Every finding on record at Gulf Coast Health and Rehabilitation, LLC

Based on observations, interviews, a review of facility policies: Food Preparation Guidelines, Use of Gloves and Hairnets, Cleaning of Miscellaneous Equipment and Utensils and the (YEAR) Food Code regulations, the facility failed to ensure staff: 1) thawed frozen meat using recognized sanitary measures; 2) utilized hair restraints while handling clean utensils and food; and 3) air dried and stored clean dome lids and bases on drying racks free of an accumulation of rust. This had the potential to affect all 87 residents for whom meals were prepared and served at the time of this survey. 1) THAWING OF FROZEN MEATS The facility policy, Food Preparation Guidelines dated 08/10/18, specifies: .food should be prepared by methods that conserve nutritive value, flavor and appearance. The process by which staff are directed to thaw frozen foods is as follows: .d. Frozen foods should be properly thawed.Thawing under cold running (less than or equal to 70 degrees) water for 2 hours or less is acceptable if food is completely submerged and water is running fast enough to agitate and float off loose ice particles. The (YEAR) Food and Drug Administration Food Code regulation 3-501.13 Thawing specifies: .TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be thawed: (B) Completely submerged under running water: (1) At a water temperature of 70 degrees F (Fahrenheit) or below, . During the initial kitchen tour, on 01/07/20 at 7:50 a.m., three long cylinders of frozen hamburger were observed in the preparation sink, with cool tap water running continuously over each. The tap water was draining into the sink. None of the meat was submerged. On 01/08/20 at 11:50 a.m., the cook, Employee Identifier/EI #5 verified she was responsible for thawing the hamburger on 01/07/20. When asked how frozen meat was typically thawed, EI #5 stated they usually let the meat thaw in the cooler, but it had not been gotten out (of the freezer) in time. On 01/08/20 at 4:26 p.m., the surveyor interviewed the facility's Registered Dietitian, EI #7. When asked how staff were to thaw frozen meat, EI #7 responded food could be thawed under refrigeration, under cold running water submerged, or in a microwave oven. When asked why it was important to submerge frozen meat under running water, EI #7 stated, because that was the Food Code regulation. 2) HAIR RESTRAINTS The facility policy, titled, Use of Gloves and Hairnets dated 08/15/09, directs staff as follows: .i. Wear hair restraints (bonnets, caps, nets, to cover hair) when preparing or handling food. The (YEAR) Food Code, regulation 2-402.11, titled: Effectiveness. specifies the following: (A) .FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS . On 01/07/20 at 7:50 a.m., the breakfast tray line was in progress. Staff member, EI #8 (identified as the dishwasher), was at the end of the tray line, adding beverages and lids on each tray. He was noted to have a light beard and mustache with no facial covering. A beard restraint was hanging unused, around his neck. On 01/07/20 at 8:10 a.m., the surveyor asked EI #8 to explain the facility's policy regarding the use of facial masks/hair restraints. EI #8 stated they were supposed to wear the mask so hair would not fall into the food. When asked if he should have had the mask on during the tray line, EI #8 responded yes. 3) CLEAN DRYING RACKS The facility policy, Cleaning of Miscellaneous Equipment and Utensils dated 09/03/19, specifies the basic procedures after cleaning equipment as follows: 1.Air dry; assemble and store in clean place. The (YEAR) Food Code, regulation 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) .cleaned EQUIPMENT and UTENSILS . shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; During the initial kitchen tour on 01/07/20 at 7:50 a.m., two metal drying racks, one with Dinex Lids, the other with Dinex bases were observed with a significant accumulation of rust. Using a dry paper towel, the surveyor was able to wipe a residue of rust off one area of the rack on which lids were stored. Both racks had a particularly heavy accumulation of rust above the wheel wells. A significant accumulation of rust was apparent all over the wire supports and support beams on both racks. On 01/08/20 at 9:50 a.m., the surveyor asked the Consultant Registered Dietitian, EI #7, when the drying racks had last been cleaned. EI #7 responded they needed more drying racks. When asked what the potential problem rust accumulation might pose, EI #7 responded, the rust could get on the surface of the dome lids. EI #7 stated the department needed new racks.

Based on observations, interviews, record review and review of a facility policy titled, INFECTION PREVENTION & (and) CONTROL MANUAL, the facility failed to ensure the treatment nurse, Employer Identifier (EI) #10, removed her gloves, sanitized her hands, and applied new gloves after cleaning Resident Identifier (RI) #17's right heel and sacrum pressure ulcers, and before applying the treatments and clean dressings to the pressure ulcers when providing wound care for RI #17 on 01/09/20. This deficient practice affected RI #17, one of one sampled resident observed for wound care. Findings Include: Review of a facility policy titled, INFECTION PREVENTION & (and) CONTROL MANUAL, dated 09/01/17, revealed the following: . Policy title: Hand Hygiene . PURPOSE: To provide guidelines to employees for proper and appropriate hand washing techniques that will aide in the prevention of the transmission of infections. STANDARD: Hand washing should be performed between procedures with resident/quest(s) based upon the principle that all blood, . non-intact skin, . may contain transmissible infection agents. PR[NAME]ESS: . III. Hand Hygiene Hand Hygiene continues to be the primary means of preventing the transmission of infection . RI #17 was admitted to the facility on [DATE], and readmitted on [DATE] with a [DIAGNOSES REDACTED]. RI #17's (MONTH) 2020 Physician order [REDACTED].#17's left heel and sacrum. 01/09/20 at 9:21 a.m., the surveyor observed EI #10, Treatment Nurse, provide wound care to RI #17. The surveyor observed a Stage 2 pressure ulcer to RI #17's left heel. EI #10, with gloved hands, cleaned the area, and then with the same soiled/contaminated gloves, applied skin prep. She then placed a clean Mepolex AG dressing over the pressure ulcer. EI #10 picked up a clean [MEDICATION NAME] dressing with the same soiled/contaminated gloves still on, and placed the [MEDICATION NAME] dressing over the Mepolex dressing on RI #17's right heel. EI #10 next put RI #17's left sock and heel protector back on, with the same soiled/contaminated gloves. EI #10 removed her gloves, washed her hands in the bathroom, applied a new pair of gloves and proceeded to provide wound care to RI #17's Stage II sacrum pressure ulcer. EI #10 cleaned the sacrum area, then, with the soiled/contaminated gloves, applied collagen powder to the sacrum pressure ulcer, picked up a clean [MEDICATION NAME] dressing and applied the dressing over the sacrum area with the same soiled/contaminated gloves. On 01/09/20 at 10:28 a.m., the surveyor conducted an interview with EI #10. The surveyor asked EI #10 what should she have done after cleaning RI #17's pressure ulcers, before she applied the clean dressings. EI #10 said she should have removed her gloves, washed her hands and applied new gloves. When asked what potential problem could result when that was not done, EI #10 said infection. On 01/09/20 at 2:48 p.m., the surveyor conducted an interview with EI #2, the Infection Control Nurse. The surveyor asked EI #2 when should the nurse remove gloves during wound care. EI #2 said when the gloves were soiled, when going from dirty to clean, and if the nurse took the bandages off she should remove the gloves and wash her hands. When asked if this is not done what type issue would that be considered; EI #10 said it was an infection control issue.

Based on interviews, record review and review of a facility policy titled, MEDICATION ADMINISTRATION STANDARDS PSYCHOACTIVE DRUG PROT[NAME]OL, the facility failed to ensure Resident Identifier (RI) #85 had a medical [DIAGNOSES REDACTED]. This deficient practice affected RI #85, one of six residents sampled for the unnecessary use of medications. Findings Include: Review of an undated facility policy titled, MEDICATION ADMINISTRATION STANDARDS PSYCHOACTIVE DRUG PROT[NAME]OL, revealed the following: Statement of Policy: The facility acknowledges the resident's right to be free from psychopharmacological drugs administered for purposes of discipline or convenience and not required to treat the resident's medical symptoms . Unnecessary drugs, as defined by federal regulations, are any drugs when used: . Without adequate indication for its use . RI #85's Level 1 Clarification for Nursing Home Admissions, dated 12/04/19, revealed the following: . Medication Clarification: 1. Medication: ([MEDICATION NAME] was written in) . Diagnosis (dementia was written in) . RI #85 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. RI #85's (MONTH) 2019 physician's orders [REDACTED]. A review of RI #85's (MONTH) 2019 eMAR (Electronic Medication Administration Record) revealed RI #85 received the [MEDICATION NAME] on the 12th, 13th, 14th, 15th and 16th of December. On 01/08/20 at 4:47 p.m., the surveyor conducted an interview with the facility's Medical Director, EI #3. The surveyor asked EI #3 were there specific medical [DIAGNOSES REDACTED]. EI #3 said yes. When asked was Dementia a justifiable medical [DIAGNOSES REDACTED].#3 said no. On 01/09/20 at 10:33 a.m., the surveyor conducted an interview with Employee Identifier (EI) #1, the Director of Nursing (DON). EI #1 said the [MEDICATION NAME] was a medication the facility's physician verified RI #85 was receiving while in the hospital. EI #1 said the physician said to reconcile the medications RI #85 was receiving in the hospital, and continue them. When asked if RI #85 had a medical [DIAGNOSES REDACTED].#1 said looking at RI #85's Level I Clarification for Nursing Home Admission, the [DIAGNOSES REDACTED].#1 was Dementia a justifiable medical [DIAGNOSES REDACTED]. EI #1 said no. EI #1 said looking at RI #85's Physician order [REDACTED].#85 was prescribed [MEDICATION NAME] on 12/12/19, and it was discontinued on 12/17/19 at the family's request. On 01/09/20 at 1:23 p.m., the surveyor conducted an interview with EI #4, the facility's Certified Registered Nurse Practitioner (CRNP) who wrote the order for the [MEDICATION NAME]. When asked if there were specific medical [DIAGNOSES REDACTED].#4 said yes. The surveyor asked EI #4 was Dementia a justifiable medical [DIAGNOSES REDACTED]. EI #4 said no. EI #4 said, looking at RI #85's medical records he did not see a medical [DIAGNOSES REDACTED].#85 receiving the [MEDICATION NAME].

Based on observations, interviews, record review and review of a policy titled, Tray Tickets, the facility failed to ensure Resident Identifier (RI) #62 received a tossed salad at the lunch and supper meals per their preference. This deficient practice affected one of two residents requesting tossed salad with lunch and dinner meals. Findings Include: A review of a facility policy titled, Tray Tickets, with an effective date of 08/10/18, revealed: .PURPOSE: Tray tickets should be used to assist dietary staff to serve the resident/guest(s) meal according to food preference profiles .PR[NAME]ESS: . b. When individual meal patterns are ordered for a resident/guest, outside the normal facility diets or meal patterns, specific information on that meal pattern should be communicated on the tray ticket . RI #62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #62's most recent quarterly Minimum Data Set Assessment, with an Assessment Reference Date of 11/29/19, indicated moderately impaired cognitive status. During the initial pool process on 01/07/20 at 10:30 a.m., the surveyor conducted an interview with RI #62. RI #62 stated he/she had asked for a side salad to come with his/her meals. The surveyor asked RI #62 if he/she had talked to anyone about getting the salad. RI #62 said the tray cards had the salad listed. The surveyor asked which meals he/she was to get a salad. RI #62 said lunch and supper. RI #62 said the staff member over the kitchen had come in and talked to him/her and made a list of the things he/she liked. However, RI #62 said the salads had just not been on the trays. Review of RI #62's Departmental Notes, dated 8/28/19 at 3:00 p.m. and 12/02/19 at 4:14 p.m., revealed Employee Identifier (EI) #6, Dietary Manager, documented RI #62's .request for fresh fruit, salad . On 01/08/20 at 12:55 p.m., the surveyor observed RI #62 eating lunch, which included: grilled ham steak, squash casserole, baked sweet potato, dinner roll, 2% milk, water and sweet tea. Tossed Salad was listed on RI #62's menu card, but it was not served. At this time, RI #62 also showed the surveyor a tray card/menu card from the night before with tossed salad listed; however, RI #62 said he/she had not received one. On 01/09/20 at 9:16 a.m., RI #62 stated he/she had also not received a salad with his/her meal the night before. On 01/09/20 at 2:05 p.m., EI #6, the Dietary Manager, said he had told RI #62 during an interview on admission that he/she could get salads with meals. When asked how often RI #62 should receive tossed salads with meals, EI #6 said the tray card designated it was for lunch and dinner each day. The surveyor asked EI #6 if an item was listed on the tray should it be given for that meal. EI #6 said, yes. The surveyor asked what issue there was if the items on the tray card were not given EI #6 said the resident did not get what was listed on the tray card, and the resident was not getting what they ordered.

Based on observations and interviews, the facility failed to ensure: 1) CNAs (Certified Nursing Assistants) did not hold residents' water pitchers against their uniforms when transporting the water pitchers in the hallways; and 2) Employee Identifier (EI) #14, a Licensed Practical Nurse (LPN) did not use a glove from her uniform pocket to open a carton of juice for a resident during the morning medication pass on 01/09/19. These deficient practices were observed on two of the three days during the survey and affected one of the two medication carts observed during medication pass on 01/09/20. Findings Include: 1) On 01/07/20 at 3:05 p.m., the surveyor observed a CNA walking in the hallway carrying four residents' water pitchers resting against her uniform top. The water pitchers/cups were supported with her arms embracing each water pitcher. On 01/07/20 at 3:06 p.m., the surveyor conducted an interview with the CNA, EI #13. The surveyor asked EI #13 how many water pitchers she had carried. EI #13 said four. The surveyor asked how were you carrying the pitchers. EI #13 said like a baby. The surveyor asked EI #13 were the pitchers touching your uniform. EI #13 said yes. The surveyor asked EI #13 what issues would result from carrying the water pitchers touching her uniform top. EI #13 said one issue would be the pitchers were touching her, and the other was she was carrying too many at one time. On 01/09/20 at 8:43 a.m., the surveyor observed another CNA, EI #15, carrying water pitchers touching her uniform top, into a resident's room. EI #15 then took the second pitcher to another resident's room. At this time, the surveyor asked EI #15 how she was carrying the pitchers. EI #15 said they were touching her top, which was dirty. The surveyor asked EI #15 what issues could result from the pitchers touching her uniform top. EI #15 said cross contamination. On 01/09/20 at 3:37 p.m., the surveyor asked EI #2, Infection Control Preventionist, how staff should carry water pitchers. EI #2 said they should be carried in a way that would not touch staff's uniform. The surveyor asked EI #2 what are the issues with staff carrying water pitchers touching their uniform. EI #2 said it was an infection control issue. 2) On 01/09/20 at 7:57 a.m., during a medication pass, the surveyor observed LPN, EI #14 remove a glove from her left uniform pocket, put the glove on her right hand, and assist a resident with opening their juice. On 01/09/20 at 8:50 a.m., the surveyor asked EI #14 from where had she removed the glove. EI #14 said she had one in her pocket. The surveyor asked EI #14 what was the clean status of the glove. EI #14 said, dirty. The surveyor asked EI #14 what were the issues with using gloves from a uniform pocket. EI #14 said it could spread germs. On 01/09/20 at 3:37 p.m., the surveyor conducted an interview with EI #2, Infection Control Preventionist. The surveyor asked EI #2 what was the clean status of a nurse's uniform pocket. EI #2 said they are dirty. The surveyor asked EI #2 when would a nurse use gloves that had been removed from her uniform pocket. EI #2 said, never. The surveyor asked EI #2 what issues could result. EI #2 said it was an infection issue.

Based on observations, interviews, record review and a review of facility policies titled, Critical Control Points-Safe Food Handling Guide and Cleaning of Miscellaneous Equipment and Utensils the facility failed to ensure: 1. plates were not stacked wet in the plate warmer; 2. okra in the freezer was labeled; 3. vents over the stove were free of a grease and dust like substance; and 4. staff did not touch or handle RI #60's food with ungloved hands. This had the potential to affect 90 of 90 residents who received meals from the kitchen. Findings Include: 1. A review of a facility policy titled, Cleaning of Miscellaneous Equipment and Utensils with an effective date of (MONTH) 23, (YEAR) revealed: .Dishes .Place dishes in dish rack; avoid overloading and nesting .allow dishes to air dry . On 11/07/2018 at 11:28 a.m., the surveyor observed EI (Employee Identifier)#5, the Cook plating food. EI #5, was pulling plates from the plate warmer with water in them. The surveyor observed EI #5, pull four plates from the plate warmer with a large amount of water in them. EI #5 pulled two more plates with water in them. The Dietician, EI #7, pulled five plates from the plate warmer and took them to the dish room. On 11/07/2018 at 12:38 p.m., an interview was conducted with EI #5. EI #5 was asked what was in the plates at the tray line that she was putting food in. EI #5 replied, water. EI #5 was asked why was there water in the plates. EI #5 replied, they did not dry properly. EI #5 was asked what did the facility policy say regarding putting food in wet plates. EI #5 replied, they were not supposed to put food in wet plates. EI #5 was asked who was responsible for making sure plates were dry. EI #5 replied the dishwasher. EI #5 was asked why should food not be put in wet plates. EI #5 replied, it was not sanitary. EI #5 was asked how should plates be allowed to dry. EI #5 replied, air dry. On 11/07/2018 at 12:45 p.m., the surveyor conducted an interview with EI #6, the Dishwasher. EI #6 was asked how should plates be allowed to dry. EI #6 replied, let them sit in the dish washer for a minute, let the steam hit the plates and dry them. EI #6 was asked why should plates be dry before giving them to the residents. EI #6 replied, just do not give them wet plates. EI #6 was asked did he put wet plates in the plate warmer. EI #6 replied, no. On 11/07/2018 at 12:46 p.m., an interview was conducted with EI #4, Dietary Manager. EI #4 was asked did he observe wet plates in the plate warmer. EI #4 replied, yes. 2. A review of a facility policy titled, Critical Control Points-Safe Food Handling Guide with a revised date of 4/29/15 revealed: .Storage of Refrigerated Foods Cover and label with item name and date . On 11/06/2018 at 4:16 p.m., the surveyor observed breaded okra in a medium bag in the freezer out of the original container without an open date or information on the bag. On 11/08/2018 at 9:21 a.m., an interview was conducted with EI #4. EI #4 was asked what was in the freezer out of the original container without a name of what the food was and no use by date. EI #4 replied, breaded okra. EI #4 was asked who was responsible for labeling food items in the freezer. EI #4 replied, all of the dietary staff. EI #4 was asked what information should be on food packages once they were out of the original container. EI #4 replied, the name of the product, date opened and the use by date. EI #4 was asked what did the facility policy say regarding what information should be on food packages. EI #4 replied, use by date. EI #4 was asked why was it important for food items to be labeled in the freezer. EI #4 replied, so it would not go bad. EI #4 was asked when should food items out of the original container be labeled. EI #4 replied, as soon as it was opened, 3. A review of a facility policy titled, Cleaning of Miscellaneous Equipment and Utensils with an effective date of (MONTH) 23, (YEAR) revealed: .30.(NAME)Filter over Stove: (monthly) Remove screen or vent from over stove Run screen or vent through dish machine . Remove and let dry Wipe off hood completely with a degreaser Replace screens over stove . On 11/06/2018 at 4:16 p.m., the surveyor observed the vents over the stove. The vents were dirty with a large amount of a grease and dust like substance in the panel. In some of the panels there were black oil like spots. On 11/08/2018 at 9:25 a.m., the surveyor conducted an interview with EI #4. EI #4 was asked what was in the vents over the stove. EI #4 replied, a grease build up. EI #4 was asked why was it there. EI #4 replied, because of cooking and the steam. EI #4 was asked when were the vents cleaned last. EI #4 replied, within 30 days. EI #4 was asked to describe what he saw in the vents. EI #4 replied, grease build up. EI #4 was asked how much of the substance was on the vents. EI #4 replied, a medium amount. EI #4 was asked what did the facility policy say regarding how often the vents should be cleaned. EI #4 replied bi-weekly. 4. On 11/07/2018 at 8:31 a.m., the surveyor observed two Certified Nursing Assistants (CNAs), EI #8 and EI #9, enter into a room with breakfast trays for both residents. EI #8 and EI #9 were observed assisting the resident in A bed with the breakfast tray. EI #8 was observed to pick the resident's biscuit up with bare hands, split the biscuit open with a knife in one hand and spread jelly on the biscuit. EI #9 was observed to peel the resident's boiled egg with bare hands and use a knife with one hand, hold the egg steady with the other bare hand, and sprinkle seasoning on the egg. On 11/7/2018 at 8:38 a.m, during an interview with EI #8 and EI #9, the surveyor asked what food items did you all touch with bare hands. EI #8 stated, Biscuit. and EI #9 stated, Egg. The surveyor asked what should they have done. EI #8 and EI #9 stated, Had gloves on. The surveyor asked when did they wash their hands after entering the residents' room. EI #8 and EI #9 stated, We did not. The surveyor asked what was the potential for harm. EI #8 and EI #9 stated, Contamination.

Based on observations, interview and a review of a facility policy titled, Garbage and Refuse, the facility failed to ensure dumpster lids were closed tightly, boxes and paper towels were not around the dumpster, and food debris was not on the front side of the dumpster. This had the potential to attract pests and affect all 93 residents residing at the facility. Findings Include: A review of a facility policy titled, Garbage and Refuse with an effective date of (MONTH) 1, 2002 revealed: .PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses. STANDARD: Garbage and refuse containers should be free from cracks or leaks and covered when not in use. PR[NAME]ESS: .e. Refuse container and dumpsters kept outside the facility should have tightly fitting lids and should be kept covered when not being loaded. f.garbage should not accumulate or be left outside the dumpster. On 11/06/2018 at 4:16 p.m., the surveyor observed one dumpster with the lid opened wide and boxes were hanging out of the dumpster. The top lids on both sides were opened to the back of the dumpster. The surveyor observed approximately 21 boxes, a wet paper towel, and a food like substance on the ground. The boxes were approximately 12 feet from the kitchen door. On 11/07/2018 at 12:30 p.m., the surveyor observed a second dumpster behind a wooden fence. Food debris was on the front side of the dumpster. There were many flies flying around the front side of the dumpster. The food debris was yellow, black, white and brown in color. The dumpster lid was not completely closed. On 11/08/2018 at 9:41 a.m., the surveyor conducted an interview with (Employee Identifier) EI #4, Dietary Manager. EI #4 was asked what did he see in and around the first dumpster. EI #4 replied, boxes and a paper towel. EI #4 was asked was there any food debris on the ground. EI #4 replied, a few black eyed peas. EI #4 was asked if both lids were opened to the back of the first dumpster. EI #4 replied, it was. EI #4 was asked what did the facility policy say regarding keeping the dumpster lids closed. EI #4 replied, it should be closed at all times. EI #4 was asked to describe what he saw regarding the second dumpster. EI #4 replied, food build up. EI #4 was asked where was the food build up located on the dumpster. EI #4 replied, on the front side of the dumpster. EI #4 was asked what pests were flying around the dumpster. EI #4 replied, flies.

Based on observation, interview, record review and a review of the facility's policy titled, Privacy Upon Entering Resident's Room, the facility failed to ensure staff knocked and received permission prior to entering RI (Resident Identifier) #60's room. This affected one of 23 sampled residents observed for privacy issues. Findings Include: A review of a facility policy titled, Privacy Upon Entering Resident's Room with an effective date of 11/6/14, revealed: .PR[NAME]ESS: 1. Prior to entering Resident's room, knock and ask permission to enter . RI #60 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of RI #60's most recent Quarterly MDS (Minimum Data Set) revealed he/she had a BIMS of 15, which indicated he/she was cognitively intact. On 11/07/18 at 8:31 AM, the surveyor observed two CNAs (Certified Nursing Assistants), EI (Employee Identifier) #8 and EI #9 enter into RI #60's room with breakfast trays. EI #8 and EI #9 did not knock or request permission prior to entering RI #60's room. On 11/7/18 at 8:38 AM, during an interview with EI #8 and EI #9, the surveyor asked what should be done before entering a resident's room. Both EI #8 and EI #9 stated, Knock on the resident's door and introduce your name and title and start with the patient's care. The surveyor asked EI #8 and EI #9 when they both entered the residents' room, was that what either of them did. EI #8 stated, I did not. EI #9 stated, I don't think I did. The surveyor asked EI #8 and EI #9 what type of issue would this be. EI #8 and EI #9 stated, Privacy. The surveyor asked EI #8 and EI #9 what else should be done before entering a resident's room. EI #8 stated, say Is it ok to come in the room. The surveyor asked EI #8 and EI #9 was that what they had done. EI #8 and EI #9 stated, No. The surveyor asked what type of issue was that. EI #8 and EI #9 stated, Privacy.

Based on observation, record review, interview and review of facility policies titled, Nebulizer and Hand Hygiene, the facility failed to ensure: 1. a nebulizer was contained in a plastic bag when not in use and 2. staff washed their hands after removing unclean gloves and before applying clean gloves and touching other items. This affected RI (Resident Identifier) #10, RI #25 and RI #31, three of seven residents observed during medication administration. Findings Include: 1. A review of a facility policy titled, Hand Hygiene with an effective date of 9/01/17, revealed: .Hand Hygiene .The following is a list of some situations that require hand hygiene .After removing gloves .Consistent use by staff of proper hygienic practices and techniques is critical to preventing the spread of infections . RI #25 was re-admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 11/07/18 at 8:15 AM, the surveyor observed EI (Employee Identifier) #11, LPN (Licensed Practical Nurse) prepare medication for RI #25. EI #11 entered RI #25's room. EI #11 administered RI #25's medications. EI #11 applied gloves, applied a [MEDICATION NAME] to RI #25's lower back and removed her gloves. EI #11 opened RI #25's curtain and elevated the head of the bed. EI #11 exited RI #25's room. EI #11 did not wash or sanitize her hands after removing her gloves and before touching other items. On 11/07/18 at 8:30 AM, during an interview, the surveyor asked EI #11 what should be done after unclean gloves were removed and before applying clean gloves and touching other items. EI #11 stated, Wash hands in between. The surveyor asked was that what she had done every time after she removed her gloves and before touching other items and applying clean gloves. EI #11 stated, I may have missed one. The surveyor asked what was the potential for harm. EI # 11 stated, Infection. RI #10 was re-admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 11/07/18 at 9:15 AM, the surveyor observed EI #11, LPN prepare medication for RI #10. EI #11 applied gloves, cleaned a insulin vial, disposed of trash from the medication cart, then removed her unclean gloves. With bare hands, EI #11 removed a card of medication, dispensed the medication, placed the medication card back in the medication cart, poured water into a cup, reviewed the MARs (Medication Administration Record) on the computer, removed insulin medication from the medication cart and applied clean gloves. EI #11 did not wash or sanitize her hands after removing her unclean gloves and before touching other items and applying clean gloves. On 11/07/18 at 9:30 AM, during an interview with EI #11, the surveyor asked what should be done after unclean gloves were removed and before touching other items and applying clean gloves. EI #11 stated, Wash hands. The surveyor asked did she wash or sanitize her hands every time she removed her gloves. EI #11 stated, No ma'am . 2. A review of a facility policy titled Nebulizer with an effective date of (MONTH) 1, 2004 revealed: . PR[NAME]ESS: . V. After completion of therapy . e.) Store in plastic bag. RI #31 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of RI #31's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/03/18, revealed RI #31 had a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment. On 11/07/18 at 8:30 a.m., an observation was made during medication administration with EI #3, LPN. RI #31's nebulizer mask was lying on the bedside table and was not in a mask. On 11/07/18 at 8:40 a.m., an interview was conducted with EI #3. The surveyor asked EI #3 what was the facility's policy on storing the nebulizer mask when not in use. EI #3 said always keep it in a bag when not in use. The surveyor asked EI #3 where was RI #31's nebulizer mask. EI #3 said lying on the bedside table and the mask was not in a bag. The surveyor asked EI #3 who was responsible to ensure the mask was in a bag when not in use. EI #3 said the nurses. The surveyor asked EI #3 why should the nebulizer mask be stored in a bag when not in use. EI #3 said to prevent the mask from getting contaminated.

Based on record reviews, an interview, and review of a policy titled, Disposal of Medications Non-Controlled Medication Destruction, the facility failed to ensure medications were disposed of with the required number of signatures. This deficient practice was found for the month of November 2017, one out of months of Drug Destruction Records reviewed. Findings Include: A review of the Facility's Policy and Procedure titled Disposal of Medications Non-Controlled Medication Destruction with a date of 03/11 revealed: Policy Discontinued medications, expired medications, and medications left in the facility after a resident has expired or has been permanently discharged (,) are destroyed or disposed of per federal/state regulations. Procedures . 3. The registered nurse and/or pharmacist witnessing the destruction, or their preparation for environmental service pickup, ensures that the following information is entered on the Record of Medication Destruction form (Exhibit 13 - Record of Medication Destruction): . J. Signature of witnesses, two witnesses required for non-controlled substances (for example, a pharmacist in Alabama and a registered nurse) in the designated areas on the destruction form. A review of the drug destruction records was conducted on 1/4/18. The eleven months of records kept since the last survey were reviewed. Twenty-seven pages of Non-Controlled Medication Destruction logs dated for the Month of November 2017 were only signed by the consultant pharmacist. The signature line for a registered nurse's signature was blank. During an interview on 1/4/18 at 8:10 p.m., EI (Employee Identifier) #1, the DON (Director of Nursing) was asked how many signatures were required as witnesses of destruction or disposal of non-controlled drugs. EI #1 answered two. EI #1 was asked what was the facility policy regarding signatures required for destruction or disposal of medications. EI #1 answered non-controlled required two signatures and controlled drugs should have three signatures. EI #1 was asked what was the concern of not having the required signatures for destruction or disposal of those drugs. EI #1 answered that the drugs may not be disposed of properly.

Based on observations, interviews and record review, the facility failed to ensure Resident Identifier (RI) #135's nebulizer mask was not stored in the top of RI #135's dresser drawer. This deficient practice affected RI #135, one of one sampled resident observed with a nebulizer set-up. Findings Include: RI #135 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #135's January 2017 Physician order [REDACTED].> . IPRAT([MEDICATION NAME])-ALBUT ([MEDICATION NAME]) 0.5-3(2.5) MG (Milligram)/3 ML (Milliliter) ONE VIAL VIA (by way of) NEBULIZER EVERY FOUR HOURS FOR [MEDICAL CONDITIONS] . On 01/03/18 at 11:37 a.m., RI #135's nebulizer mask was observed stored uncovered, in the top of the dresser drawer in RI #135's room. On 01/03/18 at 5:35 p.m., RI #135's nebulizer mask remained in the top of the dresser drawer. The mask was again observed not to be stored in a covering. On 01/04/18 at 8:23 a.m., the nebulizer mask remained stored uncovered, in the top dresser drawer in RI #135's room. On 01/04/18 at 4:35 p.m., RI #135's nebulizer mask remained in the top dresser drawer. The mask was observed still not to be stored in a covering. 01/04/18 at 4:36 p.m., the surveyor conducted an interview with Employee Identifier (EI) #3, the Licensed Practical Nurse assigned to care for RI #135 on the 3-11 PM shift on 01/04/18. The surveyor asked EI #3 was RI #135 receiving nebulizer treatments. EI #3 said yes. EI #3 said she had just finished giving RI #135 a nebulizer treatment. The surveyor asked EI #3 where was RI #135's nebulizer mask stored. EI #3 replied, in RI #135's drawer. The surveyor asked EI #3 how should the mask be stored. EI #3 replied, inside a plastic bag. When asked why the mask should be stored on the inside of a plastic bag, EI #3 replied for infection control reasons. 01/04/18 at 5:28 p.m., the surveyor conducted an interview with EI #2, the ADON (Assistant Director of Nursing)/Infection Control Nurse. The surveyor asked EI #2 how should the residents' nebulizer mask be stored. EI #2 said the mask should be stored in a Ziploc plastic bag. The surveyor asked EI #2, when not stored in a covering, what could that be considered. EI #2 replied, a risk for infection.

Based on medical record review, interviews, and review of a facility policy titled, Person Centered Care Plans, the facility failed to ensure a plan of care was developed with approaches specific to RI (Resident Identifier) #1's shoulder and hip injuries. This affected RI #1, one of four sampled residents whose care plans were reviewed. Findings Include: A review of the facility policy titled, Person Centered Care Plans with an effective date of November 28, 2016, revealed: . PURPOSE Person centered plans of care are developed . to coordinate and communicate care approaches and goals of the resident/guest's rights. PR(NAME)ESS . Admission Plan of Care - should be initiated by admitting nurse based on assessment . A review of RI #1's medical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. A review of the admission Nursing assessment revealed the resident had impaired mobility, was continent of bowel and bladder, and had a history of [REDACTED]. A review of RI #1's care plans revealed no problems, approaches, or goals regarding RI #1's shoulder and hip injury. An interview was conducted with EI (Employee Identifier) #2, RN(Registered)/Supervisor/Admission Nurse on 9/13/17 at 2:21 p.m. EI #2 was asked was RI #1's injuries to the shoulder and hip addressed in the plan of care. EI #2 looked at the care plan and answered no. EI #2 was asked what was the facility policy regarding a plan of care meeting a resident's needs. EI #2 answered to initially start a generic care plan. EI #2 was asked if the care plan should have included care related to RI #1's injuries. EI #2 answered she assumed it should have. An interview was conducted with EI #1, the Director of Nursing, on 9/13/17 at 3:01 p.m. EI #1 was asked if RI #1's care plan should have included the right shoulder and left hip injuries. EI #1 answered yes. EI #1 was asked what was the facility policy for developing a plan of care to meet the residents needs. EI #1 answered to go through and personalize the care plan. EI #1 was asked if RI #1's care plan was personalized to meet their needs and she answered no. This deficiency was cited as a result of the investigation of complaint/report number AL 327.

Based on review of the medical record, Departmental Notes, the NURSING ADMISSION REVIEW, interviews, and review of the facility policy titled, Charting and Documentation Guidelines, the facility failed to ensure staff documented accurately and completely in the medical record for RI (Resident Identifier) #1 in the following ways: 1. there was no documentation from the initial Nurse responsible for RI #1's care and 2. there was an error on the entry of the electronic medical record by the admission nurse and the time of the assessment was not documented. This affected RI #1, one of four sampled residents whose medical records were reviewed. Findings Include: 1. A review of the facility policy titled, Charting and Documentation Guidelines with an effective date of October 1, 2010, revealed: . Purpose Documentation in medical records of residents, . should provide: Communication of the resident's care, treatment, response to care, signs, symptoms and progress of the resident to providers of care . PR(NAME)ESS I. Rules for Charting and Documentation a) Chart all pertinent changes in the resident's condition, . as well as routine observations. A review of RI #1's medical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. A review of the admission Nursing assessment revealed the resident had impaired mobility, was continent of bowel and bladder, and had a history of [REDACTED]. A review of the medical record revealed no documentation from the Nurse first responsible for RI #1's care. An interview was conducted with EI (Employee Identifier) #3, a Licensed Practical Nurse, on 9/13/17 at 9:22 a.m. EI #3 was asked where would documentation be found of what she did for RI #1. EI #3 answered, In my note, if I didn't, I must have been overwhelmed. I thought the note was done, (I) can't find it. EI #3 was asked how one could know what was done for the resident if there was no note. EI #3 answered, All you have is my word. EI #3 was asked what was the facility policy on documentation. EI #3 answered if you did not chart it, you did not do it. 2. A review of the facility policy titled, Charting and Documentation Guidelines with an effective date of October 1, 2010, revealed: . Purpose Documentation in medical records of residents, . PR(NAME)ESS I. Rules for Charting and Documentation . b) Be concise, accurate and complete . A review of the medical record revealed an error on the electronic assessment entered by the admission Nurse and the time of the initial assessment was not documented. A review of the Departmental Note documented by EI #2, RN (Registered Nurse)/Supervisor/Admission Nurse on 9/1/17 at 6:04 p.m., indicated RI # 1 reported his/her pain level was 8/10 on the pain scale to the right shoulder when hurting and PRN (as needed) medication was effective when provided. A review of the NURSING ADMISSION REVIEW for RI #1 dated 9/1/17 and documented at 8:21 p.m. by EI #2, revealed: . Is the resident experiencing any pain? Yes . There was no documentation of the time the resident was assessed. An interview was conducted with EI #2 on 9/13/17 at 2:21 p.m. EI #2 was asked what time she performed the admission assessment for RI #1. EI #2 answered about 4:05 p.m. EI #2 was asked what time was documented on the NURSING ADMISSION REVIEW and she answered 7:30 p.m. EI #2 was asked where her documentation indicated the assessment was done at 4:05 p.m. EI #2 answered it did not, she just documented later and did not enter the time the assessment was done. EI #2 was asked how one would know when the initial assessment was done. EI #2 answered (you) would not be able to. EI #2 was asked what was the facility policy regarding documentation. EI #2 answered to document accurately and completely. An interview was conducted with EI #1, the Director of Nursing, on 9/13/17 at 3:01 p.m. EI #1 was asked how one would know what staff were informed of regarding RI #1, if it was not documented. EI #1 answered one would not. This deficiency was cited as a result of the investigation of complaint/report number AL 327.

Based on the State Agency's online report, Resident Identifier (RI) #1's medical record, staff interviews and review of the facility's corrective action plan, the facility failed to ensure Employee Identifier (EI) #2 and EI #3, both Licensed Practical Nurses (LPNs) honored the rights of RI #1 on [DATE]. On [DATE] at 4:40 AM, EI #2 found RI #1, a resident with Full Code status, without a pulse or respirations. EI #2 summoned for the assistance of EI #3, a LPN. EI #3 entered RI #1's room and found the resident without a pulse. Without initiating CPR, both EI #2 and EI #3 left RI #1's room and went to the nurses' station to notify facility staff that RI #1 had expired. According to RI #1's FACE SHEET, the resident expired in the facility on [DATE] at 4:50 AM. This deficient practice placed RI #1, one of five sampled residents, in immediate jeopardy of serious injury, harm or death. On [DATE] at 12:53 PM, EI #8, the Director of Nursing and EI #9, the Administrator were notified of the findings of substandard quality of care at the immediate jeopardy level in the area of Resident Rights, F 155. Findings include: On [DATE], the facility submitted an online report of neglect to the State Agency which indicated Cardiopulmonary Resuscitation (CPR) was not started on RI #1, a resident with Full Code status, on [DATE]. RI #1 was readmitted to the facility on [DATE] with an admit [DIAGNOSES REDACTED]. RI #1's physician progress notes [REDACTED].#1 had Full Code status. RI #1's Nursing Notes dated [DATE] written by EI #2, a LPN, documented . 0440 (4:40 AM) Walked to room . to check (RI #1's) status. Tapped (RI #1) on the foot asked If (he /she) was ok. (RI #1) did not respond. I then walked to head of bed to turn the light on over the bed. I called (his/her) name again with no response. I then checked for a pulse on (RI #1's) wrist, no pulse noted. I shouted (RI #1's) name again as I began a sternum rub, with no response. I leaned over to put my ear to (RI #1's) mouth to hear or feel any breathe and breathe sounds. There were none. 0445 (4:45 AM) I stepped out (RI #1's) door and called to the CNA (Certified Nursing Assistant) to get help, from (EI #3) on the East Station. I did continue to attempt to wake (RI #1) by firm sternum rubs and calling (his/her) name. I took my stethoscope from my neck and tried to auscultate an apical pulse. 0447 (4:47 AM) (EI #3) and the CNAs arrived she asked if we started CPR I said no . During a telephone interview on [DATE] at 9:00 AM, EI #2, the LPN assigned to care for RI #1 during the 11:00 PM to 7:00 AM shift on [DATE], was asked to describe what occurred. EI #1 stated at approximately 4:30 AM, she started down the hall to begin medication pass and parked the medication cart at the end of the hall. EI #2 stated she went in to check on RI #1 and tapped the resident's foot and there was no response. EI #2 stated she then walked to the head of RI #1's bed and turned on the light so she could get a visual look at the resident. EI #2 stated the resident was cool to touch. She checked RI #1 for a radial pulse and there was no pulse. EI #2 then performed a sternal rub while calling RI #1's name and there was no response. Then EI #2 told the CNAs to get EI #3 (LPN) from the East Station. EI #2 returned to RI #1's bed and tried to wake the resident up. EI #2 took her stethoscope and tried to listen for an apical pulse and there was none. According to EI #2, EI #3 then entered RI #1's room and asked her if she had started CPR. EI #2 said no. When asked what the facility's policy and procedure directed the staff to do when a resident was found with no pulse or respirations, EI #2 stated to begin basic life support, CPR. EI #2 was asked was this done and she said no. When asked what should have been done, EI #2 stated she should have started CPR and had the other nurse call 911. On [DATE] at 3:55 PM, an interview was conducted with EI #3, a LPN who worked in the facility during the 11:00 PM to 7:00 AM shift on [DATE] when RI #1 was found without a pulse. EI #3 stated a CNA came and got her and stated they needed help with RI #1. When EI #3 arrived in RI #1's room she stated she touched RI #1 and the resident was cold. EI #3 stated she checked for an apical pulse and could not find a pulse. EI #3 stated she then looked into the RI #1's eyes and could tell they were not moving; the resident looked as if he/she had expired. Without initiating CPR, EI #3 left RI #1's room. According to EI #3, she walked to the nurses' station and informed EI #2 (LPN) of the people she needed to call, then left and returned to East station. In an interview on [DATE] at 7:16 PM, EI #4, a CNA was asked if she saw EI #2 or EI #3 perform CPR. EI #4 stated, no. On [DATE] at 7:20 AM, an interview was conducted with EI #5, a CNA. EI #5 stated she overheard EI #2 (LPN) tell EI #1 (CNA) that RI #1 was not breathing and to go get EI #3 (LPN). EI #5 then followed the nurse (EI #2) to RI #1's room and observed RI #1 with his/her eyes shut and mouth open. According to EI #5, EI #2 (LPN) touched RI #1's feet, chest and called the resident's name, but RI #1 did not respond. When asked if she saw anyone perform CPR on RI #1, EI #5 stated no. During an interview [DATE] at 7:46 AM, EI #11, the LPN/Restorative Nurse stated when she came in to work around 4:55 AM on [DATE], EI #2 (LPN) told her that RI #1 had passed. When asked if she knew if CPR was performed on RI #1, EI #11 stated, Not that I was made aware of, No. During a telephone interview on [DATE] at 5:29 PM, EI #15, the Certified Registered Nurse Practitioner, acknowledged she was notified on [DATE] that RI #1 had passed away. EI #15 stated when she arrived at the facility she found out the staff did not perform CPR. On [DATE] at 10:45 AM, an interview was conducted with EI #6, the facility's Medical Director and RI #1's primary Physician. EI #6 was asked if RI #1 was a full code. EI #6 said yes. According to EI #6, the facility's Administrator (EI #9) told him there was a problem the night RI #1 expired in the facility. The nurse did not activate the emergency protocol. EI #6 stated he did not understand why the nurse did not start CPR. When asked, what the the nurse should have done, EI #6 stated in his opinion they definitely should have activated the emergency protocol system and followed the standard protocol. During an interview on [DATE] at 12:37 PM, EI #9, the Administrator was asked, what the facility's policy and procedure directed the staff to do when a resident was found without a pulse or respirations. EI #9 stated if the resident had Full Code status, CPR should be started. According to EI #9, he received a text from the Director of Nursing (DON) that RI #1 was a Full Code and CPR was not performed on the resident. EI #9 stated he began an investigation, self-reported the incident to the State Agency, terminated the two nurses (EI #2 and EI #3) and reported them to the Alabama Board of Nursing. In an interview on [DATE] at 12:45 PM, EI #8, the DON stated she received a text around 6:05 AM on [DATE] that RI #1 had expired. When asked if CPR was initiated by the nurse, EI #8 stated not that she knew of. EI #8 was asked, what was the results of the facility's investigation and she replied, CPR was not performed. The facility immediately implemented corrective action to prevent recurrence of the identified deficient practice on [DATE]. These corrective actions included: On [DATE], the facility provided re-education to the licensed nursing staff (EI #2, EI #3, EI #10 and EI #11) on the facility's emergent care protocol. Beginning [DATE], the facility provided re-education and training to all licensed nursing staff on the facility's emergent care protocol and resident rights, honoring the resident's code status. Nursing staff were not allowed to work without completing the re-education. All facility re-education and training concluded on [DATE]. On [DATE], the facility held a Quality Assurance meeting with a topic of discussion Emergent Protocol. During this meeting, the facility's emergent care protocol dated [DATE] was reviewed. Starting on the 3:00 PM to 11:00 PM shift on [DATE], the facility implemented code drills each shift for seven days. As ongoing monitoring, after seven days, the facility will continue code drills on random shifts for 30 days. On [DATE], the facility conducted an audit of each resident's code status. On [DATE], the facility held a Resident Council Meeting with 11 residents in attendance. The Administrator discussed advance directives and Full/DNR code status. Beginning [DATE], the facility provided re-education to the Certified Nursing Assistant staff regarding resident rights; honoring the resident's code status. On [DATE], EI #2's and EI #3's employment with the facility was terminated for . significant failure to perform duties as assigned. [DATE] you failed to perform CPR on a resident was a full code. On [DATE], EI #2 and EI #3, both LPNs were reported to the Alabama Board of Nursing for Nurse failed to follow facility emergent protocol on [DATE] when resident found without a pulse and not breathing. The referral listed EI #2's and EI #3's current status of employment as terminated. This deficiency was cited as a result of the investigation of complaint/report number AL 060.

Based on staff interviews, Resident Identifier (RI) #1's medical record review, the facility's PROTOCOL FOR EMERGENT CARE, the facility's Cardio [MEDICAL CONDITION] Resuscitation (CPR) policy, the HIGHLIGHTS of the 2015 American Heart Association (AHA) Guidelines Update for CPR and ECC (Emergency Cardiovascular Care) and the facility's corrective action plan, the facility failed to ensure Employee Identifier (EI) #2 and EI #3, both Licensed Practical Nurses (LPNs) followed the AHA guidelines for providing cardiopulmonary resuscitation to RI #1, a resident with Full Code status. Code status describes what type of intervention a health care facility will conduct should a resident stop breathing and/or their heart stops beating. Full Code status means when a resident stops breathing and/or their heart stops beating, staff are to immediately initiate Cardiopulmonary Resuscitation (CPR), in an attempt to revive the resident. According to the AHA, the emergency response system should be activated and CPR initiated, if the lay rescuer found an unresponsive victim. The rescuer should continue CPR until an AED (Automated External Defibrillator) arrives and is ready for use, EMS (Emergency Medical Services) providers take over care of the victim, or the victim starts to move. On [DATE] at 4:40 AM, EI #2 found RI #1, a resident with Full Code status, without a pulse or respirations. EI #2 summoned for the assistance of EI #3, a LPN. EI #3 entered RI #1's room and found the resident without a pulse. Without initiated CPR or activating EMS, both EI #2 and EI #3 left RI #1's room and went to the nurses' station to notify facility staff that RI #1 had expired. According to RI #1's FACE SHEET, the resident expired in the facility on [DATE] at 4:50 AM. This deficient practice placed RI #1, one of five sampled residents, in immediate jeopardy of serious injury, harm, or death. On [DATE] at 12:53 PM, EI #8, the Director of Nursing and EI #9, the Administrator, were notified of findings of substandard Quality of Care at the Immediate Jeopardy level in the area of Quality of Care, F 309. Findings include: The facility's PROTOCOL FOR EMERGENT CARE revised [DATE], documented If a resident is found to be unresponsive to verbal and physical stimuli, you must initiate the following protocol for emergent care: 1. Call stat to __ (location) or code blue __ (location) for help . 4. CPR as indicated per AHA CPR guidelines if there is no DNR order. 5. Have a staff member call EMS immediately to facility as a 911 emergency . The facility's policy titled Cardio [MEDICAL CONDITION] Resuscitation (CPR) (NP.VII-4) effective [DATE], documented PURPOSE: To circulate blood containing oxygen to vital organs pending the arrival of emergency medical services (EMS) to a resident who experiences [MEDICAL CONDITION] (cessation of respirations and/or pulse) in accordance with the resident's advance directives or in the absence of advance directives or a Do Not Resuscitate (DNR) order. STANDARD: . The licensed nurse should follow AHA established evidence based decision making guidelines for initiating CPR when [MEDICAL CONDITION] occurs. PROCESS: . 4. Follow AHA CPR guidelines . The American Heart Association's HIGHLIGHTS of the 2015 American Heart Association Guidelines Update for CPR and ECC with a copyright date of 2015 documented . Adult Basic Life Support and CPR Quality: Lay Rescuer CPR Summary of Key Issues and Major Changes . Recommendations have been strengthened to encourage immediate recognition of unresponsiveness, activation of the emergency response system, and initiation of CPR if the lay rescuer finds an unresponsive victim is not breathing or not breathing normally . The recommended sequence for a single rescuer has been confirmed: the single rescuer is to initiate chest compressions before giving rescue breaths to reduce delay to first compression. The single rescuer should begin CPR with 30 chest compressions followed by 2 breaths . Emphasis on Chest Compressions* . The rescuer should continue CPR until an AED arrives and is ready for use, EMS providers take over care of the victim, or the victim starts to move . On [DATE], the facility submitted an online report of neglect to the State Agency which indicated Cardiopulmonary Resuscitation (CPR) was not started on RI #1, a resident with Full Code status, on [DATE]. RI #1 was readmitted to the facility on [DATE] with an admit [DIAGNOSES REDACTED]. RI #1's physician progress notes [REDACTED].#1 had Full Code status. RI #1's Nursing Notes dated [DATE] written by EI #2, a LPN, documented . 0440 (4:40 AM) Walked to room . to check (RI #1's) status. Tapped (RI #1) on the foot asked If (he /she) was ok. (RI #1) did not respond. I then walked to head of bed to turn the light on over the bed. I called (his/her) name again with no response. I then checked for a pulse on (RI #1's) wrist, no pulse noted. I shouted (RI #1's) name again as I began a sternum rub, with no response. I leaned over to put my ear to (RI #1's) mouth to hear or feel any breathe and breathe sounds. There were none. 0445 (4:45 AM) I stepped out (RI #1's) door and called to the CNA (Certified Nursing Assistant) to get help, from (EI #3) on the East Station. I did continue to attempt to wake (RI #1) by firm sternum rubs and calling (his/her) name. I took my stethoscope from my neck and tried to auscultate an apical pulse. 0447 (4:47 AM) (EI #3) and the CNAs arrived she asked if we started CPR I said no . During a telephone interview on [DATE] at 9:00 AM, EI #2, the LPN assigned to care for RI #1 during the 11:00 PM to 7:00 AM shift on [DATE], was asked to describe what occurred. EI #1 stated at approximately 4:30 AM, she started down the hall to begin medication pass and parked the medication cart at the end of the hall. EI #2 stated she went in to check on RI #1 and tapped the resident's foot and there was no response. EI #2 stated she then walked to the head of RI #1's bed and turned on the light so she could get a visual look at the resident. EI #2 stated the resident was cool to touch. She checked RI #1 for a radial pulse and there was no pulse. EI #2 then performed a sternal rub while calling RI #1's name and there was no response. Then EI #2 told the CNAs to get EI #3 (LPN) from the East Station. EI #2 returned to RI #1's bed and tried to wake the resident up. EI #2 took her stethoscope and tried to listen for an apical pulse and there was none. According to EI #2, EI #3 then entered RI #1's room and asked her if she had started CPR. EI #2 said no. When asked what the facility's policy and procedure directed the staff to do when a resident was found with no pulse or respirations, EI #2 stated to begin basic life support, CPR. EI #2 was asked was this done and she said no. When asked what should have been done, EI #2 stated she should have started CPR and had the other nurse call 911. On [DATE] at 3:55 PM, an interview was conducted with EI #3, a LPN who worked in the facility during the 11:00 PM to 7:00 AM shift on [DATE] when RI #1 was found without a pulse. EI #3 stated a CNA came and got her and stated they needed help with RI #1. When EI #3 arrived in RI #1's room she stated she touched RI #1 and the resident was cold. EI #3 stated she checked for an apical pulse and could not find a pulse. EI #3 stated she then looked into the RI #1's eyes and could tell they were not moving; the resident looked as if he/she had expired. Without initiating CPR, EI #3 left RI #1's room. According to EI #3, she walked to the nurses' station and informed EI #2 (LPN) of the people she needed to call, then left and returned to East station. In an interview on [DATE] at 7:16 PM, EI #4, a CNA was asked if she saw EI #2 or EI #3 perform CPR. EI #4 stated, no. On [DATE] at 7:20 AM, an interview was conducted with EI #5, a CNA. EI #5 stated she overheard EI #2 (LPN) tell EI #1 (CNA) that RI #1 was not breathing and to go get EI #3 (LPN). EI #5 then followed the nurse (EI #2) to RI #1's room and observed RI #1 with his/her eyes shut and mouth open. According to EI #5, EI #2 (LPN) touched RI #1's feet, chest and called the resident's name, but RI #1 did not respond. When asked if she saw anyone perform CPR on RI #1, EI #5 stated no. During an interview [DATE] at 7:46 AM, EI #11, the LPN/Restorative Nurse stated when she came in to work around 4:55 AM on [DATE], EI #2 (LPN) told her that RI #1 had passed. When asked if she knew if CPR was performed on RI #1, EI #11 stated, Not that I was made aware of, No. During a telephone interview on [DATE] at 5:29 PM, EI #15, the Certified Registered Nurse Practitioner, acknowledged she was notified on [DATE] that RI #1 had passed away. EI #15 stated when she arrived at the facility she found out the staff did not perform CPR. On [DATE] at 10:45 AM, an interview was conducted with EI #6, the facility's Medical Director and RI #1's primary Physician. EI #6 was asked if RI #1 was a full code. EI #6 said yes. According to EI #6, the facility's Administrator (EI #9) told him there was a problem the night RI #1 expired in the facility. The nurse did not activate the emergency protocol. EI #6 stated he did not understand why the nurse did not start CPR. When asked, what the the nurse should have done, EI #6 stated in his opinion they definitely should have activated the emergency protocol system and followed the standard protocol. During an interview on [DATE] at 12:37 PM, EI #9, the Administrator was asked, what the facility's policy and procedure directed the staff to do when a resident was found without a pulse or respirations. EI #9 stated if the resident had Full Code status, CPR should be started. According to EI #9, he received a text from the Director of Nursing (DON) that RI #1 was a Full Code and CPR was not performed on the resident. EI #9 was asked, was CPR provided by the nurse to RI #1. EI #9 replied, no. When asked, did the nurse call a code, EI #9 said no. In an interview on [DATE] at 12:45 PM, EI #8, the DON stated she received a text around 6:05 AM on [DATE] that RI #1 had expired. When asked if CPR was initiated by the nurse, EI #8 stated not that she knew of. EI #8 was asked, what was the results of the facility's investigation and she replied, CPR was not performed. In a follow-up interview with EI #8, the DON, on [DATE] at 5:00 PM, she stated if a resident with Full Code status was found with no pulse or respirations, CPR should be initiated. The facility immediately implemented corrective action to prevent recurrence of the identified deficient practice on [DATE]. These corrective actions included: On [DATE], the facility provided re-education to the licensed nursing staff (EI #2, EI #3, EI #10 and EI #11) on the facility's emergent care protocol. Beginning [DATE], the facility provided re-education and training to all licensed nursing staff on the facility's emergent care protocol and resident rights, honoring the resident's code status. Nursing staff were not allowed to work without completing the re-education. All facility re-education and training concluded on [DATE]. On [DATE], the facility held a Quality Assurance meeting with a topic of discussion Emergent Protocol. During this meeting, the facility's emergent care protocol dated [DATE] was reviewed. Starting on the 3:00 PM to 11:00 PM shift on [DATE], the facility implemented code drills each shift for seven days. As ongoing monitoring, after seven days, the facility will continue code drills on random shifts for 30 days. On [DATE], the facility conducted an audit of each resident's code status. On [DATE], the facility held a Resident Council Meeting with 11 residents in attendance. The Administrator discussed advance directives and Full/DNR code status. Beginning [DATE], the facility provided re-education to the Certified Nursing Assistant staff regarding resident rights; honoring the resident's code status. On [DATE], EI #2's and EI #3's employment with the facility was terminated for . significant failure to perform duties as assigned. [DATE] you failed to perform CPR on a resident was a full code. On [DATE], EI #2 and EI #3, both LPNs were reported to the Alabama Board of Nursing for Nurse failed to follow facility emergent protocol on [DATE] when resident found without a pulse and not breathing. The referral listed EI #2's and EI #3's current status of employment as terminated. This deficiency was cited as a result of the investigation of complaint/report number AL 060.

Based on observations, interviews, and record reviews, the facility failed to ensure the accuracy of an MDS (Minimum Data Set) assessment for RI (Resident Identifier) #s 3 and 10. This affected RI #s 3 and 10, two of sixteen open records reviewed. Findings include: A review of the Facility's Policy and Procedure titled, Nursing Assessments, with an Effective Date: October 1, 2010, revealed, PURPOSE: The facility conducts, a comprehensive, standardized assessment of each resident's functional capacity necessary to develop a care plan and to modify the care plan and care / services based on the resident's status. STANDARD: Comprehensive assessments should be completed on admission, quarterly and with a significant change in the resident's condition. PROCESS: Close coordination between the MDS nurse, the nursing staff and other departments should occur, to develop the comprehensive assessment and interdisciplinary plan of care. Information in the medical record, as documented by nursing personnel aids in the development of accurate plans. A review of the Facility's Policy and Procedure titled, Care Plans, with an Effective Date of April 29, 2015, revealed, PURPOSE: Plans of Care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals for the resident. STANDARD: According to federal regulations, the facility develops a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing and mental/psychosocial needs, that are identified in the comprehensive assessment. PROCESS: I. Assessment and Plan of Care Process . Admission Plan of Care - should be initiated by admitting nurse based on assessment Resident Assessment Instrument (RAI) - within 14 days of admission; quarterly, annually and with a significant change of condition Comprehensive Plan of Care - within 7 days of admission RAI care plan should be reviewed; quarterly and with a significant change of condition. A review of RI #3's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The review of RI #3's Admission MDS, with an ARD (Assessment Reference Date) of 8/8/16, revealed a BIMS (Brief Interview for Mental Status) score of twelve out of a possible fifteen points. This score indicated RI #3 was moderately cognitively impaired for daily decision making skills. RI #3's MDS was coded as always incontinent, with no episodes of continent voiding or bowel movements. A review of RI #10's medical record revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #10's quarterly MDS, with an ARD of 8/26/16, revealed RI #10's cognitive skills were severely impaired. RI #10 never/rarely made decisions. RI #10's MDS was coded as Limited assistance-resident highly involved in activity for eating. A review of RI #10's care plan dated 2/5/16 revealed the approach, . Encourage to eat Provide set up assistance as needed i.e. (in example) opening packages, cutting food, seasoning food, identifying food, . An interview was conducted with EI (Employee Identifier) #4, a CNA (Certified Nursing Assistant), at 11:02 a.m. on 11/3/16. EI #4 was asked how RI #10 fed self. She answered, (He/She) don't. EI #4 was asked what the care plan indicated and she answered, They have (Him/Her) as an assist. EI #4 was asked if the care plan matched the level of assistance the resident received. She answered, I don't think so. EI #4 was asked why the care plan, that was guided by the MDS assessment, should reflect the actual care the resident needed. She answered, To let other people know what assistance (He/She) needs. An interview was conducted with EI #5, a CNA, at 12:58 p.m. on 11/3/16. EI #5 was asked what assistance RI #3 required regarding incontinence care. She answered, Toilet every 2 hours. EI #5 was asked if RI #3 was incontinent at times. She answered yes. EI #5 was asked what the care plan indicated. She answered occasionally incontinent of bowel and bladder. An interview was conducted with EI #6, an LPN (Licensed Practical Nurse), at 1:17 p.m. on 11/3/16. EI #6 was asked how RI #10 fed self. She answered, The staff or family feeds (them) all the time.EI #6 was asked what assistance the care plan indicated RI #10 required for eating. She answered, Assist him to feed and observe. EI #6 was asked if the care plan and MDS matched. She answered, No. EI #6 was asked why should the plan of care, that was driven by the MDS, reflect the needed assistance of the resident. She answered because things change and they want the resident's needs to be met. A subsequent interview was conducted with EI #6 at 1:34 p.m. on 11/3/16. EI #6 was asked what assistance did RI #3 require for incontinence care. She answered, Assist to toilet. EI #6 was asked if RI #3 was incontinent at times. She answered, Yes ma'am. EI #6 was asked what the care plan indicated. She answered occasionally incontinent of bowel and bladder. EI #6 was asked what the MDS dated [DATE] indicated. She answered, Always incontinent. An interview was conducted with EI #7, an RN (Registered Nurse)/MDS Coordinator, at 2:34 p.m. on 11/3/16. EI #7 was asked if the care plan and most recent full MDS assessment matched regarding incontinence status for RI #3. She answered, They do not match. EI #7 was asked why and she answered she did not know. EI #7 was asked what the care plan for RI #10 indicated as the assistance needed with eating. She answered, Cue and prompt; Set up. EI #7 was asked what the MDS indicated. She answered, Extensive assistance. EI #7 was asked what would that mean and she answered, Assist to feed. EI #7 was asked why the care plan and MDS assessment did not match. She answered, I cannot answer that question. EI #7 was asked what was the facility policy regarding the accuracy of the MDS assessment and the plan of care. She answered, The MDS and plan of care to match.

Based on interviews and record reviews, the facility failed to ensure a plan of care was developed regarding the Foley catheter for RI (Resident Identifier) #s 2, 4, 6, & 10. This affected RI #s 2, 4, 6, & 10, four of four residents sampled with indwelling catheters. Findings include: A review of the Facility's Policy and Procedure titled, Nursing Assessments, with an Effective Date: October 1, 2010, revealed, PURPOSE: The facility conducts, a comprehensive, standardized assessment of each resident's functional capacity necessary to develop a care plan and to modify the care plan and care / services based on the resident's status. STANDARD: . I. Initial Nursing Assessment on admission should include: (within 24 hours of admission) . · Preliminary plan of care completed within 24 hours of admission . A review of the Facility's Policy and Procedure titled, Care Plans, with an Effective Date: April 29, 2015, revealed, PURPOSE: Plans of Care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals for the resident. STANDARD: According to federal regulations, the facility develops a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental/psychosocial needs, that are identified in the comprehensive assessment. PROCESS: I. Assessment and Plan of Care Process . · Admission Plan of Care - should be initiated by admitting nurse based on assessment · Resident Assessment Instrument (RAI) - within 14 days of admission; quarterly, annually and with a significant change of condition · Comprehensive Plan of Care - within 7 days of admission RAI care plan should be reviewed; quarterly and with a significant change of condition II. Preparation for Care Plan Committee Meeting a) The Registered Nurse completing the Care Area Assessment (CAA) Summary, (a part of the RAI), should sign and date the CAA Summary Form after completion. This date is used to determine the date by which the care plan is completed. The seven day requirement for completion of a care plan, after development of the RAI, applies to admission, quarterly, annual and significant change of condition and significant connection to prior comprehensive assessments. 1) A review of RI #2's medical record revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a Quarterly MDS (Minimum Data Set) for RI #2, with an ARD (Assessment Reference Date) of 10/20/16, revealed RI #2 had short term and long term memory problems and was moderately impaired for cognitive skills for daily decision making. RI #2 was coded as having an indwelling urinary catheter on the MDS. A review of a Nurse's Note for RI #2, dated 9/9/16, revealed, . THE RESIDENT IS A RE-ADMISSION TO THE FACILITY . INDWELLING 16 FR (French) CATH (Catheter) PATENT AND DRAINING CLEAR YELLOW URINE. A review of the November physician's orders [REDACTED].# 16 FR/10 CC (Cubic centimeters) BULB TO BEDSIDE URINARY DRAINAGE BAG. CHANGE CATHETER WITH INSERTION TRAY/GU ([MEDICAL CONDITION]) BAG & BAND EVERY MONTH AND PRN (As needed) OCCLUSION/MALFUNCTION/DISLODGEMENT/LIFE TIME DX (Diagnosis) [MEDICAL CONDITION]. A review of RI #2's care plans revealed a care plan with Problem Onset: 04/14/2016(:) Potential for skin breakdown r/t (related to) thin fragile skin. Incontinence and decrease mobility; decrease [MEDICATION NAME]. This care plan was last reviewed on 9/9/2016 by facility staff. There was no care plan found related to the Foley catheter which the resident had upon readmission to the facility on [DATE]. On 11/2/16 at 5:05 p.m., an interview was conducted with EI (Employee Identifier) #2, an LPN, Licensed Practical Nurse. EI #2 was asked if RI #2 was care planned for the Foley catheter when she documented the Foley catheter on 9/19/16. EI #2 stated, I am not seeing one. EI #2 was asked if she knew why a care plan was not developed for the Foley catheter when it was inserted. EI #2 stated, No ma'am. EI #2 was asked why a care plan should be developed when a Foley catheter was inserted. EI #2 stated, Urinary Tract Infections, make sure (the) catheter is working properly. EI #2 was asked what the potential negative outcome for the resident was if a care plan was not developed when a Foley catheter was inserted. EI #2 stated, UTI (Urinary Tract Infection.) On 11/3/16 at 9:13 a.m., a phone interview was conducted with EI #1, an RN, Registered Nurse. EI #1 was asked what was the facility's Policy regarding the development of care plans when a resident enters the facility with a Foley catheter. EI #1 stated, Make sure we have the size, when it was placed, make sure we know the next time we need to change it, is it draining properly, and, (the) color of (the) urine, and why they have a catheter, diagnosis. EI #1 was asked who was responsible for developing the care plan for the Foley catheter when a resident entered the facility with a catheter. EI #1 stated, I am responsible for initiating the Foley catheter into the care plan. EI #1 was asked when the care plan was developed. EI #1 stated, On admission. EI #1 was asked if a care plan was developed for RI #2 on 9/9/16, upon readmission to the facility. EI #1 stated, No, I am not sure if I initiated one or not. EI #1 was asked what the potential negative outcome for the resident was if a care plan was not developed for a Foley catheter. EI #1 stated, Risk of infection. On 11/3/16 at 1:55 p.m., an interview was conducted with EI #3, an RN/MDS Coordinator. EI #3 was asked when a care plan should have been developed for the Foley catheter if RI #2 re-entered the facility from the hospital on [DATE] with a Foley catheter. EI #3 stated when the resident came back into the facility. EI #3 was asked who was responsible for developing the care plan for the Foley catheter. EI #3 stated the Admit Nurse was responsible. EI #3 was asked why a care plan was not developed for the Foley catheter at the time RI #2 was readmitted to the facility. EI #3 stated she did not know why a care plan was not developed for RI #2. 2) A review of RI #4's medical record revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #4's Quarterly MDS, with an ARD of 9/15/16, revealed a BIMS (Brief Interview for Mental Status) score of thirteen out of a possible fifteen points. This indicated RI #4 was cognitively intact. RI #4 was also coded for an indwelling urinary catheter. The review of a care plan for RI #4, dated 6/27/14, with a Problem Onset: 2/27/14, revealed, Foley catheter R/T (Related to) STAGE 4 PRESSURE TO SACRUM . *Follow physician orders *Vital signs per schedule and as needed *Pericare (Perineal Care) after each incontinent episode *Keep resident/responsible party informed *Observe for signs and symptoms of infections (Example: increased temp (Temperature), urine odor or color, sediment in urine) *Evaluate for medical necessity PRN (As Needed). There was no mention of how to care for the indwelling urinary catheter. 3) A review of RI #6's medical record revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #6's Quarterly MDS, with an ARD of 8/12/16, revealed a BIMS score of four out of a possible fifteen points. This indicated RI #6 was severely cognitively impaired for daily decision making skills. RI #6 was also coded as having an indwelling urinary catheter. The review of a care plan for RI #6, dated 9/14/15, with a Problem Onset: 08/05/2014, revealed, Foley catheter R/T (Related to) [MEDICAL CONDITION] . *Follow physician orders *Vital signs per schedule and as needed *Observe for complaints of pain or discomfort *Pericare (Perineal Care) after each incontinent episode *Observe for signs and symptoms of infections (Example: increased temp, urine odor or color, sediment in urine) *Keep resident/responsible party informed *Evaluate for medical necessity. There was no mention of how to care for the indwelling urinary catheter. 4) A review of RI #10's medical record revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #10's Quarterly MDS, with an ARD of 8/26/16, revealed RI #10's cognitive skills were severely impaired. RI #10 never/rarely made decisions. RI #10's MDS was coded for an indwelling urinary catheter. The review of a care plan for RI #10, dated 9/14/15, with a Problem Onset: 10/18/2016, revealed, Foley catheter dx (Diagnosis) [MEDICAL CONDITION] . *Follow physician orders *Evaluate for medical necessity *Vital signs per schedule and as needed *Observe for complaints of pain or discomfort *Pericare (Perineal Care) after each incontinent episode *Observe for signs and symptoms of infections (Example: increased temp, urine odor or color, sediment in urine) *Keep resident/responsible party informed. RI #10 was not care planned for the care of the indwelling urinary catheter. An interview was conducted with EI #4, a CNA, Certified Nursing Assistant, at 11:02 a.m. on 11/3/16. EI #4 was asked what the plan of care for RI #4 indicated regarding care for the indwelling catheter. She answered, It's not in the care plan. EI #4 was asked what the plan of care for RI #10 indicated regarding care for the indwelling catheter. She answered, I don't see anything about how to care for the catheter. EI #4 was asked why should the care plan address catheter care. She answered, Because it should state how to do proper care. An interview was conducted with EI #5, a CNA, at 12:58 p.m. on 11/3/16. EI #5 was asked what assistance RI #6 required for incontinence care. EI #5 answered the resident required full assistance with catheter care. EI #5 was asked what did the care plan indicate as the care to be provided regarding the catheter. She answered there was no indication. EI #5 was asked what was the importance of the plan of care for a catheter to include how and when to care for it. She answered, So you know how to perform the care. EI #5 was asked what was the facility policy regarding care plans. She answered, Follow it. An interview was conducted with EI #6, an LPN (Licensed Practical Nurse), at 1:17 p.m. on 11/3/16. EI #6 was asked what did the plan of care indicate regarding RI #4's catheter care. She answered nothing, just pericare after each episode. EI #6 was asked why. She answered it should state for the CNA to clean and let it drain to gravity. EI #6 was asked what did the plan of care indicate regarding RI #10's catheter care. She answered it's not in there. EI #6 was asked why the care plans for RI #'s 4 and 10 did not address catheter care. EI #6 answered she was not sure. EI #6 was asked why should the care plans address catheter care. She answered so that any CNA that was not familiar with the resident can go through the care plan and know how to clean and care for it properly. A subsequent interview was conducted with EI #6 at 1:34 p.m. on 11/3/16. EI #6 was asked what assistance or care RI #6 required for incontinence care. EI #6 answered the resident was incontinent and had a catheter. EI #6 was asked what did the care plan indicate regarding the care that was supposed to be provided for the catheter. She answered, Nothing except for pericare. An interview was conducted with EI #7, an RN (Registered Nurse), at 2:34 p.m. on 11/3/16. EI #7 was asked how the catheter care was addressed in the plan of care for RI #6. She answered, It's nothing in there. EI #7 was asked what should the plan of care include regarding catheter care. She answered, How to take care of the Foley catheter and when to provide care for it. EI #7 was asked how the catheter care was addressed in the plan of care for RI #4. She answered, It's not addressed. EI #7 indicated the same contents should be present in RI #4's care plan regarding the catheter as for RI #6. EI #7 was asked how the catheter care was addressed in the plan of care for RI #10. She answered, It's not there. EI #7 was asked why the plan of care should include care for the catheters. She answered, So whoever the Aide or Nurse, (they would) know how to care for the catheter.

Based on an observation, record reviews, and interviews, the facility failed to ensure an interim care plan was developed for RI (Resident Identifier) #3 when a Foley catheter was placed for [MEDICAL CONDITION]. This affected RI #3, one of seventeen sampled residents whose care plans were reviewed. Findings include: The review of a facility document titled, NURSING MANAGEMENT MANUAL, dated 11/1/2001, revealed, . Section: Quality of Care Policy Title: Change in Medical Condition of Residents Policy Number NM.I-20 According to CMS's (Centers for Medicare and Medicaid Services) the RAI (Resident Assessment Instrument) Manual, a change of condition is defined as a major change in the residents' health status . c) requires interdisciplinary review/revision of the plan of care. Process: III Documenting the Change of Condition a) Nurses notes should include documentation of the symptoms and observations associated with the change in condition, the date and time of contact with the physician and family member/legal representative. Notes also should include comments on the care provided by the nursing personnel. e) The plan of care may be altered to reflect a change in condition where new goals and approaches are developed. A review of the medical record revealed RI #3 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the facility document titled, Nursing Admission Review, dated 12/4/2015, revealed, RI #3 was .modified independent with some difficulty in new situations only, . with daily decision making skills. The assessment also revealed RI #3 was bowel and bladder incontinent. A review of the facility document titled, Care Plan, dated 12/3/2015, revealed, Problem Onset: 12/03/2015 Potential for skin breakdown bowel and bladder incontinence. There was no care plan regarding the care or maintenance of a Foley catheter. A review of the facility document titled, Departmental Notes, dated 12/04/2015 at 10:30 PM, revealed, Resident returned to the facility. Has 14fr (French) Foley catheter that is intact and draining amber color urine. On 12/9/2015 at 8:05 AM, an observation was made of RI #3's Foley catheter with the urinary drainage bag hanging on the left side of the bed. On 12/10/2015, at 1:33 PM, an interview was conducted with EI (Employee Identifier) #1, an RN (Registered Nurse) and the MDS (Minimum Data Set) Coordinator. EI #1 was asked who was responsible for developing the care plan on a resident's admission or re-entry to the facility. EI #1 responded, the admit nurse and the interdisciplinary team. EI #1 was asked why it was important to have an updated care plan on the chart. EI #1 responded so staff will be aware of any changes in the residents status. EI #1 was asked what was the purpose of a care plan. EI #1 said to guide the residents care and ensure all their needs are met. EI #1 was asked why a care plan was not developed for RI #3 regarding the Foley catheter. EI #1 stated there could be several reasons why the care plan was not developed. EI #1 said any time a resident goes out of the facility and comes back, the whole IDT (Interdisciplinary Team) would meet and discuss changes. EI #1 said RI #3 came back into the facility with a Foley catheter and she was going to capture it with any other changes upon completion of the MDS assessment. EI #1 was asked how the staff would know how to care for the catheter. She stated the staff had been trained on pericare through inservices and they would know the procedure. EI #1 was asked how staff would know RI #3 had a catheter if it was not documented on the care plan. EI #1 said when RI #3 had an ER (emergency room ) visit, along with the admit visit, the resident was placed under review for a significant change assessment, which was not due until 12/10/2015. EI #1 was asked if she would have waited until the tenth of the month to capture all the resident's changes and she said yes. She responded everything was done by a report system. EI #1 was asked where the nurse was going to obtain the information to give the report and she stated, I'm not sure where else it would be written. EI #1 stated, Legally, we are pretty much following the policy and the guidelines of CMS. Everything is correct regarding the care plan. EI #1 was asked what did the facility's policy indicate in regards to changes in a resident's plan of care. She said the policy stated when a resident comes in, an initial care plan would be in place. The RAI would be completed, reviewed, and a care plan would be developed within the first twenty-one days. The whole process would be reviewed by the IDT. EI #1 was asked what could be the potential negative effect of not having an accurate, updated care plan for a resident on the chart. EI #1 stated, The only negative thing would be nothing showing how effective our system works. EI #1 was asked if she meant CMS approved of the care plan not reflecting changes in a residents plan of care. EI #1 responded CMS gave her time to document the plan of care. EI #1 went on to say, In this case, the Foley catheter care plan would not appear until 12/10/2015, she paused and then stated, No, I would have twenty-one days, which would be 12/23/2015. On 12/10/2015 at 3:15 PM, an interview was conducted with EI #2, RN, the acting DON (Director of Nursing). EI #2 was asked who was responsible for developing care plans for residents on an admission or re-entry to the facility. EI #2 responded the IDT. EI #2 was asked why it was important to have an updated care plan on the chart. EI #2 stated to meet the needs of the residents. EI #2 was asked what was the purpose of a care plan. EI #2 responded, to provide a consistent plan to meet the physical, psychosocial, and emotional needs of the residents. EI #2 was asked why a care plan was not developed for RI #3 regarding the placement and care for the Foley catheter. EI #2 stated the facility had a period of time to complete a care plan. EI #2 was asked how someone would know to care for RI #3's catheter if it was not documented on the care plan. EI #2 stated the staff Were waiting to see if this was not going to be a short term problem. The nurse should have put the order in.

Based on observations, interviews, and record reviews, the facility failed to ensure that Privacy/Dignity was maintained for residents during incontinence care for RI (Resident Identifier) #7 and wound care for RI #1. This was observed on 1 of 3 survey days and had the potential to affect RI #1 and RI #7, two of seventeen sampled residents. Findings include: A review of RI #7's current medical record revealed RI #7 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Annual Minimum Data Set for RI #7, with an Assessment Reference Date of 10/01/2014, indicated RI #7 was coded as frequently incontinent of bowel and bladder function. A review of the Brief Interview for Mental Status shows that RI #7 was unable to complete scoring. RI #7 required extensive assistance with transfer, dressing, and toileting. On 12/17/2014 at 5:15 AM, RI #7 was found in the bed with the door open and privacy curtain not pulled. EI (Employee Identifier) #7, a CNA (Certified Nursing Assistant) was providing incontinence care with the resident lying on the left side. RI #7's buttocks was observed. The surveyor stood at the door for 2-3 minutes before EI #7 realized a surveyor was watching. When EI #7 realized the surveyor was watching, EI #7 pulled the privacy curtain. On 12/17/2014 at 6:58 AM, an interview was conducted with EI #7. EI #7 was asked what the facility's policy was on providing privacy during incontinence care. EI #7 stated, "I was supposed to close the door, but RI #7 had took (the) covers off and diaper off and I was trying to hurry up and cover (RI #7) up, we had a lot of lights going off and it was just 2 of us. It was a mistake." EI #7 was asked why should privacy be provided during incontinence care. EI #7 replied, "To protect their (Resident's) dignity, I close(d) the door, but (RI #7) had the diaper off and I ran in there and covered (RI #7) up." EI #7 was asked why she did not close the door when she went in the room. EI #7 stated, "I don't know." EI #7 was asked why the privacy curtain wasn't pulled and closed on RI #7 at 5:15 AM. EI #7 responded, "The privacy curtain wasn't pulled because I was using the light from the other side of the room. The pull string over (RI #7's) bed is short and I couldn't reach it." EI #7 was asked what the potential harm to the resident was if not providing privacy during incontinence care. EI #7 replied, "They could be exposed, but when I came in there (RI #7) was already uncovered. I just ran in there to cover (RI #7) up." A review of the facility's policy and procedure titled, "Dressings-Clean", with an effective date of January 15, 2010, revealed, "Purpose: To provide guidelines for the care of wounds and soiled dressings, to decrease the potential for nosocomial infection. Each wound site should be treated individually. ... Process: 1. Explain the procedure to the resident and screen for privacy ..." A review of RI #1's current medical record revealed, RI #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 12/17/2014 at 9:19 AM, RI #1 received wound care from EI #9, an LPN(Licensed Practical Nurse)/Treatment Nurse, with the assistance of EI #8, a CNA. During the performance of the wound care, the privacy curtain was pulled between the residents, but the blinds were left open, and RI #1 was in the bed by the window. On 12/18/2014 at 10:30 AM, the surveyor and EI #10, a CNA, went outside of the room. EI #10 and the surveyor observed (RI #1's) bed (by the window) and contents on the BS (bedside) table. The lights were turned off in the room and a visitor of the resident in bed 1 was seen. On 12/18/2014 at 10:50 AM, an interview was conducted with EI # 8. EI #8 was asked what the facility's policy was on providing privacy during wound care. EI #8 stated, "We're supposed to close curtains, windows, and doors when providing care, all residents have a right to privacy." EI #8 was asked why should privacy be provided during wound care. EI #8 replied, "I wouldn't want anyone to walk in on me when I'm exposed. Everybody should have their right to privacy during care. I wouldn't want to be exposed and I treat my residents as I want to be treated." EI #8 was asked the potential harm to the resident if privacy was not provided during wound care. EI #8 replied, "Embarrassment if anyone came in and saw them with(out) any clothes on, it would be indignant." EI #8 was asked if blinds should be closed prior to treatment for [REDACTED]. EI #8 stated, "Yes, for privacy, you could have anybody walking by the window and see everything." EI #8 was asked why the blinds were not closed during wound care for RI #1 on 12/17/2014. EI #8 responded, "We forgot, I just thought about that. When we went outside and looked at the bed this morning, I thought, did we close the blinds yesterday." EI #8 was asked the potential harm of not closing blinds during the wound care observation for RI #1 on 12/17/2014. EI #8 said, "Somebody seeing us doing the wound care on (RI #1) yesterday." On 12/18/2014 at 11:05 AM, an interview was conducted with EI #9. EI #9 was asked what the facility's policy was on providing privacy during wound care. EI #9 stated, "We need to close the door, pull the curtains and close the blinds if there is a possibility you can see in the windows. All windows, the blinds should be closed." EI #9 was asked why should privacy be provided during wound care. EI #9 replied, "For patient dignity, also as part of HIPAA (Health Insurance Portability and Accountability Act). A family member of another resident could come by and see their wound." EI #9 was asked if blinds should be closed prior to treatment for [REDACTED]. EI #9 stated, "Yes, for privacy, you want to make sure you establish that before you start anything." EI #9 was asked why the blinds were not closed during wound care for RI #1 on 12/17/2014. EI #9 responded, "It completely slipped my mind, I'll be honest with you." EI #9 was asked the potential harm of not closing blinds during the wound care observation for RI #1 on 12/17/2014. EI #9 said, "Someone could have seen in, (RI #1) could have been embarrassed. Someone could have seen (RI #1) had a wound and talked about it with other people. Other family members could have seen that (RI #1) wasn't getting privacy and got upset to think their family member may not get privacy as well." On 12/18/2014 at 2:35 PM, an interview was conducted with EI #2, DON (Director of Nursing). EI #2 was asked what the facility's policy was on providing privacy during incontinence care. EI #2 stated, "It's for the staff to look around the room. If in private room, close the door and look around the room for other things that might impede on their privacy and if in a semi-private (room), there's a privacy curtain in the room." EI #2 was asked why should privacy be provided during incontinence care and wound care. EI #2 replied, "Because the resident could be exposed, to be respectful; they (the resident) have a right to privacy." EI #2 was asked what the potential harm to the resident was if not providing privacy during wound care. EI #2 replied, "Potentially emotional, if someone was to walk in, emotional, dignity". EI #2 was asked if blinds should be closed prior to treatment for [REDACTED]. EI #2 stated, "Yes, there's the potential someone from the outside could view."

Based on observations, interviews, and record reviews, the facility failed to ensure a Licensed Nurse did not recap an insulin syringe after removing insulin from a vial and prior to administering the insulin to a resident. This had the potential to affect RI (Resident Identifier) #8, one of eight residents observed for medication administration. Findings include: 1) A review of the facility's Policy and Procedure titled "Medication Administration Procedures Subcutaneous Medications," with a date of 03/2011, revealed, "... Procedures 1. Follow instructions 1-6 on Intramuscular Injection. ..." A review of the facility's Policy and Procedure titled, "Medication Administration Procedures Intramuscular Medications," with a date of 03/2011, revealed, "... Procedures ... 4. Prepare medication as follows: ... H. Cover needle via protective sleeve to ensure safety. ... J. Identify resident before administering medication. ..." A review of RI #8's medical record revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 12/09/14 revealed RI #8 had a BIMS (Brief Interview for Mental Status) score of 8 out of a possible 15. This score indicated RI #8 was moderately impaired for cognitive skills for daily decision making. On 12/16/14 at 4:50 PM, the surveyor observed EI (Employee Identifier) #1, an LPN (Licensed Practical Nurse), withdraw 30 Units of insulin from a vial and then recapped the needle prior to administering the insulin to RI #8. On 12/18/14 at 1:05 PM, a phone interview was conducted with EI #1. EI #1 was asked what the facility's policy was on recapping needles. EI #1 stated, "You don't recap the needle after you use them. You push up the safety guard and put them (needles/syringe) in the sharps container." EI #1 was asked how the needle should be protected for transport or until the resident was injected after the insulin was drawn up. EI #1 stated, "You recap it until you use it. After you use it you don't recap." EI #1 was asked how she protected the insulin needle prior to administering the insulin to RI #8 on 12/16/14 during the medication pass observation. EI #1 stated, "I put the cap back on it." EI #1 stated, "I then put it on (RI #8's) bedside table until (the resident) took her oral medications." EI #1 was asked what the potential harm was of recapping insulin needles. EI #1 stated, "You can stick yourself while recapping that's why you don't recap." EI #1 also stated, "I thought you could recap needles after you draw up the insulin, but you couldn't recap after you use it. You use your safety guard and put in the sharps container." On 12/18/14 at 2:41 PM, an interview was conducted with EI #2, DON (Director of Nursing). EI #2 was asked what the facility's Policy was on recapping needles. EI #2 stated, "We do not recap needles." EI #2 was asked how the needle should be protected for transport until the resident was injected after drawing up the insulin. EI #2 stated, "There's a safety shield on the syringe. This shield should be used to cover the needle." EI #2 was asked what the potential harm was of recapping insulin needles. EI #2 stated, "A needle stick injury, the potential for it."