Every finding on record at Luverne Health and Rehabilitation, LLC

Based on observations, interviews, record review, and review of facility policies titled, Documentation of Routine ADL Care, and Hygiene and Grooming, the facility failed to ensure a resident did not have brown substance under three finger nails on the left hand. This affected Resident Identifier (RI) #76 one of one resident sampled for Activities of Daily Living (ADL's), and was observed on 7/27/21 and 7/28/21. Findings Include: A review of a facility policy titled Documentation of Routine ADL Care with an effective date of October 1, 2010 revealed . STANDARD: Activities of Daily Living are considered routine care services . Routine ADL care may include: .nail and hair care . A review of a facility policy titled Hygiene and Grooming with an effective date of October 1, 2010 revealed PURPOSE Good hygiene and grooming help prevent the spread of infection and promote the resident's feelings of self worth and dignity. PROCESS: VI. Essential Points . e) Nail care is a part of grooming. RI #76 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #76 Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/20/21 Section G revealed RI #76 was total dependent for personal hygiene. On 7/27/21 at 9:34 AM, RI #76 was observed in the bed. The surveyor observed three fingers on RI #76's left hand with a brown substance under the nails. The brown substance was visible under the first, second, and third fingernails. On 7/27/21 at 4:50 PM, RI #76 was observed in bed. The surveyor observed RI #76 with a brown substance under the first, second, and third fingernails on the left hand. On 7/28/21 at 8:36 AM, RI #76 was observed in the bed. The surveyor observed RI #76's three fingers on the left hand with a brown substance under the nails. On 7/28/21 at 10:29 AM, the surveyor observed RI #76's first, second, and third fingers with a brown substance under nails. Employee Identifier (EI) #2, Licensed Practical Nurse (LPN) came in RI #76's room. The surveyor asked her to look at RI #76's nails. EI #2 looked at the nails and said she would clean them. An interview was conducted at that time with EI #2, LPN, the nurse that came in the room. The surveyor asked EI #2, how many of RI #76's nails were observed with a brown substance under them. EI #2 replied, three. EI #2 was asked who should clean nails. EI #2 replied, the CNAs (Certified Nursing Assistants) with the bath and should look at them every shift when giving care. EI #2 was asked if RI #76 had had a bath already today. EI #2 replied she was not sure would need to ask the CNA. The CNA assigned to RI #76, EI #4, entered the room. On 7/28/21 at 10:36 AM EI #4 was interviewed. EI #4 was asked if RI #76 had already had a bath. EI #4 replied not yet. EI #4 was asked what was under RI #76's fingernails on the left hand. EI #4 replied she did not know. EI #4 was asked how many times she had already checked RI #76 today. EI #4 replied, once. EI #4 was asked if she looked at RI #76's nails; she replied no. EI #4 was asked if nail care was included in ADL care. EI #4 replied, yes. EI #4 was asked why she did not look at RI #76's nails when she gave care earlier. EI #4 replied she did not think about it. On 7/28/21 at 10:37 AM, another CNA, EI #3, came in RI #76's room, she said she took care of RI #76 the day before. An interview was conducted. EI #3 was asked if she looked at RI #76's nails yesterday, 7/27/21. EI #3 replied, no she did not, she just changed RI #76, because RI #76 did have a bowel movement. EI #3 was asked if looking at the nails was included when taking care of a resident. EI #3 replied, it was part of ADL care, like doing peri care and incontinent care. EI #3 was asked when she had noticed the resident scratching the anal area. EI #3 replied she had seen it sometimes when RI #76 had a bowel movement. EI #3 was asked, what was under RI #76's nails. EI #3 replied, it may have been bowel movement. EI #3 was asked how often nail care was done. EI #3 replied it was usually done with baths; RI #76 got a bath on the 2:00 PM to 10:00 PM shift, but they should look at the nails when giving care. EI #3 was asked when had RI #76's nails been noticed before today (7/28/21). EI #3 replied, she should have looked at them yesterday (7/27/21) when she cleaned RI #76 and she did not. EI #3 was asked when had she saw bowel movement on RI #76's fingers before. EI #3 replied, when RI #76 had a bowel movement sometimes RI #76 had put his/her hands in the brief and she had to clean it from RI #76's hand before. EI #3 was asked what would the harm be with the brown substance under RI #76's nails. EI #3 replied it could cause infection and the resident may put his/her fingers in his/her mouth. On 7/28/21 at 10:44 AM EI #2, LPN, was asked to look at RI #76's nails on the left hand and describe what she saw. EI #2 replied something brown under three fingernails on the left hand. EI #2 took a nail stick and cleaned out under the nails. EI #2 described the substance as brown and dried. EI #2 was asked what it appeared to look like. EI #2 replied she could not say for sure what it was; it could have been bowel movement. EI #2 was asked how often should nails be looked at. EI #2 replied every shift and if dirty should be cleaned.

Based on observation, interview, record review, and review of facility policy titled Tube Feeding -Bolus and through review of information contained in the Fundamentals of Nursing, Ninth Edition, Chapter 45, Nutrition, the facility failed to ensure Resident Identifier (RI) #22's head of bed was elevated above 20 degrees while tube feeding was administered by feeding pump. This was observed on one of four residents on sample who received tube feeding by feeding pump. Findings Include: A review of facility policy titled Tube Feeding - Bolus with an effective date of May 1, 2018 revealed . PURPOSE: To provide liquid nourishment . through a tube into alimentary tract. PROCESS: . a. Keep the head of the bed elevated in the Semi-Fowler's position . The Fundamentals of Nursing Textbook, Ninth Edition, Chapter 45, page 1090 under Skill 45-3, titled, ADMINISTERING ENTERAL FEEDINGS VIA NASOENTERIC, GASTROSTOMY, OR JEJUNOSTOMY TUBES directs staff to Elevate the head of the bed to a minimum of 30 degrees . RI #22 was admitted to the facility on [DATE] and readmitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 10/16/20 . Tube feeding per pump pole only . [MEDICATION(S)] 1.5 at 65 mL/hr (milliliter/hour) per g-tube (gastric-tube) . On 7/27/21 at 11:34 AM an observation was made of RI #22's tube feeding being administered at a rate of 65 mL/hr and RI #22's head of bed was elevated 20 degrees. On 7/27/21 at 11:38 AM an interview was conducted with Employee Identifier (EI) #5 at bedside of RI #22. EI #5 was asked, how high was the head of the bed. EI #5 replied, not high enough, 15 to 20 degrees and it should be 35 to 45 degrees. EI #5 was asked, who changed the head of the bed elevation. EI #5 replied, the CNAs (Certified Nursing Assistants) when they come into reposition the resident. EI #5 was asked, were there any signs or visuals in the room indicating head of the bed elevation. EI #5 replied, no. EI #5 was asked, why was it important for the head of the bed to be elevated 35 to 45 degrees. EI #5 replied, to prevent aspiration. On 7/28/21 at 4:03 PM an interview was conducted with EI #1, Registered Nurse, Director of Nursing. EI #1 was asked, what training was provided to Certified Nursing Assistants (CNAs) regarding positioning of residents with tube feeding. EI #1 replied, they did an in-service on hire and educated staff that head of the bed needs to be at 45 degrees and then we do monthly in-service on infection control and other items. EI #1 was asked, what was facility's policy for elevating the head of bed for residents who received tube feeding via pump. EI #1 replied, the head of the bed should be positioned semi-fowlers positions. EI #1 was asked, what was semi-fowlers position. EI #1 replied, 45 degrees. EI #1 was asked, when should a resident receiving tube feeding via pump have head of the bed less than 20 degrees. EI #1 replied, the head of the bed needed to be up at all times. EI #1 was asked, who was responsible to ensure residents with tube feeding have head of bed elevated per policy. EI #1 replied, the charge nurse or unit managers. On 7/29/21 at 9:44 AM a follow-up interview was conducted with EI #1. EI #1 was asked, what was the potential harm when a resident received tube feeding via pump and had the head of bed lower than 20 degrees. EI #1 replied, risk of aspiration pneumonia.

Based on observations, interviews, record review, and review of a facility policy titled Oxygen Administration, the facility failed to ensure the oxygen tubing and nebulizer mask for Resident Identifier (RI) #57 was changed weekly. This affected one of two residents sampled for respiratory care. Findings Include: A review of a facility policy titled Oxygen Administration with an effective date of (MONTH) 8, 2005 revealed, . PR[NAME]ESS: .11. Cannulas and masks should be changed weekly . RI #57 was admitted to the facility on [DATE]. A [DIAGNOSES REDACTED]. A review of RI #57's Physician order [REDACTED]. [MEDICATION NAME]-[MEDICATION NAME] . give one every six hours . oxygen (O2) at two liters (2L) per nasal cannula (NC) as needed for shortness of breath (SOB) . On 12/17/19 at 9:55 AM, the surveyor observed the humidification bottle and oxygen tubing for RI #57 had no date on them. The nebulizer mask for RI #57 was in a plastic bag dated 12/9/19. On 12/17/19 at 3:15 PM, an observation was made of the oxygen humidification bottle being empty. On 12/17/19 at 4:42 PM, an interview was conducted with Employee Identifier (EI) #5, Licensed Practical Nurse (LPN). EI #5 was asked how did she you know when the humidification bottle and tubing and masks have been changed. EI #5 replied, there should be a date on them. EI #5 was asked what was missing from the humidification bottle. EI #5 replied, it was empty, there was no water in it. EI #5 was asked what was the date on the plastic bag containing the nebulizer mask. EI #5 replied, 12/9/19. EI #5 was asked what was the potential risk to the resident when oxygen tubing and nebulizer masks were not changed. EI #5 replied, bacteria. On 12/18/19 at 4:20 PM, an interview was conducted with EI #2, LPN and Infection Control Nurse. EI #2 was asked who was responsible for changing the oxygen tubing, nebulizer masks and humidification bottles. EI #2 replied, the LPN charge nurses. EI #2 was asked when was oxygen tubing, nebulizer masks and humidification bottles changed. EI #2 replied, the oxygen tubing and nebulizer masks are changed every Monday, the humidification bottles were to be changed as it runs out. EI#2 was asked how do you know if the oxygen tubing and nebulizer masks have been changed. EI #2 replied, it should have a date on it. EI #2 was asked should oxygen tubing, nebulizer masks and humidification bottles be dated. EI #2 replied, yes. EI #2 was asked what was the purpose of putting a date on the oxygen tubing, nebulizer masks and humidification bottles. EI #2 replied, so you would know when they were changed. EI #2 was asked what was the potential risk to the resident if oxygen tubing, nebulizer mask and humidification bottle were not changed. EI #2 replied, infection. On 12/19/19 at 11:38 AM, an interview was conducted with EI #9, LPN. EI #9 was asked how often were oxygen tubing and nebulizer masks changed. EI #9 replied, every Monday. EI #9 was asked where was this documented. EI #9 replied, every resident should have an order for [REDACTED].#9 replied, yes. EI #9 was asked how often were humidification bottles changed. EI #9 replied, it varied because some residents use it up faster then others; but usually every Monday. EI #9 was asked when she changed a humification bottle, did she put a date on it. EI #9 replied, yes. EI #9 was asked to read RI #57's orders and find the order to change the oxygen tubing and nebulizer mask. EI #9 replied, no.

Based on observations, interviews and review of facility policies titled Urinary Catheter Care and Laundry-Storage, Collection & Transport, the facility failed to ensure: 1. Resident Identifier (RI) #135's Foley Catheter drainage bag was not on the floor and the Certified Nursing Assistant (CNA) did not step on it, and 2. Residents' personal clothing was not transported by laundry staff to the units uncovered. This affected one of three residents observed with Foley Catheters and one of one laundry cart observed. Findings Include: 1. A review of a facility policy titled Urinary Catheter Care with an effective date of 11/10/14 revealed .PR[NAME]ESS: I.h) Catheter tubing and drainage bags are kept off the floor to prevent contamination . RI #135 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of RI #135's (MONTH) 2019 Physician order [REDACTED]. FOLEY CATHETER MAY USE LEG BAND. # (NUMBER) 16FR(French)/10 cc (cubic centimeter) BULB TO CLOSED URINARY DRAINAGE BAG . On 12/17/19 at 6:00 AM, the surveyor observed RI #135 sitting in the chair in the room. The surveyor observed the urinary catheter drainage bag on the floor in front of RI #135's chair. The surveyor observed the drainage bag on the floor from the hallway. A brief interview with RI #135 revealed he/she was assisted to the chair from the bed for the staff to change the linen. On 12/17/19 at 6:10 AM, the urinary catheter drainage bag remained on the floor. A CNA stepped into the doorway/threshold and said to RI #135 she would return with sheets to finish the bed change soon. As she left the doorway the catheter drainage bag remained on the floor. On 12/17/19 at 6:20 AM, the surveyor observed the catheter drainage bag remained on the floor. On 12/17/19 at 6:31 AM, Employee Identifier (EI) #3, CNA entered RI #135's room. EI #3 stated, Your bag is on the floor. EI #3 assisted RI #135 to stand, moved the chair back towards the wall and then transferred RI #135 back to the chair. During the transfer the catheter drainage bag was dragged across two and one half floor tiles. EI #3 was observed to step on the corner of the drainage bag with the front portion of the bottom of her shoe. After EI #3 assisted RI #135 to sit in the chair, EI #3 picked the catheter drainage bag up with a gloved hand and placed it on the bed frame. On 12/17/19 at 6:37 AM, an interview was conducted with EI #3, CN[NAME] EI #3 was asked where was RI #135's catheter drainage bag when she entered the room. EI #3 replied, on the floor, but it was not on the floor after she assisted RI #135 from the bed to the chair. EI #3 added it was hanging on the chair. EI #3 was asked to demonstrate how it was hanging on the chair. EI #3 demonstrated the catheter drainage bag plastic hook was placed on the wooden chair leg. The surveyor observed the catheter plastic hook was too small to be placed over the wooden chair leg securely. EI #3 was asked if the catheter bag's hook was just propped up on the chair leg. EI #3 replied, yes. EI #3 was asked when should a catheter urinary drainage bag be on the floor. EI #3 replied, never. On 12/17/19 at 11:45 AM, an interview was conducted with EI #4, Registered Nurse (RN), Unit Manager. EI #4 revealed RI #135 was admitted with a catheter for overactive bladder, enlarged prostate, hydro[DIAGNOSES REDACTED] and had a Urinary Tract Infection [MEDICAL CONDITION] on admission. EI #4 was asked when should a foley catheter drainage bag be on the floor in a resident's room. EI #4 replied, never. EI #4 was asked when should a foley catheter drainage bag be on the floor and stepped on by staff while staff assisted a resident to stand from the chair and sit back in the chair. EI #4 replied, never, the foley drainage bag should be secured at all times. EI #4 was asked what was the potential harm to a resident when a foley catheter drainage bag was on the floor, and while a resident was being transferred. EI #4 replied, infection and accidental dislodgement. On 12/18/19 at 4:20 PM, an interview was conducted with EI #2, Licensed Practical Nurse (LPN), Infection Control. EI #2 was asked where should the catheter drain bag be. EI #2 replied, hanging on the bed, above the floor, lower than the bladder. EI #2 was asked when should the catheter drainage bag be on the floor. EI #2 replied, never. EI #2 was asked what was the potential risk for the resident when the catheter drainage bag was on the floor. EI #2 replied, contamination, infection, and whatever germs were on the floor compromised the integrity of the drainage bag. 2. A review of a facility policy titled Laundry-Storage, Collection & Transport with no effective date revealed . POLICY : All linens will be stored, handled, transported and processed in a manner that prevents the transmission of microorganisms to other patients and areas. Clean linen: Clean linens shall be transported to patient care areas by use of covered carts with solid bottoms by the Laundry staff . On 12/17/19 at 3:55 PM, the surveyor observed laundry staff distributing clothing on the dementia unit. The laundry cart with residents' personal clothing on both sides of the rack was observed in the hallway. The clothes on the cart were not covered. The cart was totally uncovered. The employee was taking clothes for two residents into a room on the secured unit. The staff member left the secured section of Unit Three and distributed clothing to a room off the secured unit. The laundry staff, EI #6, was then asked what was the process for distribution of clean laundry. EI #6 stated distrubution was started on the dementia unit as it was the first unit she arrived to after leaving the laundry. EI #6 then leaves the secured section of unit 3 to enter the other side of unit three for distribution. EI #6 was asked how were she trained to distribute the clothes. EI #6 stated to cover the rack with a sheet. EI #6 was asked was the cart covered with a sheet or anything. EI #6 stated no. EI #6 was asked why was it important to cover the clothes on the clothes rack when distributing residents' personal clothing. EI #6 stated it was important to keep residents' clothing covered so the clothing would stay clean and not get contaminated during the delivery. On 12/18/19 at 2:57 PM, an interview was conducted with EI #7, Housekeeping/Laundry Manager. EI #7 was asked, if EI #6 was trained on transporting clean personal clothing items to rooms. EI #7 replied, yes she was. EI #7 was asked, what was the policy on transporting clean linens and residents' personal clothing. EI #7 replied, clothes were hung on the cart, covered and transported to the residents' rooms. EI #7 was asked, what was the potential harm in transporting residents' clean clothing to their rooms in a cart that was uncovered. EI #7 replied, the clothing could get dust or someone touches and contaminates them. On 12/19/19 at 10:37 AM an interview was conducted with EI #2, Staff Development/ Infection Control Director. EI #2 was asked what was the policy on transporting clean linens and clean residents' clothing from the laundry. EI #2 replied, they should be covered. EI #2 was asked, when should residents' clean clothing be transported from the laundry to the residents' rooms on an uncovered cart. EI #2 replied, never. EI #2 was asked, what would be the potential harm in transporting clean residents' clothes from the laundry to residents' rooms on an uncovered cart. EI #2 replied, contamination and germs.

Based on observation, interviews and a review of facility policies titled, Cleaning of Miscellaneous Equipment and Utensils, Food Receipts and Storage and Handling Serviceware/Silverware, the facility failed to ensure: 1. the ceiling and walls were free of brown spots and a dust like substance: 2. vegetable sticks in the freezer were labeled and; 3. utensils in utensils bags were free of water and free of brown substance. This had the potential to affect 135 of 135 residents who received meals from the kitchen. Finding Include: 1) A review of a facility policy titled, Cleaning of Miscellaneous Equipment and Utensils, with an effective date of 8/23/2017, revealed: .40. walls and ceiling (as needed) .walls and ceilings should be washed thoroughly at least twice each year. Heavily soiled surfaces should be cleaned frequently and as required. On 01/13/2019 at 9:54 a.m., the surveyor observed dust (dust-like substance) on the ceiling, over the steam table and in the light fixtures. At the beginning of the steam table in the ceiling a vent had a large amount of dust. There was dust on the walls at the kitchen entrance. The surveyor observed brown spots on the ceiling and heavy dust in six ceiling lights. Two of the lights at the tray line had very heavy dust. There was dust around a clock at the kitchen entrance. On the wall next to the milk cooler were brown spots. There were also brown spots on the wall next to the three compartment sink. 01/13/19 at 10:48 a.m., the surveyor conducted an interview with Employee Identifier (EI) #5, Dietary Assistant. EI #5 was asked what did she see over the tray line in the vents and ceiling. EI #5 replied, dust. EI #5 was asked why was it there. EI #5 replied, an accumulation over a period of time. EI #5 was asked what was the facility policy on cleaning the ceiling vents in the kitchen. EI #5 replied, they were to be cleaned once a month by maintenance. EI #5 was asked how much dust did she see in the vents and ceiling near the steam table. EI replied, a medium amount. EI #5 was asked what can happen with the food when the ceiling was dusted and the steam table was located under the ceiling. EI #5 replied, dust can get inside the food, on the trays, and dust particles can fly around. EI #5 was asked what was on a vent at the beginning of the steam table. EI #5 replied, dust. EI #5 was asked how much dust. EI #5 replied, heavy amount of dust. EI #5 was asked what was on the lights fixture. EI #5 replied, dust. EI #5 was asked how many lights had dust on them. EI #5 replied, six .EI #5 was asked what was on the walls. EI #5 replied, dust and grease. EI #5 was asked why was it there. EI #5 replied, it was a build up. EI #5 was asked what was the brown spots in the ceiling. EI #5 replied, grease spots. EI #5 who was responsible for calling maintenance when the ceiling and walls were dusted. EI #5 replied she was. On 01/15/19 at 09:56 a.m., an interview was conducted with EI #9, Maintenance Assistant. EI #9 was asked if anyone from the kitchen informed him of the need for cleaning the kitchen ceiling and wall . EI #5 replied, no ma'am. EI #5 was asked when was the kitchen ceiling and wall cleaned last. EI #5 replied, about three months ago. EI #5 was asked how often should the ceiling and the walls be cleaned in the kitchen. EI #5 replied, every two months. EI #5 was asked who was responsible for cleaning the ceiling and the walls in the kitchen. EI #5 replied maintenance and the supervisor. EI #5 was asked what did the facility policy say regarding the cleaning of the kitchen ceiling and walls. EI #5 replied, if it was dirty clean it. On 1/16/19 at 09:24 a.m., an interview was conducted with EI #10, Maintenance Supervisor. EI #10 was asked who was responsible for cleaning the ceiling and walls in the kitchen. EI #10 replied, not sure about that. EI #10 was asked how often were the walls and ceiling cleaned in the kitchen. EI #10 replied, he did not know. EI #10 was asked what was the facility policy on cleaning the ceiling and walls. EI #10 replied, he did not know. EI #10 was asked should the walls and ceiling be free of brown spots and a dust substance, EI #10 replied, for a clean environment. 2) A review of a facility policy titled, Food Receipt and Storage, with an effective date of 8/23/2017, revealed: .PURPOSE: Foods should be .stored properly to prevent food borne illnesses.II. Storage Foods: .p. If food items with expiration dates are removed from the original containers, the expiration date should be transferred to the food item, and identified as the expiration date. On 01/13/2019 at 9:54 a.m., the surveyor observed vegetable sticks in the freezer in a medium bag out of original box with no use by date or no information on the bag. On 01/13/2019 at 11:02 the surveyor conducted an interview with EI #5. EI #5 was asked what was in the freezer with no name or date on it. EI #5 said vegetable sticks. EI #5 was asked if the vegetable sticks were out of the original box. EI #5 replied, yes they were. EI #5 was asked what was the facility policy on food items out of their original container. EI #5 replied, all food must be placed in the original container, and if not in the original container, must be labeled with the date and what it was. EI #5 was asked why should food items be labeled. EI #5 said so you will know what it was. EI #5 was asked what was the potential harm to the residents when food items are not labeled. EI #5 replied, if not labeled they would not know how long it has been there and it could be freezer burnt. 3) A review of facility policy titled, Handling Serviceware/Silverware, with an effective date of 2/1/2002, revealed: . STANDARD: Serviceware and silverware should be cleaned and handled according to method that reduce contamination. PR[NAME]ESS: a. soiled silverware should be soaked in a pre-soak solution to loosen debris, in preparation to be washed and sanitized. h. Serviceware should be air dried 01/14/19 at 10:35 a.m., EI #7, Assistant Cook, was packaging silverware. Some bags were wet with utensils inside the plastic bag. The bags were placed in a plastic container. There were four bags wet. One bag with a knife and spoon had brown spots on the utensils. The brown spot was on the front and back side of the spoon. On 01/14/19 at 12:15 p.m., an interview was conducted with EI #7, Assistant Cook. EI #7 was asked what was on a spoon and knife in a utensil bag ready to go out to the residents. EI #7 replied the bags were wet. EI #7 was asked why were the bags wet. EI #7 replied, the silverware was not dry. EI #7 was asked who was responsible for washing utensils. EI #7 replied, she was. EI #7 was asked what was the facility policy of spots on utensil and wet utensils in resident silverware bags. EI #7 replied, they were not suppose to send utensils out like that. EI #7 replied, silverware was suppose to be fully dry. EI #7 also said if the silverware was dull or stained, it should be thrown away. EI #7 was asked if the utensils were wet in the bag with water on them. EI #7 replied yes ma'am. EI #7 was asked how many bags had water in them. EI #7 replied, 4. On 01/14/2019 at 12:46 p.m., the surveyor conducted an interview with EI #5. EI #5 was asked what did she see in the utensil bags. EI #5 replied water moisture. EI #5 was asked to describe the spots on the knife and spoon. EI #5 replied, it was rust on the handle of the knife and rust on the back of the spoon. EI #5 was asked did the rust come off when scraping it. EI #5 replied, it came off when she rubbed it. EI #5 was asked should residents be served utensils with rust on them. EI #5 replied, no. On 01/14/2019 at 01:02 p.m., an interview was conducted with EI # 4, Dietary Manager. EI #4 was asked what did she observe on the utensils. EI #4 replied, rust. EI #4 was asked why was it there. EI #4 replied, she did not know. EI #4 was asked should residents be served utensils with rust on them. EI #4 replied, no.

Based on observations, interviews and review of a facility policy titled, Garbage and Refuse, the facility failed to ensure the dumpsters' lids were closed. This had the potential to affect all 138 residents residing in the facility. Finding include: A review of a policy titled, Garbage and Refuse, with an effective date of 2/1/2002, revealed: .STANDARD: Garbage and refuse containers should be free from cracks or leaks and covered when not in use .PR[NAME]ESS: .e. Refuse container and dumpsters kept outside the facility should have tightly fitting lids and should be kept covered when not being loaded. f.garbage should not accumulate or be left outside the dumpster. On 01/13/2019 at 10:07 a.m., the surveyor, along with Employee Identifier (EI) #5, Dietary Assistant, observed the dumpster area. Dumpster number one's lid on the right side was opened all the way back and seven trash bags were up out of the dumpster. At dumpster number two, both lids were opened. There were 4 trash bags hanging out on the left side. The surveyor observed a trash bag, gloves and papers on the ground next to the dumpster. 01/14/2019 at 4:58 p.m., the surveyor conducted an interview with EI #8, RN (Register Nurse). EI #8 was asked to describe what she saw at dumpster number one and number two. EI #8 replied, several pairs of gloves on the ground, lids partially opened. EI #8 was asked did she see trash bags hanging out of the dumpster. EI #8 replied, there was a white bags hanging out. EI #8 was asked why was it there. EI #8 replied, she did not know. EI #8 was asked who was responsible for making sure the dumpster lids were closed. EI #8 replied, whoever took the trash out. EI #8 was asked when should the dumpster be closed. EI #8 replied all the time. EI #8 was asked what can happen when the dumpster was not closed. EI #8 replied animals or people can get in there. EI #8 was asked should the dumpster lids have been closed on 1/13/19. EI #8 replied, yes. On 1/15/2019 at 3:58 p.m., the surveyor conducted an interview with Dietary Assistant, EI # 5. EI #5 was asked to tell the surveyor what she saw at the dumpster. EI #5 replied, gloves, the dumpster opened and trash. EI #5 was asked what was on the ground. EI #5 replied, trash. EI #5 was asked who was responsible for making sure the dumpster lids were closed. EI #5 replied, nursing. EI #5 was asked when should the dumpster lid be closed. EI #5 replied at all times.

Based on observation, interview, record review and review of a facility policy titled Infusion Therapy Products Label, the facility failed to ensure an Intravenous (IV) medication that was being administered on 1/13/19 to Resident Identifier (RI) #86 was labeled. This was observed on 1/13/19 and affected one of two sampled residents receiving IV medications. Findings include: A review of a facility policy titled Infusion Therapy Products Label, with an effective date of 3/11, revealed: .Policy Infusion therapy products are labeled in accordance with facility requirements and applicable state and federal laws. The label includes sufficient additional information as required to assure safe and efficient administration to residents. Procedures .2. An auxiliary label is completed and affixed to each infusion therapy product container (when removed from outer packaging) .A. The nurse administering the infusion therapy product completes the following on the auxiliary label: (1) Resident name. (2) Infusion rate. (3) Number of bag or bottle if more than one . (4) Date and time started. (5) Name of nurse starting the bag or bottle. RI #86 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of RI #86's Physician order [REDACTED]. On 1/13/19 at 3:15 PM, the surveyor observed an IV medication bag hanging and infusing on RI #86. The IV medication bag had manufactured writing on the bag indicating it was [MEDICATION NAME] 500 milligrams IV. The IV medication bag was not labeled with a resident name, nor a date and time the medication was hung or any initial or name of the person that administered the medication. On 1/13/19 at 3:30 PM, two nurses entered RI #86's room. The surveyor asked what was the concern. EI #1, Registered Nurse/Unit Manager, replied there was no label to indicate the resident's name, date, time and the nurse who hung it on the IV medication bag. The surveyor asked who hung the IV medication. EI #1 replied EI #3, Licensed Practical Nurse, who was already gone for the day. On 1/13/19 at 3:35 PM an interview was conducted with EI# 1. EI #1 was asked what time was the IV medication started. EI #1 replied it was scheduled for 2 PM and hung around 1:30 PM by EI #3,the first shift nurse who had already left for the day. EI #1 was asked what was the date the IV medication was hung. EI #1 replied today (1/13/19) but with no label she was not sure. EI #1 was asked where was the label for the IV medication. EI #1 replied it was not there. EI #1 was asked if IV medications should have a label. EI #1 replied yes, with the resident name, the time and the date on it. EI #1 was asked who prepared the IV medication. EI #1 replied it was already premixed so the LPN could hang it. EI #1 was asked what was the harm in the IV medication bag hung without a label to include resident name and time and date and the nurse's name that hung the medication. EI #1 replied the nurse needed to know what time and date it was hung to ensure the medication infused in appropriate time, and without the label you could not tell how long it had been hanging or infusing. On 1/15/19 at 10:10 AM an interview was conducted with EI #3, the LPN that hung the IV medication on 1/13/19. EI #3 was asked what was the policy when hanging an IV medication. EI #3 replied she should have placed a label on the IV medication bag before she hung it. EI #3 was asked what was to be on the label. EI #3 replied the resident name, room number, time, date, medication and nurse name or initials. EI #3 was asked if she had placed a label on the IV medication bag before she administered it. EI #3 replied no. EI #3 was asked why she did not place a label on the IV medication bag before administering the medication. EI #3 replied she did not think about it. EI #3 was asked what was the harm in the IV medication bag not having a label. EI #3 replied the next nurse would not know if it was the right resident, the right medication, the right time and date and the nurse that administered it.

Based on observation, record review and interview, the facility failed to ensure nurse staffing postings included all required information for 12 days of the 18 months reviewed. This had the potential to affect all 138 residents residing in the facility and any visitors. Findings Include: On 1/13/19 at 09:30 AM the nurse staffing posting was observed without documentation of the facility's census. On 1/14/19 at 4:04 PM the surveyor reviewed 18 months of nurse staffing postings. The Review of the POS [REDACTED] On 12/19/17, the evening and night shift staffing information was blank. On 12/21/17, the evening and night shift staffing information was blank. On 2/2/18, the nurse staff posting did not indicate the number of Registered Nurse (RN) or Licensed Practical Nurse (LPN) staff working day shift or the total number of hours worked. On 4/23/18, the posting did not indicate the total number of Certified Nursing Assistant (CNA) hours worked for the evening shift. This form also did not indicate the number of CNAs working or the total number of CNA hours worked for the night shift. On 4/24/18, the nurse staff posting was not completed for evening or night shift. The areas for number of staff, total hours worked, and census were blank. On 7/13/18, the nurse staff posting did not include the number of RNs or the total number of RN hours worked for the day shift. On 8/16/18, the nurse staff posting did not include the census for evening or night shift. On 8/23/18, the nurse staff posting was not completed for the night shift. All areas were blank, and it did not include the number of staff, total number of hours worked, or the census. On 10/1/18, 10/16/18, 11/12/18, and 11/13/18, the nurse staff postings were not completed for the evening or night shift. All areas were blank, and it did not include the number of staff, total number of hours worked, or the census. On 1/14/19 at 5:10 PM, the surveyor and EI #2, Staff Development, Licensed Practical Nurse, conducted a review of the above nurse staff posting forms. An interview followed the review of the forms. EI #2 was asked what was the policy on nurse staff posting. EI #2 replied nurse staff posting should be posted every shift at the beginning of each shift with all the areas filled in. EI #2 was asked, from each form, what was missing. EI #2 replied, it varied. She indicated some forms were missing the number of RNs, LPNs, or CNAs, the actual hours worked, or the census. EI #2 was asked who was responsible for completing the nurse staff posting. EI #2 replied she was, when she was there, and an LPN on the hall when she was not. EI #2 was asked what was to be included on the nurse posting form. EI #2 replied it was to be done each shift and include the census, number of RNs, number of LPNs, number of CNAs, number of Nurse aide trainees, and the total number of hours each of those worked under total hours worked. EI #2 was asked, of the sheets she reviewed, were those areas completed. EI #2 replied no. EI #2 was asked why was it important for the nurse staff posting to be completed daily and for each shift. EI #2 replied so residents, visitors and anyone else will know there was adequate staff to care for the residents. EI #2 was asked what was the harm in the nurse staff posting form not being completed daily and for each shift. EI #2 replied residents and visitors would not know how many staff were working for the day and it was a regulation to have the nurse staff posting form posted daily and at the beginning of each shift and be completed. .

Based on observations, interview and review of a facility policy titled, Cleaning of Miscellaneous Equipment and Utensils, review of a facility document titled, SANITATION CHECKLIST FOR DIETARY FOR THE CLEANING TO BE DONE WEEKLY DATE and review of the 2013 FOOD CODE U.S. (United States) Public Health Service FDA (Food and Drug Administration), the facility failed to ensure: 1) the tea urn did not have a build up of a brown substance; 2) the mixing bowl to the robot coupe did not have a food like substance on the inside of it; 3) the light covers and sprinklers under the stove hood did not have an accumulation of a dust and grease-like substance; 4) the outside of two coffee pots were free of a build up of a grease and dust like substance; 5) the deep fryer was free of a thick accumulation of a grease and dust like substance; 6) nine glasses did not have water droplets on the inside of them; and 7) two ceiling vents in the dietary area were free of a dust like substance. This had the potential to affect 138 residents who received meals from Dietary. Findings Include: 1) A review of a facility policy titled, Cleaning of Miscellaneous Equipment and Utensils, with an effective date of 08/23/17 revealed the following: .Tea Urns: a. Daily Cleaning · Unplug and drain · Wash, rinse, sanitize . Further review of a facility document titled, SANITATION CHECKLIST FOR DIETARY FOR THE CLEANING TO BE DONE WEEKLY DATE revealed the following dates the tea urn was cleaned: .TEA URN .4-10-18 4-14-18 . On 04/17/18 at 3:55 p.m., the inside of the tea urn was observed empty; however, the surveyor observed a build up of a brown substance around the top of the urn. The Dietitian, Employee Identifier (EI) #7, took a white napkin and wiped around the top and a brown substance was observed on the napkin. On 04/19/18 at 3:42 p.m., an interview was conducted with EI #5, the Dietary Manager (DM). EI #5 was asked how often was the Tea Urn cleaned. EI #5 explained the tea urn was cleaned every night. EI #5 was asked why should the tea urn be free of a build up of a brown substance. EI #5 said, because it could cause the tea urn to sour with left over tea inside and it would not be sanitary. 2) A review of a facility policy titled, Cleaning of Miscellaneous Equipment and Utensils, with an effective date of 08/23/17 revealed: . 26. Mixer: · . Take out bowl . Wash in pot and pan sink or dishmachine · Rinse · Sanitize . · Air dry . On 04/18/18 at 10:14 a.m., the mixing bowl to the industrial sized Mixer was observed with food-like debris on the inside of the bowl. On 04/19/18 at 3:40 p.m., the mixing bowl to the industrial sized Mixer was observed to remain with food-like debris on the inside of the bowl. On 04/19/18 at 3:42 p.m., the surveyor was accompanied by EI #5. EI #5 was asked what did she see inside of the mixing bowl. EI #5 said, it was a little area of batter that had not been cleaned and also batter was on the outside of the mixing bowl. EI #5 was asked, why should the bowl to the mixer be free of left over food debris. EI #5 explained, because that would be putting clean batter into an unsanitary bowl, which was cross contamination. 3) On 04/18/18 at 10:30 a.m., observations were made of the inside of the(NAME)on the left side above the stove. There was a black substance observed on the inside of the hood. The hood light covers were observed with a thick accumulation of a dust and grease like substance. On 04/19/18 at 3:34 p.m., the black substance remained on the inside of the(NAME)on the left side above the stove. The hood light covers also remained with the thick accumulation of a dust and grease like substance. On 04/19/18 at 3:42 p.m., an interview was conducted with EI #5. EI #5 was asked what did she see under the hood on the left of the area. EI #5 said, grease and dust. EI #5 was asked, what did she see hanging from the sprinklers under the hood next to the light covers. EI #5 said she saw cob webs and build up. EI #5 was asked, why should light bulb covers be clean and free of an accumulation of dust and grease. EI #5 explained, so dietary staff could see what they were doing. EI #5 was asked, why should the sprinklers under the hood be free of dust and cobwebs. EI #5 explained, so the sprinklers could work. EI #5 was asked, what could happen if dust and spider webs were under the hood, above the stove, where food was being prepared. EI #5 explained, it could get in the food. EI #5 was asked, why should the area under the hood be cleaned. EI #5 replied, so dust and spider webs and other things could not drop into the food when it was being cooked on the stove. 4) A review of a facility policy titled, Cleaning of Miscellaneous Equipment and Utensils, with an effective date of 08/23/17 revealed: . 5. Coffee . a. Daily Cleaning · Unplug and drain · Wash, rinse, sanitize . On 04/18/18 at 10:46 a.m., two coffee pots were observed with a thick build up of dust and dried liquid on the outside of each pot. On 04/19/18 at 3:38 p.m., the two coffee pots were observed to remain with the thick build up of dust and dried liquid on the outside of each pot. On 04/19/18 at 3:42 p.m., an interview was conducted with EI #5. EI #5 was asked what did she see on the outside of the coffee pot. EI #5 said, a build up of grease and stains. EI #5 was asked, how often were coffee pots cleaned. EI #5 said, every day. EI #5 was asked, why should the coffee pots be free of a build up on the outside of them. EI #5 explained they did not look clean because there was a greasy film on them. 5) A review of a facility policy titled, Cleaning of Miscellaneous Equipment and Utensils, with an effective date of 08/23/17 revealed: . Deep Fat Fryer: a. After each use: · Air dry on clean surface or dry with clean paper towels or cloth to prevent rust . On 04/18/18 at 11:16 a.m., observations were made of an accumulation of a grease and dust like substance on the left side and bottom of the deep fryer. On 04/19/18 at 3:30 p.m., the accumulation of a grease and dust like substance remained on the left side and bottom of the deep fryer. On 04/19/18 at 3:42 p.m., an interview with EI #5 was conducted. EI #5 was asked what did she see on the left side and bottom of the deep fryer. EI #5 said, it was grease and underneath it was grease and dust. EI #5 was asked how often was the deep fryer to be cleaned. EI #5 said each time the deep fryer was used. EI #5 was asked, who was responsible for ensuring the deep fryer was cleaned on the outside and underneath. EI #5 said, it was assigned. EI #5 was asked why should the deep fryer be free of an accumulation of a grease like substance on the outside of it. EI #5 replied, because that was not sanitary. EI #5 was asked what could an accumulation of grease attract. EI #5 said, flies and insects. EI #5 was asked what was the potential harm of having the deep fryer with an accumulation of a grease like substance on the outside of it. EI #5 said it could attract roaches. 6) A review of the 2013 FOOD CODE U.S. Public Health Service FDA Administration, revealed the following: . Drying 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried . before contact with FOOD; . On 04/18/18 at 11:19 a.m., nine glasses were observed with droplets of water on the inside at the bottom. During the lunch meal, a dietary staff placed ice and poured tea from a pitcher into the glasses. On 04/19/18 at 03:42 p.m., an interview was conducted with EI #5. EI #5 was asked, why should glasses be air dried. EI #5 explained so they would be sanitized. EI #5 was asked should glasses that had not completely air dried be used to serve tea to residents. EI #5 said, no. EI #5 was asked, why. EI #5 explained, because they were not sanitized if they had water in them. EI #5 was asked, what was the potential harm of pouring a beverage into glasses with water droplets and serving them to residents. EI #5 explained, it would not be sanitary and could transfer germs by pouring tea in them, and could make residents sick. 7) On 04/18/18 at 10:50 a.m., observations were made of a dust like substance in the air vents in the ceiling above the preparation table across from the steamtable. On 04/19/18 at 3:31 p.m., the dust like substance remained in the air vents in the ceiling above the preparation table across from the steamtable. On 04/19/18 at 03:42 p.m., an interview was conducted with EI #5. EI #5 was asked, what did she see in the ceiling vent above the preparation table. EI #5 said dust, grease and build up. EI #5 was asked what did she see on the vent in the ceiling next to the steam table. EI #5 said, dust. EI #5 was asked, why should the air vents above the preparation tables be free of an accumulation of a dust like substance. EI #5 said, so dust would not get into the food when it was prepared.

Based on observations, interviews and a review of a facility policy titled, Resident Environmental Quality, the facility failed to ensure Room Locator (RL) #'s 1-12 were free of scratched and chipped paint on residents' walls; missing caps on toilet bolts; missing facing on dressers; large opening gaps between air conditioning units; air conditioning units were free of dust; vents were free of an accumulation of dust like substance; residents' foot boards was free of chipped wood; and a wall was free of cracked plaster. Furthermore, the facility failed to ensure Resident Identifier (RI) #131's wheelchair was not missing an armrest, the back of the wheelchair seat was not torn, and the wheelchair was free of an accumulation of a dirt like substance, and RI #130's wheelchair was free of a tan/brown crusty substance on the arm rest and seat of the wheel chair. These deficient practices affected RL #'s 1-12, 12 of 80 rooms in the facility, and was observed on two of three days of the survey, RI #130 and 131, two of 32 sampled residents and was observed on three of three days of the survey. Findings Include: 1) A review of a facility policy titled, Resident Environmental Quality, with an effective date of 03/01/10, revealed: . PURPOSE: The facility should be designed . and maintained to protect the health and safety of residents . PR[NAME]ESS: a) Preventive maintenance schedules, for the maintenance of the building . should be followed to maintain a safe environment. On 04/17/18 at 4:34 p.m., the surveyor observed in RL #1 on the A side of the room, there was a large scratch in the wall paint. On 04/17/18 at 4:35 p.m., the surveyor observed in RL #1 on the B side of the room behind the bed, there was a brown liquid substance with a large scratch in the wall. On 04/17/18 at 4:39 p.m., the surveyor observed in the bathroom of RL #1, there were uncapped toilet bolts. On 04/17/18 at 4:42 p.m., the surveyor observed in RL #3 on side A of the room, the first dresser drawer was off track and the wall was observed with a long deep scratch in the paint. On 04/17/18 at 4:44 p.m., the surveyor observed in RL #3 on side B side of the room, there was a large scratch paint in the sheet rock behind the bed. In the bathroom ceiling of RL #3, on the vent there was a large accumulation of dust like substance. On 04/17/18 at 4:54 p.m., the surveyor observed in RL #2 on the B side of the room, the wall air conditioner was detached from the wall with the outside exposed and there was a large accumulation of a dust like substance on the right side of the unit. On 04/17/18 at 5:04 p.m., the surveyor observed in RL #4, there was scratched sheetrock on side A and B at the head of the beds. The bathroom toilet bolts of RL #4 were exposed on both sides. On 04/17/18 at 5:18 p.m., the surveyor observed in RL #5, there was a thick accumulation of a dust like substance in the ceiling vent. On 04/18/18 at 9:20 a.m., the surveyor observed in RL #6 above the air conditioner unit on the B side of the room, there was a crack in the sheetrock. On 04/18/18 at 9:31 a.m., the surveyor observed in RL #7 on side B of the room, there was a large gap between the wall and air conditioner unit with an accumulation of dust in the corner. There was chipped wood on the footboard of bed B and chipped paint on the wall behind the head of the bed. There was chipped paint on the wall behind both bed A and B. On 04/18/18 at 10:06 a.m., the surveyor observed in RL #8, there was cracked plaster on the left side of the air conditioner unit on side B of the room. On 04/19/18 at 8:49 a.m., the surveyor observed in RL #9, the air conditioner unit had an accumulation of dust in the vents. On 4/18/18 at 8:52 a.m., the surveyor observed in RL #10's bathroom there were uncapped toilet bolts. On 04/18/18 at 9:09 a.m., the surveyor observed in RL #11's bathroom there were uncapped toilet bolts. On 04/18/18 at 9:14 a.m., the surveyor observed in RL #12, there was a crack in the wall on the left and right side of the air conditioner unit. On 04/19/18 at 5:20 p.m., a walk through was completed with the Maintenance Assistant, Employee Identifier (EI) #6. On 04/19/18 at 6:01 p.m., an interview was conducted with EI #6, the Maintenance Supervisor. EI #6 was asked who was responsible for ensuring residents' bathrooms were free of an accumulation of dust in the ceiling vents. EI #6 replied, housekeeping. EI #6 was asked why should bathrooms air vents be free of an accumulation of dust. EI #6 replied, so the air vent can work properly. EI #6 was asked why should residents' air conditioner units be intact and free of gaps between the walls and the actual unit. EI #6 replied, to ensure air will not seep out of the room and the room was at a comfortable temperature. EI #6 said bugs could also come through the cracks. EI #6 replied, bugs. EI #6 was asked how were needed repairs reported to maintenance. EI #6 replied, staff told them or staff used the computer to report needed repairs. EI #6 was asked why should toilet bolts be capped. EI #6 replied, to make sure residents did not get hurt. EI #6 was asked how did uncapped toilet bolts look cosmetically. EI #6 replied, it did not look good. EI #6 was asked why should walls be free from chipped paint and sheetrock be free of scratches. EI #6 replied to make the room look more homelike. EI #6 was asked why should the bed foot boards be free of chipped wood. EI #6 replied, so the resident would not get scratched from the chipped wood. EI #6 was asked why should facing on dressers be smooth and not chipped. EI #6 replied, so the resident would not get harmed. EI #6 was asked how often did maintenance make rounds to check for needed repairs. EI #6 replied, he did not know. EI #6 was asked what was the potential harm of scratched and chipped paint being on the walls in the residents room. EI #6 replied, the rooms should look home like and be a home like environment. EI #6 was asked what was the potential harm of uncapped toilet bolts in the residents' bathrooms. EI #6 replied, it could cause an accident. 2) A review of a facility policy titled, Resident Environmental Quality, with an effective date of 03/01/10 revealed: . STANDARD: According to federal regulation, the facility must: . Maintain all essential mechanical, electrical, and patient care equipment in safe operating condition. RI #131 was re-admitted to the facility on [DATE]. A review of RI #131's Quarterly MDS (Minimum Data Set) assessment, with an ARD (Assessment Reference Date) of 03/27/18, revealed RI #131 used a wheelchair for mobility. On 04/17/18 at 5:07 p.m., the surveyor observed the armrest of RI #131's wheelchair was missing on the left side, the material in the seat was ripped, the handles on the wheelchair was missing and there was a dirt like substance on the wheelchair. On 04/19/18 at 5:39 p.m., a second observation was made of RI #131's wheelchair. The wheelchair remained the same. On 04/19/18 at 8:39 p.m., an interview was conducted with EI #1, the Administrator. EI #1 was asked why should wheel chairs be in good repair and not have missing armrest and torn seats. EI #1 replied, skin tears could occur. EI #1 was asked who was responsible for ensuring the wheelchairs were in good repair. EI #1 replied, all staff and maintenance would do the repairs. EI #1 was asked why should wheelchairs be free of a dirt-like substance. EI #1 replied, they need to be clean. (3) RI #130 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. On 04/17/187 at 3:30 p.m., RI #130 was observed up in the wheelchair sitting in the room. The wheelchair was observed with a crusty tan and brown colored substance on both wheelchair arms and in the seat. On 04/18/18 at 5:15 p.m., RI #130 was observed in the wheelchair in the room. The wheelchair was again observed with a crusty tan and brown colored substance on both wheelchair arms and in the seat. On 04/19/18 at 9:40 a.m., RI #130's wheelchair was observed with tan and brown crusty like substance remaining on the wheelchair arms and in the seat. On 04/19/18 at 9:47 a.m., EI #4, a Licensed Practical Nurse (LPN) observed RI #130's wheelchair with the surveyor. An interview was conducted in conjunction with the observation. EI #4 was asked, what did she see on the wheelchair. EI #4 stated, It is nasty. EI #4 was asked who was responsible for cleaning the wheelchairs. EI #4 replied, there was a schedule for the 10 PM to 6 AM shift, and the Certified Nursing Assistants cleaned the wheelchairs. EI #4 was asked what was the harm in the wheelchair being dirty. EI #4 replied, infection control.

Based on interviews and record review, the facility failed to ensure: (1) Resident Identifier (RI) #63's Quarterly Minimum Data Set (MDS) assessment, dated 03/04/18, reflected RI #63 was receiving an anticoagulant medication; (2) RI #72's Quarterly MDS assessment, dated 03/06/18, reflected RI #72 was receiving an anticoagulant medication; and (3) RI #127's Significant Change MDS assessment, dated 01/10/18 and a Quarterly MDS dated [DATE], reflected RI #127 was using Oxygen. These deficient practices affected RI #'s 63, 72 and 127, three of 32 sampled residents whose MDS assessments were reviewed. Findings Include: (1) RI #63 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. An Annual MDS assessment, with an Assessment Reference Date (ARD) of 03/04/18, revealed under Section N - Medications, RI #63 was not receiving an Anticoagulant medication. A review of RI #63's (MONTH) (YEAR) Physician order [REDACTED]. On 04/19/18 at 6:21 p.m., the surveyor conducted an interview with Employee Identifier (EI) #2, a Registered Nurse (RN)/MDS Coordinator. The surveyor asked EI #2 was RI #63 receiving any type of anticoagulant medication. EI #2 said RI #63 was receiving Eliquis. The surveyor asked EI #2 what was the drug classification of Eliquis. EI #2 said Eliquis was an anticoagulant. The surveyor asked EI #2 should Anticoagulants be reflected on the MDS assessment. EI #2 replied, yes. The surveyor asked EI #2, according to RI #63's 03/04/18 MDS assessment, was RI #63 coded as receiving an Anticoagulant. EI #2 said no. When asked should the MDS assessment reflect RI #63 was receiving the Anticoagulant, EI #2 said yes. The surveyor asked EI #2 was this an accurate assessment. EI #2 said no, not on section N. (2) RI #72 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A Quarterly MDS assessment, with an ARD of 03/06/18, revealed under Section N - Medications, RI #72 was not receiving an Anticoagulant medication. A review of RI #72's (MONTH) (YEAR) Physician order [REDACTED]. On 04/19/18 at 6:32 p.m., a second interview was conducted with EI #2. The surveyor asked EI #2 was RI #72 receiving any type of anticoagulant medication. EI #2 said RI #72 was receiving Xarelto. EI #2 said Xarelto was an anticoagulant and should be reflected on the MDS assessment. The surveyor aked EI #2, according to RI #72's 03/06/18 MDS assessment, was RI #72 coded as receiving an Anticoagulant. EI #2 said no. When asked should the MDS assessment reflect RI #72 was receiving the Anticoagulant, EI #2 said yes. The surveyor asked EI #2 was this an accurate assessment. EI #2 said no, not on section N. (3) RI #127 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #127's Significant Change MDS assessment with an ARD of 01/10/18, revealed under Section O, Oxygen therapy was not coded. A review of RI #127's Quarterly MDS assessment with an ARD of 03/27/18, revealed under Section O, Oxygen therapy was not coded. On 04/17/18 at 3:10 p.m., RI #127 was observed in bed. The oxygen was observed infusing at 2.5 liters per minute by nasal cannula. On 04/18/18 at 5:00 p.m., RI #127 was again observed in the bed. The oxygen continued to infuse at 2.5 liters per minute by nasal cannula. On 04/19/18 at 10:18 a.m., an interview was conducted with EI #3, a RN unit manager. EI #3 was asked, what was RI #127's [DIAGNOSES REDACTED]. EI #3 replied, shortness of breath. EI #3 was asked how long had RI #127 been receiving oxygen. EI #3 replied, since 01/03/18. On 0 4/19/18 at 11:49 a.m., an interview was conducted with EI #2, the RN/MDS Coordinator. EI #2 was asked, in reviewing RI #127's MDS assessment dated [DATE], was it coded for oxygen use. EI #2 replied, no. EI #2 was asked in reviewing RI #127's MDS assessment dated [DATE], was it coded for oxygen use. EI #2 replied, no it was not. EI #2 was asked if the MDS's should be coded for oxygen use. EI #2 replied, yes. EI #2 was asked if those assessments would be considered accurate. EI #2 replied, no. EI #2 was asked what was the harm in not coding the MDS assessment accurately. EI #2 replied, false information.

Based on observations, interview and review of a facility policy titled, Oxygen Administration, the facility failed to ensure Resident Identifier (RI) #127's Oxygen was infusing at 2 liters per minute as ordered by the Physician. This deficient practice affected RI #127, one of three residents sampled using Oxygen, and was observed on two of three days of the survey. Findings Include: A review of a facility policy titled, Oxygen Administration, with an effective date of 12/08/05, revealed: . STANDARD: Oxygen should be administered under orders of the attending physician . PR[NAME]ESS: 1. Obtain physician's orders [REDACTED]. 6. Turn the unit on to the desired flow rate . 8. Check oxygen flowmeter for correct liter flow . RI #127 was readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #127's (MONTH) (YEAR) Physician order [REDACTED].> .1/03/18 OXYGEN @ (at) 2 L/M (liters per minute) NC (nasal cannula)-MAY REMOVE FOR PERSONAL CARE DX. (diagnosis) SOB (shortness of breath) . On 04/17/18 at 3:10 p.m., RI #127 was observed in the bed. The oxygen was observed infusing per nasal cannula at 2.5 liters per minute. On 04/18/18 at 5:00 p.m., RI #127 was observed in bed and the oxygen continued to infuse at 2.5 liters per minute by nasal cannula. On 04/19/18 at 10:18 a.m., an interview was conducted with Employee Identifier (EI) #3, a Registered Nurse (RN)/Unit Manager. The surveyor informed EI #3 of the observations of RI #127's oxygen infusing at 2.5 liter per minute on 04/17/18, and on 04/18/18. EI #3 was asked what should RI #127's oxygen rate be. EI #3 replied, it should be at 2 liters per minute. EI #3 was asked if the Physician order [REDACTED]. EI #3 replied, no. EI #3 was asked what was the harm in the Physician order [REDACTED].#3 replied, it was not what the physician wanted. EI #3 was asked, what was the [DIAGNOSES REDACTED]. EI #3 replied, shortness of breath.

Based on observations, interview and review of a facility policy titled, Resident Environmental Quality, the facility failed to ensure: 1) Rooms and equipment were well maintained through out the facility for Room Locators (RL) 1-16, including loose faucets in resident bathrooms as well as a detached (from wall) resident bathroom sink, scraped paint, closet doors did not close, drawer handles partially detached, ceiling tiles stained, missing laminate on dressers, unsealed gaps around heating/air conditioning units and dining room area vent without a cover. This affected RL's # 1-16, 15 of 79 resident rooms and one of two dining rooms in the facility. 2) The facility further failed to ensure the armrests of Resident Identifier (RI) #15's wheelchair was free of cracked material and in good condition. This affected 1 of 17 residents sampled with wheel chairs and was observed three of three days of the survey. Findings Include: 1) A review of a facility policy titled, Resident Environmental Quality with an effective date of March 1, 2010 revealed the following: .PURPOSE: The facility should be .equipped and maintained to protect the health and safety of residents . STANDARD: .Maintain all essential .patient care equipment in safe operating condition. .Functional furniture appropriate to the resident's needs . The following observations were made: RL #1: Side dresser drawer handles half off, hanging loosely off drawer and side with scrapped paint on wall. This was observed 03/02/2017. RL #2: Side A's dresser drawer with handle half off and hanging loosely on the fourth drawer. This was observed 02/28/2017 and 03/01/2017. RL #3: Bathroom faucet loose when both knobs were turned on. This was observed 03/01/2017. RL #4: Heat lamp in ceiling, in the bathroom, with a missing ring/rim. This was observed on 02/27/2017 and 03/01/2017. Bathroom faucet loose when both knobs are turned on. This was observed 03/01/2017. RL #5: Heat Lamp in ceiling located in the bathroom with a missing ring. This was observed 02/27/2017 and 03/01/2017. Bathroom sink observed detached an inch from the wall. This was observed 03/01/2017. RL #6: Bathroom faucet loose when both knobs were turned on. This was observed 02/27/2017 and 03/01/2017. RL #7: Side A's ceiling tile with a large brown stain and bathroom faucet loose when both knobs are turned on. This was observed 02/27/2017 and 03/01/2017. RL #8: A/C (Air conditioning) and Heating unit unsealed with gap between the wall and the unit. This was observed 02/27/2017, 02/28/2017 and 03/01/2017. RL #9: A/C and Heating unit unsealed with gap between the wall and the unit. This was observed 02/27/2017, 02//28/2017 and 03/01/2017. RL #10: A/C and Heating unit unsealed with gap between the wall and the unit. This was observed 02/27/2017, 02/28/2017 and 03/01/2017. RL #11: Side A with an inch hole in ceiling tile above bed. This was observed 02/27/2017, 02/28/2017 and 03/01/2017. RL #12: Side B damaged drywall to the left of the window with a long gash in the drywall plaster. This was observed 02/27/2017 and 02/28/2017 and 03/01/2017. RL #13: Ceiling tile on side A with brown substances splattered on two of the tiles. This was observed 02/27/2017, 02/28/2017 and 03/01/2017. RL #14: Large damaged area to drywall behind Side B's chair approximately three feet from the head of bed. Wall covering completely gone and plaster gouged deeply. This was observed 02/27/2017, 02/28/2017 and 03/01/2017. RL #15: A/C unit caulking around unit dried and separated from the wall. This was observed 02/27/2017, 02/28/2017 and 03/01/2017. RL #16: Cover over air vent in Alzheimer's/Dementia unit missing. This was observed 02/27/2017, 02/28/2017 and 03/01/2017. On 03/01/2017 beginning at 5:15 pm and 03/02/2017 beginning at 9:10 am, an observation tour was conducted with the Maintenance Supervisor, Employee Identifier (EI) #3 of the RL environmental concerns. On 03/02/2017 at 9:33 am, an interview was conducted with EI #3, Maintenance Supervisor. EI #3 was asked how did staff inform maintenance of needed repairs. EI #3 explained staff reported issues verbally and by the computer system. EI #3 was asked how often did he make rounds to check for needed repairs. EI #3 said they check one hall a month. EI #3 was asked why should resident's bathroom faucets be in good repair and not loose when knobs are turned on. EI #3 said it could cause a resident to loose their balance and a loose faucet could cause a water leak. EI #3 was asked how often were rounds made to ensure faucets in resident bathrooms were not loose but in good repair. EI #3 explained he did not make rounds just for faucets so staff should inform him because if he was not aware of the needed repair he could not fix it. EI #3 was asked should staff have informed maintenance of this. EI #3 said yes. EI #3 was asked what caused brown stains to form on the ceiling tiles observed. EI #3 said leaks. EI #3 was asked why should ceiling tiles be free of brown stains and holes. EI #3 said to keep the rooms in good order and prevent mold build up. EI #3 was asked why should resident's dresser drawers be in good repair and handles on drawers be tightly fitted. EI #3 explained if handles are loose, residents could loose their balance and handles fitting securely allowed the resident to get their clothing items out of drawers. EI #3 further explained dressers should be in good repair for appearance. EI #3 was asked why should resident's walls be free of scuffed and gashed drywall. EI #3 said for appearance and to keep a homelike atmosphere. EI #3 was asked why should the areas around the A/C units be sealed and not with cracked and damaged caulking allowing sunlight to penetrate through the cracked areas. EI #3 explained to prevent anything from coming in. EI #3 was asked why should there be a cover for the ceiling vent unit in the Alzheimer's/Dementia unit. EI #3 said to deflect the air from coming straight down. EI #3 was asked was he aware of the needed repairs observed. EI #3 said he was aware of the drywall but not the rest of the needed repairs. EI #3 was asked how did he keep an account of repairs submitted by staff in the maintenance computer system. EI #3 said he usually saves it in the work order. EI #3 was asked did he have a work order for any of the needed repairs observed. EI #3 said No ma'am. EI #3 was asked who was responsible for ensuring faucets, walls, A/C units, dresser drawers were in good repair and in an attractive state. EI #3 said maintenance. EI #3 was asked why should bathroom sinks be firmly attached to walls. EI #3 said to ensure they work properly. EI #3 was asked what may occur if bathroom sinks were detached from the wall. EI #3 said leaks. EI #3 was asked why should closet doors shut firmly. EI #3 said for appearance. 2) A review of a facility policy titled, Resident Environmental Quality with an effective date of March 1, 2010 revealed the following: .STANDARD: .Maintain all essential .patient care equipment in safe operating condition. Observations were made on 02/27/2017, 03/01/2017 and 03/02/2017 of RI #15's wheelchair. The armrest material was cracked. RI #15 was re-admitted to the facility on [DATE]. A review of a Minimum Data Set (MDS) with an Assessment Reference Date of 02/16/2017 revealed the resident had a Brief Interview for Mental Status score of 10, indicating RI #15 was moderately impaired for daily decision making. Further review of RI #15's MDS revealed RI #15 uses a wheelchair for mobility. On 03/02/2017 at 9:03 am, an observation was made of RI #15's wheelchair armrest by EI #3 Maintenance Supervisor. On 03/02/2017 at 9:03 am, an interview was conducted with EI #3. EI #3 was asked who was responsible for the maintenance and upkeep of resident wheelchairs. EI #3 said they (maintenance) did. EI #3 was asked what did he observe when he looked at RI #15's wheelchair. EI #3 explained the armrests were cracking on the leather. EI #3 was asked who was responsible for ensuring RI #15's armrests were in good repair. EI #3 said maintenance. EI #3 was asked how would he know the wheelchair was in need of repair. EI #3 explained the nursing staff would have to let maintenance know. EI #3 was asked why should RI #15's wheelchair armrests be in good repair and not cracked. EI #3 said to prevent irritation of the skin. EI #3 was asked what was the potential harm in RI #15's wheelchair armrests having cracked material. EI #3 explained the cracks could become bigger causing it to be unsightly.

Based on review of a Medication Administration Record (MAR) and Minimum Data Set (MDS) assessment, and interview with staff, the facility failed to ensure a Registered Nurse, Certified (RN,C) MDS Coordinator accurately assessed Resident Identifier (RI) #19 as receiving an antipsychotic medication on a Quarterly MDS assessment dated [DATE]. This affected RI #19, one of 21 residents whose MDS assessments were reviewed. Findings Include: RI #19 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A facility document titled, MAR Administration Record documented that RI #19 received the antipsychotic medication of Quetiapine [MEDICATION NAME] during the MDS assessment 7 day look back period of December 14, 15, 16, 17, 18, 19 and 20, 2016. A Quarterly MDS assessment, with an Assessment Reference Date (ARD) of 12/20/2016, Section N0410A Medications Received, Antipsychotic was assessed at 0 (zero) indicating that RI #19 did not receive antipsychotic medications during the last seven days. On 03/02/2017 at 11:25 a. m., the surveyor interviewed Employee Identifier EI #5 RNC, MDS Coordinator. EI #5 was asked who was responsible for completing section N Medications on the MDS. EI #5 stated Me. The surveyor reviewed with EI #5 the MAR and Quarterly MDS 12/20/2016 Section N0410A Medications Received, Antipsychotic. EI #5 was asked what should be assessed on the MDS in Section N0410A Medications Received if a resident was on an antipsychotic medication of Quetiapine [MEDICATION NAME]. EI #5 stated The Antipsychotic slot. EI #5 was asked if RI #19 received the antipsychotic medication Quetiapine [MEDICATION NAME] during the seven day look back period for the Quarterly MDS assessment, with an ARD of 12/20/2016. EI #5 stated Yes. EI #5 was asked if N0410A Medications Received assessed RI #19 as receiving antipsychotic medications. EI #5 stated I missed it, I did it, and it was an oversight. EI #5 was asked what would be the concern with not assessing RI #19 as receiving antipsychotic medications on the Quarterly MDS assessment with ARD of 12/20/2016. EI#5 stated It would be incorrect.

Based on observation, interviews and review of facility policy Hand Hygiene, the facility failed to ensure: 1. A Certified Nursing Assistant (CNA) sanitized his hands after picking up a bottle of hand sanitizer from the floor and before opening a carton of milkshake and giving it to Resident Identifier (RI) #4 during the breakfast meal on 2/28/17; 2. Licensed staff turned off a faucet with a paper towel instead of their hands, forearms and elbows for RI #7 and #13; 3. Licensed staff disposed of a soiled gauze dressing from the wound of RI #13 into the proper receptacle; and 4. Licensed staff did not remove clean items from the treatment cart with her wet hands during the provision of wound care for RI #7. This affected 2 of 2 residents observed for wound care and one of 13 residents observed for meals. Findings include: A review of facility policy Hand Hygiene with an effective date of November 14, 2016 revealed: PURPOSE: To provide guidelines to employees for proper and appropriate hand washing techniques that will aide in the prevention of the transmission of infections. STANDARD: Hand washing should be performed between procedures . may contain transmissible infectious agents 1. RI #4 was readmitted to the facility 12/12/16 with a [DIAGNOSES REDACTED]. On 2/28/17 at 8:43 a.m. Employee Identifier (EI) #2, CNA, was observed coming out of RI #4's room. He dropped his bottle of hand sanitizer on the floor, then picked it up and placed it in his pocket. EI #2 then got a carton of milkshake from a cooler and took it into RI #4's room. EI #2 opened it and served the milkshake to RI #4 without sanitizing or washing his hands. On 2/28/17 at 8:50 a.m. an interview was conducted with EI #2. He was asked if he dropped the bottle of hand sanitizer on the floor and picked it up, then got the carton of milkshake from the cooler and served it to RI #4. EI #2 replied yes. EI #2 was asked what should he have done after picking up the bottle of sanitizer from the floor. EI #2 replied washed or sanitized his hands. EI #2 was asked what was the harm in not sanitizing his hands after handling an item picked up off the floor, before touching and serving a resident's milkshake. EI #2 replied cross contamination. On 3/2/17 at 9:00 a.m. an interview was conducted with EI #1, Licensed Practical Nurse, Infection Control. EI #1 was asked what was the policy if staff touched a contaminated or dirty item. EI #1 replied they should wash or sanitize their hands before touching the clean item. EI #1 was asked if a staff person dropped a bottle of hand sanitizer on the floor what should they do. EI #1 replied pick it up, then sanitize their hands before touching a clean item. EI #1 was asked if it would be an acceptable practice for a CNA to pick up a bottle of hand sanitizer from the floor, place it in his pocket, then get a carton of milkshake from a cooler and serve a resident without washing or sanitizing his hands. EI #1 replied no. EI #1 was asked what was the harm in a CNA handling a resident's carton of milkshake with bare hands after picking up a dirty item off the floor. EI #1 replied cross contamination. 2. The facility policy titled: Hand Hygiene with an effective date of November 14 2016 further stated: PROCESS: I. Handwashing . 4. Dry hands thoroughly with paper towels and turn off faucets with those towels . A second facility policy titled: Dressings - Clean Policy with an effective date of December 20, 2016 revealed: PURPOSE: To provide guidelines for the care of wounds . PROCESS: 1. Explain the procedure to the resident . 15. Discard disposable items and gloves into appropriate trash receptacle and wash hands. RI #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #7's Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/12/2017 indicated RI #7 had a BIMS (Brief Interview for Mental Status) of 6 out of 15. This score indicated that RI #7 was moderately impaired for cognitive decision making skills of daily living. On 2/28/2017 at 9:20 a.m., a Registered Nurse, EI #6 was observed during the provision of wound care for RI #7. After preparing all the equipment needed and her assistant had cleaned the bedside table, EI #6 knocked and entered the resident's room. EI #6 placed a clean barrier on the bedside table, then went into the bath room and washed her hands. EI #6 dried her hands with paper towels and turned the faucet off with the midpoint of her left forearm. EI #6 then placed the paper towels in the trash can and returned to the bedside. The resident was rolled to the right side by the assistant and cleaned in preparation for his wound dressing. EI #6 removed the dressing, placed it in the red trash bag at the end of resident's bed. EI #6 then measured the wound, removed her gloves, and placed them in the trash bag. EI #6 then went into the bathroom, and washed her hands turning the faucet off with the midpoint of her left forearm. EI #6 donned gloves, returned to the bedside, performed the prescribed wound care, removed her gloves and placed them in the red trash bag. She then went into the bathroom. EI #6 again washed her hands and dried them with paper towels. She turned off the faucet with the midpoint of her left forearm. EI #6 donned gloves. The prescribed treatments and dressings were applied and dated. Trash was collected and placed in the red contaminated trash bag with gloves and sealed. EI #6 went to the bathroom, washed her hands, dried them with a paper towel and then turned off the faucet with the midpoint of her left forearm. EI #6 then took the red trash bag to the dirty utility room where she placed it in the correct receptacle. She then washed her hands, turning the faucet off with her bare left hand. Finding the paper towel dispenser was broken, EI #6 exited the dirty utility room with wet hands. EI #6 unlocked the treatment cart, reached into the clean interior with her wet hands. On 3/1/2017 at 3:45 p.m. an interview was held with EI #6. EI #6 was asked when washing hands during hand hygiene what was recommended for turning off faucets. EI #6 replied it was paper towels but she always used her elbows. When EI #6 was asked what possible harm was there of turning off the faucet with elbows during hand hygiene, she replied water could drip down leading to cross contamination. EI #6 was asked to explain how she had turned the faucet off in the dirty utility room when washing her hands there. EI #6 stated that she thought she had used her elbow. When asked how EI #6 had dried her hands in the dirty utility room after washing them, she replied the towel dispenser was broken. EI #6 was asked, how did you dry your hands after washing them in the dirty utility room and turning the faucet off with your left hand. EI #6 replied, I didn't. I had to go to another room and rewash and dry my hands. The Surveyor asked when we (EI #6 and Surveyor) left the utility room and went to the treatment cart, what was your next action. EI #6 replied, I don't remember. When the Surveyor prompted EI #6 about opening the treatment cart, EI #6 replied, if she had opened it, it would have been for a trash bag to place in the bin on the end of the cart. EI #6 was asked to explain the possible harmful effects of her actions. EI #6 replied contamination. On 3/2/2017 at 9:00 a.m., an interview was conducted with EI #1, the Staff Development and Infection Control Nurse. EI #1 was asked how should facility staff turn off faucets during hand washing. EI #1 replied, with paper towels. EI #1 was then asked the possible harm of turning off faucets using the midpoint of the left forearm or bare hand during hand washing for wound treatment/care. EI #1 replied it could cause cross contamination. EI #1 was asked should a staff member exit a dirty utility room with wet hands and then enter the treatment cart to retrieve an item. EI #1 replied no. When asked what was the possible harm of placing wet hands in the treatment cart to retrieve an item, EI #1 replied, cross contamination to anything touched in the cart. 3. RI #13 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/27/2016 assessed RI #13 as requiring extensive assistance of one person for bed mobility, transfer and personal hygiene needs. RI #13 was assessed as always being incontinent of bowel function with the presence of Stage 3 and 4 pressure ulcers. On 03/01/2017 at 9:25 a.m., EI #4 performed wound care on RI #13. The following was observed as EI #4 turned off the faucet, after washing her hands: At 9:35 a.m. EI #4 turned off the faucet with her bare hand. At 9:39 a.m. EI #4 turned off the faucet with her left elbow. At 9:54 a.m. EI #4 turned off the faucet with her right hand. At 9:55 a.m. EI #4 turned off the faucet with her right elbow. At 10:04 a.m. EI #4 turned off the faucet with her left elbow. At 10:09 a.m. EI #4 turned off the faucet with elbows. At 10:11 a.m. EI #4 turned off the faucet with left hand. At 10:25 a.m. EI #4 turned off the faucet with left elbow. At 10:26 a.m. EI #4 turned off the faucet with right elbow. At 10:34 a.m. EI #4 turned off the faucet with left elbow. At 10:37 a.m. EI #4 turned off the faucet with left elbow. On 03/01/2017 at 3:36 p.m., the surveyor interviewed EI #4 the RN, Unit Manager. EI #4 was asked when washing hands during hand hygiene, what was the policy for turning off the faucet. EI #4 said they did not want to touch the faucet, which was why she turned it off with her elbow. EI #4 reviewed the facility policy on Hand Hygiene. EI #4 was asked what method she used to turn off the faucet. EI #4 stated Apparently I needed to turn off the faucet with a towel. EI #4 was asked what the harm was in turning the faucet off during hand hygiene with her hand, forearm or elbow. EI #4 stated, Potentially lethal infection. On 03/02/2017 at 9:10 a.m., the surveyor interviewed EI #1, LPN, Infection Control. EI #1 was asked how the staff was trained to turn off the faucet while performing hand hygiene. EI #1 said they were to use a paper towel after drying hands. EI #1 was asked what was the harm in a staff turning off the faucet with their bare hand or elbow. EI #1 replied it could cross contaminate. 4. A facility policy titled NURSING PROCEDURES MANUAL, Section: Advanced Care Procedures, Dressing--Clean . Effective Date: December 20, 2016 documented the following: .PROCESS . 15. Discard disposable items and gloves into appropriate trash receptacle and wash hands . On 03/01/2017 at 10:21 a.m., wound care was observed for RI #13. EI #4 cleaned an open wound on RI #13. EI #4 rolled the soiled gauze in her gloves and threw the gauze and gloves into the trash can in RI #13's bathroom. On 03/01/2017 at 3:36 p.m., the surveyor interviewed EI #4, the RN Unit Manager. EI #4 was asked after she cleaned a wound with gauze, what was the appropriate receptacle in which to dispose the gauze. EI #4 replied a red bag. EI #4 was asked where did she dispose the gauze that was used to clean RI #13's open wound after she wrapped it in her glove. EI #4 said she put it in the trash can in the bathroom. EI #4 was asked what was the harm in not disposing the gauze used to clean RI #13's open wound, into a red bag. EI #4 replied, Spread of infection in other places.

Based on review of Minimum Data Set (MDS) assessments, Careplan Attendance Forms, a facility policy entitled, Person Centered Care Plans as well as interviews with residents and facility staff members, the facility failed to document care plan meeting invitations and participation by residents and/or their sponsors. This affected four of eight residents for whom documentation was reviewed, including Resident Identifier (RI) #s: 5, 8, 14 and 17. Findings included: The facility policy, Person Centered Care Plans dated 11/28/16, specifies a purpose as: Person centered plans of care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals of the resident/guest, consistent with the resident/guest's rights. The process detailed in conducting the care plan meeting is as follows: III. a) The team including the resident . and their desired representatives . input . should be recorded in the plan of care and the resident/guest should sign the care plan acknowledging their involvement. b) When the resident/guest is unable to participate in the care plan meeting (due to illness or cognitive impairments) the resident/guest's family members should be encouraged to attend . Family members should sign the care plan acknowledging their involvement. c) When the resident/guest is unable to attend, but able to comprehend the plan of care, a review of the plan should be conducted by the care plan designee. The resident/guest should sign the care plan, as able, acknowledging the review. d) When the family members/legal representatives are unable to attend the meeting, a review of the plan should be conducted by the care plan designee. Contact with the family should be made, by phone. This communication should be recorded in the medical record, and entered on the care plan attendance record as a 'telephone' participant.' . 1) RI #5 was readmitted to the facility on [DATE]. This resident was assessed via the quarterly review MDS (dated 01/03/17) as having no cognitive impairment, with a Brief Interview for Mental Status (BIMS) score of 15. The resident's Careplan Attendance Form included records for meetings conducted on 07/29/16, 10/17/16 and 01/03/17. Neither the resident nor a family member had signed the form as attending (or refusal). Nor had the facility documented involvement by either the resident or a representative by telephone, with a review of the meeting results. 2) RI #14 has resided in the facility since 08/19/13. The most current quarterly review MDS assessment dated [DATE], identified the resident as cognitively intact (with a BIMS score of 13). A review of RI #14's Careplan Attendance Forms revealed meetings had been conducted on: 01/26/16, 04/12/16, 06/30/16, 09/13/16, 11/29/16 and 02/14/17. At no time had either the resident or a designated family member signed the form as having attended. Nor was there documented evidence of the information provided by telephone. 3) RI #17 was readmitted to the facility on [DATE]. Careplan Attendance Forms revealed meetings had been conducted on 02/18/16, 05/03/16, 07/19/16, 10/04/16 and 12/21/16. Neither the resident nor a family member had signed as having attended, nor was there documentation that a phone interview had been conducted to review the results of the care plan meeting. 4) RI #8 was admitted to the facility on [DATE]. The 02/17/17 quarterly review MDS determined this resident was cognitively intact with a BIMS of 15. A review of Careplan Attendance Forms indicated meetings had been conducted on 08/29/16, 11/08/16 and 02/21/17. However, there was no documentation to verify the attendance or lack thereof and review of the results with either the family or resident. On 03/01/17 at 3:58 p.m., the Social Services Director (Employee Identifier/EI) #8 was interviewed. When the surveyor asked EI #8 about the lack of signatures on the Careplan Attendance Forms, EI #8 explained neither those residents nor their sponsors had attended the meeting if no signature was present. On 03/01/17 at 4:20 p.m, during an interview, the Care Plan Coordinator (EI #5) stated she had not documented the residents' lack of attendance. No documentation was provided to indicate the results of these meetings had been reviewed with any resident or sponsor.

Based on observation and interview the facility failed to ensure staff did not stand to feed Resident Identifier (RI) #5 and 15 on 1/27/2016 for the lunch meal. This affected two of five sampled residents dependant on staff for feeding. Findings Included: RI #5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/27/16 at 12:25 PM Employee Identifier (EI) #9, a Certified Nursing Assistant, was observed standing beside RI #5's bed feeding the lunch meal. EI #9 stood the entire time completing the feeding of RI #5 at 12:40 PM. On 1/27/16 at 12:40 PM an interview was conducted with EI #9. EI #9 was asked if she should stand to feed residents. EI #9 replied if they are in bed we stand and if they are off the bed we sit. EI #9 was asked what was the difference, she replied she did not know. EI #9 was asked what was the harm in standing to feed a resident. EI #9 replied she did not know. EI #9 was asked would if be a dignity issue standing to feed a resident. EI #9 replied it could be. RI #15 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 1/27/16 EI #10, a Certified Nursing Assistant, was observed standing beside RI #15's bed feeding the lunch meal. The surveyor observed EI #10 feeding RI #15 from 11:55 AM until 12:20 PM, standing the entire time. On 1/27/16 at 12:20 PM an interview was conducted with EI#10. EI #10 was asked how should you be when feeding residents. EI #10 replied I should sit but I am too short. EI #10 was asked should you stand to feed residents. EI #10 replied no. EI #10 was asked what was the harm in standing to feed a resident. EI #10 replied it could make them feel like I was hurrying them.

Based on observation, interviews and record review the facility failed to ensure Resident Identifier (RI) #9's call light was in reach during an observation on 1/27/16. This affected one of 14 sampled residents during the survey. The findings include: A facility policy titled: Answering the Call Light, with and effective date of October 1, 2010 . PURPOSE: Call lights serve as notice to the staff the resident has a need or request PROCESS: .g) Place the call light within reach of the resident before leaving the room and anticipate other needs of the resident, such as a drink of water or having tissues placed in reach. RI #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During a continuous observation on 1/27/16, beginning at 8:50 AM. RI #9 was sitting in his/her room in a geri-chair. The call light was observed on the bed not in reach of the resident. At 9:50 AM, Employee Identifier (EI) #1, Certified Nursing Assistant (CNA) was observed to enter RI #9's room. The surveyor asked EI #1 where she observed RI #9's call light pad. EI #1 stated, On the bed. EI #1 was asked if RI #9 would be able to reach the call light from his/her geri-chair. EI #1 stated, No. EI #1 was asked if she was aware the call light pad had been on the bed since 8:50 AM. EI #1 stated, No ma'am. EI #1 was asked where RI #9's call light should be. EI #1 stated, It should be in his/her reach. EI #1 was asked what would be the potential for harm if RI #9's call light was not in his/her reach. She replied, could fall. An interview was conducted with EI #2 the Charge Nurse at 10:05 AM on 1/27/16 in RI #9's room. She was asked to observe RI #9's call light pad and tell the surveyor where it was. EI #2 replied, on the bed on the pillow. EI #2 was asked if RI #9's call light should be in his/her reach. EI #2 stated, Yes. EI #2 was asked what the potential for harm would be if the call light pad was out of RI #9's reach. EI #2 stated, Safety issue he/she could not ask for help. At 10:25 AM on 1/27/16 RI #9 was observed in the dining room for activities. At 10:44 AM RI #9 was observed in his/her room in the geri-chair. The call light pad was observed on RI #9's bed not in his/her reach. At 10:47 AM on 1/27/16 EI #3 and #4 entered RI #9's room. The surveyor asked EI #3 and #4 who transported RI #9 from activities to his/her room. EI #3 replied she was not sure it may have been EI #5 the Activity Assistant. EI #3 and #4 were asked if RI #9's call light should be in his/her reach. They replied, Yes. EI #3 and #4 were asked where they observed RI #9's call light. They replied, on the bed and he/she was not close enough to use it. EI #3 and #4 was asked what the potential for harm would be if the call light was not in reach. They replied he/she could fall if he/she needed something and tried to get up. An interview was conducted with EI #5 the Activities Assistant on 1/27/16 at 11:15 AM. She was asked if she transported RI #9 to his/her room after activities. EI #5 replied yes that she had moved RI #9 outside in the hallway in front of his/her room not inside of the room. EI #5 was asked if she knew who transported RI #9 inside his/her room. EI #5 said she thought it was EI #6 from housekeeping. An interview was conducted with EI #6 from the Housekeeping Department on 1/27/16 at 11:20 AM she was asked if she had transported RI #9 in his/her room after activities. EI #6 stated,Yes. EI #6 was asked if she had placed RI #9's call light in his/her reach. EI #6 stated, No someone else will come behind me and do that. EI #6 was asked what the potential for harm would be if RI #9's call light was not in his/her reach. EI #6 replied he/she could be calling or needing something and nobody would come to see. EI #6 was asked if RI #9 had ever fallen. EI #6 replied that she did not think so. An interview was conducted with EI #8 Restorative Licensed Practical Nurse (LPN) on 1/28/16 at 1:55 PM. EI #8 was asked where residents call lights were care planned. EI #8 said call lights were a holistic approach and should be in reach for everyone.

Based on record review and interview the facility failed to ensure Resident Identifier (RI) #9's care plan was implemented for a chair alarm. This was observed on 1/27/16. This affected one of 21 sampled residents reviewed for care plans. The findings include: A review of a facility document titled: Care Plan Residents Name .Problem Onset: 01/08/10 Potential for falls R/T: ABNORMALITY OF GAIT .pg. 6, 7-30-15-BED/CHAIR ALARM AT ALL TIMES FOR SAFETY . RI #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During a continuous observation on 1/27/16, beginning at 8:50 AM, RI #9 was sitting in his/her room in a geri-chair. The chair alarm monitor box was not observed on the geri-chair. The surveyor asked EI # 1, a Certified Nursing Assistant (CNA) if RI #9 was at risk for falls. EI #1 stated, Yes and she should have an alarm and I don't know where her alarm is. An interview was conducted with EI #2 the Charge Nurse on 1/27/16, at 10:05 AM. She was asked what RI #9's care plan documented for the chair alarm. EI #2 reviewed RI #9's care plan for Potential for Falls while in the surveyors presence and replied on 7/30/15, a Bed/Chair alarm at all times for safety was added after a fall on 7/29/15. An interview was conducted with EI #7 a Registered Nurse who worked in the Care Plan office on 1/28/16, at 1:48 PM. She was asked who was responsible for updating the residents care plans after a fall. She replied EI #8 Restorative Licensed Practical Nurse (LPN). EI #7 was asked to review RI #9's accident/incident report for a fall on 7/29/15 and tell the surveyor what approach was added for RI #9's care plan. EI #7 replied bed/chair alarm. EI #7 was asked if the chair alarm had been discontinued since that date. She stated, No it should not have been it has been in effect since 7/30/15. An interview was conducted with EI #8 Restorative Licensed Practical Nurse (LPN) on 1/28/16 at 1:55 PM. EI #8 was asked to review RI #9's care plan for falls and tell the surveyor what the approach was for RI #9's fall on 7/29/15. EI #8 replied, Bed/Chair alarm at all times.

Based on observation, interviews and record review the facility failed to ensure Resident Identifier (RI) #9 a resident with a history of falls chair alarm was in place. This affected one of six residents sampled for falls. The findings include: A review of RI #9's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/07/2015 documented a Brief Interview for Mental Status (BIMS) score of 08 which indicates RI #9 is moderately impaired for cognition. Section J indicated RI #9 had a fall with no injuries. RI #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During the initial tour on 1/26/16, at 9:15 AM, RI #9 was observed in his/her room sitting in the geri-chair with an alarm box observed on the chair. During a continuous observation on 1/27/16, beginning at 8:50 AM. RI #9 was sitting in his/her room in a geri-chair. The chair alarm monitor box was not observed on the geri-chair. At 9:50 AM, Employee Identifier (EI) #1 a Certified Nursing Assistant (CNA) was observed to enter RI #9's room and attempted to move him/her. The CNA stated she was about to carry RI #9 to activities. The surveyor asked EI #1 if RI #9 was at risk for falls. EI #1 stated, Yes and she should have an alarm and I don't know where her alarm is. EI #1 was asked what would be the potential for harm if RI #9's chair alarm was not on the geri-chair. She replied, he/she could fall. An interview was conducted with EI #2 the Charge Nurse at 10:05 AM in RI #9's room. EI #2 was asked where RI #9's alarm was. EI #2 replied on the bed. EI #2 was asked if the alarm should be on RI #9's geri-chair. EI #2 replied I will check. EI #2 reviewed the orders in the surveyors presence and replied, Alarm is to bed/chair for safety, so yes. She was then asked if RI #9 had fallen while in the facility. EI #2 stated Yes. EI #2 was asked what RI #9's care plan documented for the alarm. EI #2 reviewed RI #9's care plan for Potential for falls while in the surveyors presence and stated on 7/30/15 Bed/Chair alarm at all times for safety. An interview was conducted with EI #7 a Registered Nurse who worked in the Care Plan office on 1/28/16 at 1:48 PM. She was asked who was responsible for updating the residents care plans after a fall. She replied EI #8 Restorative Licensed Practical Nurse (LPN). EI #7 was asked to review RI #9's accident/incident report for a fall on 7/29/15 and tell the surveyor what approach was added for RI #9's care plan. EI #7 replied bed/chair alarm. EI #7 was asked if the chair alarm had been discontinued since that date. She stated, No it should not have been it has been in effect since 7/30/15. EI #7 was asked if the chair alarm should have been on RI #9's geri-chair on 1/27/16 at 8:50 AM. EI #7 stated, Yes. An interview was conducted with EI #8 Restorative Licensed Practical Nurse (LPN) on 1/28/16 at 1:55 PM. EI #8 was asked to review RI #9's care plan for falls and tell the surveyor what the approach was for RI #9's fall on 7/29/15. EI #8 replied Bed/Chair alarm at all times. EI #8 was then asked if RI #9's chair alarm should have been on the geri-chair on 1/27/16. She replied yes.