Every finding on record at Lafayette Extended Care

Based on interviews, review of Resident Identifier (RI) #64's medical record, the facility's WEEKLY SKIN REPORT FOR THE TIME PERIOD ENDING, 24 HOUR SHIFT REPORT and the policy titled Abuse, Neglect, Misappropriation of Resident Property, Exploitation, and Injuries of Unknown Source, the facility failed to investigate a suspicious injury of unknown source. On 7/17/2019, RI #64 was observed to have a red and blue/green large bruise that was rectangular and covered most of the breast area from the nipple up and the chest wall. This deficient practice affected RI #64, one of one sampled resident identified by the facility as having an injury of unknown source. Findings include: The facility's policy titled Abuse, Neglect, Misappropriation of Resident Property, Exploitation, and Injuries of Unknown Source with an effective date of 11/28/2016, documented . PURPOSE: To ensure the safety and well-being of each resident, the facility will promote and protect the rights of each resident. POLICY: . INJURIES OF UNKNOWN SOURCE an injury should be classified as an injury of unknown source when both of the following conditions are met: (1) The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and (2) the injury is suspicious because of the extent of the injury or the location of the injury . V. INVESTIGATION . C. The Abuse Coordinator or designee is responsible for conducting a thorough investigation and obtaining witness statements . RI #64 was readmitted to the facility on [DATE]. RI #64 has a medical history to include [DIAGNOSES REDACTED]. RI #64's PHYSICIAN ORDERS [REDACTED]. According to www.webmd.com, Eliquis is an anticoagulant medication used to treat and prevent blood clots. Nausea, easy bruising or minor bleeding may occur while taking Eliquis. RI #64's Quarterly Minimum Data Set with an assessment reference date of 5/19/2019, indicated the resident was severely impaired in cognitive skills for daily decision making with a Brief Interview for Mental Status score of four. RI #64 was assessed as being independent with most Activities of Daily Living. During this assessment period, RI #64 received an anticoagulant medication. RI #64's PHYSICIAN ORDERS [REDACTED].#11, a Registered Nurse (RN), documented Monitor Bruising on (L) (left) breast q (every) shift until healed. In an interview on 1/17/2020 at 5:12 PM, EI #11, a RN stated on 7/17/2019, she was called to look at the bruise on RI #64's left breast by EI #8, a Certified Nursing Assistant. When asked to describe the bruising, EI #11 stated the bruise was red and blue/green in color, it was large, rectangular and covered most of the breast area from the nipple up and the chest wall. When asked how she had investigated to determine what happened, EI #11 said, she asked the CNA, EI #8, but the CNA did not know what happened. During an interview on 1/17/2020 at 10:30 AM, EI #2, the Director of Nursing (DON) was asked when she became aware of the bruising to RI #64's left breast. EI #2 stated she read it on the shift report. When asked what she had done to investigate how the bruise occurred, EI #2 said she had not investigated it. When asked if the facility had determined the cause of RI #64's bruising to the left breast, EI #2 said she was sure they talked about it, but she could not remember. The facility's 24 Hour Shift Report for 7/17/2019 and 7/18/2019 indicated RI #64 had a large bruise to the left breast and left forearm. The facility's WEEKLY SKIN REPORT FOR THE TIME PERIOD ENDING 7/28/2019, 8/10/2019, 8/18/2019, 9/1/2019, 9/7/2019, 9/15/2019, and 10/5/2019 indicated the facility monitored the bruising to RI #64's left breast until healed on 10/5/2019. On 1/18/2020 at 11:51 AM, an interview was conducted with EI #1, the Administrator/Abuse Coordinator. EI #1 was asked if the bruising to RI #64's left breast was considered an injury of unknown source. EI #1 said yes. EI #1 acknowledged there was not an investigation to determine what caused the suspicious bruising to RI #64's left breast. In an interview with RI #64's responsible party on 1/20/2020 at 10:15 AM, she acknowledged that she had been notified of the bruising to RI #64's breast. RI #64's responsible party stated the facility notified her weekly the status of bruising and that it was getting better. When asked what concerns she had regarding the bruising, RI #64's responsible party stated she did not think RI #64 had been mistreated and she was never afraid the resident has been harmed.

Based on interviews, review of Resident Identifier (RI) #64's medical record and the facility's policy titled Abuse, Neglect, Misappropriation of Resident Property, Exploitation, and Injuries of Unknown Source, the facility failed to timely report an injury of unknown source to the State Agency. On 7/17/2019, RI #64 was observed to have a red and blue/green large bruise that was rectangular and covered most of the breast area from the nipple up and the chest wall. This injury of unknown source was not reported to the State Agency until 1/21/2020. This deficient practice affected RI #64, one of one sampled resident identified by the facility as having an injury of unknown source. Findings include: The facility's policy titled Abuse, Neglect, Misappropriation of Resident Property, Exploitation, and Injuries of Unknown Source with an effective date of 11/28/2016, documented . PURPOSE: To ensure the safety and well-being of each resident, the facility will promote and protect the rights of each resident. POLICY: . INJURIES OF UNKNOWN SOURCE an injury should be classified as an injury of unknown source when both of the following conditions are met: (1) The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and (2) the injury is suspicious because of the extent of the injury or the location of the injury . VII. REPORTING/RESPONSE [NAME] the Abuse Coordinator or designee will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source . are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency .) in accordance with State law through established procedures . RI #64 was readmitted to the facility on [DATE]. RI #64 has a medical history to include [DIAGNOSES REDACTED]. RI #64's PHYSICIAN ORDERS [REDACTED]. According to www.webmd.com, Eliquis is an anticoagulant medication used to treat and prevent blood clots. Nausea, easy bruising or minor bleeding may occur while taking Eliquis. RI #64's Quarterly Minimum Data Set with an assessment reference date of 5/19/2019, indicated the resident was severely impaired in cognitive skills for daily decision making with a Brief Interview for Mental Status score of four. RI #64 was assessed as being independent with most Activities of Daily Living. During this assessment period, RI #64 received an anticoagulant medication. RI #64's PHYSICIAN ORDERS [REDACTED].#11, a Registered Nurse (RN), documented Monitor Bruising on (L) (left) breast q (every) shift until healed. In an interview on 1/17/2020 at 5:12 PM, EI #11, a RN stated on 7/17/2019, she was called to look at the bruise on RI #64's left breast by EI #8, a Certified Nursing Assistant. When asked to describe the bruising, EI #11 stated the bruise was red and blue/green in color, it was large, rectangular and covered most of the breast area from the nipple up and the chest wall. In an interview on 1/17/2020 at 4:21 PM, EI #1, the Administrator/Abuse Coordinator, was asked what types of incidents are reported to the State Agency. EI #1 said any abuse, neglect, misappropriation of property, and injuries of unknown origin. During a follow-up interview on 1/18/2020 at 11:51 AM, EI #1, the Administrator/Abuse Coordinator was asked what the facility policy directed the staff to when an injury of unknown source had been identified. EI #1 replied, to report it. When asked if the bruise to RI #64's left breast was injury of unknown source, EI #1 said yes. EI #1 acknowledged RI #64's injury of unknown source had not been reported to the State Agency. On 1/21/2020 at 2:41 PM, the facility reported to the State Agency an injury of unknown source. The injury was listed as bruising to RI #64's left breast.

Based on interviews and review of Resident Identifier (RI) #43's medical record, the facility failed to ensure RI #43 was not ordered and administered a PRN (as needed) antipsychotic medication, [MEDICATION NAME], for greater than 14 days, without documented rationale in the resident's medical record for the continued use of the PRN antipsychotic medication. This deficient practice affected RI #43, one of five sampled residents reviewed for unnecessary medications. Findings include: RI #43 was readmitted to the facility 8/27/2019. RI #43 has a medical history to include [DIAGNOSES REDACTED]. RI #43's PHYSICIAN ORDERS [REDACTED]. In an interview on 1/16/2020 at 4:42 PM, Employee Identifier (EI) #2, the Director of Nursing acknowledged RI #43's order for [MEDICATION NAME] had not been renewed since it was ordered on [DATE]. When asked if the physician gave a rationale to continue use beyond 14 days, EI #2 said no. When asked if the facility had re-evaluated RI #43's use of as needed [MEDICATION NAME], EI #2 said no. During a telephone interview on 1/16/2020 at 5:12 PM, EI #5, the facility's Medical Director and RI #43's Primary Physician was asked if RI #43 had been re-evaluated for the extended use of the antipsychotic medication, [MEDICATION NAME], that was ordered to be administered on an as needed basis. EI #5 replied no and it should have been done within 14 days of the order. RI #43's (MONTH) 2019 MEDICATION SHEET revealed the resident was administered [MEDICATION NAME] once during the month. RI #43's (MONTH) 2019 Medication Administration Record [REDACTED]. RI #43's (MONTH) 2019 Medication Administration Record [REDACTED]. RI #43's (MONTH) 2019 Medication Administration Record [REDACTED]. RI #43's (MONTH) 2019 Medication Administration Record [REDACTED]. RI #43's (MONTH) 2020 Medication Administration Record [REDACTED]. RI #43's Physician order [REDACTED].

Based on observation, interview, and review of the facility policy titled Labeling and Dating Foods . the facility failed to ensure all frozen items were sealed, labeled and dated in the walk in freezer. During the entrance tour of the kitchen on 12/18/18, an unlabeled and undated clear plastic bag of breaded okra was open and exposed the okra to the air in the walk in freezer. This had the potential to affect 65 residents who received meals from the kitchen. Findings include: Review of a facility policy titled Labeling and Dating Foods . and dated (YEAR) revealed the following: Guideline: All foods stored will be properly labeled according to the following guidelines. Procedure: . 3. * Date marking for freezer storage food items . Once a package is opened, it will be re-dated with the date the package was opened and shall be used by the safe food storage guidelines . During the entrance observation of the facility kitchen on 12/18/18 at 9:15 AM, the walk-in freezer was observed with the Certified Dietary Manager, Employee Identifier (EI) #3. In the walk-in freezer was an unlabeled and undated, open, clear, plastic bag of breaded okra. EI #3 removed the bag of okra from the freezer and stated, it should not be stored without a label, a date and it should have been sealed. On 12/19/18 at 1:45 PM, EI #3, CDM was asked what the facility policy was for food items stored in bags in the freezer. EI #3 said, they should be secured, dated, labeled and put away. EI #3 was asked what dates should have been on the okra. EI #3 said, the date it came in, the date it was opened and the use by date. EI #3 was asked how it should have been put away. EI #3 said, if something is left over it would be labeled and dated and closed up. When asked how to close or secure an open bag of okra in the freezer, EI #3 said, roll it down tight, in a dated zip-lock bag. When asked how long the okra had been in the freezer open, EI #3 replied, she could not say for sure how long. When asked why frozen food items should not be in the freezer in an open bag, EI #3 said, it could be freezer burned and could make someone sick if it got contaminated.

Based on observations, interviews and record review, the facility failed to ensure Resident Identifier (RI) #22's suprapubic urinary catheter and tubing was shielded from the view of other residents and visitors. This effected one of two residents with suprapubic catheter. Findings include: RI #22 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the (MONTH) (YEAR) physician's orders [REDACTED]. CHANGE SUPRA PUBIC CATH (CATHETER) Q (EVERY) MONTH ON THE 13TH (20 FRENCH (FR) CATH W(WITH)/30 ML (milliliters) H2O (water) BULB) . A review of RI #22's Care Plan for FOLEY CATHETER dated 12/31/16 revealed the presence of a suprapubic catheter. On 12/19/18 at 1:29 p.m. the surveyor observed RI #22's suprapubic catheter hanging on the bed frame without a covered bag to shield it from the view of other residents or visitors. On 12/19/18 at 3:06 p.m. an interview was conducted with Employee Identifier (EI) #4, Certified Nursing Assistance (CNA). The surveyor asked EI #4 what was that (referring to the resident's catheter). EI #4 said it was RI #22's catheter. The surveyor asked EI #4 how was the catheter supposed to be. EI #4 said it was supposed to hang below RI #22's body and be in a bag to cover it. The surveryor asked EI #4 what concerns there were with the catheter not being covered. EI #4 said it was sealed so it was not going to leak unless it was bumped really hard. The surveyor asked EI #4 why should the facility put the catheter inside of a bag. EI #4 said, it was for privacy first and then for protection of the catheter bag. On 12/19/18 at 3:07 p.m. the surveyor conducted an interview with RI #5, License Practical Nurse (LPN). The surveyor asked EI #5 what was that (referring to the resident's catheter bag). EI #5 said that was RI #22's catheter bag. The surveyor asked EI #5 how it was supposed to be. EI #5 said, it was supposed to have a drainage bag holder over it. The surveyor asked EI #5 what issues there were with that. EI #5 said it was a dignity issue. On 12/19/18 at 4:17 p.m. the surveyor conducted an interview with RI #22. The surveyor asked RI #22 how it made him/her feel for the catheter to be on the side of the bed, exposed with urine, without a cover. RI #22 said, he/she was so used to it, he/ she did not think about it anymore. RI #22 said, if he/she was going out he/she would want it covered. The surveyor asked RI #22 how often the catheter was covered. RI #22 said, is was the first time that bag had been on the catheter in awhile.

Based on observation, interview and record review, the facility failed to ensure Resident Identifier (RI) #31's prescribed diet was followed. This affected one of four residents whose diets were reviewed. Findings Include: RI # 31 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of RI #3's (MONTH) (YEAR) Physician order [REDACTED]. An observation was made on 12/18/2018 at 6:00 p.m. RI #31's meal tray was observed for intake amount. RI #31's meal tray was noted to have hashbrowns. RI #31 said she/he did not eat them because they told her/him she/he could not have them. Employee Identifier (EI) #2, Director of Nursing (DON) was present and also observed RI #31's tray. On 12/19/2018 at 1:53 p.m., the surveyor conducted an interview with EI #2. The surveyor asked EI #2 what was on RI #31's supper tray the evening before. EI #2 said hash browns. The surveyor asked EI #2 who was responsible for ensuring meals on the trays were correct. EI #2 said dietary and nursing staff that put out trays. The surveyor asked EI #2 what would be some issues with RI #31 receiving potatoes. EI #2 said, RI #31 could have abnormal labs.

Based on observations, record review and interviews, the facility failed to monitor the amount of fluid for Resident Identifier (RI) #35, a resident receiving [MEDICAL TREATMENT] and on a 1500 cc (centimeter) fluid restriction. This affected RI # 35, one of three residents sampled for [MEDICAL TREATMENT]. Findings Include: RI #35 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 09/03/17, revealed RI #35 had a Brief Interview for Mental Status score of 3 indicating severely impaired cognition. RI #35's February 2018 Physician order [REDACTED].#35 was receiving [MEDICAL TREATMENT] Monday, Wednesday and Friday. A review of RI #35's chart, MAR (Medication Administration Record), care plan nor the CNA (Certified Nursing Assistant) Kardex revealed documentation of the daily amount of fluids RI #35 was receiving. On 02/02/18 at 11:30 a.m., the Dietary Manager, Employee Identifier (EI) #3 was asked who is responsible for dividing the amount of fluids nursing and dietary is to provide to RI #35. EI #3 stated it was the nursing staffs duty. On 02/02/18 at 3:10 p.m., EI #2 the RN (Registered Nurse) Supervisor was asked how the CNAs know when a resident is on fluid restriction. EI #2 stated it was on the ADL (Activity of Daily Living) sheet. When asked if the fluid amounts were added up to prevent giving too much fluid, EI #2 stated she didn't think so. When asked why it is important to monitor fluid intake, EI #2 stated to prevent fluid overload. 02/01/18 at 1:45 p.m., the LPN (Licensed Practical Nurse) EI #6 was asked where the amount of fluids given to RI #35 with the medications was documented. EI #6 stated there was no place to document the amount. When EI #6 was asked whose responsibility it was to divide the amount of fluid for the staff to provide, EI #6 stated she did not know.

Based on observations, record review and interviews, the facility failed to ensure: (1) the amount of fluid allowed for Resident Identifier (RI) #35, a resident on [MEDICAL TREATMENT] and fluid restriction, was documented on the care plan; and (2) a care plan was developed for RI #15's no use of straws. These deficient practices affected RI #15 and #35, two of 19 sampled residents whose plans of care were reviewed. Findings Include: (1) RI #35 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 09/03/17, revealed RI #35 had a Brief Interview for Mental Status score of 3 indicating severely impaired cognition. A review of RI #35's careplan titled Risk for complications related to [MEDICAL CONDITION] requiring [MEDICAL TREATMENT] did not specify the amount of fluids allowed for each discipline. The care plan failed to designate the amount of fluid restriction allowed. A review of RI #35's February 2018 Physician order [REDACTED]. The Plan of Care Kardex for the CNAs (Certified Nursing Assistants) did not address the fact RI #35 was on fluid restriction or the amount of the restriction. A review of the MAR (Medication Administration Record [REDACTED]. On 02/02/18 at 3:10 p.m., the Registered Nurse (RN) supervisor, Employee Identifier (EI) #2 was asked if the care plan for a resident on fluid restriction should have the amounts allowed. EI #2 stated yes, it should also be on the meal card. When asked how the CNAs would know the amount of the fluid restriction, EI #2 stated it should be on their ADL (Activity of Daily living) card. (2) RI #15 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. On 01/31/18 at 8:57 a.m., the surveyor observed a no straws please sign posted over RI #15's bed. On 02/01/18 at 12:00 p.m., the surveyor observed a straw in RI #15's water pitcher. On 02/01/18 at 3:57 p.m., RI #15's assigned Licensed Practical Nurse (LPN) on the 3-11 PM shift, EI #7, and the surveyor entered RI #15's room. The straw remained in RI #15's water pitcher. The surveyor asked EI #7 could RI #15 reach the water pitcher and drink from it. EI #7 said if RI #15 was in the room, yes. When asked why RI #15 had the sign above the bed that the resident was not to have a straw, EI #7 said she did not know. On 02/01/18 at 4:12 p.m., the surveyor conducted an interview with EI #4, a LPN Rehabilitation Nurse. The surveyor asked EI #4 was RI #15 cared planned for the use of no straw. EI #4 looked in RI #15's medical records and said she did see one. The surveyor asked EI #4 should there be a care plan for RI #15's no usage of straws. EI #4 said she did not write one and there probably should have been one.

Based on observation and interviews, the facility failed to ensure 62 stock [MEDICATION NAME] Suppositories, with the expired date of 12/2017, were not stored in the refrigerator in the medication room. This deficient practice had the potential to affect all residents in the facility with a physician's orders [REDACTED]. Findings Include: On 02/01/18 at 2:49 p.m., the surveyor made an observation of the medication room on the South Unit with Employee Identifier (EI) #7, a Licensed Practical Nurse. The surveyor observed a box of 62 stock [MEDICATION NAME] suppositories with an expiration date of 12/2017. The surveyor asked EI #7 should the expired suppositories be in the refrigerator. EI #7 said no. The surveyor asked EI #7 who was responsible for ensuring expired medications were not stored in the refrigerator. EI #7 said all of the nurses. The surveyor asked EI #7 what could be the result of a resident receiving an expired medication. EI #7 said they could have a reaction to or not get the full benefits of the medication. On 02/01/18 at 5:46 p.m., the surveyor conducted an interview with EI #4, the Registered Nurse/Quality Assurance/Infection Control Nurse. The surveyor asked EI #4 who was responsible for ensuring expired medications were disposed of. EI #4 said the nurses that work should check for expired medications and the pharmacist comes monthly and checks too. The surveyor asked EI #4 what should happened to expired medications. EI #4 replied, they should be destroyed. The surveyor asked EI #4 should the expired suppositories have been left in the refrigerator. EI #4 said no. When asked what were some of the consequences of administering an expired medication to a resident, EI #4 said the medication could not be as effective when it is expired.

Based on observations and interviews the facility failed to ensure: (1) Resident Identifier (RI) #20's nebulizer mask was stored properly; and (2) a Certified Nursing Assistant, Employee Identifier (EI) #8, did not touch Resident Identifier (RI) #56's cornbread with her bare hands while assisting RI #56 with the lunch meal 01/31/18. These deficient practices affected RI #20, one of two residents observed with a nebulizer mask, and RI #56 one of two residents observed being assisted with meals. Findings Include: (1) RI #20 was admitted to the facility on [DATE], and readmitted on [DATE], with a [DIAGNOSES REDACTED]. RI #20's February 2018 Physician order [REDACTED].> . [MEDICATION NAME] - [MEDICATION NAME] 2.5 MG (milligram) - 0.5 MG 3 ML (milliliters) INHALATION SOLUTION. TID (three times a day) PRN (as needed) SOB (shortness of breath) . On 01/31/18 at 9:37 a.m., the surveyor observed RI #20's nebulizer mask lying on top of dresser drawer. The nebulizer mask was not in a covering at this time. On 01/31/18 at 2:07 p.m., RI #20's nebulizer mask remained uncovered lying on top of the dresser drawer. On 02/01/18 at 10:02 a.m., the surveyor once again observed RI #20's nebulizer mask lying on top of the dresser drawer not in a covering. On 02/01/18 at 1:30 p.m., the surveyor conducted an interview with the Licensed Practical Nurse assigned to care for RI #20 on 02/01/18, on the 3 - 11 PM shift, EI #7. The surveyor asked EI #7 did RI #20 receive nebulizer treatments. EI #7 said yes. The surveyor asked EI #7 how should RI #20's nebulizer mask be stored when not in use. EI #7 said the mask should be stored in a Ziploc or plastic bag. The surveyor asked EI #7 what was there a potential for when the nebulizer mask was not stored properly. EI #7 replied the mask could hit the floor and be contaminated from being on the floor. (2) RI #56 was admitted to the facility on [DATE], and readmitted on [DATE], with a [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set assessment, with an Assessment Reference Date of 10/01/17, assessed RI #56 as being totally dependant on staff for feeding. On 01/31/18 at 11:25 a.m., the surveyor observed EI #8, the CNA assisting RI #56 with the lunch meal, pick up the resident's cornbread with her bare hands and hand it to resident. On 02/01/18 at 2:00 p.m., the surveyor conducted an interview with EI #8. The surveyor asked EI #8 should the resident's food be handled by staff with their bare hands. EI #8 said no. The surveyor asked EI #8 what would it be considered if you touched a resident's food with your bare hands. EI #8 said cross-contamination. The surveyor asked EI #8, if staff needed to touch a resident's food, what should they do first. EI #8 replied, grab a napkin first or put on gloves.

Based on observations, interview and record review, the facility failed to ensure the Physician's Orders for Resident Identifier (RI) #15 to not have a straw was followed. This deficient practice affected RI #15, one of 19 residents whose Physician Orders were reviewed. RI #15 was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. A review of RI #15's Plan of Treatment for Outpatient Rehabilitation, with an onset date of 04/23/16, documents: . 20. INITIAL ASSESSMENT . 0 (No) straws c (with) orders for Glucerna c meals . RI #15's Weekly Progress Note, with summary dates from 04/29/16 - 05/05/16, documented: . GOAL: . (2). Patient will tolerate thin liquids c 0 s/s (signs/symptoms) aspiration . Current: . via (by way of) cup rim - NO STRAWS . RI #15's February 2018 Physician Orders documented: . NO STRAWS. ALL THIN LIQUID FROM CUP RIM . On 01/31/18 at 8:57 a.m., the surveyor observed a no straws please sign posted over RI #15's bed. On 02/01/18 at 12:00 p.m., the surveyor observed a straw in RI #15's water pitcher. 02/01/18 at 4:12 p.m. the surveyor conducted an interview with a Licensed Practical Nurse/Rehabilitation Nurse, Employee Identifier (EI) #4. The surveyor asked EI #4 why was RI #15 given a Physician's Order for no straws. EI #4 said from her understanding it was related to RI #15's dysphagia. The surveyor asked EI #4 what could possibly happed if RI #15 used the straw. EI #4 said RI #15 could possible choke if the liquid went down to fast.

Based on observations and interview, the facility failed to ensure the survey results were posted in an area, on a bulletin board near the front door of the facility, which was accessible to all residents. This deficient practice was observed on three of three days of the survey, and had the potential to affect all residents in wheelchairs at the facility. Findings include: On 01/30/18 at 3:23 p.m., the surveyor observed a sign at the South hall nurses station which documented: State Survey Results Located on Bulletin Board at Front Door and Day Room. The survey resulted were posted near the top of bulletin board, not accessible to residents in wheelchairs. On 01/31/18 at 8:30 a.m., the surveyor observed that the survey result remained near the top of the bulletin board unaccessible to residents in wheelchairs. On 02/01/18 at 9:59 a.m., the survey results were observed by the surveyor to remain posted at the top of the bulletin board out of reach of residents in wheelchairs. On 02/01/18 at 5:25 p.m., the surveyor conducted an interview with the Administrator, Employee Identifier (EI) #1. The surveyor asked EI #1 should the survey results that are posted be easily accessible to all residents. EI #1 said yes. The surveyor asked EI #1 were the survey results posted on the bulletin board at the front door accessible to residents in wheelchairs. EI #1 replied no, they are at the top of the bulletin board

Based on observations and interview, the facility failed to ensure the Daily Nurse Staffing Form consistently included the actual total hours worked by the nursing staff each shift. This was observed on three of three days of the survey, and had the potential to affect all residents residing in the facility. Findings Include: On 01/30/18 at 3:23 p.m., the surveyor observed the Daily Nurse Staffing Form. The form was dated 01/30/2018, the census was 65, and there were no total hours worked for staff on the form for the day, evening or night shifts. On 01/31/18 at 8:27 a.m., the surveyor observed the Daily Nurse Staffing Form. The form was dated 01/31/2018, the census was 64, and there were no total hours worked for staff on the form for the day shift. On 02/01/18 at 9:58 a.m., the surveyor observed the Daily Nurse Staffing Form. The form was dated 02/01/2018, the census was 64, and there were no total hours worked for staff on the form for the day shift. On 02/01/18 at 5:25 p.m., the surveyor conducted an interview with the Administrator, Employee Identifier (EI) #1. The surveyor asked EI #1 what information should be listed on the Daily Nurse Staffing Form. EI #1 said the Registered Nurses, the Licensed Practical Nurses, the Certified Nursing Assistants and the hours worked. The surveyor asked EI #1, when should that information be posted. EI #1 said at the beginning of the shift.

Based on observations, record review, and interview the facility failed to ensure The following food items were labeled and dated and the spice condiments were securely closed after use. 1. Three bowels of applesauce in the reach in refrigerator were not label or dated with a used by date. 2. Three containers on the prep table containing potato flakes, grits, and oatmeal were not dated with used by dated or label with contents. 3. The spice table contain one open container of black pepper, one white pepper, and one open box of salt. This had the potential to affect all residents receiving trays from dietary. Findings include: A review of the facility's policy for Food Storage (Dry/ Refrigerated/Frozen) Health Technologies, Inc. Guideline & Procedure Manual, 2011 Edition. Procedure: 1. General storage guideline to be followed: All food items will be labeled. The label must include the name the food and date by which it should be sold , consumed, or discarded. During the initial tour of the dietary department on 11/15/16 at 3:00 PM, three bowls of applesauce was observed in the reach in refrigerator without labels as to what was in the bowls or use the by dated. On a prep table was three plastic containers without labels or use by dates and each container had a white substance in them. The Certified Dietary Manager Employee Identifier (EI) #6 identified one container had potato flakes, one as oatmeal, and the other as grits. The spice table contained multiple spices, it was noted the pour tap on the black pepper, white pepper and the box of salt was left open. During an interview with EI #6 on 11/17/2016 at 6:15 PM, She was asked when should the food be dated and labeled. EI #6 relied we are to date and label it the day we open it. EI #6 was asked about food that is placed in the refrigerator, when should that be dated and labeled. EI#6 relied It should be labeled the day we put it in the refrigerator, we keep it for three days. EI #6 was why the containers did not have dates or labels on them. EI #6 replied I have a lot of new staff that have just started working and they probably forgot.

Based on record review and interview, the facility failed to accurately identify the change in Resident Identifier (RI) #2 Significant Change Minimum Data Set (MDS) with the Assessment Reference Date of 09/09/2016. A review of the Physician orders [REDACTED]. However, a review Of the MDS dated [DATE] did not identify the resident was on hospice in section J or O. This affected one of 15 residents records reviewed. Finding include: RI #2 was readmitted to the facility on [DATE], with [MEDICAL CONDITION], Hypertension, and Hypertensive [MEDICAL CONDITION]. A review of the physician orders [REDACTED]. A review of the Significant Change MDS dated [DATE], Section J - Health Conditions . J1400: Prognosis: life expectancy of less than 6 months No. A review of Section O -Special Treatments, Procedures, and and Programs additionally, Hospice was not identified as part of the residents need. A review of the CAT(care area triggers) work sheet dated 09/09/2016, section .Worksheet Problem Area : 05. ADL Functional / Rehabilitation Potential revealed a a work note that identified the resident was readmitted to the facility and to hospice with [DIAGNOSES REDACTED]. On 11/17/2016, at 4:45 PM,The MDS Orator, Employee Identifier #3 was asked about the significant change MDS identifying the residents was on Hospice. EI #3 reviewed the MDS and said the significant change was being done because the resident was now on Hospice. However, when section J was reviewed, section J was not checked in section J 1400. EI #3 was asked how would she correct this, EI #3 replied, to sent in a modification.

Based on record review and interviews, the facility failed to ensure a Certified Nursing Assistant washed her hands when providing Incontinence Care to Resident Identifier #3 and RI # 9. This affected 2 of 3 residents observed during incontinence care. The facility also failed to ensure a Registered Nurse washed her hands between administering medications to three residents this affected 3 of 9 residents observed during medication pass. Findings include: 1. RI #3 was admitted to the facility with [DIAGNOSES REDACTED]. A review of the Minimum Data Set revealed the resident was always incontinent of bowel and bladder and to be Totally Dependent for Personal Hygiene. A review of the facility policy Lafayette Extended Care Incontinent Care policy, revised 02/2010 revealed: Purpose: To establish a routine method for providing incontinent care that will minimize exposure to potentially infectious materials . Procedure: 11 During incontinent care, if gloves become soiled, change and use alcohol gel before continuing 14. Wash hands . A review of the Infection Control Policy titled LAFAYETTE EXTENDED CARE LLC Infection Prevention and Control Program Procedures revealed: Hand washing: Wash hands immediately and use alcohol gel after completing tasks involving blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn. A review of the Medication Pass(not dated) reveals: .4 Give the resident the medications . 5 Wash your hands before touching anything on your cart An observation was made on 11/16/16 at 4:50 PM of Certified Nursing Assistant (CNA), Employee Identifier (EI) #1 during incontinent care. The CNA was observed to enter the room with supplies, positioned RI #3 for the procedure, wiped her buttocks on the right from the top to bottom with wipes, positioned her on her back and was observed to wipe the perineal area with wipes. The CNA continued to position the resident and cleaned the left buttock area using wipes. The CNA used pads under the resident without placing a brief on the resident or using moisture barrier. The buttocks were observed to be very red. The CNA was observed to remove the soiled pads and place them in a plastic bag and to change gloves without washing her hands or using alcohol gel. The CNA was observed while carrying the plastic bag with the soiled wipes and linens to the soiled linen room on another hall, and to open doors and soiled containers. The CNA was not observed during the procedure to wash her hands or use alcohol gel. The CNA was ask about washing her hands before starting peri care. She stated she used hand sanitizer before entering the room. The surveyor ask the CNA if she washed her hands during the procedure. She stated, I didn't, I'm sorry. When asked about washing her hands after disposing of the soiled linen and wipes, she stated, That's where I am going now. RI # 9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The annual MDS dated [DATE] revealed RI#9's cognitive status for daily decision making was 3, severely impaired .RI # 9 was coded as dependent for ADL (activities of daily living) and incontinent of bowel and bladder. On 11/16/2016 at 5:15 PM, EI # 2 and # 5 two CNA's were observed providing incontinence care for RI # 9. Upon entering the room, the door, blinds and curtain was closed, the CNA's washed their hands and applied gloves. EI # 5 unfastened RI # 9's brief and placed her on her right side. EI#5 wiped from front to back. RI#9 was positioned onto her back and the brief was removed. After placing RI#9 onto her left side, EI#2 wiped the buttock area, changed gloves and applied barrier cream. Positioning RI@9 on her back, EI#2 washed across the pubic area, the groins and separated the labia and cleaned front to back. The brief was then fastened and RI # 9 was covered. EI#2 was interviewed on 11/17/2016 at 11:10 AM. EI # 2 was asked when should you wash your hands during incontinence care. EI # 2 stated between glove changes. When asked why she had not washed her hands when changing her gloves she stated she forgot. When asked why was the potential harm to the resident from not washing her hands, she stated , spreading germs and causing urinary infection. EI # 4 the Director of Nursing was interviewed on 11/17/2016 at 11:15 AM. EI#4 was asked if changing gloves took the place of handwashing. EI # 4 stated that it did not take the place of handwashing. On 11/15/2016 at 5:35 PM, EI # 3, a Registered Nurse was observed during a medication pass. EI # 3 prepared the first residents medication, entered the room poured water into the glass and administered the medication. Without washing her hands or using hand gel, she returned to the medication cart and prepared the 2nd resident's medication. EI#3 entered the 2nd residents room, poured water into the resident's cup and administered the medication. After patting the resident on the hand, EI # 3 returned to the cart. Without washing her hands or using sanitizing gel, medication was prepared for the third resident which required the pill to be crushed. On 11/17/2016 at 9:15 AM, EI#3 was asked what is the potential harm from failing to was or sanitize hands between residents. EI #3 stated it was transferring germ from one person to another.

Based on record review and interview, the facility failed to ensure Certified Nursing Assistant (CNA) education records were maintained in a manner to reflect 12 hours of education provided per year. This affected Employee Identifier (EI) #s 3, 4, 5, 6, and 7, five of five CNAs employed by the facility for at least a year, whose training records were reviewed. Findings include: The facility's policy addressing INSERVICES, dated 11/01/1990, did not indicate the number of educational hours required per year for CNAs. A review of the training records for EI #s 3 through 7 revealed their education was not documented in a manner to reflect the amount of hours for each PROGRAM ATTENDED. EI #1, the Administrator, was interviewed on 08/25/2016 at 10:45 AM. EI #1 stated she thought the required number of educational hours per year required for CNAs was six, but explained they provided 12 hours. EI #1 said sometimes they did a lunch style inservice and other times they did handouts. When asked how they accounted for the amount of time spent for the various inservices provided, EI #1 said they do not keep up with the time. EI #1 said they did not have evidence to show the CNAs were provided 12 hours of educational training per year.

Based on record review and interview, the facility failed to ensure Resident Identifier (RI) #1's Falls care plan, which specified mechanical lift for transfers, was followed on 2/14/2016 and 5/19/2016. RI #1 sustained falls without injury during a transfer without the use of a mechanical lift on these two days. This affected RI #1, one of eight residents for whom careplans were reviewed. Findings include: A review of an undated facility document titled, LAFAYETTE EXTENDED CARE STANDARDS OF CARE, revealed, .8. Immobile residents are dressed .and placed up in a chair via mechanical lift .10. Residents will be assisted with transfer .as needed . A review of Potter and Perry's, FUNDAMENTALS OF NURSING, EIGHTH EDITION, copyright 2013, Chapter 18, Planning Nursing Care, Page 244 revealed: . A nursing care plan reduces the risk for incomplete, incorrect, or inaccurate care. As the patient's problems and status change, so does the plan . The plan of care communicates nursing care priorities to . health care professionals . in a care plan you list specific supplies necessary to use . RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS), assessment dated [DATE], revealed the resident was totally dependent on staff for transfers and the resident did not move from a seated to a standing position during the assessment period. RI #1's monthly physician orders [REDACTED]. RI #1's Fall careplan documented that the resident had a fall in the bathroom on 7/24/2015 and an intervention was added to the careplan to, please use mechanical lift for all transfers. The careplan further revealed that RI #1 had a fall in the bathroom on 2/14/2016 and again an intervention was added to the care plan to, please use mechanical lift for all transfers. The careplan also documented another fall on 5/19/2016 in the bathroom/shower room. After this fall, the care plan was updated with the following intervention: Please! Please! use mech (mechanical) lift for all transfers. RI #1's Nurse's Notes revealed that on 2/14/2016 at 2:30 p.m., RI #1 was in the bathroom with staff assistance and attempted to stand up using the walker to transfer from the toilet to the wheelchair. RI #1 fell back onto the toilet because his/her legs gave out. RI #1 then began to slide off of the toilet and was eased to the floor by Employee Identifier (EI) #3, a Certified Nursing Assistant (CNA). RI #1's Nurse's Notes further revealed that on 5/19/2016 at 2:45 p.m., CNAs were attempting to dry the resident in the bathroom/shower room when RI #1's legs buckled and the CNAs helped the resident to a sitting position on the floor. There was not any injury to the resident. On 08/24/2016 at 1:56 p.m., an interview was conducted with EI #3, the CNA who was assisting RI #1 at the time of the falls on 2/14/2016 and 5/19/2016. According to EI #3, she assisted RI #1 with toileting on 2/14/2016 by standing the resident with the aid of a walker at the time of the fall. EI #3 stated that the Rehab nurse talked to her (EI #3) after the fall and told her not to try to stand the resident anymore but to use the mechanical lift for transfers. According to EI #3, she was unaware that RI #1's careplan specified to use a mechanical lift at that time. EI #3 was asked about the fall on 5/19/2016 and according to EI #3, she was aware that she should have transferred the resident with a lift on that day but there was not one available at that time so she and another staff member assisted the resident to stand without using a lift and the resident's legs gave out. According to EI #3, she should have waited for a lift to become available. The surveyor asked EI #3 what the risk was of transferring a resident without a lift if the careplan and physician orders [REDACTED].#3 stated that the employee or the resident could get hurt. On 8/24/2016 at 4:05 p.m., an interview was conducted with EI #8, Licensed Practical Nurse (LPN)/Rehab Nurse. According to EI #8, if a careplan or order states to use a mechanical lift, staff know to use a full lift and not a stand-up lift. EI #8 confirmed she had talked to the CNA about the method of transfer for RI #1 and also confirmed that the resident's careplan and physician order [REDACTED]. When asked if it caused any risk to the resident by staff not using a mechanical lift, EI #8 stated that there was a risk of falls and in her opinion it was safer to use a mechanical lift.

Based on observations, record review, and interviews, the facility failed to ensure Resident Identifier (RI) #2's incontinence care plan was updated to reflect current bowel and bladder approaches. The facility further failed to ensure RI #s 1 and 8's care plans were updated to reflect the current methods of transfer. This affected RI #s 1, 2, and 8, three of eight sampled residents for whom care plans were reviewed. Findings include: 1) RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1's Quarterly Minimum Data Set Assessment, dated 07/31/2016, indicated RI #1 was cognitively intact and was totally dependent on staff for transfers. RI #1's ADL (Activities of Daily Living) Functional Rehab care plan, dated 08/2015, listed interventions to transfer RI #1 with a mechanical lift as needed and a walker. RI #1's current Falls Care Plan, dated 07/17/2015, listed an intervention to transfer RI #1 using the mechanical lift. On 08/23/2016 at 9:49 a.m., staff was observed transferring RI #1 from the wheelchair to the bed using a stand up lift. Employee Identifier (EI) #8, the Restorative/Rehab Nurse, was interviewed on 08/24/2016 at 4:05 p.m EI #8 explained they had gone back and forth on the type of lift to use when transferring RI #1. EI #8 said if the care plan said mechanical lift it would mean a mechanical lift with sling, not the stand up lift. EI #8 said she had not changed RI #1's orders from a mechanical lift to a stand up lift. EI #2, the Director of Nursing, was interviewed on 08/25/2016 at 12:03 p.m EI #2 said if a resident's care plan said mechanical lift staff should use the full sling lift. EI #2 said one to two weeks prior, it was determined that RI #1 could be transferred using the stand up lift. 2) RI #2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #2's annual Minimum Data Set (MDS) assessment, dated 07/24/2016, indicated RI #2 had moderately impaired cognition and was always incontinent of bowel and bladder. RI #2 was totally dependent on staff for toileting and required extensive assistance with personal hygiene. RI #2's PLAN OF CARE KARDEX, used by Certified Nursing Assistants, indicated RI #2 was continent of both bowel and bladder and staff should provide a bedpan upon resident request. This same plan of care indicated RI #2 was incontinent and should be checked and changed every two hours and as needed. RI #2's current Incontinence Care Plan indicated the resident was incontinent of bowel and bladder and listed an approach to offer RI #2 the bedpan at frequent intervals. This care plan also listed an approach to change pads/briefs at intervals as needed. Employee Identifier (EI) #8, the Restorative Nurse, was interviewed on 08/25/2016 at 3:00 p.m EI #8 explained RI #2 was recently readmitted to the facility on hospice with a [DIAGNOSES REDACTED].#8 said RI #2 no longer wanted to use a bed pan or bedside commode due to complaints of pain and preferred for staff to provide incontinent care. When asked if the resident's preferences were reflected on the care plan, EI #8 said she had not updated RI #2's care plan to reflect the resident no longer wanted to be offered the bedpan. 3) RI #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #8's quarterly Minimum Set (MDS) Assessment, dated 05/08/2016, indicated RI #8 had moderately impaired cognition and required extensive assistance of one person for transfers. RI #8 had range of motion impairment of both lower extremities and was only able to stabilize with staff assistance. RI #8's current comprehensive care plans listed the following approaches: 1) may use rolling walker for transfers with assistance (dated 05/2016) 2) may use mechanical lift if unable to stand (dated 12/2015) However, RI #8's PLAN OF CARE KARDEX reflected staff should utilize a standing (sit to stand) lift if RI #8 was unable to stand. On 08/24/2016 at 9:30 a.m., Employee Identifier (EI) #3, a Certified Nursing Assistant (CNA), was observed transferring RI #8 using a sit to stand lift. During an interview with EI #9, Care Plan Coordinator, on 08/23/2016 at 3:42 p.m., EI #9 stated if the care plan states mechanical lift, it is referring to the lift with sling. She explained if a resident were to use a sit to stand lift it would specifically state it could be used. EI #9 said the Restorative Nurse was responsible for care plans addressing how residents should be transferred. EI #8, the Restorative Nurse, was interviewed on 08/24/2016 at 10:33 a.m. to determine what method staff should be using when assisting RI #8 with transfers. She reviewed documentation on RI #8 and stated staff could use a mechanical lift (sit to stand) if RI #8 was unable to stand. EI #8 then reviewed RI #8's care plans and stated she had not updated them to reflect the sit to stand lift. EI #8 also stated they needed to clarify mechanical lift verses sit to stand lift on the care plans. EI #8 said it was important to update care plans and the PLAN OF CARE KARDEX so CNAs will be aware of the proper transfer and for the safety of the resident.

Based on record reviews and interviews, the facility failed to ensure individualized care plans were developed to address Resident Identifier (RI) #s 1 and 3's toileting and/or incontinence needs. This affected RI #s 1 and 3, two of eight sampled residents for whom care plans were reviewed. Findings include: A review of the facility's policy titled, BOWEL AND BLADDER RETRAINING PROGRAM, revised 11/03/1997, revealed the following: . 6. AFTER COMPLETING THE BOWEL AND BLADDER QUESTIONNAIRE FORM THE REHAB NURSE ALONG WITH THE CARE PLAN TEAM WILL PLACE THE RESIDENT ON AN INDIVIDUALIZED BOWEL AND BLADDER PROGRAM USING DATA COLLECTED FROM THE . TRACKING FORM . 9. THE RESIDENT WILL BE ASSISTED TO THE TOILET OR OFFERED THE BEDPAN/URINAL AT THE SCHEDULED TIMES . 1) RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1 was tracked by staff for bowel and bladder from 04/28/2015 through 05/03/2015 to determine if a voiding pattern was evident. On 07/31/2015 an ASSESSMENT FOR BOWEL AND BLADDER RETRAINING was completed for RI #1. The Plan for management listed a goal of retraining to increase continence. RI #1's current care plan addressing incontinence listed a goal to increase level of control and was dated 08/2016. The following approaches were listed: offer toilet, bed pan at frequent intervals and change pads / briefs at intervals. The care plan approaches did not reflect data obtained during RI #1's bladder tracking. During an interview with Employee Identifier (EI) #8, the Restorative Nurse, on 08/25/2016 at 11:30 a.m., EI #8 reviewed the care plan approaches listed on RI #1's incontinence care plan and stated they would not be consistent with bowel and bladder retraining. She said they would be more of a maintenance program. EI #8 said this was not consistent with her assessment of RI #1. EI #8 then reviewed RI #1's tracking information and stated a pattern was evident and the facility should have done bowel and bladder retraining with scheduled toileting at 8 a.m., 10 a.m., and 2 p.m When asked if RI #1's care plan was individualized to his/her needs, EI #8 said it would have been better to offer scheduled toileting. 2) RI #3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Bowel and Bladder Tracking forms indicated RI #3 was tracked from 10/06/2015 through 10/11/2015 to determine a voiding pattern. RI #3's current incontinence care plan, initiated 12/29/2014, listed current approaches to offer bed pan, urinal at frequent intervals and change pads / briefs at intervals. During an interview with EI #8, the Restorative Nurse, on 08/25/2016 at 3:00 p.m., EI #8 said RI #3's tracking revealed a pattern of urine at 8 a.m., 10 a.m., 12 p.m., and 2 p.m EI #8 said RI #3's voiding pattern was not incorporated into the care plan. EI #8 said they should have provided the bed pan/urinal to RI #3 at scheduled times. EI #9, the Care Plan Coordinator, was interviewed on 08/25/2016 at 12:00 PM. EI #9 stated EI #8, the Restorative Nurse, was responsible for developing incontinent care plans. EI #9 said the care plans should be individualized to meet the needs of the residents. When asked why it was important to individualize care plans, EI #9 said it was important because every resident had a different (voiding) pattern and different needs.