Every finding on record at Jackson Health Care Facility

Based on interviews, record review, and review of a facility document titled RESIDENT'S RIGHTS the facility failed to ensure Resident Identifier (RI) #1 was provided care in a manner to maintain his/her dignity when staff failed to provide a bedpan when he/she voiced the need to toilet. This affected one of four residents sampled for residents' rights. Findings include: On 12/9/2021 the State Agency received a complaint alleging staff had instructed RI #1, an alert and oriented resident that was aware of his/her needs, to have a bowel movement in his/her bed. Review of a facility document titled RESIDENT'S RIGHTS with a copyright date of 1992 revealed: Each and every resident in the facility has the right to: .10. Be treated . with the fullest measure of dignity. RI #1 was admitted to the facility on [DATE] with an Admission Diagnosis of Displaced Intertrochanteric Fracture of the Right Femur and had other diagnoses that included Muscle Weakness, Need for Assistance with Personal Care, and History of Falling. Review of RI #1's admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date of 11/19/2021 revealed RI #1 scored a 15 out of 15 for the Brief Interview for Mental Status Score, indicating he/she was cognitively intact. This assessment also documented RI #1 required extensive assistance of two plus people for bed mobility, transfers, and toilet use (including the use of a bed pan). A Physical Therapy Treatment Encounter Note(s) for RI #1 made by Employee Identifier (EI) #3, Physical Therapy Assistant (PTA), on 11/15/2021 documented: .Pt (patient) not safe to transfer to BSC (bedside commode) at this time. Recommend bed pan . On 12/14/2021 at 10:30 AM a telephone interview was conducted with a family member of RI #1. This family member reported that while he/she was visiting RI #1 at the facility on at least one occasion RI #1 requested to use the toilet and two unknown female staff members told RI #1 to use the brief. On 12/14/2021 at 10:35 AM a telephone interview was conducted with another family member of RI #1. This family member reported that twice unknown staff told RI #1 to void in his/her brief. On 12/14/2021 at 10:45 AM a telephone interview was conducted with RI #1. RI #1 reported that he/she was using the brief while at the nursing home and he/she did not like that. RI #1 reported staff did put him/her on a bed pan maybe once while he/she was at the facility. RI #1 said it made him/her feel like staff just did not want to take the time to assist. On 12/15/2021 at 3:30 PM an interview was conducted with EI #3, PTA. EI #3 reported, in the first week of RI #1's admission to the facility, RI #1 was wanting to go to the toilet, so they got a bedside commode and tried working with RI #1 on using it, but it did not go well due to him/her being fearful of falling. EI #3 reported that therapy had attempted to assist RI #1 with using a bedside commode and it was determined to be unsafe for RI #1, so the fracture style bed pan should have been used when RI #1 voiced the need to toilet. EI #3 reported that it was standard practice that when a resident asked to use the toilet and was unable to be transferred, for the resident to be offered the bedpan instead. When asked if RI #1 was continent, EI #3 said she thought RI #1 knew when he/she had to go void or have bowel movement and would ask for assistance. On 12/15/2021 at 4:35 PM an interview was conducted with EI #6, Licensed Practical Nurse (LPN). EI #6 reported that she was in the room once and overheard RI #1 voice the need to toilet to a visitor that was present in the room. EI #6 said she heard the visitor respond to RI #1 that he/she could not get up and needed to use the brief. When asked if she had offered RI #1 a bedpan when she heard this, EI #6 said she did not. EI #6 was asked, when a resident voiced the need to use the toilet but was unable to transfer safely, what should be done. EI #6 replied, the bedpan should be offered, and she should have done it that day. During a follow-up interview with EI #6 on 12/16/2021 at 11:05 AM, EI #6 was asked, what was the concern when she was in RI #1's room and did not offer the bedpan when she heard the resident tell a visitor he/she needed to toilet and then the visitor instructed the resident to soil the brief. EI #6 replied, it could have caused a dignity concern with the resident. On 12/15/2021 at 4:50 PM an interview was conducted with EI #7, a Certified Nursing Assistant (CNA) that cared for RI #1 during his/her stay at the facility. EI #7 reported that RI #1 would turn on the call light when he/she needed to void or have a bowel movement and she would put RI #1 on the bedpan. EI #7 explained RI #1 knew when he/she had to go to the bathroom but was dependent on staff to get on the bedpan. On 12/16/2021 at 9: 00 AM an interview was conducted with EI #9, LPN/Restorative Nurse. EI #9 was asked how staff should have been toileting RI #1 when he/she requested the need to toilet and was unable to safely transfer to the bedside commode or toilet. EI #9 replied, offer the bed pan. EI #9 was asked what was the potential harm to a resident who had the urge to void and was not offered the bedpan and then soiled their brief. EI #9 replied, it would be a dignity concern. EI #9 was asked, how would that make most residents feel. EI #9 replied, they could be embarrassed. On 12/16/2021 at 12:20 PM an interview was conducted with EI #1, Registered Nurse/Director of Nursing. EI #1 said if RI #1 was not incontinent 100% of the time and if RI #1 knew when he/she had to void or have a bowel movement, it would not be appropriate to tell him/her to use a brief rather than placing him/her on the bed pan. EI #1 was asked, what should a staff member have done when staff were in RI #1's room and heard a visitor telling RI #1 that he/she could not get out of bed and needed to use the brief to void or have bowel movement. EI #1 replied, the staff should have corrected the visitor and let them know that if the resident voiced a need to toilet that the bedpan could be provided without getting out of bed. EI #1 said the staff member should have offered the bedpan. EI #1 was asked, what was the potential harm to RI #1 when he/she voiced the need to toilet and was not offered the bedpan and then soiled his/her brief. EI #1 replied, it would be a loss of dignity and would be degrading to the resident.

Based on observation, interview, record reviews, and review of facility's policy, the facility failed to provide appropriate treatment, care and services to address the resident's positioning needs in accordance with professional standards of practice, comprehensive care plan and physician's orders [REDACTED].#22). Observations on 3/23/21, 3/24/21 and 3/25/21 revealed Resident #22 was not turned and repositioned per the physician's orders [REDACTED].#22 did not have his/her hand towels in his/her hands per the care plan. Findings include: Review of the facility's policy titled Care Planning Policy and Procedure, dated 02/2018, revealed the care plan is a guide for all staff on a course of action that will attain or maintain a resident's highest practicable level of well-being. The care plan will be written in accordance with professional standards of practices and documentation. Communication about care plan changes should be ongoing among interdisciplinary team members. Review of the facility's policy titled Writing, Transcribing, and Keying in Physicians Orders, dated 3/2002 and revised 3/2015, revealed the purpose was to provide a protocol for writing physician orders [REDACTED]. Orders are to be taken, recorded, and carried out by qualified licensed professional staff within their area of expertise. Review of the clinical record revealed Resident #22 was admitted to the facility on [DATE]. The resident was assessed on the Quarterly Minimum Data Set (MDS) assessment, dated 1/5/21, to have [DIAGNOSES REDACTED]. Resident #22 had a Brief Interview for Mental Status (BIMS) score of 99, which indicated the resident was severely cognitively impaired. The MDS assessment identified the resident's functional status for activities of daily living (ADLs) as indicating Resident #22 required total assistance from staff. The MDS revealed the resident had functional limitations in range of motion and impairment to the resident's upper and lower extremities on both sides. The MDS revealed Resident #22 did not participate in skilled therapies or restorative nursing programs during the assessment review period. Under Section G Functional Status, the resident was coded as requiring the assistance of two (2) persons with bed mobility. Review of the Care Plan dated 5/24/19 with a revision date of 2/21, for Resident #22 revealed ADL functional/rehabilitation potential was identified as a problem deficit. The goal established stated, The resident will maintain with the same ability in self-care with ADLs through the next review. The approaches included Occupational Therapy (OT) consult PRN (as needed) to help establish a maintenance program for self-care with ADLs, turn and reposition with the assistance of one (1) person and sheet, and use positioning pillows/wedges to assist in resident comfort. Continued review of the care plan revealed an approach to place hand towels in both hands due to the resident keeping his/her hands held tightly. Review of Resident #22's physician's orders [REDACTED]. Review of the Skilled Occupational Therapy (OT) Services Progress Notes revealed the services were provided as indicated with each physician's orders [REDACTED].#22's goal was not met (goal expected date of 6/24/19), and demonstrated AROM (active range of motion) of bilateral upper extremities from 0 to 0 (indicating the resident was unable to straighten out the upper extremities). The note revealed the resident made no improvement in overall strength and endurance. An observation of Resident #22 on 3/24/21 at 9:40 a.m., 11:45 a.m., and 1:30 p.m. revealed the resident had not been turned per physician ordered turn schedule and remained on his/her back and no hand towels were in each hand. An observation of Resident #22 on 3/25/21 at 10:00 a.m., revealed the resident was still positioned on his/her back and had not been turned and no hand towels were in each hand. An interview was conducted on 3/24/21 at 1:34 p.m. with the Therapy Supervisor who stated, For residents who require hand towels in their hands, restorative staff are responsible for that. Resident #22 reached his/her maximum ability to improve on 6/12/19 and received OT from 5/27/19 through 6/12/19 and Physical Therapy (PT) from 5/27/19 through 6/12/19 as well. The Therapy Supervisor further stated, Resident #22 was admitted to the facility with the contractures from home and I did not order the hand towels for the resident's hand. An interview was conducted on 3/24/21 at 1:47 p.m. with Certified Nurse Aide (CNA) #1. CNA #1 stated, I bathed Resident #22 and placed him/her on his/her back. I did not turn Resident #22 until just before I came to speak with you. I have not been putting hand towels in his/her hands and as far as I know he/she has not had them in for a while. Continued interview revealed the CNA had a Caesarean Section six (6) months ago and it was painful when he/she turned the residents. The CNA further stated, Our turning schedule is on the back of our badge, but I left mine in the car. We are required to turn all residents who are bed bound every two (2) hours and I did not do that. An interview was conducted on 3/24/21 at 2:13 p.m. with CNA #2. CNA #2 stated, We are expected to turn the residents every two (2) hours and follow our turning schedules which are on our badges for all residents who are bed bound or if they request to be turned. I have not put towel rolls in Resident #22's hands for about three (3) months. I noticed it was not done by other staff, so I stopped doing it too. We are expected to follow the care plan for all residents, and I should have looked at it, but I did not. An interview was conducted on 3/24/21 at 2:20 p.m. with Restorative Licensed Practical Nurse (LPN) #1 who stated, The wound care nurse placed the recommendation on the care plan to put hand towels in both hands of Resident #22. I only check the care plans quarterly unless something has changed and we discussed it, then I will update it and not wait until quarterly. According to therapy, her range of motion was 0 to 0, so a splint device was not recommended. I would agree that Resident #22 has not had the hand towels in place since the survey entry date, but I feel that her clinical condition is unavoidable. In an interview on 3/24/21 at 3:00 p.m., with the Director of Nursing (DON) revealed it was his/her expectation that staff follow the care plan and turning schedule for all residents. The DON stated, They (staff) are checked off on the skills check list and know to look at the care plan and follow it. Interview on 3/24/21 at 3:35 p.m. with the Wound Care Nurse (WCN) revealed he/she placed the recommendation on the care plan for the bilateral hand towels in each hand for Resident #22 due to his/her hands being closed which caused sweating. The WCN stated, I felt having the hand towels would prevent sweating and any potential for skin breakdown.

Based on observation, interview, record review and facility policy review, the facility failed to ensure a resident with limited Range of Motion (ROM) received appropriate treatment and services to prevent further decrease in range of motion per the comprehensive care plan and physician's orders [REDACTED].#51). Observations on 3/23/21, 3/24/21, and 3/25/21 of Resident #51 revealed the resident was not wearing the ROM devices per the care plan and physician's orders [REDACTED]. Findings include: Review of the facility's policy titled Care Planning Policy and Procedure, dated 02/2018, revealed the care plan is a guide for all staff on a course of action that will attain or maintain a resident's highest practicable level of well-being. The care plan will be written in accordance with professional standards of practices and documentation. Communication about care plan changes should be ongoing among interdisciplinary team members. Review of the facility's policy titled Writing, Transcribing, and Keying in Physicians Orders, dated 3/2002 and revised 3/2015, revealed the purpose was to provide a protocol for writing physician orders [REDACTED]. Orders are to be taken, recorded, and carried out by qualified licensed professional staff within their area of expertise. Review of the clinical record revealed Resident #51 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 11/27/2020, revealed [DIAGNOSES REDACTED]. The resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating the resident was moderately impaired in cognition. The MDS assessment revealed Resident #51 was assessed to have no ambulation or locomotion activity during the review period. The resident was further assessed to have functional limitations in range of motion (ROM) to the lower extremities and no impairment on both sides of the upper extremities. The resident had received no skilled therapy services or restorative nursing services during the assessment review period. The resident was assessed to require total dependence of staff every time during the entire seven (7) day look back period. Review of the Care Plan for Resident #51, dated 2/14/2020 and revision date of 3/9/21, revealed a problem and . Under the approaches section, the following interventions were listed: Apply soft beaded splint to the left lower extremity after a.m. (morning) care; remove at night (HS); inspect skin for irritation/breakdown for fifteen (15) minutes; remove splint at bedtime, and apply right knee immobilizer after a.m. care. Review of physician's orders [REDACTED].#51 was ordered to have a right knee immobilizer after a.m. care and inspect the skin for irritation for 15 minutes. Further review of the physician's orders [REDACTED].#51 was to have a soft beaded splint to the left lower extremity daily after a.m. care. Review of the DW McMillian Home Medical Equipment Invoice dated 3/25/21 at 8:56 a.m. revealed a purchase of one (1) each of an L1830 16-inch knee immobilizer canvas De-Royal/7041-02. Observation on 3/23/21 at 10:00 a.m. revealed Resident #51 was resting in bed without the splint devices in place. Further observations on 3/23/21 at 11:00 a.m., 1:00 p.m., 2:30 p.m. and 4:30 p.m. revealed the resident remained in bed without the splint devices in place. Observation on 3/24/21 at 10:50 a.m. revealed CNA #3 was providing care to Resident #51 with the beaded splint applied to the left knee, but not to the lower extremity. The resident did not have on the knee immobilizer. Observation on 3/24/21 at 12:20 p.m. with the Restorative Nurse revealed Resident #51 did not have the knee immobilizer on his/her right leg. Resident #51 had the soft beaded splint on his/her left knee; however, it was not applied to the lower extremity per the care plan. Observation on 3/25/21 at 8:15 a.m. and 8:30 a.m. revealed Resident #51 was resting in bed with no splint devices in place. Observation on 3/25/21 at 10:00 a.m. revealed Resident #51 was in bed with the soft beaded splint in place but the knee immobilizer was not in place. An interview was conducted on 3/24/21 at 10:30 a.m. with Restorative License Practical Nurse (LPN) #1. LPN #1 stated, Nurses on the floor are responsible for putting splints on the residents based on what is recommended from therapy. Once care plans are updated, the Certified Nursing Aides (CNAs) and restorative are to follow the care plan. My responsibility is to monitor activities of daily living (ADLs), notify the physician, and get orders for splint devices or therapy. Therapy and I communicate on what needs a resident may have. An interview was conducted on 3/24/21 at 11:15 a.m. with Certified Nurse Aide (CNA) #3 revealed he/she placed the soft beaded pad on Resident #51 daily after morning care and it stayed on until the resident was put to bed at night. CNA #3 stated, The splint is used to help prevent contractures. The only thing Resident #51 has on during the day is the soft beaded pad; the resident use to wear a knee immobilizer but about a month ago it went down to the laundry and never came back. I asked about getting a new one but they (therapy) wanted to see if Medicaid would pay for it. I have not heard anything since. An interview was conducted on 3/24/21 at 12:15 p.m. with the Rehab Director revealed if there were any issues with splints or devices, the restorative nurse was good about completing an evaluation. The Rehab Director stated, I can't remember if we were told recently about a missing splint device and I was never notified of the missing knee immobilizer by staff or the restorative nurse for Resident #51. The restorative nurse is responsible for informing me of any residents who may need a splint device. Interview on 3/24/21 at 12:50 p.m. with the Administrator and Director of Nursing (DON) revealed it was their expectation that staff would have notified them when Resident #51 did not have the ordered knee immobilizer. The Administrator and DON further stated, If we had known this, we could have ordered one through our medical supply store or through our vendor and replaced it; we plan on getting the immobilizer tomorrow.

Based on observation and interview, the facility failed to ensure a dietary staff member did not place the thermometer through the foil to take the temperatures of the food during the preparation of the dinner meal on 02/27/19. This affected 72 of 73 residents receiving the dinner meal from the kitchen on 02/27/19. Findings Include: On 02/27/19 at 4:33 p.m., an observation was made during the tray line. The surveyor observed six containers of food items on the tray line covered with foil. EI (Employee Identifier) #2, Dietary staff member, did not remove the foil, and took all six of the temperatures by placing the thermometer though the foil and into the food. An interview was conducted with EI #1, the Dietary Manager on 02/28/19 at 12:11 p.m. EI #1 was asked, what should be done before taking the temperatures of the food. EI #1 replied, remove any film or foil on top of the food and stir it, then sanitize the thermometer and take the temperatures. EI #1 was asked, why was the film or foil removed before taking temperatures. EI #1 replied, because sticking the thermometer in the film or foil could cause contamination. EI #1 was asked, what was the potential concern of not removing the film or foil from the food before taking the temperatures. EI #1 replied, it could be harmful to the residents.

Based on observations, interviews and a facility policy titled, Care Planning Policy and Procedure, the facility failed to ensure RI (Resident Identifier) #14's and RI #53's care plans addressing contractures (shortening and hardening of muscles, tendons or other tissue) with the use of a hand roll were followed. This deficient practice affected RI #14 and RI #53, two of 23 sampled residents whose care plans were reviewed. Findings Include: A review of a facility policy titled, Care Planning Policy and Procedure with a revised date of 2/18, revealed: Policy: The care plan is a guide for all staff on a course of action that will attain or maintain a resident's highest practicable level of well being . Procedure . 6.The care plan team will develop measurable goals for improvement, prevention, or maintenance of the resident's status 1) RI #14 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #14's Care Plan documented the following: .Problem Onset: 10/14/2014 .I have the potential for injury related to contractures . Goal & (and) Target Date . I will not have worsening of contracture through Mar(March) 2019 . Approaches .Apply hand roll . On 2/27/19 at 4:36 p.m., RI #14 was observed in bed. His/her left hand was contracted and did not have a hand roll in it. On 2/28/19 at 8:37 a.m., RI #14 was observed sitting up in bed eating breakfast, feeding her/himself with the right hand. RI #14's left hand was contracted and did not have a hand roll in it. On 2/28/19 at 10:21 a.m., Employee Identifier (EI) #8, Registered Nurse (RN), accompanied the surveyor to RI #14's room and observed his/her left hand. The left hand was contracted and did not have a hand roll in it On 2/28/19 at 10:23 a.m., an interview was conducted with EI #8. EI #8 was asked to describe the condition of RI #14's left hand. EI #8 said, (He/she) has some contractures in (his/her) left hand. EI #8 was asked, according to the care plan, should EI #14 have a hand roll in his/her hand. EI #8 said,Yes. EI #8 was asked if RI #14's care plan was being followed. EI #8 said, No. EI #8 was asked why was it important to follow the care plan. EI #8 said, It tells you about the care to provide to the resident. On 2/28/19 at 11:16 a.m., an interview was conducted with EI #5, Licensed Practical Nurse,(LPN), Restorative Nurse. EI #5 was asked which hand of RI #14's was contracted. EI #5 said the left hand. EI #5 was asked if RI #14 had been assessed by OT (Occupational Therapy) for contractures. EI #5 said she/he had. EI #5 was asked what was OT's recommendation. EI #5 said keep a hand towel in his/her hand. EI #5 was asked, if it was documented on RI #14's care plan to have a hand roll, should the care plan be followed. EI #5 said, Yes. EI #5 was asked why was it important to follow RI #14's care plan addressing contractures. EI #5 said, If the hand roll is not in (her/his) hand, (he/she) could get skin irritation, for the well being of the patient (and to) make sure they are getting the best care. 2) RI #53 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #53's Care Plan documented the following: .Problem Onset: 02/24/2009 .(RI #53) is at risk for injury related to contractures . Goal & (and) Target Date . (RI #53) will not have worsening of contractures through (MONTH) 2019 . Approaches .Apply splints per protocol . On 2/25/19 at 5:02 p.m., a contracture to RI #53's left hand was observed. The therapy carrot hand splint was in a plastic bag at the bedside. On 2/26/19 at 3:17 p.m., RI #53's therapy carrot hand splint was observed in a plastic bag at the bedside. RI #53 had a contracture to the left hand. No hand roll was in the left hand. On 2/27/19 at 10:24 a.m., RI #53 was observed lying in bed. The therapy carrot hand splint was hanging in a plastic bag at the bedside. On 2/28/19 at 10:42 a.m., RI #53 was sleeping. The therapy carrot hand splint was not in the left hand. It was hanging in a plastic bag at the bedside. On 2/28/19 at 11:04 a.m., an interview was conducted with EI #5. EI #5 was asked if RI #53 was supposed to have the therapy carrot applied daily. EI #5 said yes. EI #5 was asked when was the therapy carrot supposed to be applied. EI #5 said it was usually placed after a.m. care and removed after first shift. EI #5 was asked who was responsible for making sure the therapy carrot was applied to RI #53' left hand. EI #5 said the CNA (Certified Nursing Assistant) and the charge nurse on the floor. EI #5 was asked what was the potential concern of RI #53 not having the therapy carrot applied daily. EI #5 said she/he could possibly get skin issues.

Based on observation, medical record review, interview and Potter and Perry's FUNDAMENTALS OF NURSING, the facility failed to ensure EI (Employee Identifier) #4, LPN (Licensed Practical Nurse) performed hand hygiene after removing gloves and before reaching into the medication cart during the administration of a bolus tube feeding to RI (Resident Identifier) #50. The facility also failed to ensure EI #4 did not use contaminated gloves to open a door. This affected one of one residents observed who received a bolus tube feeding. Findings Include: A review of Potter and Perry's FUNDAMENTALS OF NURSING, Ninth Edition, Copyright (YEAR), Chapter 29, Infection Prevention and Control, page 458 and 465 revealed: .Hand Hygiene. The most effective basic technique in preventing and controlling the transmission of infection is hand hygiene . the WHO (World Health Organization) (2009) recommend the following hand hygiene guidelines: .After removing gloves . Gloves help to prevent the transmission of pathogens by direct and indirect contact .Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces . RI #50 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #50 had a physician's orders [REDACTED]. On 2/27/19 at 3:16 PM, EI #4 entered RI #50's room to administer the bolus tube feeding. EI #4 washed her hands and put on gloves. EI #4 wiped the bedside table down with Saniwipes, then removed her gloves. EI #4 did not wash or sanitize her hands before she reached in the medication cart and removed an alcohol prep and touched other items. EI #4 cleaned her stethoscope with an alcohol prep and placed gloves on a towel. EI #4 grabbed a drinking cup and a medication cup off of the medication cart. EI #4 moved the bedside table and lifted the bed. EI #4 closed the door and pulled the curtain. EI #4 washed her hands and put on a pair of gloves and administered the bolus tube feeding to RI #50. EI #4 then opened the bathroom door and turned on the faucet with those same gloves. On 2/27/19 at 3:44 PM, an interview was conducted with EI #4. EI #4 was asked what should be done after she removed gloves. EI #4 said wash hands. EI #4 was asked did she perform hand hygiene after she removed her gloves and before she got an alcohol pad out of the medication cart. EI #4 said she did not think she did. EI #4 was asked what was the potential harm in not performing hand hygiene after removing gloves. EI #4 said infection. EI #4 was asked what should she do after giving a tube feeding and before she touched a door handle. EI #4 said she should have taken a glove off to open the door. EI #4 was asked if she removed her gloves before she opened the bathroom door. EI #4 said no. EI #4 was asked what was the potential for harm in touching the door handle with contaminated gloves. EI #4 said infection. On 2/28/19 at 11:59 AM, an interview was conducted with EI #3, Infection Control Nurse. EI #3 was asked what should a nurse do when they remove their gloves. EI #3 said wash their hands. EI #3 was asked what was the potential concern of not doing that. EI #3 said spreading germs.

Based on interviews, record reviews, and review of Potter and Perry's FUNDAMENTALS OF NURSING, Ninth Edition, the facility failed to accurately assess RI (Resident Identifier) #23 on the MDS (Minimum Data Set) regarding Anticoagulants (blood thinners) and RI #32 on the MDS regarding Hospice services. This affected RI #s 23 and 32, two of 19 residents whose MDS were reviewed. Findings Include: A review of Potter and Perry's FUNDAMENTALS OF NURSING, Ninth Edition, Copyright 2017, Chapter 16, Nursing Assessment, page 210 revealed: .As a nurse you learn to make clinical judgments from assessment data to identify a patient's level of wellness and desire for health promotion or to identify existing health problems. A comprehensive assessment leads to making accurate nursing diagnoses, allowing you to then create an appropriate plan of care for a patient. The next step, implementation, involves performing the planned interventions or collaboration. After implementation you evaluate the patient's responses and whether the interventions were effective. The nursing process is central to your ability to provide timely and appropriate care to your patients. A review of RI #23's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a Significant Change in Status MDS, with an ARD (Assessment Reference Date) of 11/17/2017, revealed RI #23 had a BIMS (Brief Interview for Mental Status) score of 3 out of a possible 15. This score indicated RI #23 was severely impaired of cognitive skills for daily decision making. The MDS was also coded for RI #23 having received Anticoagulant medication within the past seven days. A review of the physician's orders [REDACTED]. [MEDICATION NAME] Stop Date 9/06/17. A review of RI #23's MAR (Medication Administration Record), dated September 2017, revealed RI #23 did not receive Xarelto after 9/6/2017. On 12/14/17 at 3:46 p.m., an interview was conducted with EI (Employee Identifier) #3, RN (Registered Nurse)/MDS Coordinator. EI #3 was asked who was responsible for coding Section N (Medications) on the MDS. EI #3 stated, I am. EI #3 was asked how she determined how to answer the questions regarding the different medications on the MDS. EI #3 stated, I go to the current MAR. EI #3 was asked why was anticoagulants marked on the 11/17/2017 Significant Change in Status MDS for RI #23. EI #3 stated, I overlooked it. EI #3 was asked if an anticoagulant was ordered for RI #23 at that time. EI #3 stated, No ma'am, not according to the MAR. EI #3 was asked should anticoagulants have been identified on the MDS for RI #23. EI #3 stated, No ma'am. EI #3 was asked why anticoagulants should not have been identified on the MDS. EI #3 stated, It had been discontinued. RI #32 had an admission date of [DATE] and had a re-admission date of [DATE]. RI #32's [DIAGNOSES REDACTED]. A review of a Significant Change in Status MDS, with an ARD of 8/10/2017, revealed RI #32's assessment was not coded accurately for receiving hospice services. On 12/14/2017 at 2:30 p.m., an interview was conducted with EI #3. EI #3 was asked when was RI #32 admitted to hospice. EI #3 answered on 8/5/2017. EI #3 was asked when RI #32 was discharged from hospice. EI #3 replied 11/2017. EI #3 was asked if RI #32's MDS reflected a significant change for hospice services and for being discharged from hospice. EI #3 said, no, for the readmit MDS she did not mark hospice. EI #3 was asked why it was not marked and EI #3 stated it was an oversight. EI #3 was asked if RI #32's MDS should have been coded for hospice and she stated yes. EI #3 was asked what the facility's policy indicated regarding coding for significant changes. EI #3 stated they have 14 days when they notice a change or a readmission to do an assessment. EI #3 stated the assessment was a significant change, but it was not marked for hospice.

Based on record reviews, interview, and review of a facility policy titled, Care Plan Policy and Procedure, the facility failed to ensure a plan of care was developed for wander guard secure ankle bracelet use. This affected RI (Resident Identifier) #21, one of fifteen residents whose care plans were reviewed. Findings Include: A review of the facility policy titled, Care Plan Policy and Procedure, with a revision date of 07/11, revealed: Policy: The care plan is a guide for all staff on a course of action that will attain or maintain a resident's highest practicable level of well being. Procedure: 1. Nursing staff will initiate a care plan to meet the basic care needs of the resident . 6. The care plan team will develop measurable goals for the improvement, prevention, or maintenance of the resident's status. A review of the job description for the Care Plan Coordinator revealed: . GENERAL PURPOSE: The primary purpose of this job title is to . assure timely, complete and accurate . CARE PLANS resulting in Quality Resident Care. A review of the medical record for RI #21 revealed a re-admission date of [DATE] with [DIAGNOSES REDACTED]. A review of the care plans for RI #21 revealed no care plan for the use of the wander guard device. During an interview on 12/14/17 at 5:17 p.m., EI (Employee Identifier) #3, the Care Plan Coordinator, was asked what was the facility's policy regarding developing a plan of care for a resident. EI #3 stated once there was a need, they assess and put interventions in place. EI #3 was asked if this was done for RI #21's wander guard and she answered no it was not. EI #3 was asked what was the concern of not developing a care plan for identified concerns. EI #3 answered the staff may not have known it was there or skin issues with the bracelet.

Based on record reviews, interview, and a review of a facility policy titled, Care Plan Policy and Procedure, the facility failed to ensure a plan of care was revised to reflect the ADL (Activities of Daily Living) assistance required for RI (Resident Identifier) #56. This affected one of 15 residents whose care plans were reviewed. Findings Include: On 12/01/17, the State Agency received a complaint regarding RI #56 receiving a bath with the assistance of one staff member on 11/20/17, where the resident's arm was noted to be swollen. According to the complainant, there should have been two staff members assisting with the bath. A review of a facility policy titled, Care Plan Policy and Procedure, with a revision date of 07/11, revealed: Policy: The care plan is a guide for all staff on a course of action that will attain or maintain a resident's highest practicable level of well being. Procedure: 1. Nursing staff will initiate a care plan to meet the basic care needs of the resident . 8. Changes in the care plan should occur as needed in order to reflect the resident's current status. 9. The care plan should be reviewed for the need for revision, at a minimum quarterly, after completion of the resident's MDS (Minimum Data Set) assessment . A review of the job description for the Care Plan Coordinator revealed: . GENERAL PURPOSE: The primary purpose of this job title is to . assure timely, complete and accurate . CARE PLANS resulting in Quality Resident Care. A review of the medical record revealed RI #56 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Annual MDS, assessment dated [DATE], revealed RI #56 was totally dependent on staff, requiring two-person assistance with dressing, toileting, and bathing. A review of the plan of care for RI #56 revealed a problem of: . requires total care with ADLs such as: bed mobility, transfers, bathing, dressing, grooming eating, toileting related to Cognitive deficits, [MEDICAL CONDITIONS] . Approaches . * 2 person assist as needed (with a line drawn through as needed) D/C 12/01/17 . During an interview on 12/14/17 at 5:14 p.m., EI (Employee Identifier) #3, the MDS/Care Plan Coordinator, was asked what was the purpose of the MDS assessment. EI #3 answered to assess how to care for a resident. EI #3 was asked what was the purpose of the plan of care. EI #3 stated for the staff to be able to know what type of care the resident needed. EI #3 was asked what did the MDS indicate as assistance needed with bathing for RI #56. EI #3 answered total care with two-person assistance. EI #3 was asked when did the plan of care indicate RI #56 should get two person assistance prior to 12/1/17. EI #3 answered the care plan indicated as needed. EI #3 was asked when did RI #56 become a two-person assist with bathing. EI #3 answered at least as of 8/13/16. EI #3 was asked what should the care plan indicate as the assistance needed for bathing. EI #3 answered total care with two-person assistance. EI #3 was asked if the care plan and MDS assessment matched and she answered no. EI #3 was asked if they should match and she answered yes. EI #3 was asked why and she answered to be accurate. EI #3 was asked why the care plan was changed on 12/1/17. EI #3 responded so it would reflect total care of two person assistance. EI #3 was asked what was the concern of the care plan not being consistent with the resident assessment. EI #3 answered the care may not match what the resident needed. EI #3 was asked what was the concern of the plan of care not being reviewed and revised. EI #3 answered the care plan and the MDS may not match. During an interview on 12/14/17 at 5:44 p.m., EI #1, the Director of Nursing, was asked what the care plan indicated for bathing RI #56 on 11/20/17. EI #1 answered two-person assistance as needed. EI #1 was asked if that matched the MDS assessment and she answered no. EI #1 was asked if they should match and she answered yes. EI #1 was asked why and she answered for consistency of care. This deficiency was cited as a result of the investigation of complaint/report #AL 454.

Based on record reviews, interview, and a review of a facility policy titled, Legal Documentation, the facility failed to ensure staff documented daily checks of a wander guard device. This affected RI (Resident Identifier) #21, one of nineteen residents whose medical records were reviewed. Findings Include: A review of a facility policy titled, LEGAL D(NAME)UMENTATION, with a revision date of 01/17, revealed: . PURPOSE Provide an account of the resident's care and treatment, handwritten, typed or electronic. POLICY 1. Documentation in the medical record should be complete, accurate, objective, timely, and legible from all disciplines. A review of the medical record for RI #21 revealed a re-admission date of [DATE] with [DIAGNOSES REDACTED]. A review of RI #21's medical record document titled, Daily Secure Care Bracelet Check Log, revealed no documented daily checks of the wander guard device in use for RI #21 since 10/14/17. There was no documentation noted in RI #21's medical record since re-admission on 10/22/17. During an interview on 12/14/17 at 5:17 p.m., EI (Employee Identifier) #3, the Care Plan Coordinator, was asked what was the facility's policy regarding monitoring a wander guard in use by a resident. EI #3 answered daily checks. EI #3 was asked if they were done for RI #21 after re-admission to the facility on [DATE]. EI #3 answered no. EI #3 was asked what was the concern of not documenting the daily checks. EI #3 answered not knowing if they were done.

Based on observations, interviews, record reviews, and review of the facility's policies and procedures titled, FOOD SERVING TEMPERATURES, Bare Hand Contact with Food and Use of Plastic Gloves, and HANDWASHING, the facility failed to ensure: 1) a Dietary staff member sanitized the thermometer between food items while checking temperatures on the trayline on 2/15/17 and 2) a Dietary staff member washed her hands after picking an item up from the floor with gloved hands and prior to applying clean gloves and returning to plating food on the trayline. These deficient practices had the potential to affect 69 residents receiving meals from the kitchen. Findings include: 1) A review of the facility's undated policy and procedure titled, FOOD SERVING TEMPERATURES revealed: Holding Temperatures . 3. The temperature will be taken and recorded for all hot and cold food items at each meal prior to starting tray service. Sanitize thermometer prior to taking temperature of each item. On 2/15/17 at 10:50 a.m., an observation was made of EI (Employee Identifier) #1, Dietary Aide/Cook, taking temperatures of food items on the lunch trayline. EI #1 was observed to use the same thermometer on all food items, but failed to clean the thermometer after use on each food item prior to checking the temperature on the next food item. On 2/16/17 at 3:45 p.m., an attempt was made to call EI #1 for a phone interview. EI #1 was unable to be reached by phone. A message was left for EI #1 to return a call to the facility. No return call was received from EI #1. 2) A review of the facility's undated policy and procedure titled, Bare Hand Contact with Food and Use of Plastic Gloves revealed: .Procedure: . 2. Staff use clean barriers such as single-use gloves .to prevent food borne illness. 3. Gloved hands are considered a food contact surface that can get contaminated or soiled. If used, single use gloves shall be used for only one task (such as working with ready-to-eat food .), used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in operation. 4. Hands are to be washed .before putting on the single-use gloves. 7. Wash hands after removing the gloves. A review of the facility's undated policy and procedure titled, HANDWASHING revealed: Policy: Staff will wash hands as frequently as needed throughout the day following proper hand washing procedures . Procedure: Clean hands and exposed portions of arms . immediately before engaging in food preparation including working with exposed food. 1. When to Wash Hands: . · After handling soiled equipment or utensils. · During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. · Before donning gloves for working with food. · After engaging in other activities that contaminate the hands. On 2/15/17 at 11:43 a.m. EI #2, Kitchen Supervisor, was observed on the trayline plating food. An employee of the facility approached the Dietary entrance and requested a list. EI #2 obtained the list from an area located to the side of the trayline with her gloved hand and the list fell on to the floor. EI #2 picked up the list from the floor with her gloved hand and gave the list to the employee. EI #2 removed her gloves, donned clean gloves and resumed plating food on the trayline. EI #2 failed to wash her hands prior to applying clean gloves. On 2/16/17 at 1:50 p.m., an interview was conducted with EI #2. EI #2 was asked what the facility's policy and procedure was regarding washing hands while on the trayline. EI #2 stated, they were to wash their hands and put on gloves before getting on the trayline. EI #2 was asked if she had to remove gloves while on the trayline, what was the policy and procedure regarding handwashing. EI #2 stated, If you have to remove your gloves, put a new pair on. EI #2 also stated, If you have to touch something else other than preparing the food like going into the refrigerator pull gloves off and put new gloves on if you are handling the food. EI #2 stated, If you drop something on the floor, you leave it there until you get off of the line. EI #2 was asked what list did the employee ask for during trayline on 2/15/17. EI #2 stated the employee asked for a sign up list, the employees sign up for meals. EI #2 stated, We use to leave it on the counter but someone had moved it at that time. EI #2 was asked should she have obtained the list for the employee with her gloves on. EI #2 stated, No, I should have pulled it off and and gave it to her. EI #2 was asked why she should not have given the list to the employee with her gloves on. EI #2 stated, Because I am standing there handling the food. I should have pulled the gloves off which I did when I got back. EI #2 was asked when the list fell to the floor and she removed her gloves after picking the list up, why she had not washed her hands prior to donning clean gloves. EI #2 stated, It did not dawn on me at the time. EI #2 was asked what the concern was regarding returning to the trayline and plating food without washing her hands after picking the list up from the floor with gloved hands. EI #2 stated, Spreading germs. On 2/16/17 at 3:50 p.m., an interview was conducted with EI #3, Dietary Manager. EI #3 was asked what the facility's policy and procedure was regarding washing hands with glove changes while on the trayline. EI #3 stated, If they got gloves on and touch something should not have then discard gloves, wash hands and put on clean pair of gloves. EI #3 was asked if an employee asked a Dietary staff member on the trayline for a list, should the staff member pick up the list with gloves used on the trayline. EI #3 stated, No ma'am. The above observation was described to EI #3 regarding EI #2 failing to wash her hands prior to donning clean gloves after picking up an item from the floor. EI #3 was asked what the concern was regarding this observation as described. EI #3 stated, Contamination. EI #3 was asked what the facility's policy and procedure was regarding thermometer use while taking temperatures of food on the trayline. EI #3 stated to sanitize the thermometer before use, after taking the thermometer out of a food item and between the food items. EI #3 was asked why the thermometer should be cleaned between each food item. EI #3 stated so the food item would not be placed into the next food item. EI #3 was asked what was the concern if the thermometer was not cleaned between each food item. EI #3 stated, I think there would be contamination.

Based on observations, interviews, record review, and the Facility's Policy titled Tube Feeding Administration, the facility failed to ensure the tube feeding container was labeled with the resident's name, date, type of formula, and rate. This affected RI (Resident Identifier) #7, one of one resident's sampled with tube feeding. Findings include: A review of an undated facility policy titled, Tube Feeding Administration revealed: Policy: To provide nutritional or fluid intake to residents unable to consume food or liquids safely or adequately via (by) enteral feeding using naso-gastric, gastro (gastrointestinal)-tube or peg tube per physician's orders [REDACTED]. Procedure: .Closed System via Infusion Pump A. Label formula container with resident's name, room number, date, rate, start time and your initials. A review of the medical record revealed RI #7 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Significant Change MDS (Minimum Data Set) assessment dated [DATE] for RI #7 revealed a BIMS (Brief Interview for Mental Status) score of 14 out of a possible 15. This score indicated RI #7 was cognitively intact for daily decision making skills. This assessment also indicated RI #7 was totally dependent on staff for eating and had a feeding tube. On 2/14/2017 at 4:33 p.m., during the facility tour, there was no name, no room number, no start time, and no date listed on the tube feeding bottle. On 2/14/17 at 5:14 p.m., a second observation was made of the resident's tube feeding bottle. There was no name, no date, no room number, and no start time on the tube feeding bottle label. On 2/16/17 at 3:09 p.m., an interview was conducted with EI (Employee Identifier) #6, a LPN (Licensed Practical Nurse). EI #6 was asked who was responsible for labeling tube feeding containers with formula. EI #6 stated, The nurse that is hanging them. EI #6 was asked why should tube feeding containers with formula be labeled. EI #6 stated, So you will know the date and time it was hung so you will know when it expires. EI #6 was asked what was the facility policy regarding tube feedings. EI #6 said, We knock, make sure to look at the order, make sure you have the right resident, the right formula, the correct rate, and the amount of fluid ounces or cc's (cubic centimeters)/(milliliters). Once you're in, tell (the) patient what you are doing, then we set it up, get to the tube, then auscultate, check (the) residual, if it is over 20 cc's, we let the doctor know, if not, we reinsert. EI #6 was asked what was the concern when tube feeding formula was not labeled. EI #6 stated, The expiration date to know when it was hung, at what rate, so you can clarify and make sure it's correct. EI #6 was asked how she knew when to change the container of tube feeding. EI #6 said, Whenever its done, it's good for 48 hours, but we normally change them daily due to resident receiving the allotted amount. EI #6 was asked if all the solution had not infused within a 24 hour period, what indication did she have it was time to change the container. EI #6 replied, You can mark it if it is some still in there. We mark it and label how much is remaining so we can take it off of the new bottle that is hanging because the formula is good for 48 hours. On 2/16/17 at 3:29 p.m., an interview was conducted with EI #7, DON (Director of Nursing). EI #7 was asked, who was responsible for labeling tube feeding containers with formula. EI #7 stated, The medication nurse, that would have been an LPN or RN (Registered Nurse). EI #7 was asked why should tube feeding containers with formula be labeled. EI #7 stated, To identify what is actually being hung. EI #7 was asked, what was the facility's policy regarding tube feedings. EI #7 stated, Make sure the order matches and the right rate is administered or volume as ordered. EI #7 was asked what was the concern when tube feeding formula was not labeled. EI #7 stated, We inservice. We would be concerned that we are not following the doctors orders. EI #7 was asked how she knew when to change the container of tube feeding. EI #7 stated, Dependent on the volume that would be given .We have the option to hold if there is extra for up to 48 hours. The bottle should be labeled with the name of milk, the rate, the volume to be infused, the start time and the resident's name. This helps to know when it has been hung. EI #7 was asked if all the solution had not infused within a 24 hour period, what indication did she have it was time to change the container. EI #7 stated, I am looking at the label and the order to tell when it is time to change the formula out.

Based on an observation, interviews, and record reviews, the facility failed to ensure the emergency kit medications were found secured. This was observed on 1 of 2 units on 1 of 3 survey days. Findings include: A review of a facility policy, with a copyright date of 2011, revealed, (Name of Corporation) Policy 3.4 Medication Storage STAT (Non-Controlled) Medication Boxes . Procedures 1. STAT medications are kept at the designated nursing station in each facility in a sealed, portable container. A review of the EMERGENCY BOX SIGN-OUT FORM, revealed the emergency kit had been opened on 2/1/16. During an observation on 2/4/16 at 10:46 AM of the medication room and emergency kit, the emergency kit was observed unsecured. Tags that were to be utilized to secure the box each time contents were removed were observed in the top tray of the box. During the observation on 2/4/16 at 10:46 AM, EI (Employee Identifier) #1, an LPN (Licensed Practical Nurse), was asked when the box was supposed to be secured and she answered, When we receive it. An interview was conducted with EI #1 on 2/4/16 at 11:11 AM. EI #1 was asked when the emergency kit should be locked. She answered, When we receive it. I checked with the RN (Registered Nurse) and she said it was supposed to be locked at all times. I did correct it. EI #1 was asked what had she done when the box was first opened. She answered, Supposed to secure it with one of the yellow tags that is in the top of the box. EI #1 was asked why extra lock tabs were provided by the pharmacy. She answered, To lock it back after we take something out of it. EI #1 was asked how the emergency kit was found during the observation on 2/4/16 at 10:46 AM. She answered, Unlocked with no tabs. Closed, but not secured. An interview was conducted with EI #2, the ADON (Assistant Director of Nursing), on 2/4/16 at 11:21 AM. EI #2 was asked when was the emergency kit locked. She answered, It comes in locked and we are supposed to re-lock it if we take anything out. EI #2 was asked what was the potential harm of the drugs in the box not being secured. She answered, Any of it could go missing that we could not account for.

Based on observation, interviews and document reviews, the facility failed to ensure a CNA (Certfied Nursing Assistant) provided incontinence care to a resident in a manner to prevent the potential for infection. This affected RI (Resident Identifier) #9, one of two residents observed for incontinence care. Findings include: A review of the facility's policy dated 12/2012, and titled, "Incontinent Care and Catheter Care Using Disposable Wipes," revealed, "OBJECTIVE: To cleanse the perineum, prevent infection and odors, and prevent skin breakdown ... PROCEDURE: ... 4. Female - clean entire perineal area (outer and inner labia) with disposable wipe, moving from front to back, while using a clean area of the disposable cloth for each wipe or a new wipe for each stroke. ... 6. Turn the resident on their side. Clean the buttocks and anal area, moving upwards toward the back in the same manner that you cleaned the perineal area. ..." A review of RI #9's medical record revealed, RI #9 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 01/11/2015 indicated RI #9 had a BIMS (Brief Interview for Mental Status) score of 9 out of a possible 15 points. This indicated RI #9 was moderately impaired for daily decision making skills. This MDS indicated RI #9 required extensive to total assistance with activities of daily living, but could feed self after meals were set up. RI #9 was also coded as always incontinent of bowel and bladder. On 2/25/2015 at 9:23 AM, EI (Employee Identifier) #1, a CNA, was observed to provide incontinence care for RI #9. EI #1 pulled the front of RI #9's brief down and cleaned underneath the abdominal fold by wiping from right to left, wiped the right groin, then the left groin using the same disposable wipe. EI #1 did not change the position of the wipe, nor separate the labia to cleanse RI #9. RI #9 was rolled onto the right side and a second CNA, EI #2 came in to assist her. EI #1 cleansed the rectal area of RI #9 by wiping in an upward motion, away from the vaginal area. Brown stool was noted. EI #1 discarded this wipe and got a second wipe and cleansed the rectal area again in an upward motion, wiping several times with the same wipe. EI #1 got another wipe and wiped the rectal area in a back and forth motion, without changing the position of the wipe. EI #1 then cleaned the upper portion of RI #9's sacral area (between the buttocks) by wiping in a downward motion one time, towards the vaginal area. EI #1 removed her gloves, washed her hands, donned clean gloves and placed a clean brief onto RI #9. An interview was conducted with EI #1 on 2/25/2015 at 11:13 AM. EI #1 was asked how incontinence/perineal care should be done for female residents. EI #1 stated, "We're supposed to wipe from side to side in the front, then the left side and right side, and never back to front. Throw that wipe away. On the back side, clean resident by cleaning each cheek (side to side), then down the middle. ..." EI #1 was asked how she had provided incontinence care for RI #9 during the observation and she replied, "I can't tell you, truthfully." EI #1 was asked if it was appropriate to clean under the abdominal fold and the groins with the same wipe, without changing the position of the wipe. EI #1 replied, "No ma'am. I know to do it (fold the wipes), but I got nervous. I know to fold the wipes and change the position of them." EI #1 was asked why and she responded, "Because when you've used it, it's dirty on that side. So you fold it to keep from using the dirty section." EI #1 was asked why she did not change the position or fold the wipe during the observation. EI #1 stated, "I got nervous." EI #1 was asked if the labia should be separated and cleaned when providing incontinence care for a female. EI #1 replied, "Yes ma'am." EI #1 was asked why and she stated, "To keep down infections." EI #1 was asked why she did not separate the labia for RI #9 during the observation. EI #1 stated, "I thought I did when (RI #9) was lying on (RI #9's) right side." EI #1 was asked if it was appropriate to wipe in a downward motion when cleaning between the buttocks. EI #1 responded, "Yes." EI #1 was asked why, and she replied, "That way I can get them clean that way." After the surveyor explained the observation, EI #1 stated, "I know it was supposed to be upward and not downward. I was calling it backwards." EI #1 was asked what the potential harm was of not changing the position of the wipe and cleaning different areas, or by wiping back and forth." EI #1 stated, "Infection." EI #1 was asked what the potential harm was of not separating the labia and cleaning when providing incontinence care. EI #1 replied, "UTIs (Urinary Tract Infections), yeast infections." EI #1 was asked what the potential harm was of cleaning or wiping between the buttocks and wiping downward. EI #1 responded, "When you are wiping downward, you're getting them dirty and that's more harmful because of bacteria." On 2/25/2015 at 12:52 PM, an interview was conducted with EI #2, the CNA which assisted EI #1 during the observation. EI #2 was asked if it was appropriate to clean under the abdominal fold and the groins with the same wipe, without changing the position of the wipe. EI #2 responded, "No. You have to change position." EI #2 was asked why and she stated, "Infection control. Whatever is in (RI #9's) urine would be spread all over (RI #9)." EI #2 was asked if the labia should be separated and cleaned when providing incontinence care for a female. EI #2 stated, "Yes ma'am." EI #2 was asked why, and she replied, "Because (RI #9) could have BM (bowel movement) in there and if not cleaned properly, (RI #9) could get a UTI or infection." EI #2 was asked if it was appropriate to wipe in a downward motion when cleaning between the buttocks. EI #2 stated, "Upward." EI #2 was asked why, and she stated, "If wiping down, you are taking whatever was in the rectum back to the vagina." EI #2 was asked what the potential harm was of not separating the labia and cleaning when providing incontinence care. EI #2 responded, "UTI or infection." On 2/26/2015 at 9:06 AM, an interview was conducted with EI #3, the Infection Control Nurse. EI #3 was asked how incontinence/perineum care should be done for a female resident. EI #3 stated, "We use disposable wipes. ... I instruct staff to use a wipe, and if able to effectively fold it to use a clean area, it's ok to do that. Otherwise they are to use a wipe one time and toss. They want to wipe across the suprapubic area, then they will wipe down either groin area to include the outer labia. Then spread the labia and wipe each side of the inner labia. Then down the middle of the labias. Then the resident is turned over... Wipe across the top of the buttocks. Then they wipe upward, away from the vaginal area until it's clean. ..." EI #3 was asked if it was appropriate to clean under the abdominal fold and the groins with the same wipe, without changing the position of the wipe. EI #3 replied, "No. That's cross-contamination." EI #3 was asked if the labia should be separated and cleaned when providing incontinence care for a female. EI #3 replied, "Yes." EI #3 was asked why and she stated, "Because it would be soiled and would need to be cleaned. We don't want trapped germs or bacteria to remain inside the labia." EI #3 was asked if it was appropriate to wipe in a downward motion when cleaning between the buttocks. EI #3 replied, "No. Because of risk of introducing or re-introducing germs into the vaginal area." EI #3 was asked what the potential harm was of not changing the position of the wipe and cleaning different areas or by wiping back and forth. EI #3 stated, "Cross-contamination. Whatever you've wiped from one soiled area, you don't want to put onto another area." EI #3 was asked what the potential harm was of not separating the labia and cleaning when providing incontinence care. EI #3 stated, "Risk of infection." EI #3 was asked what the potential harm was of cleaning or wiping between the buttocks and wiping downward. EI #3 replied, "Putting (the) resident at risk for infection. Bringing germs from the buttocks to the vaginal area."

Based on observations, record reviews, and interviews, the facility failed to ensure a licensed nurse did not wash her hands and turn the water faucet off with wet, bare hands during a medication pass observation. This was observed on one of four survey days and affected (Resident Identifier) RI #5, one of nine residents observed for medication pass. Findings include: A review of the facility's Policy and Procedure titled, "Handwashing Policy and Procedure," with a revision date of 2/10 revealed, "Procedure: ... 6... Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet. ..." A review of the medical record revealed RI #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Admit Nursing History and Assessment, dated 2/12/15, revealed RI #5 was alert and oriented. The resident was continent of bowel and bladder. RI #5 required assistance with ADLs but was able to feed self. An observation was made on 02/23/2015 at 5:40 PM of medication pass on RI #5. The surveyor observed (Employee Identifier) EI #4, a licensed nurse, enter RI #5's room for medication pass. EI #4 washed her hands at the sink. After rinsing her hands EI #4 turned the water faucet off with her left, wet, bare hand. EI #4 pressed the lever on the towel dispenser on the wall with her right, wet, bare hand. EI #4 proceeded to perform a finger stick blood glucose on RI #5. After obtaining the blood glucose, EI #4 washed her hands at the sink. After rinsing her hands she turned the water faucets off with her wet, bare hands. EI #4 pressed the lever on the towel dispenser on the wall using her wet, bare right hand. EI #4 dried her hands and discarded the towel in the trash. On 02/26/2015 at 9:16 AM an interview was conducted with EI #4. The surveyor asked EI #4 if it was appropriate to turn the water faucets off, after handwashing, with wet bare hands. EI #4 responded that it was not appropriate. EI #4 was asked why and EI #4 answered contamination/cross contamination. EI #4 was asked how she turned the water faucet off during medication pass on RI #5 on 02/23/2015 at 5:40 PM. EI #4 responded that she just put her hand on the faucet and turned it on. She stated she turned it off the same way knowing she wasn't supposed to. EI #4 was asked what could be the potential negative outcome of turning the water faucets off with wet, bare hands after washing her hands. EI #4 said there could be potential for someone to catch a bug/germ from someone else. On 02/26/2015 at 9:35 AM, an interview was conducted with EI #3, the Infection Control Nurse. The surveyor asked EI #3 if it was appropriate to turn the water faucets off, after handwashing, with wet, bare hands. EI #3 answered no. EI #3 was asked why. EI #3 responded that the hands have already been washed and they are clean. The faucets are not clean so the hands have been recontaminated. EI #3 was asked what could be the potential negative outcome of turning the water faucets off with wet, bare hands after washing her hands. EI #3 responded the spread of infection or infectious organisms to residents.

Based on observations, interview, and document reviews, the facility failed to ensure food was served in a manner to prevent the potential for cross-contamination and food borne illness by the following: 1. Wet nesting was observed during the tour on 6/24/14. 2. The dish machine water wash temperature was 110 degrees Fahrenheit instead of a minimum of 120 degrees Fahrenheit per manufacturer's recommendations. These deficiencies had the potential to affect 74 residents who were served meals from the dietary department. Findings include: 1. Wet Nesting A review of a document presented by the facility titled: "Food Safety Education / For Consumers ..." (no date documented) revealed: "...The food code requires that items must be allowed to air dry before being stacked or stored. Stacking wet items, such as pans and dishes, prevent them from drying and might allow an environment where microorganisms can begin to grow. Stacking dishes before they are dried is called wet nesting. ..." During a tour of the kitchen on 6/26/14 at 4:07 PM, the Dietary Manager, EI (Employee Identifier) #1, and the surveyor observed three of three serving pans stacked wet on a shelf near the tray line. At 4:08 PM on 6/26/14, EI #1 and the surveyor observed two of two large serving pans stacked wet on a shelf near the tray line. An interview was conducted on 6/26/14 at 4:50 PM, with EI #1. The surveyor discussed the above findings with EI #1, then asked what was the potential negative outcome when wet nesting was present in the kitchen. EI #1 stated, "I would remove the pans, re-wash and allow to air dry. I would also in-service staff to make sure that there is no water, and make sure the items are air dried. The surveyor asked why was that important. EI #1 stated, "Because it is spreading the germs with the water that is sealed inside." 2. Dish Washing Machine A review of the facility's policy titled: "Resource: Sanitation of Dishes/Dish Machine ... Spray Type Dish Machine Using Chemicals to Sanitize... Wash Temperature... 120 (sign for degree) F(Fahrenheit)..." A review of the manufacturer's recommendations for the dishwasher in the facility's kitchen was reviewed. The document revealed: "... Model Series ... Wash Temperature: 120 (symbol for degree) minimum ..." On 6/25/14 at 8:15 AM, dishwashing was observed. The dish washing machine, water wash temperature was 110 degrees Fahrenheit. Three cycles were observed and the wash cycle water temperature remained at 110 degrees Fahrenheit. On 6/26/14 at 1:05 PM, dishwashing of the silverware was observed. The dish washing machine, wash water temperature was 110 degrees Fahrenheit. The surveyor asked the staff who were present during the observation, what should the temperature of the dish washing machine wash water temperature be. The staff present during the observation, who included two dietary aides, EI #1, and the corporate representative for the kitchen, EI #6, said they did not know the proper temperatures for the dish machine. The staff members said it was a new dish washer. On 6/26/14 at 1:15 PM, attempts were made to locate any type of documentation for the proper dish machine temperatures. No documentation was located. An interview was conducted on 6/26/14 at 4:50 PM with EI #1. The surveyor discussed the above observations with EI #1, and asked what was the potential negative outcome when the dish washing machine wash water temperature was not at the proper temperature. EI #1 stated, "Because of the bacteria that could build up on the dishes and it could be harmful to the residents and even employees who eat here." The surveyor asked EI #1 when was the last in-service on the dish machine, regarding maintaining the proper temperatures of the wash and rinse cycles. EI #1 said they had not had an in-service on the temperatures, but they did have an in-service on how to use the new dish machine. EI #1 said the new machine was installed about a week and a half ago.

Based on observation, interviews and record reviews, the facility failed to ensure the dignity of a resident was maintained when a staff member ignored a resident's request. This was observed on 1 of 3 survey days and affected RI (Resident Identifier) #5, 1 of 17 sampled residents. Findings include: A review of Potter/Perry 7th Edition, copyright date 2009 revealed, "Chapter 30" page 475, "Promote Dignity and Self-Esteem. A sense of dignity includes a person's positive self-regard, an ability to invest in and gain strength from one's own meaning in life, feeling valued by others, and how one is treated by caregivers. Nurses promote a client's self-esteem and dignity by respecting him or her as a whole person with feelings, accomplishments, and [MEDICATION NAME] independent of the illness experience." A review of the facility's undated policy revealed, "DIGNITY AND RESPECT Policy Interpretation and Implementation 1. Our staff shall display respect for residents when speaking with, caring for, or talking about them, as constant affirmation of their individually and dignity as human beings. ... Residents' individual preferences regarding such things as menus, clothing, ... are elicited and respected by the facility. ... 5. Violations of the resident's rights to dignity and respect should be promptly reported to the director of nursing and/or administrator." An observation was made on 6/25/2014 at 11:55 AM of a lunch meal tray being delivered to RI #5 by EI (Employee Identifier) #7, a CNA (Certified Nursing Assistant). During this observation, the resident reported to the CNA, "There's no way I can eat that chicken." EI #7 did not respond to the resident's request. EI #7 posed the question to the resident, "Do you want water or one of your Cokes?" EI #7 exited the room to retrieve a Coke then returned and stated to RI #5, "I want you to eat for me. Try to eat what you can." Then EI #7 exited the room. RI #5's request was not addressed. A review of the medical record revealed RI #5 was re-admitted on [DATE] with [DIAGNOSES REDACTED]. A review of RI #5's most recent MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 5/1/2014, revealed, a BIMS (Brief Interview for Mental Status) score of 14 out of a possible 15. This score indicated RI #5 was cognitively intact for daily decision making. This assessment also indicated that RI #5 was coded for set-up and cueing with meals. A review of RI #5's Care Plan indicated that RI #5 was to have meal and supplement preferences honored. The Care Plan also revealed that staff were to provide set up assist if needed to include opening items, seasoning food, cutting food, and identifying foods. A resident interview was conducted with RI #5 on 6/25/2014 at 5:20 PM. The surveyor asked if RI #5 had ever refused to eat something that had been served. RI #5 responded, "Yes." RI #5 was asked if the facility had offered something else to eat. RI #5 answered not always. RI #5 was asked if another food was requested. RI #5 answered yes. RI #5 was asked what was the facility's response to the request. RI #5 responded, "CNA ignored me; you were right here." RI #5 was asked when the request was made for something other than the chicken thigh, what was the response. RI #5 responded, "Nothing." The surveyor asked how that made RI #5 feel. RI #5 answered, "What I need doesn't matter." An interview was conducted with EI #7 on 6/26/2014 at 1:07 PM. EI #7 was asked what should be done if RI #5 reports not being able to eat something. EI #7 answered, "I try to encourage her to eat, sometimes if she says she doesn't like it, if it sits in front of her long enough she eats it." EI #7 was asked what response RI #5 was given after reporting the inability to eat the fried chicken thigh. EI #7 answered, "I told her it looks real good, give it a try." The surveyor asked EI #7 if aware of why RI #5 couldn't eat the fried chicken. EI #7 answered, "Like I said, she is a picky eater." The surveyor repeated the question to which EI #7 responded, "No." The surveyor asked what EI #7 should have been done when RI #5 reported not wanting something served at mealtime. EI #7 responded, "Offer them an alternative." EI #7 was asked if that had happened with RI #5 on 6/25/2014 at lunch. EI #7 answered, "No." EI #7 was asked if that was respectful. EI #7 answered, "I guess not." EI #7 was asked what could be the potential negative outcome if resident's preferences are not honored. EI #7 answered, "They may stop eating." An interview was conducted with EI #4, a Licensed Practical Nurse on 6/26/2014 at 2:07 PM. EI #4 was asked what should be done if RI #5 reported being unable to eat the fried chicken thigh that was served for lunch. EI #4 answered, "We should offer to see if we could get her something else from the kitchen." EI #4 was asked what could be the potential negative outcome if a resident that has lost weight and does not have their preferences honored. EI #4 responded, "She could continue to be on weight loss." An interview was conducted with EI #5, the DON (Director of Nursing) on 6/26/2014 at 2:19 PM. EI #5 was asked what should be done if RI #5 reported being unable to eat the fried chicken thigh that was served for lunch. EI #5 answered, "We should provide her something else." EI #5 was asked what could be the potential negative outcome if a resident that has lost weight and does not have their preferences honored. EI #5 answered, "The outcome will be continuous weight loss." A second interview was conducted with EI #5 on 6/26/2014 at 4:45 PM. The surveyor asked EI #5 when a resident expresses a need and the requests are ignored by the CNA, how would it make the resident feel. EI #5 answered, "It will make them feel like sombody don't care." EI #5 was asked if that was a dignified way to treat a resident. EI #5 answered, "No Ma'am."

Based on observations, interviews, and record reviews, the facility failed to ensure 3 vials of insulin were not found in the Medication Carts more than 28 days after being opened. This affected RI (Resident Identifier) #'s 16 and 17. The vials were found in 2 of 4 medication carts. Findings include: The facility's document entitled, "Policy 7.13 Medication Administration Procedures Vials and Ampules (Injectable Medications), Page 1 of 1", dated ,[DATE], revealed: "7.13: VIALS AND AMPULES (INJECTABLE MEDICATIONS) Policy Vials and ampules of injectable medications are used in accordance with the manufacturer's recommendations or the provider pharmacy's directions for storage, use, and disposal. Procedures ... 3. Storage requirements are to be strictly observed. ... A. ... When opened, most multidose vials of insulin may be used (refrigerated or at room temperature) for four weeks. See package labeling. ... 5. ... Opened medications will either be discarded immediately after use or in compliance with the manufacturer storage requirements. ..." The facility's document titled, "MEDICATIONS WITH SHORTENED EXPIRATION DATES," with a revised date of ,[DATE], revealed: "Humulin R ... Vials: Expire 31 days after opening or removing from refrigerator, ... Lantus ... Vials/Cartridges/SoloStar (copyright symbol) expire 28 days after opening or removing from refrigerator, ..." 1) A review of the medical records revealed RI #16 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #16's most recent MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of [DATE], revealed a BIMS (Brief Interview for Mental Status) score of 5 out of a possible 15. This indicated RI #16 was severely impaired for decision making skills. This MDS also revealed RI #16 required extensive assistance with ADLs (Activities of Daily Living), but was able to eat after meals were set up. The Physicians Orders, dated [DATE], for RI #16 included the following: "SLIDING SCALE INSULIN SQ TID (Subcutaneously, three times daily) AC (before meals) ON TUES, THUR, SAT & SUN. USE HUMULIN R INSULIN: 0 -150 = 0 UNITS 151 - 200 = 4 UNITS 201 - 250 = 8 UNITS 251 - 300 = 10 UNITS 301 - 350 = 12 UNITS 351 - 400 = 16 UNITS >400 = 12 UNITS AND CALL MD." "SLIDING SCALE INSULIN SQ BID (two times daily) ON M-W-F (Monday, Wednesday, Friday). USE HUMULIN R INSULIN: 0 -150 = 0 UNITS 151 - 200 = 4 UNITS 201 - 250 = 8 UNITS 251 - 300 = 10 UNITS 301 - 350 = 12 UNITS 351 - 400 = 16 UNITS >400 = 12 UNITS AND CALL MD" "LANTUS INSULIN 20 UNITS SQ QD (every day) @ (at) 6PM." The MAR (MEDICATION ADMINISTRATION RECORD) for RI #16 revealed Humulin R Insulin had been administered to RI #16 on [DATE], [DATE], and [DATE], after the insulin had passed it's expiration date. During an observation of the medication carts on Unit 1 (One) on [DATE] at 8:52 AM, opened vials of Humulin R and Lantus Insulins for RI #16 were observed in Medication Cart # (number) 2. The vial boxes were labeled as opened, "[DATE]." The labels had been pulled to be re-ordered "[DATE]," as stated by EI (Employee Identifier) #2, a Licensed Practical Nurse. EI #2 stated, "Insulin good for 28 days after opened." The insulins were pulled from the cart at this time. These were the only opened vials of insulin for this resident. 2) A review of the medical records revealed RI #17 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The most recent MDS for RI #17 with an ARD of [DATE], revealed RI #17 had short and long term memory impairment and was cognitively impaired for decision making skills. EI #17 was totally dependent on staff for ADLs and eating. A review of the Physician order [REDACTED]. The MAR for RI #17 revealed Lantus Insulin had been administered to RI #17 on days [DATE] through [DATE], after insulin had expired. During an observation of the medication carts on Unit 2 (Two) on [DATE] at 9:10 AM, an opened vial of Lantus Insulin for RI #17 was observed in Medication Cart # 1. The vial box was labeled as opened, "[DATE]," and the label had not been pulled for re-order, per EI #3, a Licensed Practical Nurse. EI #3 stated, "Insulin good for 28 days after opening." An interview was conducted with EI #2 on [DATE] at 2:30 PM. EI #2 was asked what the facility's policy was on dating insulin. EI #2 stated, "As soon as we pull it, we put the open date on the sticker." EI #2 was asked what dates were placed on insulin. EI #2 replied, "The open date and sometimes we put the date sticker pulled for re-order." EI #2 was asked how many days insulin was good for after opening. EI #2 stated, "28 days." EI #2 was asked if insulins (Humulin R and Lantus) for RI #16 were opened on [DATE], when did it expire. EI #2 stated, "Insulin expired [DATE]." EI # 2 was asked when the Lantus Insulin for RI #17 expired, if it was opened [DATE]. EI #2 stated, "Insulin expired [DATE]." EI #2 was asked what the potential negative outcome was for using unrefrigerated insulin more than 28 days after being opened. EI #2 replied, "It would not have the desired effect." On [DATE] at 2:45 PM, an interview was conducted with EI #5, the DON (Director of Nursing). EI #5 was asked what the facility's policy was on dating insulin. EI #5 stated, "It's to be dated when opened and they are to date it and initial it." EI #5 was asked what dates were placed on insulin. EI #5 stated, "The date it's first opened to use it. They could put the date it's to be pulled off (cart) on there also." EI #5 was asked if insulins (Humulin R and Lantus) for RI #16 were opened on [DATE], when did they expire. EI #5 stated the Lantus and Humulin R Insulins expired, "[DATE]." EI #5 was asked when the Lantus Insulin for RI #17 expired if it was opened on [DATE]. EI #5 stated, "Expired [DATE]." EI #5 was asked what the potential negative outcome was for using unrefrigerated insulin more than 28 days after opening. EI #5 stated, "Potency can be affected if left out of the refrigerator."

Based on observations, interviews and record reviews the facility failed to accurately code the Range of Motion (ROM) status of three sampled residents. Upper and lower extremities were coded as impaired on the Minimum Data Sets (MDS) for both sides of the upper and lower extremities despite residents' abilities to use their arms and/or legs. This affected Resident Identifier (RI) # 4, 6, and 8; three resident assessments of the 14 sampled residents. Findings Include: The CMS - 672 form, Resident Census and Conditions of Residents completed by facility staff on 6/6/13, identified the current census as 82 residents. A total of 82 residents were identified with contractures ("...a restriction of full passive range of motion of any joint due to deformity, disuse, pain, etc...") and all 82 residents had been admitted with contractures. The CMS (Center for Medicare/Medicaid Services) RAI (Resident Assessment Instrument)Version 3.0 Manual, Chapter 3: Page G-29, documented: "Functional Limitation in Range of Motion (ROM) Code for limitation that interfered with daily functions or placed resident at risk of injury. Coding: 0. No Impairment 1. Impairment on one side 2. Impairment on both sides A. Upper extremity (shoulder, elbow, wrist, hand) B. Lower extremity (hip, knee, ankle, foot). Intent: The intent of (above) is to determine whether functional limitation in range of motion (ROM) interferes with the resident's activities of daily living or places him or her at risk of injury. When completing this item, staff should refer back to item G0110 (functional abilities) and view the limitation in ROM taking into account activities that the resident is able to perform.... " 1) RI #6 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/09/13, identified RI #6 as having a Brief Interview of Mental Status (BIMS) score of 15 (verifying RI #6 was cognitively intact). The Functional Status for RI #6 was coded as able to transfer himself independently, provide bed mobility for himself, dress and feed himself with set up help only, and to independently toilet himself. Despite this, the ROM (Range of Motion) for RI #6's upper extremities was coded on the MDS as a "2." The lower extremities were also coded as a "2" to indicate impairments on both sides." However, with the upper extremities, RI #6 was independent in transfers, eating, bathing and was dependent on staff very little for his care and services. The Occupational Therapy Notes dated 01/04/13, identified RI #6 as having a hospital stay from 12/31/12 to 01/03/13. The reason for referral to skilled OT (Occupational Therapy) services was documented as due to recent hospitalization with [MEDICAL CONDITION] congestion and difficulty with shortness of breath. "Prior Residence and Living Arrangement: Patient was a resident of the SNF (Skilled Nursing Facility) and required setup for ADLs (Activities of Daily Living skills) was modified independent with wheelchair mobility and transfers with sliding board. Previous Therapy: no prior OT services within last 12 months. Precautions: Hard of hearing, [MEDICAL TREATMENT] access left forearm. Uses sliding board for transfers. Wheelchair bound due to B (Bilateral) BKA (Below knee [MEDICAL CONDITION]). Discharge Plans: Remain in SNF (Skilled Nursing Facility) with Functional Maintenance Program. Initial Assessment Resdt (Resident) has had no functional decline in self care skills. ... Resident noted with no ROM (Range of Motion) deficits. Therapy will establish and implement FMP (Functional Maintenance Plan) for resident to maintain UE (Upper Extremities) strength." The FMP for RI #6 developed on 01/07/13 was a strengthening program, which stipulated: "Resident will perform UE (Upper Extremities) dowel rod exercises 3 x 10 reps to shoulder and biceps flexors to promote and maintain strength to B UE (Bilateral Upper Extremities)." The Restorative Nurse's Progress Notes dated 1/7/13 documented, "RI #6 is on Readmission Assessment with diagnosis... Resident turns and reposition self ad lib in bed, is able to sit up in bed and on the side of the bed independently... Resident is able to wash his face and hands and can comb (brush) his hair ad lib... performs bathing and dressing skills with setting up equipment and cueing him as necessary. ...feed self..." The Quarterly Assessment with an ARD of 4/8/13 coded the resident "2/2" for ROM limitation :upper and lower extremities. The 4/3/13 Restorative Progress Note states: "... Resident is alert and verbally responsive and able to make his basic needs known ...transfer self ad lib using sliding board, feeds self..., propels self throughout the facility ad lib in wheelchair, preforms bathing and dressing skills under staff supervision, washes his face and combs/brushes his hair ad lib,...goes to [MEDICAL TREATMENT] three days a week, continent of bowel functions, does exercise program per FMP schedule." Nurses Notes dated 4/13/13, 4/20/13, 5/5/13, 5/25/13 documented RI #6 was able to transfer independently using a sliding board, ("... able to get in and out of bed and wheelchair") propels self in wheelchair ad lib without any difficulties and is able to attend [MEDICAL TREATMENT] three times a week. The Rehab Supervisor, Licensed Practical Nurse (LPN) EI #6 was interviewed on 06/06/13 at 2:10 p.m. EI #6 was asked how she coded RI #6 as a "2" impaired on both upper extremities. EI #6 said the resident had a shunt in his one arm and it sometimes hurt him. It might prevent him from doing the transferring and taking care of himself. EI #6 was asked how she did her testing. EI #6 said she had a 7 day window. She went into his room one time to see how he is doing. EI #6 said she did a test on him and if he cannot put his arms straight up, then she marks him as a two (impairments on both arms). The surveyor asked EI #6 if we could go to the resident's room and do the test again. We entered RI #6's room at 2:21 p.m. EI #6 asked RI #6 to raise his arms completely straight up and he did. She asked him to put his hands behind his head and he did. Then she asked him to put his arms straight out, and he did. The surveyor asked EI #6 do you think he has any limitations in either side. EI #6 said "No." The surveyor then asked, do you think he is a "2" with limitations on both sides of his upper body. EI #6 said yes, because that is what I said before, but I can understand what you are saying. In an interview on 06/06/13 at 3:30 p.m., the Administrator (EI #5) stated she had called the corporate nurse who had taught the LPN how to do the coding for ROM at the facility. The corporate nurse told the LPN that when in doubt to code the resident as a 2/2 (impairments on both upper and lower extremities); so the LPN coded most of the residents in the facility as a "2/2." EI #5 said she knew they were 100% on all residents needing ROM due to the "2/2" coding on the MDS. EI #5 said they would re-look at all residents and see that they are correctly coded. 2) RI #8 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. RI #8 had an Annual MDS with an ARD of 05/03/13. This MDS identified the resident as having short term memory problems, but no long term memory problems. She was identified as having modified independence in cognitive skills for daily decision-making. Under the physical functional level, RI #8, was coded as a "2/2" to indicate impairments on both upper (shoulder, elbow, wrist, hand) and lower extremities (ankle, foot, knees and hip). RI #8's "Restorative Nurse's Progress Notes" of 4/13/13 documented: "... resident exhibits full weight bearing status bilaterally - is non ambulatory - requires staff to support her weight to help her pivot for transfers; utilizes a wheelchair for primary mode of transportation on and off unit with one person providing total assistance with locomotion. Resident is on Restorative care ROM exercises program per FMP schedules..." The Functional Maintenance Plan from the Occupational Therapist (OT) dated 5/07/13 discharged RI #8 from routine maintenance to Rehabilitation Nursing/Restorative nursing assistance: "Resident is able to perform various aspects of self care skills with/without proper verbal cues. Resident currently has WFL (Within Functional Limits) UB (Upper Body) strength and ROM to B (Bilateral) UE's (Upper Extremities) and able to assist with performing all self care needs..." The OT Therapist Progress and Discharge Summary dated 4/11/13, documented RI #8's "Current Level of Function as: "The patient is able to feed self after set-up utilizing no assistive feeding equipment for 25% of meal requiring minimum Assistance. ... The patient demonstrates B UE muscle strength of 3/5 fair (full ROM against gravity with no added resistance)." 3) RI #4 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A "Discharge Summary" from the Occupational Therapist with an discontinuation date of 04/03/13 for gross motor coordination, identified RI #4 had "good gross motor control of his bilateral upper extremities with no more help than standby assistance, supervision or set-up." Regarding general strength, the OT documented, "The patient demonstrates B UE (bilateral upper extremity) muscle strength of 4/5 to 4+/5 good plus (full ROM against and takes moderate to strong resistance)." Regarding toilet transfers, the OT documented, "The resident is able to transfer to toilet/commode requiring Minimum Assistance (Patient requires 1% to 25% physical assistance to complete the activity and may need minimal cueing for safety." The OT ended all care with RI #4 on 05/11/13. A "Discharge Summary" from the Physical Therapist dated 04/18/13, identified the resident's need of a "rolling walker and minimum assistance ... for safe ambulation for 250 feet." Regarding general strength, the PT documented: "The patient demonstrates B LE (bilateral lower extremity) muscle strength of 3+/5 fair plus. "The patient is able to safely transfer from bed (to) wheelchair requiring Minimum Assistance." "The patient is able to safely transition from sit (to) stand requiring Moderate Assistance." Physician order [REDACTED].) for 15 min(utes) qd." A Significant Change MDS assessment with an ARD of 05/04/13, identified the resident as having a need for limited assistance with bed mobility, transfers, ambulation in the room and corridor, dressing, toileting, personal hygiene and bathing. Total dependence upon staff was coded only for locomotion on and off the unit, and eating. Despite these abilities, the resident was coded as having impaired ROM on both the right and left sides of his upper and lower extremities. A care plan dated 05/14/13, related to the resident's need of guidance assistance due to [MEDICAL CONDITION] included: "...Direct to raise arms/legs, button/zip clothing..." "Transfers with guidance and use of walker." "Encourage, provide guidance assistance with ambulation as needed." "Encourage and give guidance assistance to resident to use toilet per protocol and prn (as needed)." On 06/06/13 at 3:00 PM, the surveyor asked the Restorative Certified Nursing Assistant (EI #2) who worked with RI #4 to explain what the resident could do. EI #2 stated the resident had total upper extremity use, with no impairments (some tremors, but not often). When questioned about the use of his lower extremities, EI #2 explained the resident did exercises with his walker, bending knees and swinging legs. The surveyor asked if RI #4 could walk. EI #2 replied yes, with assistance.

Based on observation, interview and the review of facility's records the facility failed to ensure the handrails on two of two units of the facility were securely attached to the walls. This had the potential to effect all residents dependent on the use of the handrails in the facility. Findings Include: On 4/5/12 at 12:30 PM, an observation of the handrails on two of two units of the facility was made and loosen handrails were observed at the following locations: In the hallway at Room Locator Numbers (RL) # 1, # 2, # 3, # 4, # 5, # 6, # 7, # 8, and # 9. An interview was conducted with the facility's Maintenance Director, EI# 6 on 4/5/12 at 1:30 PM, when asked are the hall handrails checked daily, EI# 6 replied, Yes, a maintenance assistant comes in at 6:00 AM and checks the handrails. An interview with EI # 6 on 4/5/12 at 3:50 PM, when asked how often the handrails in the facility were checked, he replied, "A maintenance assistant comes in and checks them at 6:00 AM every morning." On 4/5/12 at 3:50 PM, EI# 6 accompanied the surveyor through the facility checking handrails. Additional loosen handrails were found at locations; RL # 2, # 3, # 4, # 5, # 6, # 7, # 8, and # 9. EI# 7 (the Administrator) was asked to provide the survey team a copy of the facility's policy and procedure for the maintenance of handrails in the facility. EI# 7 provided a written and signed statement, "There is not a specific policy relating to handrail maintenance. All handrails are to be checked routinely and repaired as necessary. Should a staff member observe a loose rail they are to report this immediately or after hours write it on the maintenance log."