Every finding on record at Mcguffey Health & Rehabilitation Center

Based on observation, interviews, record review, and review of Potter and Perry, Fundamentals of Nursing, the facility failed to ensure: A licensed staff washed her hands and changed gloves after removing the soiled dressing from the wound before cleaning the wound for Resident Identifier (RI) #119. This affected RI #119, one of three opportunities of wound care observation. Findings Include: A review of Potter and Perry Fundamentals of Nursing ninth edition, chapter 48, page 1225 revealed . Implementation 1. Perform hand hygiene. Open sterile packages and topical solution containers as necessary. 2. Remove bed linen and patient's gown as necessary to expose ulcer and surrounding skin. Keep remaining parts covered and apply clean gloves. 3. Clean ulcer thoroughly with normal saline or cleaning agent. 4. Remove gloves perform hand hygiene and apply clean or sterile gloves. 5. Apply topical agents as prescribed. RI #119 was admitted on [DATE] and readmitted on [DATE]. On 5/26/21 at 10:47 AM, Employee Identifier (EI) #1, Licensed Practical Nurse (LPN), Treatment Nurse was observed performing wound care. EI #1, gathered needed supplies. EI #3 assisted with wound care. EI #3 washed her hands with soap and water donned gloves, cleaned area on bedside table for supplies. EI #1 washed her hands with soap and water and donned gloves, gathered supplies, opened kerlix and 4 x 4s placed on the clean table. EI #1 sprayed wound cleanser on 4x4s, applied [MEDICATION(S)] to 4x4, EI #3 assisted in holding extremity up for EI #1. EI #1 used scissors to cut off the old dressing, that was dated 5/25/21. EI #1 removed the old dressing and threw it in the trash. EI #1 described the wound, she stated, yellow slough and the surrounding skin was dried with yellow skin and redness. EI #1 with the same gloves she removed the old dressing EI #1 cleaned the wound with wound cleanser-soaked gauze and then dried the wound with gauze. EI #1 applied the treatment and wrapped with kerlix. EI #1 then removed her gloves and washed her hands with soap and water. EI #1 dated the tape and applied it to the kerlix. On 5/26/21 at 11:35 AM, an interview with EI #1 was conducted. EI #1 was asked, when should gloves be changed during wound care. EI #1 replied, when you go in the room wash hands, put gloves on, take the dressing off, take off gloves, wash hands and/or use hand sanitize, then apply gloves, clean the wound, take off gloves, then wash hands, put on gloves, apply the dressing and cover with gauze, take off gloves then wash hands or sanitize, then put the tape on, wash hands again leave room. EI #1 was asked, when should hands be washed during dressing change. EI #1 replied, the same as the last question, when you go in the room wash hands, put gloves on, take the dressing off, take off gloves, wash hands and/or use hand sanitize, then apply gloves, clean wound, take off gloves, then wash hands, put on gloves, apply the dressing and cover, take off gloves then wash hands or sanitize, then put the tape on wash hands again leave room. EI #1 was asked, what was the policy for washing hands during wound care. EI #1 replied, she would have to look it up, wash hands before entering the room, before any care, put on gloves, remove dressing, remove gloves wash hands don gloves apply dressing, remove gloves wash hands. EI #1 was asked, what was the harm of not changing gloves and washing hands during wound care. EI #1 replied, infection. On 5/27/21 at 11:59 AM, an interview was conducted with EI #2, Registered Nurse (RN), Infection Preventionist. EI #2 was asked, when was hand hygiene indicated. EI #2 replied, literally before and after everything you do, before shift, before and after bathroom, before and after resident care and in between if indicated during that care period, before and after any resident contact, coming back from break EI #2 was asked, when should you change gloves when changing a dressing on a wound. EI #2 replied, before care, when changing soiled dressing remove gloves wash hands don new gloves and then after treatment was complete. EI #2 was asked, what was the risk of not washing hands after taking off the soiled dressing. EI #2 replied, cross contamination, we do not want dirty on the clean. EI #2 was asked, when should Staff remove the old dressing and clean the wound with the same gloves. EI #2 replied, never. EI #2 was asked, when were gloves indicated. EI #2 replied, anytime handling bodily fluids, blood, [MEDICATION(S)] membranes, doing personal care, contact or droplet isolation precautions, and during any treatments or wound care.

Based on observation, interviews, record review, and review of facility policy titled Perineal Care the facility failed to ensure: 1) Certified Nursing Assistant (CNA) used soap while cleaning perineal area for Resident Identifier (RI) #97 during incontinent care 2) CNA changed gloves after removing soiled brief and cleaning resident's perineal area and before applying clean brief. This affected one of one resident observed during incontinent care. Findings Include: A review of a facility policy titled Perineal Care with an effective date of 12/19/07 revealed . Purpose . The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections . Infection Control Protocol and Safety 1) Wash your hands thoroughly with soap and water at the following intervals as indicated: a) Before the procedure . c) Anytime they become soiled with . body fluids . e) Whenever in doubt . 3) Maintain clean technique . Steps in the Procedure . 2) Wash and dry your hands thoroughly . 6) Raise the gown or lower pajamas. 7) Put on gloves. 9) For a . resident: a) Wet washcloth and apply soap or skin cleansing agent b) Wash perineal area, wiping front to back . 12) Remove gloves and discard . Wash and dry . hands . 13) Reposition the bed covers. Make resident comfortable. RI #97 was admitted to the facility on [DATE] and readmitted last on 11/04/2020 and had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Laboratory results for RI #97 revealed Laboratory Results . Collected . 1/28/2021 . Type . Urine . Culture Urine (Final Result) . Urine Culture . > (greater than) 100,000 CFU/mL(Colony-forming units per milliliter) Escherichia coli (AA) Panic. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . injection intramuscular twice per day . For: Complicated Urinary Tract Infection . Laboratory results for RI #97 revealed Laboratory Results . Collected . 2/19/2021 . Culture Urine (Finale Result) . Urine Culture . >100,000 CFU/mL Enterococcus faecalis (A) (Abnormal). A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . For: Urinary Tract Infection . Laboratory results for RI #97 revealed Laboratory Results . Collected . 4/8/2021 . Culture Urine (Finale Result) . Urine Culture . > (greater than) 100,000 CFU/mL Proteus mirabilis (A) Abnormal . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . For: Urinary Tract Infection. On 5/25/21 at 1:04 PM an interview was conducted with RI #97's sponsor. RI #97's sponsor reported the resident had several Urinary Tract Infections (UTI) recently and the most recent was within the past four months. On 5/25/21 at 4:52 PM an observation was made of Employee Identifier (EI) #5, CNA, performing incontinent care for RI #97. EI #5 was assisted by EI #6, CNA. EI #5 gathered supplies and donned gloves. EI #5 performed task while EI #6 assisted with positioning RI #97. EI #5 unfastened and removed the soiled brief. EI #5 did not change gloves or perform hand hygiene. EI #6 wet a cloth washcloth at the sink and passed to EI #5. No soap was added to the washcloth. E I#5 used the washcloth to clean RI #97's perineal area. EI #5 did not change gloves or perform hand hygiene. EI #5 applied a clean brief to RI #97. RI #97 was repositioned, and brief secured. EI #5 positioned the resident and removed gloves and washed her hands. On 5/26/21 at 10:30 AM an interview was conducted with EI #7, Registered Nurse (RN). EI #7 was asked, when did RI #97 have a UTI in 2021. EI #7 checked RI #97's medications and replied, on 1/30/21 RI #97 started antibiotics for UTI, on 2/21/21 the antibiotic was changed to [MEDICATION(S)], on 2/22/21 it was changed to [MEDICATION(S)] and on 4/13/21 RI #97 started [MEDICATION(S)] for UTI. EI #7 was asked, in general, what were possible causes for recurrent UTIs. EI #7 replied, incontinence, decreased fluid intake, poor hygiene, and inappropriate peri-care technique. On 5/26/21 at 3:43 PM an interview was conducted with EI #6, CNA. EI #6 was asked, during the surveyor's observation of incontinent care on 5/25/21, when did EI #5 change her gloves. EI #6 replied, she knew EI #5 put gloves on at the beginning and took them off at the end, but she did not remember if she changed gloves in between. EI #6 was asked, what did EI #5 use to clean RI #97's perineal area. EI #6 replied, a washcloth and water. EI #6 was asked, during incontinent care, when should gloves be changed. EI #6 replied, after the dirty brief was removed and before the clean brief was placed. EI #6 was asked, during incontinent care, what should be used to clean resident's perineal area. EI #6 replied, soap and water and dry; the soap and water then dry was repeated for each area. On 5/26/21 at 3:49 PM an interview was conducted with EI #5, CNA. EI #5 was asked, during surveyor's observation of incontinent care of RI #97, how did she clean RI #97's perineal area. EI #5 replied, with a wet washcloth that did not have soap on it. EI #5 was asked, when did she change her gloves. EI #5 replied, she was supposed to change her gloves after she finished cleaning him/her up and before she applied the clean brief. EI #5 was asked, did she change her gloves at that time. EI #5 replied, no, she knew she should have, but did not. On 5/26/21 at 4:23 PM a follow-up interview was conducted with EI #7. EI #7 was asked, what should be used to clean RI #97's perineal area. EI #7 replied, they used a mild soap with water and a cloth rag. EI #7 was asked, when should staff only use water and a cloth rag to clean while providing incontinent care. EI #7 replied, she thought that was the general practice if only providing incontinent care and soap should be used daily during bathing. On 5/26/21 at 4:56 PM an interview was conducted with EI #4, RN, Director of Nursing. EI #4 was asked, who was responsible for ensuring staff provide incontinent care per policy and standards of practice. EI #4 replied, the CNA was the direct patient care provider and they worked under a charge nurse. EI #4 was asked, when should staff change gloves during incontinent care. EI #4 replied, the staff should don gloves, clean front perineal area, roll resident to side, clean the resident's back side, roll soiled brief under the resident, change gloves, and apply clean brief. EI #4 was asked, what was used to clean a resident's perineal area during incontinent care. EI #4 replied, soap and water. EI #4 was asked, when should soap and water not be used to clean a resident during incontinent care. EI #4 replied, she could not think of a reason staff would not use soap and water. EI #4 was asked, what would the harm be when staff provide incontinent care without using soap and water or peri-wash. EI #4 replied, the possibility of infection.

Based on observation, interviews, and review of FUNDAMENTALS OF NURSING NINTH EDITION, the facility failed to ensure Employee Identifier (EI) #2, a Licensed Practical Nurse (LPN) did not place Resident Identifier (RI) #1's eye drop medication container in her pocket prior to administration. Once inside of RI #1's room, EI #1 placed the eye drop medication container on the resident's over-bed table without a barrier and she failed to wash and/or sanitize her hands before she put gloves on to administer RI #1's eye drop medication. This deficient practice RI #1, one of two residents observed for medication pass. Findings include: Page 445 of Chapter 29 titled Infection Prevention and Control of FUNDAMENTALS OF NURSING NINTH EDITION documented . Modes of Transmission . The major route of transmission of pathogens identified in the health care setting is the unwashed hands of the health care worker. Equipment used within the environment often becomes a source for the transmission of pathogens . During medication pass observation on 9/1/2020 at 3:59 PM, EI #2, an LPN placed RI #1's eye drop medication container in her scrub pocket prior to entering the resident's room. Once inside RI #1's room, EI #2 removed the eye drop medication container from her pocket and placed in on the resident's over-bed table without a barrier. EI #2 was also noted to put gloves on, without washing or sanitizing her hands prior to the administration of RI #1's eye drops. In an interview on 9/1/2020 at 7:07 PM, EI #2, an LPN was asked when she should wash or sanitize her hands during medication pass. EI #2 said before handling medications, before entering the room, before putting on and after taking off gloves and any time they become contaminated. EI #2 was asked where did she put RI #1's eye drop bottle prior to administration. EI #2 replied in her pocket. EI #2 was asked was her pocket clean. EI #2 stated no. EI #2 was asked where she put the container and cap when she entered RI #1's room. EI #2 said she put them on the bedside (over-bed) table with no barrier. EI #2 was asked should she have placed them there. EI #2 replied no, she should have placed a barrier between the container and the table. EI #2 was asked did she sanitize or wash her hands prior to putting on gloves to administer RI #1's eye drops. EI #2 said no. EI #2 was asked should she have sanitized her hands. EI #2 stated yes, because whatever she touched before she put her gloves on would have contaminated her hands before she put them on. During an interview on 9/1/2020 at 7:57 PM, EI #1, the Director of Nursing/Acting Infection Control Preventionist was asked when a nurse should wash her hands during medication pass. EI #1 said before they touch anything on the cart, before they put on and take off gloves, when visibly soiled, before and after administration, and after coming out of the room. EI #1 was asked where the eye drop container should be placed prior to administration. EI #1 replied on the barrier. EI #1 was asked should a nurse place an eye drop container in her pocket. EI #1 stated no. EI #1 was asked why not. EI #1 replied it was an infection control issue, because she does not know where the pocket had been. EI #1 was asked should a nurse place an eye drop container on an overbed table without a barrier. EI #1 said absolutely not, it should not have been placed there without a barrier to begin with because of infection control. EI #1 was asked should a nurse apply clean gloves without washing or sanitizing her hands. EI #1 replied no. EI #1 was asked what the concern was with the issues discussed. EI #1 answered infection control because of cross contamination.

Based on observations, interviews, record review, review of the 2017 U.S. (United States) Public Health Service Food Code, and review of a facility policy titled Hand Hygiene, the facility failed to ensure: 1) a Certified Nursing Assistant (CNA) washed hands when filling water pitchers with ice for Resident Identifier (RI) #s 35 and 100; and 2) CNAs did not touch food and utensils with bare hands when assisting RI #125 and RI #74 with meal set-up and/or feeding. These findings affected four of 157 total residents residing in the facility. Findings include: 1) A review of a facility policy titled, Hand Hygiene, with a revision date of 2/29/2020, revealed . 1) All personnel shall follow our established hand hygiene procedures to prevent the spread of infection and disease to other personnel, patients, and visitors. 2) Employees must perform hand hygiene procedures, either using an alcohol based hand rub or handwashing under the following conditions . After handling items potentially contaminated with . secretions . After removing gloves . RI #100 was readmitted to the facility on [DATE]. RI #35 was readmitted to the facility on [DATE]. On 03/10/2020 at 11:02 a.m., the surveyor observed Employee Identifier (EI) #1, a CNA, on Hall 500. EI #1 put gloves on both of her hands prior to entering RI #35's room, picked up RI #35's water pitcher from the bedside table, walked outside of RI #35's room with the water pitcher in her left gloved hand. EI #1 opened the lid of the ice chest with her right gloved hand, and picked up the ice scoop to fill RI #35's water pitcher with ice. EI #1 did not remove her gloves and wash or use hand sanitizer prior to entering or leaving RI # 35's room with the water pitcher. EI #1 reentered RI #35's room and placed the water pitcher on RI #35's bedside table. EI #1 did not remove her gloves or wash her hands prior to leaving the RI # 35's room. EI #1 then entered RI #100's room with the same gloves on from RI #35's room. RI #1 did not remove her gloves or wash her hands prior to entering RI #100's room. EI #1 picked up RI #100's water pitcher, walked out of RI #100's room with the water pitcher in her left gloved hand, opened the ice chest lid with her right gloved hand. EI #1 reentered RI #100's room with the same gloves on. EI #1 placed the water pitcher on the bedside table of RI #100 with her left gloved hand. On 3/10/2020 at 2:57 p.m., the surveyor conducted an interview with EI #1, a CNA. EI # 1 was asked what she should have done prior to leaving RI # 35's and RI #100's rooms with the water pitchers to fill them with ice, and prior to re-entering their rooms with the water pitchers. EI #1 stated she should have removed her gloves and washed her hands prior to leaving their rooms with the water pitchers and again before re-entering their rooms. EI #1 was asked what would be the concern if a CNA did not remove her gloves and wash or sanitize her hands when entering resident rooms and filling their water pitchers with ice. EI #1 stated it could cause contamination, illness, sickness, or infection to a resident or herself. On 3/10/2020 at 2:57 p.m., the surveyor conducted an interview with EI #2, Infection Control Preventionist/Director of Nursing/Registered Nurse. EI #2 was asked what should a CNA do prior to leaving a resident's room with the water pitcher to fill it with ice and prior to re-entering the resident's room with the water pitcher. EI #2 replied that she should have removed her gloves and washed her hands or used hand sanitizer. EI #2 was asked what would be the concern if a CNA did not remove her gloves and wash or use hand sanitizer on her hands. EI #2 stated the CNA could transport any kind of organism from one area to another or one resident to another resident. 2) The FDA 2017 Food Code included the following: . 3-301.11 Preventing Contamination from Hands . bare hand contact with ready-to-eat foods can contribute to the transmission of foodborne illness . critical factors in reducing food borne illness . no bare hand contact. . highly susceptible populations include persons who are immunocompromised . the elderly . may not use alternatives to the no bare hands contact with ready-to-eat food . RI #125 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #125's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed RI #125 had severe cognitive impairment and required extensive assistance of one person for eating. On 03/10/2020 at 11:56 a.m., the surveyor observed EI #5, CNA, pick up a piece of garlic bread with her bare hand and feed it to RI #125 during a meal observation in the dining room. An interview was conducted with EI #5 on 03/11/2020 at 02:30 p.m EI #5 was asked if she touched RI #125's garlic bread with her bare hands while feeding him/her lunch on 03/10/2020. EI #5 stated yes. EI #5 was asked if she continued to feed the resident the garlic bread after touching it with her bare hands. EI #5 stated yes. EI #5 was asked if she should have touched the garlic bread with her bare hands. EI #5 stated no. EI #5 was asked what the potential harm was in touching bread with her bare hands. EI #5 stated cross contamination. An interview was conducted with EI #2, Infection Control Preventionist/Director of Nursing/Registered Nurse, on 03/11/2020 at 6:25 p.m EI #2 was asked when should staff touch a resident's garlic bread with bare hands. EI #2 stated never. EI #2 was asked why should you not touch a resident's garlic bread with your bare hands. EI #2 stated you would not want to contaminate the resident's food with anything on your hands. EI #2 was asked should staff ever touch a resident's food with their bare hands. EI #2 stated no. EI #2 was asked what the potential harm is in touching bread with your bare hands. EI #2 stated cross contamination. RI #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #74's Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE], revealed RI #74 had severe cognitive impairment and required extensive assistance of one person for eating. On 03/11/2020 at 05:09 p.m., the surveyor observed EI #6 , A CNA, setting up a meal tray for RI #74. EI #6 was observed to take the paper wrapping off the straw and place it into RI #74's sweet tea touching the top of the straw with her bare hand. After RI #74 drank the tea, EI #6 was observed to place the same straw in RI #74's milk. An interview was conducted with EI #6 on 03/11/2020 at 05:58 p.m EI #6 was asked if she used her bare hands to put the straw in RI #74's sweet tea. EI #6 stated yes. EI #6 was asked if she should have used her bare hands. EI #6 stated no. EI #6 was asked why she should not have used her bare hands. EI #6 stated germs. EI #6 was asked what the potential harm is in touching the top of the straw that goes into the resident's mouth with your bare hands. EI #6 stated cross contamination.

Based on observations, interviews, record review, and review of a facility policy titled Hand Hygiene, the facility failed to ensure a Licensed Nurse did not use gloves that were placed on top of the vanity sink in Resident Identifier (RI) #39's room to administer RI #39's oral medication inhaler. Further, the Licensed nurse did not wash or sanitize her hands prior to putting on another pair of gloves. This affected one of four residents and one of three Licensed Nurses observed during medication administration pass. Findings include: A review of a facility policy titled, Hand Hygiene, with a revision date of 2/29/2020, revealed . 1) All personnel shall follow our established hand hygiene procedures to prevent the spread of infection and disease to other personnel, patients, and visitors. 2) Employees must perform hand hygiene procedures, either using an alcohol based hand rub or handwashing under the following conditions . After handling items potentially contaminated with . secretions . After removing gloves . RI #39 was readmitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. On 3/12/2020 beginning at 8:14 a.m., the surveyor observed EI #3, a Licensed Practical Nurse (LPN), during medication administration pass for RI #39. EI #3 applied gloves to her hands that had been placed on top of the vanity sink in RI #39's room prior to administering RI #39's oral medication inhaler. EI #3 did not wash or sanitize her hands after she removed her gloves and prior to putting on another pair of gloves, then administered RI #39's eye drops. On 3/12/2020 at 11:48 a.m., an interview was conducted with EI #3, a LPN. EI #3 was asked where did you get the gloves that you put on after you washed and dried your hands at RI #39's sink, and prior to administering RI #39's oral medication inhaler. EI #3 stated she picked the gloves up from the top of the vanity sink in RI #39's room. EI #3 further stated she should have put on a clean pair of gloves. EI #3 was asked why she put on the gloves from the top of the vanity sink in RI #39's. EI #3 stated she was nervous. When asked what the concern in this was, #3 stated it could cause cross contamination and could cause an infection to a resident or herself. EI #3 was asked what she should have done after giving RI #39's oral medication inhaler, prior to putting on another pair of gloves to administer RI #39's eye drop medication. EI #3 stated she should have washed or sanitized her hands because it could cause an infection to the staff, visitors, residents and herself. On 3/12/2020 at 12:16 p.m., an interview was conducted with EI #4, Director of Clinical Services. EI #4 was asked what would be the concern if a Licensed Nurse did not wash or sanitize her hands after she gave RI #39's oral medication inhaler, prior to putting on a new pair of gloves. EI #4 stated it was a potential for contamination. EI #4 was asked what would be the concern if a Licensed Nurse put on gloves from the top of the vanity sink in RI #39's room, prior to administering RI #39's oral medication inhaler. EI #4 stated it was a potential for contamination. EI #4 was asked what the facility's Hand Washing Policy stated should be done after touching the environment in a resident's room and after removing gloves. EI #4 stated you should perform hand hygiene.

Based on observation, record review, interview, and review of the facility policy titled Self Administration of Medication, the facility failed to ensure an order was in place in accordance with facility policy specifying Resident Identifier (RI) #31 could self-administer medication before a Licensed Practical Nurse (LPN) left medication at RI #31's bedside to be administered at a later time. This affected one of eight residents observed for medication administration. Findings include: Review of the facility's policy titled Self Administration of Medication, effective 7/05/2010, revealed the following: . General Guidelines 1) A resident may not be permitted to administer or retain any medication in his/her room unless so ordered, in writing, by the attending physician. 3) Should the resident's attending physician permit the resident to administer his/her medication(s), the following conditions will apply: a) The physician's order must be signed and dated prior to self-administration . RI #31 was admitted to the facility on [DATE]. Review of RI #31's 02/2019 PHYSICIAN ORDERS revealed no order for RI #31 to self-administer medications. On 02/06/19 at 12:34 PM, RI #31 was observed in his/her room eating lunch. A medication cup was observed sitting on the overbed table with three tablets and two gel caps . RI #31 stated, The nurse (Employee Identifier (EI) #5), Licensed Practical Nurse /LPN) left them for me to take. The Surveyor asked what the medications were, and RI #31 stated, [MEDICATION NAME], stool softener and Potassium. I guess I will take them after I eat. On 02/06/2019 at 6:18 PM, EI #5, LPN, stated the medication cup contained [MEDICATION NAME], Potassium, and [MEDICATION NAME]. When asked if RI #31 had been assessed to self administer medications, EI #5 said no. On 02/07/2019 at 5:24 PM, EI #1, the Director of Nursing (DON), stated RI #31 was not assessed for self-administration of medication. EI #1 further stated RI #1 also did not have a physician's order for self-administration.

Based on observation, record review, interviews, and review of Potter and Perry Fundamentals of Nursing, Ninth Edition, the facility failed to ensure Resident Identifier (RI) #71's intravenous (IV) access site was dated/timed and initialed. This affected one of two residents in the facility with IVs. Findings include: Review of Potter and Perry Fundamentals of Nursing, Ninth Edition, copyright (YEAR), Chapter 42, page 976, revealed the following: .Skill 42-1 INITIATING INTRAVENOUS THERAPY . Step . 24. Include date and time of IV insertion . and your initials . RI #71 was re-admitted to the facility on [DATE]. RI #71's (MONTH) 2019 Physician order [REDACTED]. On 2/05/19 at 10:45 AM RI #71's IV access site in the right hand was observed with no date anywhere on the IV or the tape that was in place to secure it. On 2/05/19 at 3:53 PM, Employee Identifier (EI) # 2, Registered Nurse (RN)/Infection Preventionist, stated the Licensed Practical Nurses (LPNs) and RNs were responsible for IV insertion. EI #2 further stated the IV access site should be labeled with the date it was inserted and the initials of the person that inserted it. EI #2 was asked to observe RI #71's IV access site, and was then asked if it was dated. EI #2 said it was not. EI #2 also confirmed RI #71's IV access site was not initialed by the person that inserted it. On 2/05/19 at 4:30 PM an interview was conducted with EI #6, an LPN. EI #6 said she administered RI #71's IV antibiotics on 2/05/19. EI #6 said she observed a clean dressing on RI #71's IV access site, but confirmed it was not dated. EI #2 said when she noticed the missing date, she should have changed the dressing, and dated and initialed it. EI #3, RN/Charge Nurse, was interviewed on 2/06/19 at 5:36 PM. EI #3 said the concern with not having a date on the IV access site, would be that staff would not know when it needed to be rotated. EI #3 said the facility's policy was to rotate the IV access site every three days.

Based on observation, interview, and review of a facility policy titled Hand washing, the facility failed to ensure a Licensed Practical Nurse (LPN) did not use her bare, wet hands to turn the water faucet off, after washing her hands, then return to the medication cart to continue medication administration. This was observed with one of three nurses observed during medication administration. Findings include: Review of the facility policy titled Hand washing, revised 11/28/2016, revealed the following: Policy: Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection . Procedure: .4. Hand hygiene when using soap and water: . f. Use towel to turn off the faucet. On 02/06/2019 at 4:54 PM, Employee Identifier (EI) #5, LPN, dispensed and administered three medications to Resident Identifier (RI) #79. EI #5 then washed her hands, but turned the faucet off using bare hands. After exiting RI #79's room, EI #5 returned to the medication cart to resume medication pass. On 02/06/2019 at 06:30 PM, during an interview with EI #5, LPN, the surveyor asked how she washed her hands after administering RI #79's oral medications. EI #5 said she turned the faucet off with her bare hands. EI #5 said the facility's policy said to turn the faucet off using a paper towel. The surveyor asked why that should be done. EI #5 said because there could be germs on the faucet. The surveyor asked what was the potential harm in turning the faucet off with bare hands after washing her hands. EI #5 said recontamination. EI #5 confirmed that she returned to the medication cart to resume medication pass after exiting RI #79's room. On 02/07/19 at 5:10 PM, EI #2, Infection Preventionist, was asked how hands should be washed. EI #2 discussed all of the steps involved in proper hand hygiene. EI #2 specified staff should use a paper towel to dry their hands, then discard that one. She said staff should then utilize another paper towel to turn the faucet off. EI #2 said staff should not use bare, washed hands to turn the faucet off, because it could contaminate their hands, and could pass germs on to the next patient.

Based on observations, a review of the (YEAR) Food Code, a review of the facility Dietary policy/procedure titled, Personal Cleanliness and Standards for Sanitation and staff interviews, the facility failed to ensure: 1. staff did not brace cylinders filled with eating utensils against their body and clothing during transport and 2. staff air dried the Robot Coupe mixer prior to storage and eating utensils were air dried prior to wrapping them in paper napkins for placement on trays. These deficient practices had the potential to affect all 159 residents who received meal trays from dining services. Findings include: 1. A review of the facility Dietary policy titled, Personal Cleanliness and Standards for Sanitation with a revision date of 11/28/16, revealed the following: Policy: Seven out ten poisonings caused by pathogens are due to poor hygiene of food handlers. Dietary personnel shall follow sanitary standards .Hand washing should follow any act that could possibly contaminate the hands. .7) After . touching unclean clothing . On 4/04/18 at 11:26 AM, Employee Identifier (EI) #4, a Dietary Assistant (DA) was observed to carry two cylinders filled with clean flatware braced against the body/clothing. The Dietary Manager, EI #3, at this time was asked what was the problem. EI #3 said there was a potential of physical contamination. 2. A review of the Food Code, U.S. (United States) Public Health Service and FDA (Food and Drug Administration) (YEAR) revealed the following: .4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried . On 4/04/18 at 4:22 PM, the Robot Coupe blender in the kitchen was observed stored on the stand with the lid cover on. Water was observed rolling downward. The Dietary Manager, EI #3, was asked what was the failure for the blender not to be air dried. EI #3 stated, a potential for bacterial growth.

Based on observation, record review, interviews, facility policies titled, Perineal Care and Standard Precautions, the facility failed to ensure a staff member changed her gloves and washed her hands during the provision of catheter care and incontinent care of Resident Identifier (RI) #77, a resident currently being treated for [REDACTED]. This affected one of two residents observed for incontinent care. Findings Include: A review of a facility policy titled, Perineal Care with an effective date of 12/19/07, revealed: . Infection Control Protocol and Safety 1. Wash your hands thoroughly with soap and water at the following intervals as indicated: a) Before the procedure; . d) When changing/removing gloves . before proceeding with procedure . A review of a facility policy titled, Standard Precautions with an effective date of 7/10/03, revealed: . Policy: Standard precautions will be used in the care of all residents . Standard precautions apply to ., body fluids, secretions, excretions, and contaminated items . Procedure: 1) Handwashing: a) Wash hands after touching . body fluids, secretions, excretions, and contaminated items . b) wash hands immediately after gloves are removed . Wash hands between tasks and procedures on the same resident to prevent cross-contamination . d) Use an antimicrobial agent or a waterless antiseptic agent . 2) Gloves: . d) Remove gloves promptly after use, before touching non-contaminated items . Wash hands immediately to avoid transfer of microorganisms . RI #77 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/26/18, revealed RI #77 was totally dependent on staff for hygiene, was always incontinent of bowel and had a suprapubic catheter. On 04/04/18 at 10:52 AM, foley supra pubic catheter care and incontinent care was observed for RI #77. Employee Identifier (EI) #2, Certified Nursing Assistant (CNA) entered RI #77's room to perform Foley catheter care and incontinent care. RI #77 stated the water in the basin was too cold with touch and EI #2 left the room to get wipes and to run more warm water into basin. EI #2 returned to the room and donned gloves without washing her hands. EI #2 began Foley catheter care. After EI #2 finished performing catheter care, RI #77's sheets and blankets were removed and changed. RI #77's heel protectors were removed and a clean sheet was placed on left side of bed. An underpad was rolled and placed under RI #77. RI #77 was placed on his/her right side where EI #2 provided care to RI #77's buttock area. EI #2 failed to change her gloves or wash her hands before she cleaned RI #77's buttock area. EI #2 placed Vaseline on her glove and applied it to RI #77's buttock area. A clean brief was placed under RI #77 and secured. RI #77 placed his/her arms inside a clean tee shirt and the resident was assisted to sitting and the shirt was placed over his/her head. EI #2 removed her gloves and failed to wash her hands prior to putting on new gloves. On 04/05/18 at 1:06 PM, a telephone interview was conducted with (EI) #2. EI #2 was asked what did the policy indicate about when hands should be washed when performing foley care and incontinent care. EI #2 said, when going into the room and when leaving the room. EI #2 was asked should hands have been washed during incontinent care and when gloves were changed. EI #2 said, yes. EI #2 was asked when did she wash her hands during incontinent care for RI #77. EI #2 said, when she left the room. EI #2 stated, she did not wash her hands when changing gloves but she washed them when she left the room. EI #2 was asked why did she not wash her hands during incontinent care and when gloves were changed. EI #2 said, she forgot. EI #2 was asked should she have washed her hands while providing care to RI #77. EI #2 said, yes. EI #2 was asked what was the importance of changing gloves and washing hands when providing care. EI #2 said, spreading of germs. On 04/05/18 at 1:30 PM, an interview was conducted with EI #1, Registered Nurse (RN)/Infection Control Nurse. EI #1 was asked what did the facility policy indicate when gloves should be changed and hands washed when providing incontinent care and Foley catheter care for a resident. EI #1 said, hands should be washed at the beginning of the procedure, when cleaning the resident after staff was done, take gloves off and wash hands. EI #1 further stated to wash hands when gloves were soiled and at the end of any procedure. EI #1 was asked what was the potential harm to a resident when hands were not washed and when gloves were not changed prior to placing a clean brief on the resident after incontinent care and foley care was provided. EI #1 said, hands were contaminated with germs and bacteria from changing the resident that could cause UTIs and other infections.

Based on observations, interviews, review of facility policies titled, DIETARY Sanitation Food Temperatures, DIETARY Sanitation Storage, DIETARY Sanitation Food Handling, a review of the Daily Temp Log and review of the Food Code, the facility failed to ensure: 1. milk and noodles temperatures were taken on the tray line during the lunch meal, 2. a food item was not expired in the dry storage , 3. food items in the freezer were labeled, 4. plates were free of black spots and bowls were free of water and 5. a dietary worker washed her hands after putting up a mop and before taking food out of the oven. This had the potential to affect 158 of 160 residents who receive meals from the kitchen. Findings Include: 1) A review of a facility policy titled, DIETARY Sanitation Food Temperatures with a revision date of 03/11/2005 revealed: .Policy: The dietary services manager or designee is responsible for seeing that all food is at the proper serving temperature (s) before trays are assembled . Guidelines: Record temperatures on temperature log or extended menu. A review of the DAILY TEMP LOG for the lunch menu on 5/17/2017, revealed there was no documentation for milk or the second pan of regular noodles. On 5/17/2017 at 11:05 a.m., the surveyor observed the Server, (Employee Identifier) EI #5 taking temperatures of the foods on the tray line. No one took the temperature of the milk or documented the milk temperature. On 5/18/2017 at 8:46 a.m., the surveyor conducted an interview with EI #5. EI #5 was asked who took the temperature of the milk on 5/17/2017. EI #5 replied, she forgot. EI #5 was asked who was responsible for taking temperatures. EI #5 replied, the server. EI #5 was asked when should milk temperatures be taken. EI #5 replied, before they start the tray line. EI #5 was asked where was it documented on the temperature log that it was taken on 5/17/2017. EI #5 replied, it was not documented because she forgot to take it. EI #5 was asked what did the facility policy say regarding temperatures on the tray line. EI #5 replied, 145 degrees F (Fahrenheit) on hot foods and 40 degrees F or below on cold foods. EI #5 was asked what was the potential harm when the temperature of the residents' milk was not taken. EI #5 replied, it could get bacteria in it and it could make the residents sick. On 5/18/2017 at 10:36 a.m., an interview was conducted with EI #4, Dietary Manager. EI #4 was asked who took the milk temperature on 5/17/2017. EI #4 replied, no one. EI #4 was asked what did the facility policy say regarding temperatures on the tray line. EI #4 replied, all temperatures should be taken on the tray line before serving. EI #4 was asked what was the potential harm when the temperature of the residents' milk was not taken. EI #4 replied, it could be too warm and not in the safe zone. EI #4 also said someone could get sick. On 5/17/2017 at 11:55 a.m., the surveyor observed the the server serving noodles from the second pan of noodles. No temperatures were taken of the second pan of noodles. On 5/18/2017 at 8:55 a.m., the surveyor conducted an interview with EI #5. EI #5 was asked who took the temperature of the second pan of noodle. EI #5 replied, no one. EI #5 was asked why not. EI #5 replied, neglect on her part. EI #5 was asked what did the facility policy say regarding temperatures on the tray line. EI #5 replied, everything was supposed to be tempted. EI #5 was asked who was responsible for taking temperatures on the tray line. EI #5 replied, the server. EI #5 was asked did she serve noodles from the second pan of noodles. EI #5 replied, yes ma'am. EI #5 was asked when should temperatures on the tray line be taken. EI #5 replied, before they served the food. EI #5 was asked what was the potential harm when residents were served foods and no temperatures were taken. EI #5 replied, if it was not at the right temperature, it could grow bacteria and could make the residents sick. On 5/18/2017 at 10:40 a.m., an interview was conducted with EI #4. EI #4 was asked who took the temperature of the second pan of noodles. EI #4 replied, no one. EI #4 was asked what was the potential harm when residents were served foods and no temperatures were taken. EI #4 replied, bacteria could grow in it and the resident could get sick. EI #4 was asked what food temperatures on the tray line should be taken. EI #4 replied, all foods on the tray line should be taken. 2) A review of a policy titled, DIETARY Sanitation Storage with an revision date of 05/19/2011 revealed: .Procedures: 1) .Expired food will not be used. On 5/16/2017 at 2:20 p.m., the surveyor along with EI #4, toured dry storage on initial tour. The surveyor observed a 16 fluid (fl) oz (ounce) container of light corn syrup with a best by date of 1/3/2017. On 5/18/2017 at 10:25 a.m., the surveyor conducted an interview with EI #4. EI #4 was asked what item in dry storage was out of date. EI #4 replied, syrup. EI #4 was asked why was it out of date in dry storage. EI #4 replied, it was over looked. EI #4 was asked who was responsible for removing expired items from dry storage. EI #4 replied, everyone in the kitchen. EI #4 was asked when should expired items be removed from dry storage. EI #4 replied, soon as staff found it. EI #4 was asked what was the potential harm when residents were served expired food. EI #4 replied, the residents could become sick. EI #4 was asked was the syrup out of date. EI #4 replied, yes ma'am. 3) A review of a facility policy titled, DIETARY Sanitation Food Handling with an effective date of 7/10/2003 revealed: .Procedure: . 8. Leftover foods are placed in containers. They are dated, labeled . On 5/16/2017 at 2:35 p.m., the surveyor along with EI #4, toured the freezer on initial tour. The surveyor observed ten chicken patties with no use by date or name of what it was. The surveyor also observed potato tarts with no name of what it was or a use by date. On 5/18/2017 at 10:33 a.m., the surveyor conducted an interview with EI #4. EI #4 was asked what items in the freezer had no label on it. EI #4 replied, chicken patties. EI #4 was asked did the potato tots have a use by date on them. EI #4 replied, no ma'am. EI #4 was asked what was the food items. EI #4 replied, potato tots and bread chicken patties. EI #4 was asked who was responsible for labeling. EI #4 replied, whoever used the items. EI #4 was asked when should items be labeled. EI #4 replied, before they were put back into storage. EI #4 was asked why should food items be labeled. EI #4 replied, so they would know what it was and the last day it could be used. EI #4 was asked what was the potential harm when residents were served food items out of the freezer with no information on it or when it was put there. EI #4 replied, they would not know what the ingredient was, it would not match with the menu and the food could be out of date and spoil. 4) A review of a policy titled, DIETARY Sanitation with an effective date of 7/10/2003 revealed: .Procedure: .6). All dish ware, .are effectively cleaned and sanitized by machine or manual dishwashing procedures. Dishes will air dry (if wetness noted, remove from circulations). On 5/17/2017 at 11:11 a.m., the surveyor observed nine bowls with water in them behind the server on a table and another 24 bowls with water in them. While EI #5 was serving food, the surveyor observed a black spot in two of the plates. EI #5 put food in one of the plates. On 5/18/2017 at 10:56 a.m., the surveyor conducted an interview with EI #4, Dietary Manager. EI #4 was asked who was responsible for washing bowls/dishes on 5/17/2017. EI #4 replied, the dietary aide. EI #4 was asked how should bowls be allowed to dry. EI #4 replied, bowls should be put on a drying rack, single stacked. EI #4 was asked why was there water in the bowls. EI #4 replied, they were not properly put up. EI #4 was asked did she observe a black spot in two plates on 5/17/2017. EI #4 replied, yes ma'am. EI #4 was asked did the server put food in one of the plates. EI #4 replied, yes ma'am. EI #4 was asked what was the black spot in the plates. EI #4 replied, she did not know. EI #4 was asked what was the potential harm when plates were not cleaned and given to the residents to eat from. EI #4 replied, bacteria on plates could get into the food and make someone sick. On 5/18/2017 at 11:10 a.m., the surveyor conducted an interview with EI #6, Dietary Aide/Dishwasher. EI #6 was asked how should dishes/bowls be allowed to dry. EI #6 replied, put on the shelf to air dry. EI #6 was asked why was water in the bowls. EI #6 replied, someone got the dishes off the shelf before they were dry. On 5/18/2017 at 11:22 a.m., the surveyor conducted an interview with EI #5 Dietary Server. EI #5 was asked did she observe spots in plates on 5/17/2017. EI #5 replied, yes ma'am. EI #5 was asked did she observe bowls with water in them. EI #5 replied, yes ma'am. EI #5 was asked what did the facility policy say regarding serving food in dirty plates or water in bowls to the residents. EI #5 replied, if she discovered dirty plates discard and do not serve food from them. EI #5 said if the bowls were wet do not use them. 5) A review of the Food Code with a date of 2013 revealed: . When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms .immediately before engaging in food preparation .clean equipment . (H) Before donning gloves to initiate a task that involves working with Food; .(I) after engaging in other activities that contaminate the hands. On 5/17/2017 at 11:05 a.m., the surveyor observed EI #7, the Cook, put items in the trash can and did not wash her hands (foil paper, tomato soup can, alcohol paper). EI #7 touched a box and the lining of the trash can. EI #7 continued to check the temperature of foods in the oven. EI #7 went into the dish room and put a mop away. EI #7 came back from the dish room and did not wash her hands. EI #7 put gloves and a cloth mitten on and removed food from the oven. EI #7 never washed her hands. On 5/18/2017 at 10:47 a.m., the surveyor conducted an interview with EI #4. EI #4 was asked should a worker wash her hands when leaving the dish room and coming back to food. EI #4 replied, yes ma'am. EI #4 was asked what was the facility policy on washing hands in the kitchen. EI #4 replied, wash your hands every time they come into contact with hair, trash and mopping. EI #4 was asked what was the potential harm when you did not wash your hands after putting up the mop and returning to remove food from the oven. EI #4 replied, germs spreading from hands to food area. On 5/18/17 at 12:00 p.m., the surveyor conducted a telephone interview with EI #7. EI #7 was asked did she take foil paper off food from the oven and alcohol prep paper and throw it in the trash. EI #7 replied, yes. EI #7 was asked did she leave the dish room and wash her hands before removing food from the oven. EI #7 replied, no. EI #7 was asked what was the facility policy on washing hands in the kitchen. EI #7 replied, anytime they contaminated their hands they were suppose to wash their hands. EI #7 was asked did she wash her hands after using a mop and returning back to the kitchen. EI #7 replied, no.

Based on observations, interviews and a review of a facility policy titled, Infection Control the facility failed to ensure: 1. laundry staff used PPE (Personal Protective Equipment) to load washers on the dirty side of the laundry room and 2. residents' linens, gowns, bed spreads and pads did not touch the laundry workers clothing and chin on the clean side of the laundry room. This was observed on 5/17/2017 and had the potential to affect 127 of 160 residents whose clothes were laundered by the facility. Findings Include: A review of a facility policy titled, INFECTION CONTROL General Laundry/Linen with an effective date of 7/10/03 revealed: .Purpose The purpose of this procedure is to provide guidelines for the proper handling, washing and storage of linen.Miscellaneous . 7. Employees sorting or washing linens must wear a gown/apron, gloves, . On 5/17/2017 at 9:10 a.m., the surveyor observed (Employee Identifier) EI #2 , Laundry Aide, unloading barrels into the washer with no PPE on. The surveyor observed EI #2 bending over in the barrel pulling out dirty clothes and her shirt touched the inside of the barrel. As EI #2 pulled sheets, gowns, pads and spreads out of the washer, the items touched her shirt. When EI #2 started folding the sheets, and spreads, they touched her shirt and under her chin. The pads and gowns touched her clothing. On 5/17/2017 at 9:10 a.m., the surveyor observed EI #3, Laundry Aide, as she loaded the washer and pulled clothes from the washer with no PPE on. EI #3 pulled sheets, pads, and gowns from the washer and dryer. The sheets, gowns and pads touched the top of EI #3's shirt. On the clean side, EI #3 folded sheets, pads and gowns and the items touched her shirt. On 5/17/2017 at 1:15 p.m. the surveyor conducted an interview with EI #3. EI #3 was asked when was she supposed to wear PPE in the laundry. EI #3 replied, when ever she was ready to load the washer. EI #3 was asked while folding, did sheets, gowns and pads touch her clothing. EI #3 replied, they touched her clothes. EI #3 was asked what did the facility policy say regarding staff wearing PPE in the laundry. EI #3 replied, when we pulled the barrel in we should have on PPE. EI #3 was asked what was the potential harm when the residents' pads, sheets and gowns touched her clothes. EI #3 replied, contaminating her clothes. EI #3 was asked did she have on an apron while putting dirty clothes in the washer. EI #3 replied, no ma'am On 5/17/2017 at 1:18 p.m., the surveyor conducted an interview with EI #2. EI #2 was asked when were she supposed to wear PPE in the laundry. EI # 2 replied, when going to the washer and touching linen. EI #2 was asked when folding clothes did sheets, gowns and spreads touch her clothes and under her chin. EI #2 replied, yes. EI #2 was asked what did the facility policy say regarding staff wearing PPE. EI #2 replied, when getting ready to touch dirty clothes wear PPE. EI #2 was asked what was the potential harm when sheets, spreads and gowns touched her clothes. EI #2 replied, contamination. EI #2 was asked did she have on an apron while putting clothes in the washer. EI #2 replied, no. On 5/17/2017 at 5:45 p.m. the surveyor conducted an interview with EI #1, Laundry Supervisor. EI #1 was asked when were workers supposed to wear PPE in the laundry. EI #1 replied, when loading the washer. EI #1 was asked what was the potential harm when resident's clothes touched the worker's clothes and the workers were not wearing PPE on the dirty side and folding on the clean side. EI #1 replied, contamination. On 05/18/17 at 1:33 p.m., the surveyor conducted an interview with EI #8, the Infection Control Nurse. The surveyor asked EI #8 should staff in the laundry use PPE Equipment. EI #8 said when going from dirty to clean they should. EI #8 said you did not want to pick up dirty laundry and then go to the clean clothes. The surveyor asked EI #8 what could it be considered when this was done. EI #8 replied, Cross contamination.

The facility failed to ensure a Certified Nursing Assistant (CNA) washed or sanitized her hands and changed her gloves after performing incontinent care and before placing a clean brief on Resident Identifier (RI) #3. This affected one of two sampled residents who were observed for incontinent care. Findings Include: A facility policy titled, Standard Precautions with an effective date of 7/10/03 indicated: Policy: Standard precautions will be used in the care of all residents . Procedure: . 1) Handwashing: a) Wash hands after touching . contaminated items . b) Wash hands after gloves are removed . 2) Gloves: . c) Change gloves between tasks and procedures. d) Remove gloves promptly after use, before touching noncontaminated items . Resident Identifier (RI) #3 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set with an Assessment Reference Date of 8/20/16 revealed RI #3 was totally dependent on staff for physical assist, impaired bilaterally to lower extremities and was always incontinent of bowl and bladder. On 9/7/16 at 1:34 p.m., an observation was made of incontinent care for RI #3. After RI #3's incontinent care, Employee Identifier (EI) #5 removed her left glove and reached inside of RI #3's bedside drawer and retrieved a barrier cream. EI #5 placed a new glove on her left hand and then applied barrier cream to RI #3's left buttock. EI #5 then placed a clean brief under RI #3. EI #5 then rolled RI #3 to the left side and cleaned and applied barrier cream to RI #3's right buttock. The soiled brief was removed and the clean brief was pulled into place between the resident's legs. The brief was secured. EI #5 did not wash her hands or change her gloves. On 9/9/16 at 10:38 a.m., an interview was conducted with EI #5, CNA. EI #5 was asked what was the facility's policy regarding when hands should be washed and gloves changed. EI #5 said, when soiled and when gloves removed. EI #5 was asked why she did not wash her hands or change her gloves, other than changing the left glove, during incontinent care. EI #5 said, she had sanitized her left hand after retrieving the barrier cream and again after pericare. Observation of surveyor discussed and reviewed. EI #5 contends she had sanitized her hands by the glove box when she retrieved a glove. EI #5 was asked what was the potential harm when hands are not washed or sanitized and gloves not changed before applying a clean brief. EI #5 said cross contamination. On 9/9/16 at 12:00 p.m., EI #2, Director of Nursing (DON) and EI #8, Corporate Nurse were asked to accompany the surveyor to RI #3's room for an observation of the hand sanitizer by the glove box or in the room. No hand sanitizer was found or observed. On 9/9/16 at 10:45 a.m. an interview was conducted with EI #6, Licensed Practical Nurse-Infection Control. She was asked when hands should be washed during incontinent care and gloves changed. EI #6 said, before going into the room, when taking the dirty diaper off, after barrier cream is applied, before the clean diaper is applied and when gloves were removed. Between dirty and clean, so you will not spread anything.

Based on interview and record review, the facility failed to ensure that Resident Identifier (RI) #1's Right BKA (Below Knee Amputation) incision site was documented clearly and concisely to include the presence of staples and the appearance of the incision site. This affected RI #1, one of four residents whose charts were reviewed. Findings include: Potter and Perry's, Fundamentals of Nursing, Eighth Edition, copyright 2013, Chapter 26, pages 348 to 349, document the following: .Documentation is anything written or printed on which you rely as record or proof of patient actions and activities. Documentation in a patient's medical record is a vital aspect of nursing practice. Nursing documentation must be accurate, comprehensive, and flexible enough to retrieve clinical data, maintain continuity of care, track patient outcomes, and reflect current standards of nursing practice. Information in the patient record provides a detailed account of the level of quality of care delivered to patients. Effective documentation ensures continuity of care, saves time, and minimizes the risk of errors . RI #1 was readmitted to the facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. RI #1's Significant Change Minimum Data Set with a reference date of 08/19/2016 documented RI #1 had surgical wound and was receiving surgical wound care. On 08/04/2016 a physician's orders [REDACTED].#1's right extremity at surgical site with wound cleanser, cover and wrap daily. A review of RI #1's physician's orders [REDACTED]. A review of RI #1's Nurses Notes from 08/03/2016 to 08/30/2016 revealed that RI #1 had a right BKA with a dressing and dressing change every day. None of the nurses notes documented the specifics about the right BKA such as appearance of incision site, staples or sutures, healing/not healing, drainage/no drainage. No where in the documentation does it show the resident had staples to the the incision site or how many. Documentation is not accurate or specific. On 09/08/2016 at 5:35 p.m., the surveyor interviewed Employee Identifier (EI) #1, the Wound Care Nurse. She stated she had assessed RI #1 on 08/04/2016, upon his return to the facility and had performed wound care. When EI #1 was asked about RI #1's right BKA site, she stated it was a clean incision with staples. (A review of EI #1's initial assessment of the incision site does not include a description of the incision or any mention of staples.) EI #1 stated the Registered Nurse (RN) on the Hall should have assessed the site on admission. On 09/09/2016 at 08:15 a.m., the surveyor interviewed EI #3, the RN who admitted EI #1. She stated she had done the initial assessment on RI #1 but had not removed the dressing to the right BKA site. EI #3 further stated that she had seen the incision site during a dressing change during RI #1's stay, prior to sending the resident to [MEDICAL TREATMENT]. She stated the incision had staples in it. When EI #3 was asked if staples and incision site should be documented, she stated yes. When asked if she had documented the staples or appearance of the incision site, she stated, no ma'am. When asked if the chart should include a description of the incision site, EI #3 stated yes, it needs to show what is going on and have a complete description of the incision. On 09/09/2016 at 10:05 a. m., the surveyor interviewed EI #2, Director of Nursing. She stated the initial assessment should include everything the nurse saw and should be documented. When asked what information should be included in an assessment of a resident with a surgical incision, EI #2 stated the assessment should include what the nurse saw when she looked at the incision area. When asked where was RI #1's surgical incision site documentation, EI #2 stated she could not find any. When asked why documentation should be clear and concise, EI #2 stated the documentation needed to paint an accurate picture of the resident.

Based on observation and interviews, the facility failed to ensure disposable razors were not left in an unlocked cabinet in a shower room. This affected one of 12 shower rooms at the facility, and had the potential to affect all residents using the shower room on Unit 1. Findings Include: On 04/06/16 at 3:27 p.m., the surveyor observed three disposable razors in an unlocked cabinet in a shower room on Unit 1. On 04/06/16 at 4:16 p.m., the surveyor conducted an interview with a Certified Nursing Assistant, Employee Identifier (EI) #4, who worked on Unit 1. The surveyor asked EI #4 where the disposable razors were kept. EI #4 said the disposable razors were kept in a supply closet. EI #4 said the closet had a code you had to enter to get into the room. The surveyor asked EI #4 should disposable razors be kept in the cabinets in the shower rooms. EI #4 said no. The surveyor asked EI #4 what was there a potential for when razors were not kept locked and away from the residents. EI #4 said the worst case scenario would be if a resident got the razor they could try to shave themselves or do bodily harm to themselves. On 04/07/16 at 8:07 a.m., the surveyor conducted an interview with EI #5, the Director of Clinical Services for Unit 1. The surveyor asked EI #5 where the disposable razors were kept. EI #5 replied, They are in a locked closet and you have to have a key to get in. When asked should the disposable razors be left in an unlocked cabinet in a shower room, EI #5 said no. The surveyor asked EI #5 what was there a potential for when razors were left out. EI #5 said the residents could cut themselves.

Based on observations, interviews and record review, the facility failed to ensure Resident Identifier (RI) #14 was provided supplements as ordered with each meal. This affected RI #14, one of 16 residents whose diet orders were reviewed. Findings Include: RI #14 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set assessment, with an Assessment Reference Date of 01/15/16, identified RI #14 to score a summary score of 12 on the Brief Interview for Mental Status, indicating moderately impaired cognition. RI #14's Physician order [REDACTED]. . DIET: Regular /add ice cream, PBJ (peanut butter jelly) sandwich, and sherbet all meals . A review of RI #14's Breakfast, Lunch and Supper meal tray cards documented: . Diet: Regular /add ice cream, PBJ sandwich, and sherbet all meals . On 04/06/16 at 11:41 a.m., the surveyor observed RI #14 eating lunch. There was no sherbet observed on RI #14's meal tray. The surveyor asked RI #14 was there any sherbet on the breakfast tray. RI #14 said no. On 04/07/16 at 7:46 a.m., the surveyor observed RI #14's breakfast tray. RI #14 had consumed 100% of the breakfast meal. There was no empty sherbet cup on RI #14's breakfast tray. On 04/07/16 at 7:50 a.m., the surveyor asked Employee Identifier (EI) #5, the Director of Clinical Services, was there sherbet on RI #14's breakfast tray. EI #5 said, no. On 04/07/16 at 8:07 a.m., the surveyor conducted an interview with EI #5. The surveyor asked EI #5 should RI #14 receive a sherbet and ice-cream with meals. EI #5 said RI #14 should. On 04/07/16 at 11:38 a.m., the surveyor observed RI #14 eating lunch. There was no ice-cream observed on RI #14's tray. On 04/07/16 at 1:22 p.m., the surveyor conducted an interview with EI #1, the Registered Dietitian. The surveyor asked EI #1 what type supplements did RI #14 received with his meals. EI #1 replied, Ice-cream, peanut butter and jelly sandwich and sherbet. The surveyor shared with EI #1 the surveyor's observations of RI #14's meals on 04/06/16 and 04/07/16. The surveyor asked asked EI #1 who was responsible for ensuring the dietary orders are followed. EI #1 said everyone who worked the tray line. EI #1 said they see the meal ticket with the diet order and know what to put on the tray.

Based on observations, interviews, record review and review of a facility policy titled Oral Medications, the facility failed to ensure Employee Identifier (EI) #6, a Licensed Practical Nurse (LPN) washed/sanitized her hands between administration of medications to Resident Identifier's (RI) #27, RI #28 and RI #29. This observation was conducted on 4/6/16, during the morning Medication Administration Observation. This affected one (1) of two (2) medication nurses and three (3) of four (4) residents observed during the Medication Administration Observation. Findings Include: Review of a facility policy titled Oral Medications, with a revision date of 05/23/11, documented: Purpose The purpose of this procedure is to provide guidelines for the administration of oral medications . Procedure: . Steps in the Procedure 1) Wash your hands thoroughly before beginning the procedure . RI #27 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. (1) On 04/06/16 at 8:40 a.m., during the morning medication administration observation, the surveyor observed EI #6 administer [MEDICATION NAME] 500 milligrams (MG) orally to RI #27. EI #6 returned to the medication cart and signed the Electronic Medication Administration Record (E- MAR). EI #6 failed to wash or sanitize her hands after this medication procedure. The surveyor observed a bottle of name brand hand sanitizer on top of the medication cart. EI #6 proceeded to pour medication for the next resident, RI #28. (2) RI #28 was originally admitted to the facility on [DATE] and readmitted on readmitted on [DATE], with [DIAGNOSES REDACTED]. On 04/06/16 at 8:45 a.m., during the morning medication administration observation, the surveyor observed EI #6 proceeded to pour medication for RI #28. EI #6 failed to thoroughly washed or sanitized her hands prior to this medication procedure. EI #6 poured [MEDICATION NAME] 500 MG one Tablet, Aspirin 81 MG one Tablet, [MEDICATION NAME] ([MEDICATION NAME]) 1 MG (2 Tablets), Folic Acid 1 MG Tablet , [MEDICATION NAME] 100 MG (3 Tablets ), Potassium Chloride ER (Extended Release) 20 MEQ (Milliequivalents) 2 Tablets, (40 MEQ) and [MEDICATION NAME] 100 MG tablet. EI #6 administered these medications to RI #28 orally. EI #6 returned to the medication cart and signed RI #28's E-MAR. EI #6 failed to thoroughly wash or sanitize her hands after this medication procedure. (3) RI #29 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 04/06/16 at 9:00 a.m., during the morning medication administration observation, the surveyor observed EI #6 prepare medication for RI #29. EI #6 failed to thoroughly wash or sanitize her hands prior to this medication procedure. EI #6 prepared the following medications: [REDACTED]. On 04/06/16 at 5:45 p.m., the surveyor conducted an interview with EI #6. The surveyor asked EI #6 what should she have done after giving medications to a resident. EI #6 said wash her hands or use hand sanitizer. The surveyor asked EI #6 what could happen if she did not wash her hands or use hand sanitizer. EI #6 said she could spread germs from one patient to another. The surveyor asked EI #6 if she washed or sanitized her hands during the medication administration this morning (4/6/16) between RI #27, RI #28 and RI #29. EI #6 said no sir. EI #6 said she got nervous and was not thinking. The surveyor asked EI #6 had she been inserviced on handwashing during medication administration. EI #6 said, yes sir, when she went through orientation. On 04/06/16 at 11:23 a.m., the surveyor conducted an interview with the DON (Director of Nursing), EI #7. The surveyor asked EI #7, should the nurses wash their hands before giving medications. EI #7 said yes, they would follow our hand washing policy. The surveyor asked EI #7 what should the nurses do after giving medications to a resident then prepare to give medications to another resident. EI #7 said typically we allow the nurse to sanitize their hands with alcohol sanitizer. The surveyor asked EI #7 where the alcohol sanitizer was kept. EI #7 said the nurses usually keep the sanitizer on the cart. The surveyor asked EI #7 what could happen if the nurses did not wash or sanitize their hands between residents during medication pass. EI #7 said the nurse could transfer infections if the patients/staff were to have any infection issues.

Based on observation, interview and record review, the facility failed to ensure Dietary staff prepared and served the pureed vegetable and starch as planned on the 04/06/16 lunch menu. This affected nine of nine residents for whom a pureed diet was ordered. Findings Include: The facility policy titled, Menu Planning (dated 07/10/03) specifies the following: Procedure: 1) Menus for regular and therapeutic diets are written at least two weeks in advance, and are dated and posted in the kitchen at least one (1) week in advance. 2) The dietitian shall approve all menus . 5) When an unexpected change is necessary, substitutions must provide equal nutritional value and be compatible with the rest of the meal while not compromising variety of food for the week . The pre-planned lunch menu for 04/06/16 consisted of: Pot Roast, Carrots/Potatoes/Onions, Rice Pilaf, Cornbread, Gooey Butter Cake, and Beverage. On 04/06/16 at 11:20 a.m., staff set up and served from each of the two trayline's (Rehabilitation Dining and the Main Kitchen), the planned lunch menu items for all but the pureed diets. Staff instead, prepared and served pureed Turnip Greens (in place of the Carrots/Potatoes/Onions) and Mashed Potatoes (in place of the Rice Pilaf). At 11:29 a.m., the surveyor asked the Registered Dietitian, Employee Identifier (EI) #1 why the pureed menu change had been made. EI #1 did not know. On 04/06/16 at 11:40 a.m., the Dietary Manager (EI #2) was questioned why Mashed Potatoes had been substituted for the Rice Pilaf. EI #2 explained the Rice would get lumpy/thicker than Mashed Potatoes when pureed, but she did not know why the Turnip Greens had been substituted for Carrots. The Cook , EI #3, was interviewed at 11:42 a.m. When asked why she had substituted the Greens, EI #3 explained the Carrots were frozen, thus difficult to puree at the time the blender (Robot Coupe) was available for use. EI #3 stated the Greens were canned (room temperature). EI #3 further explained they did not puree Rice because it would turn into clumps, which the residents did not like. On 04/07/16 at 9:00 a.m., EI #1, the Dietitian, was again questioned about the pureed menu changes. EI #1 accepted full responsibility, stating she should have over-seen the preparation; it was a mistake due to a lack of communication, but nutritionally comparable.

Based on observation, interview and record review, the facility failed to ensure the rooms of RI (Resident Identifier) #15, #20 and #22; and the rooms of unsampled resident #s: 1-7 were maintained in a home-like and personalized manner. This was observed on all 3 days of the survey, and affected 3 of 24 sampled residents, and 7 unsampled residents. Findings Include: The "Resident Handbook" (undated), specifies: "...III. YOUR RIGHTS AS A RESIDENT ...The facility strives to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect, in full recognition of his or her individuality." RI #15 was readmitted to the facility on [DATE]. RI #20 was readmitted to the facility on [DATE]. RI #22 was readmitted to the facility on [DATE]. UR (Unsampled Resident) #1 was readmitted to the facility on [DATE]. UR #2 was admitted to the facility on [DATE]. UR #3 was admitted to the facility on [DATE]. UR #4 was admitted to the facility on [DATE]. UR #5 was readmitted to the facility on [DATE]. UR #6 was admitted to the facility on [DATE]. UR #7 was readmitted to the facility on [DATE]. The following observations were made in the facility from 3/24/14 - 3/26/14: 1) During the initial tour of the facility on 3/24/15 at 8:30 AM, the following resident rooms were observed to have no personalization or home-like appearance: The rooms of RI #15, #20 and #22 were observed with no personal items. No pictures were hung on the wall, no personal decorative items were placed in the room. RI #22 had no curtains in the window and no blinds, only a curtain rod. The rooms of UR #1 - #7 were observed with no personal items, and no pictures on the walls. 2) A second observation was completed on 3/25/15 at 9:30 AM. The rooms of RI #15, #20 and #22 were observed with no personal items and no pictures on the wall. RI #22 also had no curtains in the window of the room. The rooms of UR #1 through #7 were observed with no personal items. No pictures were on the wall. 3) A third observation was completed on 3/26/15 at 9:00 AM. The rooms of RI #15, #20 and #22 were observed with no personal items and no pictures on the wall. The window in RI #22's room had no curtains, and no blinds. The rooms of UR #1 through #7 were observed with no personal items and no pictures on the wall. An interview was completed with the Social Worker (EI #7) on 3/26/15 at 9:25 AM. EI #7 was asked who was responsible for ensuring residents' rooms were home-like. EI #7 stated she was responsible and talked to the families at admission when a social history was completed. EI #7 was asked if she thought the rooms of RI #15, #20 and #22, and UR #1 through #7 were home-like, and were there personal items in the rooms. EI #7 stated the following about each of the residents' rooms: RI #15 had no family nearby. EI #7 stated she had asked the family to send items. EI #7 had spoken with RI #20's family twice about bringing items. EI #7 stated she felt the room was homelike. The facility had recently located family for RI #22 and were trying to get personalized items. EI #7 stated RI #22 did not complain about the room. EI #7 stated UR #1 lost things and it had been addressed with the family several times. EI #7 stated UR #2 and #3 used to have personal items in the room; there were no complaints from the residents or their families. EI #7 stated UR #4 had one picture in the room. EI #7 stated that UR #5 had no family. EI #7 stated she had spoken to the families of UR #6, and asked them to send items. EI #7 explained UR #7 was in a temporary room due to isolation status. EI #7 was asked who was responsible for personalizing a resident's room for those without a family. EI #7 stated she was currently working with activities to get pictures to make the rooms personal; this was started a couple of weeks ago. EI #7 explained the benefits of having a personalized room would be if the resident was confused, it could remind them who they were and where their room was located. EI #7 stated when a family would not bring personalized items, she would follow-up with them for several weeks to get the items. EI #7 was asked why the facility had not purchased items for the above residents' rooms. EI #7 stated they probably would, because this was a project she was working on. EI #7 was asked of the rooms they observed, did she feel they were home-like. EI #7 stated she felt the rooms were home-like, but could use work.

Based on observation record reviews and interviews the facility failed to ensure 1) (Resident Identifier) RI 7's oxygen filters were free of an accumulation of a dust like substance. This was observed on three days of the survey; 2) RI #10 received humidified oxygen and that RI #10's oxygen was administered at the prescribed 2 liters per minute. This was observed on two days of the survey. This affected two of four residents sampled for oxygen concerns. Findings Include: 1. A review of a facility policy titled "NURSING Oxygen Administration with a revision date of 7/25/07 reveals Policy:...Purpose The purpose of this procedure is to provide guidelines for oxygen administration....Equipment and Supplies...3) Humidifier bottle (>2/lpm) as applicable...Procedure:...9)turn on the oxygen. Unless otherwise ordered...11)Adjust the delivery...and the proper flow of oxygen is being administered...Supplies 2) Change humidifier bottle every seventy-two hours when in use..." RI # 10 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. A review of a facility document titles PHYSICIAN ORDERS [REDACTED]. On 3/24/2015 at 7:52 AM RI #10's oxygen was observed at 3 liters per minute and not humidified. On 3/25/2015 at 9:00 AM RI #10's oxygen was observed at 3 liters per minute and not humidified. On 3/26/2015 at 9:30 AM RI #10's oxygen was observed not humidified. On 3/26/2015 at 11:30 AM an interview was conducted with (Employee Identifier) EI #4, RN (Registered Nurse) Charge Nurse. EI #4 was asked can you tell me why RI #10's oxygen was not humidified. EI # 4 replied I checked and it did not say it had to be humidified. EI # 4 was asked if she could show surveyor RI #10's orders, together they reviewed the orders. EI #4 was then asked what was the potential for harm in not humidifying oxygen when administering to residents' with chronic conditions such as [MEDICAL CONDITION]. EI #4 replied, dryness of the respiratory tree and nasal passages, coughing and shortness of breath. EI #4 was then asked why was RI #10's oxygen deliver rate at 3 liters per minute for the last 2 days. EI #4 replied, to be honest I could not tell you I will try to find out. EI #4 was then asked what was the potential for harm in using a higher rate of oxygen than prescribed. EI #4 replied it could cause to become more dependant on oxygen, and the more oxygen a [MEDICAL CONDITION] resident uses the more damage it could cause. 2. A review of a facility policy titled "Oxygen Administration" with a revision date of 07/25/07 revealed the following: "...Procedure: 13) Check the mask, tank, etc,. to be sure they are in good working order..." RI #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a most recent MDS (Minimum Data Set) with a ARD (Assessment Reference Date) of 03/09/2015, revealed RI #7's BIMS (Brief Interview for Mental Status) score of 15, indicating resident is cognitively intact. A review of facility document titled "PHYSICIAN ORDERS" with a charting date of 3/20/15, revealed the following: "... Orders... 3/06/2015...2 L(liters) oxygen via nasal cannula continuous... 03/20/2015...RESPIRATORY TREATMENT: Change tubing/clean filter 1 x(time) wk(week). Sunday PM..." On 3/24/15, at 8:20 AM, during the initial tour of the facility, RI #7's O2 concentrator filter on each side of the concentrator cabinet was observed with an accumulation of a dust like substance. RI #7 was asked how often were the O2 filters cleaned. RI #7 explained that since being admitted and living in the facility for 6 weeks, the filters have not been cleaned. On 3/25/15, at 11:54 AM, RI # 7 was observed using O2. The surveyor observed RI #7's O2 filters, one filter on each side of the O2 concentrator cabinet, with an accumulation of a thick white dust like substance. On 3/26/15 at 8:58 AM, another observation was made of RI #7's O2 concentrator filters. Both filters were observed with a accumulation of a dust like substance. On 3/26/15 at 9:14 AM, an interview was conducted with EI #3, a registered nurse. EI # 3 was asked to observe RI #7's O2 concentrator filters and to describe what she saw on the filters. EI #3 explained that that it looks like dust. EI #3 was asked who was responsible for ensuring that O2 filters are to be cleaned. EI # 3 explained that the nurse on each shift should check to make sure that the O2 filters are clean. EI #3 was asked when were the O2 filters to be cleaned and or changed. EI #3 explained that they change the filters once a week on Sunday evenings. EI #3 was asked why should O2 filters be cleaned and or changed. EI #3 explained so purified air can come in and if dust particles are on them, it won't work. EI #3 was asked what was the potential harm in not cleaning or changing the O2 filters. EI #3 stated that the saturation will go down and they, the resident, wont be able to breath because the air won't be purified if the filter is completely clogged.

Based on interviews and record review, Employee Identifier (EI) #8, a Certified Nursing Assistant, failed to provide supervision to Resident Identifier (RI) #1, a resident with a history of Cerebral Vascular Accident (CVA) and right-sided weakness. RI #1 was admitted to the facility on [DATE] and assessed as being at high risk for falls. During the Occupational Therapist (EI #11)'s initial evaluation of RI #1 on 11/28/12, she recommended RI #1 be provided with contact guard assistance for balance. EI #11 stated contact guard assistance meant having your hands on the resident. EI #8, the CNA who assisted RI #1 with a shower on the morning of 11/29/12, stated she turned away from the resident to get a towel and when she turned back to the resident, RI #1 was on the floor. RI #1 was transferred and admitted to a local hospital for evaluation and treatment, with the following injuries: a head injury with laceration, a black eye, facial pain, facial lacerations, facial bone fractures, nasal bone fractures, facial swelling, facial bruising and a laceration to the corner of her mouth. This deficient practice affected RI #1, one of three sampled residents reviewed for falls. Findings include: On 12/04/12, the State Agency received a complaint via the hotline. The complainant stated RI #1 was admitted to McGuffey on 11/28/12 for short stay rehabilitation. The complainant alleged the aide, assisting RI #1 with a shower on the morning of 11/29/12, was on her cell phone and not tending to RI #1, which resulted in RI #1 trying to get up her on her own, falling and fracturing the bones in her face. According to the complainant, RI #1 had facial fractures to include the orbital area and sinuses and a gash in her head that required 15 stitches to close. RI #1's local hospital "In-patient Physical Therapy Evaluation" dated 11/27/12 indicated RI #1 had a [DIAGNOSES REDACTED]. According to this evaluation, contact guard assistance meant " ... Touch Assist for balance or to guide ... ." Mosby's Medical Dictionary 7th Edition with copyright date of 2006, page 601 indicates dynamic means " ... tending to change or to encounter change ... ." Page 1765 indicates static means " ... without motion, at rest ... ." Resident Identifier (RI) #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility's "Investigative Summary" dated 11/30/12 documented " ... (RI #1) ... was a resident of McGuffey Health and Rehab Center since 11/28/12 ... On 11/29/12 it was reported to administrations that an incident occurred while (RI #1) was receiving a shower. {Employee Identifier (EI) #8} CNA (Certified Nursing Assistant) was in the shower room on Rehab at 8:50 am November 29, 2012 showering (RI #1) when the incident occurred. (EI #8) CNA reports that (RI #1) was sitting on the shower chair and she was just finishing showering her. "I (EI #8) told her (RI #1) don't move and I (EI #8) turned to get a towel. That's when I (EI #8) heard her (RI #1) fall ... (EI #10) LPN (Licensed Practical Nurse) and (EI 12) RN (Registered Nurse) Clinical Nurse Manager both report that upon entering the shower room they observed (RI #1) lying on the shower room floor ... She (RI #1) was noted to have a laceration to the right side and middle of her forehead. There was also discoloration to (RI #1)'s nose and a cut noted to her lip ... (RI #1)'s physician ... was notified and orders to transport to (local hospital) for evaluation ... ." In a telephone interview with RI #1's sponsor on 12/11/12 at 4:50 PM, she stated she received a call about 8:55 (AM) stating her mother had fallen and was being sent to a local hospital. RI #1's sponsor stated her mother (RI #1) told her the girl (EI #8) was on her cell phone. According to RI #1's sponsor, EI #12 called her either that afternoon (11/29/12) or the next morning (11/30/12) and stated the facility had fired the assistant that had been with RI #1 when she fell . RI #1's sponsor stated she later met with the facility staff and they informed her there had been an investigation and the CNA was fired. According to RI #1's sponsor, she was told the CNA said she had turned to get a towel. In an interview on 12/12/12 at 9:25 AM, EI #4, a CNA, was asked where are the towels located in the shower room. EI #4 replied the towels are on a shelf behind the shower curtain and that you would have to take a few steps to get a towel. Contained within the facility's investigation file was a statement from EI #8 dated 11/29/12 12:37 PM, which documented " ... I (EI #8) was in the shower room with (RI #1). She (RI #1) was sitting on the shower chair ... I had just finished bathing her. I told her don't move and I turned to get a towel. That's when I heard her fall ... ." In a telephone interview on 12/12/12 at 12:40 PM, EI #8, the CNA who assisted RI #1 with her shower on 11/29/12, acknowledged she was assigned to care for RI #1 when she fell . When asked what happened, EI #8 stated she sat RI #1 in a wheelchair and rolled her to the shower. EI #8 stated she gave RI #1 a shower and told RI #1 to be still and not move. EI #8 stated when she turned to get a towel; RI #1 leaned up and fell . In an interview on 12/12/12 at 1:20 PM, EI #10, a LPN Charge Nurse stated she was at the desk, when a CNA came out and said RI #1 fell . According to EI #10, when she entered the shower room, she observed RI #1 on the floor bleeding and EI #8 was present with a towel in her hand. EI #10 stated she took the towel from EI #8 and used it to apply pressure to RI #1's head. EI #10 was asked if RI #1 told her what happened and she stated yes. According to EI #10, RI #1 told her she was trying to turn around and position herself when she lost her balance and fell over. On 12/12/12 at 1:20 PM, EI #9, a Physical Therapist (PT), was asked if he knew why RI #1 may have fallen. EI #9 stated that he didn't know about RI #1 specifically, but patients with a history of stroke (CVA) sometimes have an altered center of balance. When asked what would have been the PT's recommendation for the CNA giving RI #1 a shower, EI #9 stated he would have recommended the CNA keep a hand on RI #1, so the CNA would realize if RI #1 was moving when the resident may not realize it. During an interview on 12/12/12 at 1:25 PM, EI #11, the Occupational Therapist, stated she met RI #1 on 11/28/12 about 4:00 PM. EI #11 stated they (she and RI #1's family) discussed RI #1's prior level of function, what Occupational Therapy (OT) does and that a full evaluation would be done on 11/29/12. EI #11 stated she transferred RI #1 to an appropriate wheelchair with contact guard assistance for balance. EI #11 explained contact guard assistance meant having your hands on the resident. EI #11 stated she documented this and communicated it to EI #12, the RN Clinical Nurse Manager, who was also present in the room. EI #11 further explained as her standard of practice, she would have stayed at the side of the resident and would not have moved away to get a towel. RI #11's "Occupational Therapy Daily Treatment Encounter Notes and Weekly Summary" indicated an Occupational Therapy evaluation was initiated on 11/28/12. An interview was conducted with EI #12, the RN Clinical Nurse Manager on 12/12/12 at 5:00 PM. EI #12 stated she was present in RI #1's room when EI #11 (Occupational Therapist) asked the resident some questions and briefly assessed her upper (arm) and lower (legs) extremities. EI #12 stated she brought the Occupational Therapist in to talk with RI #1's family on 11/28/12 because the family had questions and the family wanted therapy to know that RI #1 was weak from her hospital stay and had only worked with therapy one time while in the hospital. EI #12 was asked what contact guard assistance is and she stated putting your hands on the person. When asked what caused the fall, EI #12 stated she didn't know and could only tell what the CNA (EI #8) told her. When asked what EI #8 said, EI #12 said EI #8 was done and she told RI #1 to sit, when she turned to get a towel that is when RI #1 fell . When asked if the CNA should have turned away from RI #1 to get a towel, EI #12 said no. When asked what could have prevented the fall, EI #12 stated if the CNA would have had her hands on the resident, she possibly could have prevented the fall or been a cushion for the resident. EI #12 was asked who is at the highest risk for falls and she stated the new resident. According to EI #12, RI #1 had been assessed as being high risk for falls by EI #13, a LPN Charge Nurse on 11/28/12. In an interview on 12/12/12 at 5:40 PM, EI #13, a LPN Charge Nurse was asked what RI #1's fall risk assessment is. EI #13 replied RI #1 had a high score of 13, which put her at high risk. Contained within the facility's investigation file is a typed statement signed by EI #19, the Director of Nursing (DON) which documented "On the date of 11/29/2012 at approximately 4:30 p.m. it was reported to me that C.N.A. (EI #8) had possibly been 'using her cell phone' while providing care to resident, (RI #1) "after showering her" on the date of (RI #1's) fall. (EI #8) was immediately interviewed regarding the allegation. She denied the allegation, becoming very tearful in the interview with Human Resources present. She stated she was not on her cell phone during anytime while showering (RI #1) and stated (RI #1) must have been confused with 'something else, such as the soap box she was holding after the shower'. She continued to say she had only turned around briefly to get a towel. She stated it was at that time that (RI #1) fell . Upon completion of the interview, (EI #8's) employment was terminated effectively immediately based on our standards of customer service." In a follow-up telephone interview with EI #8 on 12/12/12 at 6:00 PM, she was asked if she was on her cell phone while providing care to RI #1 and she said no. EI #8's "Counseling Record Form" dated 11/29/12 indicated EI #8's current infraction as job performance and the date of the infraction as 11/29/12. The form further indicated " ... Failure to provide appropriate care to resident while showering resident. Failure to provide quality customer service ... Employment terminated effective 11-29-12 ... ." During an interview on 12/12/12 at 7:05 PM, EI #14, the 7P - 7A LPN Charge Nurse stated she was told by EI #13 that RI #1 was a fall risk and required two person assistance. In an interview on 12/13/12 at 11:45 AM, EI #19, the Director of Nursing was asked what she thought could have prevented RI #1 from falling. EI #19 replied that the CNA should have never turned her back on the patient. In a telephone interview with RI #1 on 12/13/12 at 2:30 PM she was asked what happened in the shower. RI #1 stated she got up and fell . When asked where the CNA was, RI #1 stated the CNA was in the room standing over by the towels. RI #1 stated she couldn't remember if the CNA was facing her. According to RI #1, she stood up, took a few steps toward the CNA and fell . RI #1 stated she doesn't know why she fell on ly that she was weak. When asked if the CNA told RI #1 to sit still while she got a towel, RI #1 stated no she didn't remember that. RI #1's "Physician Orders" dated 11/29/12 documented "Send to (local hospital) ER (emergency room ) for eval (evaluation) due to fall ... ." RI #1's local hospital "History and Physical" with an admitted [DATE] documented " ... CHIEF COMPLAINT: Fall. HISTORY OF PRESENT ILLNESS: The patient (RI #1) ... who presented to the emergency room ... from McGuffey's Health Care, where she was at rehab ... She was in the shower with the aid when she fell face first from the upright position ... She was not being watched very closely. She had right-sided weakness from her previous admission. The patient states that she fell on to the right side. She sustained a head injury with laceration about 5 cm (centimeter). She had to have 15 sutures placed. She sustained a black eye along with fractures to her face ... Symptoms are moderate in intensity. Symptoms are exacerbated by falling, alleviated by nothing. Associated signs and symptoms include facial pain, facial lacerations, facial bone fractures, nasal bone fractures, facial swelling, facial bruising, right-sided weakness. Laceration at the corner of her mouth, fall ... PAST MEDICAL HISTORY: ... CVA (Cerebral Vascular Accident) ... REVIEW OF SYMPTOMS: ... MUSCULOSKELETAL: Positive for fall. Positive for weakness mainly on the right side ... IMAGING: ... 2. CT of the face showed left nasal bone fracture, nondisplaced, right anterior maxilla fracture, nondisplaced, right frontal scalp laceration, hematoma in the paranasal sinuses ... ." RI #1's local hospital "Discharge Summary" with an admitted [DATE] 9:24 AM documented RI #1 was discharged home with home health on 11/30/12, with the following Diagnoses: [REDACTED]. status [REDACTED]. Facial laceration ... ." This deficiency was cited as a result of the investigation of complaint/report number AL 995.

This deficiency is being cited as the result of an investigation into Complaint # AL 548. Based on observation, record review, and interview, the facility failed to notify the Medical Director/Attending Physician when RI #26 was returned to the facility after a failed attempt to discharge a resident to the home of the daughter. RI # 26 was discharged from the facility on 6/21/11 at 8:30 AM. She was returned to the facility by the ambulance company and the Emergency Medical Technicians (EMTs) were told they had no physician orders or Admission paperwork for readmission. The resident remained in the ambulance from 8:30 a.m. until 3:06 p.m. (greater than 6 hours) on 6/21/11. Per hospital records she was finally transported to a local hospital Emergency Department (ED) at 3:06 p.m. on 6/21/11. On 06/25/11 at 12:50 PM, the facility's Administrator, Director of Nursing (DON), Assistant Director of Nursing, Director of Assessment Services and Vice President of Care Services were notified that immediate jeopardy had been identified in the area of Resident Rights, F 157 at a "J" level surrounding RI #26's discharge from the facility on 6/21/11 at 8:30 a.m. The immediate jeopardy began on 6/21/11 and was relieved onsite on 6/26/11 at 6:55 p.m. with the scope and severity of the deficiencies being lowered to a "D" level to allow the facility time to monitor and revise their corrective actions as needed to achieve substantial compliance. This deficient practice affected RI #26, one of three sampled residents reviewed for appropriate discharge. Findings Include: The Facility Policy and Procedure titled, "Nursing Service Administrative Policies, Change in a Resident's Condition or Status Revision: 09/27/10" documented, "Policy: Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical. mental condition and/or status (I.e. transfer to hospital) Procedure: 1) The nurse supervisor/charge nurse will notify the resident's attending physician or on-call physician when there has been: a) An accident or incident involving the resident..." The hospital discharge summary dated 05/25/11 documented RI # 26 as "a pleasant [AGE] year old white female...for the treatment of [REDACTED]. RI # 26 was admitted to the facility after hospitalization on [DATE] with [DIAGNOSES REDACTED]. The most recent Admission Minimum Data Set ((MDS) dated [DATE] identified RI # 26 as scoring a "9" on the Brief Interview for Mental Status (BIMS) (scale of 8- 12 indicates moderately impaired) and totally dependent upon facility staff for Bed mobility, Transfers, Dressing, Toilet use, Bathing and Locomotion on/off the unit. RI # 26 was assessed as being incontinent of bowel and bladder. She also had range of motion limitation in a lower extremity and required the use of a wheelchair. She was identified as being at risk for pressure sores. A review of Physician written orders from 6/20/11 to 6/21/11 document the following: "...06/20/11 OK to evaluate and admit to (name of hospice agency)...06/20/11 (name of ambulance company) to pick up at 0730 AM 6/21/11...6/21/11 D/C (discharge) 6/21/11 with (name of hospice agency)." On 6/21/11 at 08:30 (a.m.) the ambulance company patient care report revealed they arrived (at the scene) at the nursing home. The report documents a time of 08:50 (a.m.) as the transport time with a destination arrival time of 08:58 (a.m.). The report documents the "Medical reason for TX (transfer) was, "Patient Discharge". On 6/21/11 at 1:04 PM, EMT # 1, was interviewed while the ambulance was back at the ambulance company (with the patient still on board) regarding the sequence of events surrounding RI # 26's transfer. During the interview she revealed the ambulance picked RI # 26 up from the nursing home at 8:30 AM. Upon arrival at the home of RI # 26's daughter/sponsor it was discovered that no one was home. After remaining at that site for one hour, the ambulance took RI # 26 back to the facility where EMT # 1 and EMT # 2 were informed the facility couldn't accept her back. The EMT said the next stop they made with RI # 26 was at the place of her former residence (an ALF). On 6/23/11 at 9:38 AM, EI # 5, a Marketing, Facility Liaison, Registered Nurse (RN) was interviewed. During the interview she revealed she was walking down the hall when she saw one of the ambulance attendants with RI # 26 on a stretcher around 9:00 a.m. to 9:15 p.m. EI # 5 was asked if she called the medical director. She replied, she did not. On 6/24/11 at 5:38 PM, EI # 5, the Marketing, Facility Liaison, Registered Nurse (RN) was interviewed again. During the interview she revealed she informed the administrator (EI # 3) that RI # 26 had come back in the ambulance. On 06/21/11 at 12:40 PM, the ambulance who was called to transfer RI # 26 was observed by the survey staff parked in front of the ALF. An ALF employee was interviewed and she revealed that the ambulance arrived at the ALF at 12:15 PM. On 06/21/11 at 12:52 PM, the surveyor called the ambulance company to find out where RI # 26 was enroute. The ambulance company reported that RI # 26 was at the station (and gave the address). The ambulance company manager was asked what was the plan. He replied he had not received instructions yet and that RI # 26 had been attended to by the same attendant (EMT # 1) since 8:30 a.m. He further stated he had been in touch with the facility, family, and Department of Human Resources (DHR) in attempts to get help. At the time of this interview (1:15 PM) RI # 26 was observed in the back of ambulance with EMT # 1. RI # 26 was interviewed and during the interview she told me her daughter (sponsor) was in Birmingham. The resident stated during this interview that the transfer made her feel horrible and like an idiot. On 06/21/11 at 1:16 PM, the facility Medical Director (Employee Identifier) EI # 1, was interviewed and made aware of the issue regarding RI # 26's discharge by telephone. He was asked if he had been contacted about RI # 26's discharge today. He stated he had not. He was asked if he was the medical director; he affirmed that he was. EI # 1 was asked what would you do if something like this happened. He revealed he would tell them (ambulance company) to take her back to the nursing home until the nursing home could come up with a discharge plan. On 6/25/11 at 12:20 p.m., EI #1 stated that he had contacted the on-call doctor to have her admitted to the hospital. EI #1 said that he had spoken to the facility's administrator (EI #3) and did offer to re-admit RI #26, but couldn't do it without McGuffey's authorization. EI #1 stated that RI #26 had no reason to be in the hospital but he didn't want to see her in the back of an ambulance. The on call doctor (EI # 2) was called on 06/21/11 at 1:25 PM. He was asked if the facility had called him regarding RI # 26 (name). EI # 2 revealed he did not know what was happening with RI # 26. The facility had not contacted him. He was asked if RI # 26 could be readmitted . EI # 2 replied that she could. On 06/24/11 at 2:53 PM, EI # 3, the administrator, wanted to discuss the the events that occurred with RI # 26 on 06/21/11. During the recap of events he revealed he discussed what to do with the Medical Director, EI # 1, after he (the Medical Director) had called to let me know he had been contacted by a lady from the state. At 3:30 p.m. on 6/21/11, a call was placed to the ambulance company to find out what happened to RI # 26. They revealed that RI #26 had been transported to a local hospital. The Hospital Physician's documentation, dated 6/21/11, revealed RI #26 "...presented to the Emergency Dept. at 1506 (3:06 p.m.) by (name of ambulance service). The patient was triaged at 1506 with the following vital signs: Temperature 99 (axillary) . . . exam time 1550 (3:50 p.m.). Clinical impression: acute pneumonia, Urinary Tract Infection, Acute [DIAGNOSES REDACTED] (mild), Bilateral lower extremity weakness...." ******************************************************** Credible Allegation of Substantial Compliance This letter is to establish a response to the statement of deficiencies given at the announcement of extended survey. This written statement constitutes a written allegation of substantial compliance with Federal Medicare and Medicaid guidelines. 1. This discharge issue has not reoccurred subsequent to education. (see policy 100-30-02) As of 6/25/11. 2. All current anticipated discharges were reviewed and discharge plan discussed with resident and/or resident representative/POA/Sponsor (whichever is applicable). 6/25/11 (see room list) 3. A Corporate Representative and the DON designee has educated Clinical Nurse Managers additional nursing staff (see list), social services, admissions department, and administration of physician notification of any failed discharge plan. 6/23/11 -6/25/11 4. The DON designee reviewed all anticipated discharges for compliance. 6/23/11 -6/25/11. DON will maintain audits for review. On 06/26/11 at 6:55 PM, after verifying in-service records and interviewing nursing staff, family and other residents the survey team concluded the facility implemented corrective measures as described in their Credible Allegation of Substantial Compliance provided to the survey team on 06/26/11 at 6:55 PM to prevent further occurrence. The immediate jeopardy was relieved on 06/26/11 at 6:55 PM and the scope and severity was lowered to a "D" level, to allow the facility time to monitor and revise corrective actions as needed to establish substantial compliance with F 157.

This deficiency is being cited as the result of an investigation into Complaint # AL 548. Based on observation, record review, and interview, the facility failed to arrange for Resident Identifier (RI) #26 to be safely and orderly discharged out of the facility to her daughter's home on 06/21/11. The paramedics returned to the facility with RI #26 and reported that the family was not at home to receive the resident. For over 6 hours, the resident stayed in the ambulance on a stretcher, with nowhere to go from 8:30 AM until 3:06 PM. On 06/25/11 at 12:50 PM, the facility's Administrator, Director of Nursing (DON), Assistant Director of Nursing, Director of Assessment Services and Vice President of Care Services were notified that immediate jeopardy had been identified in the area of Admission, Transfer and Discharge, F 204 at a "J" level surrounding RI #26's discharge from the facility on 06/21/11 at 8:30 AM. The immediate jeopardy began on 06/21/11 and was relieved onsite on 06/26/11 at 6:55 PM, with the scope and severity of the deficiencies being lowered to a "D" level to allow the facility time to monitor and revise their corrective actions as needed to achieve substantial compliance. This deficient practice affected RI #26, one of three sampled residents reviewed for appropriate discharge. Findings Include: RI #26, after a lengthy hospitalization , was admitted to the facility with [DIAGNOSES REDACTED]. The hospital discharge summary, dated 5/25/11, documented RI# 26 was " a pleasant [AGE] year old lady . . . for treatment of [REDACTED]. . . examination shows a frail, elderly, mildly confused white female . . . very weak, appetite still poor . . .. There are no skin issues . . . had an episode of chest pain . . .. " The Admission Minimum Data Set ((MDS) dated [DATE] identified RI #26 as scoring a "9" on the Brief Interview for Mental Status (BIMS) (scale of 8-12 indicates moderately impaired) and totally dependent upon facility staff for bed mobility, transfers, dressing, toilet use, bathing, and locomotion on/off the unit. RI #26 was assessed as incontinent of bowel and bladder. She also had a range of motion limitation in a lower extremity and required the use of a wheelchair. RI #26 was identified as being at risk for pressure sore development. On 6/21/11 at 11:35 a.m., a call was received by state surveyor from the local Ombudsman office. The call was to inform the state surveyor of an incident that was occurring while the surveyors were in the facility. The report had to do with an inappropriate discharge of a resident, (RI #26). The Ombudsman stated RI #26 was discharged from the facility on 6/21/11 at 8:30 a.m. and she was still in the ambulance. The ambulance "Patient Care Report", # , dated 6/21/11, documented an arrival time at the facility of 8:30 a.m. for transport of "patient to residence...Nurse stated upon our arrival she (the resident) was going to daughter's home for care - she would be there upon our arrival... Note on door advising someone she went to Birmingham, we advised dispatch - we were told to hold on scene...after some time on scene asked to take to McGuffy's 'til arrangements made." An additional page of narrative documentation revealed "patient is transported back to McGuffy Health Care...upon our arrival told to take her to the ER (emergency room ) at (name of hospital), nowhere else to take her because she has been discharged ...waiting on scene...for decision. Taking patient to parking area to wait." The Emergency Medical Technician (EMT) #1 confirmed in an interview on 6/21/11 at 1:04 PM that the ambulance parked under trees (in the hospital parking lot). A second "Patient Care Report" # , with a date of service of 6/21/11 documented: ..." we took her back to McGuffey's and they declined to keep pt (patient) 'til family returned. Stated to take to ER for no reason than no one to tend to her. Pt is verbal but has dementia . . . McGuffey's new (knew) there were problems with paperwork and care prior day . . . pt was kept in truck . . . pt taken to (assisted living facility) . . . pt kept in truck til . . . was able to get pt to ER bed with [DIAGNOSES REDACTED]. " On 6/21/11 at 1:04 p.m., EMT #1 was interviewed regarding the sequence of events surrounding RI #26's ambulance ride and time spent waiting in the parking lot. During the interview, she revealed the ambulance picked up RI #26 at 8:30 a.m. Upon arrival at the home of RI #26's daughter, no one was home. The ambulance took RI #26 back to the facility after waiting for approximately one hour. EMT #1 and EMT #2 were told the resident had been discharged and the facility had no physician orders or admission paperwork. The next stop they made with RI #26 was at the place of her former residence prior to hospitalization (an ALF), where they were unable to accept RI #26. She revealed they (EMTs and RI #26) returned to the shop (base) to await further instructions. During this interview (1:04 p.m.), RI #26 was observed in the back of the ambulance with EMT#1. RI #26 was interviewed and she stated her daughter (sponsor) was in (name of city). RI #26 was asked if her daughter had room for her at her home. RI #26 replied, " No..." She also stated that due to her daughter's husband's illness that they had to go to Birmingham 2 times a month. She stated she had a great grandson who is sick and her daughter is taking care of him. She was asked if anyone at the nursing home told her where she was going today. She replied, "No." She was unable to recall if she was going to the daughter's home. On 6/24/11 at 8:53 a.m., the ambulance manager was interviewed. He was asked what he was told about the facility not taking RI #26 back when the ambulance returned her to the facility. The administrator (EI#3) told the ambulance manager that RI #26 could not be accepted back into the facility because he needed an MD (medical doctor) order to take the resident back and suggested that RI #26 be taken to the local hospital's emergency room . The ambulance manager stated that he came to the facility to talk to EI#3 between 9:20 and 9:40 a.m. On 06/24/11 at 5:38 p.m., EI #5, the Marketing Facility Liaison, stated: "I saw the ambulance paramedics with Mrs. (RI #26) on the stretcher in the hallway." When asked if she had spoken with the paramedics, EI #5 affirmed that she did. According to EI #5, the paramedics informed her that RI #26 was being returned because there was a note (where they tried to take the resident). This note said that the family had gone to Birmingham. EI #5 said that she informed the social worker and the administrator. On 6/21/11 at 12:40 p.m. the surveyor observed the ambulance, with RI #26 inside. The ambulance was located in front of the Assisted Living Facility (ALF) where the resident had once resided. A care worker at the ALF was interviewed and she revealed that the ambulance arrived at the facility at 12:15 p.m. In an interview on 6/24/11 at 1:40 p.m., the ALF Director stated RI #26 had been admitted to the ALF in June 2010 and she had to be discharged on [DATE] to a local hospital. She further stated that prior to the hospitalization and admission to the nursing home on 5/26/11, RI #26 was able to walk with a walker. The ALF Director also said she told the facility last week that RI #26 could not return to the ALF as she was not suitable for placement. A facility social services note dated 06/15/11; 4:59 p.m. documents: "...: This sw contacted (son's name) re: d/c plan. (Son) has decided on LT (Long Term) care after the administrator at the (name of assisted living facility) came to evaluate RI #26 on 6/13...." On 6/21/11 at 12:52 p.m., the state surveyor called the ambulance service to find out where RI #26 was. They reported that the ambulance had returned to base (shop). The ambulance manager was asked what was their plan. He revealed that he had not gotten instructions yet and that RI #26 had been attended to by the same attendant (EMT#1) since 8:30 that morning. He further revealed he had been in touch with the facility, family, and Department of Human Resources (DHR) in attempts to get help. At 1:16 p.m. on 6/21/11, the state surveyor contacted the facility Medical Director (EI #1) by telephone. He was asked if he had been contacted about RI #26's discharge today. He reported that he had not been called by the facility today and that he was out of town. He further stated he had another doctor on call for him. EI#1 was asked what he would do if something like this happened. He replied he'd tell them (the ambulance company) to take her back to the nursing home until the nursing home could come up with a discharge plan. On 6/25/11 at 12:20 p.m., EI#1 (Medical Director) stated he had contacted the on-call doctor to have her admitted to the hospital. EI#1 said he had spoken to the facility administrator (EI#3) and did offer to re-admit RI #26, but couldn't do it without McGuffey's authorization. EI #1 explained that RI #26 had no reason to be hospitalized ; but, he (EI #1) didn't want to see the resident in the back of an ambulance. The Hospital Physician's documentation, dated 6/21/11, revealed RI #26 "...presented to the Emergency Dept. at 1506 (3:06 p.m.) by (name of ambulance service). The patient was triaged at 1506 with the following vital signs: Temperature 99 (axillary) . . . exam time 1550 (3:50 p.m.). Clinical impression: acute pneumonia, Urinary Tract Infection, Acute [DIAGNOSES REDACTED] (mild), Bilateral lower extremity weakness...." ************************************ Credible Allegation of Substantial Compliance This letter is to establish a response to the statement of deficiencies given at the announcement of extended survey. This written statement constitutes a written allegation of substantial compliance with Federal Medicare and Medicaid guidelines. 1. Written notice of discharge revised. 6/25/11 2. Written notice of discharge was delivered to each resident and phone confirmation of discharge completed 6/25/11. delivered by (names of facility staff) 3. A Corporate Representative and the DON designee have educated Clinical Nurse managers, additional nursing staff, social services, admissions department and administration to ensure resident, sponsor, and /or POA receives written advanced notice of intended discharge date , in a timely (72 hour) manner as to allow for the opportunity of appeal and or to find other suitable living arrangements for resident. 6/23/11-6/25/11 4. The DON designee reviewed all anticipated discharges for compliance. 6/23/11-6/25/11. DON will maintain audit for review... A Corporate Representative interviewed facility social workers to ensure that any current discharge planning issues were identified and were appropriately addressed. Social Workers and nurses followed up with each resident representative 6/25/11... A Corporate Representative and Licensed Bachelor of Social Worker (LBSW) had educated social services to ensure a Licensed Social worker/designee will plan for alternate placement for any resident if evaluation by outside entity fails to be a valid placement for any resident or family voices concerns of an inability to accommodate the resident's needs in their home 6/25/11... The administrator and social worker were suspended from employment on 6/26/11... On 06/26/11 at 6:55 PM, after verifying in-service records and interviewing nursing staff, family and other residents the survey team concluded the facility implemented corrective measures as described in their Credible Allegation of Substantial Compliance provided to the survey team on 06/26/11 at 6:55 PM to prevent further occurrence. The immediate jeopardy was relieved on 06/26/11 at 6:55 PM and the scope and severity was lowered to a "D" level, to allow the facility time to monitor and revise corrective actions as needed to establish substantial compliance with F 204.