Every finding on record at Limestone Nursing and Rehabilitation Center, LLC

Based on observations, interviews, review of the (YEAR) Food and Drug Administration (FDA) Food Code, and review of the facility's policies titled, General Food Preparation and Handling, General Sanitation of Kitchen, Food Storage, Cleaning Dishes/Dish Machine, Cleaning Instructions: Ovens, Cleaning Instructions: Floors, Tables and Chairs, and Cleaning Instructions: Refrigerators, the facility failed to ensure: 1) seven items in the reach in cooler were discarded on the used by date, 2) the floors in the dry food storeroom were clean from rodent droppings, underneath the shelving, 3) there was not a white substance on a pan observed on the clean rack, 4) open food items in the walk-in freezer were sealed, 5) the interior of the walk-in cooler was clean and dry, 6) the convection oven did not have a heavy build-up of dark black residue inside the oven, 7) a pole with chipping, flaking paint was not hanging directly beside and above a food preparation area, and 8) a frying pan did not have a non-stick coating peeling off. This had the potential to affect 149 of 149 residents receiving meals from the kitchen. Findings include: 1.) A review of a facility policy titled, Food Storage with a date of 2013, revealed: . Procedure: . 13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 3 days or discarded. 14. Refrigerated Food Storage: . f. All foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. On 02/11/20 at 08:48 a.m., Employee Identifier (EI) #1, the Dietary Cook, accompanied the surveyor during the initial tour of the kitchen. In the reach-in refrigerator, the surveyor and EI #1 observed the following: (1) two full pans of leftover mechanical soft meatballs-cooked labeled with a use by date of 2/10/20; (2) leftover cooked carrots labeled with a use by date of 2/10/20; (3) mozzarella cheese with a use by date of 1/29/20; (4) leftover cooked English peas labeled with a use by date of 2/10/20; (5) leftover cooked red beans and sausage labeled with a use by date of 2/10/20; (6) chicken base broth- labeled with an opened date of 1/8/20 and no use by date; and (7) beef base broth- labeled with an opened date of 12/25/19 and no use by date. An interview was conducted on 2/11/20 at 8:48 a.m. with EI #1. EI #1 was asked if these items should have been in the reach-in refrigerator. EI # 1 stated no. EI #1 was asked what the potential harm was in the outdated items being left in the refrigerator. EI #1 stated the residents might get food poisoning. EI #1 was then asked what the facility's policy was on dating food placed in the refrigerator. EI #1 stated they date the items with the day they place it in and the day they throw it away. EI #1 said leftovers are good for three days and the chicken and beef base broth are good for one month after opening. 2.) The (YEAR) FDA Food Code included the following: . 6-501.12 Cleaning, Frequency and Restrictions. (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. A review of a facility policy titled, Cleaning Instructions: Floors, Tables and Chairs, dated 2013, revealed: . Policy: Kitchen and dining room floors . will be kept clean and sanitary. Procedure: 1. Kitchen floors will be swept and cleaned after each meal. A thorough cleaning using a disinfectant will be done at least daily. A review of a facility policy titled, General Sanitation of Kitchen, dated 2013, revealed: .Policy: The staff shall maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. Procedure: 1. Cleaning and sanitation tasks for the kitchen will be recorded. On 2/11/20 at 10:04 a.m., the floor to the dry storage room was observed to have a medium amount of rodent droppings underneath the dry storage shelving. The surveyor asked EI #2, District Support Manager of the kitchen, to sweep out from underneath the dry storage shelving. After EI #2 swept out from underneath the shelving, the surveyor asked EI #2 what it looked like to her. EI #2 stated it was mouse droppings. The surveyor asked EI #2 should the mouse droppings be underneath the shelving in the dry storage room. EI #2 stated no. EI #2 was asked what the potential harm was in the mouse droppings being in the dry storage room. EI #2 stated bacterial infection, diseases, you do not know what they are carrying. During a follow-up interview with EI #2 on 2/12/20 at 08:31 a.m., EI #2 was asked if she could provide the cleaning logs for the dry storage area. EI #2 stated no she could not. On 2/13/20 at 11:19 a.m., EI #2 was asked if she had a record of when staff clean or do deep cleaning. EI #2 stated no, she did not. EI #2 was asked if she should have a record of when staff do any type of cleaning (per facility policy). EI #2 stated yes, to show proof that it has been done, and to follow up with the specific person if it has not been done properly. EI #2 was then asked if the facility policy specified that there should be a record or log for cleaning. EI #2 stated yes. 3.) The (YEAR) FDA Food Code included the following: . 4-601.11 Equipment, Food-Contact Surfaces, Nonfood Contact Surfaces, and Utensils. (A) . EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) . The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. A review of a facility policy titled, Cleaning Dishes/Dish Machine, dated 2013, revealed: . Policy: All . cookware will be washed, rinsed and sanitized after each use. 2. Scrape dishes clean . 3. Rinse dishes thoroughly in the sink, . scrub pots and pans with a non-metallic scouring pad when necessary . On 02/11/20 at 10:19 a.m., an observation was made of a four inch deep large cooking pan. The pan was on the clean dish rack and was noted to have a white, thin substance inside of it. EI #2, District Support Manager of the kitchen, was asked what the pan was used for. EI #2 stated it was used for meat in the oven. EI #2 was then asked if she saw the white substance. EI #2 stated yes. EI #2 was asked if it rubbed off of the pan. EI #2 stated yes. EI #2 said the white substance should not be on the pan. EI #2 was asked what the potential harm was with the white substance inside the pan. EI #2 stated the potential for bacteria being spread if it is not being cleaned and sanitized properly. 4.) A review of a facility policy titled, Food Storage, dated 2013, revealed: . Procedure: .15. Frozen Foods: . c. All foods should be covered . On 2/11/20 at 10:56 a.m., the surveyor observed the following items in the walk-in freezer: a plastic bag of breaded squash opened to air, a box of rolls in a plastic bag opened to air, and a box of pork fritters in a plastic bag opened to air. On 2/12/20 at 8:55 a.m., an interview was conducted with EI #2, Dietary District Support Manager. EI #2 was asked if the breaded squash, rolls and pork fritters should be left opened to air in the freezer. EI #2 stated no, it causes freezer burn. EI #2 was then asked what the potential harm was in these items being left opened to air and not sealed in the freezer. EI #2 stated they are exposed to all kinds of germs and elements coming into contact with them. 5.) The (YEAR) FDA Food Code included the following: . 4-601.11 Equipment, Food-Contact Surfaces, Nonfood Contact Surfaces and Utensils. (C) . NONFOOD FOOD CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other residue. A review of a facility policy titled, Cleaning Instructions: Refrigerators, dated 2013, revealed: .Policy: . Spills and leaks will be cleaned as they are noticed. Procedure: . 8. Spills should be cleaned at the time they occur. On 2/11/20 at 10:56 a.m., the surveyor walked through the walk-in cooler to get to the walk in freezer. A puddle of water was observed in the floor of the walk-in cooler at the entrance to the freezer. EI #2, the Dietary District Support Manager, was asked what the water was from. EI #2 stated the freezer goes through a defrost cycle. On 2/11/20 at 4:01 p.m., the surveyor and EI #4, the Maintenance Supervisor, went into the walk-in cooler. The surveyor observed a small puddle of water in the floor of the walk- in cooler at the door of the entrance to the freezer. EI #4 was asked if he saw the water. EI #4 stated yes, it looks like water. EI #4 was then asked what the water was from. EI #4 stated it may be condensation from the freezer when the door is opened. On 2/12/20 at 7:56 a.m., a puddle of water was observed in the same area of the floor of the walk-in cooler at the entrance of the freezer door. On 2/12/20 at 09:00 AM, an interview was conducted with EI #3, Dietary Manager. EI#3 was asked if she observed the water in the floor in the cooler on 2/11/20 and 2/12/20. EI #3 stated yes. EI #3 was asked should there be water in the floor of the walk-in cooler. EI #3 stated no. EI #3 was asked what the potential harm was in the water being in the floor in the cooler. EI #3 stated bacteria build-up and bugs. EI #3 was then asked who was responsible for making sure there was no water on the walk-in cooler floor. EI #3 stated the Dietary Aides are supposed to clean it out everyday. EI #3 was asked if she could provide the cleaning logs for the walk-in cooler, and EI #3 stated no; they did not have any. 6.) The (YEAR) FDA Food Code included the following: . 4-601.11 Equipment, Food-Contact Surfaces, Nonfood Contact Surfaces, and Utensils. (A) . EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) . The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) . NONFOOD FOOD CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other residue. A facility policy titled, CLEANING INSTRUCTIONS: OVENS, dated (YEAR), revealed: Policy: Ovens will be cleaned as needed . Spills and food particles will be removed after each use. On 2/11/20 at 11:02 a.m., the surveyor and EI # 2, the District Support Manager of the kitchen, observed a thick black substance in the bottom of the convection oven. EI # 2 was asked what the potential harm was with the black substance being in the oven. EI # 2 replied, a fire and the spread of bacteria with food being left in there. 7.) The (YEAR) FDA Food Code included the following: . 4-601.11 Equipment, Food-Contact Surfaces, Nonfood Contact Surfaces and Utensils. (C) . NONFOOD FOOD CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other residue. . Annex 4, Table 2b . Added Chemical Hazards . chemicals used . paint . (5) . Illness and Injury can result in foreign objects being in food. These physical hazards can result from contamination . at many points . within the food establishment. On 2/11/20 at 4:12 p.m. , the surveyor and EI #3, the Dietary Manager, observed a pole with hanging utensils on it located directly over a food preparation area. There appeared to be gray paint peeling/flaking off of the pole. EI #3 rubbed her finger over the pole and the paint came loose. EI #3 was asked what it looked like to her. EI #3 stated it looked like peeling paint, and it should not be there. EI #3 was then asked what the concern was in the peeling paint over the food preparation area. EI #3 stated it could get into the residents' food and cause sickness. 8.) Review of the facility's policy titled General Food Preparation and Handling, dated 2013, revealed: Policy: Food items will be prepared to . keep free of injurious organisms and substances. Procedure: .5. Equipment . b. dishware that has lost its glaze or is chipped or cracked must be disposed of. On 2/11/20 at 4:18 p.m., an eight inch skillet was observed with a non-stick coating peeling off hanging on a rack, ready for use. EI #3, the Dietary Manager, was asked what she observed. EI #3 stated the non-stick coating was peeling off. EI #3 was asked what the concern was in the non-stick coating coming off or peeling off the pan. EI #3 stated it could be a foreign object in the food and could cause stomach pain as well. EI #3 went on to state the skillet should have been thrown away a long time ago.

Based on observations, interviews, record review and review of a facility policy titled, Urinary Catheter Care, the facility failed to ensure Resident Identifier (RI) #84's Foley catheter bag was in a privacy bag and not visible from the hallway on 02/11/20. This deficient practice affected RI #84, one of one resident sampled with a Foley catheter. Findings Include: A review of a facility policy titled, Urinary Catheter Care, with an effective date of 01/16/14, and a supersedes date of 11/01/01, documented: . PR[NAME]ESS: . i) . Bags should be covered to provide privacy. RI #84 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 12/22/19, assessed RI #84 as having an indwelling catheter. On 02/11/20 at 10:16 a.m., RI #84's Foley urinary catheter bag was observed uncovered, attached to the left lower side of bed. The bag contained clear yellow urine that was visible from the hallway. On 02/11/20 at 12:50 p.m., RI #84's Foley urinary catheter bag was observed uncovered, attached to the left lower side of bed. The bag contained clear yellow urine that was visible from the hallway. On 02/11/20 at 3:39 p.m., the surveyor conducted an interview with Employee Identifier (EI) #8, RI #84's assigned Registered Nurse (RN). EI #8 stated RI #84's Foley catheter bag was not in a privacy bag when she began her shift at 10:00 a.m. EI #8 was asked if the Foley catheter should have had a privacy bag. EI #8 said yes. The surveyor asked EI #8 what was the concern when a resident's Foley catheter bag was not covered. EI #8 replied, invasion of the resident's privacy. On 02/13/20 at 02:04 p.m., the surveyor conducted an interview with EI #10, RN/DON (Director of Nursing). The surveyor asked EI #10 who was responsible for ensuring the Foley catheter bag was covered with a privacy cover for each resident. EI #10 said all clinical staff that are assigned to that unit. EI #10 was asked what was the concern of a Foley catheter bag not being covered. EI #10 said it was a dignity issue. EI #10 further stated, per facility policy, Foley catheter bags should be covered with a privacy cover.

Based on observations, interviews, medical record review, and review of a facility policy titled Hand Hygiene, the facility failed to ensure: 1) a Licensed Practical Nurse (LPN) washed hands or used hand sanitizer after administering Resident Identifier (RI) #213's nebulizer treatment and placing a garbage bag in the medication cart garbage can, prior to reentering RI #213's room to clean RI #213's facemask; and 2) a Certified Nursing Assistant (CNA) washed hands or used hand sanitizer after she emptied RI #105's urinal, prior to exiting RI #105's room. This affected one of four residents observed during medication administration pass and one of one sampled resident for whom a CNA was observed emptying a urinal. Findings Include: A review of a facility policy titled Hand Hygiene, with a date of 7/30/2016, revealed . Hand Hygiene procedures include the use of alcohol-based hand rubs . and handwashing with soap and water . Always perform hand hygiene in the following situations . Before exiting the patient's care area after touching the patient or the patient's immediate environment . after glove removal . 1) RI #213 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/13/20 at 9:04 a.m., the surveyor observed Employee Identifier (EI) #7, a LPN, during medication administration pass for RI #213. EI #7 gave RI #213's nebulizer treatment and placed a plastic garbage bag in the medication cart garbage can. EI #7 did not wash or sanitize her hands prior to reentering RI #213's room. EI #7 then cleaned RI #213's facemask attached to the nebulizer machine, removed her gloves, and did not wash or sanitize her hands prior to exiting RI #213's room. On 2/13/20 at 9:56 a.m., the surveyor conducted an interview with EI #7, a LPN. EI #7 was asked what she should have done after she started RI #213's nebulizer treatment, placed a plastic garbage bag in the medication cart garbage can, and prior to reentering RI #213's room. EI #7 stated she should have washed her hands or used hand sanitizer. EI #7 was asked what she should have done after she removed her gloves after cleaning RI #213's facemask, prior to leaving RI #213's room. EI #7 stated she should have washed her hands or used hand sanitizer. EI #7 was asked what the facility hand washing/hygiene policy stated should be done after a licensed nurse touched a resident's equipment, environment, and prior to leaving a resident's room. EI #7 stated staff should wash hands or use hand sanitizer. EI #7 was asked what would be the concern in not washing hands or using hand sanitizer after a licensed nurse started RI #213's inhalation nebulizer treatment, placed a plastic garbage bag in the medication cart garbage can, and prior to reentering RI #213's room. EI #7 stated it could spread germs to everyone and they could get an infection. EI #7 was asked what would be the concern if a licensed nurse did not wash her hands or use hand sanitizer after she cleaned RI #213's facemask, removed her gloves, and prior to leaving RI #213's room. EI #7 stated it could spread germs to everyone and they could get an infection. EI #7 said she forgot to wash her hands. On 2/13/20 at 11:06 a.m., the surveyor conducted an interview with EI #6, Infection Control Preventionist/Registered Nurse (RN). EI #6 was asked how are the licensed staff trained at the facility on hand hygiene. EI #6 was asked what a licensed nurse should do after after she started RI #213's inhalation nebulizer treatment, placed a plastic garbage bag in the medication cart garbage can, and prior to reentering RI #213's room. EI #6 stated she should have washed her hands or use hand sanitizer. EI #6 was asked what should a licensed nurse have done after she cleaned RI #213's facemask, removed her gloves, and prior to leaving RI #213's room. EI #6 stated she should have washed her hands or used hand sanitizer prior to leaving the room. EI #6 was asked what the facility policy on hand hygiene stated should be done after a licensed nurse touched a resident's equipment, environment and prior to leaving a resident's room. EI #6 stated staff should wash hands or use a hand sanitizer. EI #6 was asked what would be the concern if a licensed nurse did not wash her hands after she started RI #213's inhalation nebulizer treatment, placed a plastic garbage bag in the medication cart garbage can, and prior to reentering RI #213 room. EI #6 stated it could have spread an infection. EI #6 was asked what would be the concern if a licensed nurse cleaned RI #213's facemask, removed her gloves and did not wash her hands prior to leaving the room. EI #6 stated there was a potential to spread an infection. 2) RI #105 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 2/11/20 at 11:49 a.m., EI #9, a CNA, was observed removing soiled gloves after she emptied RI #105's urinal. EI #9 placed her gloves into the trash can and exited the room without washing her hands. An interview was conducted on 2/11/20 at 11:54 a.m EI #9 was asked what she was doing in RI #105's room. EI #9 said, emptying the urinal, and then placed the urinal back on the side of the bed. EI #9 further stated she threw her gloves in the trash can and did not wash her hands before exiting RI #105's room. The surveyor asked EI #9 if she was supposed to wash her hands after emptying the urinal, before exiting the room. EI #9 replied yes, to prevent the spread of germs, cross contamination and break in infection control. On 02/13/20 at 10:19 a.m., an interview was conducted with EI #6, Infection Control Preventionist/RN. EI #6 said staff should wash their hands before and after resident care, including after emptying a urinal. The surveyor asked EI #6 why staff should wash their hands after emptying a urinal. EI #6 replied, to decrease the spread of infection.

Based on observation, interview and review of facility policies titled, FOOD STORAGE, CLEANING DISHES/DISH MACHINE AND CLEANING INSTRUCTIONS OVEN, the facility failed to ensure: 1. a plastic bag of riblets in the refrigerator was labeled with a date and use by date, 2. staff air dried sectional plates; and 3. the main baking oven was free of a thick black substance. This had the potential to affect 128 of 128 residents receiving meals from the kitchen. Findings Include: A review of a facility policy titled, FOOD STORAGE, with a 2013 date revealed: PR[NAME]EDURE: . 14. Refrigerated Food Storage: . f. All foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates . A facility policy titled, CLEANING DISHES/DISH MACHINE with a 2013 date revealed: PR[NAME]EDURE: . 9. Allow the dishes to air dry on the dish racks. A facility policy titled, CLEANING INSTRUCTIONS: OVENS with a (YEAR) date revealed: Policy: Ovens will be cleaned as needed . Spills and food particles will be removed after each use. 1. On 3/18/19 4:56 PM a plastic double sealed bag, labeled riblets, was observed in the walk in refrigerator. No date or use by date was on the bag. The surveyor asked Employee Identifier (EI) #3, Dietary Manager what was in the bag. EI #3 replied, riblets. EI #3 was asked where was the date or use by date. EI #3 replied, it did not have one. EI #3 was asked if the riblets should be labeled with the use by date. EI #3 replied, yes. EI #3 was then asked why should it have a use by date. EI #3 replied because it was opened, so you will know when it was opened and it does not make anyone sick. 2. On 3/18/19 at 5:55 PM, the surveyor observed, during tray line, a divided plate with water on the inside of the plate in two sections. EI # 3 stated she observed the water on the inside of the divided plate in two compartments as well. EI # 3 was asked should there be water droplets on the plate. EI # 3 replied, no, it should be air dried completely to prevent bacteria growth. 3. On 3/18/19 at 5:59 PM, the surveyor and EI # 3 observed a thick black substance in the main baking oven. The surveyor asked EI # 3 should there be a black substance there. EI # 3 replied no it should be cleaned out and scrubbed. EI # 3 was then asked what was the potential harm with the black substance being in the oven. EI # 3 replied, because it could catch on fire.

Based on observation, interview and review of a facility policy titled, Dressing - Clean, the facility failed to ensure staff gloves were removed and hand hygiene was performed after cleaning a sacral wound and before applying ointment and touching other parts of the resident's body, pillow, blanket and bed remote. This affected Resident Identifier (RI) #65, one of 2 residents observed for wound care. Findings include: A facility policy titled, Dressings-Clean, with an effective date of (MONTH) 1, 2001, revealed: . Process: . 13. Remove gloves and wash hands. A facility policy titled, Hand Washing, with an effective date of (MONTH) 1, 2001, revealed: . Standard: Hand washing should be performed between procedures with residents. RI #65 was readmitted to the facility on [DATE] with two sacral ulcers. [DIAGNOSES REDACTED]. Review of the resident's physician's orders [REDACTED]. On 03/19/19 at 10:14 am, the surveyor observed pressure ulcer care provided by Employee Identifier(EI) #2, the facility Certified Registered Nurse Practitioner, and EI #4 Registered Nurse/Wound Nurse, to RI #65. EI #2 was observed to remove the dressing to the sacral area and discarded it into the trash container. She then discarded the gloves into the trash container, washed her hands in the bathroom sink and applied new gloves. EI #4 stated this was a new wound area from around the (MONTH) 15 th, 2019. EI #2 cleaned the sacral area wound with normal saline applied to folded gauze handed to her by EI # 4. EI#2 then wiped the wound on the sacral area with the gauze. EI #2 proceeded to touched the resident on the gown with the same gloved hand. EI #2 applied [MEDICATION NAME] powder mixed with Venalex ointment from a medicine cup with a Q-tip. After applying the ointment EI #2 then touched RI #65's pillow under the resident's head, the resident's arm and then the blanket lying on the bed, pulling it up over RI #65's, wearing the same soiled gloves. EI #2 picked up the bed remote, operated it lowering the bed and touched the resident's left upper arm. EI #2 then removed the gloves and threw them in the trash container. On 03/19/19 at 01:40 pm, the surveyor interviewed EI #2. She was asked what should she do in between wound care and contact with other items in the resident's room. EI#2 replied she should remove the gloves and wash her hands if it is contaminated. EI #2 was asked did she touch other items in the residents room with the same gloves on after she cleaned the sacral wound with the saline gauze and applied ointment. EI#2 replied she did, but her hand was not contaminated. EI #2 was asked after caring for the wound, what items in the resident's room did she touch with those same gloves on. EI#2 replied she touched the patient, the bed linens, and she touched the resident's bed control. She said it was not a draining wound and she never came in contact with the wound bed. The surveyor asked what was the potential harm when you are caring for a wound and then touch other items in the room with the same gloves on. EI #2 responded, that could be contamination and cross contamination if the gloved hand was contaminated. On 03/19/19 at 04:40 pm, the surveyor interviewed EI #1, Assistant Director of Nursing. EI #1 was asked what should staff do after cleaning and applying ointment to a sacral wound before touching other objects in a resident's room. EI #1's response was they should take the gloves off, dispose of them properly and wash their hands properly. The surveyor asked what was the potential harm for using the same gloves worn to clean a wound and apply ointment and then touching the pillow under the resident's head. EI #1 replied you have a potential to spread germs.

Based on observations, interview of the Certified Dietary Manager (CDM), Employee Identifier (EI) #4, and a record review of the Food Code U.S. Public Health Service (USPHS) and FDA (Food and Drug Administration) 2013, the facility failed to assure: 1. adequate immersion time for food preparation equipment sanitized in hot water which measured 175 degrees Fahrenheit (3-compartment sink). 2. effective cleaning/sanitizing of utensils and equipment to prevent the potential growth of foodborne organisms, a. assure dinnerware, sectional plates, was cleaned to sight/touch (machine dishwashing) and air dried, b. assure equipment, a Tea Urn/spigot a non Time/Temperature control for safety, was cleaned every 24 hours. The spigot was observed with a brown solid build-up, 3. the dishmachine, which sanitizes with chemical, maintained chemical efficacy, by testing, monitoring/documenting the concentration prior to use, These failures had the potential to affect all 132 residents receiving meals from the facility's kitchen. Findings include: 1. Review of the 2013 Food Code by the United States Public Health Service (USPHS) and the Food and Drug Administration (FDA) included the following: 4-7 SANITIZING OF EQUIPMENT AND UTENSILS METHODS 4-703.11 Hot Water and Chemical: After being cleaned .shall be SANITIZED in: (A) Hot water manual operation by immersion for a least 30 seconds and as specified under . 02/13/2018 @7:00 PM, manual dishwashing (pots/pans) was observed. Water in 3rd sink (sanitizing) temperature was measured by the CDM (EI #4), to be 175 degrees F. The employee was observed to dip a washed pot in and out of the hot water, while holding the handle. (For sanitizing, item must remain in hot water 170 or above and less than 180 degrees F. for 30 seconds.) After the above observation, the CDM (EI #4), was asked, why staff failed to leave the item in the hot water for 30 seconds. The CDM responded by saying she could not answer but knows better. 2. (a) Review of the 2013 Food Code by the United States Public Health Service (USPHS) and the Food and Drug Administration (FDA) included the following: 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch . and 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried . On 02/14/2018 at 10:15 AM, an observation was made of clean/sanitized sectional plates stored at the trayline. Seven sectional plates were stacked (not inverted). One of the seven contained water and one contained debris. An interview at this time with the CDM, (EI #4) revealed the first line aide failed to monitor dishes for adequate cleaning. EI #4 was asked what was the potential risk for failure to monitor. EI #4 responded, that there was a potential for food borne illness or bacterial growth. (b) A review of the 2013 Food Code by the United States Public Health Service (USPHS) and the Food and Drug Administration (FDA) included the following: Frequency 4-602.11 Equipment Food-Contact Surfaces and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be cleaned: (E) .surfaces of UTENSILS and EQUIPMENT contacting food that is not TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cleaned: .(2) At least every 24 hours for iced tea dispensers . An observation on 02/13/2018 at 6:50 PM was made of a 5 gallon Tea Urn container. A request was made for the CDM (EI #4) to disassemble the faucet/spigot assembly. The CDM (EI #4) broke the faucet down from the dispenser. The plastic faucet seat was observed to have a brown build-up. The CDM (EI #4) was asked if there was a brown build-up. The CDM (EI #4) acknowledged a build-up. The CDM (EI #4) was asked, what was the potential risk. The CDM (EI #4) responded by saying there was a potential for cross contamination. 3. Line staff failed to monitor/document the chemical sanitizer on (MONTH) 11 and 12. This discrepancy was evidenced by reviewing the facility's document titled, LOW TEMPERATURE DISH MACHINE MONITORING. An observation on 02/13/18 at 6:14 PM, during the initial kitchen tour, operation of the dishmachine was made. The sanitizing method in use was chemical (chlorine). The (MONTH) (YEAR), monitoring log for the dishmachine was located in the CDM's (EI #4's) office. A review of the monitoring data revealed omissions for (MONTH) 10 & 11 @ noon meals. On 02/13/2018 at 7:02 PM the CDM (EI #4), was interviewed and asked, why the data was missing. The CDM (EI #4) responded by saying she has not kept track and has a few trainees. The CDM (EI #4) was asked, what are the risk factors for a failure to monitor chemical concentration. The CDM (EI #4) responded by saying there is a potential for bacterial contamination.

Based on observation, record review, interviews, and review of a facility policy titled RESIDENT SELF ADMINISTRATION OF MEDICATION, the facility failed to ensure Resident #293 was assessed for self-administering nebulizer treatments. This affected one of one resident reviewed for self administration. Findings include: Review of the facility's policy titled RESIDENT SELF ADMINISTRATION OF MEDICATION, updated 10/31/2017, revealed the following: POLICY: Each resident who desires to self-administer medication may be permitted to do so if Facility Interdisciplinary Care-Plan Team has determined that the practice would be safe for the resident and other residents of the facility. 1. The medication self-administration assessment is conducted by the interdisciplinary team . 2. The results of the interdisciplinary team assessment are recorded on the Self-Administration Assessment Form, which is placed in the resident's medical record. Resident #293 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #293's (MONTH) (YEAR) physician's orders [REDACTED]. There were no orders listed indicating Resident #293 could self-administer medications or nebulizer treatments. Review of Resident #293's comprehensive care plans revealed no care plan or approaches addressing self-administration of medications. On 02/14/18 at 9:26 AM, Resident #293 was observed receiving a nebulizer treatment. No staff were present in the room at the time. Resident #293 reached over and turned the machine off while the surveyor was speaking with the spouse; visible nebulizer solution remained in the nebulizer cup. Employee Identifier (EI) #1, Registered Nurse, was interviewed on 02/15/18 at 05:26 PM. When asked which residents she had that could self-administer nebulizer treatments, EI #1 referred to a list she had, and said Resident #293 was one of the ones she had that was able to self-administer nebulizer treatments. EI #1 explained she put the medication in the nebulizer cup, turned on the machine, and placed it on the resident. EI #1 said she sometimes started the treatment then, but other times, if the resident was not ready, she would let them start it when they were ready. When asked what type of evaluation or assessment was done to determine if residents could safely administer their treatments, EI #1 said she was not sure. She was unaware of the facility's policy. EI #1 said there should usually be a note in the chart or an assessment of some kind. EI #1 said it was important to assess residents to determine they could safely self-administer medications to ensure they were competent to do it and do it properly. EI #2, the Director of Nursing, was interviewed on 02/15/18 at 05:49 PM. EI #2 said the facility had not completed a self-administration assessment on Resident #293. EI #2 further explained the nurse had started the nebulizer treatment, left the resident while it was going, then came back. When asked about the facility's policy on administration of nebulizer treatments, EI #2 said they did not have one. EI #2 stated if a resident was going to self-administer medications, it should be addressed in their care plans, and an evaluation should be completed quarterly or with a significant change in the resident's status.

Based on observation of incontinent care on 02/14/18, medical record review, staff interviews, and review of facility policies titled Urinary Catheter Care, and a facility document titled Perineal/Catheter Care, the facility failed to ensure the Certified Nursing Assistant (CNA) properly cleaned Resident #33's catheter tubing. Further, the CNA failed to clean Resident #33's perineal area of fecal matter, prior to the completion of care. These failures were observed during one of one catheter and incontinence care observations. Findings Include: A review of a facility policy titled: Urinary Catheter Care with an effective date of (MONTH) 16, 2014 documented: . PURPOSE: Urinary catheter care helps to prevent urinary tract infection . PR[NAME]ESS: . II. Catheter Care . c) Wash the catheter itself by holding on to the catheter at the insertion site; wash with one stroke downward . A review of a facility document titled: . Perineal/Catheter Care . with a date of 12/18/16 documented: . CATHETER CARE . 2 . Gently . to expose meatus . A review of RI #33's Quarterly Minimum Data Set with an assessment reference date of 11/22/17 revealed RI #33 was severely impaired in cognition, incontinent of bowel and dependent upon staff for hygiene. A review of the hospital DISCHARGE SUMMARY dated 01/04/2018 documented: . DISCHARGE Diagnosis: [REDACTED]. RI #33 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 02/14/2018 at 5:45 p.m., Certified Nursing Assistant, Employee Identifier (EI) #7 provided incontinent care for RI #33. The resident rolled his/her self to left side and EI #7 wiped the buttock area three times front to back, using a clean wash cloth with each wipe. Bowel movement was visible on each wash cloth used. RI #33 had a foley catheter in place. EI #7 then cleaned the catheter tubing toward the residents perineum. RI #33 rolled onto his/her back. Without changing the soiled gloves or washing her hands, EI #7 then placed a clean brief under RI #33 and put a clean gown on the resident. EI #7 wiped down the left side of the outer perineal area and across. EI #7 then wiped down the right outer perineal area and across. EI #7 fastened the brief, removed the (soiled) gloves and without washing her hands, she applied clean gloves. At the completion of care, the surveyor asked EI #7 if she had visualized the perineal area. EI #7 said no. EI #7 then unfastened the brief, separated the perineal area, and wiped front to back three additional times (using a clean wash cloth each time). Additional bowel movement was apparent on the wash cloth each time. On 02/14/2018 at 6:00 p.m., EI #7 was asked which direction had she wiped the catheter. EI #7 said, she had wiped (incorrectly) back to front (from the residents perineum down the catheter tubing), and she should not have because of contamination. EI #7 was asked why it was important to ensure all bowel movement was removed from the perineal area. EI #7 explained it was necessary to avoid infection and skin breakdown. When asked if she had washed her hands after changing the soiled gloves, EI #7 said no. EI #7 said she should have changed the gloves, due to contamination. EI #7 was asked if she should she have handled the clean brief, clothes and clean linen with soiled gloves. EI #7 said no, due to the contamination of those items. On 02/15/2018 at 5:37 p.m., an interview was done with EI #2, the Director of Nursing/Infection Control. EI #2 stated the staff should wash their hands after taking off soiled gloves and before putting on clean gloves in order to prevent the spread of infection. EI #7 said staff should never touch clean items/linen with soiled gloves so as to prevent the spread of infection. EI #7 was asked what was the facility's policy on catheter care. EI #7 said staff were to wipe front to back, and always visualize the perineal area because you do not want germs near the urinary tract.

Based on observations, record review, interviews, and review of the facility's policy titled FOOD PREFERENCES, the facility failed to ensure Resident #117 was served foods in accordance with his/her assessed preferences. This affected one of 132 residents for whom meals were observed. Findings include: Review of the facility's undated policy titled FOOD PREFERENCES revealed the following: POLICY: Information will be gathered upon admission to inform the dietary department of the resident/patient's food preferences and diet history. PR[NAME]EDURE: 1. Interview the resident for the following information: . *Food preferences, intolerances, allergies [REDACTED]. Resident #117 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 02/14/18 at 12:00 PM, Resident #117 was observed eating the lunch meal. Resident #117 said he/she was not supposed to get any fried foods but did so today. The tray card on Resident #117's lunch tray listed fried foods as a dislike. Resident #117's family member (also present) stated he/she could not eat the fried french fries or fried macaroni bites the facility had provided on the tray. On 02/14/18 at 12:20 PM, Employee Identifier (EI) #3, Certified Nursing Assistant, was asked who was responsible for making sure residents received items in accordance with their likes/dislikes. EI #3 stated the dietary department was responsible. EI #3 verified Resident #117 had received fried foods on his/her tray. On 02/15/18 at 06:52 PM, EI #4, the Certified Dietary Manager, explained the Dietary staff list residents' likes and dislikes on their tray tickets and keep each resident's preferences on file in the computer. When asked what system was in place to ensure the items listed on the tray tickets under likes and dislikes were honored, EI #4 said the cooks or person plating the trays read the tickets. EI #4 explained dietary staff were supposed to look at the preferences and, if a resident had a dislike listed, they were not supposed to put it on the tray. EI #4 said it was important to follow residents' preferences for foods because that was what the resident wanted, either for a medical reason, or allergy. EI #4 further stated you want to honor what the resident wants and what they like to eat. EI #4 confirmed the potato wedges (french fries) and macaroni bites were fried. EI #4 said she could not say what happened with Resident #117's lunch tray, but indicated they must have misread the ticket. EI #4 further said the error should not have occurred.

Based on observation of incontinent care on 02/14/2018 and medication administration on 02/13/2018, a review of the facility's policy's titled Urinary Catheter Care and Hand Hygiene, as well as staff interviews, the facility failed to ensure: 1) A Licensed Practical Nurse (LPN) did not place her ungloved fingers inside medication crush pouches to empty the crushed medications for administration of Resident #58's medications: [REDACTED] 2) A Certified Nursing Assistant (CNA) failed to wash her hands after removing soiled gloves and before putting on clean gloves during the provision of incontinence care. The CNA then touched clean items, including linens and Resident Identifier (RI) #33's clean brief and gown. These failures affected one of four nurses observed during medication pass observations and one of one incontinent care observations, involving RI #58 and RI #33. Findings Include: A review of Potter and Perry, Ninth Edition: FUNDAMENTALS OF NURSING Chapter 32 Medication Administration, page 656, documented: . (1) . Do not touch medication with fingers. (2) To prepare unit-dose tablets . place tablet . directly into medicine cup . A review of a facility policy titled: Hand Hygiene with a date of 07/30/16 documented: . 2. Indications for Hand Hygiene Always perform hand hygiene in the following situations: . After glove removal . 1) RI #58 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #58's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 12/11/17 revealed RI #58 was severely impaired in cognition (with a Brief Interview for Mental Status score of 4 of a possible 15). On 02/13/18 at 7:10 p.m., LPN/Employee Identifier (EI) #6 administered medication to RI #58. EI #6 placed [MEDICATION NAME] 20 milligram (1 tablet) in a crush pouch and crushed the medication. EI #6 opened the pouch with her ungloved fingers and emptied the medication into a medication cup. EI #6 placed [MEDICATION NAME] 50 mg (1 tablet) in a crush pouch and crushed the medication. EI #6 opened the pouch with her ungloved fingers and emptied the medication into medication cup. On 02/13/18 at 7:23 p.m., an interview was conducted with EI #6. EI #6 was asked what did she do when opening the medication pouch. EI #6 explained she had put her bare fingers in the pouch and should have put a glove on, to prevent contamination. On 02/15/2018 at 5:37 p.m., an interview was conducted with the Director of Nursing/Infection Control Director, EI #2. EI #2 was asked why should staff not use ungloved fingers to open a medication crush pouch. EI #2 responded, to prevent cross contamination. 2) RI #33 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #33's Quarterly MDS with a ARD of 11/22/17 revealed RI #33's BIMS score of 2, indicating severe cognitive impairment, dependent upon staff for toileting and hygiene needs, and incontinent of bowel function. RI #33's hospital DISCHARGE SUMMARY dated 01/04/18, documented: . DISCHARGE Diagnosis: [REDACTED]. On 02/14/18 at 5:45 p.m., Certified Nursing Assistant, EI #7 provided incontinent care for RI #33 in the presence of the surveyor. RI #33 rolled to the left side of the bed, EI #7 wiped the buttock area three times front to back, using a clean wash cloth with each wipe. Bowel movement was visible on the wash cloth after each wipe. EI #7 wiped RI #33's catheter tubing, after which RI #33 rolled self onto his/her back. Without removing her dirty gloves, washing hands and changing gloves, EI #7 then placed a clean brief under RI #33 and put a clean gown on the resident. On 02/14/18 at 6:00 p.m., the surveyor asked EI #7 if she had washed her hands or changed soiled gloves. EI #7 said she had not, but she should have, due to contamination. When asked if she should have handled the clean brief, clothes and clean linen with soiled gloves, EI #7 replied, no because of contamination to the items. On 02/15/18 at 5:37 p.m., an interview was done with EI #2, the DON and Infection Control director. EI #2 said staff should wash hands after taking off soiled gloves and before putting on clean gloves to prevent the spread of infection. EI #7 said staff should never touch clean items/linen with soiled gloves to prevent the spread of infection.

Based on observations, interview, and review of facility policies, the facility failed to ensure: 1) commercial shakes were labeled in a manner such that the use by dates were evident; 2) cream of wheat was not stored past the use by date; 3) open items in the refrigerator were labeled with open dates and use by dates; 4) sheet pans were allowed to air dry and not stacked while wet; and 5) staff obtained the temperature of batch cooked items prior to adding them to the steam table for meal service. These failures had the potential to affect all 153 residents receiving meals from the dietary department. Findings include: 1) Review of the manufacturer's information for mighty shakes revealed they had a shelf life of up to 14 days once thawed. The facility's undated policy titled FROZEN SUPPLEMENT STORAGE AND LABELING documented the following: POLICY: To properly store supplement products in a manner that maintains sanitation and product quality. PROCEDURE: Frozen milkshake supplements ( . Mighty Shakes, Health Shakes .) . The products will be moved to the refrigerator prior to use. A storage label will be added to these cases when they are moved to refrigerated storage. During the initial tour of the kitchen on 11/28/2016 beginning at 4:30 p.m., two cases of mighty shakes were observed in the walk-in cooler, not labeled with use by dates. Employee Identifier (EI) #13, the Dietary Manager, stated staff should have labeled the cases with a use by date. During a follow-up interview with EI #13, the Dietary Manager, on 11/30/2016 at 1:30 p.m., EI #13 said mighty shakes were good for 14 days once thawed. She said the shakes should be labeled with the date they came in, the thaw date, and the use by date. She explained they could not ensure the mighty shakes were used within the appropriate timeframes if they were not labeled, which could lead to spoilage and could potentially make someone sick. 2) During the initial tour of the facility on 11/28/2016 beginning at 4:30 p.m., a container of cream of wheat in the dry storage room was observed. This container was labeled Prepared 10-18-16 Use By 10-28-16. EI #13, the Dietary Manager, stated someone probably forgot to change the label. During a follow-up interview with EI #13, the Dietary Manager, on 11/30/2016 at 1:30 p.m., EI #13 was asked who was responsible for ensuring items were discarded once the use by date was exceeded. She said she or a helper checked the dates. EI #13 said the potential harm in storing cream of wheat past the use by date was that it could make someone sick. 3) Review of the Food and Drug Administration Food Code 2013, Chapter 3 Food, page 92, revealed the following: . 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. . (B) . refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded . During the initial tour of the kitchen on 11/28/2016 beginning at 4:30 p.m., the following items were observed in the reach-in refrigerator, not labeled with use by dates: 1) mayonnaise opened 11/24/2016; 2) open container of Creole mustard dated 07/06/2016. According to EI #13, the Dietary Manager, the date on the item was the date it was received, not an open or use by date; and 3) open container of cranberry sauce dated 06/27/2016. According to the Dietary Manager the date was the day the product was received. She said this item should have been used within 10 days of opening it. The container was not labeled with an open date or a use by date. During a follow-up interview with EI #13, the Dietary Manager, on 11/30/2016 at 1:30 p.m., EI #13 stated items should be labeled with the date they were received, an open date, and a use by date. After discussing the open containers of mayonnaise, mustard, and cranberry sauce not labeled with use by dates, EI #13 said the items could make someone sick if they were used. 4) Review of the facility's undated policy titled POT AND PAN WASHING revealed the following: POLICY: Proper pot and pan washing procedures reduce the possibility of food contamination. The following procedures will be used: PROCEDURE: . 5. Pots and pans must be air dried on the drain board . After the pots and pans are dry, they must be inspected and then stored in a clean, dry, protected area. During the initial tour of the kitchen on 11/28/2016 beginning at 4:30 p.m., four sheet pans were observed stacked one on top of the other. Three of the four were wet. During an interview with EI #13, the Dietary Manager, on 11/30/2016 at 1:30 p.m., EI #13 said items should be air dried after washing and not stacked on top of one another while wet due to the potential for germs. 5) Review of the facility's policy titled Food Cooking and Serving Temperatures, dated 03/21/2003, revealed the following: .PURPOSE: Safe and sanitary food handling practices include effective control of food temperatures, in order to prevent food borne illnesses . PROCESS: I. Food Cooking Temperatures: . b. The temperature of foods should be taken and recorded immediately at the end of cooking . to ensure doneness . III. General Guidelines: . b. Food temperatures should be recorded on the menu, after each food container is placed in the steam table . During trayline observations on 11/29/2016 beginning at 4:25 p.m., staff were observed adding a batch of fried pickles to a pan already on the steam table. Staff did not check the temperature of the second batch of pickles and added them to the pan already on the steam table. During an interview with EI #13, the Dietary Manager, on 11/30/2016 at 1:30 p.m., EI #13 said staff should check the temperatures of the items when batch cooking. She said if staff did not check the temperature prior to adding another batch to the steam table the food could be served at the wrong temperature.

Based on observations, record review, and interview, the facility failed to ensure the dumpster lids and side doors were closed in a manner to prevent pest and rodent infestation. This had the potential to affect all 155 residents residing in the facility. Findings include: Review of the facility policy titled Garbage and Refuse, effective 05/2003, revealed the following: .PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses. STANDARD: Garbage and refuse containers should be free from cracks or leaks and covered when not in use . PROCESS: . e. Refuse containers and dumpsters kept outside the facility should have tightly fitting lids and should be kept covered . During the initial tour of the kitchen on 11/28/2016 at 5:50 p.m., the facility's five dumpsters were observed. Three of the five dumpsters had open lids and/or doors: 1) one dumpster was noted with the top lid open; garbage was noted inside 2) another dumpster was noted with the side door open approximately one and a half feet and the top lid was open; garbage was noted inside 3) the third dumpster was noted with the side door opened approximately three feet; garbage was noted inside. On 11/29/2016 at 5:01 p.m. the following concerns were noted with two of the five dumpsters: 1) one dumpster's top left lid was not secured and closed; garbage bags were observed protruding through the opening and 2) another dumpster's left side door was completely open greater than three feet; garbage was noted inside. During an interview with Employee Identifier (EI) #13, the Dietary Manager, on 11/30/2016 at 1:30 p.m., EI #13 said the lids and doors to the dumpsters should be kept closed to prevent flies, insects, animals, and germs. EI #13 said everyone at the facility was responsible for ensuring the dumpster lids and doors are closed after use.

Based on observations, interviews and record review: 1) The facility failed to ensure a care plan was developed to address Resident Identifier (RI) #7's use of O2 (Oxygen). 2) Further, a care plan was not developed to address RI #18's preferred activity involvement; and 3) The facility also failed to assess and develop care plans for entrapment risk related to use of side rails for RI #s 2, 3, 4, 6, 7, 9, 12, 13, and 14. These failures affected ten of twenty one sampled residents for whom care plans were reviewed. Findings include: 1) RI #7 was readmitted to the facility on [DATE]. RI #7 had [DIAGNOSES REDACTED]. RI #7's November 2016 physician's orders [REDACTED]. Review of RI #7's current comprehensive care plans revealed there was no care plan addressing RI #7's O2 use. Employee Identifier (EI) #10, Licensed Practical Nurse responsible for RI #7's care plans, was interviewed on 11/30/2016 at 9:39 a.m When asked how RI #7's care plans addressed O2 use, EI #10 said O2 use should be addressed in the cardiovascular care plan. After reviewing RI #7's care plans, she said O2 use was not addressed in the care plans. EI #10 said RI #7's O2 was ordered on [DATE] and it should have been added to the care plans. EI #10 said it was important to develop care plans addressing O2 use because there needed to be interventions related to the use of the O2. 2) RI #18 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #18's 11/08/2016 Quarterly Minimum Data Set (MDS) Assessment indicated RI #18 was cognitively intact. Review of RI #18's current comprehensive careplans revealed there were no care plan approaches related to RI #18's activity preferences. During an interview with RI #18 on 12/01/2016 at 11:05 a.m., RI #18 said he/she occasionally attended activities. RI #18 also stated he/she would like to attend activities more often than he/she already did. Employee Identifier (EI) #4, Registered Nurse/ MDS/ Care Plan Coordinator, was interviewed on 12/01/2016 at 10:20 a.m EI #4 said RI #18 had no care plan addressing activities but should have. EI #4 explained activity care plans were important to promote activities of preference and provide residents with choices in what they would like to do. During an interview with EI #6, the Activities Director, on 12/01/2016 at 10:31 a.m., EI #6 said residents were assessed to determine their preferences for activities and daily routine. She said these preferences should be specified in the care plan to make it a more person-centered. EI #6 acknowledged RI #18 did not have a care plan addressing activity preferences. 3) Review of the manufacturer's information for the facility's crank-style beds, provided on 12/01/2016 at 8:15 a.m., revealed the following: . ENTRAPMENT WARNING Proper patient assessment and monitoring . is required to reduce the risk of entrapment . Review of the manufacturer's information for the facility's siderails used with electric beds, provided on 12/01/2016 at 10:51 a.m., revealed the following: . When assessing the risk for entrapment, you need to consider your bed, mattress, head/foot panels, assist devices and other accessories, as a system. It is also extremely important to review the resident's physical and mental condition and initiate an appropriate individual care plan to address entrapment risk . RI #2: RI #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #2's Significant Change Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 10/25/2016 revealed RI #2 had no upper or lower body impairments and was totally dependent of 2 staff members for bed mobility. RI #2's Physician order [REDACTED]. RI #2's care plan for Impaired Bed Mobility, dated 11/08/2016, documented an intervention of . siderails elevated per current MD (Doctor) orders . RI #2's comprehensive care plans did not specify the size of siderail to be used and did not include any interventions or approaches related to the risk of entrapment. On 11/28/2016 at 5:45 p.m., 11/29/2016 at 08:08 a.m., 10:00 a.m., 11:35 a.m. and 3:25 p.m., and on 11/30/16 at 08:12 a.m., RI #2 was observed in bed with full side rails up times two. RI #3: RI #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #3's Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 09/07/2016 documented RI #3 had moderate cognitive impairment and no upper or lower extremity range of motion limitations. RI #3 required extensive assistance of two people for bed mobility. This assessment documented bed rail restraints were used daily during the assessment period. RI #3's November 2016 Physician order [REDACTED].#3's right side of the bed to be placed against the wall, with the right side rail up to assist with bed mobility and left siderail down. The order did not specify the size of RI #3's siderail. RI #3's care plan for potential for injury due to falls, dated 09/07/2016, documented an intervention of right siderail up to assist with bed mobility and left siderail down. RI #3's comprehensive care plans did not specify the size of siderail to be used and did not include any interventions or approaches related to the risk of entrapment. During the initial tour of the facility on 11/28/2016 beginning at 5:23 p.m., RI #3 was observed in bed. The left three quarter (3/4) side rail (on the room side of the bed) was up and the right side rail was down. RI #4: RI #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #4's Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 09/05/2016 documented RI #4 had short and long term memory impairment and moderately impaired daily decision making skills. RI #4 required extensive assistance of two people for bed mobility and had upper and lower extremity range of motion limitations on one side. This assessment also documented bed rail restraints were used daily during the assessment period. RI #4's November 2016 Physician order [REDACTED].#4 was in bed for safe bed mobility. The order did not specify the size of RI #4's siderail. RI #4's care plan for potential for injury due to falls, dated 09/15/2016, documented an intervention of bed siderail up on right side of bed. RI #4 also had a care plan for restraints dated 09/05/2016. This careplan documented RI #4 utilized one bed side rail on the right side for the following reasons: history of falls, weakness due [MEDICAL CONDITION], for safe bed mobility, cognitive deficits, and Arthritis. RI #3's comprehensive care plans did not specify the size of siderail to be used and did not include any interventions or approaches related to the risk of entrapment. During the initial tour of the facility on 11/28/2016 beginning at 5:23 p.m., RI #4 was observed seated on the side of the bed with knees bent, cross-legged. RI #4's right three quarter (3/4) siderail was up in front of him/her. RI #6: RI #6 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #6's Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 10/26/2016 documented RI #6 had short and long term memory impairment and severely impaired daily decision making skills. RI #6 required extensive assistance of two people for bed mobility and had upper and lower extremity range of motion limitations on both sides. RI #6's November 2016 Physician order [REDACTED]. RI #6's care plan for potential for injury due to falls, dated 10/26/2016, included an approach for bilateral side rails up times two when in bed. RI #6's comprehensive care plans did not specify the size of siderail to be used and did not include any interventions or approaches related to the risk of entrapment. During the initial tour of the facility on 11/28/2016 beginning at 5:23 p.m., RI #6 was observed in bed with three quarter (3/4) side rails up times two. RI #6 was again observed in bed with 3/4 side rails up times two on 11/29/2016 at 8:00 a.m RI #7: RI #7 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #7's Annual Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 11/15/2016 documented RI #7 had severe cognitive impairment and no upper or lower extremity range of motion limitations. RI #7 required extensive assistance of two people for bed mobility. RI #7's November 2016 Physician order [REDACTED]. RI #7's care plan for potential for injury due to falls, dated 11/28/2016, documented an intervention of side rails up times two for safe bed mobility. RI #7's comprehensive care plans did not specify the size of siderail to be used and did not include any interventions or approaches related to the risk of entrapment. RI #9: RI #9 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #9's quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 9/23/2016 revealed RI #9 had no upper or lower body range of motion impairments and required extensive assistance of two or more staff members for bed mobility. RI #9's November 2016 Physician order [REDACTED]. Bedside Rails up x2 (times two) at the top of the bed for safe bed mobility . RI #9's care plan for potential for injury due to falls and weakness, with a problem onset date of 9/23/2016, documented an approach of . Bedside rails up x2 at head of bed for safe bed mobility . RI #9's care plan for impaired mobility with a problem onset date of 3/12/2016 documented an approach of . use siderails as specified in current MD (medical doctor) orders . There were no care plans to address the risk of entrapment. On 11/29/2016 at 7:45 a.m., RI #9 was observed in bed with the top side rail up on the exit side of the bed, the top side rail down on the side of the bed against the wall, and both side rails up at the foot of the bed. A sign on the wall over RI #9's bed revealed the top two side rails should be up and the bottom two down. On 11/30/2016 at 7:40 a.m., RI #9 was observed in bed with top side rails up times two and a lower side rail up on the wall side of the bed. RI #12: RI #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #12's admission Physician order [REDACTED]. RI #12's Admission Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 9/29/2016 revealed RI #12 had no upper or lower body range of motion impairments and required limited assistance of 2 staff members for bed mobility. RI #12's care plan for Potential for injury due to falls and weakness, with a problem onset date of 10/12/2016, documented an intervention of . Bedside rails up x2 (times two) at head of bed for safe bed mobility . There were no care plans to address the risk of entrapment. RI #13: RI #13 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #13's most recent quarterly MDS (Minimums Data Set) Assessment with an ARD (Assessment Reference Date) of 10/25/2016 revealed that the resident had severe cognitive impairment. The MDS further revealed bed rail restraints were used daily. A review of RI #13's Physician Orders dated November 2016 revealed 3/4 (three quarter) length BSR (Bed Side Rails) up times two for safe bed mobility, dementia with decreased safety awareness with fall history. Review of RI #13's comprehensive care plans revealed a care plan dated 05/13/2016 for Resident is at risk for injury/immobility due to need for side rails. This care plan indicated RI #13 required 3/4 length siderails up times two for safe bed mobility, dementia with decreased safety awareness with fall history. There were no care plan approaches related to RI #13's risk of entrapment. RI #14: RI #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #14's significant change MDS with an Assessment Reference Date of 11/21/2016 revealed RI #14 required extensive assistance of two people for bed mobility and total assistance of two people for transfers. The MDS also revealed RI #14 had lower extremity range of motion impairments on one side. RI #14's November 2016 Physician order [REDACTED]. Bedside Rails up x2 (times two) at the top of the bed for safe bed mobility . RI #14's care plan for potential for injury due to falls, with a problem onset date of 11/28/2016, revealed an approach for . BSR (bed side rails) up x2 at top of bed for safe bed mobility . There was no care plan to address the risk of entrapment. On 11/29/2016 at 7:50 a.m., RI #14 was observed in bed with both upper and lower side rails up on both sides of the bed. On 11/30/2016 at 10:30 a.m., an observation was made of RI #14 in bed with the head of the bed elevated. Both upper and lower side rails on both sides of the bed were observed up. On 12/1/2016 at 10:00 a.m., RI #14 was observed in bed with both the upper and lower side rails up on both sides of RI #14's bed. On 11/30/2016 at 9:39 a.m., Employee Identifier (EI) #4, Registered Nurse/MDS/Care Plan Coordinator, and EI #10, Licensed Practical Nurse/MDS, were interviewed. When asked what the facility's process was for determining what size of side rail a resident required, EI #4 said she was unaware of an assessment to determine the need for a siderail or the size of the side rail to be used. EI #4 said if residents were not assessed to determine the appropriate size of side rail needed it could lead to injury. EI #4 also said entrapment risk was not addressed in residents' care plans, but should be. On 12/01/2016 at 10:35 a.m., an interview was conducted with EI #7, DON/RN (Director of Nursing/Register Nurse). EI #7 was asked when should residents be assessed for bed rails. EI #7 replied, on admission, with each MDS, and as needed. EI #7 was asked what was the potential harm when residents are not assessed for bed rails and entrapment. EI #7 replied, entrapment and injury.

Based on observations, record review, and interviews, the facility failed to ensure Resident Identifier (RI) #s 3, 4, 9, and 14's siderails were used in accordance with their plan of care to promote resident safety. Further, the facility failed to assess RI #s 2, 3, 4, 6, 7, 9, 12, 13, and 14 for the use of side rails; nor did they assess these residents for the risk of entrapment. These failures affected nine of nine residents sampled for side rail use. Findings include: Review of the manufacturer's information for the facility's crank-style beds, provided on 12/01/2016 at 8:15 a.m., revealed the following: . ENTRAPMENT WARNING Proper patient assessment and monitoring . is required to reduce the risk of entrapment . APPENDIX . A Guide to Bed Safety Bed Rails in . Nursing Homes . : The Facts . Patient Safety Patients who have problems with memory, sleeping, incontinence, pain, uncontrolled body movement . MUST be carefully assessed for the best ways to keep them from harm, such as falling . The Benefits and Risks of Bed Rails . Potential risks of bed rails may include: * Strangling, suffocating, bodily injury, or death when patients or part of their body are caught between rails or between the bed rails and mattress. * More serious injuries from falls when patients climb over rails . Meeting Patients' Needs for Safety Most patients can be in bed safely without bed rails . When bed rails are used, perform an on-going assessment of the patient's physical and mental status; closely monitor high risk patients . Review of the manufacturer's information for the facility's siderails used with their electric beds, provided on 12/01/2016 at 10:51 a.m., revealed the following: . When assessing the risk for entrapment, you need to consider your bed, mattress, head/foot panels, assist devices and other accessories, as a system. It is also extremely important to review the resident's physical and mental condition and initiate an appropriate individual care plan to address entrapment risk . 1) RI #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #2's Significant Change Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 10/25/2016 revealed RI #2 had no upper or lower body impairments and was totally dependent for bed mobility. RI #2's Physician order [REDACTED]. The order did not specify the size of siderails to be used. RI #2's care plan for Impaired Bed Mobility, dated 11/08/2016, documented an intervention of .siderails elevated per current MD (Doctor) orders . RI #2's comprehensive care plans did not specify the size of siderail to be used and did not include any interventions or approaches related to the risk of entrapment. The only side rail assessment in RI #2's clinical record was a Restraint/Enabler Assessment for New Admission and Readmissions from a prior admission, dated 04/09/2010. On 11/28/2016 at 5:45 p.m., 11/29/2016 at 08:08 a.m., 10:00 a.m., 11:35 a.m. and 3:25 p.m., and on 11/30/16 at 08:12 a.m., RI #2 was observed in bed with full side rails (SR) up times two. 2) RI #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #3's Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 09/07/2016 documented RI #3 had moderate cognitive impairment and no upper or lower extremity range of motion limitations. RI #3 required extensive assistance of two people for bed mobility. This assessment also documented bed rail restraints were used daily. There were no assessments for the use of the side rail or for the risk of entrapment included in RI #3's medical record. A fall investigation report dated 06/29/2016 documented RI #3 was found on the floor without injury. Staff reported prior to the fall RI #3 was in bed with both siderails up. The report documented the following intervention to prevent further falls: right side of bed against wall in lowest position with fall mattress times two on the floor next to the left side of the bed; right siderail up to assist with bed mobility and left siderail down. RI #3's physician's orders [REDACTED].#3's right side of the bed to be placed against the wall, with the right side rail up to assist with bed mobility and left siderail down. The order did not specify the size of RI #3's siderail. RI #3's care plan for potential for injury due to falls was updated on 06/30/2016 to reflect the intervention of right side of bed against wall in lowest position with fall mattresses times two on the floor next to the left side of the bed; right side rail up to assist with bed mobility and left siderail down. However, RI #3's comprehensive care plans did not specify the size of siderail to be used and did not include any interventions or approaches related to the risk of entrapment. A second fall investigation report indicated RI #3 was again found on the floor without injury on 07/28/2016. The Nurses Note attached to this investigation, also dated 07/28/2016, documented staff found RI #3 on the floor on his/her back with the left side rail up. The investigation also included a statement from Employee Identifier (EI) #14, a Certified Nursing Assistant. EI #14 reported she observed RI #3 in the room on the floor beside the fall mattresses. EI #14 reported RI #3 appeared to have crawled out of the bed, over the side rails because RI #3's side rails were up and the mattresses were beside the bed when EI #14 observed RI #3 following the incident. During the initial tour of the facility on 11/28/2016 beginning at 5:23 p.m., RI #3 was observed in bed. The left three quarter (3/4) side rail (on the room side of the bed) was up and the right side rail was down. On 11/29/2016 at 6:02 p.m., RI #3 was observed in bed without either side rail up. EI #10, Licensed Practical Nurse responsible for RI #3's care plans, was interviewed on 11/30/2016 at 9:39 a.m EI #10 said RI #3's care plan specified the right side of the bed should be against the wall with the right side rail up and the left side rail down. She said this meant the siderail on the room side of the bed should be down. EI #10 said RI #3's care plan was updated on 06/29/2016 for the left siderail to be down after a fall. She further stated when RI #3 fell on [DATE] the care plan was not being followed because the left siderail was up. The surveyor then reviewed the observations of RI #3 in bed with the left side rail up and again with both side rails down. EI #10 said staff were not following the care plan at those times either. EI #10 explained, with RI #3's history of falls and going over the siderails, if staff were not following the care plan related to side rail use, it could result in fractures or head injury. 3) RI #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #4's Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 09/05/2016 documented RI #4 had short and long term memory impairment and moderately impaired daily decision making skills. RI #4 required extensive assistance of two people for bed mobility and had upper and lower extremity range of motion limitations on one side. This assessment also documented bed rail restraints were used daily during the assessment period. There were no assessments for the use of the side rail or for the risk of entrapment included in RI #4's medical record. RI #4's November 2016 Physician order [REDACTED].#4 was in bed for safe bed mobility. The order did not specify the size of RI #4's siderail. RI #4's care plan for potential for injury due to falls, dated 09/15/2016, documented an intervention of bed siderail up on right side of bed. RI #4 also had a care plan for restraints dated 09/05/2016. This careplan documented RI #4 utilized one bed side rail on the right side for the following reasons: history of falls, weakness due to CVA (Cerebrovascular Accident), for safe bed mobility, cognitive deficits, and Arthritis. RI #4's restraint care plan included approaches for restraint free time, including when in bed and during meals. RI #4's comprehensive care plans did not specify the size of siderail to be used and did not include any interventions or approaches related to the risk of entrapment. During the initial tour of the facility on 11/28/2016 beginning at 5:23 p.m., RI #4 was observed seated on the side of the bed with knees bent, cross-legged. RI #4's right three quarter (3/4) siderail was up in front of him/her. RI #4's supper tray was on the over the bed table. EI #10, Licensed Practical Nurse responsible for RI #4's care plans, was interviewed on 11/30/2016 at 9:39 a.m EI #10 said RI #4 was care planned to have the right side rail (room side of bed) up. She said RI #4's side rail should not be up during meals. She said RI #4's side rail should not have been utilized during the supper meal when RI #4 was observed sitting cross-legged. When asked what potential harm could occur if RI #4's siderail was up during meals, EI #10 said if RI #4 was to push the meal tray back, he/she could crawl over the side rail and fall to the floor resulting in fractures or head injury. 4) RI #6 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #6's Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 10/26/2016 documented RI #6 had short and long term memory impairment and severely impaired daily decision making skills. RI #6 required extensive assistance of two people for bed mobility and had upper and lower extremity range of motion limitations on both sides. RI #6's November 2016 Physician order [REDACTED]. RI #6's care plan for potential for injury due to falls, dated 10/26/2016, included an approach for bilateral side rails up times two when in bed. RI #6's comprehensive care plans did not specify the size of siderail to be used and did not include any interventions or approaches related to the risk of entrapment. There were no assessments for the use of the side rail or for the risk of entrapment included in RI #6's medical record. During the initial tour of the facility on 11/28/2016 beginning at 5:23 p.m., RI #6 was observed in bed with three quarter (3/4) side rails up times two. RI #6 was again observed in bed with 3/4 side rails up times two on 11/29/2016 at 8:00 a.m 5) RI #7 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #7's Annual Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 11/15/2016 documented RI #7 had severe cognitive impairment and no upper or lower extremity range of motion limitations. RI #7 required extensive assistance of two people for bed mobility. RI #7's November 2016 Physician order [REDACTED]. RI #7's care plan for potential for injury due to falls, dated 11/28/2016, documented an intervention of side rails up times two for safe bed mobility. RI #7's comprehensive care plans did not specify the size of siderail to be used and did not include any interventions or approaches related to the risk of entrapment. There were no assessments for the use of the side rail or for the risk of entrapment included in RI #7's medical record. 6) RI #9 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #9's quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 9/23/2016 revealed RI #9 had no upper or lower body impairments and required extensive assistance of two or more staff members for bed mobility. RI #9's November 2016 Physician order [REDACTED]. Bedside Rails up x2 (times two) at the top of the bed for safe bed mobility . RI #9's care plan for potential for injury due to falls, with a problem onset date of 9/23/2016 documented an approach of . Bedside rails up x2 at head of bed for safe bed mobility . RI #9's care plan for impaired mobility, with a problem onset date of 3/12/2016, documented an approach of . use siderails as specified in current MD (medical doctor) orders . There were no care plans to address the risk of entrapment. RI #9's medical chart was reviewed for a side rail assessment. No assessment was found. On 11/29/2016 at 7:45 a.m. RI #9 was observed in bed with the top side rail up on the exit side of the bed, the top side rail down on the side of the bed against the wall, and both side rails up at the foot of the bed. A sign on the wall over RI #9's bed the tope two side rails should be up and the bottom two down. On 11/30/2016 at 7:40 a.m., RI #9 was observed in bed with top side rails up times two and a lower side rail up on the wall side of the bed. On 12/1/2016 at 10:25 a.m., EI #9, RN (Registered Nurse), who was RI #9's nurse, was asked why RI #9 had side rails in use. EI #9 said, side rails were used because RI #9 was at risk for falls and the top two rails were used for safety. When asked how RI #9 was care planned for the use of side rails, EI #9 said, the bed side rails were to be up times two at the head of the bed for safe bed mobility. When asked why there was a sign on the resident's wall regarding the side rails, EI #9 said, so the staff would put the top two rails up and not the bottom. When asked why the care plan was not being followed, EI #9 replied, it was supposed to be followed. EI #9 was asked what the potential for harm was if RI #9's care plan for side rails was not followed. EI #9 said, if the top two rails were not up, RI #9 would have a greater risk for a fall. When asked what the risk was if the bottom two were up, EI #9 said, it was more restraining and they should not be up. 7) RI #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #12's admission Physician order [REDACTED]. RI #12's Admission Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 9/29/2016 revealed RI #12 had no upper or lower body impairments and required limited assistance of 2 staff members for bed mobility. RI #12's care plan for potential for injury due to falls, with a problem onset date of 10/12/2016, revealed an approach of . Bedside rails up x2 (times two) at head of bed for safe bed mobility . There were no care plans to address the risk of entrapment. RI #12's medical chart was reviewed for a side rail assessment. No assessment was found. 8) RI #13 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #13's most recent quarterly MDS (Minimum Data Set) Assessment with an ARD (Assessment Reference Date) of 10/25/2016 revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 2, which indicated that RI #13 was severely cognitively impaired for daily decision making. The MDS further revealed under section bed rail restraints were used daily. Review of RI #13's comprehensive care plans revealed a care plan dated 05/13/2016 for Resident is at risk for injury/immobility due to need for side rails. This care plan indicated RI #13 required three quarter (3/4) length siderails up times two for safe bed mobility, dementia with decreased safety awareness with fall history. There were no care plan approaches related to RI #13's risk of entrapment. A review of RI #13's Physician Orders dated November 2016 revealed 3/4 length BSR (Bed Side Rails) up times two for safe bed mobility, dementia with decreased safety awareness with fall history. There were no bedside rail and elopement assessments in RI #13's chart. On 12/01/2016 at 10:35 a.m., an interview was conducted with EI #7 DON/RN (Director of Nursing/Register Nurse). EI #7 was asked when was RI #13 assessed for bed rails. EI #7 replied, they look at family information, hospital information, therapy and restorative nurses information. EI #7 was asked what was the resident's medical condition for the use of bed rails. EI #7 replied, dementia, decreased safety awareness, with a fall history, and safe bed mobility. EI #7 was asked who was responsible for assessing the resident for bed rails. EI #7 replied, restorative care plan team. EI #7 was asked what other method was used before the use of side rails. EI #7 replied, she did not know. EI #7 was asked where was it documented that an assessment was completed. EI #7 replied, there was not an assessment. 9) RI #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #14's significant change MDS with an Assessment Reference Date of 11/21/2016 revealed RI #14 required extensive assistance of two people for bed mobility and total assistance of two people for transfers. The MDS also revealed RI #14 had lower extremity range of motion impairments on one side. RI #14's November 2016 Physician order [REDACTED]. Bedside Rails up x2 (times two) at the top of the bed for safe bed mobility . RI #14's care plan for potential for injury due to falls, with a problem onset date of 11/28/2016, revealed an approach for . BSR (bed side rails) up x2 at top of bed for safe bed mobility . There was no care plan to address the risk of entrapment. RI #14's medical chart was reviewed for a side rail assessment. No assessment was found. On 11/29/2016 at 7:50 a.m., RI #14 was observed in bed with both upper and lower side rails up on both sides of the bed. On 11/30/2016 at 10:30 a.m., an observation was made of RI #14 lying in bed with the head of bed elevated. Both upper and lower side rails on both sides of the bed were observed up. On 12/1/2016 at 10:00 a.m., RI #14 was observed in bed with both the upper and lower side rails up on both sides of RI #14's bed. On 12/1/2016 at 10:10 a.m., an interview was conducted with EI #9, RN. EI #9 was asked how RI #14 was care planned for the use of side rails. EI #9 said, for safety and bed mobility and potential injury due to falls. EI #9 was asked why observations were made of the bottom rails up on the bed. EI #9 said, she did not know why they were up. EI #9 was asked who should have noticed the side rails were up at the foot of the bed. EI #9 said, they all should have. EI #9 was asked what the potential harm was for the resident in not following the care plans for side rails. EI #9 said it was restraining and there was not an order for [REDACTED]. On 11/30/2016 at 9:39 a.m., Employee Identifier (EI) #4, Registered Nurse/MDS/Care Plan Coordinator, and EI #10, LPN/MDS, were interviewed. When asked what the facility's process was for determining the size of side rail a resident required, EI #4 said she was unaware of an assessment to determine the need for a siderail or the size of the side rail to be used. EI #4 said if residents were not assessed to determine the appropriate size of side rail needed it could lead to injury. EI #4 also said entrapment risk was not addressed in residents' care plans, but should be. EI #7, the Director of Nursing (DON), was interviewed on 11/30/2016 at 2:11 p.m EI #7 said when residents are admitted they ask how active the residents are in the bed and if they have ever fallen from the bed. She said they should try the least restrictive options first. When asked what assessment is used to determine if side rails are appropriate for a resident, EI #7 said they only look at the side rails that would be considered restraints. EI #10 also stated there were no siderail assessments included in the residents' charts. She further stated the facility had provided all of the documentation they had and she was unaware of an assessment related to the use of side rails. When asked if she was familiar with the new regulatory requirements, EI #10 said she attended a seminar and was aware residents should be assessed for the risk of entrapment. She said they had to develop a form to assess for entrapment risk, but did not know the criteria or what to assess residents for. EI #7 again stated the facility had no assessments for bed side rails or entrapment risk. During a follow-up interview with EI #7, the DON, on 12/01/2016 at 7:40 a.m., EI #7 said the residents (RI #s 2, 3, 4, 6, 7, 9, 12, 13, and 14) were not assessed for alternatives to side rail use and there was no documentation of risks and benefits of the side rails in the residents' charts. EI #7 also said the least restrictive side rail they had in the facility was a half (1/2) side rail. When asked how they determined which siderails were most appropriate for the residents, EI #7 said none of the residents were assessed to determine which side rail was most appropriate for their use.

Based on record review and interviews, the facility failed to ensure Resident Identifier (RI) #18 was assessed for activity preferences, care planned for resident specific activity approaches, and provided with a calendar of available activities. This affected one of 17 residents reviewed for activities. Findings include: Review of the facility's policy titled Activities, dated 11/14/2016, revealed the following: Policy: It is the policy of this facility to provide an ongoing program of activities designed to meet the interest choice and preferences . of each resident. Policy Explanation and Compliance Guidelines: 1. Each resident's interest and needs will be assessed on a routine basis. Included in assessment will be: . b. Activity assessment to include resident's interest, preferences . 2. Activities will be designed with the intent to: a. Enhance the resident's sense of well-being. . e. Promote self-esteem, dignity, pleasure, comfort, education, creativity, success, and independence . 4. Activities may be conducted in different ways: . b. Person Appropriate- activities relevant to the specific needs, interests, culture, background, etc. (et cetera) for the resident they are developed for . 5. Scheduled activities are posted in the resident's room . RI #18 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #18's 11/08/2016 Quarterly Minimum Data Set (MDS) Assessment indicated RI #18 was cognitively intact. Review of RI #18's current comprehensive careplans revealed there were no care plan approaches related to RI #18's activity preferences. RI #18's Activity Participation Logs for September 2016 through November 2016 were blank and did not reflect any activity participation during that time. During an interview with RI #18 on 12/01/2016 at 11:05 a.m., RI #18 said he/she occasionally attended activities. EI #18 voiced enjoyment of television, radio, and Bingo. RI #18 said staff posted an activity calendar on the bathroom door out of sight. RI #18 never utilized the bathroom, and said he/she would like to have an activity calendar he/she could see. RI #18 also stated he/she would like to attend activities more often than he/she already did. RI #18 said staff assist to activities only if notified of the desire to attend. Employee Identifier (EI) #4, Registered Nurse/ MDS/Care Plan Coordinator, was interviewed on 12/01/2016 at 10:20 a.m EI #4 said RI #18 had no care plan addressing activities but should have. EI #4 explained activity care plans were important to promote activities of preference and provide residents with choices in what they would like to do. During an interview with EI #6, the Activities Director, on 12/01/2016 at 10:31 a.m., EI #6 said residents were assessed to determine their preferences for activities and daily routine. She said these preferences should be specified in the care plan to make it a more person-centered. EI #6 acknowledged RI #18 did not have a care plan addressing activity preferences. A follow-up interview was conducted with EI #6, the Activities Director, on 12/01/2016 at 11:40 a.m When asked how residents were informed of the scheduled activities, EI #6 said they post activity calendars on the bathroom doors in each room. EI # 6 was asked how a calendar on the bathroom door would aide RI #18 in knowing which activities were planned if it was on the other side of the room. EI #18 said it would probably be a good idea to provide activity calendars to both residents in the room. EI #18 also explained activity participation would be documented on the Activity Participation Logs. EI #6 said residents were assessed quarterly to determine their activity preferences. During the interview, EI #6 provided a copy of RI #18's Activity Assessment and History, dated 07/26/2006. EI #6 said she had no documentation RI #18 had been reassessed for activity preferences. EI #6 explained activity preference assessments and enabling residents to participate in an activities program were important for the residents' well-being.

Based on observations, record review, and interviews, the facility failed to ensure care plan approaches for siderail use were implemented for Resident Identifier (RI) #s 3, 4, 9, and 14. This affected four of 21 sampled residents for whom care plans were reviewed. Findings include: 1) RI #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #3's Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 09/07/2016 documented RI #3 had moderate cognitive impairment and no upper or lower extremity range of motion limitations. RI #3 required extensive assistance of two people for bed mobility. This assessment also documented bed rail restraints were used daily. A fall investigation report dated 06/29/2016 documented RI #3 was found on the floor without injury. Staff reported prior to the fall RI #3 was in bed with both siderails up. The report documented the following intervention to prevent further falls: right side of bed against wall in lowest position with fall mattress times two on the floor next to the left side of the bed; right siderail up to assist with bed mobility and left siderail down. RI #3's care plan for potential for injury due to falls was updated on 06/30/2016 to reflect the intervention of right side of bed against wall in lowest position with fall mattresses times two on the floor next to the left side of the bed; right side rail up to assist with bed mobility and left siderail down. A second fall investigation report indicated RI #3 was again found on the floor without injury on 07/28/2016. The Nurses Note attached to this investigation, also dated 07/28/2016, documented staff found RI #3 on the floor on his/her back with the left side rail up. The investigation also included a statement from Employee Identifier (EI) #14, a Certified Nursing Assistant. EI #14 reported she observed RI #3 in the room on the floor beside the fall mattresses. EI #14 reported RI #3 appeared to have crawled out of the bed, over the side rails because RI #3's side rails were up and the mattresses were beside the bed when EI #14 observed RI #3 following the incident. During the initial tour of the facility on 11/28/2016 beginning at 5:23 p.m., RI #3 was observed in bed. The left three quarter (3/4) side rail (on the room side of the bed) was up and the right side rail was down. On 11/29/2016 at 6:02 p.m., RI #3 was observed in bed without either side rail up. EI #10, Licensed Practical Nurse responsible for RI #3's care plans, was interviewed on 11/30/2016 at 9:39 a.m EI #10 said RI #3's care plan specified the right side of the bed should be against the wall with the right side rail up and the left side rail down. She said this meant the siderail on the room side of the bed should be down. EI #10 said RI #3's care plan was updated on 06/29/2016 for the left siderail to be down after a fall. She further stated when RI #3 fell on [DATE] the care plan was not being followed because the left siderail was up. The surveyor then reviewed the observations of RI #3 in bed with the left side rail up and again with both side rails down. EI #10 said staff were not following the care plan at those times either. EI #10 explained, with RI #3's history of falls and going over the siderails, if staff were not following the care plan related to side rail use, it could result in fractures or head injury. 2) RI #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #4's Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 09/05/2016 documented RI #4 had short and long term memory impairment and moderately impaired daily decision making skills. RI #4 required extensive assistance of two people for bed mobility and had upper and lower extremity range of motion limitations on one side. This assessment also documented bed rail restraints were used daily during the assessment period. RI #4's care plan for potential for injury due to falls, dated 09/15/2016, documented an intervention of bed siderail up on right side of bed. RI #4 also had a care plan for restraints dated 09/05/2016. This careplan documented RI #4 utilized one bed side rail on the right side for the following reasons: history of falls, weakness due [MEDICAL CONDITION], for safe bed mobility, cognitive deficits, and Arthritis. RI #4's restraint care plan included approaches for restraint free time, including when in bed and during meals. During the initial tour of the facility on 11/28/2016 beginning at 5:23 p.m., RI #4 was observed seated on the side of the bed with knees bent, cross-legged. RI #4's right three quarter (3/4) siderail was up in front of him/her. RI #4's supper tray was on the over the bed table. EI #10, Licensed Practical Nurse responsible for RI #4's care plans, was interviewed on 11/30/2016 at 9:39 a.m EI #10 said RI #4 was care planned to have the right side rail (room side of bed) up. She said RI #4's side rail should not be up during meals. She said RI #4's side rail should not have been utilized during the supper meal when RI #4 was observed sitting cross-legged. When asked what potential harm could occur if RI #4's siderail was up during meals, EI #10 said if RI #4 was to push the meal tray back, he/she could crawl over the side rail and fall to the floor resulting in fractures or head injury. 3) RI #9 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #9's most recent quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 9/23/2016, revealed a Brief Interview for Mental Status (BIMS) score of 1, which indicated RI #9 was severely impaired for decision making. RI #9's November 2016 Physician order [REDACTED]. Bedside Rails up x2 (times two) at the top of the bed for safe bed mobility . RI #9's care plan for impaired mobility with a problem onset date of 3/12/2016 documented an approach of . use siderails as specified in current MD (medical doctor) orders . RI #9's care plan for potential for injury due to falls, with a problem onset date of 9/23/2016, documented an approach of . Bedside rails up x2 at head of bed for safe bed mobility . On 11/29/2016 at 7:45 a.m., RI #9 was observed in bed with the top side rail up on the exit side of the bed, the top side rail down on the side of the bed against the wall, and both side rails up at the foot of the bed. A sign on the wall over RI #9's bed indicated the top two side rails should be up and the bottom two down. On 11/30/2016 at 7:40 a.m., RI #9 was observed in bed with top side rails up times two and a lower side rail up on the wall side of the bed. On 12/1/2016 at 10:25 a.m., EI #9, RN (Registered Nurse), who was RI #9's nurse, was asked why RI #9 had side rails in use. EI #9 said, side rails were used because RI #9 was at risk for falls and the top two rails were used for safety. When asked how RI #9 was care planned for the use of side rails, EI #9 said, the bed side rails were to be up times two at the head of the bed for safe bed mobility. When asked why there was a sign on the resident's wall regarding the side rails, EI #9 said, so the staff would put the top two rails up and not the bottom. When asked why the care plan was not being followed, EI #9 replied, it was supposed to be followed. EI #9 was asked what the potential for harm was if RI #9's care plan for side rails was not followed. EI #9 said, if the top two rails were not up, RI #9 would have a greater risk for a fall. When asked what the risk was if the bottom two were up, EI #9 said, it was more restraining and they should not be up. 4) RI #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #14's significant change MDS Assessment with an Assessment Reference date of 11/21/2016 revealed RI #14 required extensive assistance of two people for bed mobility and total assistance of two people for transfers. The MDS also revealed RI #14 had lower extremity range of motion impairment on one side. RI #14's Physician order [REDACTED]. Order Date 9/14/16 . Bedside rails up x 2(times two) at the top of the bed for safe bed mobility . RI #14's care plan for potential for injury due to falls, with a problem onset date of 11/28/2016, revealed an approach for . BSR (bed side rails) up x 2 (times two) at top of bed for safe bed mobility . On 11/29/2016 at 7:50 a.m., RI #14 was observed in bed with both upper and lower side rails up on both sides of the bed. On 11/30/2016 at 10:30 a.m., an observation was made of RI #14 lying in bed with the head of the bed elevated. Both upper and lower side rails on both sides of the bed were observed up. On 12/1/2016 at 10:00 a.m., RI #14 was observed in bed with both the upper and lower side rails up on both sides of RI #14's bed. On 12/1/2016 at 10:10 a.m., an interview was conducted with EI #9, RN. EI #9 was asked how RI #14 was care planned for the use of side rails. EI #9 said, for safety and bed mobility and potential injury due to falls. EI #9 was asked why observations were made of the bottom rails up on the bed. EI #9 said, she did not know why they were up. EI #9 was asked who should have noticed the side rails were up at the foot of the bed. EI #9 said, they all should have. EI #9 was asked what the potential harm was for the resident in not following the care plans for side rails. EI #9 said it was restraining and there was not an order for [REDACTED].>

Based on observations, interviews and record review, the facility failed to ensure: 1) Resident Identifier (RI) #11's catheter bag and tubing were not directly in contact with the floor; and 2) CNAs (Certified Nursing Assistants) provided incontinence care to RI #s 9 and 10 in a manner to prevent cross contamination. These failures affected one of three residents sampled for urinary catheters and two of two incontinent care observations. Findings include: 1) Review of the facility's policy titled UTI (Urinary Tract Infection) Prevention with Indwelling Catheter Use, dated 11/01/2001, revealed the following: Policy: A resident with an indwelling catheter is susceptible to urinary tract infections. Policy Explanation and Compliance Guidelines: . 3. Urinary drainage tubing or bag should be positioned so as not to touch the floor . RI #11 was admitted to the facility on [DATE] and had a [DIAGNOSES REDACTED]. RI #11's November 2016 physician's orders [REDACTED]. During the initial tour of the facility on 11/28/2016 beginning at 5:23 p.m., RI #11 was observed seated in a recliner in the resident's room. RI #11's catheter bag and tubing, containing clear yellow urine, were noted directly on the floor. During an interview with Employee Identifier (EI) #11, Registered Nurse, on 11/29/2016 at 3:30 p.m., EI #11 said catheter bags and tubing should not be positioned on the floor due to the increased risk of infection. 2) A facility policy titled Perineal Care, with an effective date of 11/01/2001, documented: . PURPOSE: Good perineal care helps prevent infection, irritation and skin breakdown . PROCESS: I. General . c) Remove any fecal matter or urine wiping with tissue from front to back . f) Apply barrier ointments or creams as needed . II. Female Resident b) Wash pubic area first, washing from front to back; use a different corner or a new wipe area with each wipe . d) . wipe from front to back wiping from vaginal area to rectum extending over the buttocks, changing wipes or corners as needed . A facility policy titled, Hand Hygiene, with a revised date of 07/30/3016, documented: . 2. Indications for Hand Hygiene Always perform hand hygiene in the following situations: * Before touching a patient, even if gloves will be worn * Before exiting the patient's care area after touching the patient or the patient's immediate environment * After contact with blood, body fluids or excretions . * Prior to performing an aseptic task . * If hands will be moving from a contaminated-body site to a clean-body site during patient care * After glove removal . RI #9: RI #9 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #9's most recent Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 09/23/2016, revealed a Brief Interview for Mental Status (BIMS) score of 1, which indicated RI #9 was severely impaired for decision making. The MDS also revealed RI #9 had an indwelling catheter, was occasionally incontinent of bowel, and required extensive assistance of two persons for toilet use. RI #9 was totally dependent on staff for personal hygiene. On 11/29/2016 at 8:05 a.m., EI #8, CNA, was observed providing perineal care for RI #9. She failed to remove her gloves and wash her hands after providing perineal care. EI #8 proceeded to place the same dirty gloves into a container of RI #9's protective skin ointment and applied it to RI #9's perineal area and feet. EI #8 continued to apply a clean brief with the same dirty gloves used for perineal care. An interview was conducted with EI #8 on 11/29/16, at 4:15 p.m. She was asked what the facility's policy was for handwashing and gloves during incontinent care. EI #8 replied, wash hands and change gloves between anything you do, especially when cleaning incontinent residents. EI #8 was asked what care she had provided for RI #9. She replied, washed RI #9's face, provided perineal care, and applied protective ointment to irritation on the penis and scrotum. EI #8 was asked why she had failed to change gloves and wash her hands while providing care and touching clean items. She replied that she was just not thinking and was just trying to help. EI #8 was then asked what the potential for harm was for not washing her hands and changing gloves per the policy. EI #8 replied, spread of germs. RI #10: RI #10 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #10's Annual Minimum Data Set (MDS) Assessment, with an Assessment Reference Date of 08/30/2016, documented RI #10 required extensive assistance with toileting and personal hygiene. RI #10 was always incontinent of bowel and bladder. RI #10's physician's orders [REDACTED].#10 was prescribed [MEDICATION NAME] for ten days due to a Urinary Tract Infection. On 11/29/2016 at 09:32 a.m., the surveyor observed Employee Identifier (EI) #3, a CNA, perform incontinence care on RI #10. RI #10 was incontinent of bowel movement (BM). EI #3 put gloves on, without washing her hands, and began to clean the BM from RI #10's buttocks. After cleaning the BM from the buttocks, EI #3 then cleaned RI #10's perineal area, dried RI #10's perineum and buttocks, cleaned the toilet seat, left the bathroom to get a clean brief from the closet, and applied the clean brief while using the same gloves. EI #3 did not wash her hands or change her gloves during this time. On 11/29/2016 at 09:45 a.m., the surveyor interviewed EI #3, the CNA performing care to RI #10 about the incontinence care observation. EI #3 stated that hands should be washed upon entering the resident's room, prior to putting on gloves, after removing gloves, before leaving the residents room, before getting clean brief from the closet and between tasks such as cleaning the buttocks and before cleaning the perineum. EI #3 stated she had not washed her hands and changed her gloves as needed. EI #3 also stated she had cleaned the BM and buttocks first and then did the perineal area. EI #3 stated not washing her hands or changing gloves could cause infection. EI #3 further stated that cleaning the buttocks first then going to the front could lead to infection. On 11/30/2016 at 3:40 p.m., the surveyor interviewed EI #7, Director of Nursing (DON)/Infection Control Nurse. EI#7 stated hands should be washed before, during and after pericare, before applying gloves and after removing gloves. EI #7 stated gloves should be changed after cleaning the front and before going to the back. When asked what the potential for harm was in not washing hands or changing gloves during incontinent care, EI #7 stated there was a potential to spread infection.

Based on observations, interview, and record review, the facility failed to ensure Resident Identifier (RI) #7's oxygen (O2) tubing/nasal cannula and nebulizer mask and tubing were stored in a manner to prevent contamination. This affected one of three residents sampled for specialty care. Findings include: RI #7 was readmitted to the facility on [DATE]. RI #7 had [DIAGNOSES REDACTED]. RI #7's November 2016 physician's orders [REDACTED]. There were also orders for as needed and routine nebulizer treatments. During the initial tour of the facility on 11/28/2016 beginning at 5:23 p.m., RI #7 was observed in his/her room. RI #7 said he/she only used O2 as needed. RI #7's nebulizer machine was noted on top of a refrigerator, and the mask and tubing were hanging down the side of the refrigerator, uncovered. On 11/29/2016 at 8:05 a.m., RI #7 was noted in bed without O2 in use. RI #7's nasal cannula and tubing were looped over the humidifier bottle of the O2 concentrator, not covered. On 11/29/2016 at 3:20 p.m., RI #7 was noted in his/her room without O2 in use. RI #7's nasal cannula and tubing were again noted hanging on the humidifier bottle of the concentrator, not covered. Employee Identifier (EI) #11, Registered Nurse, was interviewed on 11/29/2016 at 3:30 p.m EI #11 said nebulizer masks and tubing should be stored in a bag when not in use due to the potential of contamination. EI #11 also stated O2 nasal cannula and tubing should be placed in a bag when not in use to prevent contamination. During the interview, EI #11 observed RI #7's O2 nasal cannula and tubing and said they were just hooked over the concentrator, but should be in a bag.

Based on observations, interviews and record review, the facility failed to ensure Certified Nursing Assistants (CNA)s washed their hands and changed gloves during incontinent care for Resident Identifiers (RI) #s 9 and 10, two of two residents observed for incontinent care. Findings Include: A facility policy titled, Hand Hygiene, with a revised date of 07/30/3016, documented: . 2. Indications for Hand Hygiene Always perform hand hygiene in the following situations: * Before touching a patient, even if gloves will be worn * Before exiting the patient's care area after touching the patient or the patient's immediate environment * After contact with blood, body fluids or excretions . * Prior to performing an aseptic task . * If hands will be moving from a contaminated-body site to a clean-body site during patient care * After glove removal . 1) RI #9 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #9's most recent Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 09/23/2016, revealed a Brief Interview for Mental Status (BIMS) score of 1, which indicated RI #9 was severely impaired for decision making. The MDS also revealed RI #9 had an indwelling catheter, was occasionally incontinent of bowel, and required extensive assistance of two persons for toilet use. RI #9 was totally dependent on staff for personal hygiene. On 11/29/2016 at 8:05 a.m., EI #8, CNA, was observed providing perineal care for RI #9. She failed to remove her gloves and wash her hands after providing perineal care. EI #8 proceeded to place the same dirty gloves into a container of RI #9's protective skin ointment and applied it to RI #9's perineal area and feet. EI #8 then applied a clean brief with the same dirty gloves used for perineal care. EI #8 removed her gloves at this time. A second CNA who assisted, gave EI #8 a glove from her pocket. EI #8 provided nail care and failed to wash their hands. EI #8 removed her gloves, placed a clean pad back in RI #9's closet and assisted RI #9 to breakfast in the dining room. An interview was conducted with EI #8 on 11/29/16, at 4:15 p.m. She was asked what the facility's policy was for handwashing and gloves during incontinent care. EI #8 replied, wash hands and change gloves between anything you do especially when cleaning incontinent residents and getting clean linens. EI #8 also stated gloves should not be worn in the hallway. EI #8 was asked what care she had provided for RI #9. She replied, washed RI #9's face, provided perineal care, and applied protective ointment to irritation on the penis and scrotum. EI #8 was asked why she had failed to change gloves and wash her hands while providing care and touching clean items. She replied that she was just not thinking. EI #8 was then asked what the potential for harm was for not washing her hands and changing gloves per the policy. EI #8 replied, spread of germs. 2) RI #10 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #10's Annual Minimum Data Set (MDS) Assessment with an Assessment Reference Date of 08/30/2016 documented RI #10 required extensive assistance of two people for toileting and personal hygiene. RI #10 was always incontinent of bowel and bladder. On 11/29/2016 at 09:32 a.m., the surveyor observed Employee Identifier (EI) # 3, a CNA, perform incontinence care on RI #10. RI #10 was incontinent of bowel movement (BM). EI #3 put gloves on, without washing her hands, assisted the resident to a standing position, and pulled down the soiled pants and brief. EI #3 then left the bathroom and got a clean brief and pants from the closet and returned to the bathroom. EI #3 then left the bathroom to look for a bag, reentered the bathroom and took her gloves off, and left RI #10's room, all without washing her hands. EI #3 came back to the bathroom with a plastic bag, and applied her gloves, without washing her hands. EI #3 began to clean the BM from RI #10's buttocks. After cleaning the BM from RI #10's buttocks, EI #3 then cleaned RI #10's perineal area, dried RI #10's perineum and buttocks, cleaned the toilet seat, left the bathroom to get another clean brief from the closet, applied the clean brief, then assisted RI #10 to a Broda chair, while using the same gloves. EI #3 did not wash her hands or change her gloves during this time. On 11/29/2016 at 09:45 a.m., the surveyor interviewed EI #3, the CNA performing care to RI #10, about the incontinence care observation. EI #3 stated that hands should be washed upon entering the resident's room, prior to putting on gloves, after removing gloves, before leaving the resident's room, before getting a clean brief from the closet and between tasks such as after cleaning the buttocks and before cleaning the perineum. EI #3 stated she had not washed her hands and changed her gloves as needed. EI #3 stated not washing her hands or changing gloves could cause infection. On 11/30/2016 at 3:40 p.m., the surveyor interviewed EI #7, Director of Nursing (DON)/Infection Control Nurse. EI #7 stated hands should be washed before, during and after pericare, before applying gloves and after removing gloves. EI #7 further stated that clean briefs should not be touched with the same gloves used when providing incontinent care due to cross contamination and spread of germs and bacteria. When asked what the potential for harm was in not washing hands or changing gloves during incontinent care, EI #7 stated there was a potential to spread infection.

Based on record review and interviews the facility failed to ensure a notice was posted to inform residents and their family members of the availability of survey results for the past three years. This had the potential to affect all 155 residents residing in the facility and their family members. Findings Include: A review of a document titled, RESIDENT RIGHTS with no revised date revealed: . EXPLANATION OF SURVEY RESULTS: . or a notice of their location, will be posted in a readily accessible place . On 11/30/2016 at 5:25 p.m., the surveyor toured all halls in the facility. There was no availability notice posted on any of the halls informing the residents of the survey results for the past three years. On 12/01/2016 at 10:20 a.m., an interview was conducted with Employee Identifier (EI) #1, Administrator in Training. EI #1 was asked who was responsible for posting an availability notice of the state survey results. EI #1 replied that he was. EI #1 was asked where was an availability notice posted informing the residents and family members of survey results for the past three years. EI #1 replied, there was not one that said three years. EI #1 was asked why not. EI #1 replied they tried to find it in the regulation book but it did not have the three year language. EI #1 was asked what does the facility policy say about survey availability notice posting for three years. EI #1 replied, they do not have a policy that says that. EI #1 was asked where the availability notice should be posted informing the residents and family members of the last three years survey results. EI #1 replied, in a readily available area for them to see the book. On 12/01/2016 at 10:41 a.m., an interview was conducted with EI #2, the Assistant Administrator. EI #2 was asked where the notice was posted informing the residents and their family members of the availability of the past three years survey results. EI #2 replied, they did not have one as far as she knew. EI #2 was asked what did the facility policy say about survey results for the last three years. EI #2 replied, she did not think they changed their policy to reflect three years.

Based on observation, interview and record review, the facility failed to ensure the Licensed Practical (Charge) Nurse (LPN) assessed Resident Identifier (RI) #6 for injury after the resident was found on the floor. In an interview with a Certified Nursing Assistant (CNA) who found the resident on the floor, she reported the Charge Nurse did not assess the resident for injury and told her not to report the fall. The sponsor and physician were not notified at that time and the resident did not receive any treatment until the next morning when RI #6's daughter reported to the day nurse the resident was complaining of pain to the left hip. The resident was x-rayed later that morning, which revealed a fracture to the left femur. This deficient practice prevented RI #6 from receiving timely treatment after sustaining a fracture to the femur on 3/23/15. This affected 1 of 11 sampled residents with history of falls. Findings include: The facility's Fall Policy and Procedure (revised 04/29/10) documented: Fall Definitions: . C). When a resident is found on the floor, the facility is obligated to investigate and try to determine how he/she got there, and to put into place an intervention to prevent this from happening again. The facility's policy, Incident/Investigations Monitoring & Medical Documentation (revised 04/29/10) documented: Policy After an incident the facility staff shall determine if injuries have occurred. The Charge Nurse should record the incident along with the resident's condition in the medical record. Procedure 1. A complete resident assessment of each incident shall be made by the Charge Nurse. Injury or lack of injury should be determined from these assessments. 3. The Charge Nurse shall record in the resident's medical record a factual description of the incident and any events that led up to the incident . 9. Any significant change in the resident's baseline physical or mental condition should be called to the physician's attention and documented in the resident's record. 10. In case of an incident that could result in an injury not easily identified by a nursing assessment, consideration should be given to transferring the resident to the hospital emergency room for evaluation and treatment, if needed, or to have in house physician evaluate the resident as indicated. The Nursing Administrator and Director of Nursing are responsible for implementation and compliance of this policy and procedure. RI #6 was readmitted to the facility on [DATE]. [DIAGNOSES REDACTED]. RI #6's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/25/15, assessed the resident as severely impaired in cognition. The MDS also indicated the resident had no issues with mood and behaviors, but required extensive assist (of one or two staff) with activities of daily living. The resident was also identified as always incontinent of urine and frequently incontinent of bowel. Review of RI #6's care plans revealed a plan for Potential for injury due to falls, Potential for injury due to unstable health conditions Related to: impaired safety awareness, Weakness, Use of [MEDICAL CONDITION] medications, Impaired mobility, Balance problems, Impaired vision, History of Falls. Problem Onset: 12/17/2014. Interventions/ Approaches included, . *Maintain a record of falls and evaluate for patterns, *Assess resident for any unmet needs (hungry, thirst, pain, bathroom). A fall investigation (dated 3/26/15) for RI #6 was reviewed. The investigation revealed the resident had an unwitnessed fall on 3/23/15 (Wednesday) at 5:30 PM. The resident was found on the floor in his/her room. The report documented the resident had attempted to self-transfer. The report also reflected the resident was alone and unattended; the resident lost strength/appeared to get weak. The report revealed the resident was unable to tell staff what he/she was trying to do just before the fall. The resident was found at the foot of the bed on the left side. The report indicated the Charge Nurse was notified by the Certified Nursing Assistant (CNA). The MDS/Care Plan staff provided the report that was given to them on 3/25/15. The report provided an interview with Employee Identifier (EI) # 5, the CNA who found the resident on the floor. The report documented CNA walked into room after hearing resident yell. Resident appeared to have scooted out of bed on to floor. was lying on (resident's) left side on the floor. Was transferred back to chair via Stella lift. CNA states resident had red mark on left (L) side. States that (resident) c/o (complained of) pain to (L) side. Reported to (charge) nurse. CNA stated that the nurse told them not to report as a fall because resident was scooted out of the bed. The report reflected the resident was in the bed prior to the fall. The statement from the CNA, EI #5, was signed 3/25/15, two days after the injury. The resident's medical record contained no Nurses Notes between 03/12/15 and 03/24/15, including documentation regarding the 03/23/15 fall. The medical record (Nurses Notes) did include the following: 3/24/2015 9:53 AM - . LPN report that res (resident) daughter reported this morning that resident complained of pain to left hip. MD (Medical Doctor) notified via (DON/Director of Nursing). X-ray ordered to rule out fracture. No unusual occurrences reported from the night shift staff. 3/24/2015 10:11 AM - Placed call to daughter regarding order for x-ray. 3/24/2015 2:59 PM - Daughter notified of left hip x-ray. She does wish to proceed with orthopedic consult. Appointment schedule . for tomorrow (am) . 3/25/2015 12:40 PM - Resident out this morning . for further eval(evaluation) of the displaced left femur. admitted to (hospital) and is being preped (prepped) for surgery on Friday . On 10/01/15 at 12:00 PM, the DON (EI #7) was interviewed. She was asked to explain the procedure for investigating Incidents and Accidents. EI #7 explained the staff completed incident reports after assessing the resident. If there were no obvious injuries, the resident was placed back in bed or wheelchair. EI #7 said neuro checks were done if a head injury was unknown and the Medical Doctor was notified. EI #7 said the incident report then was given to the DON and the MDS/CP (care plan) staff, and an investigation was started. EI #7 explained the Fall Investigation Report was filled out and the nurses documented the incident in the nurses notes. When asked about the interviews, EI #7 said if the injury was suspicious they would get interview statements. When the DON was informed of the concern with the lack of interviews, she said she understood there was a problem and she was working on it. On 10/01/15 at 12:10 PM, EI #8, the Human Resource Director/Abuse Coordinator was interviewed. EI #8 was asked if he interviewed the two CNAs and the Charge Nurse mentioned in the Fall Investigation Report. He said he did not; he terminated the nurse immediately and in-serviced the two CNAs. On 10/01/15 at 2:24 PM, the CNA who found the resident on the floor, (EI #5), was interviewed via phone. She was asked to explain what occurred with RI #6 on 03/23/15 during her shift. EI #5 said she and another CNA placed the resident in the bed and when they returned about twenty minutes later (because the resident was quiet) the resident was on the floor on the door side of the bed. EI #5 said she asked the resident if he/she was hurting and the resident said no. The CNA said she went and told the nurse the resident was on the floor. EI #5 said the nurse told her not to report it because the resident scooted off the bed. The CNA said she did not know how the resident got on the floor. EI #5 was asked if the resident had complained of pain. EI #5 said the resident did not; she asked the resident and she said no. EI #5 said the other CNA may have told the nurse the resident had pain. EI #5 was asked if the nurse assessed the resident. She said the nurse took vital signs. EI #5 was asked if the nurse examined the resident for injuries at all. She replied, No.

Based on observation, interview and facility record review, the facility failed to implement a fall care plan intervention for Resident Identifier (RI) #4, a resident with a fall on 10/4/10 resulting in a left leg fracture. Also the facility failed to reassess and revise the plan of care for falls for RI #10, a resident who had multiple falls and fractured a hip from a fall on 9/7/10. This affected two of five residents sampled for falls. Findings Include: 1.) RI #4 was admitted to the facility on [DATE]. The most current Annual Minimum Data Set (MDS) with a assessment reference date of 04/02/10, assessed RI #4 as having short term memory problems and moderately impaired cognitive skills for daily decision making. RI #4 had [DIAGNOSES REDACTED]. This MDS further documents the resident as totally dependent on staff, requiring two person assistance with transfers, physical support to sit and was not able to stand without physical help. Review of RI #4's care plan with an original date of 4/9/10 and a revised date of 9/22/10 revealed the following problem, "(02) Physical mobility, impaired R/T (related to) fatigue, DJD (degenerative joint disease), deformities of feet & (and) Rheumatoid Arthritis, Osteoporosis Non-ambulatory requires total assist with mobility..." One Approach for this care plan was "(03) 04/09/2010 ... Transfer with 2 person assist. Encourage to assist w/ (with) transfer." A Nurse's Note dated 10/04/10 at 9:30 A.M., confirmed Employee Identifier (EI) #4, attempted to put RI #4 into a "wheelchair and had to put resident in floor..." Another entry dated 10/04/10 at 1:00 P.M., documented the resident was complaining of pain in her left leg. A physician's orders [REDACTED].M., ordered an x-ray of the residents left leg. On 10/04/10 at 6:45 P.M., the Radiology service notified the facility that RI #4's left femur was fractured. The X-Ray report dated 10/04/2010, documented "Opinion: Fracture of the distal femur metaphysis in near anatomic alignment and position, most likely recent." On 10/06/10 at 8:30 A.M. RI #4 was observed in bed covered with a sheet, Intravenous fluid was infusing in her left forearm at 80 cc (cubic centimeters) per hour via a dial a flow. RI #4 said, a CNA (Certified Nursing Assistant) dropped her a few days ago and banged her up and broke her leg. On 10/07/10 at 9:00 A.M. during an interview with EI #4, she confirmed she attempted to transfer RI #4 from the bed to her electric wheelchair. EI #4 said the resident went down on her and she had to be lowered to the floor. EI #4 confirmed RI #4 was a two person assist but she did not have assistance to transfer RI #4. EI #4 said she attempted to transfer her alone. 2.) RI #10 was discharged from the facility on 9/7/10 with a possible fractured hip and readmitted to the facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. The most current MDS with an assessment reference date of 9/20/10, RI #10 was assessed as having short and long term memory problems and as being moderately impaired for cognitive skills for daily decision-making. A review of the facility's "Alleged Incident Statement Form" revealed RI #10 had falls on the following dates: 6/3/10, 6/13/10, 6/22/10, 7/28/10 and 9/7/10. A review of the "Comprehensive Care Plan" with the problem "Trauma, potential for R/T (Related to) external factor: Falls D/T (Due to) recurring falls...Requires limited to total assist with mobility." with an original onset date of 5/7/10 revealed, Goal "Will remain free from falls thru (through out) nursing intervention & (and) prevention as evidenced by no further fall related injuries." The care plan was revised on 5/17/10 in the goal area with "5/17/10 Not Achieved... Resident will not sustain life threatening injuries R/T fall thru 10/10." The following approaches were put in place on 5/7/10, "(01) Keep corridors, room well lighted. (02) Keep Adjusted bed in low position for safe transfers. (03) Side rails up when in bed at all times for safety and support. (04) Sensor mat alarm to bed and/or chair. Check placement every shift. (05) Respond to call light promptly. Keep call light accessible. Remind and encourage her to use for assist. (06)..." On 5/16/10 the following approaches were put into place, "(7) Foley cath (Catheter) reinserted D/T urinary retention, & treated for [REDACTED].}, OT (Occupational Therapy)) to (arrow up) increase her strength and mobility status." On 6/23/10 "Patient care alarm on when out of bed. check placement q (every) shift.", was added to the care plan approaches. On 7/29/10 "Place PCA (Patient Care Alarm) out of residents reach when placed on her.", was added to the approaches. After RI #10's 6/3/10 fall the facility "Alleged Incident Statement Form" was completed. It documents the fall was "unwitnessed" and she was found "sitting on her buttocks in floor just outside bathroom." The resident stated "She was trying to make a BM (Bowel Movement)...Interventions at time of alleged incident/injury and documented on the Fall Care Plan: Replaced S/M (Sensor Mat) pad to chair and sensor box D/T found to be not functioning properly." There was no revision of care plan made to prevent an additional fall. The facilty "Alleged Incident Statement Form" completed after RI #10's 6/13/10 fall documents " Resident sitting upright on floor next to her recliner...0 injuries noted...Interventions at time of alleged incident/injury and document on Fall Care Plan: Put resident to bed and toileted also." There was no revision of care plan made to prevent an additional fall. The facility "Alleged Incident Statement Form" completed after RI #10's 6/22/10 fall documents, "...Resident found on floor on Left side, outside her bathroom...Body audit revealed redness to posterior and left scalp, and redness to left buttock and hip...Were alarms ordered? Yes (checked) If yes, what alarms are ordered and if they sounded. Already in use, and in place, but did not sound...Interventions at time of alleged incident/injury and document on Fall Care Plan: Have replaced S/M pad and box." There was no revision of care plan made to prevent an additional fall. The facility "Alleged Incident Statement Form" completed after RI #10's 7/28/10 fall documents, "...Noted laying on right side in her bathroom floor...0 injuries...Resident stated she was trying to go to the bathroom...Were alarms ordered? Yes (checked) If yes, what alarms are ordered and if they sounded. Already in use, and in place, but did not sound...Interventions at time of alleged incident/injury and document on Fall Care Plan: Replaced S/M box and mat, placed PCA clip where resident could not reach it." There was no revision of care plan made to prevent an additional fall. The facilty "Alleged Incident Statement Form" completed after RI #10's 9/7/10 fall documents, "...In bathroom floor on left side...ST (skin tear) to left elbow, entire midsection of back red, bruise forming to posterior left ribs, comp (complaint) of pain to left knee, thigh, hip and arm...Were alarms ordered? Yes (checked) If yes, what alarms are ordered and if they sounded. See above, all sounded...Interventions at time of alleged incident/injury and document on Fall Care Plan: Res (Resident) was sent out to hospital, ASAP (as soon as possible), did explain to res why call for help was important." A review of the 9/7/10 "Discharge Summary" completed on 9/8/10 documents, "Medical History: Current (L) (Left) hip fx (Fracture)..." In an interview with EI # 3, Nursing Administrator, on 10/7/10 at 8:55 AM, she was asked, are the fall interventions working for RI #10? She responded, "No, not at that time."