Every finding on record at Marengo Nursing Home

Based on observations, interviews, record review and review of facility policies titled Nebulizer Therapy and SELF-ADMINISTRATION OF MEDICATIONS, the facility failed to ensure the licensed nurses remained with Resident Identifier (RI) #39, a resident not assessed to self-administer his/her nebulizer breathing treatment, when RI #39 received nebulizer treatments on 01/03/2022 and on 01/05/2022. This deficient practice affected RI #39; one of one sampled resident observed receiving a nebulizer breathing treatment. Findings Include: RI #39 was admitted to the facility on [DATE], and has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a facility policy titled Nebulizer Therapy, with an implemented date of 05/2020, revealed the following: Policy: It is the policy of this facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed . Policy Explanation and Compliance Guidelines: Care of the Resident . 14. Observe resident during the procedure . Review of a second undated facility policy titled SELF-ADMINISTRATION OF MEDICATIONS, revealed the following: If a resident requests to self-administer medications, the care plan team will meet and discuss the ability of that resident to know his/her medications, dosages and times. RI #39's January 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 01/03/2022 at 5:18 PM, RI #39 was observed holding a hand-help nebulizer while receiving his/her nebulizer treatment. There was no licensed staff in the room at this time. On 01/05/2022 at 1:48 PM, the surveyor observed Employee Identifier (EI) #2, an LPN (Licensed Practical Nurse) prepare to administer RI #39's nebulizer treatment. EI #2 opened a vial of [MEDICATION(S)]/[MEDICATION(S)] solution, poured the solution in the reservoir of RI #39's handheld nebulizer, and handed the handheld nebulizer to RI #39. EI #2 then turned on the nebulizer machine and informed RI #39 she would be back in 15 minutes. On 01/05/2022 at 2:10 PM, EI #2 re-entered RI #39's room, cleaned the mouthpiece on the handheld nebulizer and stored the handheld nebulizer in a plastic bag. On 01/06/2022 at 11:29 AM, the surveyor conducted an interview with EI #2. The surveyor asked EI #2 what should the nurse do concerning the resident when a nebulizer treatment was administered. EI #2 said the nurse should stay there and make sure the resident was getting the medication. The surveyor asked EI #2 had RI #39 been assessed to self-administer his/her breathing treatment. EI #2 said she did not think RI #39 had been assessed to self-administer him/herself the breathing treatment. When asked why she did not stay with RI #39 the entire time on yesterday when RI #39 received the nebulizer treatment, EI #2 said RI #39 was the type that liked to do for him/herself. EI #2 said she knew she should have stayed with RI #39 the entire time. On 01/06/2022 at 2:01 PM, the surveyor conducted an interview with EI #1, the Director of Nursing. The surveyor asked EI #1 what should the nurse do concerning the resident when a nebulizer treatment was being administered. EI #1 said the nurse needs to stay in the room with the resident. When asked had the care plan team meet to assess RI #39 for self-administering of his/her breathing treatments, EI #1 said he did not think so.

Based on observation, interviews, the (YEAR) Food Code, review of the facility policies titled, MACHINE WAREWASHING, WASTE DISPOSAL and Cleaning of Ice Machine, the facility failed to ensure: (1) dust like particles were not present on the ice maker vents on two of four days of the survey, (2) staff did not move a meal tray in an up and down motion over the dishes/meal trays after rinsing in order to dry them; and (3) the area on the inside of the recycle bin was free of garbage and debris. This had the potential to affect 69 of the 73 residents who received the lunch meal from the kitchen on 05/07/19. Findings Include: (1) A review of the facility policy titled, Cleaning of Ice Machine with a revised date of 3/18, revealed: Purpose: To distribute clean ice to residents .by keeping the ice free of potential harmful microorganisms . Procedure: . Maintenance will check the air filters monthly and clean as needed . A review of the (YEAR) U.S. (United States) Public Health Service Food Code revealed: .4-6 CLEANING OF EQUIPMENT AND UTENSILS .4-601.11 . NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris . On 05/05/19 at 5:24 PM, during the surveyor's initial tour of the kitchen, there were dust like particles on the vent of the ice maker. On 05/07/19 at 9:50 AM, the surveyor conducted an interview with Employee Identifier (EI) #4, Dietary Manager. The surveyor asked EI #4 what was on the ice maker vents. EI #4 said it was some dust on the edge of the vents. The surveyor asked EI #4 what was next to the ice maker. EI #4 said it was bread. The surveyor asked EI #4 what was stacked next to the bread. EI #4 said dishes. The surveyor asked EI #4 what did that have the potential for. EI #4 said getting dust on the bread bags and on the bottom of the dishes. The surveyor asked EI #4 what were the concerns when the bread bags were opened. EI #4 said if dust was on the bread bags, it was possible for dust to get onto the bread. On 05/08/19 at 12:48 PM, the surveyor conducted an interview with EI #6, Environmental Supervisor. The surveyor asked EI #6 how often was the ice maker vent system cleaned. EI #6 said every three months and it was done from an outside vendor every six months. The surveyor asked EI #6 had the vents on the ice maker been cleaned during the survey. EI #6 said yes. The surveyor asked EI #6 what was the reason for the cleaning. EI #6 said it was brought to his attention by the supervisor that the ice maker vents needed cleaning. The surveyor asked EI #6 what did he remove from the vents while cleaning. EI #6 said he removed the old filters, replaced them with new filters and cleaned the vents. The surveyor asked EI #6 what did he remove from the vents. EI #6 said lint. (2) A review of facility policy titled, Machine Warewashing with a review date of 1/19, revealed: . PR[NAME]EDURE: . 4. d. All dishes, glassware, and silverware are air dried . On 05/07/19 at 9:53 AM, the surveyor observed EI #5, Dietary Worker, with a meal tray using an up and down movement over the other meal trays/dishes. At this time, the surveyor asked EI #4 what was EI #5 doing with the meal tray. EI #4 said EI #5 was fanning the trays trying to get the water to dry. The surveyor asked EI #4 how were the trays/dishes supposed to be dried. EI #4 said they were to air dry. The surveyor asked EI #4 what were the concerns with drying the trays by fanning them (using an up and down movement over trays/dishes). EI #4 said fan particles. On 05/07/19 at 10:17 AM, the surveyor conducted an interview with EI #5. The surveyor asked EI #5 what was she doing with the meal tray moving it up and down over the other meal trays/dishes. EI #5 said fanning the trays dry. The surveyor asked EI #5 how were the meal trays/dishes supposed to dry. EI #5 said they were supposed to air dry. The surveyor asked EI #5 what was air drying. EI #5 said that was when the dishes were standing stationary. The surveyor asked EI #5 what were the concerns with drying the meal trays/dishes with another meal tray. EI #5 said by fanning it, it could get particles on the dishes. (3) A review of a facility policy titled, Waste Disposal with a reviewed date 01/19, revealed: .PR[NAME]EDURE: . 4. Outside storage areas are: . d. Kept clean of garbage and debris . A review of the (YEAR) U. S. Public Health Service Food Code revealed: .5-501.112 Outside Storage Prohibitions.(B) .Cardboard or other packaging material . may be stored outside .if it is stored so that it does not create a rodent harborage problem . On 05/07/19 at 10:32 AM, the surveyor observed a drink top with a straw, blue Rice Krispie wrapper, plastic bags, styrofoam cups, two wood pallets and multiple cardboard pieces on the ground around the recycle bin. On 05/07/19 at 11:11 AM, the surveyor conducted an interview with EI #4. The surveyor asked EI #4 what was this (pointing inside of the recycle box bin). EI #4 said pallets on the ground, four rubber gloves, several pieces of plastic bags, three stryofoam cups, several pieces of cardboard and one blue Rice Krispies wrapper. On 05/08/19 at 12:48 PM, during an interview with EI #6, the surveyor asked how would he identify the pallets on the ground, four rubber gloves, several pieces of plastic bags, three Styrofoam cups, several pieces of cardboard on the inside and one blue Rice Krispies wrapper. EI #6 said it was disposal waste that was left behind on 05/06/19, from the one that picked up all of the recycling. The surveyor asked EI #6 what was used to stack the waste on. EI #6 said pallets.

Based on observations, interviews, record review and review of a facility policy titled, Resident Assessment Using the MDS (Minimum Data Set), the facility failed to ensure: (1) Resident Identifier (RI) #16 was coded as having a Urinary Tract Infection [MEDICAL CONDITION] on his/her 04/18/19, Significant Change (SC) MDS assessment, (2) RI #34 was coded as being admitted with pressures ulcers on one area of his/her 11/21/18, Admission MDS assessment; and (3) RI #42's Quarterly MDS assessment, dated 12/12/18, coded the resident as having a restraint. These deficient practices affected RI #'s 16, 34 and 42, three of 22 sampled residents whose MDS assessments were reviewed. Findings Include: (1) An undated facility policy titled, Resident Assessment Using the MDS revealed the following: Policy Every resident will be assessed using the Minimum Data Set (MDS) according to guidelines set forth in the Resident Assessment Instrument (RAI) manual . Completing the MDS . 2. During this assessment period, various persons will gather assessment data on the resident to complete all sections of the MDS . In addition, the clinical record during this 7-day period is also utilized to gather data including (but not limited to) nursing notes, medication/treatment records, lab results, physician notes, and demographic information . RI #16 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #16's (MONTH) 2019 physician's orders [REDACTED]. . 4/11/19 - incontinence, pelvic pain, malodeordous (malodorous) urine - U/A (Urinalysis) c (with) C & S (Culture and Sensitivity) R/T (related to) above symptoms . A review of RI #16's urine culture results dated 04/14/19, reveled RI #16 had Escherichia Coli in his/her urine. A review of RI #16's (MONTH) 2019 physician's orders [REDACTED]. . 4/15/19 Bactrim DS (Double Strength) 1 po (by mouth) x (times) 10 days for growth of E. Coli in urine . A review of RI #16's SC MDS assessment, with an Assessment Reference Date (ARD) of 04/18/19, did not identify RI #16 as having a UTI during this assessment period. On 05/08/19 at 12:13 p.m., the surveyor conducted an interview with Employee Identifier (EI) #2, the RN (Registered Nurse) MDS/Coordinator. The surveyor asked EI #2 when was RI #16's last MDS assessment completed. EI #2 said on 04/18/19, and it was a Significant Change MDS. The surveyor asked EI #2 how many days can she look back on an MDS assessment to see if the resident has had a UTI. EI #2 said 30. The surveyor asked EI #2, according to RI #16's physician orders [REDACTED].#16 have a UTI during this assessment period. EI #2 said she assumed it was Asymptotic Bacteremia and that was why she did not code RI #16 as having a UTI during the 04/18/19, SC MDS assessment. The surveyor asked EI #2 should RI #16 have been coded on the MDS assessment as having a UTI. EI #2 said looking at the symptoms of incontinence and pelvic pain on 04/11/19, yes. When asked was the SC MDS assessment dated [DATE], an accurate assessment, EI #2 said no. (2) RI #34 was admitted to the facility on [DATE], and readmitted on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #34's Admission MDS assessment, with an ARD of 11/21/18, did not identify RI #34 as having pressure ulcer under the Determination of Pressure Ulcer/Injury Risk section on the MDS during this assessment period. On 05/07/19 at 2:46 p.m., the surveyor observed Employee Identifier (EI) #7, the LPN (Licensed Practical Nurse)/Treatment Nurse provide treatments to RI #34's right outer ankle, right outer heel and left outer ankle. EI #7 said RI #34 was admitted with the pressure ulcers. On 05/08/19 at 1:05 p.m., the surveyor conducted an interview with EI #3, LPN, the Restorative Nurse . The surveyor asked EI #3 was RI #34 admitted with any pressure ulcers. EI #3 said yes. The surveyor asked EI #3 should RI #34 have been coded on his/her 11/21/19, Admission MDS assessment as having pressure ulcers. EI #3 said yes. The surveyor asked EI #3, looking at the 11/21/19, Admission MDS assessment, was he/she coded as having pressure ulcers under the determination section. EI #3 said no. When asked was this an accurate assessment, EI #3 said it would not be. (3) EI #42 was admitted to the facility on [DATE] and readmitted [DATE], with [DIAGNOSES REDACTED]. A review of RI # 42's Quarterly MDS assessment, with an ARD of 12/12/18, did not identify RI #42 as having a restraint during this assessment period. RI #42 was observed sitting in a geri-chair with a lap tray on three of the four days during survey tour. On 05/08/19 at 10:21 a.m., the surveyor conducted an interview with EI#3, Restorative Nurse. The surveyor asked EI #3 what type of restraint was being used for RI #42. EI #3 said RI #42 had a geri chair with a tray. The surveyor asked EI #3 what should have been coded on RI #42's Quarterly MDS assessment dated [DATE], under the restraint section. EI #3 said chair prevents rising should have been documented. The surveyor asked EI #3 why was RI #42's Quarterly MDS assessment not coded for restraints. EI #3 said it had to be an oversight. The surveyor asked EI #3 should this Quarterly MDS assessment have been coded for restraints. EI #3 said yes it should have.

Based on interviews, record review and review of a facility policy titled,THE CARE PLANNING TEAM, the facility failed to ensure: 1) Resident Identifier (RI) #34 had a Quarterly Minimum Data Set (MDS) assessment completed when the assessment was due; and 2) a Quarterly care plan meeting was scheduled for RI #34 when the meeting was due. These deficient practices affected RI #34, one of 22 sampled residents whose care plan meetings and MDS assessments were reviewed. Findings Include: A review of an undated facility policy titled THE CARE PLANNING TEAM revealed the following: . Residents will be evaluated by the team at ninety (90) day intervals and a quarterly MDS done to provide basis for care plan changes . Cognitive residents are invited to quarterly care plan meetings and informed of their medical condition . If a resident is not cognitive, sponsors are informed of any changes and also invited (through mailing bills) to the care plan (meeting). All sponsors are invited to the care plan (meeting) and are informed of any changes as they occur. RI #34 was admitted to the facility on [DATE], and readmitted on [DATE]. A review of RI #34's Admission MDS assessment, with an Assessment Reference Date (ARD) of 11/21/18, assessed RI #34 as scoring an 11 on the Brief Interview for Mental Status during this assessment period, which indicated RI #34 was moderately cognitively impaired for daily decision making. During record review, the surveyor discovered the (MONTH) 2019 Quarterly MDS assessment was not completed. On 05/06/19 at 9:26 a.m., RI #34 stated to the surveyor he/she had not been to a care plan meeting since being admitted to the facility. On 05/07/19 at 5:32 p.m., the surveyor conducted an interview with Employee Identifier (EI) #2, the RN (Registered Nurse) MDS/Coordinator. The surveyor asked EI #2 what was the date of RI #34's current admission. EI #2 said 11/14/18. The surveyor asked EI #2 had RI #34 had a care plan meeting since that date. EI #2 said no. The surveyor asked EI #2 how often should care plan meetings be held. EI #2 said Quarterly. When asked when should RI #34 have had a care plan meeting, EI #2 said in (MONTH) of 2019. The surveyor asked EI #2 what were care plan meetings held for. EI #2 said to make sure the facility was providing the care appropriate for the resident and to let staff know what needed to be done. The surveyor asked EI #2 why was a care plan meeting not held for RI #34. EI #2 said her system for notifying herself that a care plan meeting was due was not done. The surveyor asked EI #2 was there a MDS assessment not completed as well. EI #2 said yes, the (MONTH) 2019 Quarterly MDS assessment was not completed.

Based on observations, interviews, record review and a review of a facility policy titled, Destruction Of Medication, the facility failed to ensure all of the non-controlled medication drug sheets for the month of (MONTH) (YEAR), had the required signatures. This deficient practice affected one of the 12 months of non-controlled drug sheets reviewed. Findings Include: An undated facility policy titled, Destruction Of Medication revealed the following: .(B) All permanently discontinued medications except control drugs, will be listed on a disposition form with the following information: . Signature of Director of Nursing or Assistant Director of Nursing and Pharmacist . The facility provided drug destruction binders containing non-controlled and controlled drug sheets for the surveyor to review from (MONTH) (YEAR) until (MONTH) 2019. The surveyor found not all the non-controlled drug sheets for (MONTH) (YEAR), had the required signatures. On 05/08/19 at 2:23 p.m., the surveyor conducted an interview with Employee Identifier (EI) #1, Director of Nursing (DON). The surveyor asked EI #1 who was responsible for signing the non-controlled drug sheets. EI #1 said he, the Assistant Director of Nursing (ADON) and the pharmacist was. EI #1 said a registered nurse could sign if he or the ADON were not available. The surveyor asked EI #1 should there be two signatures on the sheets. EI #1 said yes it should. The surveyor asked EI #1 how many signatures were noted on the non-controlled drug sheets for (MONTH) 25 and (MONTH) 26, (YEAR). EI #1 said there was one signature.

Based on observations, interview and review of a facility policy titled, Nurse Staffing Posting Information, the facility failed to ensure the DAILY STAFFING AND RESIDENT CENSUS form contained the name of the facility on four of four days of the survey. This deficient practice had the potential to affect all 73 residents residing in the facility. Findings Include: 05/05/19 at 5:21 p.m., the surveyor observed the DAILY STAFFING AND RESIDENT CENSUS form without the facility name on it. On 05/06/19 at 9:03 a.m., the DAILY STAFFING AND RESIDENT CENSUS form did not have the facility name on it. On 05/07/19 at 8:56 a.m., the DAILY STAFFING AND RESIDENT CENSUS form did not have the facility name on it. On 05/08/19 at 7:52 a.m., the DAILY STAFFING AND RESIDENT CENSUS form remained without the name of the facility on it. On 05/08/19 at 1:28 p.m., the surveyor conducted an interview with Employee Identifier (EI) #1, the Director of Nursing (DON). The surveyor asked EI #1 who was responsible for ensuring the nurse staff posting was posted daily. EI #2 said he did it mostly through the week. The surveyor asked EI #1 what information should be on the form. EI #1 said the number of RNs (Registered Nurses), LPNs (Licensed Practical Nurses), and CNAs (Certified Nursing Assistants), how many there were on each shift, how many hours they work and the daily census. The surveyor asked EI #2 what information did he not see on the facility's Daily Staffing and Resident Census form. EI #2 said the facility name. On 05/08/19 at 2:00 p.m., the facility presented to the survey team a facility policy titled Nurse Staffing Posting Information with an implemented date of 05/08/19, and a copyright date of (YEAR), which revealed the following: . Policy Explanation and Compliance Guidelines: 1. The nurse staffing information will be posted on a daily basis and will contain the following information: a. Facility name .

Based on record reviews, interviews, and review of the facility's Policy and Procedure for Handling Resident's Funds, the facility failed to ensure Resident Trust Fund Accounts were managed such that: 1) Medicaid residents with balances greater than $50 had funds placed in an interest bearing account; 2) there was a clear accounting of when each resident received their $30 per month personal allowance and what it was used for; 3) staff coordinated payment arrangements with the residents or the residents' legal representative prior to applying residents' $30 per month personal allowance to monthly billing statements; and 4) residents received quarterly statements of their funds. These failures affected RI #1 - RI #3, RI #5, RI #12 - RI #13 and RI #17 - 24, 14 of 16 sampled residents for whom Resident Trust Fund Accounts were reviewed, with the potential to affect all residents residing in the facility with the right to have their funds managed by the facility. The RESIDENT CENSUS AND CONDITIONS OF RESIDENTS (Form CMS-672) dated 2/7/2016 indicated the facility had a total of 76 residents. Findings include: On 02/14/2017 at 9:25 a.m., Employee Identifier (EI) #2, the Administrator stated the facility did not have a policy related to the management of resident funds. However, on 02/15/2017 at 2:00 p.m., EI #2, provided a copy of an undated policy she was previously unaware of titled Policy and Procedure for Handling Resident's Funds. The facility's undated Policy and Procedure for Handling Resident's Funds documented Upon written authorization from a resident, Marengo Nursing Home will hold, safeguard, manage, and account for the personal funds of a resident if he or she chooses to deposit funds with Marengo Nursing Home . Personal funds of a resident can be kept in office safe or deposited into an account at the local bank of choice. Funds exceeding $50.00 will be deposited into an interest bearing account . Interest will be credited each quarter and a copy of the savings statement along with the facility's record will be given to the resident or sponsor each quarter . During the resident account review on 02/14/2017 beginning at 9:25 a.m., EI #2, the Administrator, and EI #3, responsible for handling resident accounts, confirmed the facility managed 21 resident accounts. EI #3 explained the facility maintained envelopes for residents that contained their money; however, not all residents had an envelope. According to EI #3, the only residents with an envelope were those that could use their own money. EI #3 stated if the residents did not have an envelope, their $30 was applied to the bill to pay towards an outstanding balance or the resident received a credit. EI #3 was asked how residents accrued interest on their balances. She said residents did not accrue interest. Each of the residents' accounts were reviewed as follows: RI #1 - During an interview on 02/14/2017 beginning at 9:25 a.m., with EI #2, the Administrator, and EI #3, responsible for managing the resident accounts, EI #3 stated RI #1's envelope hit a balance of $49.40 in September 2014 so they started applying the resident's $30 to the monthly bill to avoid going over a $50 balance and the need for an interest bearing account. EI #3 said RI #1's billing statement currently showed a credit in the amount of $681.11. A review of RI #1's account ledger for the time period 10/12/2015 to 1/19/2017 revealed there was no documentation of when RI #1 received $30 per month or when it was applied to the resident's monthly bill. During an interview with RI #1's sponsor on 02/14/2017 at 7:19 p.m., the sponsor stated she used her own money to pay for RI #1's needs. She said she did not recall ever telling the facility they could apply RI #1's $30 per month to the monthly bill as a credit. She acknowledged if the facility did that with RI #1's money instead of leaving it in the resident's account, it would not accrue interest. RI #2 - During the interview 02/14/2017 at 9:25 a.m. with EI #2, the Administrator, and EI #3, responsible for managing the resident accounts, EI #3 stated according to RI #2's monthly bill there was currently a balance due of $84. EI #3 then reviewed RI #2's ledger for the time period June 2015 to February 2017 with the surveyor. The ledger reflected they were giving money to RI #2 but EI #3 they were actually gave the money to RI #2's family. EI #3 stated the ledger did not reflect RI #2 received #30 in November 2015, February 2016 and May 2016. EI #3 said the family probably picked it up before she listed it on the ledger. RI #3- During the interview on 02/14/2017 beginning at 9:25 a.m. with EI #2, the Administrator, and EI #3, responsible for managing the resident accounts, EI #3 explained RI #3 did not have an envelope or ledger for the $30 personal allowance per month because it was applied directly to the monthly bill towards the old balance. RI #3's sponsor was interviewed on 02/14/2017 at 5:00 p.m The sponsor was under the impression the facility was holding RI #3's money in case there was a need for any personal items. She stated she had not asked the facility to apply RI #3's $30 per month to the outstanding balance. RI #3's sponsor also stated she did not know the amount of money RI #3 currently had because she did not receive statements from the facility. RI #5 - During the interview on 02/14/2017 beginning at 9:25 a.m. with EI #2, the Administrator, and EI #3, responsible for managing the resident accounts, EI #3 stated RI #5 had an envelope but the $30 per month had not been going into it. She said instead, it was applied towards the monthly bill as a credit. RI #5's current monthly bill showed a credit in the amount of $80.52. Review of RI #5's account ledger for the time period March 2009 to January 2017 revealed a balance of zero. There was no documentation of when RI #5 received the $30 per month personal allowance or when it was applied to the monthly bill as a credit. RI #5's sponsor was interviewed on 02/14/2017 at 6:31 p.m He said the resident's $30 per month went into an account at the facility to build up if RI #5 needed anything. He said the facility had never discussed applying the $30 to the monthly bill. RI #12 - During the interview on 02/14/2017 at 9:25 a.m. with EI #2, the Administrator, and EI #3, responsible for managing the resident accounts, EI #3 explained she had applied RI #12's $30 to the resident's bill so the resident's account would not go over $50. RI #12's account ledger for the time period October 2016 to January 2017 revealed RI #12 only received $30 in November 2016. RI #13- During the interview on 02/14/2017 beginning at 9:25 a.m. with EI #2, the Administrator, and EI #3, responsible for managing the resident accounts, EI #3 said RI #13 currently had an old outstanding balance from when the resident was private pay. She said RI #13's son was paying towards the balance each month, so RI #13's $30 per month went into the account envelope. However, when RI #13's account ledger for 01/2016 through 01/2017 was reviewed, it was noted there was no documentation the $30 dollars had been added in January - February 2016, April - May 2016, August - October 2016, December 2016, or January 2017. EI #3 said each of those months the $30 deposit would have brought RI #13's balance over $50 so it was applied to the monthly bill instead. RI #13's sponsor was interviewed on 02/14/2017 at 7:30 p.m The sponsor stated he was making payments to the facility every month towards a balance accrued before RI #13 qualified for Medicaid. He said RI #13 should be receiving the $30 per month personal allowance. RI #13's sponsor said he never asked the facility to apply RI #13's $30 per month to the outstanding balance, but said they told him they did not want RI #13 spending the whole $30 so they could apply it to the bill. He also said he was not pleased with the situation, because he wanted RI #13 to receive the $30 per month just like the other residents in the facility. RI #20 - During the interview on 02/14/2017 at 9:25 a.m. with EI #2, the Administrator, and EI #3, responsible for managing the resident accounts, EI #3 said RI #20 currently had a credit in the amount of approximately $150.30. EI #3 explained RI #20 did not have an envelope with money for personal use, but the money was applied to the monthly bill as a credit. Review of RI #20's monthly bill dated 01/31/2017, confirmed a credit. During an interview with RI #21's sponsor on 02/14/2017 at 5:26 p.m., the sponsor stated she had authorized the facility to handle the resident's funds. She was under the impression the money would build up to pay for anything RI #20 might need. When asked if she had discussed applying RI #20's $30 per month to the monthly bill with the facility, RI #20's sponsor stated she had not authorized that. She also stated she did not receive quarterly statements from the facility regarding RI #20's funds. RI #21 - During the interview on 02/14/2017 beginning at 9:25 a.m. with EI #2, the Administrator, and EI #3, responsible for managing the resident accounts, EI #3 said they give RI #21's $30 per month to the family. She said RI #21 did not have an envelope for money because the family came to pick up the money every month. EI #3 said they did not require receipts to determine what the family was using RI #21's money for. During an interview with RI #21's sponsor on 02/14/2017 at 4:50 p.m., the sponsor said RI #21's check went directly to the facility each month, but she picked up the resident's $30 per month and maintained it in a separate account. She also stated she did not receive any statements from the facility regarding RI #21's funds. RI #21's billing statement dated 01/31/2017 and billing activity from February 2016 to January 2017, did not reflect that RI #21's $30 per month was given to the family. During a follow-up interview with EI #2, the Administrator, on 02/15/2017 at 12:40 p.m., EI #2 said RI #3 and RI #17 - RI #24 did not receive quarterly statements of their funds because they did not have their money maintained in an envelope like the other residents; instead it went directly towards their bills. When asked if these residents should receive quarterly statements, EI #2 said they received monthly bills. However, she agreed the monthly bill was not clear and not itemized. EI #2 was also asked how the facility knew what the residents' $30 per month was being used for if the family picked it up. EI #2 said the family told them, but they did not require receipts or documentation of what the money was used for.

Based on record review, interviews, and review of a facility's Policy and Procedure for Handling Resident's Funds, the Administrator, Employee Identifier (EI) #2, failed to ensure EI #3, the staff member responsible for managing resident accounts, was trained on the facility's policy for resident trust fund management. This had the potential to affect 29 of 29 residents for whom the facility currently managed their funds. Findings include: The Administrator's job description documented the following: General Purpose: To direct the day-to day functions of the facility in accordance with current federal, state, and local standards . Essential Job Functions: A. Administrative Functions . interpret and ensure compliance with all facility policies and procedures . D. Residents' Rights Functions . ensure that all personnel know and comply with Residents' Rights rules; monitor services to ensure residents' needs and rights are met . Other Job Functions: . Staff Development Functions . on-the-job training and other educational activities for personnel . During a review of resident funds on 02/14/2017 beginning at 9:25 a.m., with Employee Identifier (EI) #2, the Administrator, and EI #3, responsible for handling resident accounts, they confirmed they were managing the funds of 21 residents. EI #2 stated the facility did not have a policy related to the management of resident funds. However, on 02/15/2017 at 2:00 p.m., EI #2, provided a copy of an undated policy she was previously unaware of titled Policy and Procedure for Handling Resident's Funds. On 02/15/2017 at 2:40 p.m., EI #3 provided a list of eight additional residents for whom they managed funds, for a total of 29 resident accounts. During an interview with EI #2, the Administrator, on 02/15/2017 at 8:30 a.m., EI #2 said EI #3 had been trained by the person who handled the residents' accounts before her. EI #2 also stated she always thought they were fine because they did not handle more than $50 per resident. She admitted they had not thought about the residents' $30 per month. When asked who was responsible for ensuring staff were trained to properly manage residents accounts, EI #2 said she was, as the Administrator. On 02/15/2017 at 2:10 p.m., EI #3, responsible for managing resident funds, was provided a copy of the policy and asked if she had ever seen it before. EI #3 responded, I have to say I haven't. After allowing EI #3 to read over the policy, she was asked if she had been educated on the items covered in the policy. She said she did not recall it being discussed. She further stated she had been doing accounts for [AGE] years. EI #3 agreed the way she was handling residents' accounts was not consistent with the policy. She said she had never been educated on the policy and was unaware the facility had a policy addressing the management of resident funds.

Based on interviews and review of the facility's policy titled Policy and Procedure for Handling Resident's Funds and an insurance CRIME AND FIDELITY PART DECLARATIONS form, the governing body failed to ensure the facility maintained a surety bond to protect residents's trust fund accounts. This had the potential to affect 29 of 29 residents for whom the facility managed resident accounts. Findings include: Review of an undated document titled BY-LAWS MARENGO NURSING HOME, revealed the following: . the Governing Body of Marengo Nursing Home, hereinafter called The Board, hereby adopts the following by-laws . Policies and and directives issued by The Board shall be in accord with . pertinent federal, state, and local requirements pertaining to this type institution . The facility's undated policy titled Policy and Procedure for Handling Resident's Funds revealed the following: . Marengo Nursing Home shall purchase a surety bond, or otherwise provide assurance satisfactory to the Secretary, to assure the security of all personal funds of residents deposited into this facility . During a review of resident funds on 02/14/2017 beginning at 9:25 a.m., with Employee Identifier (EI) #2, the Administrator, and EI #3, responsible for handling resident accounts, they confirmed they were managing the funds of 21 residents. On 02/15/2017 at 2:40 p.m., EI #3 provided a list of eight additional residents for whom they managed funds, for a total of 29 resident accounts. On 02/14/2017 at 5:09 p.m., the facility's Administrator, Employee Identifier (EI) #2, was asked for a copy of their surety bond. She provided a copy of a document from their insurance company. This document was titled CRIME AND FIDELITY PART DECLARATIONS. This policy listed coverage in the amount of $250,000 for employee theft per occurrence, with a deductible of $1,000 per occurrence. There was no coverage listed for other items, including the following: forgery or alteration, inside the premises- theft of money and securities, inside the premises- robbery or safe burglary of other property, and funds transfer fraud. EI #2 said they thought the policy they had was one step better than a surety bond. When asked who the payee of any claims would be, she said the facility. EI #2 said they used to have a surety bond but they did away with it. EI #2 explained the board (governing body) had suggested they change to the policy, and said she should have done more research when they decided to go with it. EI #4, the Chairman of the Board, was interviewed on 02/15/2017 at 7:50 a.m When asked if she was aware the facility was required to have a surety bond to protect residents' funds, EI #4 stated they had discussed bonds and insurance back in early 2015. She said they checked into it and increased what they had previously to a broader coverage. She said at the time, they did not realize what it was they needed.

Based on interview and review of the facility's Policy and Procedure for Handling Resident's Funds and an insurance CRIME AND FIDELITY PART DECLARATIONS form, the facility failed to ensure resident funds were protected with a surety bond. Instead, the facility had an insurance policy, with the facility named as the payee. This had the potential to affect 29 of 29 residents for whom the facility currently managed their funds. Findings include: Review of the facility's undated policy titled Policy and Procedure for Handling Resident's Funds revealed the following: . Marengo Nursing Home shall purchase a surety bond, or otherwise provide assurance satisfactory to the Secretary, to assure the security of all personal funds of residents deposited into this facility . During a review of resident funds on 02/14/2017 beginning at 9:25 a.m., with Employee Identifier (EI) #2, the Administrator, and EI #3, responsible for handling resident accounts, they confirmed they were managing the funds of 21 residents. On 02/15/2017 at 2:40 p.m., EI #3 provided a list of eight additional residents for whom they managed funds, for a total of 29 resident accounts. On 02/14/2017 at 5:09 p.m., the facility's Administrator, EI #2, was asked for a copy of their surety bond. She provided a copy of a document from their insurance company. This document was titled CRIME AND FIDELITY PART DECLARATIONS. This policy listed coverage in the amount of $250,000 for employee theft per occurrence, with a deductible of $1,000 per occurrence. There was no coverage listed for other items, including the following: forgery or alteration, inside the premises- theft of money and securities, inside the premises- robbery or safe burglary of other property, and funds transfer fraud. EI #2 said they thought the policy they had was one step better than a surety bond. When asked who the payee of any claims would be, she said the facility. EI #2 said they used to have a surety bond but they did away with it. EI #2 explained the board (governing body) had suggested they change to the policy, and said she should have done more research when they decided to go with it.

Based on observation, interview, and review of the facility policy titled Dating of Commercially Prepared Shake Products the facility failed to ensure six of seven Mighty Shakes were used within 14 days of being thawed as outlined by the manufacturer as well as the facility policy. This had the potential to affect 3 residents who receive Mighty Shakes. Findings include: A review of Mighty Shakes' manufacturer's product overview revealed Storage after open: Refrigerated Shelf life after open: Up to 14 days Refrigerated . The facility Policy, Dating of Commercially Prepared Shake Products revealed: Policy: All commercially prepared shake products will be properly dated . Procedure: . All shakes are good for 14 days after thawing plus one day for thawing, for total of 15 days from the time it is placed in the refrigerator. This used by date will also be put on the case . During the initial tour of the kitchen on 2/7/17 at 2:15 p.m., the containers of Mighty Shake Plus, No Sugar Added Mighty Shake and Mighty Shake were observed to be stored in a plastic container in the walk-in cooler. The container had a date affixed to the outer side. The Mighty Shake Plus date was 2/10/17, No Sugar added date was 2/15/17 and the Mighty Shake date was 2/5/17. The surveyor counted six of seven cartons of Mighty Shakes in the container; with the expired date of 2/5/17. On 2/9/17 at 1:30 p.m., Employee Identifier (EI) #1 stated the shakes were good for 14 days after thawing. When asked how many shakes were labeled with the 2/5/17 date, EI #1 replied the cartons she had not counted, but she had seen the 2/5/17 date on the bucket.

Based on record review, observation and interview, the facility failed to ensure a dietary worker: 1. washed her hands after cleaning a table with a cloth that contained a chemical solution and before removing food from the oven, tempting food with bare hands and plating food with bare hands and 2. did not place her ungloved thumb to the inside top surface of five plates then place food on the plates during the lunch tray line on 1/27/2016. This had the potential to affect 72 of 76 residents who receive meals from the kitchen. Findings Include: A review of a facility policy titled, TRAY ASSEMBLY with a date of 1/2011 revealed: .PROCEDURE: .11. Safe food handling techniques are used throughout tray preparation and delivery, such as, proper hand washing, proper handling of . plates . On 1/27/2016 at 10:55 AM, EI (Employee Identifier) #5, Dietary worker, was observed wiping off a table with a cloth containing a chemical solution using her bare hands. EI #5 did not wash her hands after cleaning the table. On 1/27/2016 at 10:56 AM, EI #5 removed pureed chicken spaghetti from the oven and began tempting the chicken spaghetti with her bare hands. On 1/27/2016 from 11:06 AM to 11:10 AM, EI #5 was observed to place an ungloved thumb on the top inside surface of five plates as she placed food onto the plates. On 1/27/2016 at 1:00 PM, an interview was conducted with EI #5. EI #5 was asked when she should wash her hands when working in the kitchen. EI #5 said before plates, spoons or gloves were touched and before anyone's food was prepared. EI #5 was asked what she should have done after wiping the table with a cloth using her bare hands and before she removed chicken spaghetti from the oven, tempted the pureed chicken spaghetti with her bare hands and began plating the resident's food with her bare hands. EI #5 said she should have washed her hands. EI #5 was asked what the potential harm was in not washing her hands after she wiped the table and before she removed the chicken spaghetti, tempted the chicken spaghetti and began plating food. EI #5 said she could have germs on her hands and the germs could get on the plates that were prepared. EI #5 was asked how plates were to be held when placing a resident's food on them. EI #5 said underneath it. EI #5 was asked if any part of her hand should touch the top surface of the plate. EI #5 said, No ma'am. EI #5 was asked if she could tell the surveyor why she was observed placing her thumb on the top inside surface of the plate five times as she was plating the food. EI #5 said the plates had to be plugged up and were hot on the bottom and she got into the habit of putting her hand on the top of the plate. EI #5 was asked what the potential harm was of placing her ungloved thumb on the surface of the plate before placing food on it. EI #5 said, You may have germs on your hand and it could get on the plate and come in contact with the food. On 1/28/2016 at 11:53 AM, an interview was conducted with EI #6, Dietary Manager. EI #6 was asked when dietary staff were expected to wash their hands. EI #6 said they washed their hands when they finished one task and moved on to the next. EI #6 was asked what should be done after a dietary worker wiped the table with a cloth containing a chemical solution with bare hands and before food was removed from the oven, before food was tempted and before plating food. EI #6 said after she wiped the table, she should have washed her hands then took the food out and continued. EI #6 was asked if it was an acceptable practice of that facility for a dietary worker to wipe a table with a cloth containing a chemical with bare hands, remove food from the oven, temp food and plate food without washing their hands. EI #6 said no, it was not. EI #6 was asked what was the potential harm if a dietary worker wiped a table off with a cloth containing a chemical solution with bare hands, then removed food from the oven, temped the food and plated the food without washing hands. EI #6 said she could possibly contaminate the food by not washing her hands. EI #6 was asked how plates should be held when plating food. EI #6 said the plate should be held by the rim, not on the inside of the plate. EI #6 was asked if it was an acceptable practice of that facility for a dietary worker to place an ungloved thumb on the inside top surface of the plate, then place food on the plate. EI #6 said no. EI #6 was asked what the potential harm was if a dietary worker placed an ungloved thumb to the inside top surface of the plate then placed food on the plate. EI #6 said it would contaminate the plate and contaminate the food.

Based on record review and interview, the facility failed to ensure the Significant Change and Quarterly MDS's (Minimum Data Set) of RI (Resident Identifier) #2, RI #5, RI #6 and RI #12 accurately reflected they were receiving hospice care. This affected four of four sampled residents observed who receive hospice care in the facility. Findings Include: A review of a facility policy titled, Resident Assessment Using the MDS without a date revealed: Policy Every resident will be assessed using the Minimum Data Set (MDS) according to the guidelines set forth in the Resident Assessment Instrument (RAI) manual. Purpose 1. To assess each resident's .care needs. 2. To use this assessment data to develop a comprehensive Plan of Care (POC) for each resident that will assist a resident in achieving and maintaining the highest practical level of mental functioning, physical functioning, and wellbeing as possible. Completing the MDS . 3. Each person completing a section of the MDS attests to its accuracy . 1. RI #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #2's May 2015 physician's orders [REDACTED]. Admit to Southern Care Hospice . A review of RI #2's most recent Quarterly MDS with an ARD (Assessment Reference Date) of 10/29/2015 revealed Hospice care was not marked under section O. A review of RI #2's Quarterly MDS with an ARD of 8/13/2015 revealed Hospice care was not marked under section O. On 1/27/2016 at 5:16 PM, an interview was conducted with EI (Employee Identifier) #4, MDS Coordinator. EI #4 was asked if RI #2 was a hospice patient. EI #4 said yes. EI #4 was asked if Hospice care under section O should be marked on the 8/13/2015 and 10/29/2015 MDS. EI #4 said yes. EI #4 was asked if Hospice care was marked on these MDS's. EI #4 said no. EI #4 was asked why Hospice care was not marked. EI #4 said it was an error on her part. EI #4 was asked if the 8/13/2015 and 10/29/2015 MDS was coded correctly since Hospice care was not marked. EI #4 said no ma'am. EI #4 was asked what the potential harm was if a MDS was not coded correctly. EI #4 said RI #2 would not receive appropriate care. 2. RI #5 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of RI #5's December 2013 physician's orders [REDACTED].cont (continue) Southern Care Hospice . A review of RI #5's most recent Annual MDS with an ARD of 10/15/2015 revealed Hospice care was not marked under section O. A review of RI #5's Quarterly MD's with ARDs of 5/14/2015 and 8/6/2015 revealed Hospice care was not marked under section O . On 1/27/2016 at 5:22 PM, an interview was conducted with EI #4. EI #4 was asked if RI #5 was a hospice patient. EI #4 said yes ma' am. EI #4 was asked if the MDSs with ARDs of 5/14/2015, 8/6/2015 and 10/15/2015 should have Hospice care under section O marked. EI #4 said yes ma'am. EI #4 was asked if Hospice care was marked on these MDSs. EI #4 said no ma'am. EI #4 was asked why Hospice care was not marked. EI #4 said it was an error on her part. EI #4 was asked if the 5/14/2015, 8/6/2015 and 10/15/2015 MDSs were coded correctly since Hospice care was not marked. EI #4 said no ma'am. EI #4 was shown RI #5's December 2013 Physician order [REDACTED].#4 said no ma'am. EI #4 was asked what the potential harm was if a MDS was not coded correctly. EI #4 said the resident would not receive the appropriate care and would not be kept at the highest level of function as possible. 3. RI #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #6's January 2015 physician's orders [REDACTED]. A review of RI #6's Significant Change MDS with an ARD of 1/21/2015 revealed Hospice care under section O was not marked. A review of RI #6's Quarterly MDS with an ARD of 10/1/2015 revealed Hospice care was not marked under section O. On 1/27/2016 at 5:07 PM, an interview was conducted with EI #4. EI #4 was asked what RI #6's significant change was at the time that the Significant Change MDS with an ARD of 1/21/2015 was done. EI #4 said the resident went on hospice. EI #4 was asked if the resident was a hospice patient at that time (1/27/2016). EI #4 said yes. EI #4 was asked when the resident was admitted to hospice. EI #4 said she thought 1/14/2015. EI #4 was asked if Hospice care under section O should be marked on the 1/21/2015 MDS. EI #4 said yes. EI #4 was asked if Hospice care was marked on the 1/21/2015 MDS. EI #4 said, No ma'am it's not. EI #4 was asked why Hospice care was not marked. EI #4 said, I just forgot to mark it. EI #4 was asked who was responsible for updating the MDS section O . EI #4 said, I would have done that section. EI #4 was asked if the 1/21/2015 Significant Change MDS was coded correctly since Hospice care was not marked. EI #4 said, No ma'am it was not. EI #4 was asked what the potential harm was if a MDS was not coded correctly. EI #4 said the resident would not receive appropriate care. EI #4 was asked if Hospice care under section O should be marked on the 10/1/2015 Quarterly MDS. EI #4 said yes. EI #4 was asked if Hospice care was marked. EI #4 said it was not. EI #4 was asked why it was not marked. EI #4 said it was an error on her part. EI #4 was asked if the 10/1/2015 Quarterly MDS was coded correctly. EI #4 said no ma'am. 7. RI #12 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #12's August 2015 physician's orders [REDACTED]. A review of RI #12's Significant Change MDS with an ARD of 8/25/2015 revealed Hospice care was not marked under section O . A review of RI #12's Quarterly MDS with an ARD of 11/12/2015 revealed Hospice care was not marked under section O. On 1/28/2016 at 11:05 AM, an interview was conducted with EI #4. EI #4 was asked what RI #12's significant change was at the time that the Significant Change MDS with an ARD of 8/25/2015 was done. EI #4 said the resident was admitted to hospice. EI #4 was asked if the resident was a hospice patient at that time (1/28/2016). EI #4 said yes. EI #4 was asked when was RI #12 admitted to Hospice. EI #4 said 8/18/2015. EI #4 was asked if Hospice care under section O should be marked on the 8/25/2015 MDS. EI #4 said yes ma'am, it should have been. EI #4 was asked if Hospice care was marked. EI #4 said no ma'am. EI #4 was asked why Hospice care was not marked. EI #4 said it was an error on her part. EI #4 was asked if the 8/25/2015 Significant Change MDS was coded correctly since Hospice care was not marked. EI #4 said no ma'am. EI #4 was asked what the potential harm was if a MDS for a hospice patient was not coded correctly. EI #4 said they would not be kept at a comfortable level, the care would not be coordinated and they would not receive appropriate care. EI #4 was asked if Hospice care under section O should be marked on the 11/12/2015 MDS. EI #4 said yes ma'am. EI #4 was asked if Hospice care was marked. EI #4 said no ma'am. EI #4 was asked why Hospice care was not marked. EI #4 said it was an error on her part. EI #4 was asked if the 11/12/2015 Quarterly MDS was coded correctly since Hospice care was not marked. EI #4 said no ma'am.

Based on record review and interviews, the facility failed to develop a coordinated Hospice plan of care for RI (Resident Identifier) #2, RI #5, RI #6 and RI #12. This affected four of four residents who receive Hospice care in the facility. Findings Include: A review of a facility policy titled, Resident Assessment Using the MDS without a date revealed: Policy Every resident will be assessed using the Minimum Data Set (MDS) according to the guidelines set forth in the Resident Assessment Instrument (RAI) manual. Purpose 1. To assess each resident's .care needs. 2. To use this assessment data to develop a comprehensive Plan of Care (POC) for each resident that will assist a resident in achieving and maintaining the highest practical level of mental functioning, physical functioning, and wellbeing as possible. Completing the Care Area Assessments (CAAs) . 3. While CAAs identify common areas of concern in nursing home residents, the POC is not to be limited to the triggered areas. The comprehensive POC must address all care issues that are relevant to the individual, whether or not they are specifically covered in the MDS/CAA process 1. RI #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #2's May 2015 physician's orders [REDACTED]. Admit to Southern Care Hospice . On 1/27/2016 at 4:10 PM, during record review, it was revealed that RI #2, RI #5 and RI #6 did not have a hospice care plan. On 1/27/2016 at 5:16 PM, an interview was conducted with EI (Employee Identifier) #4, MDS Coordinator. EI #4 was asked if RI #2 was a hospice patient. EI #4 said yes. EI #4 was asked if RI #2 had a hospice care plan. EI #4 said no ma'am. EI #4 was asked should RI #2 have a hospice care plan. EI #4 said yes. EI #4 was asked why RI #2 did not have a hospice care plan. EI #4 said it was an error on her part. EI #4 was asked what the potential harm was if a resident on hospice did not have a hospice care plan. EI #4 said it could cause a decline in condition, discomfort and the resident would not receive the care that was needed. 2. RI #5 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of RI #5's December 2013 physician's orders [REDACTED].cont (continue) Southern Care Hospice . On 1/27/2016 at 5:22 PM, an interview was conducted with EI #4. EI #4 was asked if RI #5 was a hospice patient. EI #4 said yes ma'am. EI #4 was asked if RI #5 had a Hospice care plan. EI #4 said, I guess not. EI #4 was asked if RI #5 should have a hospice care plan. EI #4 said yes ma'am. EI #4 was asked why RI #5 did not have a care plan. EI #4 said it was an error on her part. EI #4 was asked what the potential harm was if a resident that was on hospice did not have a hospice care plan. EI #4 said they would not receive appropriate care and would not be kept at the highest level of function as possible. 3. RI #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #6's January 2015 physician's orders [REDACTED]. On 1/27/2016 at 5:07 PM, an interview was conducted with EI #4. EI #4 was asked what RI #6's significant change was at the time that the Significant Change MDS with an ARD (Assessment Reference Date) of 1/21/2015 was done. EI #4 said the resident went on hospice. EI #4 was asked if the resident was a hospice patient at that time (1/27/2016). EI #4 said yes. EI #4 was asked when the resident was admitted to hospice. EI #4 said she thought 1/14/2015. EI #4 was asked if RI #6 had a hospice care plan. EI #4 said there was not a hospice care plan, per say. EI #4 was asked if RI #6 should have a hospice care plan. EI #4 said it was kind of worked in. EI #4 was asked how it was decided what Hospice provided and what the facility provided. EI #4 said she did not know how to answer that. On 1/28/2016 at 10:48 AM, during record review, it was revealed that RI #12 did not have a hospice care plan. 4. RI #12 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #12's August 2015 physician's orders [REDACTED]. On 1/28/2016 at 11:05 AM, an interview was conducted with EI #4. EI #4 was asked what RI #12's significant change was at the time that the Significant Change MDS with an ARD of 8/25/2015 was done. EI #4 said the resident was admitted to hospice. EI #4 was asked if the resident was a hospice patient at that time (1/28/2016). EI #4 said yes. EI #4 was asked when RI #12 was admitted to Hospice. EI #4 said 8/18/2015. EI #4 was asked if RI #12 had a hospice care plan. EI #4 said no. EI #4 was asked if the resident should have a hospice care plan. EI #4 said yes. EI #4 was asked why RI #12 did not have a hospice care plan. EI #4 said the care plan was not done appropriately. EI #4 was asked what the potential harm was if a resident that was on hospice did not have a hospice care plan. EI #4 said they would not be kept at a comfortable level, the care would not be coordinated and they would not receive appropriate care.

Based on observation, interview, and record review, the facility failed to ensure: 1. A CNA (Certified Nursing Assistant) washed her hands and changed gloves during incontinent care in a manner to prevent cross contamination for RI (Resident Identifier) #10. 2. CNAs washed their hands and changed gloves after handling a foley catheter drainage bag and tubing for RI #8. 3. A CNA changed gloves and washed hands after cleaning bowel movement (BM) and urine from RI #5 and before touching the resident's brief, lap tray, blanket and gait belt. This affected three of four residents observed during perineal care and incontinent care during the survey. Findings include: A policy provided by the facility titled GLOVE USE revealed the following: PURPOSE: To provide guidelines for the use of gloves for resident and employee protection. II. MISCELLANEOUS . E. Perform hand hygiene after removing gloves. An outline of Education provided to facility staff dated 7/21/2015 included the following: .TOPIC: INFECTION CONTROL/HANDWASHING . When to wash your hands/Decontaminate . when going from dirty to clean . When you remove gloves (Each time gloves are removed) . ALABAMA BOARD OF NURSING . Title of Education Activity: Infection Control/Handwashing . Content (Topics) . 4. Steps to proper handwashing: - Before donning gloves and after removal of gloves. -Before and after direct contact with patients, .secretions, .and body fluid . -Touch a contaminated object. 1.) RI #10 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #10's admission MDS (Minimum Data Set) with an Assessment Reference Date of 12/1/2015 revealed severely impaired cognition and bowel and bladder incontinence with total dependence on staff for hygiene. On 1/26/2016 at 4:10 PM, EI (Employee Identifier) #8 CNA, provided incontinent care for RI #10. EI #8 cleaned bowel movement from RI #10's perineum and without washing her hands, changed gloves, applied moisture barrier, and placed a clean brief under RI #10. EI #8 then removed the soiled brief and pad, used a disposable wipe to clean BM from RI #10's right hip, and without washing hands or changing gloves, applied moisture barrier, clean pants, and house shoes to RI #10. EI #8, while still wearing the same gloves, lowered the bed, replaced the mat on the floor at the bedside, then removed her gloves and washed her hands. On 1/26/2016 at 4:40 PM, EI #8 was asked when she was trained to wash her hands. EI #8 said, before performing any care and after you finish. When asked about handwashing with change of gloves, EI #8 said, you should wash after removal of soiled gloves. When asked why she continued with care while wearing the same gloves worn for cleaning BM, EI #8 said, I just forgot, I know to change gloves. When asked what the importance of washing hands and changing gloves was, EI #8 said, to keep down infection and make sure the resident is clean. On 1/28/2016 at 11:40 AM, EI #3, Infection Control RN (Registered Nurse), was asked what the facility policy was on handwashing. EI #3 said, wash hands before care, when gloves are changed or gloves are soiled. When asked why CNAs continued care for residents while wearing soiled gloves, EI #3 said, they have been inserviced to decontaminate when they change gloves. When asked how CNAs were trained to change gloves and wash hands during pericare, EI #3 said, When dirty, wash hands and change gloves. EI #3 said washing hands with glove changes was important because of potential contamination during care. 2.) RI #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #8's most recent quarterly MDS (Minimum Data Set) with an Assessment Reference Date of 11/11/2015 revealed the following: a BIMS (Brief Interview for Mental Status) score of 3 which indicated severely impaired cognition and use of a urinary catheter. On 1/27/2016 at 10:05 AM, EI #9 CNA and another CNA passed RI #8's urine drainage bag from one side of the bed to the other while repositioning RI #8. EI #9 and the other CNA changed gloves without sanitizing their hands. The two CNAs then repositioned the resident in bed, with a wedge, a pillow, and then covered the resident before removing their gloves and using hand sanitizer. On 1/27/2016 at 10:20 AM, EI #9 was asked what the facility policy was for handwashing. EI #9 said, before care and after care. EI #9 was asked when she moved the catheter bag from one side of the bed to the other if she sanitized her hands. EI #9 said, Just changed gloves. When asked why should she sanitize after care, EI #9 said to keep down cross contamination. On 1/28/2016 at 11:45 AM, EI #3 was asked about the facility policy on handwashing. EI #3 said to hand wash before and after care, when they change gloves or if hands or gloves are soiled. When asked why CNAs did not wash hands between glove changes when handling catheter bag and tubing, EI #3 said the CNAs were nervous. When asked why it was important to wash hands with glove changes, EI #3 said, because of potential contamination during care. 3) RI #5 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #5's most recent Quarterly MDS with an ARD of 1/14/2016 revealed the resident was moderately impaired for daily decision making. The MDS also revealed the resident was totally dependent on staff for toilet use and personal hygiene. The MDS further revealed the resident was occasionally incontinent of bowel and bladder. On 1/26/2016 at 4:15 PM, RI #5 was observed being assisted to the bedside commode by EI #7, CNA and another CNA. EI #7 said the resident urinated and had a small bowel movement (bm) in the bedside commode. The resident was assisted up from the bedside commode by the two CNAs. EI #7 removed disposable wipes from the pack and wiped up the resident's buttocks five times. RI #5's brief was pulled up by EI #7. EI #7 did not change gloves or wash her hands after cleaning the resident and before touching the brief. EI #7 then applied the gait belt to her waist and removed her gloves. EI #7 placed the resident's lap tray on the resident's bed. EI #7 placed the resident's blanket on the resident. EI #7 donned new gloves and cleaned the bedside commode. EI #7 did not wash hands till after she cleaned the bedside commode. On 1/26/2016 at 5:20 PM, an interview was conducted with EI #7. EI #7 was asked what training she had received on hand washing during care. EI #7 said, We wash our hands when we get done with care, well before and after. EI #7 was asked what she should have done after she cleaned bm and urine and before she touched anything else. EI #7 said she should have removed her gloves. EI #7 was asked what the potential harm was in removing the gait belt from the resident and placing around her without removing her gloves and washing her hands. EI #7 said the bacteria could go from the gloves to the belt. EI #7 was asked at what point during the care did she wash her hands. EI #7 said after she completed all of her tasks. On 1/28/2016 at 11:17 AM, an interview was conducted with EI #3, ADON. EI #3 was asked when CNAs were expected to wash their hands during perineal care. EI #3 said before they start, anytime they change gloves and at the end of the procedure. EI #3 was asked what should be done after a CNA cleaned urine and bm from a resident with gloved hands and before the CNA pulled the resident's brief up, touched the gait belt, the resident's lap tray and blanket. EI #3 said change gloves and wash their hands. EI #3 was asked if it was an acceptable practice of that facility for a CNA to clean urine and bm from a resident with gloved hands and then pull up the resident's brief, place gait belt around herself and the resident, touch the lap tray and the resident's blanket without removing gloves and washing their hands. EI #3 said no, they have been trained. EI #3 was asked what was the potential harm if a CNA wiped urine and bm from a resident with gloved hands then pulled the resident's brief up, touched the gait belt and applied to the resident and herself, touched the lap tray and the resident's blanket without removing gloves and washing hands. EI #3 said it could spread germs or bacteria.

Based on observation, interview, and record review, the facility failed to ensure foreskin was retracted for cleaning during incontinent care provided for RI (Resident Identifier) #10 on 1/26/2016. The facility further failed to ensure a CNA (Certified Nursing Assistant) did not clean RI #10's perineum using the same area of a disposable wipe more than one time and did not wipe in a back and forth motion. This affected one of four residents observed during incontinent and perineal care. Findings include: An undated facility policy titled Pericare and Foley Catheter Care revealed the following: .Purpose: To aid in the prevention of Urinary Tract Infections and to provide cleanliness to residents who are unable to use the toilet assisted or unassisted.Clean inner groins first in a single motion from front to back .repeat each area until clean using different corner of the cloth or obtain new cloth . wash penis from the urethral opening or tip of the penis in a circular motion -Pull back foreskin . and clean under it then return the foreskin -Wash shaft of penis and the scrotum in a single downward motion changing position of the cloth on each wipe . RI #10 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #10's admission MDS (Minimum Data Set) with an (ARD) Assessment Reference Date of 12/1/2015 revealed severely impaired cognition and bowel and bladder incontinence with total dependence on staff for hygiene. On 1/26/2016 at 4:10 PM, EI (Employee Identifier) #8 CNA, provided care for RI #10's bowel and bladder incontinence episode. EI #8 used disposable wipes to clean RI #10's groin and penis without changing the position of the wipes. EI #8 used disposable wipes to clean bowel movement from under and around RI #10's scrotum wiping back and forth without changing the position of the wipe. RI #10's foreskin was not retracted for cleaning. EI #8 cleaned bowel movement from RI #10's right hip in a back and forth motion without changing the position of the wipe. On 1/26/2016 at 4:40 PM, EI #8 was asked what the facility policy was for providing perineal care. EI #8 said to wipe from front to back, wipe each side, and then the middle. When asked what was to be done with the foreskin, EI #8 said to pull it back and wipe around the penis. When asked why she did not pull the foreskin back for cleaning, EI #8 said RI #10's legs were held together. When asked why she wiped back and forth with the wipes, EI #8 said she tried to make sure she had cleaned all the bowel movement. When asked what she should have done, EI #8 said she should have wiped once, discarded the wipe, and got another wipe. When asked about the importance of using good technique for perineal care and using one wipe, EI #8 said, to keep down infection and make sure the resident was clean. On 1/28/2016 at 12:00 PM, EI #3 Education Coordinator, was asked how CNAs were trained to perform perineal care using disposable wipes. EI #3 said, to clean with one stroke and not reuse a portion of the wipe that had touched the resident. EI #3 was asked why the CNA used disposable wipes to wipe multiple times with the wipe in the same position. EI #8 replied, that was not appropriate. When asked why the CNA wiped back and forth with the wipes, EI #3 said, there should have been one wipe. EI #8 admitted there could be the potential for infection if bowel movement is involved. When asked how CNAs were trained to clean the penis and scrotum, EI #3 said, clean the head in a circular motion, and wipe the shaft down and away from the meatus, then wipe down the scrotum. EI #3 said, the foreskin should be retracted to clean the meatus. When asked why the foreskin was not retracted during incontinent care, EI #3 said she did not know, and CNAs have to maintain cleanliness. When asked why the scrotum was wiped back and forth, EI #3 said she did not know and CNAs have done return demonstrations. EI #3 admitted there was a potential for infection if stool was involved.

Based on record review, observation and interview, the facility failed to ensure a CNA (Certified Nursing Assistant) separated and cleaned RI (Resident Identifier) #5's labia during perineal care on 1/26/2016. RI #5 is a resident with a history of UTI (Urinary Tract Infection). This affected one of four residents observed during incontinent care and perineal care. Findings Include: A review of a facility policy titled, Pericare and Foley Catheter Care without a date revealed: Purpose: To aid in the prevention of Urinary Tract Infections . Procedure: . Separate labia majora-clean down 1 side then the other side then the center . RI #5 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #5 's most recent Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/14/2016 revealed the resident was moderately impaired for daily decision making. The MDS also revealed the resident was totally dependent on staff for toilet use and personal hygiene. The MDS further revealed the resident was occasionally incontinent of bowel and bladder. A review of RI #5's care plan revealed: .Problem/Need 8/26/14 uti . Approaches Bactrim DS (Double Strength) .po (by mouth) BID (twice daily) X (times) 7 days [MEDICATION NAME] 150 mg (milligram) tab( tablet) .po q (every) day On 1/26/2016, RI #5 was observed being assisted to the bedside commode by EI (Employee Identifier) #7, CNA and another CNA. EI #7 said the resident urinated and had a small bowel movement in the bedside commode. The resident was assisted up from the bedside commode by the two CNAs. EI #7 removed disposable wipes from a pack and wiped up the resident's buttocks five times. RI #5's brief was pulled up. EI #7 did not separate RI #5's labia and clean. On 1/26/2016 at 5:20 PM, an interview was conducted with EI #7. EI #7 was asked should the labia be separated and cleaned on a resident who urinated during perineal care. EI #7 said, Yes. EI #7 was asked how she had cleaned RI #5. EI #7 said she reached underneath and wiped front back to back. EI #7 was asked if she separated the labia and cleaned. EI #7 said she tried to. EI #7 was asked if she used one hand to separate and then cleaned the labia. EI #7 said, No, I did not. EI #7 was asked what the potential harm was in not separating the labia and cleaning. EI #7 said, UTI. EI #7 also said, I have been thinking about it and I know where I messed up. On 1/28/2016 at 11:19 AM, an interview was conducted with EI #3, ADON (Assistant Director of Nursing). EI #3 was asked if the CNA should separate the labia and clean during perineal care after a resident urinated. EI #3 said yes. EI #3 was asked if it was an acceptable practice of that facility for a CNA to perform perineal care after the resident urinated and not separate the labia and clean. EI #3 said if the resident was toileted, they had to make sure they wiped all three sections. EI #3 was asked what the potential harm was if a CNA did not separate the labia of a resident with a history of UTI and clean after the resident urinated. EI #3 said skin irritation from the urine.

Based on interviews and record reviews, the facility failed to ensure that the CNA (Certified Nursing Assistant) Abuse Registry screening was verified on three employees upon hire. This affected three of five employees whose personnel files were reviewed. Findings include: A review of 5 of the facilities personnel records revealed, the facility failed to screen and print the CNA Abuse registry for 3 staff members upon hire. Checking the CNA registry would have ensured that EI (Employee Identifier) #s 3, 4, and 5 were properly screened for abuse prior to hiring. On 12/04/2014 at 8:04 AM, an interview was conducted with EI #1, the Administrator. EI #1 was asked how the facility screens for abuse. EI #1 stated that the facility performs, "Background checks, Nurse abuse registry and reference checks." EI #1 was asked what was the facilities policy on abuse. EI #1 responded that the facility performs, "Drug test, background checks and Nurse aide registry (screening)." On 12/04/2014, at 10:10 AM, an interview was conducted with EI #2, DON (Director of Nursing). EI #2 was asked, who was responsible for screening the CNA abuse registry upon hiring. EI #2 responded, "Me". EI #2 was asked to review the personnel records for EI #s 3, 4, and 5. EI #2 was asked if a CNA abuse registry screening was performed on EI's #3, #4, and #5. EI #2 stated, "No", "No", and "No." EI #2 was then asked the potential negative outcome of not screening these employees. EI #2 replied, "You can have an abuser or perpetrator in your facility, however, we do check the abuse list periodically to make sure they have not abused elsewhere." On 12/04/2014 at 10:35 AM, a second interview was held with EI #1. EI #1 was asked who was responsible for screening the CNA abuse registry upon hiring. EI #1 responded, "Supervisors who are hiring." EI #1 was asked if a CNA abuse registry screening was performed on EI #s 3, 4, and 5. EI #1 stated, "No", "No", and "No." EI #1 was asked what could be the potential negative outcome of not screening these employees. EI #1 replied, "Potential for abuse of residents."

Based on an observation, interviews, and document reviews, the facility failed to ensure a Licensed Nurse did not administer medications to RI (Resident Identifier) #11 on Contact Isolation, without first donning a gown. This was witnessed during one of twelve medication pass observations. Findings include: A review of the facility document dated 2012 and titled, "CONTACT PRECAUTIONS," revealed, "..Direct Contact Transmission - microorganisms are transmitted directly from person to person. Indirect Contact Transmission - transfer of the infectious agent through a contaminated intermediate object or person. ... III. GOWNS A. A gown should be donned prior to entering the room or resident's cubicle. B. The gown should be removed before leaving the resident's room. C. After removal of the gown, clothing should not contact potentially contaminated environmental surfaces." A review of the facility sign on RI #11's door, without a date, titled, "CONTACT PRECAUTIONS" revealed, "...Wear gown when entering patient room if you anticipate contact with patient or environment." A review of RI #11's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Quarterly MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 10/30/14, revealed RI #11 was severely impaired for cognitive daily decision making skills. This MDS also indicated RI #11 required extensive assistance with ADLs (Activities of Daily Living). An observation was made on 12/3/2014 at 5:10 PM of EI #6, an LPN (Licensed Practical Nurse) entered into RI #11's room, designated as contact isolation, without donning a gown. EI #6 intended to give medications through RI #11's PEG (Percutaneous Endoscopic Gastrostomy) tube, with a wound to the stoma where VRE had been identified. An interview was conducted on 12/4/14 at 9:50 AM with EI #6. EI #6 was asked what should be worn when entering a resident's room that was on contact isolation for VRE. EI #6 stated, "If we are doing care and we don't touch the drainage we must wear gloves. The wound care nurse is the only one that needs to wear a gown because she is taking the dressing off and providing care." EI #6 was asked if RI #11 was on contact isolation for VRE. EI #6 stated, "Yes, ma'am." EI #6 was asked if she had worn a gown while giving care to RI #11. EI #6 stated, "No ma'am." EI #6 was asked if she gave medications through RI #11's PEG tube. EI #6 stated, "Yes ma'am." EI #6 was asked where RI #11's VRE was located. EI #6 stated, "Around the Stoma site. They cultured it." EI #6 was asked what potential harm could occur to other residents and employees if a gown was not worn while taking care of a resident on contact isolation, with VRE. EI #6 stated, "You can pass infection to others as well as to ourselves." EI #6 was asked what did the Contact Isolation Policy state about wearing a gown. EI #6 stated, "It said we should wear a gown. ..." EI #6 was asked what did the instructions state on the Contact Precaution sign on RI #11's door. EI #6 stated, "Wear gown when entering room if you anticipate contact with patient or environment." EI #6 was asked if she had opened the PEG tube to give medicines. EI #6 stated, "Yes." EI #6 was asked if the PEG tub was in the same area as the stoma. EI #6 stated, "Yes." An interview was conducted on 12/4/14 at 10:20 AM with EI #7, the Infection Control Nurse. EI #7 was asked if a gown should be worn when entering the room of a resident that was on contact isolation. EI #7 stated, "Gloves should be worn. Gowns should be worn if you're coming in contact with the site or if you're coming in contact with the residents clothing. If providing care and moving that resident or if they will be touching me." EI #7 was asked what was the potential harm to residents and other employees if EI #6 did not wear a gown when entering RI #11's room, a resident on contact isolation for VRE. EI #7 stated, "If a staff member did not wear a gown it could spread, if she came in contact with infectious materials or objects." EI #7 was asked if she had told EI #6 she didn't have to wear a gown when providing care to a resident with VRE. EI #7 stated, "I told her if she wasn't going to be coming in contact with the site of infection, she wouldn't have to wear a gown." EI #7 was asked when EI #6 opened the PEG tube to give medications which was located near the stoma, would that have been an infection control issue, when the nurse was not wearing a gown. EI #7 stated, "If there's no drainage at the site and the infection is contained and if EI #6's body is not making contact with the bed or residents body, there would no need to wear a gown." EI #7 was asked what did the Policy on contact isolation state. EI #7 stated, "It says wear gown when entering room if you anticipate contact with patient or environment." EI #7 was asked what did the instructions state on the Contact Precaution sign on RI #11's door. EI #7 stated, "It says a gown should be donned when entering a residents room or cubicle." An interview was conducted on 12/4/14 at 11:00 AM, with EI #2, the DON (Director of Nursing). EI #2 was asked should a gown be worn when an employee is providing direct care to a resident, on contact isolation with VRE. EI #2 stated, "Gloves and gown and handwashing." EI #2 was asked what did the Contact Isolation Policy state about wearing a gown when taking care of a resident on Contact Isolation Precautions with VRE. EI #2 stated, "Gloves and gown and handwashing." EI #2 was asked what did the instructions state on the Contact Precaution sign on RI #11's door. EI #2 stated, "Gloves, gown and handwashing." EI #2 was asked what potential harm to residents and employees could occur if a gown was not worn while taking care of a resident on contact isolation, for VRE. EI #2 stated, "You can cross contaminate and transmit it to other residents and your staff could carry it to others and the environment."

Based on observation, record review and interviews the facility failed to maintain RI (Resident Identifier) # 2's privacy. Licensed staff obtained RI # 2's pulse in the main dining room in front of two residents seated at the table prior to giving medication. This was observed on 2/12/14. The facility also failed to maintain privacy for RI # 11. Licensed staff administered eye drops in front of other residents near the B nursing station. This was observed on 2/11/14. The facility further failed to ensure RI # 10's privacy was maintained in the Restorative Dining room on 2/12/14 during breakfast. The licensed staff took RI # 10's blood pressure in the dining room in front of other residents. This affected 3 of 13 sampled residents. A review of a document titled Resident Bill of Rights undated documented the following: "...12. Each resident has the right to have personal privacy in...medical treatment...personal care..." Findings Include: 1. RI # 2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI # 2's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/27/2013 documented a Brief Interview of Mental Status (BIMS) score of 14 out of 15 indicating RI # 2 was cognitively intact. A review of RI # 2's most recent Physicians Orders dated 2/1/14 - 2/28/14 documented the following: "[MEDICATION NAME] 125MCG TABLET...TAKE 1 TABLET BY MOUTH EVERY MORNING...CHECK PULSE..." A review of RI # 2's most recent Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]..2/12/2014...pulse 72..." On 02/12/2014 at 8:15 AM the surveyor observed Employee Identifier (EI) #6, Licensed Practical Nurse/Medication Nurse in the Main Dinning Room with her Medication Cart during the Breakfast Meal. At 8:41 AM EI #6 was observed at RI #2's table. At 8:41 AM RI #2 and two other residents were observed sharing a table while eating their meal. EI #6 came to the table and took RI #6's pulse at the table. At 8:44 AM EI #6 went back to the Medication Cart and prepared RI #2's medications before returning to the table. EI #6 gave RI #2 her medication at the table. During an interview on 02/13/2014 at 9:45 AM, the surveyor asked EI #6, LPN (Licensed Practical Nurse) if she had given RI #2 her medication in the Dinning Room during Breakfast on 2/12/2014. EI #6 stated, "Yes". The surveyor asked EI #6 what steps she took when giving the medication. EI #6 explained she has to take RI #2's pulse for 60 seconds before she can give her medication. The surveyor asked EI #6 if she did that yesterday, EI #6 stated, "Yes". The surveyor asked EI #6 if she had ever asked RI #2 if she wanted her pulse checked in the Dinning Room, EI #6 stated, "I've never asked her but I do let her know that I'm going to check." The surveyor asked EI #6 if RI #2's medical history or medications should be discussed in front of other residents, EI #6 stated, "No". On 2/13/2014 at 3:00 PM, the surveyor completed a Resident Interview with RI #2. During the interview the surveyor asked RI #2 if she preferred to have her medication and pulse taken in her room or the Dinning Room. EI #2 stated she would rather have them both in her room. An interview was conducted with EI # 5, RN (Registered Nurse) DON (Director of Nursing) on 2/13/14 at 1:45 PM. EI # 5 was asked what is your policy on giving medication in front of other residents in the dining room. EI # 5 stated there was no policy we just have residents sign permission/consent. EI # 5 was asked what is your policy on doing exams in front of other residents such as blood pressure checks or pulse. EI # 5 stated before some medications a blood pressure and pulse is taken. EI # 5 was asked if the residents privacy is violated if medication is given in front of other residents. EI # 5 stated not if they have signed a permission slip and the residents agree. 2. On 02/11/2014 at 5:07 PM, an observation was made of a nurse administering eye drops to RI #11 in the hallway next to the Wing B nurses station. The surveyor had walked up to the nurses station when the observation was made. There were three female residents near the nurses station and in view of RI #11 when the eye drops were administered. RI #11 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. RI #11's most recent Quarterly Minimum (MDS) data set [DATE], documented a score of 11 on his Brief Interview for Mental Status (BIMS). A score of 08-12 indicated moderately impaired cognition. The facility's "physician's orders [REDACTED]." On 02/11/14 at 5:22 PM, an interview was conducted with the Licensed Practical Nurse (LPN), Employee Identifier (EI) #1, who administered the eye drops. In the interview EI #1 was asked what the facility policy and procedure was regarding privacy in the administration of eye drops. She said it was usually a privacy thing and you should ensure the resident has privacy. EI #1 was asked why privacy was important and she said that certain people may not want anyone to know they had eye drops. When asked why she administered RI #11's eye drops in public, EI #1 said she was administering his meds (pills) and noticed he had eye drops due at that time. An interview was conducted with EI # 5, RN (Registered Nurse) DON (Director of Nursing) on 2/13/14 at 1:45PM. EI # 5 was asked what is your policy on giving eye drops in front of other residents. EI # 5 stated it would depend on the person but there is no policy. EI # 5 was asked if the residents privacy is violated if medication is given in front of other residents. EI # 5 stated not if they have signed a permission slip and the residents agree. 3. RI # 10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI # 10's most recent Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/12/2013 documented a Brief Interview of Mental Status (BIMS) score of 4 out of 15 indicating severe cognitive impairment. A review of RI # 10's most recent physician's orders [REDACTED]. A review of RI # 10's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"[MEDICATION NAME] 2.5 MG TABLET TAKE 1 TABLET BY MOUTH ONCE DAILY CHECK B/P PRIOR...8:00AM...2/12/14...132/70..." On 2/13/14 the surveyor observed EI # 4, LPN (Licensed Practical Nurse) take RI # 10's blood pressure in the dining room. EI # 10 asked if she was through eating but RI #10 was unable to speak. EI # 4 then said "I need to take your blood pressure" EI # 4 then took RI # 10's blood pressure. While EI # 4 took RI # 10's blood pressure the dining room was full of other residents eating breakfast. An interview was completed with EI # 4, LPN (Licensed Practical Nurse on 2/13/14 at 1:15PM. EI # 4 was asked what is your policy on giving medication in the dining room. EI # 4 stated most residents sign a form that says they want medication with meals and some medication require blood pressure checks or a pulse check. EI # 4 was asked if it was appropriate to take a residents blood pressure when they are eating and in front of other people. EI # 4 stated we usually ask them first. EI # 4 was asked if a residents privacy can be maintained if medications or exams are given in the dining room. EI # 4 sated it is if that is the way they want it. EI # 4 was asked if she took RI # 10's blood pressure this morning prior to given her medications. EI # 4 stated yes prior to receiving her blood pressure medication. EI # 4 was asked if RI # 10's privacy was maintained during this process. EI # 4 stated she was away from other residents in front of a Certified Nursing Assistant. EI # 4 was asked if RI # 10 was able to tell you if she wants her medication. EI # 4 stated she is confused occasionally. An interview was conducted with EI # 5, RN (Registered Nurse) DON (Director of Nursing) on 2/13/14 at 1:45PM. EI # 5 was asked what is your policy on giving medication in front of other residents in the dining room. EI # 5 stated there was no policy just have residents sign permission/consent. EI # 5 was asked what is your policy on doing exams in front of other residents such as blood pressure checks or pulse. EI # 5 stated before some medications a blood pressure and pulse is taken. EI # 5 was asked if the residents privacy is violated if medication is given in front of other residents. EI # 5 stated not if they have signed a permission slip and the residents agree.