of side rails required for each resident, EI #4 said they use 1/2 rails on the majority of their residents. The surveyor then asked EI #4 how entrapment risk was addressed for each resident and where that information would be documented. EI #4 said they did not have a specific piece of paper addressing that. When asked if she could provide evidence that RI #s 13 and 28 were assessed to determine if they were at risk for entrapment, EI #4 said she did not have documentation of that. She further stated neither of these residents had informed consent for the use of their side rails. The surveyor then asked EI #4 what system the facility had in place for evaluating/assessing residents to determine if side rails were appropriate and whether the residents were at risk for entrapment, as well as a method for ongoing evaluation. EI #4 said the facility did not have a system in place. When asked which residents could potentially be impacted by the facility's lack of policy, assessment and ongoing monitoring, EI #4 said all of the residents with side rails could be affected.

Based on observations, record review, and interview, the facility's Quality Assessment and Assurance (QAA) Committee failed to identify and address concerns related to the facility's side rail usage process. This affected Resident Identifier (RI) #s 13 and 28, two of seven sampled residents reviewed for side rail use, and had the potential to affect all 33 residents with orders and/or careplans in place for side rail use. The facility provided a Census List identifying 33 residents that utilized side rails out of a total facility census of 62. Findings Include: Cross Reference F700. During the recertification survey from 03/13-03/15/2018, the survey team identified concerns with side rail and entrapment risk assessments, lack of alternatives attempted prior to side rail use, and no informed consent for RI #s 13 and 28's side rails. On 3/14/2018 at 2:17 PM, Employee Identifier (EI) #4, the Director of Nursing (DON), stated the facility did not do side rail assessments and also did not have a policy addressing side rails. On 3/15/18 at 7:01 PM, EI #4, DON, was asked how the QAA committee addressed regulatory changes and new requirements. EI #4 explained they discussed what each department would need to do. EI #4 also stated they had a book that discussed all of the changes. EI #7, QAA Director, was interviewed on 03/15/18 at 8:09 PM regarding the team's identified concerns with side rail use. When asked if the QAA committee had identified side rail use, assessment, and lack of policy as an area of concern, EI #7 said they had not. When asked what information the committee utilized to determine areas of concern, EI #7 said they reviewed any falls, skin tears, and unusual occurrences, at least three times per week. EI #7 further stated the committee does discuss facility policies to determine if they are consistent with federal regulations, but clarified the facility did not have policies addressing everything.

Based on record review and interview, the facility failed to ensure a Significant Change Minimum Data Set (MDS) Assessment was completed after Resident Identifier (RI) #13's admission to Hospice on 3/12/2017. This affected one of 19 sampled residents for whom MDS Assessments were reviewed. Findings include: RI #13 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #13's (MONTH) (YEAR) Physician order [REDACTED]. On 3/15/2018 at 3:06 PM RI #13's MDS assessments were reviewed and revealed there was no Significant Change MDS assessment completed after RI #13's admission to hospice services. Employee Identifier (EI) #2, the MDS Coordinator, was interviewed on 3/15/2018 at 1:53 PM. EI #2 stated a significant change assessment should have been completed after RI #13's admission to hospice, but she would need to check to see if one was done. EI #2 returned at 2:20 PM and confirmed RI #13 was admitted to hospice on 3/12/2017, but no Significant Change MDS assessment had been completed.

Based on observation, interviews and review of Nursing Inservice information, the facility failed to ensure Employee Identifier (EI) #3, Registered Nurse (RN), labeled a multiple dose insulin vial for Resident Identifier (RI) #32 with an expiration date after the vial was opened. This deficient practice was observed during one of 25 medication pass opportunities. Findings include: RI #32 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #32's (MONTH) (YEAR) Physician order [REDACTED].>On 3/13/2018 at 4:15 PM, EI #3, RN, was observed preparing to administer RI #32's [MEDICATION NAME]from a new vial. After withdrawing the insulin from the vial, EI #3 placed the new insulin vial back into the box, without dating the box or vial. EI #3 then placed box into the medication cart drawer and locked it. The surveyor asked EI #3 what should have been done after opening the new vial of insulin. EI #3 stated, Dated the bottle. On 3/15/2018 at 3:15 PM, EI #4, Director of Nursing (DON), provided a copy of an undated inservice titled, Nursing Inservice MedPass (Medication Pass) Procedures. This document revealed the following: . Date all vials when punctured (expire in 28 days) . On 3/15/2018 at 3:36 PM, EI #4, DON, was interviewed and asked, what should be done when an insulin bottle was opened. EI#4 stated it should be initialed and dated. EI#4 was then asked why that was important. She explained it was an infection control issue and the medication needed to be wasted after 28 days.

Based on observation and interview, the facility failed to ensure a notice of the availability of the previous three years of survey results was posted for residents and/or visitors. This had the potential to affect all 62 of 62 residents residing in the facility and any visitors. Findings include: On 3/15/2018 at 8:40 AM, the survey result notebook was observed attached below the bulletin board inside the main entry door/lobby. A sign on the bulletin board indicated State Survey Results. The notebook contained reports from the (YEAR) Recertification Survey and the (YEAR) Life Safety Code Survey. There was no notice posting the availability of the previous three years of results. Employee Identifier (EI) #1, the Administrator, was interviewed on 3/15/2018 at 3:52 PM. EI #1 stated the survey results were posted by the front door entrance at railing height so that anyone could access them. When asked which survey results were contained within the binder, EI #1 said the (YEAR) Recertification Survey and the (YEAR) Life Safety Code Survey. When asked if there were any signs notifying residents or visitors of the availability of the previous years' survey reports, EI #1 said she did not think they had a sign that indicated the previous survey reports were available if requested.

Based on observations, interview, review of a facility policy titled Procedures for Cleaning Equipment and review of the Food and Drug Administration Food Code 2013, the facility failed to ensure: 1) a mop was not left in a bucket of water on 02/14/17; 2) an opened five pound bag of shredded cheese was not labeled with a use by date on 02/14/17; 3) the Robot Coup Blender was not air dried prior to being stored on 02/15/17, and 4) two of three sprinkler heads in the large storage room were free of dust. These deficient practices were observed during the survey and had the potential to affect all residents receiving meals from the kitchen. Findings Include: 1) Review of the Food and Drug Administration Food Code 2013, page 185, documented: . 6-501.16 Drying Mops. After use, mops shall be placed in a position that allows them to air-dry . On 02/14/17 at 2:34 p.m., during the initial tour of the kitchen, the surveyor observed a mop in a bucket of water near the entrance door of the kitchen. On 02/14/17 at 2:52 p.m., the surveyor observed the mop to remain in the bucket of water. The surveyor asked the Dietary Manager, Employee Identifier (EI) #7, should the mop be left in the water. EI #7 said no. On 02/16/17 at 12:08 p.m., the surveyor conducted an interview with EI #7. The surveyor asked EI #7, how should the mop be stored. EI #7 replied, On the top compartment of the mop bucket or hung up outside. The surveyor asked EI #7 why should the mop not be stored in water. EI #7 replied, Water can sour and cause bacteria growth and when we use it to mop we can spread bacteria. 2) Review of the Food and Drug Administration Food Code 2013, page 92, documented: . 3-501.17 Ready-to-eat, Time/Temperature Control for Safety Food, Date Marking . (B) . refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING 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 02/14/17 at 2:39 p.m., during the initial tour of the kitchen, the surveyor observed an opened five pound bag of shredded cheese on a shelf in the walk-in-cooler. The outside of the bag had a label dated 02/14/17. There was no use by date on the bag of shredded cheese. On 02/16/17 at 12:08 p.m., the surveyor conducted an interview with EI #7. The surveyor asked EI #7, when a food item such as the shredded cheese that was observed in the walk-in-cooler on 02/14/17, had been opened, what should be on the outside of the bag. EI #7 replied, A use by date. The surveyor asked EI #7 what was the rationale for the use by date. EI #7 replied, To keep or prevent serving spoiled foods. 3) Review of the Food and Drug Administration Food Code 2013, page 148, documented: . 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air dried . Review of a facility policy titled PROCEDURES FOR CLEANING EQUIPMENT, no date, documented: . Blender Immediately after use: . 3. Wash top of base . 4. Rinse with clean water and air dry . On 02/15/17 at 2:22 p.m., the surveyor observed a lid on top of the Robot Coupe blender. EI #7 removed the lid and water was observed at the bottom of the Robot Coupe blender. On 02/16/17 at 12:08 p.m., the surveyor conducted an interview with EI #7. The surveyor asked EI #7, how should the Robot Coupe blender be stored. EI #7 replied, Open so it can air dry. The surveyor asked EI #7, what is there a potential for when appliances are not allowed to air dry. EI #7 replied, Bacteria growth. 4) On 02/15/17 at 2:16 p.m., the surveyor observed two of three of the sprinkler heads in the ceiling of the large stock room to have dust-like particles on them. On 02/16/17 at 12:08 p.m., the surveyor conducted an interview with EI #7. The surveyor asked EI #7 what did she observe on the sprinkler heads in the large storage room. EI #7 replied, There were some dust particles. The surveyor asked EI #7, how often did the facility clean their sprinkler head (in the dietary department). EI #7 said, Usually when we visually see something on them. There is also an annual inspection. But I am going to add it to the new cleaning job list. A review of the facility's last annual fire sprinkler system inspection revealed the inspection was done on 04/25/16.

Based on observations, interviews, record review and review of Resident Identifier (RI) #3's Incontinent of Bowel and Bladder care plan, the facility failed to ensure RI #3 was checked and changed every two hours. This affected RI #3, one of 13 sampled residents whose plan of care was reviewed. Findings Include: RI #3 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #3's care plan titled Incontinent of bowel and bladder, with a Problem Onset date of 06/30/16, documented under approaches: . *Check and change q (every) 2 hours and prn (as needed). A Quarterly Minimum Data Set assessment, with an Assessment Reference Date of 12/11/16, assessed RI #3 to be always incontinent of bowel and bladder. On 02/15/17, from 3:00 p.m. through 6:15 p.m., the surveyor observed RI #3 in bed positioned to the left side. On 02/15/17 at 6:20 p.m., Employee Identifier #2, the Director of Nursing, entered RI #3's room to help the assigned Licensed Practical Nurse perform a body audit on RI #3. EI #2 said RI #3 had a small amount of urine in the adult brief. The surveyor shared with EI #2 that the surveyor had observed RI #3 from 3:00 p.m. to 6:15 p.m., and no staff had checked RI #3 for his/her incontinent status. The surveyor asked EI #2 how often should RI #2 be checked for his/her incontinent status. EI #2 replied, every two hours. On 02/15/17 at 6:58 p.m., the surveyor conducted an interview with EI #4, the Certified Nursing Assistant assigned to care for RI #3 on the evening shift on 02/15/17. The surveyor asked EI #4 was RI #3 continent or incontinent. EI #4 replied, Incontinent. The surveyor asked EI #4, how often should RI #3 be checked for his/her incontinent status. EI #4 replied.Every two hours.

Based on observation, interviews, record review, a review of Potter and Perry's Fundamentals of Nursing, and a review of the faciliyt's Cenuse and Condition of Residents report, the facility failed to ensure Resident Identifier (RI) #3's tube feeding container was labeled and dated, indicating the tube feeding had been changed within a 24 hour time span. This affected RI #3, one of one sampled residents with a tube feeding, and has the potential to affect the other 8 residents in the facility receiving tube feedings. Findings Include: A review of Potter and Perry's Fundamentals of Nursing, ninth edition, with a copyright date of 2017, page 1092, Unit VII, Physiological Basic for Nursing Practice documented: . (4) . change bag every 24 hours RATIONALE . Helps decrease bacterial growth in feeding tube system . RI #3 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set assessment, with an Assessment Reference Date of 12/11/16, assessed RI #3 to have a feeding tube during this assessment period. A review of the facility's Census and Condition of Residents, dated 02/15/17, revealed there were nine residents in the facility receiving a tube feeding. RI #3's February 2017 Physician order [REDACTED].> . GLUCERNA 1.2 RTH (ready to hang) AT 40 ML (milliliters)/HR (hour) X (times) 23 HRS VIA (by way of) PUMP . On 02/14/17 at 2:57 p.m., during the initial tour of the facility, the surveyor observed RI #3 to have a 1000 ml container of Glucerna 1.2 infusing via a feeding pump at 40 cc's (centimeters) an hour. There was 400 cc's of the tube feeding left in the container. The label on the container was not labeled or dated with any information. Employee Identifier (EI) #3, the Registered Nurse touring with the surveyor was asked when was the tube feeding hung. EI #3 said at midnight. The surveyor asked EI #3, should the container be labeled. EI #3 replied, yes Ma'am. On 02/15/17 at 10:32 a.m., and 02/16/17 at 12:59 p.m., attempts were made to contact the nurse responsible for hanging RI #3's tube feeding on 02/14/17. On 02/16/17 at 1:44 p.m., the surveyor conducted an interview with EI #2, the Director of Nursing. The surveyor asked EI #2, what should be on the label of a container of tube feeding. EI #2 replied, The flow rate, the date, time hung. The surveyor asked EI #2 what was the rationale for having that information on the label. EI #2 said you did not want the tube feeding to hang more than 24 hours. The surveyor asked EI #2 was that a standard of practice for the flow rate, the date and time hung to be on a tube feeding label. EI #2 replied, Yes Ma'am.

Based on observations, interviews and record review, on 02/15/16 during the evening shift for over a period of 3 hours and 15 minutes, the facility failed to ensure incontinent care was provided to Resident Identifier (RI) #3, a resident totally dependent on staff for Activities of Daily Living (ADL). This affected RI #3, one of four residents observed for incontinent care. Findings Include: RI #3 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set assessment, with an Assessment Reference Date of 12/11/16, assessed RI #3 as scoring a 9 on the Brief Interview for Mental Status indicating cognitive impairment. RI #3 was also assessed as being totally dependent on staff for all ADLs and was always incontinent of bowel and bladder. On 02/15/17, from 3:00 p.m. through 6:15 p.m., the surveyor observed RI #3 in bed positioned to the left side. No staff was observed to provide any type care to RI #3 during this time frame. On 02/15/17 at 6:20 p.m., Employee Identifier #2, the Director of Nursing, entered RI #3's room to help the assigned Licensed Practical Nurse perform a body audit on RI #3. The surveyor asked EI #2 what type care did RI #3 require. EI #2 replied RI #3 was total care. On 02/15/17 at 6:58 p.m., the surveyor conducted an interview with EI #4, the Certified Nursing Assistant assigned to care for RI #3 on the evening shift on 02/15/17. The surveyor asked EI #4 what was the purpose for checking a resident for their incontinent status. EI #4 said, so the resident would not have any skin break down. The surveyor asked EI #4 what type care did RI #3 require. EI #4 said RI #3 was total care.

Based on observation, interviews and review of a facility Checklist for Incontinent/Perineal Care, the facility failed to ensure a Certified Nursing Assistant (CNA), Employee Identifier #5, did not use gloves from her uniform pocket to provide incontinent care to Resident Identifier (RI) #5 on 02/15/17. This affected one of four CNAs observed providing incontinent care. Findings Include: RI #5 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set assessment, with an Assessment Reference Date of 02/05/17, assessed RI #5 to be totally dependent on staff for personal hygiene and to be always incontinent of bowel and bladder. A review of the facility Checklist for Incontinent /Perineal Care, no date, documented: . (5) Turn resident to the side to perform cleansing the anal area . (7) Wash hands or use hand sanitizer-Put on clean gloves! . On 02/15/17 between 4:07 p.m. and 4:45 p.m., the surveyor observed EI #5 provide incontinent care to RI #5. EI #5 had two incontinent pads, two adult briefs, Aloe Touch wipes, gloves and moisture barrier set up on the over-the-bed table. EI #5 positioned RI #5 to the left side, removed the pair of gloves she had on, used hand sanitizer on her hands and using gloves from the over the bed table, gloved. EI #5 proceeded to use an Aloe Touch wipe and wiped RI #5's anus in an upward motion, removing bowel movement from RI #5. EI #5 wiped RI #5's anus again in the same manner. EI #5 threw the used wipes in the trash can, then pulled gloves out of her uniform pocket and placed the gloves on the over-the-bed table. EI #5 went to the bathroom, washed her hands, came back to the bedside and gloved, using a pair of gloves that had been removed from her uniform pocket. On 02/15/17 at 4:55 p.m., the surveyor conducted an interview with EI #5. The surveyor asked EI #5, after she used all the gloves from the over the bed table, where did she get the other gloves from. EI #5 said she got them out of her pocket. The surveyor asked EI #5 was the pocket of a uniform considered clean or dirty. EI #5 said she knew the inside of her pocket was contaminated because she was in and out of her pockets. The surveyor asked EI #5 what could using gloves from the inside of a pocket be considered. EI #5 replied, Contamination. On 02/16/17 at 12:39 p.m., the surveyor conducted an interview with EI #6, the Infection Control Nurse. The surveyor asked EI #6 should CNAs use gloves from their uniform pocket to provide care with. EI #6 replied, Never. The surveyor asked EI #6 what was there a potential for when that was done. EI #6 replied, There is a potential for the spread of infection. The surveyor asked EI #6 was the pocket of a uniform considered a clean area. EI #6 said, No. On 02/16/17, EI #6 presented to the surveyor a facility form titled STAFF INSERVICE EDUCATION which documented: SUBJECT INCIDENT: Infection Control . Date: 2-16-17 TIME OF INITIAL INSERVICE 2:10 p.m. INTERVENTION: All gloves must be clean that are used for patient care . Never use gloves from your pocket for patient care .

Based on observations and interview, the facility failed to ensure the Daily Staffing List was not posted with all three shifts, at the beginning of the day shift, on three of three days of the survey. This had the potential to affect all residents residing at the facility. Findings Include: On 02/14/17 at 1:50 p.m., the Daily Staffing Form was observed on the bulletin board with all three shifts posted (day, evening and night), and documented all the required posting information (date, census, number of licensed and unlicensed staff and hours worked). On 02/15/17 at 7:45 a.m., the Daily Staffing List was observed on the bulletin board with all three shifts posted (day, evening and night), and documented all the required posting information (date, census, number of licensed and unlicensed staff and hours worked). On 02/16/17 at 8:05 a.m., the Daily Staffing List was observed on the bulletin board with all three shifts posted (day, evening and night), and documented all the required posting information (date, census, number of licensed and unlicensed staff and hours worked). On 02/16/17 at 11:55 a.m., an interview was conducted with the Administrator, Employee Identifier (EI) #1. EI #1 was asked who was responsible for completing and posting the Daily Staffing List. EI #1 replied, I am. EI #1 was asked, when do you post the Daily Staffing List. EI #1 replied, the first thing in the morning before the beginning of the first shift. EI #1 was asked if all three shifts (day, evening and night) are posted at the beginning of the first shift for the day. EI #1 replied, yes. EI #1 was asked what does the regulations say about the posting requirements. EI #1 replied the staff posting should be posted at the beginning of each shift. The surveyor then asked EI #1 if the Daily Staffing Listwere posted according to the regulation. EI #1 replied, no because they were not posted right before each shift.

Based on observations, record reviews, and interviews, the facility failed to ensure a Certified Nursing Assistant (CNA) separated the labia and cleaned the vaginal area when performing incontinent care for Resident Identifier (RI) #6, a resident with a history of UTI's (Urinary Tract Infections), on 1/27/16. This affected RI #6, one of two residents observed during perineal and incontinence care. Findings Include: A review of a facility document titled, Checklist for Incontinent /Perineal Care with no date, documented: Policy: Pericare is performed on incontinent residents . Procedure: . 14. Female Resident: a. Wash the entire area . c. Wipe each side of the labia . RI #6 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of RI #6's most recent Quarter MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/9/15 revealed the resident had short-term and long-term memory problem and further indicated the resident's cognition was severely impaired for daily decision making. The MDS also revealed the resident required total dependence with personal hygiene and toileting. A review of RI #6's Plan of Care documented: . Problem . 10/11 UTI, 1/13 UTI, 3/13 UTI . 3/2/15 . TX (Treatment) for UTI with Abx (antibiotic) [MEDICATION NAME] 350 mg (milligram) IM (Intra-muscular) qd (everyday) x (times) 7 days . A review of RI #6's Urinalysis w/ (with) micro labs documented: 7/30/15 the urinalysis out of range results: Leucocytes 1+, WBC (white blood cell) 5-10, and Bacteria 3+ with culture result dated 8/1/15 documented GRAM NEGATIVE RODS with colony count greater than 100,000 . 8/14/15 the urinalysis out of range results: Appearance Hazy, Leucocytes 1+, WBC Rare, Bacteria 1+, [MEDICATION NAME] Cells Few with the culture result dated 8/17/15 documented GRAM POSITIVE COCCI with colony count greater than 100,000 . 9/11/15 the urinalysis out of range results: Specific Gravity less than 1.005, Leucocytes 1+, WBC 1-5, Bacteria 1+, [MEDICATION NAME] Cells Few with the culture result dated 9/12/15 GRAM NEGATIVE RODS with colony count 100,00 . On 1/27/16 at 3:48 PM, the Surveyor observed EI #2 and EI #3, (two CNAs), perform perineal and incontinence care on RI #6. Both CNAs gel sanitized their hands and donned gloves. With the same gloves on, EI #2 unfastened the left side of RI #6's brief as EI #3 unfastened the right side of the brief. EI #2 obtained a clean wipe and wiped down RI #6's right groin, tossed that wipe in the trash bag then obtained a clean cloth and wiped down RI#6's left groin. Then EI #2 wiped down the middle vaginal area after obtaining another clean wipe. EI #2 was observed wiping from front to back, but did not separate the labia and clean the labial folds from outer to inner before cleansing down the middle of the perineal area. On 1/28/16 at 11:15 AM, the Surveyor conducted an interview with EI #4, the QA (Quality Assurance)/ Infection Control Nurse. EI #4 was asked how should pericare be performed on a female's vaginal area. EI #4 replied it should be from front to back with a clean wipe with every stoke. Open the vaginal gently with a gloved hand to exposed the vaginal inside. With a gloved hand go down one outside and toss that wipe in the trash, take a second clean wipe go down the front to back, toss that in the trash and the third wipe, come down the center from front to back. EI #4 was asked what potential harm to the resident can occur if the labia is not parted and wiped appropriately. EI #4 stated, There could be fecal material that was not removed or it could possibly lead to UTI or vaginal discomfort. On 1/28/16 at 3:15 PM, the Surveyor conducted an interview with EI #2, a CNA. EI #2 was asked, when performing incontinence care how should the labia be cleansed. EI #2 stated, You have to open it (labia) up and wipe downward. EI #2 was asked if she opened the labia. EI #2 stated, Well I thought I did. EI #2 was asked how she was taught to wipe the labia. EI #5 stated, Open it up and wipe down. EI #5 was asked what was the facility policy on cleansing the vaginal area during incontinence care. EI #2 stated, Wipe 3 times downward then turn then over and do the bottom and wipe more than 3 times to get what ever off. EI #2 was asked what potential harm to the resident could occur if the vaginal area was not cleansed by parting the labia and properly cleansing it. EI #2 stated, Infection.

Based on observation, interview, and record review, the facility failed to ensure a licensed staff sanitized her hands during medication administration on 01/27/2016. This affected Resident Identifier (RI) #15 and RI #16, two of six residents observed during medication administration. Findings include: A review of a facility document titled, Nursing Inservice Med Pass Procedure, with no date revealed the following: . Infection Control - This is to ensure that contamination between residents does not occur. You must: 1) Use alcohol between residents when there has not been direct resident contact 2) Washing with soap and water is done after direct resident contact. A review of a facility document titled, Med Pass Procedures with no date, revealed the following: . Hand Washing . If you have to handle a resident, reposition, . then wash your hands after you finish with the resident. If you just go into a room and give the resident a few medicines in a cup and there is no contact then a alcohol prep is sufficient. On 1/27/2016 at 7:45 AM, Employee Identifier (EI) # 6 (LPN/ (Licensed Practical Nurse) was observed administering medications to RI #15 and RI #16. EI #6 administered medications to RI #15 and then administered medications to RI #16. EI # 6 did not wash her hands or use an alcohol based hand sanitizer before and after administering medications to RI #15, and before administering medications to RI #16. On 1/27/2016 at 2:00 PM, an interview was conducted with EI #6. EI #6 was asked what did she fail to do when administering medications to RI #15 and RI #16. EI #6 said she failed to clean her hands between patients. EI #6 was asked what did the facility policy document regarding hand washing during medication administration. EI #6 replied when hands come in contact with a resident we are to wash our hands before we go to the next resident. EI #6 was asked what the potential harm in not washing hands during medication administration. EI #6 said infection.

Based on observation, interview, and record review, the facility failed to post nurse staffing prior to the beginning of each shift. The facility further failed to ensure the daily nurse staffing form contained all of the required data. This had the potential to affect all residents residing in the facility. Findings include: The facility was unable to provide a policy prior to 01/28/2016. On 1/26/2016 at 5:10 PM, the surveyor observed the nurse staffing form attached to a bulletin board in the entryway of the nursing facility. All shifts were filled in with the number of staff working without the hours of licensed and unlicensed staff tabulated. On 1/27/2016 at 11:10 AM, the surveyor observed the nurse staffing form. All shifts were filled in with the number of staff working without the hours of licensed and unlicensed staff tabulated. On 1/28/2016 at 7:30 AM, the surveyor observed the nurse staffing form. All shifts were filled in with the number of staff working without the hours of licensed and unlicensed staff tabulated. On 1/28/2016 at 2:30 PM, an interview was conducted with Employee Identifier (EI) #5, Administrator. The surveyor asked if the facility was posting hours according to guideline. EI #5 said they had just started adding hours to the staff posting. EI #5 said this had not been done for the 1/26/2016, 1/27/2016 and the 1/28/2016.

Based on record review, observations and interviews, the facility failed to ensure a CNA (Certified Nursing Assistant) was seated while feeding RI (Resident Identifier) #15 during the evening meal on 12/16/2014. This affected 1 of 1 residents observed being fed during the evening meal on 12/16/2014. The facility further failed to ensure a CNA knocked on resident's doors before entering. The CNA was observed from 3:07 PM to 3:50 PM on 12/17/2014 to enter RL (Room Locator) #1,#2,#3,#4,#5 and #6 without knocking. This affected 4 of 8 sampled residents with rooms located on Station II. Findings Include: A review of a facility document titled,"( Name of Facility)Standards of Care" with an effective date of 2/5/2009 revealed: "...16. Resident's rights are honored and residents are treated with dignity and respect...." A review of a facility document titled, "STAFF INSERVICE EDUCATION SUBJECT INCIDENT TYPE- Knocking on doors; addressing resident's appropriately" with a date of 11/05/14 revealed: "...Attention: Nursing Staff ...3. Remember to Knock on doors, allow the resident time to respond if able...." RI #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI#15's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/17/2014 revealed RI #15 had modified independent cognitive skills for daily decision making. The MDS also revealed RI#15 was totally dependent for all ADL's (Activities of Daily Living). On 12/16/2014 at 5:28 PM, the surveyor observed EI #6, CNA standing while feeding RI#15. On 12/16/2014 at 5:35 PM, the surveyor conducted an interview with EI #6. The surveyor asked EI #6 how long had she worked at the facility. EI #6 said she had worked at that facility for three years and had been a CNA since 2007. EI #6 was asked what position was she supposed to be in when feeding a resident. EI #6 said she could sit but she mostly stood. EI #6 was asked was she standing while feeding RI #15. EI #6 said yes. EI #6 was asked what kind of harm could come from standing while feeding a resident. EI #6 said she didn't know and she asked the surveyor if she was supposed to sit. EI #6 was asked if she was supposed to sit when feeding a resident. EI #6 said she thought she was but didn't know. On 12/17/2014 at 11:32 AM , the surveyor conducted an interview with EI #2 Quality Assurance/Infection Control RN (Registered Nurse). EI #2 was asked who trained CNA staff on ADL's, for example, bathing, feeding and incontinent care. EI #2 said when we hire them, they are already certified, we do follow up especially with the new ones. EI #2 was asked how long had she assisted with training the CNA's. EI #2 said 2 1/2 years. EI #2 was asked how were the CNA's taught to position themselves when feeding residents. EI #2 said they are supposed to sit at eye level to make the resident feel comfortable as if they were sitting at a table eating with them. EI #2 was asked how did she ensure CNA's understood what they had been taught. EI #2 said they have routine inservices that cover various subjects. EI #2 also said spot checks were frequently done by all the nurses as daily care was given. EI #2 was asked what was the potential harm in staff standing while feeding. EI #2 said the main potential harm would be the dignity of the resident. On 12/17/14, EI #6, CNA was observed from 3:07 PM to 3:50 PM entering RL (Room Locator) #1, RL #2, RL #3, RL #4, RL #5 and RL #6 without knocking. On 12/17/14 at 4:58 PM, an interview was conducted with EI #6,CNA. EI #6 was asked what she was supposed to do before entering a resident's room. EI #6 said knock. EI #6 was asked if she knocked on RL #1, RL #2, RL #3, RL #4, RL #5 or RL #6 before she entered that day. EI #6 said truthfully she could not say that she did but she knew she was supposed to. EI #6 was asked why she did not knock on the resident's door. EI #6 said she was just used to walking in and sometimes she did knock, she had to get in the habit of knocking. EI #6 was asked what did the facility policy say about knocking on doors before entering a resident's room. EI #6 said it told them to knock on all doors. EI #6 was asked what was the potential harm in not knocking on a resident's door before she entered. EI #6 said it would be interrupting their privacy. She said she would not want anyone to walk in her house. On 12/18/14 at 1:55 PM, an interview was conducted with EI #2, RN (Registered Nurse), Quality Assurance Nurse/Infection Control Nurse. EI #2 was asked what the CNAs were taught to do before entering resident's rooms. EI #2 said they were taught to always knock on the door, announce their presence and wait to be invited in. EI #2 was asked what the facility policy said staff should do before entering a resident's room. EI #2 said she did not know what the policy said, but it was the facility's rule to knock on doors, announce yourself and wait for permission to come in; that's their home. EI #2 was asked what was the potential harm in not knocking on a resident's door before entering. EI #2 said it would be a dignity issue, that was their home and it would be a lack of respect and depending on the situation, someone who was not presentable could be exposed. On 12/18/14 at 3:39 PM, an interview was conducted with EI #1, DON (Director of Nursing). EI #1 was asked how CNAs were supposed to be positioned when feeding residents. EI #1 said sitting in a chair beside the resident. EI #1 was asked if it was an acceptable practice for that facility for a CNA to stand while feeding a resident. EI #1 said no. EI #1 was asked what was the potential harm if a CNA stood while feeding a resident. EI #1 said they could feed them too fast and make them feel hurried. EI #1 was asked what the facility policy said about CNAs entering rooms; what were they supposed to do. EI #1 said knock and say may I come in. EI #1 was asked if it was an acceptable practice for that facility for a CNA to enter 6 different resident's rooms without knocking. EI #1 said no. EI #1 was asked what was the potential harm if a CNA entered residents' rooms without knocking. EI #1 said it was a dignity issue, respect, privacy.

Based on record review, and interview the facility failed to ensure residents whose funds are managed by the facility received a receipt after requesting personal funds from petty cash. This affected 6 of 40 residents whose funds are managed by the facility. Findings Include: A facility's policy titled "GOODWATER HEALTHCARE CENTER, Petty Cash Receipts" with no revealed date, "... A receipt is made for each resident transaction whether a deposit or withdrawal."... On 12/18/2014 at 2:40 PM, an interview was conducted with EI #4 (employee Identifier), Bookkeeper. EI #4 was asked what was your policy on giving receipts to residents when requesting funds from petty cash. EI #4 replied if they ask for a receipt. EI #4 was asked who was responsible for managing the residents personal financial accounts. EI #4 replied she was. EI #4 was asked when can residents request monies from their account. EI #4 replied 24 hours a day. EI #4 was asked how often are residents given a receipt for money they request from petty cash. EI #4 replied whenever they ask or request for a receipt. EI #4 was asked are residents given a receipt when requesting personal funds from petty cash. EI #4 replied no. EI #4 was asked why are residents not given a receipt when requesting funds from petty cash. EI #4 replied they have not asked for a receipt. EI #4 was asked should residents be given a receipt when requesting funds from petty cash. EI #4 replied yes ma'am.

Based on record review, observation and interview, the facility failed to ensure RI (Resident Identifier) #11's O2 ( Oxygen) tubing and water bottle was changed every Friday per physician's orders [REDACTED].#11's O2 tubing and water bottle was observed on 12/17/14 and 12/18/14 with a date of 12/9/14 documented on them. This affected 1 of 3 residents observed wearing O2. Findings Include: A review of a facility policy titled, "OXYGEN THERAPY" with an approved date of August 29, 2008 revealed: "...PROCEDURES: ...4. Change humidifier bottle weekly and/or PRN (as needed). 5. Clean concentrator, change filter and tubing weekly and/or PRN...." A review of RI #11's physician's orders [REDACTED]. RI #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #11's most recent Annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/29/14 revealed the resident was severely cognitively impaired for daily decision making. The MDS further revealed that the resident was totally dependent on staff for all ADLs (Activities of Daily Living). The MDS also revealed that RI #11 received oxygen therapy. On 12/17/14 at 3:55 PM, the surveyor observed RI #11 with O2 infusing at 2L/NC. O2 tubing and water bottle was dated 12/9/14. On 12/18/14 at 8:10 AM, the surveyor observed RI #11 with O2 infusing at 2L/NC. O2 tubing and water bottle was dated 12/9/14. On 12/18/14 at 9:04 AM, an interview was conducted with EI #5, RN (Registered Nurse). EI #5 was asked what date was on the O2 tubing and water bottle of RI #11. EI #5 said 12/9/14. EI #5 was asked how often was RI #11's water bottle and O2 supposed to be changed. EI #5 said weekly and PRN. EI #5 was asked who was responsible for changing the O2 tubing and water bottle of RI #11. EI #5 said it was on the treatment record to be changed weekly and whatever night it fell on and whatever nurse was on duty that night should change it. EI #5 was asked why was it not changed per physician's orders [REDACTED].#5 said she did not know. EI #5 was asked what was the potential harm in not changing the O2 tubing and water bottle according to physician's orders [REDACTED]. sanitary issue. On 12/18/14 at 3:47 PM, an interview was conducted with EI #1, DON (Director of Nursing). EI #1 was asked when was RI #11's O2 tubing and water bottle to be changed. EI #1 said weekly. EI #1 was asked what the physician's orders [REDACTED].#11's O2 tubing and water bottle. EI #1 said weekly. EI #1 was asked why would RI #11's O2 tubing and water bottle be dated 12/9/14 on 12/17/14 and 12/18/14 if the physician's orders [REDACTED]. EI #1 said the nurse's didn't change it. EI #1 was asked who was responsible for changing the water bottle and O2 tubing. EI #1 said 7p-7a nurse. EI #1 was asked could any nurse change the O2 tubing and water bottle. EI #1 said any nurse could change it. EI #1 was asked what was the potential harm in not changing the O2 tubing and water bottle as ordered. EI #1 said risk of infection.

Based on record review, observation and interview, the facility failed to ensure a CNA (Certified Nursing Assistant) changed her gloves or washed her hands after cleaning RI (Resident Identifier) #11's buttocks and before touching a clean brief and linen during incontinent care on 12/17/14. The facility also failed to ensure the CNA did not place a urine soiled brief on the bed next to the resident during incontinent care on 12/17/14. This affected 1 of 2 residents observed during incontinent care. Findings Include: A review of a facility policy titled, " STANDARD PRECAUTIONS replaces UNIVERSAL PRECAUTIONS " with no date revealed: " ...A. HANDWASHING 1. Wash hands after touching ...excretions, and contaminated items, whether or not gloves are worn....It may be necessary to wash hands between tasks and procedures on the same patient to prevent cross-contamination of different body sites.... B. GLOVES ...Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching noncontaminated items ...and wash hands immediately to avoid transfer of microorganisms ... " RI #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #11's most recent Annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/29/14 revealed the resident was severely cognitively impaired for daily decision making. The MDS further revealed that the resident was totally dependent on staff for all ADLs (Activities of Daily Living). The MDS also revealed that RI #11 was always incontinent of bowel and bladder. On 12/17/14 at 3:55 PM, EI (Employee Identifier) #3 was observed performing incontinent care for RI #11. EI #3 wiped RI #11's buttocks and placed a clean brief underneath the resident without changing her gloves or washing her hands. EI #3 removed the soiled brief and left the brief laying on the bed while she and another CNA pulled the resident up in bed. EI #3 then placed the soiled brief in a plastic bag and pulled the covers up on the resident. EI #3 then removed her gloves and washed her hands. On 12/17/14 at 4:20 PM, an interview was conducted with EI #3,CNA. EI #3 was asked during incontinent care when are hands supposed to be washed. EI #3 said she washed after she finished and she could have washed during her clean up of RI #11. EI #3 was asked what should she have done after she cleaned RI #11's buttocks and before she touched the clean brief and linen. EI #3 said peeled gloves off and got new ones. EI #3 was asked if she changed gloves or washed her hands after she cleaned RI #11's buttocks and before she touched the clean brief and linen. EI #3 said no. EI #3 was asked what was the potential harm in not changing her gloves or washing her hands after she cleaned RI #11's buttocks and before she touched a clean brief and linen. EI #3 said germs. EI #3 was asked where should a urine soiled brief be placed after removing it from the resident. EI #3 said in the bag. EI #3 was asked where she had placed the brief. EI #3 said on the bed. EI #3 was asked what was the potential harm in placing a urine soiled brief on the resident's bed. EI #3 said germs; spreading germs. On 12/18/14 at 2:00 PM, an interview was conducted with EI #2, RN (Registered Nurse), Infection Control Nurse/Quality Assurance Nurse. EI #2 was asked how were infections prevented in the facility. EI #2 said good handwashing was the main thing to do to prevent the spread of infection. EI #2 was asked how were infections controlled in the facility. EI #2 said every infection was tracked to see if there was a pattern of certain bacteria that was occurring in certain residents. EI #2 was asked if direct care staff were washing their hands and changing their gloves according to facility protocol. EI #2 said they were supposed to be, they were directed to and they have been trained. EI #2 was asked how she monitored direct care staff to ensure they were washing their hands and changing gloves according to facility protocol. EI #2 said she watched as she was out on the hall and staff were providing care. EI #2 also said she watched during perineal care and incontinent care and made sure they were using the correct procedure. On 12/18/2014 at 3:50 PM, an interview was conducted with EI #1, DON (Director of Nursing). EI #1 was asked when were CNAs supposed to wash their hands or change gloves during incontinent care. EI #1 said before and after. EI #1 was asked what should be done after cleaning a resident's buttocks and before touching a clean brief. EI #1 said gloves should be removed and discarded in a plastic bag, wash or sanitize hands and then put on clean gloves. EI #1 was asked if it was an acceptable practice for that facility for a CNA to clean a resident's buttocks and then touch a clean brief without changing gloves or washing their hands. EI #1 said no. EI #1 was asked where should a urine soiled brief be placed after it was removed from underneath the resident. EI #1 said placed in a plastic bag. EI #1 was asked if it was an acceptable practice for that facility for a CNA to remove a urine soiled brief from underneath the resident and place it on the bed next to the resident. EI #1 said no. EI #1 was asked what was the potential harm in cleaning a resident's buttocks and then touching the clean brief without changing gloves or washing hands and then placing that brief on the resident. EI #1 said contamination. EI #1 was asked what was the potential harm in removing a urine soiled brief from underneath the resident and placing it on the bed next to the resident. EI #1 said contamination and infection.

Based on observation, interview and record review, the facility failed to maintain stored ice cream in a completely frozen state, and failed to consistently date and label stored left-overs. Facility staff also failed to ensure all food was stored off of the floor. This had the potential to affect all 47 residents for whom meals were prepared and served at the time of this survey. Findings included: During the initial kitchen tour on 01/06/14, between 3:20 PM and 3:25 PM, the following was observed: 1) Three individual (3-4 oz) portions of ice cream were stored in the reach-in ("True") freezer. These individual cups of ice cream were soft to the touch, rather than in a frozen hard state. Regulation #3-501.11 of the 2013 Food Code mandates that: "Stored frozen foods shall be maintained frozen." 2) Several containers of left-over foods were stored in the reach-in refrigerator without dated labels, including one container of cooked turnip greens, and one container of cooked bacon. The facility policy related to "Food Storage" (undated) specifies: "4. ...All containers must be legibly and accurately labeled." Another facility policy titled, "Reusable Food Storage Containers" (undated) specifies: "Food storage containers used to store any prepared foods or foods that must be removed from their original containers will meet standards of acceptability and safety." "Responsible Personnel: The Food Service Supervisor and all food service personnel are responsible for implementing and adhering to this policy." "Procedure: 4. All reusable containers must be properly labeled listing the stored food item and the date the food was stored." 3) One container of vanilla pudding was stored in the reach-in refrigerator with a use-by date of 01/04 (and an "in" date of 01/02). A container of fruit cocktail was labeled with dates of 01/01 to 01/03 (to not be used beyond 01/03). A facility policy titled, "Leftover Food Usage" (undated) specifies as one procedure: "4. Refrigerated leftover food items must be used within 48 hours of original preparation..." 4) One large net bag of fresh onions was stored inside an open plastic crate, directly on the floor of the pantry. The Dietary Manager was interviewed on 01/08/14 at 7:55 AM regarding the above concerns. When asked how onions were supposed to be stored, the Dietary Manager confirmed the (bags) were usually stored on top of another crate (off of the floor); not directly on the floor. Regulation #3-305.11 (A) of the 2013 Food Code, related to "Food Storage" specifies: "...Food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor."

Based on record review and interviews the facility failed to ensure staff reported an allegation of possible verbal abuse of Resident Identifier (RI) #4 to the administrator. Therefore the facility failed to report this allegation of abuse to the State Agency. This affected 1 of 12 sampled residents. Findings Include: A review of the facility's "ABUSE PREVENTION POLICY AND PROCEDURES" revealed, "It is the policy of Goodwater Health Care that residents must not be subjected to abuse by anyone (including ...family members... To ensure the safety and well being of each resident, Goodwater Health Care will promote and protect the right of each resident to be free from verbal, sexual, physical or mental abuse ..." Verbal abuse is defined as "... any use of oral, written, or gestured language that includes disparaging and derogatory terms to residents..." The "ABUSE PREVENTION POLICY AND PROCEDURES" also documented "IV. IDENTIFICATION OF POSSIBLE INCIDENTS OR ALLEGATION WHICH NEED INVESTIGATION 1. All incidents/accidents are reported to charge nurse whether or not there is evidence of apparent injury. 2. Incident/Accident form is completed upon examination of resident identified and placed at nurses station for review by supervisor and appropriate follow up and/or investigation by Administrator, Director of Nursing, or Q. A. (Quality Assurance) Nurse. ...V. INVESTIGATION AND REPORTING OF INCIDENTS AND/OR ALLEGATIONS POLICY AND PROCEDURE: ... 3. Complete Investigative Report form required by Division of Health Care Facilities... Fax the form to the Complaint Unit within 24 hours of the suspected abuse..." Resident Identifier (RI) #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #4's Quarterly Minimum Data Set with an Assessment Reference Date of 12/12/12 revealed RI #4 to have a Brief Interview of Mental Status (BIMS) score of 12. A score of 12 revealed RI #4's cognitive status to be moderately impaired. A review RI #4's medical record, nurses notes, revealed "12-29-12 900 AM Into Resident's Room to give meds (medication). Resident was crying, ask why and she stated, 'My son (name) called me and talked so ugly to me. I just can't stand it when he calls and does that. I just don't know what to do'." During an interview 01/04/2013 at 12:45 PM, the surveyor asked Employee Identifier (EI) #2 what was considered to be verbal abuse. EI #2 explained she would report anytime that a staff member talked rough to the resident or if staff told a resident they would not do get something they had requested. The surveyor asked EI #2 what would she do if she heard of a family member being verbally abusive to a resident. EI #2 stated she would report it. The surveyor asked EI #2 if she was aware of RI #4's family being verbally abusive. EI #3 stated she had given her the medication on 12/29/12. EI #2 explained the resident was not talking with the son at the time. EI # 2 stated if she had heard the sponsor talking to RI #4 she would have reported it. The surveyor asked EI #2 what would she had done if RI #4 had told her a staff member had said something ugly to her. EI #2 explained it would have been different, explaining that she would have talked to the staff member and found out why they did that. During an interview on 01/04/2013 at 1:25 PM, the surveyor asked EI #1, the Administrator, how were staff trained to report potential abuse from family members. EI #1 explained it is part of the normal abuse training and that abuse could be caused by a visitor, family or other residents. EI #1 explained she provided monthly in-services which required feedback from the staff. She further explained during these monthly in-services she stressed to the staff to report things to her. The surveyor asked EI #1 if she was aware of RI #4 being upset regarding the son's call on 12/29/2012. EI #1 said she was not. The surveyor provided EI #1 with the nurse's note dated 12/29/2012. The surveyor asked EI #1 if this should have been reported to her. EI #1 stated, "I think it should have". The surveyor asked EI #1 if she would have investigated the statement RI #4 made on the 29 th. EI #1 said she would have.