Every finding on record at Madison Manor Nursing Home

Based on staff interviews, record review, and facility policy review, the facility failed to ensure an abuse allegation by of staff to resident (Resident (R) 63 and resident to resident abuse (R26 and R66) of nine residents reviewed for abuse were reported in a timely manner. Specifically, the facility failed to ensure an initial incident report was submitted to the state survey agency within two hours. Findings include: Review of the facility's policy titled, Abuse Policy, dated October 2022, revealed It is the policy of {Facility}to ensure that each resident is free from verbal, sexual, physical, and mental abuse, neglect, misappropriation of resident's personal property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms .each new employee will receive education regarding the facility policies concerning resident rights and physical, verbal, mental and sexual abuse, corporal punishment, involuntary seclusion, and misappropriation of resident's personal property to include methods of properly reporting any such alleged violation of resident rights .Training includes appropriate intervention methods that may become necessary to remove a resident from potential harm in the event that a resident or visitor exhibits aggressive or catastrophic behavior .The facility must also initiate an immediate investigation and take all necessary steps to prevent further potential abuse. Examples of steps that the facility may put in place immediately to prevent further potential abuse include suspension of any employee who is alleged to have participated in an abusive incident .An investigation of the incident must be initiated immediately by the administrator or his/her designee. The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to DHCF and to adult protective services and local law enforcement in accordance with State law. 1. Review of R63's undated Admission Record, located under the Profile tab in the EMR, revealed R63 was admitted to the facility on [DATE]. Review of R63's significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/04/24, revealed a Brief Interview for Mental Status (BIMS) with a score of 99, which indicated severe cognitive impairment. The resident was documented as dependent for toileting and personal hygiene and required substantial/maximal assistance with rolling left and right. A 08/03/23 physician progress note documented the resident with moderate cognitive deficits. Review of the facility's Incident Report, provided by the facility, revealed that on 08/03/23 at approximately 2:15 PM, revealed that While providing therapy to a resident in 7A, therapist [Speech Therapist(ST)]heard [Certified Nursing Assistant (CNA)2] say to R63 who was behind the privacy curtain, Your [expletive] stinks. Review of the facility provided Confirmation of Receipt of Online Incident Report revealed that the facility reported incident had occurred on 08/03/23 at 2:15 PM. The report was submitted on 08/04/23 at 9:48 AM. Review of the Facility Reported Incident, provided by the state survey agency revealed the facility reported incident on 08/04/23 at 9:48 PM, which confirmed the facility did not report the incident until approximately 19 hours after the incident. During an interview on 08/15/24 at 1:33 PM, ST stated on 08/03/23 at approximately 2:15 PM while she was in R63's room working with the resident's roommate, with the privacy curtain pulled. ST said that while R63 was being changed, CNA2 said, (R63) your [expletive]stinks. ST said that CNA2 said it in a nonaggressive way and the resident was not in danger, but it was inappropriate. ST said R63's memory is very poor, and he would not have remembered it at that time or now. She said she stepped into the hallway with CNA2 and told her she could not speak to residents in that way. She said that she made a mental note of what happened and to go to the Nursing Home Administrator after she was done working with her resident. She said that CNA2 had left for the day, when she had reported and written up what had happened. She confirmed CNA2 never returned to the facility. ST stated that she had received abuse training and was given additional training afterwards. She said that she should have reported it immediately. During an interview on 08/15/24 at 1:44 PM, Interim Director of Nursing said that she was the staff developer at the facility when the situation occurred. She said that she found out on 08/04/23, the day after. She said that ST had reported to the supervisor, who had reported to the Nursing Home Administrator and then she found out. She stated that she went to speak with R63 but he did not recall the incident. She called the resident's family, and CNA2 was terminated. She said that CNA2 stated that she had not meant anything by it, but confirmed she said it. The Interim Director of Nursing stated ST should have reported it immediately. Interim Director of Nursing said that the facility had a brief time to report the incidents, ST was written up and was reeducated. She said that she provided additional reporting education to staff. She said that R63 has not had any ongoing concerns. She confirmed that the facility tried to get their abuse incidents in within two hours, which would be reported by the Nursing Home Administrator regardless of the day it occurred and could be reported from home. During an interview on 08/15/24 at 2:14 PM, Nursing Home Administrator stated that ST did not report the situation timely. She said that she initiated the incident report as soon as she had heard about it. She confirmed that the ST had disciplinary actions, and there was staff retraining. Nursing Home Administrator stated that CNA2 was terminated for abuse. She said that when she had been informed of the abuse incident she had been at home and did not have internet service due to weather. She said that she came to the facility to report but also had no service. She said that she reported the incident when internet access returned on 08/04/23.

Based on observations, medical record reviews, and interviews, the facility failed to prevent accidents for one resident (R)36) of 31 sampled residents. Specifically, a Certified Nurse Aid (CNA) 1 attempted to transfer R36 without assistance during and after the resident's shower. Findings include: Review of the Facesheet found in the electronic medical record (EMR) indicated that R36 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, history of falls and chronic pain syndrome. Review of R36's quarterly Minimum Data Set (MDS) found under the MDS tab of the EMR with an assessment reference date (ARD) of 05/21/24 revealed R36 required extensive to dependent level of assistance (helper does ALL of the effort for task) with transfers, bathing and dressing. R36 was unable to ambulate independently and required assistance of at least one staff for all mobility needs. R36's undated care plan was for extensive to dependent assist from staff for transfers and bathing/showers. During a observation on 08/14/24 at 12:10 PM, CNA1 was observed transporting R36 from the shower room to the beauty shop. CN 1 used her left hand to push/guide R36's wheelchair; while attempting to move an empty mechanical lift with her right hand. As the wheelchair moved down the hallway R36's right foot bent under the chair with her toes pointed behind her. The resident could not reposition her foot herself, and she mumbled to the CNA that her foot hurt. It took a moment for the CNA to hear and understand what R36 was saying. CNA1 stopped as quickly but the incline caused the wheelchair to continue to move forward several feet, pinning the resident's foot underneath her with toes pointing behind her. When CNA1 brought the wheelchair to a complete stop, she tried to reposition R36's foot and the resident cried out in pain. Registered Nurse (RN) 1 was passing in the hallway and stopped to assist CNA1 and R36. The resident's foot was brought back to a natural position and no obvious injury was noted when she was assessed, other than the resident stating it hurt. In an interview with Licensed Practical Nurse (LPN) 1 at 1:00PM on 08/14/24 revealed LPN 1 was the charge nurse on the back hallway when this incident occurred. LPN1 had spoken to and provided reeducation to CNA1. LPN1 stated the CNA was distraught about the incident and tearfully stated that she was trying to do too much, and she should have waited for another staff member to assist her, .I should have gotten R36 to the beauty shop and come back to move the lift. LPN1 confirmed the facility's policy is, .all transfers requiring a mechanical lift require a minimum of two staff members to prevent these types of accidents . CNA 1 was present & tearfully said, . I was trying to do too much and hurrying to get her to the beauty shop . In an interview with the Administrator at 08/14/24 at 2:30PM, she stated a mobile Xray was ordered, and completed and the results were pending. She stated the CNA was re-educated and the appropriate notifications were made to the physician and R36's daughter/Power of Attorney (POA). The Administrator stated there was no policy that would specifically address these circumstances. The Administrator provided CNA1's initial training and competency check off document, completed on 07/12/24, related to transfers and using mechanical lifts. The Administrator also provided a copy of the re-education provided to the CNA1 immediately following this incident on 08/14/24. On 08/15/24 at 8:30 AM R36 was visited in her room. She was sitting in her wheelchair after breakfast. She was dressed and groomed for the day and wearing clogs. The shoe was easily removed by LPN 1 and R36 had mild bruising/discoloration to her right foot/ankle, but no serious injury. The resident did not appear to remember the incident the day before in her wheelchair when she was asked. During an interview on 08/15/24 at 9:15 AM the Administrator confirmed the Xray results were negative for fracture to R36's right foot/ankle. She stated the incident prompted an opportunity for reeducating staff on the importance of two person/staff transfers for dependent residents.

Based on record review, interview, review of facility investigation, and facility policy review, the facility failed to ensure one (Residents (R) R63) of nine residents reviewed for abuse were protected from abuse, specifically staff to resident verbal abuse. Refer to F609 Findings include: Review of the facility's policy titled, Abuse Policy, dated October 2022, revealed It is the policy of [Facility]to ensure that each resident is free from verbal, sexual, physical, and mental abuse, neglect, misappropriation of resident's personal property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms .each new employee will receive education regarding the facility policies concerning resident rights and physical, verbal, mental and sexual abuse, corporal punishment, involuntary seclusion, and misappropriation of resident's personal property to include methods of properly reporting any such alleged violation of resident rights .Training includes appropriate intervention methods that may become necessary to remove a resident from potential harm in the event that a resident or visitor exhibits aggressive or catastrophic behavior .The facility must also initiate an immediate investigation and take all necessary steps to prevent further potential abuse. Examples of steps that the facility may put in place immediately to prevent further potential abuse include suspension of any employee who is alleged to have participated in an abusive incident .An investigation of the incident must be initiated immediately by the administrator or his/her designee. The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to DHCF and to adult protective services and local law enforcement in accordance with State law. Review of R63's undated Admission Record, located under the Profile tab in the EMR, revealed R63 was admitted to the facility on [DATE] with a diagnoses that included Alzheimer's disease with mood disturbance, dementia, and peripheral vascular disease Review of R63's significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/04/24, revealed a Brief Interview for Mental Status (BIMS) with a score of 99, which indicated severe cognitive impairment. The resident was documented as dependent for toileting and personal hygiene and required substantial/maximal assistance with rolling left and right. A 08/03/23 physician progress note documented the resident with moderate cognitive deficits. Review of the facility's Incident Report, provided by the facility, revealed that on 08/03/23 at approximately 2:15 PM, revealed that While providing therapy to a resident in 7A, therapist [Speech Therapist (ST)] heard Certified Nursing Assistant (CNA)2 say to R63 who was behind the privacy curtain, Your [expletive] stinks. Review of the 08/04/23 Self-Report Summary provided by the facility, which documented, in part, that The therapist followed the CNA into the hallway and told her we do not speak to residents in that manner, because it could have been very hurtful. The facility investigation substantiated the verbal abuse of CNA2 to R63 and the staff member was terminated. During an interview on 08/15/24 at 1:33 PM, ST stated that she was in R63's room working with the resident's roommate, with the privacy curtain pulled. ST said that while R63 was being changed, CNA2 said, (R63) your [expletive] stinks. ST said that CNA2 said it in a nonaggressive way and the resident was not in danger, but it was inappropriate. ST said R63's memory is very poor, and he would not have remembered it at that time or now. She said she stepped into the hallway with CNA2 and told her she could not speak to residents in that way. She said that she made a mental note of what happened and to go to the Nursing Home Administrator after she was done working with her resident. She said that CNA2 had left for the day, when she had reported and written up what had happened. She confirmed CNA2 never returned to the facility. ST stated that she had received abuse training and was given additional training afterwards. She said that she should have reported it immediately. During an interview on 08/15/24 at 1:44 PM, interim Director of Nursing said that she was the staff developer at the facility when the situation occurred. She said that she found out on 08/04/23, the day after. She said that ST had reported to the supervisor, who had reported to the Nursing Home Administrator and then she found out. She stated that she went to speak with R63 but he did not recall the incident. She called the resident's family, and CNA2 was terminated. She said that CNA2 stated that she had not meant anything by it, but confirmed she said it. ST should have reported it immediately. Interim Director of Nursing said that the facility had a brief time to report the incidents, ST was written up and was reeducated. She said that she provided additional reporting education to staff. She said that R63 has not had any ongoing concerns. She confirmed that the facility tried to get their abuse incidents in within two hours, which would be reported by the Nursing Home Administrator regardless of the day it occurred and could be reported from home. During an interview on 08/15/24 at 2:14 PM, Nursing Home Administrator stated that ST did not report the situation timely. She said that she initiated the incident report as soon as she had heard about it. She confirmed that the ST had disciplinary actions, and there was staff retraining. Nursing Home Administrator stated that CNA2 was terminated for abuse. She said that when she had been informed of the abuse incident she had been at home and did not have internet service due to weather. She said that she came to the facility to report but also had no service. She said that she reported the incident when internet access returned on 08/04/23.

Based on observations, staff interviews and review of the facility's policies entitled, Hand Hygiene Policy and Procedure, Donning and Doffing of PPE (personal protective equipment) With Gown Reuse, facility documents entitled, PPE Skills Evaluation for Standard Transmission-Based Precautions 1, and Infection Control Overview for All Staff, the facility failed to ensure staff performed hand hygiene for 10 of 23 residents on the North hall (Resident #'s 1, 2, 3, 4, 5, 6, 7, 8 , 9, and 10) and failed to ensure one (1) of 4 Certified Nurses Aids (CNAs) observed wore a face mask over her face and mouth to prevent the spread of infection. The findings included: On 5/4/20 at 12:15 p.m. Certified Nurses Aid (CNA) #1 was observed on the North hall wearing a cloth mask with her nose uncovered. She was observed entering and exiting the rooms of Resident #'s 1, 2, 3, 4, 5 and 6 without performing hand hygiene. She was observed in the hallway donning gloves from a box before attempting to re-enter Resident # 3 and 4's room. She was immediately interviewed and stated she had gone into the above mentioned rooms to check the bathrooms for urinals and bedpans. She confirmed she had not performed hand hygiene and said, I didn't touch anything but the bathroom door handles. She also confirmed she did not wash or sanitize her hands before donning gloves upon attempting to re-enter Resident #'s 3 and 4 rooms. The CNA also stated she had been in-serviced on the proper way to wear a mask, but she was unable to breathe and kept it pulled down under her nose. During an observation of lunch on the North Hall on 5/4/20 at 12:30 p.m., CNA #1 was observed serving and setting up trays for Resident #'s 7, 8, 9 and 10. The CNA first served Resident #7 and without sanitizing her hands, served Resident #8. She had touched the over bed table and her face mask (which remained pulled down under her nose). Without sanitizing her hands, she served Resident #9 and touched the over bed table, her face and her facemask. Without sanitizing her hands, she served Resident #10 and touched the over bed table and placed a clothing protector on the resident. During an interview with the Director of Nursing (DON) on 5/4/20 at 3:38 p.m., she stated it was her expectation for staff to perform hand hygiene after coming in contact with surfaces in resident rooms. The DON stated staff had been taught the proper way to wear masks and it was her expectation masks were to be worn properly. She also stated she expected staff to wash their hands before and after donning gloves. The facility policy entitled, Hand Hygiene Policy and Procedure, revised April 2020 read, 3. Perform hand hygiene .when otherwise indicated to avoid transfer of microorganisms to other residents or environments. The facility document entitled, Donning and Doffing of PPE With Gown Reuse, revised 4/15/20 read, 6. If putting on a new Mask/Respirator .Fit flexible band to Nose Bridge. Fit snug to face and below chin. The undated facility document entitled, PPE Skills Evaluation for Standard Transmission-Based Precautions 1 read, Masks Covers nose and Mouth. The facility document entitled, Infection Control Overview for All Staff, dated 5/18 read, 3. Perform hand hygiene .assisting a resident with meals .prior to donning and after gloves are removed, and when otherwise indicated to avoid transfer of microorganisms to other residents or environments. Review of a CNA sign in sheet entitled Hand Hygiene with Soap & Water, Sanitizing Hand ABHR (alcohol based hand rub), Sani Wipes, Donning and Doffing PPE ., dated 4/27/2020-4/29/2020, revealed CNA #1 had received training for performing hand hygiene and the use of PPE.

Based on observation, interviews, review of a facility's form titled, DISHWASHING MACHINE TEMPERATURE LOG and the (YEAR) Food Code, the facility failed to ensure the temperature gauge of the dish machine provided accurate readings for wash and rinse temperatures. This had the potential to affect all 72 residents for whom meals were prepared and served at the time of this survey. Findings Include: The (YEAR) Food and Drug Administration Food Code revealed: .4-501.110 Mechanical Warewashing Equipment, Wash Solution Temperature .(B) The temperature of the wash solution in spray-type warewashers that use chemicals to SANITIZE may not be less than .(120 degrees F) (Fahrenheit) . The data plate affixed to the dish machine specified a minimum water temperature of 125 degrees F. During the initial kitchen tour, on 07/23/19 at 7:50 AM,the surveyor observed the posted DISHWASHING MACHINE TEMPERATURE LOG on which staff documented daily wash temperatures of 130 degrees F, daily rinse temperatures of 140 degrees F and a chlorine concentration of 50 parts per million (PPM). Despite the recording of three sets of data (breakfast, lunch and supper) daily for 24 days of July, there was no variation in any of the documentation. On 07/24/19, at 11:45 AM, the surveyor observed the water temperature gauge of the dish machine (located under the dish counter), to be 124 degrees F for the wash water (after two cycles had run) and 124 degrees F for the rinse. The staff member (and surveyor) had to squat down and put their head under the counter to view the gauge. The staff member verified with the surveyor, an adequate chlorine concentration on the surface of a utensil. All temperatures and all chemical concentrations (PPM) were consistently documented the same on 07/24/19, as for every other day. On 07/24/19 at 1:30 PM, during the processing of the lunch dishes, the surveyor observed a wash temperature of 98 degrees F and a rinse of 115 degrees F. The next cycle yielded temperatures of 110 degrees F for the wash and 118 degrees F for the rinse. The Certified Dietary Manager (CDM) , Employee Identifier (EI) #3, stated, As long as it's in the blue, I'm good. On 07/24/19 at 3:10 PM, the surveyor interviewed the Auto-Chlor Technician, who had been called in to check the dish machine. At this time, the Auto-Chlor Technician affirmed the gauge was reading good and affirmed a temperature reading in the blue area of the gauge indicated a temperature to be be too cool. Due to the difficulty in determining the water temperature, the Auto-Chlor Technician stated he would install a different gauge, making it easier to read. On 07/25/19 at 8:15 AM, a dishwasher, EI #4, had again documented the machine temperatures as 130 degrees for the wash and 140 degrees for the rinse. When asked, EI #4 demonstrated how she checked the temperatures, by squatting down and bending her head under the counter. She stated, It's in the blue section. At the surveyor's request, EI #3, ran another cycle of dishes. The surveyor observed the gauge to be reading in the yellow section at about 125 degrees. EI #3 stated, It's impossible to read. EI #3 stated she would contact the Auto-Chlor Technician again, and request documentation to ensure it was permissible to check the machine's reservoir with a food thermometer to determine the water temperature. On 07/25/19 at 9:30 AM, the surveyor video scanned the temperature gauge with a cell phone camera to reveal the following readings on the gauge: Blue section=90-118 degrees F Yellow section=118 to 134 degrees F Green section=136 to 148 degrees F Red section=150-162 degrees F After viewing the video, the above temperatures were agreed upon by EI #3 and EI #6, Dietary Aide and the surveyor. On 07/25/19 at 9:30 AM, the Auto-Chlor Technician returned to the dish room and stated, The gauge is wrong. The Auto-Chlor Technician brought a larger and easier to read gauge, showing it to both EI #3 and to the surveyor.

Based on observations, interviews, medical record review and review of facility policies titled, Hand Hygiene Policy and Procedure and Medication Administration Procedures Nasal Inhalers, Sprays, and Pumps, the facility failed to ensure a Licensed Practical Nurse (LPN): 1. changed gloves and washed her hands after assisting Resident Identifier (RI) #31 to blow his/her nose, 2. wiped off the nasal spray bottle prior to recapping the bottle and returning it to the cart, 3. washed her hands before applying gloves to administer RI #31's eye drops after pulling the light cord and privacy curtain with bare hands, and 4. removed gloves used to administer eye drops before adjusting RI #31's bed control and pulling the light cord. This affected RI #31, one of five residents observed during medication pass observations. Findings Include: A review of a facility policy titled, Hand Hygiene Policy and Procedure with a revised date of 6/17, revealed: .Procedure: 1. Hand hygiene is a general term that applies to either washing hands with soap and water or the use of an antiseptic hand rub, also known as alcohol-based rub . 3. Perform hand hygiene after contact with .mucous membranes . prior to donning and after gloves are removed, and when otherwise indicated to avoid transfer of microorganisms to other .environments. 4. It may be necessary to perform hand hygiene between tasks and procedures on the same resident to prevent cross contamination . A review of a facility policy titled, Medication Administration Procedures Nasal Inhalers, Sprays, and Pumps, with a date of 01/12, revealed: .Wipe the administration device with a clean tissue and replace the protective cap . RI #31 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 07/23/19 at 8:24 a.m., the surveyor observed Employee Identifier (EI) #2, LPN, administer medications to RI #31. The surveyor observed EI #2 assist RI #31 to blow his/her nose and without changing gloves, administer the nasal spray to the resident. EI #2 was observed placing the cap back on the nasal spray without wiping the tip of the bottle off and placing it back into the container. EI #2 obtained eye drops from the medication cart and re-entered RI #31's room and pulled the light cord and the privacy curtain with her bare hands. EI #2 applied her gloves without washing her hands and administered RI #31's eye drops. While still wearing the same gloves, EI #2 was observed adjusting the bed control, pulling the light cord and the privacy curtain. On 07/25/19 at 12:22 p.m., an interview was conducted with EI #2. EI #2 was asked when should she change gloves and wash her hands during medication pass. EI #2 said at the very beginning and depending on what she was doing. EI #2 said if she touched anything that was considered contaminated or dirty she should change her gloves and wash her hands. EI #2 was asked should she change her gloves after pulling the light cord and privacy curtain. EI #2 replied yes. EI #2 was asked did she change her gloves and wash her hands in RI #31's room after pulling the light cord and privacy curtain, before administering his/her eye drops. EI #2 stated no, she did not. EI #2 was asked did she change her gloves and wash her hands after she held the tissue for RI #31 to blow his/her nose before continuing to administer the nasal spray. EI #2 said no. EI #2 was asked did she clean the tip of the nasal spray before storing it back in the medication cart. EI #2 answered no. EI #2 was asked what was the concern with these issues. EI #2 answered the spread of bacteria, infection control. On 07/25/19 at 12:37 p.m., an interview was conducted with EI #1, Registered Nurse (RN)/Director of Nursing. EI #1 was asked when should nurses wash their hands during med pass. EI #1 said in between each task, in between each room and each patient, and if there were different types of medications such as eye drops, ear drops and those sort of things. EI #1 was asked should nasal spray be wiped off after administration before storing in the cart. EI #1 replied yes. EI #1 was asked should a nurse change her gloves and wash her hands after holding a Kleenex tissue for a resident to blow his/her nose before continuing with nasal spray administration. EI #1 stated yes. EI #1 was asked should a nurse change gloves and wash her hands after pulling a light cord and privacy curtain while wearing gloves and then administering eye drops. EI #1 said yes. EI #1 was asked what was the concern with nurses not changing gloves and washing their hands when contaminated. EI #1 answered passing infection around, bacteria and bugs from one person to another, including staff, visitors and residents; transmission of infection.

Based on interview and record review, the facility failed to ensure Resident Identifier (RI) #10's Significant Change (SC) Minimum Data Set (MDS) assessment, dated 04/15/19, reflected RI #10 was receiving Hospice Services. This deficient practice affected RI #10 one of 19 sampled residents whose MDS assessments were reviewed. Findings Include: RI #10 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #10's physician orders, dated 03/29/19, revealed Amedisys Hospice was to evaluate and treat, as indicated. A review of RI #10's SC MDS assessment, dated 04/15/19, did not identify RI #10 as having received hospice services during this assessment period. On 07/25/19 at 10:50 a.m., the surveyor conducted an interview with Employee Identifier (EI) #5, Registered Nurse/MDS Coordinator. The surveyor asked EI #5 was she familiar with RI #10. EI #5 said no but she did know RI #10's name. The surveyor asked EI #5 when was RI #10's hospice ordered. EI #5 said on 3/29/19. The surveyor asked EI #5 how long had RI #10 been receiving hospice services. EI #5 said about four months. The surveyor asked EI #5 was RI #10 coded for hospice services during the SC assessment dated [DATE]. EI #5 said no. EI #5 was asked should RI #10 have been coded for hospice during the SC assessment period. EI #5 said yes. EI #5 was asked if this was an accurate assessment . EI #5 said probably not, it was not correct for hospice.

Based on observations, interviews and medical record review, the facility failed to ensure Resident Identifier (RI) #55 was not wearing a hand roll with another resident's name on it on 06/19/18 and 06/20/18. This deficient practice affected RI #55, one of two residents sampled for splints. Findings Included: RI #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #55's medical record revealed a Functional Maintenance Plan dated 01/07/18 which documented the following: .3. Continue to place hand roll at on left hand and assess at this time in order to complete ADL (Activities of Daily Living) tasks . On 06/19/18 at 8:17 a.m., survyeor observed resident sitting up in wheelchair with a hand roll in his/her left hand with another resident's name written in black across a white strip of fabric on the back of the resident's hand. Resident stated facility had lost his/her hand roll and gave him the other resident's to wear. On 06/20/18 at 8:21 a.m., surveyor again observed resident with the hand roll in his/her left hand with another resident's name on it. On 06/20/18 at 3:21 p.m., an interview was conducted with Employee Identifier (EI) #1, Licensed Practical Nurse(LPN)/Restorative Nurse. EI #1 was asked did she observe a hand roll in RI #55's left hand that day. EI #1 said, yes. EI #1 was asked did the hand roll have a another resident's name on it. EI #1 replied it did. EI #1 was asked should EI #55 have had a hand roll with another resident's name on it. EI #1 answered, no. EI #1 was asked what did she do when she saw the other resident's name on the hand roll. EI #1 answered she marked it out. EI #1 was asked what was the concern with RI #55 wearing a hand roll with another resident's name on it. EI #1 said it was a dignity issue. On 06/21/18 at 10:34 a.m., an interview was conducted with EI #2, Social Services Designee. EI #2 was asked did she participate in training the staff regarding resident's rights. EI #2 said she did if they called on her to, but the Ombudsman did it the last time. EI #2 was asked should a resident have any item on that has another resident's name on it. EI #2 replied, no. EI #2 was asked what was the concern with a resident wearing a hand roll with another resident's name on it. EI #2 said it was a dignity issue.

Based on staff interviews, medical record review and review of a facility policy titled, Medication Monitoring Psychoactive Drug Monitoring, the facility failed to ensure Resident Identifier (RI) #21's Abnormal Involuntary Movement Scale (AIMS)was performed timely to monitor resident's response to ordered antipsychotic medication. This deficient practice affected RI #21, one of three residents sampled for use of an antipsychotic medication. Findings Included: A review of a facility policy titled, Medication Monitoring Psychoactive Drug Monitoring dated 01/12 revealed: .Policy Residents who receive psychoactive/psychopharmacological medications are monitored. These are defined as any medication used for managing behavior, stabilizing mood, or treating psychiatric disorders. Every effort is made to ensure that residents receiving these medications obtain the maximum benefit with the minimum of unwanted side effects.Procedures .2.Effects and side effects of the medications are documented and monitored. RI #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #21's medical record revealed a physician's orders [REDACTED].> .04/17/18 [MEDICATION NAME] 100 MG (milligram) tablet - give 1/2 (one half) tablet to equal 50 MG by mouth three times a day . A review of RI #21's medical record further revealed a AIMS dated 09/12/17. On 06/21/18 at 11:30 a.m., an interview was conducted with Employee Identifier (EI) #4, Registered Nurse(RN)/Minimum Data Set (MDS) Coordinator. EI #4 was asked when were AIMS performed and who was responsible for them. EI #4 said she tried to do them when doing quarterly assessments and filled out the AIMS form every six months. EI #4 was asked when was the last AIMS performed for RI #21 prior to this survey. EI #4 replied 09/12/17. EI #4 was asked how many months ago was that assessment. EI #4 said nine. EI #4 was asked when should the AIMS have been performed . EI #4 replied (MONTH) (YEAR). EI #4 was asked what was the concern with potential side effects of an antipsychotic not being monitored timely. EI # stated Tardive Dyskinesia. On 06/21/18 at 12:50 p.m. an interview was conducted with EI #3, RN/Director of Nursing(DON). EI #3 was asked what assessments were routinely done when a resident was on an antipsychotic medication. EI #3 said normally an AIMS test on admission or a new order and then every six months. EI #3 was asked was RI #21's AIMS performed within the six months time period. EI #3 replied, no. EI #3 was asked should it have been according to your routine. EI #3 said, yes.

Based on observation, interview with facility staff, and review of facility document titled ,DIRECTOR OF MAINTENANCE JOB DESCRIPTION, the facility failed to ensure that the screws holding the commode in place were not exposed and were not at a length to cause potential injury. This affected 17 rooms on hall 2. Findings include: Review of the facility's DIRECTOR OF MAINTENANCE JOB DESCRIPTION, date of hire 1-13-12, documented : .ensuring that the facility is maintained in a safe, comfortable condition . During the initial tour of the facility on 5/31/17 at 11:58 a.m., the surveyor observed exposed screws protruding from base of commodes in Room Locator (RL) #1 through RL #17. Resident Identifiers (RI) # 8, # 9, and # 17 toilet independently and had the potential to sustain an injury while in these areas. On 6/1/17 at 10:20 a.m. an interview was conducted with Employee Identifier (EI) #5, Maintenance Director. EI #5 was asked, should screws be protruding from base of commodes. EI #5 replied, I've been here for four years, that's the way they have always been, should have protective covers. EI #5 was asked , what is the potential for harm. EI #5 stated, a resident could potentially fall on them.

Based on observations, interview with facility staff, and medical record review, the facility failed to ensure: 1. Employee Identifier (EI) #4, a licensed practical nurse, did not use gloves from her pocket during medication administration for Resident Identifier (RI) #7. 2. EI #4 did not use scissors from her pocket, without cleaning them, to trim RI #7's bandage during application of UNA boots. 3. EI #3, a licensed practical nurse, washed her hands prior to donning gloves and after removing gloves during medication administration for RI #17. This affected two of 15 sampled residents RI #'s 7 and 17) with two nurses (EI#'s 3 and 4) observed during medication pass observations. Findings include: 1. A review of a facility policy titled, Policy: Infection Control, dated 6/22/04 documented: . III. Gloves: a.Wash hands, put on clean gloves . Remove gloves promptly after use and wash hands immediately . On 05/31/17 at 4:01 p.m. during medication pass observation for RI #7, EI #4 pulled gloves from her pocket before administering Refresh eye drops in RI #7's eyes. EI #4 was then observed pulling scissors from her pocket. She then used the scissors, without cleaning them, to trim a bandage during application of RI #7's UNA boots. On 5/31/17 at 4:53 p.m. during medication pass observation for RI #17, EI #3 was observed donning gloves without washing her hands. EI #3 then removed gloves without washing her hands during administering medication to RI #17. On 06/01/17 at 11:33 a.m. a telephone interview was conducted with EI #3. EI #3 was asked, when are you supposed to wash your hands when using gloves. EI #3 answered, before putting them on and after taking them off. EI #3 was asked, did you wash your hands before putting on your gloves and after taking off your gloves during RI #17's medication pass observation. EI #3 said, I think I forgot to. EI #3 was asked, what is the problem with not washing your hands before and after using gloves. EI #3 replied, it's an infection control issue. On 06/01/17 at 12:08 p.m. an interview was conducted with EI #2, a registered nurse, Assistant Director of Nursing (ADON), infection control nurse. EI #2 was asked, should an employee use gloves out of her pocket. EI #2 replied, No. EI #2 was asked should an employee use scissors out of her pocket. EI #2 said, No. EI #2 was asked, are those infection control issues. EI #2 answered, Yes, they are. Most definitely. On 06/01/17 at 2:14 p.m. an interview was conducted with EI #4. EI #4 was asked, is your pocket considered clean. EI #4 replied, No. The surveyor asked EI #4, did you use gloves from your pocket during the medication pass observation for RI #7. EI #4 said, I did. EI #4 was asked, did you use scissors from your pocket without cleaning them to trim the wrap on his/her UNA boots. EI #4 answered, I did. EI #4 was asked, is using items from your pocket an infection control issue. EI #4 said, It is.

Based on observation, interviews with facility staff, review of a facility policy titled, A Matter of RIGHTS A Guide to Your Rights and Responsibilities as a Resident and review of FUNDAMENTALS OF NURSING, NINTH EDITION, POTTER | PERRY, Medication Administration, the facility failed to ensure Employee Identifier (EI) #4, a licensed practical nurse, pulled the privacy curtain and closed the door when obtaining a fingerstick blood sugar, administering eye drops and administering an insulin injection to Resident Identifier (RI) #7. This affected one of four nurses and RI #7, one of six residents observed during medication pass observation. Findings include: A review of a facility policy titled, A Matter of RIGHTS A Guide to Your Rights and Responsibilities as a Resident documented: Privacy, Confidentiality and HIPPAA Your right to privacy and confidentiality is as important to you as it is to any other person. You have the right to: have other people respect your personal privacy . as you receive care . Our policies and procedures addressing privacy and confidentiality are: 1. A resident is entitled to privacy in accommodations, medical treatment . A review of Potter | Perry, FUNDAMENTALS OF NURSING, NINTH EDITION, UNIT V, Foundations for Nursing Practice, Chapter 32, Medication Administration, page 671, SKILL 32-4, documented: IMPLEMENTATION STEP . 3. Close room curtain or door RATIONALE Provides privacy. On 05/31/17 at 4:01 p.m., EI #4, was observed obtaining RI #7's blood sugar without pulling the privacy curtain and while the door to RI #7's room was open. EI #4 then administered two different eye drops and an insulin injection to RI #7 without pulling the privacy curtain or closing the door. On 06/01/17 at 12:08 p.m., an interview was conducted with EI #2, a Registered Nurse (RN), Assistant Director of Nursing. EI #2 was asked, should a nurse pull the curtain and close the door when administering eye drops and an insulin injection. EI #2, answered, Yes. EI #2 was asked, is that a privacy/dignity issue. EI #2 replied, It is a privacy and dignity issue for a resident to be provided privacy during med (medication) administration. On 06/01/17 at 2:14 p.m., an interview was conducted with EI #4. EI #4 was asked, did you pull the curtain between residents and close the door before checking RI #7's blood sugar, administering his/her eye drops and giving his/her insulin injection. EI #4 said, No. EI #4 was asked, since the curtain was not pulled between the residents and the door was not closed while you were performing these tasks, is that a privacy issue. EI #4 responded, Yes.

Based on observation, interview with facility staff, medical record review and a review of a facility policy titled, Policy and Procedure for Oxygen Administration, a review of POTTER |PERRY , FUNDAMENTALS OF NURSING, the facility failed to ensure a Licensed Nurse, filled RI (Resident Identifier) #1's humidifier bottle container with water during oxygen administration. This was observed on 05/31/17 during the initial tour This affected one of fifteen sampled residents (RI #1). Findings include: A review of POTTER| PERRY, FUNDAMENTALS OF NURSING, NINTH EDITION, Chapter 41, Oxygenation, page 902 revealed: .12 Keep humification container filled at all times . A review of a facility policy titled, Policy and Procedure for Oxygen Administration with an effective date of 07/2016 revealed: . Purpose: To administer oxygen to the resident as ordered by the physician and as indicated on an as needed basis for shortness of breath .Procedure . A Licensed Nurse is to set the liters on flow meter per order and initiate the O2. Fill the humidifier to the fill line and connect to the flow meter or connect the prefilled humidifier . RI #1 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #1's 2017 May's physician's orders [REDACTED].O2 (Oxygen) @ (at) 3L (liters)/MIN (minutes) PER NASAL CANNULA . RI #1's 5-day Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/23/2017 documented in the Section O, as RI #1 requiring oxygen therapy. On 05/31/2017 at 12:11 p.m. the surveyor observed RI #1 lying in bed with on O2 infusing at 3 liters per minute per nasal canual. There was no water in the humidifier bottle. On 05/31/2017 at 12:15 p.m. Employee Identifier (EI) #1 accompanied surveyor to RI #1's room and an interview was conducted. EI #1 was asked should RI #1's humidifier bottle have water it. EI #1 said yes it should have water in it. On 06/01/2017 at 11:55 a.m., a follow up interview was conducted with EI #1 per phone. EI #1 was asked what is the potential harm with the humidifier bottle not having water in it. EI #1 said the humidifier is not getting the moisture, it can cause a really dry nose and a nose bleed.

Based on record review, observation and interview, the facility failed to ensure a licensed staff member correctly administered an inhalation medication to RI (Resident Identifier) #10 and RI #16 during medication administration on 06/14/16 and 06/15/16. This affected two of two residents observed who received inhalation medication. Findings Include: A review of the Alabama Board of Nursing Alabama Administrative Code Chapter 610-X-6 Standards of Nursing Practice revealed: .610-X-6-.07 Medication Administration and Safety (1) The registered nurse or licensed practical nurse shall have applied knowledge of medication administration and safety, including but not limited to . (c) Expected therapeutic benefit of medication. A review of a policy titled Oral Inhalation dated 1/2012 revealed: . 6. If more than one inhalation is ordered, wait one minute then repeat. 1) RI # 10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #10's physician order [REDACTED]. [MEDICATION NAME] 160-4.5 mcg (Micrograms) Inhaler-2 puffs by mouth twice a day . On 06/14/2016 at 4:18 PM, EI (Employee Identifier) #5 LPN (Licensed Practical Nurse), was observed preparing medication for RI #10. EI #5 administered the medication without waiting one minute between puffs from the inhaler. On 06/16/16 at 10:22 AM, an interview was conducted by telephone with EI #5. EI #5 was asked if she waited one minute between each puff of the inhaler. EI #5 answered she was not sure. She counted fast and she was nervous. EI #5 was asked if she should have waited a full minute between each puff. EI #5 answered yes. EI #5 was asked why she did not wait one minute between each puff. EI #5 answered she was just nervous. She stated it felt like five minutes. EI #5 was asked what was the potential harm for not waiting one minute between each puff. EI #5 answered the resident may not get the medication as needed or ordered. EI #5 was asked how long did she wait. EI #5 answered maybe 30-45 seconds. She said she counted fast and she was nervous. 2) RI # 16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a doctor's order for RI #16 dated 03/10/15 revealed: .[MEDICATION NAME] 160-4.5 MCG INHALE 2 PUFFS ORALLY TWICE DAILY--RINSE MOUTH AFTER EACH USE . On 06/15/16 at 12:20 PM, an interview was conducted with EI #4, LPN. EI #4 was asked to tell about the facility policy of administering an inhaler. EI #4 answered to tell the resident to exhale and then as the resident was inhaling with the inhaler in their mouth, administer the medication. With the 2nd puff, wait a minute and then administer the 2nd puff. EI #4 was asked to tell the surveyor how she administered it. EI #4 stated that she administered it just as she described. EI #4 was asked if she waited one minute between puffs. EI #4 said that she did not wait the full minute. EI #4 was asked if she should have waited a full minute between puffs. EI #4 answered that she should have waited. EI #4 was asked why she did not wait the full minute between puffs. EI #4 said she did not wait because she was nervous. EI #4 was asked about the potential harm when not waiting one full minute between inhalations. EI #4 answered the resident may not get the accurate dosage. EI #4 was asked how long did she wait. EI #4 answered about ten seconds.

Based on record review, observation and interview, the facility failed to ensure a CNA (Certified Nursing Assistant) changed gloves and washed her hands after cleaning RI (Resident Identifier) #3's buttocks and before touching and placing a clean brief underneath the resident. This affected one of one sampled residents observed during incontinent care. The facility further failed to ensure dietary staff washed their hands after using the three compartment sink and when picking up an item off the floor. This affected 63 of 64 residents who received meals from the kitchen. Findings Include: A review of a facility policy titled, Incontinent Care and Catheter Care Using Disposable Wipes with a revised date of 12/2012 revealed: .PROCEDURE: . 6.Clean the buttocks . 9. Remove and dispose of gloves, wash hands. Apply clean gloves. 1. RI #3 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #3's most recent Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 03/11/2016 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 4, which indicated the resident was severely cognitively impaired for daily decision making. The MDS also revealed the resident required extensive assistance with toilet use and personal hygiene. The MDS further revealed the resident was frequently incontinent of bowel and bladder. On 6/15/16 at 6:53 PM, EI (Employee Identifier) #2, CNA, was observed performing incontinent care for RI #3. RI #3 had been incontinent of urine. EI #2 washed her hands and donned gloves and performed perineal care for RI #3. EI #2 removed her gloves, washed her hands and donned clean gloves. The resident was rolled onto the right side and EI #2 wiped down the resident's buttocks with a wipe and then wiped up the resident's buttocks with a wipe. EI #2 touched a clean brief and placed it underneath the resident without changing gloves or washing her hands. On 6/15/2016 at 7:13 PM, an interview was conducted with EI #2. EI #2 was asked what she should have done after she cleaned RI #3's buttocks and before she touched the clean brief. EI #2 said wash her hands and change gloves. EI #2 was asked if she washed her hands and changed her gloves. EI #2 said, No. EI #2 was asked what the potential harm was if she did not change gloves and wash her hands after cleaning the resident's buttocks and before touching the clean brief. EI #2 said cross contamination. On 6/16/2016 at 10:15 AM, an interview was conducted with EI #1, ADON (Assistant Director of Nursing)/Infection Control Nurse. EI #1 was asked if the facility had an Infection Committee. EI #1 said yes. EI #1 was asked how often the Infection Committee met. EI #1 said weekly. EI #1 was asked what systems were in place to monitor and investigate the cause(s) of infection and the manner of how infection was spread. EI #1 said she kept an infection control log, CDC (Centers for Disease Control) criteria sheets, end of the month tally of cultures and monthly compliance records. EI #1 was asked what systems were in place to maintain records of incidents and corrective actions related to infection. EI #1 said she looked through the log to see why there were more incidences in a particular area and she would plan training in-services for the staff to focus on those areas. EI #1 was asked what types of infection were currently being monitored. EI #1 said UTI, GI (Gastrointestinal) infections, Pneumonia and skin infections. EI #1 was asked if staff were washing their hands and changing gloves per facility protocol. EI #1 said yes, but with frequent reminders for the newer staff. EI #1 was asked how she monitored to ensure staff were washing their hands and changing gloves according to facility protocol. EI #1 said staff demonstrated on compliance rounds and in the skills fair. EI #1 said she observed if hand washing was done correctly on walking rounds. EI #1 also said the entire staff was in-serviced when a resident came in on isolation. EI #1 was asked what the potential harm was in not hand-washing and changing gloves. EI #1 said cross contamination. 2. A review of a facility document titled, Hand Washing with a date of 2010 revealed the following: .Policy: Staff will wash hands .Procedure: 1. When to Wash Hands: .During food preparations, as often as necessary to remove soil and contamination and to prevent cross contamination when changing task .After engaging in other activities that contaminate the hands . On 06/15/2016 at 10:01 AM, an observation was made of a Dietary Staff member washing a knife at the three compartment sink. The staff member finished washing, rinsing and sanitizing the knife and walked to the preparation area and placed on gloves without washing her hands. On 06/15/2016 at 10:49 AM, another observation was made during lunch tray-line. The Dietary Manager picked up an empty alcohol packet off of the floor while she assisted the cook with taking the alcohol swipes out of the packet. The Dietary Manager placed the empty packet on to a brown tray and proceeded to remove alcohol swipes out of the packetsand had them to the cook. The cook used the alcohol swipes given by the Dietary Manager to clean the thermometer while temping food items of the lunch meal. The Dietary Manager failed to wash her hands after picking up the empty packet from the floor. On 06/16/2016 at 4:33 PM, an interview was conducted with EI (Employee Identifier) #6, Dietary Manager. EI #6 was asked when was dietary staff to wash their hands. EI #6 stated when they go from one area to the next area. EI #6 was asked why dietary staff should wash their hands after washing, rinsing and sanitizing an item at the three compartment sink. EI #6 explained because their leaving from one area to go to the next area. EI #6 was informed of the observation of a dietary staff at the three compartment sink washing and sanitizing an item, returning to the preparation area and placed on gloves without washing her hands. EI #6 was asked what did the staff member fail to do. EI #6 explained the staff member failed to wash her hands before putting clean gloves on. EI #6 was asked why she should have washed her hands before placing on clean gloves. EI #6 stated to prevent cross contamination. EI #6 was asked when should the staff member have washed her hands. EI #6 explained after the staff member left the three compartment sink. EI #6 was asked what was the potential harm in a dietary staff member not washing her hands after using the three compartment sink. EI #6 stated cross contamination. EI #6 was also informed of an observation involving her picking up an item off of the floor and not washing her hands while assisting the cook with sanitizing the thermometer during lunch tray-line. EI #6 was asked when picking up an item from the floor why should staff immediately wash their hands. EI #6 said the floor is dirty and it goes under cross contamination. EI #6 was asked why staff should wash their hands after picking up an item off the floor. EI #6 stated to prevent cross contamination. EI #6 was asked what was the potential harm in picking up an item off of the floor and not washing hands. EI #6 explained that you could transfer dirty items to clean items. EI #6 further explained she remembered picking up an item from the floor and washed her hands when she realized her assistance was needed. That was the only time she recalls picking up anything off of the floor.

Based on observation and interview, the facility failed to ensure the handrails were secured to the wall on two resident hallways. This affected two of four resident hallways located in the facility. Findings Include: On 6/14/16 at 4:08 PM, observations were made of the handrail between RL (Room Locator) #3 and RL #8. It was not secured to the wall. On 6/15/16 at 3:00PM, an observation was made of the handrail outside of the maintenance office, it was not secured to the wall. On 6/15/16 at 4:55 pm, an interview was conducted with EI (Employee Identifier) # 3, Maintenance Director. EI # 3 was asked to tell the surveyor about the condition of the handrails. EI#3 answered, the handrails were loose outside of RL #3. EI #3 said the handrail between RL #3 and RL #8 needed to be tightened up. EI #3 said the handrail outside of the maintenance office was loose. He could not deny it. EI #3 was asked if the handrails were secured to the walls. EI #3 answered no ma'am. On 6/16/16 at 9:15 AM, a second interview was conducted with EI #3. EI # 3 was asked who was responsible for maintaining the handrails. EI #3 answered the maintenance department. EI #3 was asked what was the condition of the handrails. EI #3 answered they were in poor condition. EI #3 was asked why were the handrails not secured to the wall. EI #3 answered the bolts were loose. EI #3 was asked how often the handrails were checked. EI#3 answered, once a month. EI #3 was asked when was the last time they were checked for maintenance. EI #3 answered May 23rd or 24th. EI#3 was asked what was the potential harm in having loose handrails. EI #3 answered falls. EI #3 was asked falls by whom. EI #3 answered the resident.

Based on observations, interview and record review the facility failed to ensure residents room doors were free of splinters and wood chips. This affected seven of twenty four rooms on unit one. Findings Include: A review of a facility documented titled, Preventative Maintenance Inspection Checklist with no revised date, revealed: . Check each items on each unit monthly . Check each item off once the check is completed if no concerns. On 6/15/2016 at 6:00 PM, on unit I the surveyor observed (RL) room locators 1, 2, 3, 4, 5, 6, and 7 with splinters on the doors. On 6/16/2016 at 9:15 AM, the surveyor toured unit I with the maintenance director. The surveyor and the maintenance director observed rooms locators 1, 2, 3, 4, 5, 6 and 7. On 6/16/2016 at 10:23 AM, an interview was conducted with the maintenance director. EI (Employee Identifier) #3 was asked what was on RL #1, 2, 3, 4, and 5 doors. EI #3 replied, splinters. EI #3 was asked why was there splinters on the doors. EI #3 replied, the doors are old. EI #3 was asked what was on room locator two and seven doors. EI #3 replied wood chips. EI #3 was asked what was the facility's policy on the up keep of the resident doors. EI #3 replied, make sure the doors open and close properly and no splinters on the wood doors. EI #3 was asked when were rounds made last on residents room doors. EI #3 replied May 2016. EI #3 was asked who was responsible for repairs on resident room doors. EI #3 replied, maintenance department. EI #3 was asked why should residents room doors be free of splinters. EI #3 replied, to prevent the resident from splinters in their hands. EI #3 was asked what was the potential harm when residents doors have splinters on them. EI #3 replied, skin tears to the arm if the resident was in a wheelchair.

Based on observation, interview and record review, the facility failed to ensure Resident Identifier (RI) #3's Care Plan was followed in order to toilet the resident before the supper meal. RI #3 was continuously observed from 3:05 PM to 6:45 PM on 06/15/2016 without being toileted or checked for incontinence. This affected one of 17 sampled residents whose Care Plans were reviewed. Findings Include: A review of a facility policy titled, Job Description Title: NURSING ASSISTANT with a revised date of 01/97 revealed: .DUTIES AND RESPONSIBILITIES . 2.II. Make continuous and frequent rounds to observe and check on residents' comfort and safety. Further review of a facility document titled, Care Plan with a review date of 09/2016 revealed: Problem/Need: . I have trouble .I am frequently incontinent of bladder . Approaches: .Toilet resident .before her/his meals and prior to bedtime even if she/he does not feel the urge to void. RI #3 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #3's most recent Quarterly Minimum Data Set (MDS) with a Assessment Reference Date (ARD) of 03/11/2016 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident was severely cognitively impaired for daily decision making. The MDS also revealed the resident required extensive assistance of one person for toileting. The MDS further revealed the resident was frequently incontinent of bowel and bladder. On 06/15/2016 from 3:05 PM to 6:45 PM, RI #3 was continuously observed without being toileted or checked for incontinence. On 06/15/2016 at 7:15 PM, an interview was conducted with Employee Identifier (EI) # 2, Certified Nursing Assistant (CNA). EI #2 was asked if she was assigned to care for RI #3. EI #2 stated yes. EI #2 was asked if RI #3 was incontinent. EI #2 stated yes. EI #2 was asked how often was RI #3 supposed to be checked for incontinence and changed. EI #2 stated every two hours. EI #2 was asked in what time frame did she check and change RI #3. EI #2 explained she believed she checked RI #3 every two hours. EI #2 was asked when was the last time she had checked RI #3 for incontinence and changed. EI #2 stated she did not know because she did not check her watch. EI #2 was informed that RI #3 was continuously observed on 06/15/2016 for three hours and 40 minutes, from 3:05 PM to 6:45 PM, without being checked for incontinence and changed. EI #2 was asked to explain why. EI #2 stated she could not give an answer. EI #2 was asked if RI #3's Care Plan was followed. EI #2 said she would say no. EI #2 was asked what did RI #3's Care Plan say about checking him/her for incontinence. EI #2 explained she did not know. EI #2 was asked how did she know to check RI #3 every two hours. EI #2 explained it was on their assignment sheet. EI #2 was asked why was RI #3's Care Plan not followed. EI #2 explained she did not know and further explained she had been busy, but did always try to do what was right. EI #2 was asked if RI #3's Care Plan was to check for incontinence before meals and was not, was his/her Care Plan followed. EI #2 stated no ma'am.

Based on record review, observation and interview, the facility failed to ensure RI (Resident Identifier) #3, a resident identified by the facility as being at risk of developing pressure ulcers, was checked for incontinence, changed or repositioned for three hours and forty minutes on 06/15/2016. This affected one of three sampled residents at risk of developing pressure ulcers. Findings Include: A review of a facility document titled, JOB DESCRIPTION . NURSING ASSISTANT . DUTIES AND RESPONSIBILITIES . hh. Preventive decubitus care. ll. Make continuous and frequent rounds to observe and check on residents' comfort and safety. A review of a facility document titled, CNA (CERTIFIED NURSING ASSISTANT) SKILLS CHECKLIST FAIR revealed EI (Employee Identifier) #2, CNA had attended a skills fair and performed a successful return demonstration of proper positioning and prevention of pressure on 04/05/2016. RI #3 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #3's most recent Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 03/11/2016 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 4, which indicated the resident was severely cognitively impaired for daily decision making. The MDS also revealed the resident was frequently incontinent of bowel and bladder. The MDS further revealed the resident was at risk of developing a pressure ulcer. On 6/15/2016, RI #3 was continuously observed from 3:05 PM to 6:45 PM sitting in a geri-chair without being checked for incontinence, changed or repositioned. On 6/15/2016 at 7:15 PM, an interview was conducted with EI #2. EI #2 was asked if she was assigned to RI #3. EI #2 said yes ma'am. EI #2 was asked if RI #3 was incontinent. EI #2 said yes. EI #2 was asked how often RI #3 was supposed to be checked for incontinence and changed. EI #2 said every two hours. EI#2 was asked if she could tell the surveyor why RI #3 had not been checked for incontinence, repositioned or changed for three hours and forty minutes. EI #2 said she could not give an answer. EI #2 was asked if RI #3 could reposition herself in the wheelchair. EI #2 said no. EI #2 was asked if RI #3 was at risk of developing a pressure ulcer. EI #2 said yes. EI #2 was asked what the potential harm was if an incontinent resident was not checked for incontinence or changed for three hours and forty minutes. EI #2 said skin breakdown or possible UTI (Urinary Tract Infection). EI #2 was asked what the potential harm was for a resident at risk of developing a pressure ulcer to not be checked for incontinence, changed or repositioned for three hours and forty minutes. EI #2 said they would probably get a bigger pressure ulcer.

Based on record review, observation and interview, the facility failed to ensure a CNA (Certified Nursing Assistant) wiped from front to back during the incontinent care of RI (Resident Identifier) #3, a resident with a history of UTI (Urinary Tract Infection), on 6/15/2016. This affected one of three sampled residents with a history of UTI. Findings Include: A review of a facility policy titled,Incontinent Care and Catheter Care Using Disposable Wipes with a revised date of 12/2012 revealed: .PROCEDURE: .6.Clean the buttocks and anal area, moving upwards toward the back . RI #3 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #3's most recent Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 03/11/2016 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 4, which indicated the resident was severely cognitively impaired for daily decision making. The MDS also revealed the resident required extensive assistance with toilet use and personal hygiene. The MDS further revealed the resident was frequently incontinent of bowel and bladder. On 6/15/16 at 6:53 PM, EI (Employee Identifier) #2, CNA, was observed performing incontinent care for RI #3. RI #3 had been incontinent of urine. EI #2 washed her hands and donned gloves. The resident was rolled onto the right side and EI #2 wiped down the resident's buttocks with a wipe. EI #2 then wiped up the resident's buttocks with a wipe. On 6/15/2016 at 7:13 PM, an interview was conducted with EI #2. EI #2 was asked in what direction she wiped RI #3's buttocks. EI #2 said, Down. EI #2 was asked how she should have wiped. EI #2 said, Up. EI #2 was asked what the potential harm was if she wiped a resident's buttocks downward. EI #2 said cross contamination.