Every finding on record at Little Sisters of the Poor Sacred Heart Residence

Based on interview, record review, and review of facility policies titled Mechanical Lift Policy, Accident/Incident Reports, Residents, and Care Plan, the facility failed to ensure staff followed safe transfer procedures using assistive devices to prevent accidents for Resident Identifier (RI) #2, one of three residents reviewed for accident hazards. Specifically, on 12/05/2024 staff failed to use two staff members while operating the mechanical lift in the morning, and later that same day, failed to use the mechanical lift at all, instead completing a two-person manual transfer. As a result, RI #2 sustained a 10-centimeter (cm) bruise to his/her left lower leg and reported a pain level of seven out of 10. This deficient practice demonstrated a failure to follow established safety procedures placing the resident at risk for injury. Findings Include: On 12/06/2024 at 4:03 PM the State Agency received a Facility Reported Incident (FRI) from the facility alleging an injury of unknown origin was identified on 12/06/2024 at 5:00 AM, during the last round of the night shift a bruise was discovered to RI #2's left lower lateral leg, which caused pain with movement. An undated facility policy titled Mechanical Lift Policy documented: PURPOSE:To ensure the safe handling and moving techniques are use on all Residents during transfers with the mechanical lifts. To ensure all who are involved in mechanical lifting operations fully understand their responsibilities in protecting the health and safety of themselves and others. USE OF THE MECHANICAL LIFT: .2. All mechanical lifts are to be performed by a TWO PERSON ASSIST: . A facility policy titled ACCIDENT/INCIDENT REPORTS, RESIDENTS with a revised date of 08/2017 documented: . DEFINITIONS1. Accident: An event that results in bodily injury or potential injury and/or causes a change in Resident status. A facility policy titled CARE PLAN with a revised date of 08/2017 documented: POLICYEvery Resident has a comprehensive care plan as part of their medical record.PURPOSETo develop quantifiable objectives for the highest level of function the Resident may be able to attain.PROCEDURE1. The comprehensive care plan includes measurable objectives and timetables to meet the Resident's medical, nursing, mental and psychosocial needs as identified in the comprehensive assessment. RI #2 was readmitted to the facility on [DATE] and had diagnoses to include Heart Failure, Chronic Pain, and Cognitive Communication Deficit. RI #2's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 10/17/2024 documented Short- and Long-Term Memory problems with severely impaired daily decision-making ability. RI #2's Care Plan with a focus area of being at risk of falls with an initiated date of 03/24/2022 documented interventions to include: . Please transfer me using the full body lift. I am not safe on the stand-up Lift.RI #2's Care Plan with a focus area of Activities of Daily Living with an initiated date of 03/24/2022 documented interventions to include: . TRANSFER: full body lift 2 person assist . RI # 2's progress note signed by Registered Nurse (RN) #5 documented: Effective Date: 12/06/2024 . Type: Health Status Note Text: Resident was observed in bed during rounds, reaching @ (at) lower extremity, grimacing and hollered out hurt. Observations of a 6 in (inch) bruise to LLE (Left Lower Extremity), from knee to mid-calf. LT (Left) knee edema +2 (plus two) noted. No recent falls or injuries noted. Resident was observed positioned in the center of bed, side railing up x 2 (times two), and bed locked and in lowest position, will F/U (follow-up) with staff. Administered PRN (as needed). Tylenol (by mouth), and it was effective. MD . (Medical Doctor) was notified and recommended X ray, will F/U with staff. Safety measures in place, bed locked and in lowest position, call pad @ hip and care resumes. RI #2's Skin assessment performed by the Director of Nursing (DON) on 12/06/2024 at 7:00 AM documented a 10 cm (centimeter) bruise and edema to RI #2's left lower leg. The Medication Administration Record (MAR) for RI #2 for December 2024 recorded that after a bruise was identified on 12/06/2024, the medical doctor prescribed Hydrocodone-Acetaminophen oral tablet was to be given as needed for pain at a frequency of one tablet every six hours; from 12/07/2024 to 12/30/2024, a total of nineteen doses were given to alleviate pain; pain levels were assessed prior to each dose, ranging between zero and six out of 10. The MAR also recorded RI #2 received Tylenol immediately after the bruise was identified on 12/06/2024 at 5:21 AM, with a pain level of 7 recorded. Additionally, four more doses of Tylenol were administered on 12/6/2024 with a pain level range between four and five. The facility investigative file for the FRI included an undated and unsigned summary of the incident which documented: . On Friday, 12/06/24 at approximately 5 a.m., (Certified Nursing Assistant) . (CNA #7 and CNA # 8) were performing their last round on the night shift when they noticed a bruise on (RI #2's) left lower lateral leg. They immediately notified the night shift supervisor (RN #5) .Results/FindingsThe investigation revealed that the injury was not an injury of unknown origin, but rather the result of staff failing to follow the policy of Resident transfer. Upon thorough investigation, it was determined that the bruising on (RI #2's) left lower leg was most likely caused by . (CNA #3 and CNA #4) performing a two-person lift transfer instead of the required two-person Hoyer (mechanical) lift transfer as outlined on the care plan. (CNA #3 and CNA #4) admitted that they did not use the Hoyer (mechanical) lift, but instead performed a two-person transfer from the Broda (rolling chair) Chair back onto the bed. Both CNAs also stated that this type of transfer might have caused the bruise to (RI #2's) left lower leg. The facility investigative file included typed follow-up interviews with CNA #3, dated 12/07/2024 and 12/09/2024. The follow-up interview dated 12/07/2024 documented: CNA #3 . stated that they did not use the lift. They picked (RI #2) up and transferred (him/her) back into the bed. She stated that might have caused the bruise to (RI #2's) leg. CNA #3 indicated that she and CNA #4 did not use the lift rather they lifted RI #2 manually and transferred him/her back into the bed, stating that this action may have resulted in the bruise on RI #2's leg. (CNA #3) was also questioned why she performed a . lift earlier in the morning by herself and stated that (CNA #4) was in another room and I did it by myself. The follow-up interview dated 12/09/2024 documented: . (CNA #3) was questioned on the technique they used transferring (RI #2) back into the bed. (CNA #3) stated that they performed a two person stand pivot transfer from (his/her) Broda chair onto (his/her) bed. (CNA #4) got (his/her) upper body and (CNA #3) got (his/her) lower legs and turned (him/her) around onto the bed. On 11/04/2025 at 12:30 PM CNA #3 was questioned regarding the incident that occurred in December 2024 involving RI #2. CNA #3 said, RI #2 suffered from Dementia and was unable to get out of bed without the assistance of a mechanical lift. CNA #3 indicated that two staff members were necessary when transferring a resident using the mechanical lift to ensure the resident's safety. CNA #3 said that on 12/05/2024 she and CNA #4 performed a two-person transfer with RI #2 from the chair to the bed. CNA # 3 stated that RI #2 should have been transferred using the mechanical lift. When asked why the mechanical lift was not utilized, CNA #3 explained that she was following CNA # 4's lead and could not provide a valid reason for not using the lift. Regarding the morning transfer on 12/05/2024, CNA #3 stated, she transferred RI #2 from the bed to the chair using the mechanical lift but did not have a second person assist. CNA #3 admitted that she should have enlisted the help of another staff member during the transfer. When questioned about her decision not to use a second person, she explained that she was in a rush and failed to call for assistance. CNA #3 said it was possible RI #2 sustained the bruise during the mechanical lift transfer on 12/05/2024. CNA #3 acknowledged that she did not follow the policy regarding the use of the lift on 12/05/2024. On 11/04/2025 at 2:45 PM CNA #4 was questioned regarding the incident involving RI #2 that occurred in December 2024. CNA #4 stated, she assisted CNA #3 in transferring RI #2 from the chair to the bed on 12/05/2024. She said the transfer was performed using a two-person assist, although it should have been conducted with a mechanical lift. CNA #4 said, RI #2 required a mechanical lift transfer due to her medical condition and inability to walk. When asked about the absence of the mechanical lift, CNA #4 stated, neither she nor CNA #3 went and retrieved the lift. CNA #4 said the importance of utilizing a mechanical lift for residents who are care-planned for such assistance was to ensure safety and prevent injury. She became aware of a bruise on RI #2's leg a few days after the incident. When asked about the cause of the bruise, she was uncertain but said that the transfer without the mechanical lift on 12/05/2024 could have been responsible. On 11/04/2025 at 5:45 PM RN #5 was questioned regarding the incident involving RI #2 that occurred in December 2024. RN #5 said, she was informed at approximately 5:00 AM on 12/06/2024, about a bruise on RI #2, who was also expressing pain. RN #5 stated, she administered Tylenol to RI #2, evaluated the bruise, documented her findings in the medical record, and communicated the situation to the Director of Nursing. On 11/04/2025 at 5:00 PM the Administrator (ADM) was questioned regarding the incident involving RI #2 that occurred in December 2024. He stated, he became aware of a bruise found on RI #2 on 12/06/2024. When asked about the findings of the investigation, the ADM said, the investigation determined that the transfer conducted without the use of a mechanical lift on 12/05/2024 was likely the cause of the bruise. The ADM said, RI #2 was prescribed pain medication after the bruise was identified due to complaints of pain. When asked about the significance of adhering to the care plan concerning the use of a lift, he emphasized that it was to ensure the safety of the resident. The ADM said, RI #2 had a care plan that included the use of a lift because the resident was unable to transfer independently and could not assist the staff with transfers. On 11/04/2025 at 3:35 PM the Director of Nursing (DON) was questioned regarding the incident involving RI #2 that occurred in December 2024. The DON said, she was informed of a bruise on RI #2 on 12/06/2024. The DON explained that the facility concluded that staff had transferred RI #2 on 12/05/2024 without utilizing the mechanical lift, which may have resulted in the bruise. The DON noted that RI #2 had a care plan that included the use of a mechanical lift due to severe mobility issues to include being unable to stand. When asked about the bruise the DON said that she observed it on 12/06/2024 soon after it was discovered. She described the size of the bruise as 10 cm on the left lower leg and was purple, blue, and red, with potential blood accumulation beneath the skin. The DON stated, RI #2 displayed facial grimacing, indicating pain during movement. Regarding pain management the DON indicated that Tylenol was administered initially upon the discovery of the bruise, and that the physician ordered PRN Hydrocodone-Acetaminophen on 12/06/2024. The DON said, the resident received three doses of Hydrocodone on 12/07/2024, three doses on 12/08/2024, one dose on 12/09/2024, two doses on 12/10/2024, one dose on 12/11/2024, and two doses on 12/12/2024. The DON stated, RI #2 also received PRN Hydrocodone on 12/16/2024, 12/17/2024, 12/19/2024, 12/21/2024, 12/29/2024, and 12/30/2024. When asked about the severity of RI #2's injury, she stated that the resident experienced moderate pain, was treated with pain medication as prescribed by the physician, and the bruise was monitored according to the physician's orders. The DON said, it was important for staff to adhere to policies and procedures, as well as the care plan concerning the use of mechanical lifts, to prevent injuries and ensure the safety of the resident. On 11/05/2025 at 12:15 PM the Medical Director (MD) was questioned regarding the incident involving RI #2 that occurred in December 2024. The MD said, he became aware of a bruise discovered on RI #2 on 12/06/2024 after being informed by the facility. The MD said, he had ordered an x-ray, a Doppler study, laboratory tests, pain medication, monitoring, and a consultation for therapy. The MD said, the investigation determined the bruise was caused by a transfer done without the mechanical lift, which was a reasonable explanation for the bruise, and experiencing pain with a bruise was normally to be expected.

Based on interviews, observations, and a facility document titled Residents- These's Are Your Rights the facility failed to ensure residents were made aware of the location of the facility survey results book. The facility further failed to ensure the survey results book was located in an area that was readily accessible to residents and visitors. This deficient practice affected all 73 of 73 residing in the facility. Findings include: A review of a facility document titled, Residents-These Are Your Rights revealed: .You have the right to examine the results of the most recent Federal and State survey . On 1/23/19 at 10:00 a.m., a group meeting was held with 10 residents attending. All 10 residents stated they were not aware of the survey results and where they were located in the facility. On 1/23/19 at 11:03 a.m., there was a notice posted on the 100 hall, The results from the previous survey have been placed in a red binder and can be found on the desk next to the window in the lobby. On 1/23/19 at 11:09 a.m., the surveyor observed the lobby and window area, unable to locate the survey results book. No notice was posted. On 1/23/19 at 11:13 a.m., the surveyor did not observe any notices posted on the hall for rooms 134-154 that indicated where the survey results book was located. On 1/23/19 at 11:16 a.m, the surveyor did not observe any notices posted on the 2nd floor that indicated where the survey results book was located On 1/24/19 at 7:46 a.m., the surveyor observed the lobby and window area, unable to locate the survey results book. On 1/24/19 at 3:31 p.m. the surveyor asked EI (Employee Identifier) #2, Social Services Designee to locate the survey results book. The surveyor accompanied EI#2 to the lobby area and EI#2 retrieved a green notebook labeled Survey Results from the front desk/receptionist window. During an interview with EI #2 at 3:32 p.m., she was asked how were the residents made aware of the survey results. EI #2 said residents were made aware of the survey results on admission. EI #2 was asked if she discussed the survey results with the residents other than on admission. EI #2 said, No I don't. EI #2 was asked if there were notices posted in the facility indicating where the survey results were located. She replied there should be. The surveyor accompanied EI#2 to the lobby area and there was no notice posted. EI #2 was asked were there notices posted throughout the facility indicating where the survey results are location. EI #2 said, No. EI #2 was asked with the survey results notebook located at the window/receptionist desk, was it accessible to residents and/or visitors. EI #2 said, No. EI #2 was asked why was it important for the residents to know about the survey results. EI #2 said because it made them aware of the citations, if given, and see the quality of care the facility provides.

Based on interview and record review, including the facility's policy titled, Nursing Education, Mandatory Training and Competency Evaluation, the facility failed to ensure nurse aides received 12 hours of training within 12 months of date of hire. This was noted on two of five CNAs (Certified Nursing Assistant) training records that were reviewed. Findings Include: A review of the facility's policy titled, Nursing Education, Mandatory Training and Competency Evaluation, dated 4/2017, revealed: POLICY It is the policy of the Home to establish, implement and maintain written policies and procedures for verification of appropriate educational preparation and competency, to include certification and/or licensure in good standing, upon hire and on an ongoing basis while employed in the Home of all Nursing Staff (Licensed Nurses and GNAs (CNA's)).3. Performance Review The Home will complete a performance review of every nurse aide at least once every twelve (12) months and provide regular in-service education based on the outcome of these reviews. Required in-service training, specific to nurse aides, will include at least twelve (12) hours per year. A review of five CNA training files was conducted on 12/28/17. Two of the five files revealed two CNAs did not receive 12 hours within 12 months of date of hire. EI (Employee Identifier) #1's training record revealed her date of hire was 8/29/14 and she had obtained 11.5 hours of training for the 12 months. EI #2's hire date was 7/08/15 and she had obtained 11.5 hours of training for the 12 months. Both EI #1 and EI #2 were CNA's. On 12/29/17 at 7:15 p.m., EI #3, DON (Director of Nursing), was interviewed. EI #3 was asked how many hours of training were required for CNAs and she stated 12 hours. EI #3 was asked who was responsible for ensuring the training was completed for CNAs. EI #3 explained that Staff Development conducted the inservices, but Human Resources also played a role in keeping up with the training for the CNA employee evaluation. When asked what was the concern of CNAs not having required hours of training, EI #3 stated, They don't have the training or education to care for the residents. EI #3 was asked what did the facility's policy indicate regarding the requirement for training of CNAs. EI #3 stated the CNAs must have 12 hours a year.

Based on observations and interviews, the facility failed to ensure scissors were not observed unattended on top of two of four medication carts on one of three survey days. In addition, scissors were observed unattended in the main dining room on two of three survey days. Findings Include: A review of RI (Resident Identifier) #10's medical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. A review of RI #10's most recent Quarterly MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 11/05/2015, indicated RI #10 had a BIMS (Brief Interview of Mental Status) score of 14 out of a possible score of 15. This score indicated RI #10 was cognitively intact for daily decision making skills. RI #10 was independent with all personal care and was ambulatory in the room and the hallway. A review of RI #4's medical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. A review of RI #4's most recent Quarterly MDS, with an ARD of 11/12/2015, indicated RI #4 was cognitively impaired for daily decision making skills. RI #4 required extensive assistance with ADLs (Activities of Daily Living) except for eating which required only set-up. A review of RI #6's medical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. A review of RI #6's most recent Quarterly MDS, with an ARD of 11/19/2015, indicated RI #6 had a BIMS score of 13 out of a possible score of 15. This score indicated RI #6 was cognitively intact for daily decision making skills. RI #6 was independent with personal care and required set-up assistance with eating and maximum assistance with ambulation outside of RI #6's room. The following is a list of observations made on 12/01/2015 beginning at 5:28 PM: On the second floor of the facility, during a medication pass, an observation was made of a pair of sharp tipped scissors approximately ten inches in length sitting on top of medication cart #1. The scissors were in a white plastic tray with paper and plastic medication cups. The scissors were lying on their side with the green handle up and visible. The handles of the scissors were visible from the front and back of the medication cart and from both sides of the medication cart. At 5:50 PM, a nurse was observed returning to medication cart #1 then left the medication cart unattended at 5:51 PM. Medication cart #2 was observed at the other end of the hallway at 5:28 PM and was unattended until 5:53 PM. A sharp, pointed pair of scissors were observed on top of the medication cart. The scissors were in a white plastic tray with plastic and paper medication cups. The plastic tray was about 10 - 12 inches long, two inches deep, and two inches wide. The scissors had brownish/golden handles and were visible from the front and back of the medication cart and also from both sides. At 6:00 PM, both medication carts were unattended until 6:02 PM when a nurse returned to cart #1. Medication Cart #2 remained unattended at 6:02 PM. At 6:07 PM, medication cart #1 was observed unattended. At 6:11 PM, medication carts #1 and #2 were unattended. At 6:16 PM, the nurse returned to medication cart #1. Medication cart #2 was still unattended. At 6:20 PM, both medication carts were observed unattended. At 6:39 PM, both medication carts were observed unattended with scissors still on both carts. At 6:41 PM, both carts were observed unattended with scissors remaining on top of the medication carts. The following observations were made of residents returning to the second floor from the elevator on 12/01/15: At 6:20 PM on 12/01/15, an observation was made of a resident coming from the elevator, ambulating without assistance, and passed medication cart #2, which was unattended with scissors on top of the medication cart. The resident entered into a resident room. At 6:32 PM on 12/1/15, medication cart #2 was observed with a pair of scissors that were unattended. A resident wearing glasses and using a rolling walker for assistance with ambulation walked past the medication cart. The resident entered a resident room. At 6:33 PM, an observation was made of an unassisted ambulating resident coming from the elevator and past medication cart #1. The medication cart was unattended and observed with scissors on top of it. The resident entered a resident room. An observation was made at 6:33 PM of residents coming from the elevator ambulating independently. One resident passed medication cart #1, with scissors observed on top of the cart. The other resident passed unattended medication cart #2, with the scissors observed on top of the cart. At 6:34 PM, a resident was observed exiting their room passing medication cart #2 in the hallway. A pair of scissors was observed on top of the medication cart. This resident was ambulating with the assistance of a rolling walker. At 6:35 PM, a resident was observed passing medication cart #2 using a rolling walker. This resident was wearing glasses. The resident then entered a resident room. At 6:35 PM an observation was made of an ambulatory resident passing unattended medication cart #1. The scissors were observed on top of the cart and were unattended. At 6:38 PM, a resident was observed self-propelling in a wheelchair past medication cart #1 with the scissors unattended. This resident leaned forward and reached for the door to open it. The distance the resident reached was noted to be approximately the same as the distance to the scissors would be from the wheelchair. The following is a list observations made in the main dining room on 12/02/2015 beginning at 8:55 AM: There were two dining tables with scissors on them. The scissors were about 6 inches in length with pointed sharp ends. There were 3 residents at table #5. One resident was sampled, RI #4, the other two were unsampled residents. At table #12, there was a pair of sharp, pointed scissors about 6 inches long. These scissors were standing up-right in the condiment caddy. Four residents were present at this table, two were sampled residents, RI #10 and RI #6. At 9:07 AM, the scissors remained on both tables. Five independent residents remained in the dining room feeding themselves. At 9:09 AM, an observation was made of the staff cleaning the tables off. The scissors were not removed from table #5 or #12. There were four residents that remained in the dining room feeding themselves. One resident was at table #5 where the scissors were observed and unattended by staff. At 9:15 AM, an observation was made of one resident remaining in the dining room at table #5, with the scissors present and unattended by staff. At 9:17 AM, an observation was made of RI #4 being removed from the dining room, from table #5, with one resident remaining in the dining room unattended. At 9:23 AM, an observation was made of the scissors on table #5 and #12. The scissors were unattended on both tables. On table #5, the scissors were standing in a condiment caddy and on table #12 the scissors were lying on the table, next to the condiment caddy. The following is a list of observations made on 12/2/2015 beginning at 12:23 PM: An observation was made in the main dining room of table #5 and #12. Each of these tables had a sharp, pointed pair of scissors on them. There were three residents at table #5 and four residents at table #12. RI #4 was at table #5. RI #6 and RI #10 were at table #12. There were forty-one residents feeding themselves and twenty-one of these residents were ambulatory and twenty were in wheelchairs. The scissors were unattended by staff. An observation at 12:40 PM revealed the scissors remained on table #5 and #12 unattended by staff. Residents were beginning to leave the dining room. At 12:50 PM, the scissors remained on table #5 and #12 unattended by staff. Fifteen residents remained in the dining room feeding themselves. At 1:00 PM, all residents had left table #5 and the scissors remained on the table unattended. Two residents remained at table #12 with the scissors on the table, unattended by staff. The following is a list of observations made on 12/3/2015 beginning at 8:50 AM in the main dining room: There were scissors on table #5 unattended by staff, with three residents eating breakfast. Four residents were observed sitting at table #12 eating breakfast. The scissors were observed on the table unattended by staff. At 9:40 AM, an observation was made of the scissors on table #5 and #12, unattended by staff, with residents present and eating breakfast. An interview was conducted on 12/01/2015 at 6:59 PM, with EI (Employee Identifier) #3, an LPN (Licensed Practical Nurse). EI #3 was on duty during the observation of the scissors left unattended on the medications carts. EI #3 was asked if there were items on top of the medication carts. EI #3 replied yes. EI #3 was asked what were the items on top of the medication carts. EI #3 replied glasses, medication cups, water, spoons, tissues, hand sanitizer, gloves, and sharps container on the side. EI #3 was asked what was allowed to be on top of the medication carts. EI #3 replied the items mentioned in the answer before. EI #3 was asked what does the facility's policy indicate regarding what was allowed on top of the medication carts. EI #3 replied no medication on top of the carts, just the items she stated in the above question. EI #3 was asked if it was acceptable for a pair of sharp, pointed tip scissors to be left on top of the medication carts, unattended. EI #3 replied no. EI #3 was asked why not. EI #3 replied, Well if you were on a hall where someone could get them they could fall and get hurt. EI #3 was asked what the potential harm could be to a resident with scissors left unattended on a medication cart. EI #3 replied, They (the resident) could stab themselves if they fell . EI #3 was asked what was in place to protect the resident from obtaining the scissors when unattended. EI #3 replied, I don't know of anything. EI #3 was asked what the scissors were used for on the two medication carts on the 2nd floor. EI #3 replied, I don't know, I guess to open the med packs, I really don't know. I just tear them open. EI #3 was asked how the scissors were maintained on top of the carts. EI #3 replied, I didn't realize they were even there. EI #3 was asked why they were kept on top of the medication carts and not locked up. EI #3 replied, I don't know. EI #3 was asked if this was a potential hazard, to have the scissors on top of the medication carts unattended. EI #3 replied, Yes they should be locked in a drawer. EI #3 was asked what was the facility's policy regarding sharp objects. EI #3 replied, They should be locked up. An interview was conducted with EI #2, a dining room aide, on 12/3/15 at 8:50 AM. EI #2 was asked if she was aware of the scissors on tables #5 and #12. She stated she was aware of the scissors being on the tables. EI #2 was asked why the scissors were on the tables. She stated the residents used them to cut open sugar packs. EI #2 was asked who had put the scissors on the tables and why. She stated the staff do not put the scissors out and it may be the residents that sit at those tables. EI #2 was asked if she had been told about any safety issues related to the scissors. She answered yes, when she was hired. She was taught about safety of the resident but she didn't recall who taught her. EI #2 was asked what were the potential hazards or harm to the residents related to the scissors being on the tables. She answered maybe they could hurt themselves, they could cut their fingers. EI #2 was asked if anyone monitored the use of the scissors and she answered no. EI #2 was asked who ensured the safe use of the scissors. She responded sometimes the staff were present, sometimes they were not, and when she served coffee, they (the residents) cut the packs in front of her. EI #2 was asked how she knew the scissors were being used safely. EI #2 answered because she had never seen anybody come pick up the scissors off the tables, other than the resident sitting at the tables. EI #2 also stated she had observed them (the residents) using the scissors to cut open condiments. An interview was conducted with EI #1, CNA (Certified Nursing Assistant), on 12/3/15 at 9:11 AM. EI #1 was asked if she brought residents into the dining room for meals. She answered, Yes, ma'am. EI #1 was asked if she stayed to assist any of the residents with meals. She answered the rehab (rehabilitation) staff feed residents in the main dining room and for lunch they feed residents on (named a specific unit). Breakfast is served from behind the food bar. Lunch on (a specific unit), staff serve and feed residents. Residents are fed by CNAs at breakfast in the main dining room. EI #1 was asked if she was aware of the items on the dining room table for the residents to use and what they were. She answered she did and listed butter, half and half, salt and pepper on some tables, eating utensils, bowls for trash, pitcher of ice water, peanut butter and some specific seasonings at certain tables, name plates with the resident's diet and table number, and napkins. EI #1 was asked if she had ever seen scissors on the dining room tables, specifically tables #5 and #12. She responded that she was not aware scissors were on the tables. She worked on (named a unit of the facility) and they assisted and fed the other half of the dining room. The people upstairs take care of the other residents on the other half of the dining hall. EI #1 was asked if the scissors present on the dining room tables were a safety issue for the residents. EI #1 stated the scissors were, if they were pointed and, depending on the level of the resident's functional ability, the scissors could be. EI #1 was asked what the potential hazards/harm was to the residents with scissors being left on the table unattended. She answered if the residents were cutting something and slipped, they could cut themselves more easily because their skin was more sensitive and their fine motor skills were less than ours. She also stated the residents eye sight may be more diminished and the residents could accidentally cut themselves. Someone could try to cut someone else. EI #1 was asked if there was potential harm to other residents with the scissors on tables in the dining room. She answered the residents could walk by and pick them up. EI #1 was asked if there were any safety measures in place to protect the residents from harm and what those measures might be. She answered at first that she was sure there were, then there probably were, then she reported she didn't know where the scissors came from. She also reported the staff shouldn't be giving scissors to the residents and the staff should be opening things for the residents. EI #1 reported she didn't know who put the scissors on the tables. EI #1 was asked if she had ever received any safety training related to the residents using scissors. She replied that she had not. EI #1 was asked who ensured the safe use of the scissors. She answered she assumed that someone was aware of the scissors on the table and monitored their use. An interview was conducted on 12/3/2015 at 4:08 PM with EI #4, the DON (Director of Nursing). EI #4 was asked were there items on top of the medication carts. EI #4 replied, There are. EI #4 was asked what were the items on top of the medication carts. EI #4 replied, Water pitcher, drinking cups, med (medication) cups, computer. EI #4 was asked what items were allowed to be on top of the medication cart. EI #4 replied, The items I just said. EI #4 was asked what the facility's policy indicate could be on top of the medication carts. EI #4 replied, I don't think it says anything different. EI #4 was asked if a pair of sharp, pointed scissors were appropriate to be left unattended on a medication cart. EI #4 replied, No. EI #4 was asked why not. EI #4 replied, Because it is a safety hazard. EI #4 was asked what the potential harm could be to a resident with scissors left on top of a medication cart, unattended. EI #4 replied, If a demented resident got them it could be a safety issue, cut themselves or someone else. EI #4 was asked how were the scissors maintained on the medication carts. EI #4 replied, I have not seen them. EI #4 was asked what the scissors were used for. EI #4 replied, I would think to cut open the med pouches. EI #4 was asked why the scissors were on top of the medication carts. EI #4 replied because someone was negligent. EI #4 was asked if a resident standing at an unattended medication cart could obtain the scissors. EI #4 replied, They could have. EI #4 was asked if every resident in the facility could safely use scissors. EI #4 replied, No. EI #4 was asked what was in place to protect the residents from obtaining the scissors. EI #4 replied, There would not be a need, if the scissors had been stored properly. EI #4 was asked if it was considered a hazard for sharp, pointed scissors, to be left unattended on a dining room table. EI #4 replied, Yes.

Based on observations, interview, and document reviews, the facility failed to ensure food was served in a manner to prevent the potential for cross-contamination and food borne illnesses by the following: 1. Two opened packages of hot dog wieners were observed in the walk in freezer, opened to the air with no expiration date, during the tour on 10/29/13. 2. A dented can of chili, a can of salsa that had no date, and two opened boxes of seasoned flour were observed stored in the pantry of the dietary department, during the tour on 10/29/13. 3. a.) The ice scoop was stored uncovered on top of the ice machine during the tour on 10/29/13. b.) A dietary worker was observed to drink water from a cup in the dish washing room on 10/30/13. 3.) The garbage can was left uncovered, and a dish towel was observed out of the sanitizing bucket on 10/31/13. 4.) The dietary worker wiped the thermometer with a paper towel then a dish towel between checking temperatures on the tray line on 10/31/13. These deficient practices had the potential to affect all 66 residents who received meals from the dietary department. Findings include: 1. Walk in Freezer: A review of the facility's policy entitled, "Section: Food and Supply Receiving and Storage" with a revision date of 01/04, revealed: "...Storage of Perishable Food Items... 11. All frozen food is dated, labeled, and wrapped. Moisture-proof, tight-fitting materials are used to prevent freezer burn. ..." During the tour of the facility's kitchen on 10/29/13 at 8:11 AM, two packages of frozen hot dog wieners were observed in the walk in freezer. Both packages were open to air and were dry in appearance. One package of wieners was full, and the other one was one forth full. Neither of the packages had a label. An interview was conducted on 10/31/13 at 2:40 PM, with EI (Employee Identifier) #5 DM (Dietary Manager). The surveyor asked EI #5 what was the concern with the above observation. EI #5 said when the packages of hot dog wieners were left open they could become freezer burned. She also explained when they were open with no label staff could not tell when they were opened. 2. Pantry: A review of the facility's policy entitled, "Section: Food and Supply Receiving and Storage" with a revision date of 01/04, revealed: "Containers and Proper Materials to Store Items in Dry Storage:... 2. Cases of product, such as cereals and pastas, are shelved without opening until the current stock has been used. When opened and dated, canned goods are stocked using the first-in, first out policy. ...Opened dry items, such as pasta, rice, and crackers are stored in labeled containers of corrosion-resistant materials with tight-fitting lids. ..." During the tour of the facility's pantry in the dietary department, on 10/29/13 at 8:25 AM, a 6 pound and 14 ounce can of Salsa was observed without a label and a large dented can of chili was observed dented at the seam of the can. During the same observation of the pantry at 8:30 AM, 2 opened large boxes of seasoning flour was observed gapped open and exposed. One of the boxes had a scoop stored inside of it. An interview was conducted on 10/31/13 at 2:40 PM, with EI (Employee Identifier) #5 DM (Dietary Manager). The surveyor asked EI #5 what was the concern with the above observation. EI #5 said the scoop should never be in anything and the dented can slipped by her. EI #5 said the dietary staff was instructed to bring all dented cans to her no matter how small the dents. EI #5 said she did not know what happened regarding the can of salsa that was not dated. 3. Cross Contamination: A review of the facility's policy entitled, "Sanitation and Maintenance" with a revision date of 01/04, revealed: "Cleaning and Sanitizing Frequency: ... 5. Cleaned and sanitized equipment and utensils are to be handled, transported and stored so that they are protected from contamination. ..." During the tour of the facility's kitchen on 10/29/13 at 8:11 AM, the ice machine scoop was observed laying uncovered on top of the ice machine in the kitchen. An interview was conducted on 10/31/13 at 2:40 PM, with EI #5. The surveyor asked EI #5 what was the concern with the above observation. EI #5 explained the outside of the ice machine was painted the night before. EI #5 said the scoop was sitting up there possibly collecting dust, and it was in an unsanitary area. During an observation of the dish washing room on 10/30/13 at 8:20 AM, EI #6, a dietary worker/cook, was observed to drink water out of a cup then placed the cup on top of the dish machine near the clean dishes. EI #5 removed the cup of water and poured it out. EI #5 told EI #6 he could not drink in the area. EI #6 said, "I guess I should not be drinking in here." The surveyor agreed. An interview was conducted on 10/30/13 at 1:25 PM, with EI #6. The surveyor asked EI #6 what was he drinking during the observation of the dish room on 10/30/13. EI #6 stated, "Water which I will never do again." When the surveyor asked what was the potential negative outcome when staff drank fluids in the dish area. EI #6 stated, I never thought about it. I guess a lot of things well, cross contamination. During an observation of the dish washing room on 10/31/13 at 11:00 AM, the garbage can was left uncovered and a staff member walked by it dropped an item in the garbage can and kept walking. During the same observation a yellow dish cloth was observed laying on top of a cart next to an empty red bucket. No staff were in the area washing dishes. An interview was conducted on 10/31/13 at 2:40 PM, with EI #5. The surveyor asked EI #5 what was the concern with the above observations. EI #5 said, EI #6 was not suppose to have water in the dish area. She said the cup was on the clean side. She said EI #6 knew not to do that. She further explained the staff knew to put the dish towels in the red bucket. EI #5 said the concern with EI #6 drinking the water in the dish room was cross contamination and staff should not drink in the wash room. EI #5 also said staff knew to keep the garbage cans covered in order to prevent the potential for cross contamination. A review of the facility's policy entitled, "Check Food Temperatures on Hot Food Bar and Cold Salad Bar" with a revision date of 01/04, revealed: "Policy: Food will be maintained and served at acceptable temperatures and cross contamination will be prevented. Procedure:... 2. Wipe thermometer probe with alcohol swab prior to using. For each food item, insert probe and record registered temperature in log. Wipe thermometer probe after checking each temperature to prevent cross contamination. ..." During the tray line observation on 10/30/13 at 10:55 AM, the following observations were made: EI #7, the cook, was observed checking food item temperatures. She checked the temperature of the pureed smothered country fried steak then wiped the thermometer probe with a paper towel that was observed lying on a table. She then checked the temperatures of the turnip greens, beef cubed steaks and the mashed potatoes. EI #7 wiped the thermometer probe with a cloth that was lying on the table between each of the other 3 food items mentioned. An interview was conducted on 10/31/13 at 12:10 PM, with EI #7. The surveyor asked EI #7 how she cleaned the thermometer when she checked the food temperatures during the lunch meal on 10/30/13. EI #7 said she wiped it with an alcohol swab before she got started. EI #7 said she then got a different piece of a paper towel to wipe the thermometer in between each item. The surveyor shared the above observation with EI #7, then asked what was the potential negative concern when the thermometer was not sanitized between checking temperatures of food items. EI #7 stated, "Cross contamination. I was real nervous." An interview was conducted on 10/31/13 at 2:40 PM, with EI #5. The surveyor shared the above observation, then asked EI #5 what was the potential negative outcome with the above observations. EI #5 stated, "Cross contamination."

Based on interviews and record reviews, the facility failed to ensure: 1) the care plan for RI (Resident Identifier) #2 was revised for falls with appropriate interventions, and 2) care plans were reviewed and revised every three months for RI #11. This affected 2 of 15 sampled residents reviewed for care plans. Findings include: 1) RI #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a significant change MDS ( Minimum Data Set) for RI #2 with an assessment reference date of 09/18/2013 revealed, RI #2 was coded as having a BIMS (Brief Interview Mental Status) score of 14 out a possible 15. This score indicated RI #2 was cognitively intact. RI #2 was coded as needing extensive assistance for transfers, dressing and toileting. A review of RI #2's Care Plan with a start date of 2/20/2012, indicated that RI #2 had sustained falls on 12/21/12, 12/22/12, 12/24/12, and 9/3/13. The facility was unable to locate the Accident / Incident Reports for falls of 12/21/12, 12/22/12 and 12/24/12, however there was a form available for the 9/3/13 fall. The following interventions with respective dates, were noted on the Care Plan for RI #2: 1) An undated entry for: "I will keep my room well lighted when attempting to move about" 2) "9/3/13 Encourage me to ask for assistance with my care" 3) An undated entry for: "Explained to Resident to put her Call Light on when need to go to BR (bathroom)" 4) "12/24/12 Call for assist with transfers & amb (ambulation)" 5) "12/24/12 PT (Physical Therapy) screen done" (difficult to read) A review of RI #2's Nurses Notes noted: 1) "12/21/12 8:30P (PM) Resident found laying on floor next to her bed, feet... . Resident was encouraged to be sure rm (room) is well lighted & to use her walker at all times & to call for assistance when needed. ..." 2) "12/22/12 10:15 Resident from next room came to nurse, stated (dificult to read) that resident on floor in BR. Nurse went to room Resident on floor by commode. Holding on to Rail on wall. ... Call light in reach and told Resident to put call light on when need assistance. ..." 3) "12/24/12 1030A (AM) Resident found lying on (R) (right) side on floor ... Resident given call light & instructed to call for assist in order to get up / transfer. ..." 4) "9/3/2013 07:49 Health Status Note Text: resident reported she slipped off side of bed onto floor and got up by herself back onto bed. ... encouraged to call for assist when getting up." On 10/31/2013 at 3:45 PM, an interview was conducted with EI #2 (DON - Director of Nursing). EI #2 was asked what was the facility's policy for investigating falls. EI #2 stated when a resident had a fall, a nurse assessed the resident by range of motion (ROM) to detect injury. The resident was assisted up if there was no injury and vital signs were assessed. EI #2 also stated that they (the nurses) would try to assess what the resident may have been trying to do, that may have precipitated the fall. EI #2 was then asked who was responsible for investigating and documenting falls. EI #2 stated, "the nurses on the units were responsible for investigating and documenting what happened. Then I do an investigation to try to determine if fall could have been prevented". She further stated the facility had fall meetings weekly, that were atttended by the DON, MDS Coordinator, Rehabilitation Manager, and a therapist, and they would also call the unit nurses to get more information, if needed. EI #2 was then asked where investigation forms for falls were kept. EI #2 stated, "we don't really have an investigation form for falls". She stated an Incident / Accident form was used as a tracking report, at the end of the month, when preparing the QA (Quality Assurance) form. EI #2 was asked to review the Nurses Notes and Care Plan for RI #2. EI #2 was asked regarding the 12/21/12 fall , if RI #2 had sustained injuries with this fall. EI #2 stated, according to the nurses notes, RI #2 sustained a 0.5 cm (centimeter) abrasion. EI #2 was then asked what interventions were put in place after this fall and she stated that she didn't see one. EI #2 was then asked where the incident report for this fall was. EI #2 stated, she couldn't find a report for this incident. She further stated that she thought the report may be in a storage room in a box somewhere, that a past employee may have filed with older material. EI #2 was asked to review nurses notes and care plan for falls that RI #2 had on 12/22/12, 12/24/12 and 9/3/13. EI #2 was asked if any injuries were noted. EI #2 stated that for the 12/22/12 fall, she did not see where there was an injury. The 12/24/12 fall, there was right tibia / fibula pain, and for the 9/3/13 fall there were no injuries, per the nurses notes. EI #2 was asked if there were any new interventions put in place after these falls. EI #2 stated she did not see any new interventions with the 12/22/12 fall. The 12/24/12 fall, resident was to "call for assist for transfers and ambulation", per the care plan. EI #2 stated for the 9/3/13 fall, "encourage me to ask for assistance with my care". EI #2 stated she did not know where the incident reports for 12/22/12 or 12/24/12 were, but there was an accident / incident tracking report for the 9/3/13 fall. EI #2 was then asked what were some potential negative outcomes for not changing or implementing new interventions after falls. EI #2 stated, "if nothing done new or different, they can continue to fall and major injuries may occur". EI #2 was asked who was responsible for implementing new interventions after falls and she stated, interventions were put on care plans, discussed in daily report or care conference, and they tried to brainstorm with each other to come up with new approaches. EI #2 stated, they made sure nurses and Sister Supervisors were made aware, and the CNA(s) (Certified Nursing Assistants) were also made aware. EI #2 was then asked how soon should new interventions be implemented and she stated, "immediately". EI #2 was then asked if there were any new interventions implemented after the falls RI #2 had. EI #2 stated, "we only saw 1 or 2; but they were the same". EI #2 was asked how often were care plans reviewed and revised. EI #2 replied, as the need came up; at set times or anytime new MDS were done - every 3 months or sooner (if significant change or accidents occurred). EI #2 was asked, who was responsible for review and revision of care plans and she stated, "for nursing care plans, the nurses are responsible to review and revise, as things occur". EI #2 was then asked how was review of care plans documented, and where. EI #2 stated, "as reviewed, in care conference, they are checked for any revisions needed, we sign during conference stating they were reviewed and revised ". On 10/31/2013 at 4:53 PM, an interview was conducted with EI #4 (MDS Coordinator). EI #4 was asked what was the facility's policy for investigating falls. EI #4 stated there was a form used as a guide to complete fall investigations and documentation, and once this form was completed, it was turned in to the DON. The DON then reviewed that all elements of the form were documented. EI #4 was then asked who was responsible for investigating and documenting falls, and she stated, "the nurses". EI #4 was then asked where were the investigation forms for falls kept. EI #4 stated, "once completed and signed by MD (Medical Doctor), thy are filed in a book with DON". She further stated that tabulations, trends, and approaches were investigated for residents who fell more often. EI #4 was asked to review the Nurses Notes and Care Plan for RI #2, for falls dated 12/21/12, 12/22/12, 12/24/12, and 9/3/13. EI #4 was asked if any injuries were sustained in these falls. EI #4 stated, for 12/21/12, she did not see an injury, then immediately stated there was a skin abrasion noted in the nurses notes. EI #4 stated, the 12/22/12 fall, "I don't see any ". EI #4 stated for the 12/24/12 fall, "resident has pain". EI #4 was then asked what interventions were put into place after these falls. EI #4 stated, for 12/21/12, "resident to keep room well lighted when attempting to move about". The 12/22/12 fall, EI #4 stated, "I don't see anything". The 12/24/12 fall, "resident to call for assistance with transfer and ambulation" and PT (Physical Therapy) screen. EI #4 was asked if there were incident reports for the three falls in December, 2012. She stated, "it should be one". EI #4 further stated the reports were probably filed somewhere with the 2012 reports. EI #4 was then asked what were some potential negative outcomes for not changing or implementing new interventions after falls. EI #4 stated, "there is a possibility of falling again; htory of falls is a(n) indicator that resident is at risk for falls". EI #4 was then asked who was responsible for implementing new interventions after falls. EI #4 stated, "we are - the nurses; we talk with CNA(s) to find out if there are any other solutions to keep falls from re-occurring; a Physical therapist also aides us with falls, with screens". EI #4 was asked how soon should new interventions be implemented after falls and she stated, "immediately". EI #4 was asked if there were any new interventions implemented after the falls RI #2 sustained, and why or why not. EI #4 stated, "we just communicated after falls and care plans were revised", to prevent re-occurrence. EI #4 was then asked how often were care plans reviewed and revised, and she stated, "every quarter and as needed". EI # 4 was asked who was responsible for the review and revision of care plans. EI #4 stated, the Inter-disciplinary Team, which included Activity, Social Services, Restorative, Dietary, and Nursing. EI #4 was then asked how was the review of care plans documented, and where. EI #4 stated, on the care plans. 2) A review of the facility's Policy and Procedure dated 7/2005 and titled, "MDS CARE PLAN POLICY" "... 5. At least every ninety (90) days and PRN, the nurse, the social worker, the dietary staff, activity staff, other staff and Resident and/or family update the comprehensive care plan." RI #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a quarterly MDS for RI #11 with an assessment reference date of 08/22/2013, revealed, RI #2 was coded as having a BIMS (Brief Interview Mental Status) score of 15 out a possible 15. This score indicated RI #11 was cognitively intact. RI #11 was coded as being independent for ADL's (Activities of Daily Living). A review of RI #11's Care Plan with a start date of 8/30/2012 for Elimination (bladder), Elimination (bowel), Pain, and one care plan untitled, but began with, " Most of the time, I use a motorized wheelchair ...," were noted with last review dates of 5/27/13. On 10/31/2013 at 3:45 PM, an interview was conducted with EI #2 (DON - Director of Nursing). EI #2 was asked how often were care plans reviewed and revised. EI #2 replied, as the need came up; at set times or anytime new MDS was done - every 3 months or sooner (if significant change or accidents occur). EI #2 was asked, who was responsible for review and revision of care plans and she stated, "for nursing care plans, the nurses are responsible to review and revise, as things occur". EI #2 was asked how was review of care plans documented and where. EI #2 stated, "as reviewed, in care conference, they are checked for any revisions needed; we sign during conference stating they were reviewed and revised". EI #2 was then asked, why was it important to review care plans at least every three months. EI #2 replied, "to make sure care plans match the resident and are up to date; to make sure that is a picture and care for that resident". On 10/31/2013 at 4:53 PM, and interview was conducted with EI #4 (MDS Coordinator); EI #4 was asked how often were care plans reviewed and revised, and she stated, "every quarter and as needed". EI #4 was then asked who was responsible for the review and revision of care plans. EI #4 stated, the Inter-disciplinary Team, which included Activity, Social Services, Restorative, Dietary, and Nursing. EI #4 was asked how was the review of care plans documented and where. EI #4 stated, on the care plans. EI #4 was then asked why was it important to review care plans at least every 3 months. EI #4 replied, "to make sure resident's condition has not changed and approaches are fitting residents needs". EI #4 was asked were any care plans not reviewed, revised and signed quarterly. She replied if the interdisciplinary team was on vacation. EI #4 also stated, they were reviewed all the time. She further stated every problem was reviewed and discussed.

Based on an observation, interviews and review of Standards of Practice (Potter and Perry, 7th Edition), the facility failed to ensure the CNA (Certified Nursing Assistant), EI (Employee Identifier) #3 did not operate the enteral feeding pump during incontinence care for RI (Resident Identifier) #7. This affected 1 of 1 residents sampled for tube feeding. Findings include: A review of standards of practice from Potter and Perry, 7th edition, page number 1118 "Delegation Considerations", revealed "Administration of enteral tube feeding via a [MEDICATION NAME], gastrostomy, or jejunostomy tube is a procedure that can be delegated to nursing assistive personnel after tube placement is verified by the nurse." A review of RI #7's medical record revealed RI #7 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/29/2013 at 4:10 p.m. RI #7 was lying on her left side with the head of the bed elevated, and gastrostomy tube feeding of Osymolite was infusing at 60 mL's (milliliters) an hour. EI #3 placed the feeding pump on hold and lowered the head of the bed to provide incontinence care for RI #7. The feeding pump was alarming, the CNA restarted the operation of the feeding pump after the head of the bed was elevated 30 degrees. During an interview with EI #3 on 10/31/2013 at 4:10 P.M., EI #3 was asked how long she had been a CNA. EI #3 responded, "[AGE] years". EI #3 was asked how long she had worked at the facility, EI #3 responded, "2 years". EI #3 was asked what did you do when you realized the feeding pump was infusing prior to incontinence care for RI #7. EI #3 responded, " I left the room and went and told the nurse EI #1 (Licensed Practical Nurse), and she told me it would be okay to turn the feeding pump off. EI #3 stated, "I turned the pump off". EI #3 was asked what she had done regarding the feeding pump after the incontinence care was completed. EI #3 responded, "I turned it back on after I let the head of the bed up 30 degrees." EI #3 was asked what were you taught to do regarding a resident with a feeding infusing via feeding pump and incontinence care was required. EI #3 stated, "we have not been trained to turn the feeding pumps on or off here. It does not take a rocket scientist to figure it out. I was trained to do the pump when I worked in home health and the nurse or the family was not there. If one tube came out and it was something I could not handle I would not do any of that. I do know how to turn the pump on and off. I trusted the nurse when you were watching me change RI #7". EI #3 was asked what the potential negative outcome was when unlicensed staff operated feeding pumps. EI #3 responded, "several things could happen. If they are off too long they won't get their proper nourishment". On 10/31/13 at 6:10 PM, an interview with EI #4, Registered Nurse (MDS Coordinator) was conducted. EI #4 was asked how were the CNA's trained to respond when a resident had a tube feeding in process via feeding pump and incontinence care needed to be provided. EI #4 stated "they can provide care to the resident as long as the head of the bed was elevated." EI #4 also stated, "in the event that the head of the bed needed to be let down, the licensed nurse needed to be notified to stop the tube feeding to prevent aspiration". The surveyor shared the observation of the CNA who turned the pump off, then provided care and then turned the pump back on. EI #4 was asked what was the potential negative outcome with this observation. EI #4 responded, "the CNA was [MEDICATION NAME] out of the scope of her CNA license and the policy and procedure of our home. It was an isolated incident, since then EI #1 and EI #3 had been instructed that this was a task for a nurse. It was not a task for a CNA to provide".

Based on an observation, interview, and record reviews, the facility failed to ensure a Certified Nursing Assistant (CNA): 1. Did not clean RI (Resident Identifier) #7 in a manner to prevent cross contamination while providing incontinence care on 10/29/13. 2. Opened the inner labia while providing incontinence care. 3. The CNA also failed to change bath water and the bath cloth after cleaning stool, during incontinence care on 10/29/13. This affected RI #7, one of two residents observed for incontinence care, and a resident with a history of UTI (Urinary Tract Infection). Findings Include: A review of, "POTTER & PERRY... Fundamentals of Nursing...7th Edition...reprint 2009," revealed: "...page- 878...39-2...Perineal Care... 3. Apply clean gloves, and assess genitals for signs of inflammation, skin breakdown, or infection. Discard gloves. Perform hand hygiene. ... 6. Prepare necessary equipment and supplies. 7. ...Assemble supplies at bedside. 8. Raise bed... 9. Apply clean gloves. ... 15. Provide Perineal care. A. Female Perineal care... (4) Wash labia majora. Use nondominant hand to gently retract labia from thigh; with dominant hand, wash carefully in skin folds. Wipe in direction from perineum to rectum (front to back). Repeat on opposite side using separate section of washcloth. Rinse and dry thoroughly. (5) Separate labia with nondominant hand to expose urethral meatus and vaginal orifice. With dominant hand, wash downward from pubic area toward rectum in one smooth stroke. ...Use separate section of cloth for each stroke ..." A review of RI #7's History and Physical from a local hospital dated 7/17/13, revealed: "...She has ... some recurrent urinary tract infections." RI #7 was re-admitted to the facility on [DATE] and re-admitted on [DATE], with [DIAGNOSES REDACTED]. A review of RI #7's current Quarterly Minimum Data Set (MDS), dated [DATE] revealed RI #7 was severely impaired for cognitive function and daily decision making. The MDS also documented RI #7 required extensive to total assistance with Activities of Daily Living. RI #7 was coded as always incontinent of bowel and bladder functioning. On 10/29/13 at 4:00 PM, the following was observed during incontinence care for RI #7. Employee Identifier (EI) #3, (CNA) washed her hands and applied gloves, obtained a basin of water, put a bar of soap, and then a wash cloth in the water. EI #3 operated the feeding pump then removed RI #7's adult brief which contained a soft brown stool. EI #3 did not change gloves or wash her hands. EI #3 wiped the front of RI #7's perineal area from front to back three times to remove the stool. EI #3 did not change the position of the wash cloth. EI #3 put the wash cloth back into the basin of water with the soap and pulled it back out and wiped RI #7's bottom from front to back on the right side, the left side, and then down the middle. EI #3 did not change the position of the wash cloth. EI #3 used the same wash cloth that she used to clean stool off of the resident. EI #3 changed the water in the basin, then washed her hands and changed her gloves. EI #3 cleaned the front of the perineal area by wiping three times without changing the position of the wash cloth. EI #3 changed the position of the wash cloth then wiped the front of the perineal area twice without changing the position of the wash cloth. EI #3 did not open the labia to clean the resident correctly. EI #3 applied a clean brief then removed her gloves and washed her hands. On 10/31/13 at 4:10 PM, EI #3, was interviewed. The surveyor asked EI #3 how was she taught to provide incontinence care for a resident with stool. EI #3 said to provide privacy, let the resident know what she was going to do. EI #3 explained she would get a basin of water and soap and wipe front to back. When the surveyor asked EI #3 how she cleaned RI #7 during the above incontinence care, EI #3 stated, "I cleaned the BM (bowel movement) off. I didn't go by proper procedure. I was just scared." The surveyor asked when she changed the position of the wash cloth. EI #3 said she did not remember. When the surveyor asked when the position of the wash cloth should be changed during incontinence care, EI #3 stated, "We are supposed to wipe then change the position of the wash cloth." The surveyor asked EI #3 when she changed the basin of water while providing incontinence care to RI #7. EI #3 stated, "I poured it out and got fresh water after I got the bowel movement off." EI #3 was asked when hands should be washed while incontinence care was provided. EI #3 stated, "Before during and after." The surveyor discussed the above incontinence care observation. EI #3 was asked what the potential negative outcome was when the contaminated water and wash cloth were not changed during incontinence care. EI #3 said spread of germs. EI #3 was also asked what the potential negative outcome was, when hands were not washed and gloves were not changed appropriately during incontinence care. EI #3 stated, "spread of germs." An interview was conducted with EI #8, the Licensed Practical Nurse, and the facility ' s Infection Control Coordinator. The surveyor discussed the above incontinence care observation, and then asked what the potential negative outcome was. EI #8 stated, "The resident could get an infection from the perineal area to the urethra from the cloth, and if the resident does get an infection/UTI (urinary tract infection), it could be fatal."

Based on interviews and record reviews, the facility failed to ensure that new interventions were put in place for RI (Resident Identifier) #2, a resident that experienced 2 of 4 falls with injuries. This affected 1 of 5 residents sampled for falls. Findings include: RI #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a significant change MDS (Minimum Data Set) for RI #2 with an assessment reference date of 09/18/2013 revealed, RI #2 was coded as having a BIMS (Brief Interview Mental Status) score of 14 out a possible 15. This score indicated RI #2 was cognitively intact. RI #2 was coded as needing extensive assistance for transfers, dressing, and toileting. A review of RI #2's Care Plan with a start date of 2/20/12 indicated RI #2 had sustained falls on 12/21/12, 12/22/12, 12/24/12, and 9/3/13. The facility was unable to locate the Accident / Incident Reports for falls of 12/21/12, 12/22/12 and 12/24/12, however there was a form available for the 9/3/13 fall. The following interventions with respective dates, were noted on Care Plan for RI #2: 1) An undated entry for: "I will keep my room well lighted when attempting to move about" 2) "9/3/13 Encourage me to ask for assistance with my care" 3) An undated entry for: "Explained to Resident to put her Call Light on when need to go to BR (bathroom)" 4) "12/24/12 Call for assist with transfers & amb (ambulation)" 5) "12/24/12 PT screen done." (difficult to read) A review of the Nurse's Notes for RI #2 revealed: 1) "12/21/12 8:30P (PM) Resident found laying on floor next to her bed, feet... . Resident was encouraged to be sure rm (room) is well lighted & to use her walker at all times & to call for assistance when needed. ..." 2) "12/22/12 10:15 Resident from next room came to nurse, stated that Resident on floor in BR. Nurse went to room Resident on floor by commode Holding on to Rail on wall. ... Call light in reach and told Resident to put call light on when need assistance. ..." 3) "12/24/12 1030A (AM) Resident found lying on (R) (right) side on floor ... Resident given call light & instructed to call for assist in order to get up / transfer. ..." 4) "9/3/2013 07:49 Health Status Note Text: resident reported she slipped off side of bed onto floor and got up by herself back onto bed. ... encouraged to call for assist when getting up..." On 10/31/2013 at 3:45 PM, an interview was conducted with EI #2 (DON - Director of Nursing). EI #2 was asked what was the facility's policy for investigating falls. EI #2 stated when a resident had a fall, a nurse assessed the resident by range of motion (ROM) to detect injury. The resident was assisted up if there was no injury, and vital signs were assessed. EI #2 further stated that they (the nurses) would try to assess what the resident may have been trying to do, that may have precipitated the fall. EI #2 was asked who was responsible for investigating and documenting falls. EI #2 stated, "the nurses on the units are responsible for investigating and documenting what happened. Then I do an investigation to try to determine if fall could have been prevented". She further stated the facility had fall meetings weekly, that were attended by the DON, MDS Coordinator, Rehab Manager, and a therapist, and they would also call the unit nurses to get more information, if needed. EI #2 was then asked where investigation forms for falls were kept. EI #2 stated, "we don't really have an investigation form for falls". She stated an Incident /Accident form was used as a tracking report, at the end of the month when preparing the QA (Quality Assurance) form. EI #2 was asked to review the Nurses Notes and Care Plan for RI #2. For the 12/21/12 fall , EI #2 was asked if RI #2 had sustained any injuries with this fall. EI #2 stated, according to the nurses notes, RI #2 sustained a 0.5 cm (centimeter) abrasion. EI #2 was asked what interventions were put in place after this fall, and she stated that she didn't see one. EI #2 was asked where the incident report for this fall was. EI #2 stated, she couldn't find a report for this incident. She further stated that she thought the report may be in a storage room in a box somewhere, that a past employee may have filed with older material. EI #2 was asked to review nurses notes and care plan for falls that RI #2 had on 12/22/12, 12/24/12 and 9/3/13. EI #2 was asked if any injuries were noted. EI #2 stated that for the 12/22/12 fall, she did not see where there was an injury. EI #2 stated the 12/24/12 fall, there was right tibia / fibula pain. EI #2 stated, the 9/3/13 fall there were no injuries, per nurses notes. EI #2 was asked if there were any new interventions put in place after these falls. EI #2 stated she did not see any new interventions with the 12/22/12 fall; for the 12/24/12 fall, resident was to "call for assist for transfers and ambulation", per the care plan. EI #2 stated for the 9/3/13 fall, "encourage me to ask for assistance with my care". EI #2 stated she did not know where the incident reports for 12/22/12 or 12/24/12 were, but there was an accident / incident tracking report for the 9/3/13 fall. EI #2 was asked what were some potential negative outcomes for not changing or implementing new interventions after falls. EI #2 stated, "if nothing done new or different, they can continue to fall and major injuries may occur". EI #2 was asked who was responsible for implementing new interventions after falls. EI #2 stated, interventions were put on care plans, discussed in daily report or care conference, and they tried to brainstorm with each other to come up with new approaches. EI #2 stated, they made sure nurses and the Sister Supervisors were aware, then the CNA(s) (Certified Nursing Assistants) were made aware. EI #2 was then asked how soon should new interventions be implemented, and she stated "immediately". EI #2 was then asked if there were any new interventions implemented after the falls RI #2 had. EI #2 stated, "we only saw 1 or 2; but they were the same". EI #2 was asked how often were care plans reviewed and revised. EI #2 replied, as the need came up; at set times or anytime new MDS was done - every 3 months or sooner (if significant change or accidents occur). EI #2 was then asked, who was responsible for review and revision of care plans and she stated, "for nursing care plans, the nurses are responsible to review and revise, as things occur". EI #2 was then asked how was review of care plans documented, and where. EI #2 stated, "as reviewed, in care conference, they are checked for any revisions needed; we sign during conference stating they were reviewed and revised " . On 10/31/2013 at 4:53 PM, an interview was conducted with EI #4 (MDS Coordinator). EI #4 was asked what was the facility's policy for investigating falls. EI #4 stated there was a form used as a guide to complete fall investigations and documentations, and once this form was completed, it was turned in to the DON. The DON then reviewed that all elements of the form were documented. EI #4 was then asked who was responsible for investigating and documenting falls, and she stated, "the nurses". EI #4 was asked where were the investigation forms for falls kept. EI #4 stated, "once completed and signed by MD (Medical Doctor) they are filed in a book with DON". She further stated tabulations, trends and approaches were investigated with residents who fell more often. EI #4 was asked to review the Nurses Notes and Care Plan for RI #2, for falls dated 12/21/12, 12/22/12, 12/24/12, and 9/3/13. EI #4 was asked if any injuries were sustained in the falls. EI #4 stated, for 12/21/12, she did not see an injury, then immediately stated there was a skin abrasion noted in the nurses notes. EI #4 stated, the 12/22/12 fall, "I don't' see any". The 12/24/12 fall she stated, "resident has pain". EI #4 was then asked what interventions were put into place after these falls. EI #4 stated, for 12/21/12, "resident to keep room well lighted when attempting to move about". The 12/22/12 fall, EI #4 stated, "I don't see anything". The 12/24/12 fall, "resident to call for assistance with transfer and ambulation" and PT (Physical Therapy) screen. EI #4 was asked if there were incident reports for these (listed) falls, and for all three falls, she stated, "it should be one". EI #4 further stated the reports were probably filed somewhere with 2012 reports. EI #4 was asked what were some potential negative outcomes for not changing or implementing new interviews after falls. EI #4 stated, "there is a possibility of falling again; history of falls is a(n) indicator that resident is at risk for falls". EI #4 was asked who was responsible for implementing new interventions after falls. EI #4 stated, "we are - the nurses. We talk with CNA(s) to find out if there are any other solutions to keep falls from re-occurring; a physical therapist also aides us with falls, with screens". EI #4 was then asked how soon should new interventions be implemented after falls and she stated, "immediately". EI #4 was asked were any new interventions implemented after the falls RI #2 sustained, and why or why not. EI #4 stated, "we just communicated after falls and care plans were revised", to prevent re-occurrence. EI #4 was asked how often were care plans reviewed and revised, and she stated, "every quarter and as needed ". EI #4 was asked who was responsible for the review and revision of care plans. EI #4 stated, the Inter-disciplinary Team, which included Activity, Social Services, Restorative, Dietary, and Nursing. EI #4 was then asked how was the review of care plans documented, and where. EI #4 stated, on the care plans.

Based on an observation, interviews, and record reviews, the facility failed to ensure medications were administered to RI (Resident Identifier) #10 at appropriate times. RI #10 had 3 medications due to be administered at 5:00 PM that were given at 3:35 PM. This gave the facility an 11% (percent) medication administration error rate. This affected RI #10, 1 of 12 residents observed during medication pass. Findings include: A review of RI #10's medical record revealed RI #10 was readmitted to the facility on 11/13/12 with [DIAGNOSES REDACTED]. A review of RI #10's Physicians Orders dated 10/1/13 through 10/31/13, revealed the following orders: "[MEDICATION NAME] 100 MG (milligrams) CAPSULE DOC-Q-LACE 100 MG SOFTGEL GIVE ONE (1) CAPSULE BY MOUTH TWICE DAILY. DX: CONSTIPATION (9AM, 5PM)"; "[MEDICATION NAME] 37.5-25 CAPSULE [MEDICATION NAME]-HCTZ 37.5-25 GIVE ONE (1) CAPSULE BY MOUTH TWICE DAILY. DX: [MEDICAL CONDITION] (9AM, 5PM)"; "[MEDICATION NAME] 300 MG CAPSULE [MEDICATION NAME] 300 MG CAPSULE GIVE ONE (1) CAPSULE BY MOUTH 3 TIMES A DAY. DX: [MEDICAL CONDITION] (9AM, 1PM, 5PM)". On 10/29/2013 at 3:35 PM the surveyor observed EI (Employee Indentifier) #1, an LPN (Licensed Practical Nurse), administer [MEDICATION NAME], and [MEDICATION NAME], ordered for 5:00 PM, to RI #10. During an interview with EI #1 on 10/31/2013 at 3:10 pm, EI #1 was asked if a medication was ordered for BID (twice a day), what times should this medication be given. EI #1 stated, 9 in the morning and 5 in the evening. When asked why, EI #1 stated as indicated by the MAR (Medication Administration Record). EI #1 was then asked if medications were ordered for TID (three times a day), what times should these medications be given. EI #1 stated, usually 9, 2, and 6 or 7, she thought based on the MAR. When asked why, EI #1 stated based on the MAR. EI #1 was asked if medications were ordered for 5:00 PM what was the time frame these medications could be administered within. EI #1 stated between 4 and 6 PM. EI #1 was asked what was the potential negative outcome for residents if medications were administered too early. EI #1 stated, overlap, too much medication in their system. EI #1 was asked if RI #10 had [MEDICATION NAME] and [MEDICATION NAME] ordered BID, what time should the afternoon dose be administered. EI #1 stated between 4 and 6 PM. EI #1 was asked if RI #10 had [MEDICATION NAME] ordered TID, what time should the evening (last dose of the day) be given. EI #1 stated it should be 5 PM (after she (EI #1), reviewed the physician's orders [REDACTED].#10. When asked why they were given early, EI #1 stated, she saw the surveyor, got to talking, and was thinking about treatments being done and getting checked. So she (EI #1), went ahead and gave these medications. When asked what was the potential negative outcome for this resident receiving these 3 medications early, EI #1 stated, side effects of drowsiness, too much in her system, side effects less likely. EI #1 was asked what was the policy at the facility for charting medication given outside of the designated time range. EI #1 stated that she should note the actual time it was given. During an interview with EI #2, DON (Director of Nursing) on 10/31/13 at 4:45 PM, EI #2 was asked if medications were ordered BID, what time should they be given. EI #2 stated 8 AM and 5 PM, no, 9 AM and 5 PM. EI #2 was then asked if medications were ordered TID, what time should they be given. EI #2 stated, 9 AM, 1 PM, and 5PM. EI #2 was asked if medications were ordered at 5 PM, what was the time frame these medications could be administered. EI #2 stated, 4 PM to 6 PM. EI #2 was asked if a resident was ordered to receive [MEDICATION NAME], and [MEDICATION NAME] at 5:00 PM, should these be administered at 3:35 PM. EI #2 stated, no. When asked why not EI #2 stated it's 25 minutes too early. When EI #2 was asked what was the potential negative outcome for the resident, if [MEDICATION NAME] (ordered TID), [MEDICATION NAME] and [MEDICATION NAME] (ordred BID) was given early. EI #2 stated too much of the medication in their system.

Based on an observation, interview and record reviews, the facility failed to ensure a Certified Nursing Assistant (CNA): 1. Did not clean RI (Resident Identifier) #7 in a manner to prevent cross contamination while providing incontinence care on 10/29/13. 2. The CNA failed to change the bath water and bath cloth after cleaning stool, during incontinence care for RI #7 on 10/29/13. This affected RI #7, one of 2 residents observed for incontinence care. Findings Include: A review of, "POTTER & PERRY... Fundamentals of Nursing...7th Edition...reprint 2009", revealed: "...page- 878...39-2...Perineal Care... 3. Apply clean gloves, and assess genitals for signs of inflammation, skin breakdown, or infection. Discard gloves. Perform hand hygiene. ... 6. Prepare necessary equipment and supplies. 7. ...Assemble supplies at bedside. 8. Raise bed... 9. Apply clean gloves. ... 15. Provide Perineal care. A. Female Perineal care... (4) Wash labia majora. Use nondominant hand to gently retract labia from thigh; with dominant hand, wash carefully in skin folds. Wipe in direction from perineum to rectum (front to back). Repeat on opposite side using separate section of washcloth. Rinse and dry thoroughly. (5) Separate labia with nondominant hand to expose urethral meatus and vaginal orifice. With dominant hand, wash downward from pubic area toward rectum in one smooth stroke. ...Use separate section of cloth for each stroke. ..." RI #7 was admitted to the facility on [DATE] and re-admitted on [DATE], with [DIAGNOSES REDACTED]. A review of RI #7's current Quarterly Minimum Data Set (MDS), dated [DATE] revealed RI #7 was severely impaired for cognitive function and daily decision making. The MDS also documented RI #7 required extensive to total assistance with Activities of Daily Living. RI #7 was coded as always incontinent of bowel and bladder functioning. On 10/29/13 at 4:00 PM, the following was observed during incontinence care for RI #7. Employee Identifier (EI) #3, (CNA) washed her hands and applied gloves, obtained a basin of water, put a bar of soap, and then a wash cloth in the water. EI #3 operated the feeding pump then removed RI #7's adult brief which contained a soft brown stool. EI #3 did not change gloves or wash her hands. EI #3 wiped the front of RI #7's perineal area from front to back three times to remove the stool. EI #3 did not change the position of the wash cloth. EI #3 put the wash cloth back into the basin of water with the soap and pulled it back out and wiped RI #7's bottom from front to back on the right side, then left side and then down the middle. EI #3 did not change the position of the wash cloth. EI #3 used the same wash cloth that she used to clean stool off of the resident. EI #3 changed the water in the basin, then washed her hands and changed her gloves. EI #3 cleaned the front of the perineal area by wiping three times without changing the position of the wash cloth. EI #3 changed the position of the wash cloth then wiped the front of the perineal area twice without changing the position of the wash cloth. EI #3 applied a clean brief then removed her gloves and washed her hands. On 10/31/13 at 4:10 PM, EI #3, was interviewed. The surveyor asked EI #3 how was she taught to provide incontinence care for a resident with stool. EI #3 explained she would get a basin of water and soap and wipe front to back. When the surveyor asked EI #3 how she cleaned RI #7 during the above incontinence care, EI #3 stated, "I cleaned the BM (bowel movement) off. I didn't go by proper procedure. I was just scared." The surveyor asked EI #3 when she changed the basin of water while providing incontinence care to RI #7. EI #3 stated, "I poured it out and got fresh water after I got the bowel movement off." EI #3 was asked when hands should be washed while incontinence care was provided. EI #3 stated, "Before, during, and after." The surveyor discussed the above incontinence care observation. EI #3 was asked what the potential negative outcome was, when the contaminated water and wash cloth were not changed during incontinence care. EI #3 said, spread of germs. EI #3 was also asked what the potential negative outcome was, when hands were not washed and gloves were not changed appropriately during incontinence care. EI #3 stated, "spread of germs." An interview was conducted with EI #8, the Licensed Practical Nurse, and the facility's Infection Control Coordinator. The surveyor discussed the above incontinence care observation, and then asked what the potential negative outcome was. EI #8 stated, "The resident could get an infection from the perineal area to the urethra from the cloth, and if the resident does get an infection/UTI (urinary tract infection), it could be fatal."

Based on observation, record review, and interviews and the facility's "A Matter of RIGHTS", the facility failed to ensure that a Licensed Practical Nurse (LPN) and Certified Nurse Assistant (CNA) covered RI #4, during wound care. On 10/11/2012 at 2:44 pm Employee Identifier (EI) #1 assisted (Resident Identifier) RI #4 into bed and removed her pants and underwear and placed her in bed. EI #1 did not cover RI #4; instead RI #4 was left naked (exposed) from the waist down, with her buttocks facing the door. EI #2, the LPN who performed wound care on RI #4, never covered RI #4, leaving her exposed from the waist down until she was done with care at 3:12 pm. This deficient practice affected one of two residents observed for wound care. Findings Include: A facility document titled, "A Matter of RIGHTS," copyright date of 2000, page 12 documented, "Your Right to privacy and confidentiality is as important to you as it is to any other person. You have the right: -to have other people respect your personal privacy ... as you receive care... Our policies and procedures addressing privacy and confidentiality are; 1. A resident is entitled to privacy in accommodations ... personal care ...." RI #4 was admitted to the facility on [DATE] and readmission date of 7/1/2009 with [DIAGNOSES REDACTED]. On 10/11/2012 at 2:44 pm, the nurse, EI #2, the CNA, EI #1 accompanied by the surveyor entered RI #4's room for the observation of wound care. EI #1 explained to resident that she needed to lay her down. RI #4 stated she understood and got up from recliner into her wheelchair. EI #1 rolled RI #4 to the edge of her bed and laid her down. EI #1 removed RI #4's pants and underwear, and then laid RI #4 on her right side with her buttocks facing the door. EI #1 did not cover RI #4 and left her exposed from the waist down. On 10/11/2012 at 2:50 pm, EI #2 washed her hands and proceeded with setting up the supplies for the dressing change and never attempted to cover RI #4. On 10/11/2012 at 2:55 pm, EI #2 left the room and closed the door, leaving RI #4 lying on the bed on her right side exposed from the waist down. EI #2 returned to room and closed the door. On 10/11/2012 at 2:56 pm, EI #1 left the room leaving the door open and RI #4 remained in bed on her right side with her buttocks facing the open door. RI #4 remained exposed from the waist down lying on her right side. EI #2 removed the old dressing from RI #4's buttocks. On 10/11/2012 at 3:02 pm, as EI #2 removed her gloves and went to wash her hands, EI #2 was observed to close the door. EI #2 did not cover RI #4, who remained exposed from the waist down on the bed. On 10/11/2012 at 3:12 pm, after observing wound care, RI #4 remained lying on her right side buttocks facing the door, exposed from the waist down, when EI #2 and the Surveyor exited the room. On 10/11/201 at 5:10 pm, EI #2 was interviewed by the surveyor regarding the care of RI #4. EI #2 was asked why RI #4 was left exposed and not covered while care was being provided. EI #2 stated she should have covered RI #4. EI #2 was asked by the surveyor what happens when you leave residents exposed. EI #2 stated that RI #4 was not provided privacy, she could have gotten cold and someone could have seen her. On 10/12/2012 at 11:53 am, EI #1, a CNA, was interviewed by the surveyor, regarding the care provided to RI #4 on 10/11/2012. EI #1 was given a summary of the observation on 10/11/2012 by the surveyor, and then asked why she did not cover RI #4. EI #1 stated she was surprised that the surveyor was in the room, she could have covered her but she wanted to get a clean sheet, she could have used the covers on RI #4's bed. EI #1 was asked how did she provide dignity and respect to the residents. EI #1 stated she closed the resident's door, knock when she entered and provide a good temperature when bathing. EI #1 stated she apologized if she had did something wrong.

Based on observation, record review, and interview the facility failed to ensure that Employee Identifier (EI) number (#) 2 was able to measure and stage pressure sores on Resident Identifier (RI) number (#) 4. On 10/11/2012 at 2:56 pm, during an observation of wound care the Licensed Practical Nurse (LPN), EI #2 acknowledged that she did not know how to properly measure and stage RI #4's wounds. On 10/12/2012 at 12:13 pm, an interview with the facility's Resident Care Coordinator, EI #3 stated that the facility nurse's had not been provided training by the facility on how to measure and stage wounds. This deficient practice affected RI #4, one of three residents sampled for pressure sores. Findings include: RI #4 was admitted to the facility on [DATE] and with a readmission date of [DATE] with [DIAGNOSES REDACTED]. On 10/11/2012 at 2:56 p.m., EI #2 removed the old dressing (undated and unsigned) from RI #4's buttocks. Surveyor observed areas to RI #4's right and left buttocks. After EI #2 cleansed the areas, the surveyor asked EI #2 to measure and describe the wounds. EI #2 picked up the clear measuring tool, then placed it back on the table and picked up the paper measuring tool and began to measure the wounds. EI #2 then measured an area to the left buttocks and gave measurements of 0.5 centimeters by 0.5 centimeters. EI #2 was asked if she was sure about the measurements. EI #2 became silent then placed the measuring tools against the wounds and began to turn the measuring tool, while fumbling with it the tool. EI #2 was asked by the surveyor if she knew how to measure and stage wounds. EI #2 stated, "I clean them (the wounds) and change the dressing when I work. No I don't. No mamam." On 10/11/2012 at 3:15 pm, EI #3, came to the floor and measured RI #4's wounds. EI #3 measured the wound on RI #4's right buttock. EI #3 gave the measurements of 3 cm (centimeters) by 1.5 cm. (which were larger than the measurements given by EI #2). EI #3 stated there were two wounds to the left buttocks and gave the measurements of 0.6 cm by 0.7 cm for the wound to the upper left buttock and measurements of 0.5 cm. by 0.5 cm.. On 10/11/2012 at 5:10 p.m., EI #2 was interviewed by the surveyor regarding the care of RI #4. EI #2 was asked when was she last trained on measuring and staging of wounds. EI # 2 stated that at her last job she did not have to be trained because they had a treatment nurse who measured and did treatments. EI #2 was asked what training had she received at this facility on measuring and staging wounds. EI #2 stated she had not been trained by this facility. On 10/12/2012 at 12:13 pm, EI #3 was interviewed by the surveyor. EI #3 was asked if she was responsible for in-servicing the staff. EI #3 stated she was. EI #3 was asked when was the last in-service on the measuring and staging of wounds. EI #3 stated she had not done an in-service but had an in-service the staff on wound prevention about a year ago. EI #3 was asked how she ensured the nurses knew how to measure and stage wounds. EI #3 stated the nurses learn it in school and when she came to the facility she was under the impression that the nurses knew. EI #3 stated she had only been in the position for about a year maybe a year and a half and she in-serviced staff based on what the previous DON (Director of Nursing) had scheduled. On 10/12/2012 at 11:12 p.m., EI #6, the current DON, was interviewed by the surveyor. EI #6 was asked how he trained the nurses on policies and procedures. EI #6 stated through in-services. EI #6 was asked how he trained the nurse on measuring and staging wounds. EI #6 stated through in-services. EI #6 was asked when was the last in-service on measuring and staging wounds. EI #6 stated he could not answer that question because he had only been at the facility since April (2012), and an in-service had not been done since he had been there. EI #6 was asked how he knew that the nurses are doing what they should be for wound care. EI #6 stated there were not many wounds in the facility. EI #3 stated if the nurse doesn't know then the nurses should ask and someone would instruct and help them. EI #3 was asked if he was aware that EI #2 did not know how to measure and stage wounds. EI #6 stated he did not. EI #6 was asked how many other nurses did not know how to measure and stage wounds. EI #6 stated he had no idea, that if the nurse don't know then they should come to him.

Based on observation, record review, and interviews the facility failed to have interventions in place to ensure that Resident Identifier (RI) number (#) 4, a resident assessed as being at high risk for developing pressure ulcers and having one stage I pressure sore to her right buttocks, did not developed two additional stage II pressure sores to her left buttocks. During an observation of wound care on 10/11/2012 at 3:15 pm, with Employee Identifier (EI) #3, RI #4 was observed to have a stage I pressure sore to her right buttock, she was also found to have two stage II pressure sores to her left buttock. This deficient practice affected one of three residents at the facility with pressure sores. Findings include: RI #4 was admitted to the facility on [DATE] and a readmission date of [DATE] with [DIAGNOSES REDACTED]. RI #4's quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 8/09/2012, assessed RI #4 as having a Brief Interview for Mental Status (BIMS) of 12 (a score of 8 to 12 indicates the resident has moderately impaired cognition). RI #4 was assessed as requiring limited assist for bed mobility, transfers and personal hygiene. RI #4 was assessed as being continent of bowel and bladder. Under section "M" (Skin Conditions) RI #4 was assessed as being at risk for pressure sore development and was not documented to have pressure sores. Review of RI #4's care plan for "SKIN INTEGRITY" dated 10/5/2012, documented, "... 10/05/12 Stage 2 to buttocks ..." The care plan listed as an intervention "10/5/12 Apply [MEDICATION NAME] to area on buttocks until healed measure & (and) document weekly". There are no other interventions listed on the care plan for this date. Review of RI #4's "NURSES NOTES", had an entry by EI #5, the nurse who found the wound, documented, "10-5-12 2 P (p.m.) Resident has a stage II ulcer to her inner right buttock, with yellow exudate in the center ... " On 10/11/2012 at 3:15 pm, EI #3, LPN, the Resident Care Coordinator, measured RI #4's wounds. EI #3 measured the wound on RI #4's right buttock. EI #3 gave the measurements of 3 cm (centimeters) by 1.5 cm. (which were larger than the measurements given by EI #2). EI #3 stated there were two wounds to the left buttocks and gave the measurements of 0.6 cm by 0.7 cm for the wound to the upper left buttock and measurements of 1.5 by 1.5 with a 0.5 cm. by 0.5 cm open area to the center. On 10/11/2012 at 2:35 pm, an interview was conducted with RI #4 at her bedside by the surveyor. RI #4 stated she had a small area on her bottom. RI #4 stated she had the (Certified Nurse Assistant) CNA's treating it and the CNA's reported it to the nurse and the nurses started treating it. RI #4 was asked how the area started. RI #4 stated she believed it started from her sliding on the bed. RI #4 explained that she slides to the edge of the bed to get up. On 10/12/2012 at 8:35 a.m., a phone interviewed was conducted by the surveyor with EI #7, the CNA who reported the area on RI #4's buttock. EI #7 stated she noticed the area while giving RI #4 a shower. EI #7 described the area as a small scraped on the right side. EI #7 stated that RI #4 told her it came from her sliding in bed and it was from rubbing on the sheets. EI #7 stated she reported it to the nurse. EI #7 was asked was she told to do anything different for RI #4. EI #7 stated not that she could remember. On 10/12/2012 at 12:10 p.m., a phone interview was conducted with EI #5, Licensed Practical Nurse (LPN) regarding RI #4's wounds. EI #5 stated that RI #4 had a pressure sore on her buttock; she called the doctor and requested an order. EI #5 stated that on the next day RI #4 was crying because the wound was hurting and she changed the dressing. EI #5 was asked when did she develope the wounds on the left side. EI #5 stated she did not have any wounds on the left side. EI #5 stated when she changed the dressing RI #4 only had an area on the right and described it as being a small open area. The DON provided the surveyor with a "FACSIMILE TRANSMITTAL" dated 10/5/2012 that documented, "... (RI #4's name and information) Resident has a stage 2 pressure ulcer on her inner right buttock, c (with)yellow exudate in center. May we have an order for [REDACTED].#5. Review of RI #4's "NURSES NOTES", had an entry by EI #5, the nurse who found the wound, which documented, " ... 10-7-12 2 P Resident c/o discomfort and pain D/T (due to) [MEDICATION NAME] cruppling (crumpling) up, dressing changed, ..." Review of RI #4's "NURSES NOTES", had an entry by EI #5, the nurse who measured the wounds, which documented, " ... 10/11/12 3:30 pm Drsg (dressing) changed & (and) measuring of open areas to buttocks, noted to have three areas, # (number) 1 RT (right) buttocks pink abraded area c (with) open area full surface, stage two, 3cm x (by) 1.5cm unblanchable .3 x .3 open area at top of area, #2, upper left 0.6cm x 0.7cm pink edges, full surface stage two, surrounded by dry peeling skin, #3, left lower buttocks 1.5cm x 1.5cm unblanchable 0.5 x 0.5cm open area to center c dry peeling skin around area, there was no drainage or odor to any of the wounds, cleansed c NS (normal saline), patted dry, applied [MEDICATION NAME] to site #1, placed call to (RI #4's physician name) to get tx. (treatment)." Review of RI #4's care plan for "SKIN INTEGRITY" date 10/5/2012, documents as interventions, "10/11/12 Assist me with turning and positioning ... Assure that a high Density Mattress is in place Assist me with toileting. Keep me off affected area ... Provide me with High Protein snacks twice daily."

Based on observation, record review and interview 1. the facility failed to ensure expired milk was not in the general refrigerated food supply. 2. The facility failed to ensure dented canned goods were not stored in the general food supply. 3. The facility failed to ensure food preparation equipment, dishes/utensils were effectively sanitized to destroy potential food borne organisms. 4. The facility failed to ensure staff washed their hands before moving from the dirty dishes to the clean dishes in the dish machine room. 5. The facility failed to monitor and follow correct manual dishwashing procedures, i.e. 3 compartment sink, correct water temperature, and immersion time. 6. The facility failed to ensure direct care staff did not contact ready to eat food with their bare hands. This had the potential to affect 71 of 73 residents receiving meals from dietary. 1. On initial tour on 11/29/11 at 11:18 AM, four expired milks were observed to be stored together with other milk in the walk in cooler. At 3:20 PM, EI #6 was observed to place the four milks with the expiration date of 11/28/11 on a cart to be served to the residents. EI #4 stepped in and removed the milks and threw them into the trash. 2. On intial tour on 11/29/11 at 11:18 AM, two dented #10 cans of sliced pineapple and three dented 4 pound cans of chunk light tuna were observed to be in the general food storage area with other canned goods. EI #4 removed the 5 cans from the storage area and placed them in the Dietary Manager Office. In an interview on 11/29/11 at 11:20 AM, with EI #4, she was asked where do you keep the dented cans. She responded, in her office. 3. On 11/29/11 at 3:15 PM, EI (Employee Identifer) #6, Food Service Worker, was observed to arrange dirty dishes in the dishmachine and then without washing his hands started putting up clean dishes. 4. On 11/29/11, EI #4, Certified Dietary Manager, was asked to provide the log for checking of the pH and temperature of the sanitizing section of the three compartment sink. In an interview on 11/29/11 at 5:17 PM, EI #4 explained to the surveyor that the facility did not have a log to record the chemical concentration or temperature of the 3 compartment sink. 5. On 11/29/11 at 3:30 PM, EI #6 was observed washing and rinsing an oversized bowl in the three compartment sink. He washed the bowl in the 1st compartment, dipped and rotated the bowl in the 2nd compartment and then transferred the bowl to the 3 compartment rotating the bowl briefly through the hot water. EI #6 then placed the bowl to air dry. After the bowl was air dried, EI #6 put the bowl back in stock with bowls to be used again. EI #6 was asked what the chemical concentration of the sink measured. He responded, I do not know. EI #6 was asked have you ever checked the chemical concentration, he responded, NO. A review of the facility policy titled "How to clean and sanitize in three compartment sink" with no review/revision date revealed, "...Sanitizing can be accomplished via chemicals or heat. Heat Sanitizing: Soak items in hot water, the water must be at least 171 degrees F (Farenheit) and must be soaked for 30 seconds. Chemical Sanitizing: is a mix of chemical sanitized and water. Check concentration of sanitizer using a test strip to =200 ppm (parts per million) as per manufacture's recommendations..." 6. On 11/30/11 at 8:15 AM, EI #7, (Certified Nurse Assistant) was observed to pick up an unsampled resident's biscuit with her bare hand, apply butter and jelly. After applying the condiments EI #7 placed the biscuit back on the resident's plate. The resident was observed to take a bite of the biscuit.

Based on record review and interview the facility failed to weigh RI (Resident Identifier) #9 weekly on Tuesdays, as care planned. This affected one of four residents sampled with weight loss. Findings Include: RI #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #9's most recent Quarterly Minimum Data Set with an Assessment Reference Date of 10/13/11 assessed her as having a BIMS (Brief Interview of Mental Status) score of 9; a score of 8-12 indicates the resident is moderately cognitive impaired. RI #9 was also assessed as needing limited to extensive assistance with all Activities of Daily Living and as being incontinent. A review of the Care Plan with a focus of "Nutrition: I have a history of dysphagia. I will need help cutting my meats. I have [DIAGNOSES REDACTED]." revealed the following Intervention: "11/21/11 Weekly wts. (weights) on Tues. (Tuesday)." A review of RI #9's "Medication Record" dated 11/01/11 through 11/30/11 revealed, a weekly weight of 161.2 was recorded on 11/22/11. No other weights were recorded for the month of November. A review of the "Vital Signs" sheet revealed a weight of 161.6 was recorded on 11/13/11, but no other weights for November 2011 were recorded. A review of the November 2011 "Nurse Notes" did not reveal weights being recorded. In an interview on 12/1/11 at 2:35 PM, with EI (Employee Identifier) #2, Director of Nursing, she was asked when was the weekly weights on Tuesdays added to RI #9's care plan. EI #2 explained, she added the intervention on 11/21/11. When asked why was RI #9 not weighed on November 29 th, EI #2 replied she did not know.

Based on observations, record review and interview the facility failed to put measures into place after an identified significant weight loss. Furthermore the facility failed to monitor weights for RI (Resident Identifier) #9; a resident with a 13.5% weight loss in six months. This affected one of four residents sampled with weight loss. Findings Include: A review of the facility policy titled "Weight, Loss or Gain" with a review date of 7/2005 revealed, "Policy Residents will be weighed upon admission and monthly thereafter. Purpose To assist in the assessing the Residents' nutrition and hydration. Procedure: Weight Loss or Gain 1. The CNA (Certified Nurse Assistant) will be responsible for obtaining the weight on the designated date. 2...3. If the reweight indicates that there's a 5 pound difference in the weight, weekly weights and/or supplements will be initiated; a registered dietician and the physician will be notified as appropriate...6. Weekly weights will be monitored until stable or until the physician deems it unnecessary to monitor on a weekly basis." RI #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #9's most recent Quarterly Minimum Data Set with an Assessment Reference Date of 10/13/11 assessed her as having a BIMS (Brief Interview of Mental Status) score of 9; a score of 8-12 indicates the resident has moderate cognitive impairment. RI #9 was also assessed as needing limited to extensive assistance with all Activities of Daily Living and as being incontinent. A review of the "Vital Signs" sheet revealed the following weights: 6/10/11 -186.2, no July weights recorded, 8/7/11 -174.8, 9/10/11-131, 9/20/11 -re-wgt (weight) 171.6, 10/10/11-168.4, 11/13/11- 161.6. A review of the Care Plan with a focus of "Nutrition: I have a history of dysphagia. I will need help cutting my meats. I have [DIAGNOSES REDACTED]." revealed the following Intervention: "11/21/11 Weekly wts. (weights) on Tues. (Tuesday)." A review of the "Progress Notes" dated 11/20/11 Type: Dietary Notes "RI #9 was readmitted from the hospital on [DATE]. she is alert and oriented x (times) 3. She will be eating meals in her room, on strict Isolation for VRE ([MEDICATION NAME] Resistant [MEDICATION NAME]) Colonization. Ordered diet: Regular. Weight 11/20- 161.6 # (pounds). Her weight is down 6.8 # since Oct. (October). 10th monthly weigh- 168.4 #; down 20.5 # or 11.26% in the past 180 days which is a significant change. Meal intake ranges from 26-50% to 76-100%. No new nutritional lab values available. See Nutritional Re-Admit assessment dated [DATE]." A review of the "Nutritional History" dated 11/16/11, revealed "...Nourishments Needs: 4 PM snack of choice. 9 HS (before bed) snack of choice..." There was no indication of weekly weights or additional supplements added. In an interview on 11/30/11 at 4:20 PM, with EI #3 ,Registered Dietitian, she was asked were interventions put into place after RI #9 was readmitted from the hospital on [DATE]. EI #3 replied, no not at this point. When asked what interventions were in place to stabilized RI #9's weight, she replied they had her on a more broad diet and EI #9 use to be on a low cholesterol puree diet. When EI #3 was asked why RI #9 was losing weight, she replied she did not know. In an interview on 12/1/11 at 1:34 PM, with EI #4, Certified Dietary Manager, she was asked had RI #9 lost weight in the last six months. EI #4 responded 20.5# or 11.3% in 180 days. When asked if that was significant, she replied 180 days is significant. EI #4 was asked if interventions were put into place after RI #9 was readmitted from the hospital on [DATE], she replied no. When asked how she would decide to put interventions into place on a resident that had a significant weight loss, EI #4 replied, they would look at it and discuss it, but because RI #9 was above her Ideal Body Weight they did not want to "plump her back up." When asked if there was a care plan for planned weight loss, EI #4 explained, the goal for the next review date from 10/19 is to get EI #9 stable between 165 and 170 pounds. She further explained there was no planned weight loss care plan. When asked if RI #9 was placed on weekly weights, she replied the resident was placed on weekly weights on 11/21/11 on Tuesdays. EI #4 was asked when should the next weekly weight after 11/22/11 be recorded, she responded the 29th but nothing was recorded on that date. When asked why not, she replied she did not know. In an interview on 12/1/11 at 10:35 AM, with EI #5, CNA (Certified Nurse Assistant), she was asked had she ever offered RI #9 a supplement when working with her. EI #5 responded no. EI #5 was asked what did she do if RI #9 did not eat her meal, she responded to let the nurse know and if RI #9 did not finish, ask her if she wanted something else from dietary. In an interview on 12/1/11 at 1:09 PM, with EI #1, Licensed Practical Nurse, she was asked if there were any supplements ordered for RI #9. EI #1 replied no, usually snacks and if she did not eat they would offer RI #9 something else. EI #1 was asked if she ever offered RI #9 a supplement. EI #1 replied , she had never had too. When asked if the CNA's had ever come to her and let her know RI #9 did not eat her meal, EI #1 replied, no.

Based on record review and interview the facility failed to collect a stool sample from RI (Resident Identifier) #9 as ordered by the Physician during the week of November 11-20, 2011. This affected one of 15 sampled residents. Findings Include: RI #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #9's most recent Quarterly Minimum Data Set with an Assessment Reference Date of 10/13/11 assessed her as having a BIMS (Brief Interview of Mental Status) score of 9; a score of 8-12 indicates the resident has moderate cognitive impairment. RI #9 was also assessed as needing limited to extensive assistance with all Activities of Daily Living and as being incontinent. A review of the "physician's orders [REDACTED]. A review of a Laboratory report revealed the following specimen information: "...COLLECTED: 11/21/2011-9:30 AM RECEIVED: 11/23/2011- 2:25 AM REPORTED: 11/25/2011- 9:24 AM..." A review of the "Bowel Movement Report" dated 11/01/2011-11/29/2011 revealed, RI #9 had a bowel movement on the following dates: 11/11/11, 11/12/11, 11/13/11, 11/14/11, 11/15/11, 11/16/11, 11/17/11, 11/19/11 and 11/20/11. In an interview on 12/1/11 at 1:09 PM, with EI (Employee Identifer) #1, Licensed Practical Nurse, she was asked what day was the stool collection ordered to start. EI #1 replied, November 11, 2011. When asked when the first stool was collected she replied, 11/21/11. In an interview on 12/1/11 at 2:35 PM, with EI #2, Director of Nursing, she was asked when was the stool collection ordered by the Physician. EI #2 responded, November 11, 2011. When asked when the first and second stool samples were collected, EI #2 responded on 11/21/11 and 11/30/11. EI #2 was asked why was the stool sample not collected the week of November 11, 2011, she responded it was being passed on.

Based on observation, interview and record review the facility failed to ensure the survey result signs were posted in areas frequented by residents. Furthermore, the facility failed to place the survey results in an area that was accessible to residents at all times, without the residents having to ask to view them. This deficient practice had the potential to affect all 73 residents in the facility. Findings include: The facility form "Residents-These Are Your Rights....", undated, read, "You have the right to examine the results of the most recent Federal or State survey of the facility." The facility booklet, "A Matter of Rights A Guide to Your Rights and Responsibility as a Resident", last revised in 2000, read, "You....have a right.... to review the results of the most recent survey of our facility, and any plans to correct deficiencies;" On 11/29/2011 at 3:15 P.M., the surveyor noted a sign in the facility lobby, posted on the window of the front desk that read, "The Survey Results From Our Previous Inspection Are Available For Viewing. Please Ask The Receptionist For Assistance." The survey results were in a red binder behind the window of the receptionist desk, requiring that anyone who wanted to view them would have to ask. On 11/30/2011 at 9:30 A.M., the surveyor asked a group of 10 residents if they knew they could see a copy of the facility's survey results and if they knew where they were kept. One, long-time resident was familiar with the survey results and what they were. The other nine residents denied knowing what the survey results were or where they were kept. In response to the questions about the survey results, one resident stated, "News to me." Throughout the survey and specifically on 11/30/2011 at 2:45 P.M., the surveyor searched the entire facility and did not locate any signs directing individuals to the survey results. In addition, the survey results were not available in any other area of the facility. On 12/01/2011 at 2:05 P.M., the surveyor and EI #2 , DON (Director of Nursing), observed the survey sign and results located in the facility lobby. EI #2 and the surveyor discussed that signs were expected to be located in areas the residents are most likely to view them and where they would not have to ask to see them.

Based on observations, interviews, and record review the facility failed to ensure that a licensed staff member wore gloves while performing fingerstick blood glucose testing on 2 residents to prevent the potential spread of infection. This affected RI (Resident Identifier) # (number) 1 and RI #11, two of two residents observed receiving a glucometer test. Findings include: On 12/21/10 at 11:27 AM, EI (Employee Identifier) #1 (an LPN-Licensed Practical Nurse) was observed performing a fingerstick blood glucose test on RI #1. EI #1 was observed gathering supplies which included a glucometer labeled for RI #1 from the medication cart. EI #1 was observed cleansing the right middle finger with an Alcohol pad, strip was placed in the glucometer, blood was obtained using a lancet and placed on the strip, results were obtained. EI #1 sanitized the glucometer with an EPA (Environmental Protection Agency) approved wipe. EI #1 placed the lancet and used test strip in the sharps container on the medication cart and washed her hands. EI #1 failed to don gloves prior to glucometer testing being performed on RI #1. On 12/21/10 at 11:37 AM, EI #1 was observed performing a fingerstick blood glucose test on RI #11. EI #1 was observed prepping the third finger of RI #11's left hand with an Alcohol pad, blood was obtained with a lancet and placed on the strip, and results were obtained. EI #1 placed the lancet and the used test strip in the sharps container. EI #1 washed her hands then sanitized the glucometer with an EPA approved wipe. EI #1 failed to don gloves prior to glucometer testing being performed. RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Quarterly MDS (Minimum Data Set), dated 11/18/10, indicated the resident had short and long term memory loss and had severe impairment of cognition for daily decision-making. RI #1 required total assistance with all ADLs (Activities of Daily Living). A review of RI #1's December 2010 physician's orders [REDACTED]. A review of RI #11's medical record indicated that RI #11 was admitted to the facility 12/5/05. RI #11 had [DIAGNOSES REDACTED]. A review of RI #11's current Physician order [REDACTED]." A review of the facility's Policy and Procedure titled "Infection Control, Universal Precautions", with date of "7/2005", revealed "POLICY Universal Policies are initiated by the Director of Nursing or Physician. Direct care providers will apply precautions as appropriate based on anticipated contact with body substance, not on Resident's diagnosis. ... PURPOSE Blood, drainage, secretions, and excretions are always treated as potentially infectious. ... EQUIPMENT 1. Gloves a. To be applied when in contact with any moist body substance, mucous membranes, non-intact skin, or contaminated surface. b. Must be changed between Residents. ... PROCEDURE ... 3. Gloves ... b. When it is reasonable to anticipate contact with blood and/or bodily fluids, staff should routinely apply gloves. These situations include, but are not limited to ... iv. Performing any invasive procedures." On 12/22/10 at 3:07 PM, an interview was conducted with EI #1. EI #1 was asked when should gloves be worn during procedures with residents. EI #1 stated that gloves should be worn for any type of procedure in example flushing tubes, suctioning, tracheostomy care, blood sugars, and injections. EI #1 was asked why gloves should be worn. EI #1 stated that gloves should be worn to prevent the transfer of infection from resident to resident, nurse to resident, or resident to nurse. EI #1 was asked what the facility Policy and Procedure was for wearing gloves. EI #1 stated that the policy for wearing gloves was at any time there was the potential for blood or body secretions you should wear gloves. EI #1 was asked what training she had received from the facility regarding wearing gloves while performing care. EI #1 stated that her basic orientation was shadowing, following fulltime nurse on the unit and that she had no inservices during orientation. EI #1 was asked what was the potential negative outcome if gloves were not worn while performing blood glucose tests. EI #1 stated that there was the potential for HIV or any other type of transmitted disease. On 12/22/10 at 3:22 PM, EI #1 returned to the surveyor and stated that she did recall a meeting where Universal Precautions were covered during orientation. On 12/22/10 at 4:25 PM, an interview was conducted with EI #3 (Director of Nursing). EI #3 was asked what was the facility's Policy and Procedure regarding wearing gloves during procedures. EI #3 stated that gloves should be worn any time blood and body fluid potential and/or actual contact with blood and body fluids, the staff should wear gloves. EI #3 was asked what was the potential negative outcome if gloves were not worn while performing accuchecks. EI #3 stated that the employee could be stuck with the needle. Also, if the employee had any nicks or cuts, contamination could occur, and potential exposure to the resident was possible. On 12/23/10 at 9:57 AM, an interview was conducted with EI #2 (Registered Nurse/MDS Coordinator/Infection Control Nurse). EI #2 was asked should gloves be worn by Nurses when performing blood glucose testing per fingerstick. EI #2 stated that yes gloves should be worn because it was a biohazard and contact with body fluids.