Every finding on record at Moundville Health and Rehabilitation, LLC

Based on interviews, record review, review of the facility's investigative file for the incident involving Resident Identifier (RI) #1 on 11/25/2022, and the facility's policy titled,Fall, the facility failed to ensure Employee Identifier (EI) #4 Certified Nursing Assistant (CNA) followed the Fall policy on 11/25/2022 when, per EI #4, she found RI #1 on the floor and moved RI #1 from the floor and onto the bed without alerting the nurse to assess RI #1's condition. This deficient practice affected RI #1, one of three residents sampled for falls. Findings include: A review of the facility's policy titled, Fall with an effective date of 11/01/2001 revealed: . PURPOSE: To provide emergency care after a fall and prevent further injury . PROCESS: 1. Do not move resident until the charge nurse has assessed the resident's condition . 3. Ascertain extent and type of injury . RI #1 was admitted to the facility on [DATE] with diagnoses to include: Cerebral Infarction, Aphasia following Cerebral Infarction, and Dementia. RI #1's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date of 10/31/2022 documented a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated RI #1 had severe cognitive impairment. The State Agency received a facility reported incident on 11/25/2022 that described an injury of a bruise to RI #1's eye and RI #1 had just had a fall. The report included actions the facility had taken to include a body audit was performed on RI #1 and EI #4 was suspended. The facility investigative file for the incident involving RI #1 contained documents to include the following: A typed facility witness statement dated 11/28/2022, signed by EI #4 CNA, documented: . On 11/25/22 at around 7:40 am I walked into resident . (RI #1's) . room and I saw . (RI #1) on the floor leaning against the chair . I then went and got . (RI #1) . off the floor. I was not thinking and acted off instinct; I did not report the fall. I know to report the fall to the nurse . I got resident . (RI #1) . up and sat . (him/her on his/her) bed to start eating and . (RI #1) said, No, no I should not be doing that; its not right. I then said again come on its food, its grits you have to try it. At that point ADON (Assistant Director of Nursing/EI #3) was coming up the hall and and that's when ADON . said no don't feed .(him/her if he/she) is not wanting to eat. At that point, . (RI #1's) eye started to swell and I left the room. The facility VERIFICATION OF INVESTIGATION for the incident dated 11/25/2022 contained a summary and outcome of the investigation that documented the facility terminated EI #4 due to several factors such as failure to report the fall or to follow fall protocol, and the injury to RI #1's eye. The summary also documented that while EI #3 was checking with RI #1, since RI #1 did not want to eat, it was then that EI #4 told EI #3 that RI #1 had a fall. RI #1 was assessed, a body audit was done and RI #1 went out for a CT (Computerized Tomography) to ensure there was no other injury to RI #1's head. RI #1's Resident Incident Report dated 11/25/2022, prepared by EI #3, documented: . Narrative of incident and description of injuries: CNA reports that resident was on the floor lying on . (his/her) right side and facing bathroom door when she walked by. CNA reports she got resident off floor and transferred . (him/her) to bed . Right eye swollen shut and has dark purple bruising . Body audit done, Placed on one on one, Notified administrator . Physician notified . Family notified . On 12/13/2022 at 9:09 AM, an interview was conducted with EI #4 CNA. EI #4 was asked about the injury to RI #1's eye. EI #4 said when she entered RI #1's room, RI #1 was on the floor against the chair in the room, so she got RI #1 up and sat RI #1 on the bed. EI #4 admitted that she received training about the fall policy and when RI #1 was found on the floor she should have called for the nurse, but she did not call for the nurse. When asked why she did not call for the nurse, EI #4 said, it was her fault because she was moving fast to get RI #1 up off the floor to start feeding RI #1 so she could go to her next resident. EI #4 was asked what was the concern with not following the fall policy. EI #4 said the current situation that was going on, an investigation and an injury which was bruising to RI #1's eye. On 12/14/2022 at 12:11 PM, an interview was conducted with EI #3, ADON. EI #3 was asked how she became aware of the incident on 11/25/2022 when RI #1 sustained a right eye injury. EI #3 said, she was walking down the hall and when she got close to RI #1's room she observed EI #4 assisting RI #1 with breakfast. EI #3 said EI #4 told her RI #1 had a fall and EI #4 moved RI #1 from the floor to the bed and started to feed RI #1. EI #3 said she told EI #4 that was not what she was supposed to do, she was not supposed to move RI #1, and she was supposed to call the nurse. EI #3 was asked to describe the injury to RI #1's right eye. EI #3 said, as she was talking with RI #1, she observed as RI #1's right eye changed colors, it was a dark purplish bruise and RI #1's eye became swollen and shut. EI #3 said the injury to RI #1's eye indicated that some type of trauma had occurred recently. EI #3 said she told EI #4 to leave the room, she called the administrator from her cell phone, then EI #4 was suspended, an investigation was started, the family and nurse practitioner were notified and RI #1 was sent to the hospital for evaluation. EI #3 was asked according to the facility's fall policy, what should EI #4 have done when she found RI #1 on the floor. EI #3 said, EI #4 should have immediately called for a nurse and she was not supposed to move the resident. EI #3 was asked if the fall policy was followed. EI #3 replied, no, the fall policy was not followed and EI #4 was told she did not follow the fall policy. EI #3 was asked what was the purpose of not moving the resident when found on the floor. EI #3 said, a CNA cannot assess a resident so the nurse has to do an assessment for injuries. EI #3 was asked what was the potential harm when RI #1 was found on the floor and EI #4 got RI #1 up without notifying the nurse. EI #3 said, you do not know what injuries a resident has; RI #1 could have had a fracture. On 12/14/2022 at 4:34 PM, an interview was conducted with EI #1, Administrator. EI #1 said she found out about the incident with RI #1 on 11/25/2022 that morning when EI #3 ADON called her from RI #1's room and said RI #1's eye was starting to swell. EI #1 said it was while she was on the phone with EI #3, that EI #4 said RI #1 had a fall and EI #4 had picked up RI #1 off the floor. EI #1 said EI #4 was sent home and suspended, pending investigation. EI #1 further stated, EI #4 admitted she was aware of the fall policy and that she was supposed to immediately report it to the the nurse, but she did not report it immediately to the nurse. EI #1 said the fall policy was not followed. EI #1 said the concern with EI #4 not reporting immediately to the nurse was that the resident could have been injured and they could not address the resident injuries immediately. EI #1 said, EI #3 stepped in and assessed the resident, sent RI #1 out to the hospital for a CT scan immediately and completed an incident report. On 12/15/2022 at 10:24 AM, an interview was conducted with EI #2, Director of Nursing (DON). EI #2 was asked how she become aware of the incident that happened with RI #1 on 11/25/2022. EI #2 said she was off when the incident occurred, but EI #3 called and gave her an update on what happened and that EI #4 had not immediately reported when RI #1 had a fall. EI #2 said, an investigation was immediately started, RI #1 was placed on one to one, EI #4 was suspended and escorted from building. EI #2 said, when she returned to work on 11/28/2022 she observed RI #1's eye with minimal swelling and green bruising around the right eye into the cheek. EI #2 said, that indicated some type of injury. EI #2 said, EI #4 should have immediately called for a nurse before moving RI #1. EI #2 said, the fall policy was not followed but it should have been to ensure there were not any injuries that could further harm the resident.

Based on resident record review, interviews, review of CMS (Centers for Medicare and Medicaid Services) training titled Hand in Hand: A Training Series for Nursing Homes, and review of a facility investigative file for Resident Identifier (RI) #1, the facility failed to ensure Employee Identifier (EI) #4 Certified Nursing Assistant (CNA) provided care and assistance appropriate for RI #1, a resident who had a diagnosis of Dementia, and per EI #4, had just been found on the floor. This occurred during the breakfast meal on 11/25/2022 when EI #4 was attempting to feed RI #1 while RI #1 was resisting. This affected RI #1, one of three sampled residents who had diagnoses of Dementia. Findings include: An undated CMS (Centers for Medicare and Medicaid Services) TOOLKIT titled Hand in Hand: A Training Series for Nursing Homes, was provided for review and was presented as guidance and training the facility staff received. Included in this documentation was the following: . Mission The mission of the Hand in Hand training is to provide nursing homes with a high-quality training program that emphasizes person-centered care for persons with dementia and abuse prevention. Learning Objectives and Key Points . Module 1. Symptoms of dementia include challenges with memory, concentration, orientation, language, . skills, . The actions and reactions of persons with dementia are related to one or more of these challenges. Delirium caused by a new or worsening medical problem may cause increased confusion or problems with thinking and functioning, especially in residents with dementia. It is very important to notify the nurses so that they can assess the resident further. We must try to understand their experience by being with them in their world. Seeing things from their perspective helps us to understand the frustrations and confusion they experience. It also helps us to recognize that we must adjust the way we act, and interact, to meet their needs. Module 2. Effective strategies for communicating with persons with dementia include: Always identify yourself. Really listen to the person. Pay attention to the body language of the person with dementia. Be patient. Give the person enough time. Ask how you can help. When we take time to communicate effectively, we save time and reduce stress in our work environment. RI #1 was admitted to the facility on [DATE] and had diagnoses to include: Legal Blindness, Cerebral Infarction, Aphasia following Cerebral Infarction, and Dementia. RI #1's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date of 10/31/2022 documented a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated RI #1 had severe cognitive impairment. RI #1's Departmental Notes documented the following: . 11/25/2022 . CNA reported that when she was passing resident's room resident was on the floor . CNA reported she got resident off floor and transferred . (RI #1) to the bed and attempted to feed . (RI #1). Signed by: . (EI #3/Assistant Director of Nursing (ADON)) . A typed facility interview dated 11/28/2022, signed by EI #4 CNA documented the following: . On 11/25/22 at around 7:40 am I walked into resident . (RI #1's) room and I saw . (RI #1) on the floor . I then went and got . (RI #1) . off the floor. I got . (RI #1) up . on the bed to start eating and . (RI #1) said, No, no I should not be doing that; its not right. I then responded and said its food come on try it. Then that's when I started to feed . (RI #1) and . (he/she) kept saying that it is not right, its not right. The first spoon of food with grits, . (RI #1) slapped and it got on (RI #1's) shoulder. I then said again come on its food, its grits you have to try it. At that point, ADON . (EI #3) was coming up the hall and that's when ADON . (EI #3) said, no don't feed . (RI #1) if . (he/she) is not wanting to eat. Resident . (RI #1) then said, She is trying to make me eat . Its not right she is trying to make me eat. A typed facility witness statement dated 11/25/2022, signed by EI #3 ADON, documented the following: At 7:45 am writer was walking pass . (RI #1's) room and witnessed . (EI #4) CNA sitting on residents bed . with spoon in her hand attempting to feed resident. Resident was moving . (his/her) head from side to side and up and down trying to prevent the spoon from going into .(his/her) mouth. Writer stopped and told . (EI #4) to stop attempting to feed . because resident was saying, No!' Writer told . (EI #4) when a resident is saying they don't want it and is resisting you can not make . (him/her) eat. Resident then stated, 'Yeah she trying to force feed me . On 12/13/2022 at 9:09 AM EI #4 was asked about what happened on 11/25/2022 with RI #1. EI #4 explained she went in RI #1's room and RI #1 was on the floor against the chair in the room, so she got RI #1 up to feed RI #1 at about 7:25 or 7:30 AM. EI #4 said, RI #1 was quiet and she told RI #1 come on, let me get you up. EI #4 said once she got RI #1 on the bed and started to feed RI #1, RI #1 was saying no, No I should not be doing that, I said it is food try it, she was shaking her hand and saying no, no, I should not be doing that. When asked if it was normal behavior for the resident to be shaking his/her head, and saying no, no , and being resistive. EI #4 replied, no, and that sometimes RI #1 would say, he/she did not want it but never like that. EI #4 said, RI #1 usually ate breakfast, it was RI #1's biggest meal, and she was trying to make sure RI #1 ate. EI #4 said, she should have asked RI #1 if he/she wanted something else or told the nurse. EI #4 said, she should have notified the nurse in the beginning when she found RI #1 on the floor but she just started feeding RI #1 so she could get on to her other residents. EI #4 said, RI #1 was moving his/her head, and swinging his/her hands, not wanting to eat, and she was telling RI #1, the food was grits. Then EI #4 said, the nurse came in and said, not to make RI #1 eat if RI #1 did not want to eat. EI #4 said, the nurse that came into the room was EI #3 ADON. On 12/14/2022 at 12:11 PM EI #3 ADON was asked about what happened on 11/25/2022 with RI #1. EI #3 said, she was headed to the laundry, got close to RI #1's room, heard RI #1 say no no I don't want it, and from the hallway saw EI #4 attempting to feed RI #1, who was waving his/her hands and bobbing his/her head to keep EI #4 from putting the spoon in RI #1's mouth. EI #3 said, she told EI #4, if RI #1 did not want to eat, she could not make RI #1 take it, and if RI #1 did not want to eat, to tell the nurse so she could document it or offer RI #1 something else. EI #3 said, when she got into the room EI #4 reported she had just got RI #1 off the floor and started to feed RI #1, but had not told anyone. EI #3 said, she told EI #4 that is not what she was supposed to do, she was not supposed to move RI #1, but was supposed notify the nurse. On 12/15/2022 at 3:42 PM a follow up interview was conducted with EI #3. EI #3 confirmed that she observed EI #4 trying to feed RI #1 while RI #1 was bobbing his/her head, turning his/her head from side to side and saying ''no, no. I don't want it. EI #3 said, she had never seen that behavior from RI #1 before and she thought RI #1 just did not want to eat at that time. EI #3 said, when RI #1 said, did not want the food, the CNA should have stopped feeding RI #1 and reported to the charge nurse or offered something else. EI #3 stated, RI #1 may have been full and though EI #4 was encouraging RI #1 to eat, when RI #1 did not want anymore, EI #4 should have stopped because RI #1 was not going to eat and it was RI #1's right to refuse. On 12/15/2022 at 5:42 PM EI #3 was asked follow up questions about what could happen to a resident who had a diagnosis of Dementia, was resistive to eating, and the CNA did not stop. EI #3 said, the resident may become combative or bring on a behavior if a resident said no, no and did not want the food. EI #3 stated EI #4 should have stopped feeding RI #1, it might make the resident upset and combative. On 12/15/2022 at 5:57 PM EI #2 Director of Nursing (DON) was asked what she knew of the incident on 11/25/2022 with RI #1 being fed breakfast by EI #4. EI #2 said, she was told RI #1 was saying no, no and putting his/her hand up. EI #2 said, at that point EI #4 should have stopped and left the resident alone and report to the nurse if the resident had not consumed 50 percent of the meal. EI #2 was asked what could happen when a resident with a diagnosis of Dementia says no, no, and staff do not stop what they are doing. EI #2 replied, it could cause the resident to become angry and agitated.

Based on observations, interviews and a review of the facility's policies titled, Leftover Food Storage and Use, Calibrating and Sanitizing Thermometers and, Food Storage Temperature Logs, the facility failed to ensure: 1) reheated food (chicken fingers) on the tray line reached 165 degrees F (Fahrenheit); 2) a dietary worker properly calibrated the thermometer at the tray line and; 3) a temperature log was placed on the resident's supplement refrigerator on Unit One. This had the potential to affect 56 of 56 residents who receive meals from the kitchen. Findings Include: 1) A review of a facility policy titled, Leftover Food Storage and Use with an effective date of 8/15/2009, revealed: .PURPOSE: To assure that food borne illnesses are avoided.PR[NAME]ESS: .e. Reheat foods to 165 degrees for at least 15 seconds . A review of a facility document dated 4/3/2019, revealed no tray line temperatures were recorded at the lunch meal. On 4/3/2019 at 11:17 a.m., (Employee Identifier) EI #5, Cook, took food temperatures on the tray line. The first temperature of the chicken fingers on the tray line was 120 degrees F. The cook pulled the chicken fingers from the tray line and put them back into the stove. The second temperature of the chicken fingers was 145 degrees F. She did not record any temperatures on the menu log. On 04/03/2019 at 12:43 p.m., an interview was conducted with EI #5. EI #5 was asked what should food temperatures be after reheating. EI #5 replied, she did not know. EI #5 was asked what was the the first temperature of the chicken fingers on the tray line before putting them back into the stove. EI #5 replied, 120 degrees or 125 degrees F. EI #5 was asked who was responsible for reheating foods. EI #5 replied she was responsible for reheating the chicken fingers. EI #5 was asked what did the facility policy say regarding reheating food. EI #5 replied, she did not know because she never had to reheat food before. EI #5 was asked when the chicken fingers were brought back to the tray line, what was the temperature. EI #5 replied, she did not remember. EI #5 was asked was the temperature 165 degrees F. EI #5 replied, no it was not. EI #5 was asked what was the harm in serving food to residents at an incorrect temperatures. EI #5 replied, it could be contaminated. 2) A review of a policy titled, Calibrating and Sanitizing Thermometers with an effective date of 2/1/2002 revealed: .STANDARD: Thermometers should be calibrated, as needed, .PR[NAME]ESS: I. Calibration: .Use a small wrench to turn the calibration nut until the thermometer reads 32 degrees Fahrenheit . On 4/03/2019 at 10:59 a.m., at the tray line, EI #5 attempted to calibrate the thermometer. EI #5 was trying to go to zero on the thermometer. EI #5 stated the thermometer should go to zero degrees. On 4/04/2019 at 09:03 a.m., the surveyor conducted an interview with EI #5. EI #5 was asked why was she trying to calibrate the thermometer to zero. EI #5 replied, she did not know what she thought. EI #5 was asked who was responsible for calibrating the thermometer. EI #5 replied, she guessed she was. EI #5 was asked when should the thermometer be calibrated. EI #5 replied, before putting it in the food. EI #5 was asked why should the thermometer be calibrated. EI #5 replied, to see if the food was at the right temperature. EI #5 was asked, did she use the dial/ wrench part of the thermometer to turn it to the correct setting. EI #5 replied, she did not know. EI #5 was asked what should the thermometer be set on. EI #5 replied, zero. 3) A review of a facility policy titled, Food Storage Temperature Logs with an effective date of 8/10/2018, revealed: .STANDARD: The . Food Code guidelines should be used for the storage of food items. Temperatures should be monitored and recorded on a food temperature log. On 4/03/2019 at 10:29 a.m., the surveyor observed there was no temperature log on the resident's supplement refrigerator on Station One. On 4/04/2019 at 9:08 a.m.,an interview was conducted with EI #4, Dietary Manager. EI #4 was asked why was there no temperature log on the refrigerator. EI #4 replied, she thought it was being recorded. EI #4 was asked who checked the refrigerator for log temperatures. EI #4 replied, the nurse on Unit (Station) One. EI #4 was asked why was it important to document the temperature of the refrigerator. EI #4 replied, for the safety of the residents. EI #4 was asked what unit was the refrigerator on. EI #4 replied, Station One. On 4/04/2019 at 09:25 a.m., an interview was conducted with EI #6, Registered Nurse (RN). EI #6 was asked who was responsible for checking the resident's supplement refrigerator log on Unit One. EI #6 replied, the nurses, LPN's (Licensed Practical Nurse) and RN's. EI #6 was asked why was there no log on the refrigerator on 4/3/2019. EI #6 replied, they used to have a log, but they were told they did not have to have a log on the refrigerator. EI #6 was asked why was it important to keep a log on the resident's supplement refrigerator. EI #6 replied, to monitor the food, to make sure it was kept cold enough and make sure the refrigerator was working properly.

Based on record review, an interview and a review of a facility policy titled, Resident Assessment Instrument (RAI), the facility failed to ensure Resident Identifier (RI) #29's Foley catheter was coded on the 1/25/19 Quarterly Minimum Data Set (MDS). This affected RI #29, one of three residents sampled with a Foley catheter. Findings Include: A review of a facility policy titled, Resident Assessment Instrument (RAI), with an effective date of (MONTH) 29, (YEAR), revealed: .STANDARD: .the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specified by the state . RI #29 was re-admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of RI #29's Quarterly MDS with an Assessment Reference Date (ARD) of 1/25/2019, did not code the resident for use of a urinary catheter. A review of RI #29's (MONTH) 2019 Physician order [REDACTED]. The order date was 9/10/2018. On 4/04/2019 at 9:27 AM, an interview was conducted with Employee Identifier (EI) #10, Registered Nurse/MDS Coordinator. EI #10 was asked what was the most recent MDS for RI #29. EI #10 replied, 1/25/2019. EI #10 was asked who was responsible for completing the MDS. EI #10 replied, different sections for different staff, but it was her on that one. EI #10 was asked if the Foley catheter was coded for RI #29. EI #10 replied, no. EI #10 was asked when was the Foley catheter ordered for RI #29. EI #10 replied, RI #29 has had the Foley catheter for a while. EI #10 was asked why was it important to have the Foley catheter coded correctly on the MDS. EI #10 replied, so that it painted an accurate picture of the resident's condition.

Based on observation, interviews, medical record review and a review of facility policies titled, Medication Administration Procedures Oral Medication and Medication Procedures Enteral Tube (given through a tube into the stomach) Administration, the facility failed to ensure licensed staff did not pour liquid medication back in the medication bottle after pouring out too much. The facility also failed to ensure a licensed staff member checked tube placement prior to administering the evening medications on 4/2/19. This affected Resident Identifier (RI) #25 one of one residents observed for medications by enteral tube. Findings Include: A review of a facility policy titled, Medication Administration Procedures Oral Medication with a date of 3/11 revealed: .Procedures .2. If medication is a liquid .Any over-pour should be disposed of according to the facility policy. A review of a facility policy titled, Medication Administration Procedures Enteral Tube Administration with a date of 3/11 revealed: . Procedures .4. Regardless of the type of tube, check for proper placement before administering medications or water. RI #25 was readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #25's (MONTH) 2019 Physician order [REDACTED].> .VITAMIN C 250 MG (milligram) TABLET GIVE TWO TABLETS BY PEG (gastrostomy) TWICE DAILY, [MEDICATION NAME] 5 MG/5 ML (millimeters) SYRUP GIVE 5 ML PER GTUBE TWO TIMES A DAY . [MEDICATION NAME] 25 MG TABLET 1 TAB PGT (per gastrostomy tube) QID (four times a day) [MEDICATION NAME] 100MG/ML GIVE 5 CC (cubic centimeters) (500MG) Q DAY AT 6 PM (every day) . On 4/02/19 at 5:03 PM, Employee Identifier (EI) #3, Registered Nurse (RN), was observed preparing RI #25's medications to be administered by gastrostomy tube. When preparing the [MEDICATION NAME] liquid, EI #3 poured 10 cc (cubic centimeters) in a medication cup, then poured 5 cc back into the medication bottle. EI #3 then prepared the Vitamin C, Topomax and [MEDICATION NAME] for administration to RI #25. EI #3 did not check the tube placement prior to administering the medications. On 4/03/19 at 9:08 AM, an interview was conducted with EI #3. EI #3 was asked if he recalled the concerns during the medication pass for RI #25 on 4/2/19. EI #3 replied, yes. EI #3 was asked what was the policy on giving tube medications. EI #3 replied, check placement by aspiration or checking for contents. EI #3 was asked if he checked placement. EI #3 replied, no. EI #3 was asked why not. EI #3 replied, he just did not. EI #3 was asked what was the harm in not checking the placement of a tube before administering medications. EI #3 replied, the tube may not be in place and the medications would then go in the airway. EI #3 was asked, when he poured the [MEDICATION NAME] how much did he pour. EI #3 replied, 10 cc. EI #3 was asked what was the amount he should have poured. EI #3 replied, 5 cc. EI #3 was asked what did he do with the overpoured medication. EI #3 replied, poured it back in the bottle. EI #3 was asked what was the policy if over pouring a medication. EI #3 replied, he should have wasted it. EI #3 was asked what would the harm be in pouring the over poured medication back in the bottle. EI #3 replied, it may be contaminated. On 4/03/19 at 5:14 PM, an interview was conducted with EI #2, Director of Nursing. EI #2 was asked what was the policy for giving tube medications and checking placement. EI #2 replied, the nurse should check placement with a stethoscope. EI #2 was asked when should tube placement be checked. EI #2 replied, before any medication and feeding are given. EI #2 was asked what was the harm in not checking tube placement before administering medications. EI #2 replied, the tube may not be in the right area. EI #2 was asked what was the policy on staff pouring too much liquid medication. EI #2 replied, he should have discarded it. EI #2 was asked when should staff pour medication back in a medication bottle. EI #2 replied, never. EI #2 was asked what would the harm be in pouring medication back in a medication bottle. EI #2 replied, an infection control issue.

Based on observation, interview, medical record review and review of facility policies titled, Contact Precautions and Wound Care Procedure for Major Wounds, the facility failed to ensure licensed staff did not clean a wound, then with the same gloves, apply the medication and outer covering. This affected Resident Identifier (RI) #32, one of one resident sampled for pressure ulcers. Findings Include: A review of a facility policy titled, Contact Precautions, with an effective date of (MONTH) 1, (YEAR), revealed: .PURPOSE : . II. Gloves and hand hygiene .B. Gloves should be changed after having contact with infective material (e.g., fecal material and wound drainage). A review of a facility policy titled, Wound Care Procedure for Major Wounds, with an effective date of (MONTH) 1, 2009, revealed: .PURPOSE : To provide guidelines for clean technique during wound care .II. Procedure .N. Clean the wound according to the order. Clean the center outward. O. Place soiled gauze used for cleaning in bag. P. Remove gloves and place in bag. Q. Put on new gloves. R. Apply clean dressing as ordered . RI #32 was readmitted on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #32's (MONTH) 2019 Physician order [REDACTED].> .WOUND STAGE-4--SITE-SACRAL--AREA--CHANGE DSG.(DRESSING) Q (EVERY)--DAY CLEANSE W (WITH)/VASHE SOLUTION--APPLY-COLLAGEN PACKET TO WOUND BED. APPLY MOISTEN VASCHE (VASHE)GAUZE. DAMP TO DRY DRESSING TO WOUND BED COVER WITH ABSORBATIVE (ABSORPTIVE) DRESSING DAILY . 04/03/19 at 2:49 PM, the surveyor observed wound care for RI #32 performed by Employee Identifier (EI) #7, Licensed Practical Nurse (LPN), Restorative/Treatment Nurse. Prior to entering RI #32's room, EI #7 and EI #9, LPN, donned a gown and gloves and entered RI #32's room. EI #7 cleaned the table and draped it with a barrier. EI #7 placed the tape measure, Qtip and gauze on top of the barrier and each item was in a plastic bag. Several plastic gloves were placed on top of the barrier. EI #7 proceeded to unzip the pack of 4 by 4's in the zip lock bag to moisten with VASHE and placed them back on the table. EI #7, with the assistance of EI #9, removed the dressing from RI #32's wound, rolled it into a soiled barrier pad and placed it in a red bag. EI #7 went to the bathroom to wash her hands. The isolation trash container was located in the bathroom. EI #7 returned to the bedside and applied gloves from table. EI #7 cleaned the wound. EI #7 patted the wound dry with her right hand. EI #7, with the same soiled gloves she wore to clean the wound, retrieved the collagen packet. EI #7 turned to the table to retrieve 4 by 4 gauze with her left hand and sprinkled it with collagen powder, without proper hand hygiene. EI #7 placed the 4 by 4, sprinkled with collagen powder, over the wound bed without changing gloves and washing her hands. EI #7 placed two moistened 4 by 4 gauze onto the wound with the same soiled gloves. EI #7 retrieved the adhesive dressing from the packet, with the same soiled gloves with which she cleaned the wound, and covered the wound with it. EI #7 removed and discarded her gloves in the red bag and washed her hands. On 4/03/19 at 4:01 PM, an interview was conducted with EI #7. EI #7 was asked, during wound care, after she cleaned the wound, did she change gloves before applying the collagen from the 4 by 4 to the wound bed. EI #7 replied, no. EI #7 was asked, after cleaning the wound, did she touch other surfaces on the table. EI #7 replied, yes. EI #7 was asked if she should have changed gloves and washed her hands after cleaning the wound. EI #7 replied, yes. EI #7 was asked, what was the potential harm in not washing her hands and putting on new gloves. EI #7 replied, she could have contaminated the wound. On 4/04/19 at 11:07 AM, an interview was conducted with EI #2, Director of Nursing (DON). EI #2 was asked when should a nurse change gloves and wash their hands during wound care. EI #2 replied, before touching the resident and after touching the resident. EI #2 was asked when should a nurse perform the cleaning of a wound then apply the medication to the wound with the same gloves they cleaned the wound with. EI #2 replied, never. EI #2 was asked what was the harm in the nurse not changing her gloves after cleaning the wound and before applying the medication. EI #2 replied, it was an infection control issue.

Based on observation, medical record review and interview, the facility failed to ensure licensed staff did not take a small water pitcher from the medication cart into Resident Identifier (RI) #25's room, place it on an unclean bedside table, then return the water pitcher to the medication cart without being cleaned. This was observed on 4/2/19, and affected one of one residents observed for medications by gastrostomy tube. Findings Include: RI #25 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of RI #25's (MONTH) 2019 Physician order [REDACTED].> .VITAMIN C 250 MG (milligram) TABLET GIVE TWO TABLETS BY PEG (gastrostomy) TWICE DAILY, [MEDICATION NAME] 5 MG/5 ML (millimeters) SYRUP GIVE 5 ML PER GTUBE (gastrostomy tube) TWO TIMES A DAY . [MEDICATION NAME] 25 MG TABLET 1 TAB PGT QID (four times a day) [MEDICATION NAME] 100MG/ML GIVE 5 CC (500MG) Q DAY AT 6 PM (every day) . On 4/02/19 at 5:03 PM, Employee Identifier (EI) #3, Registered Nurse (RN), was observed preparing and administering RI #25's medications by gastrostomy tube. EI #3 took a small water pitcher from the medication cart into RI #25's room and placed it on the overbed table with no barrier. EI #3 administered the medications to RI #25 using water from the small water picture. EI #3 finished the task, washed his hands and returned the small water pitcher to medication cart. On 4/03/19 at 9:08 AM, an interview was conducted with EI #3. EI #3 was asked if her recalled the concerns during the medication pass for RI #25 on 4/2/19. EI #3 replied, yes. EI #3 was asked what was the policy on taking water in a resident's room for medication pass. EI #3 replied, they should take water in, but he should not have taken the pitcher then returned it to the cart. EI #3 was asked what was the harm in returning the pitcher to the cart without cleaning it. EI #3 replied, it could contaminate the medication cart from any germs picked up in the resident's room. On 4/03/19 at 5:14 PM, an interview was conducted with EI #2, Director of Nursing (DON). EI #2 was asked where should staff get water from during medication pass for tube medications. EI #2 replied, the sink or carry some in cups from the pitcher on the medication cart. EI #2 was asked when should staff take a water pitcher from the medication cart in a resident's room then return it to the medication cart without cleaning. EI #2 replied, they should not do that. EI #2 was asked what would the harm be in staff taking a water pitcher from the medication cart into a resident's room, then returning it to the medication cart without being cleaned. EI #2 replied, an infection control issue.

Based on observation, interview and review of a facility policy titled, Nurse Staff Posting Protocol, the facility failed to ensure the nurse staff posting form was in an area visible for residents and visitors. This was observed on three of three days of the survey and had the potential to affect all residents in the facility. Findings Include: A review of a facility policy titled, Nurse Staff Posting Protocol with an effective date of 12/27/05, revealed: The Administrator will select a prominent location to post the nursing direct care staffing form that is readily accessible to visitors and residents On 4/2/19 at 10:00 AM, the surveyor attempted to locate the nurse staff posting form. The surveyor was unable to locate the nurse staff posting form. On 4/2/19 at 3:00 PM, the surveyor continued to be unable to locate the nurse staff posting form. The other surveyors also looked without finding the nurse staff posting form. On 4/3/19 at 11:00 AM, the surveyor observed the nurse staff posting forms on an information board in the hallway leading to the kitchen area. The forms were inside a yellow folder midway of the information board, with only the very top of the form visible. A review of the visible areas on the form revealed, Reports of .Nurse Staff .Facility . Date .DAY SHIFT Census . The nurse staff posting form was not visible for residents and visitors. The surveyor pulled the forms from inside the folder and reviewed the forms dated 4/2/19, with all the areas completed, and 4/3/19, which had the information completed for the day shift. On 4/04/19 at 8:30 AM, the surveyor observed the nurse staff posting form in the folder on the information board in the hall leading to the kitchen. The forms dated 4/2/19, 4/3/19 and 4/4/19 were inside the folder. The visible areas on the top form revealed, Reports of .Nurse Staff .Facility . Date .DAY SHIFT Census . On 4/04/19 at 8:40 AM, the surveyor conducted an interview with Employee Identifier (EI) #1, the Administrator. EI #1 was asked where was the nurse posting. As the surveyor and EI #1 walked to the board, EI #1 replied, on this board where all the information is posted. EI #1 was asked, if a resident or visitor was in a wheelchair or seated position, was the form visible for residents and visitors. EI #1 replied, probably not. The surveyor asked for a measurement of the folder on the board from the floor. EI #1 and maintenance measured the distance with a reading of 64 inches from the floor. EI #1 was asked, with the form inside the folder with only a few words readable from the folder at a height of 64 inches, would the form be accessible to residents and visitors. EI #1 replied, no. EI #1 was asked what was the risk of the nurse staff posting form not being accessible to residents and visitors. EI #1 replied, they may not be able to identify the number of staff available for providing care.

Based on observation, interview, medical record review and review of a facility policy titled, Person Centered Care Plans, the facility failed to ensure a care plan was developed for RI (Resident Identifier) #13's [MEDICAL CONDITION] to the right forearm. This affected one of seventeen sampled residents whose care plans were reviewed. Findings Include: A review of a facility policy titled, Person Centered Care Plans, with an effective date of (MONTH) 28, (YEAR) revealed: .STANDARD: .the facility develops a comprehensive person centered plan of care for each resident .that includes measurable objectives and timetables to meet a resident/guest's medical, nursing and mental/psychosocial needs . RI #13 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #13's (MONTH) (YEAR) Physician order [REDACTED]. On 03/21/18 at 3:03 p.m., the surveyor observed a bandage on RI #13's right forearm. Surveyor asked RI #13 what happened to her/his arm. RI #13 stated she/he had [MEDICAL CONDITION] but decided with her/his family not to have any treatment. RI #13 further stated the bandage was changed daily. A review of RI #13's current comprehensive care plans, printed 03/22/2018, revealed no care plan addressing RI #13's [MEDICAL CONDITION] to the right forearm. On 3/22/18 at 4:00 p.m., an interview was conducted with EI (Employee Identifier) #5, RN (Registered Nurse)/UM (Unit Manager). EI #5 was asked when was RI #13's [MEDICAL CONDITION] lesion identified. EI #5 stated the lesion was identified on admission, which was 5/19/17. EI #5 was asked who was responsible for developing care plans on admission. EI #5 stated the MDS (Minimum Data Set ) Coordinator, but she was trained to develop, change and revise care plans. EI #5 was asked if RI #13 was care planned for the [MEDICAL CONDITION] of her/his right forearm. EI #5 stated, No Ma'am. EI #5 was asked should RI #13 have had a care plan for the [MEDICAL CONDITION] on her/his right forearm. EI #5 stated, RI #13 should have had a care plan because he/she received treatment for [REDACTED].#5 was asked what is the importance of developing a care plan. EI #5 stated for the staff to be able to care for the resident in a specific way.

Based on observation, interview, medical record review, and a review of POTTER AND PERRY'S FUNDAMENTALS OF NURSING and the facility' policy titled, Urinary Catheter Care the facility failed to ensure a Certified Nursing Assistant (CNA): 1. wiped to clean the length of the exposed catheter and 2. the catheter was secured to Resident Identifier (RI) #20's adhesive stabilization device. This affected one of one resident observed for catheter care. Findings Include: A review of POTTER AND PERRY'S FUNDAMENTALS OF NURSING, NINTH EDITION, UNIT VII, page 1122, revealed: . BOX 46-10 Preventing Catheter-Associated Urinary Tract Infection (CAUTI) . Secure indwelling catheters to prevent movement and pulling on the catheter. Perform routine perineal hygiene daily and after soiling using antiseptic wipes. Be sure to a wipe to clean the length of the exposed catheter. A review of the facility's policy titled, Urinary Catheter Care, with an effective date of (MONTH) 10, 2014 revealed: . PURPOSE: Urinary catheter care helps prevent urinary tract infection. PR[NAME]ESS: . II. Catheter Care . c) Wash the catheter itself by holding on to the catheter at the insertion site; wash with one stroke downward approximately 3 inches from the meatus while holding the catheter to prevent pulling. f) Secure the catheter with a leg band . RI #20 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/21/18 at 10:41 a.m., Employee Identifier (EI) #4 was observed performing catheter care for (RI) #20. EI #4 did not clean the length of the exposed catheter tubing and did not securing/re-place the dangling, unattached, adhesive devise used to stabilize the catheter. An interview was conducted on 3/22/18 at 1:40 p.m. with EI #4. EI #4 was asked if she had cleaned the length of the exposed catheter tubing. EI #4 stated, she had wiped down each side of the perineal area. EI #4 was asked what was the potential for harm. EI #4 replied, Infect it. EI #4 was asked if the catheter securing devise was attached to the resident. EI #4 replied, No, it was not attached to RI #20. EI #4 was asked what should have been done. EI #4 stated, It should have been reported. EI #4 was asked what was the potential for harm if the catheter was not securely fastened to the resident's leg. EI #4 replied, It would pull.

Based on observation, interview, and review of a facility policy titled, Medication Storage, the facility failed to ensure three vials of a controlled drug, (Lorazepan) [MEDICATION NAME] were stored in a locked box, inside the of the refrigerator of the medication room. This deficient practice was observed in one of two medication rooms. Findings Include: A review of a facility policy titled, Medication Storage, with a date of 3/11, documented the following: Policy Medications and biologicals are stored safely, securely and properly, . Procedures .7. Controlled medications are stored separately from other medication in a locked drawer or compartment designated for that purpose On 3/21/18 at 5:39 p.m., the surveyor was accompanied by EI (Employee Identifier) #6, a Registered Nurse (RN), to observed the medication room. EI #6 opened the refrigerator lock with a key. The surveyor observed a box attached to a rack but the box was unlocked. The box contained three vials of [MEDICATION NAME] 2 mgs( milligrams) each. An interview was conducted on 3/22/18 at 1:54 p.m. with EI #1 Director of Nurses (DON). EI #1 was asked should the attached box in the medication room refrigerator be locked. EI #1 stated, Yes ma'am. EI #1 was asked if the box was locked on 03/21/18 when, the surveyor was accompanied to the medication room with EI #6. EI #1 stated no ma'am. EI #1 was asked what was the potential harm in the attached box not be locked. EI #1 said, Something could come up missing, someone else could get the narcotics.

Based on observations, interviews, medical record reviews, a review of POTTER AND PERRY'S FUNDAMENTALS OF NURSING, and a review of the facility's policy titled, Hand Hygiene, the facility failed to ensure: 1. a licensed nurse did not use the gloves she had in her uniform pocket while administering medications to Resident Identifier (RI) #39, 2. a licensed nurse did not lay RI #160's inhaler on the bathroom sink while washing her hands during medication administration, and 3. a Certified Nursing Assistant (CNA ) washed her hands after cleaning stool from RI #20's buttocks and before applying clean gloves during catheter care. This affected two of six residents observed during medication pass administration and one of one resident observed for catheter care. Findings Include: A review of POTTER AND PERRY'S FUNDAMENTALS OF NURSING, NINTH EDITION, CHAPTER 29, page 445, revealed: . Modes of Transmission . Equipment used within the environment . often becomes a source for transmission of pathogens. 1. RI #39 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/21/18 at 11:00 a.m., Employee #2, a Licensed Practical Nurse (LPN), was observed removing gloves from her right uniform pocket and putting them on to administer insulin to RI #39. An interview was conducted on 3/22/18 at 1:30 p.m. with EI #2. EI #2 was asked if gloves should be stored in your uniform pocket. EI #2 replied, No. EI #2 was asked if she had removed gloves from her pocket and put them on before administering insulin to RI #39. EI #2 replied, Probably so. EI #2 was asked what was the potential for harm in storing gloves in your pocket. EI #2 replied, Contamination. 2. RI #160 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/21/18 at 8:26 a.m., EI #3, a Licensed Practical Nurse (LPN) was observed laying RI #160's inhaler on the bathroom sink while she washed her hands during medication administration. An interview was conducted on 3/22/18 at 1:50 p.m. with EI #3. EI#3 was asked should a resident's inhaler be placed on the bathroom sink while you wash your hands. EI #3 replied, No ma'am. EI #3 was asked if she had placed the inhaler on the sink while she washed her hands. EI #3 replied, Yes. EI #3 was asked what was the potential for harm. EI #3 replied, Bacteria, could cause an infection. 3. A review of the facility's policy titled, Hand Hygiene, with an effective date of (MONTH) 1, (YEAR) revealed: . Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene.After contact with a resident/guest(s) mucous membranes, and body fluids or excretions. RI #20 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/21/18 at 10:41 a.m. EI #4, a CNA, was observed performing catheter care for RI #20. EI #4 applied clean gloves without washing her hands after removing stool from RI #20's buttocks. An interview was conducted on 3/22/18 at 1:40 p.m. with EI #4. EI #4 was asked what should be done after cleaning stool from RI #20's buttocks and before applying clean gloves. EI #4 replied,Wash my hands. EI #4 was asked if she had washed her hands after cleaning stool from RI #20's buttocks and before applying clean gloves. EI #4 replied, No, I didn't. EI #4 was asked what was the potential for harm. EI #4 replied, Spreading germs.

Based on a review of Resident Identifier (RI) #3's medical record, incident report and interview with Employee Identifier (EI) #4, the Director of Nursing, the facility failed to ensure staff implemented RI #3's care plan approach of not to leave the resident unassisted on the commode. On 1/8/2017, RI #3 was left alone on the toilet and fell while trying to wipe himself/herself. This deficient practice affected RI #3, one of 13 sampled residents. Findings include: RI #3 was admitted to the facility on [DATE]. RI #3's Annual Minimum Data Set (MDS) with an assessment reference date of 12/16/2016, identified RI #3 as requiring extensive physical assistance of one person for toilet use. RI #3 was assessed as being occasionally incontinent of bowel and bladder. RI #3's care plan titled Potential for falls r/t (related to) need for assistance . with a problem onset date of 4/9/2015 and last reviewed 10/26/2016 had a documented approach of . * Staff is not to leave Resident unassisted on commode . The Resident Incident Report revealed RI #3 sustained a fall with no head injury on 1/8/2017 7:00 PM. The report further documented . CNA (Certified Nursing Assistant) came and reported resident was on the floor, when write entered the room, resident was noted sitting on buttom (bottom) in front of toilet on the floor in the restroom. When asked what happen, resident states, I was trying to wipe myself and gave over . An interview was conducted on 2/2/2017 at 5:28 PM, EI #4, the Director of Nursing (DON) was asked, if the staff was with RI #3 when the resident fell in the bathroom on 1/8/2017. EI #4 replied no. When asked, if RI #3's care plan was followed, EI #4 replied no.

Based on a review of Resident Identifier (RI) #3's medical record, incident report and interview with Employee Identifier (EI) #4, the Director of Nursing, the facility failed to ensure staff did not leave RI #3, a resident at risk for falls, unattended in the bathroom on 1/8/2017. RI #3 was found on the floor in the bathroom in front of the toilet. This deficient practice affected RI #3, one of four sampled residents reviewed for falls. Findings include: RI #3 was admitted to the facility on [DATE]. RI #3's Annual Minimum Data Set (MDS) with an assessment reference date of 12/16/2016, identified RI #3 as requiring extensive physical assistance of one person for toilet use. RI #3 was assessed as being occasionally incontinent of bowel and bladder. RI #3's care plan titled Potential for falls r/t (related to) need for assistance . with a problem onset date of 4/9/2015 and last reviewed 10/26/2016 had a documented approach of . * Staff is not to leave Resident unassisted on commode . The Resident Incident Report revealed RI #3 sustained a fall with no head injury on 1/8/2017 7:00 PM. The report further documented . CNA (Certified Nursing Assistant) came and reported resident was on the floor, when write entered the room, resident was noted sitting on buttom (bottom) in front of toilet on the floor in the restroom. When asked what happen, resident states, I was trying to wipe myself and gave over . An interview was conducted on 2/2/2017 at 5:28 PM, EI #4, the Director of Nursing (DON) was asked, if the staff was with RI #3 when the resident fell in the bathroom on 1/8/2017. EI #4 replied no. When asked, if RI #3's fall on 1/8/2017 was avoidable, EI #4 replied yes.

Based on record review and interview the facility failed to ensure a Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2-16-16 documented RI (Resident Indentifer) # 7 was receiving Hospice. This affected 1 of 4 residents sampled for Hospice services. Findings Include: RI # 7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI # 7's most recent Physician order [REDACTED].HOSPICE TO EVALUATE & (and) TX (treat) AS INDICATED . The Surveyor reviewed Section O of the Significant Change MDS with an ARD of 2/16/16. Section O did not document RI # 7 was receiving Hospice services. An interview was conducted with EI (Employee Indentifer) # 1, Registered Nurse on 3/10/16 at 2:00PM. EI # 1 indicted she completed the Significant Change MDS dated [DATE] for RI # 7. EI # 1 stated the MDS was completed because RI # 7 went on Hospice. EI # 1 was asked if Section O of the 2/16/16 MDS was checked to show RI # 7 was receiving Hospice. EI # 1 replied the original was not checked but a correction was completed today. EI # 1 was asked if the original MDS should have been checked to show RI # 7 was receiving Hospice services. EI # 1 replied yes, that is why a correction was completed. EI # 1 was asked why the original was not checked and she replied human error. EI # 1 was asked what is the importance of documenting to show a resident is receiving Hospice. EI # 1 replied that is why we did the Significant Change MDS to show RI # 7 was receiving Hospice.

Based on observations, record review and interview: 1) MACHINE DISHWASHING The facility failed to assure dishes and utensils were effectively sanitized to destroy potential food borne organisms. a. Flatware was observed wet, nested and with food debris. The facility failed to adequately cover flatware with water for soaking. b. The facility failed to prevent the nesting of spoons which resulted in a failure to air-dry and remove food debris. (Six spoons were observed with pooled water or food debris). 2) MANUAL DISHWASHING Dietary staff failed to assure the Robo Coupe blender was not stored wet. 3) The facility failed to assure that stored frozen food (ice cream) received frozen was maintained frozen. 4) MIGHTY SHAKES The facility failed to assure frozen Mighty Shakes, after thawing, were identified with a use by date per manufacturer's direction. "Use within 14 days after thawing" and 2013 Food Code, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. 5) The facility failed to designate a person in charge who was present at the food establishment during all hours of operation and could demonstrate knowledge of foodborne disease prevention, application of the Hazard Analysis and Critical Point principles and the requirements of the food code. (One of the three cooks/supervisors was Serv-Safe qualified. (Food Code 2-202.11) The above practices posed the potential for food contamination and compromised food safety. This had the potential to affect the 60 residents who received meal trays from dining services. Findings include: 1) MACHINE DISHWASHING The facility failed to assure dishes and utensils were effectively sanitized to destroy potential food borne organisms. a. Flatware was observed wet, nested and with food debris. The facility failed to adequately cover flatware with water for soaking. b. The facility failed to prevent the nesting of spoons which resulted in a failure to air-dry and remove food debris. (Six spoons were observed with pooled water or food debris). The 2013 Food Code by the United States Public Health (USPHS) and the Food and Drug Administration (FDA) included the following: "Drying 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 ..." On 2/04/2015 at 9:15 AM, clean spoons were observed wet nested. Failure to clean/sanitize both back and front of spoons during nesting creates an atmosphere for potential bacterial growth. a. The facility failed to adequately cover flatware and glasses with water for soaking. On 2/04/2015 at 9:15 AM, the breakdown of returned food trays was observed. Staff used a large bus pan to soak flatware and juice glasses. The items extended approximately six inches above the top rim of the pan. b. The facility failed to prevent the nesting of spoons which resulted in a failure to air-dry and remove food debris. (Six spoons were observed with pooled water or food debris). On 2/04/2015 at 9:58 AM, flatware was observed divided into 4 overstuffed cylinders. According to an interview with the Certified Dietary Manager (CDM), Employee Identifier, EI #1 on 2/04/2015 at 10:00 AM, there would be a total of 192 eating utensils or 48 items in each cylinder. EI #1 further stated there was visible water on the utensils and they were all nested in the cylinders. On 2/04/2015 at 9:58 AM, the Registered Dietitian, EI #2 was asked how many items should be in a cylinder. EI #2 responded, about 20. 2) MANUAL DISHWASHING Dietary staff failed to assure the Robo Coupe blender was not stored wet. "Drying 4-901.11 Equipment and Utensils, Air-Drying Required. See data above. On 2/04/2015 at 9:55 AM the Robo Coupe blender was observed stored on the stand. Water was pooled on the bottom. On 2/04/2015 at 10:00 AM the CDM, EI #1 was asked, was there rolling water observed on the bottom of the container. EI #1 stated she saw water. 3) The facility failed to assure that stored frozen food (ice cream) received frozen was maintained frozen. The 2013 Food Code by the United States Public Health (USPHS) and the Food and Drug Administration (FDA) included the following: "Temperature and Time Control, 3-501.11 Frozen Food. Stored frozen foods shall be maintained frozen." On 2/03/2015 at 2:24 PM, during the initial kitchen tour, ice cream storage was observed. An individual cup of ice cream was soft to touch and left finger indentations. The internal temperature of the Ice Cream was +5 degrees F (Fahrenheit). On 2/05/2015 at 10:00 AM the CDM, EI #1 was interviewed and asked, did pressure on the individual cup of chocolate ice cream leave finger indentations? EI #1 responded, "It sorta gave". 4) MIGHTY SHAKES The facility failed to assure frozen Mighty Shakes, after thawing, were identified with a use by date per manufacturer's direction. "Use within 14 days after thawing" and 2013 Food Code, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. The 2013 Food Code by the United States Public Health (USPHS) and the Food and Drug Administration (FDA) included the following:" Section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking... (B) Except as specified in (E) - (G) of this section, refrigerated, Ready-To-Eat Time/Temperature Control for Safety Food prepared and packaged BY A FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations ... " On 2/03/2015 at 2:24 PM, during the initial tour of dietary services frozen/thawed Health Shakes were observed not labeled with a use by date. The date labeled on the box containing numerous cartons was the thaw date. During the meal delivery at 12:00 PM, on 2/04/2015, a meal tray was observed with a Vanilla Shake. There was no individual label with a use by date. On 2/05/2015 at 9:57 AM the CDM, EI #1 was asked, if found on nursing unit, how would staff know the date to discard? EI #1 said, "I'm gonna have to have it dated when put on tray". On 2/05/2015 at 12:05 PM, the 2nd Hall nourishment refrigerator was observed to contain three Mighty Shakes and one Vanilla Shake. At 12:10 PM the CDM, EI #1 was asked were Mighty Shakes dated with a use by date. EI #1 said they were dated inside the kitchen and not on the nursing station. 5) The facility failed to designate a person in charge who was present at the food establishment during all hours of operation and could demonstrate knowledge of foodborne disease prevention, application of the Hazard Analysis and Critical Point principles and the requirements of the food code. The 2013 Food Code by the United States Public Health (USPHS) and the Food and Drug Administration (FDA) included the following: "Responsibility 2-101.11 Assignment. (A) Except as specified in ? (B) of this section, the PERMIT HOLDER shall be the PERSON IN CHARGE or shall designate a PERSON IN CHARGE and shall ensure that a PERSON IN CHARGE is present at the FOOD ESTABLISHMENT during all hours of operation. (B) In a FOOD ESTABLISHMENT with two or more separately PERMITTED departments that are the legal responsibility of the same PERMIT HOLDER and that are located on the same PREMISES, the PERMIT HOLDER may, during specific time periods when food is not being prepared, packaged, or served, designate a single PERSON IN CHARGE who is present on the PREMISES during all hours of operation, and who is responsible for each separately PERMITTED FOOD ESTABLISHMENT on the PREMISES. Knowledge 2-102.11 Demonstration. Based on the RISKS inherent to the FOOD operation, during inspections and upon request the PERSON IN CHARGE shall demonstrate to the REGULATORY AUTHORITY knowledge of foodborne disease prevention, application of the HAZARD Analysis and CRITICAL CONTROL POINT principles, and the requirements of this Code. The PERSON IN CHARGE shall demonstrate this knowledge by: (A) Complying with this Code by having no violations of PRIORITY ITEMS during the current inspection;..." On 2/05/2015 at 4:30 PM, the Certified Dietary Manager (CDM), EI #1 was asked how many Cooks/Supervisors were Serv-Safe qualified. EI #1 responded, none. A review of the January/February 5, 2015 schedule revealed a morning cook, an evening cook and 6 assistant cooks and 1 Dietary Aide. A total of 9 employees and two shifts: 5:00 AM until 1:00 PM the second shift was 10:30 until 6:30 PM. The CDM was observed to fill in as a cook (who called off) on 2/03/2015.

Based on observation, record review and interview the facility failed to ensure 40 doses of Pneumovax (pneumonia vaccine) was not available for administration after its expiration date. These vaccines were found in the medication refrigerator at nurses station number two and had the potential to affect 40 residents who could have received the vaccines. Findings Include: Review of a facility policy titled, "Medication Storage Storage of Medications and Biologicals" with a date of 03/11 documented the following: "Policy Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier...Procedures...11. Outdated medications...are removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy, if a current order exists..." Review of another facility policy titled, "Disposal of Medications Non-Controlled Medication Destruction" with a date of 03/11 documented the following: "Policy Discontinued medications, expired medications, and medications left in the facility after a resident has expired or has been permanently discharged are destroyed or disposed of per federal/state regulations..." On 02/05/15, while reviewing medications in medication room [ROOM NUMBER], the surveyor observed 4 unopened boxes (40 doses) of Pneumovax (pneumonia vaccines) with an expiration date of 09/25/2014. Review of the box containing the 40 doses of Pneumovax vaccine, revealed an imprint stamped on the outer label that was dated 25SEP14 (September 25, 2014). On 02/05/15 at 3:35 PM an interview was conducted with EI (Employee Identifier) #3, LPN (Licensed Practical Nurse) Charge Nurse. EI #3 was asked what she had observed in medication room number two. EI #3 stated she had observed expired Pneumovax vaccines which had expired in September 2014. When asked what was the potential harm if expired vaccines were administered to a resident, EI #3 said that it could cause an anaphylactic reaction or it could not be as effective. On 02/05/15 at 3:35 PM, EI #4, RN (Registered Nurse)/DON (Director of Nursing) was interviewed. EI #4 was informed of the expired boxes of Pneumovax vaccine in medication room number two and was then asked what would be the potential harm if the Pneumovax vaccine had been given to residents after their expiration date. EI #4 said it could cause an adverse reaction and it could not be as potent as it should be.

Based on record review and interview, the facility failed to ensure that an intramuscular antipsychotic medication was administered to RI (Resident Identifier) #1 on 8/19/14 with proper indication for medication usage. This affected 1 of 2 residents observed for antipsychotic medication usage. Findings Include: RI #1 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. RI #1's most recent Readmission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 8/5/14 revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 8 which indicated RI #1 was moderately impaired for daily decision making. A review of the facility's policy titled, "Medication Monitoring Antipsychotics" with a date of 03/11 revealed: " ...Procedures ...5. Antipsychotics are not used solely for the following conditions if there is no other indication: ...C. Restlessness. ...J. Fidgeting. ...L. Uncooperativeness. ... " A review of RI #1's "Physician Orders" with a date of August 2014 revealed: "[MEDICATION NAME] 10 MG (MILLIGRAM) INJECTED 2.1 STERILE WATER GIVE TOTAL CONTENT OF VIAL IM (INTRAMUSCULAR) PRN (AS NEEDED) Q (EVERY) 8 HOURS AS NEEDED FOR DX (DIAGNOSIS): CONFUSION..." A review of RI #1's "MAR (Medication Administration Record)" with a date of August 2014 revealed: "[MEDICATION NAME] 10 MG VIAL INJECTED 2.1 STERILE WATER GIVE TOTAL CONTENT OF VIAL IM PRN Q 8 HOURS AS NEEDED FOR DX: CONFUSION..." EI (Employee Identifier)#2, LPN (Licensed Practical Nurse) signed the MAR indicated [REDACTED]. A review of RI #1's "Administration Record" with a date of August 2014 revealed: "...5:20 AM, 8/19/14 (Administered: 5:21 AM, 8/19/14; [MEDICATION NAME] 10 MG VIAL) [MEDICATION NAME] 10 MG VIAL INJECTED 2.1 STERILE ... .Confusion noted trying to get out of bed. Sitter present in room. pulling cover off kicking legs out of bed // 08/19/2014 5:20 AM 08(EI #2 ' s first initial and last name) 5:21 AM, 8/19/14 (Administered: 5:21 AM, 8/19/14; [MEDICATION NAME] 10 MG VIAL) ..." A review of the facility's document titled, "ADL (Activities of Daily Living)" with a date of August 2014 revealed: "...Observe for episodes of behaviors and response to interventions ..." There were not any behaviors documented for RI #1 for the month of August. On 8/20/14 at 8:35 AM, an interview was conducted with EI #2, LPN. EI #2 was asked if she had administered any medication to RI #1 on 8/18/14 or 8/19/14. EI #2 said yes, she administered eye drops, two blood pressure pills and [MEDICATION NAME] to RI #1 on 8/19/14 around 5:00 AM. EI #2 was asked why she administered [MEDICATION NAME] to RI #1. EI #2 said RI #1 continuously tried to get out of bed and when they (herself and the sitter) offered to get RI #1 out of bed, the offer was refused. EI #2 further stated that RI #1 became increasingly more confused and uncooperative. EI #2 was asked if any other interventions were tried before the [MEDICATION NAME] was administered. EI #2 said they (herself and the sitter) tried to get RI #1 up from the bed and make the resident comfortable. She said a urinal was provided to RI #1 and was used after approximately 5 minutes. EI #2 was asked if she documented RI #1's behaviors and if so, where were the behaviors documented. EI #2 said she documented RI #1's behaviors in the nurse's notes. She further stated that she documented that RI #1 was confused, agitated and swinging both legs out of the bed. EI #2 was asked of RI #1 was more agitated or uncooperative. EI #2 said both. EI #2 was asked what was her definition of agitation and uncooperative. EI #2 said agitation meant fidgeting, getting upset, and frowning. EI #2 said uncooperative was saying no, saying stop and saying that you don't want to do something. EI #2 was asked if RI #1 was a danger to themselves. EI #2 said yes. When asked why she thought RI #1 was a danger to themselves, she stated that if RI #1 got out of bed and fell , RI #1 could end up with a broken bone. EI #2 was asked if the [MEDICATION NAME] was administered to prevent a fall and she said no, it was given for RI #1's protection. EI #2 was asked when she said [MEDICATION NAME] was given for RI #1's protection, did she think that he was going to fall and she said yes. EI #2 was asked if she felt RI #1 was a danger to her and she said no. EI #2 was asked how many times she entered RI #1's room before administering the [MEDICATION NAME]. EI #2 said she went in RI #1's room twice before 5:00 AM. She said at 5:00 AM, RI #1 was becoming more and more agitated. EI #2 was asked on the third time that she entered RI #1's room what was observed. EI #2 said that RI #1 had both legs outside of the bed and was trying to pull up on the side of the bed. EI #2 was asked if she retrieved and administered the [MEDICATION NAME] at this time and she said yes. EI #2 was asked what was different about that observation and the two previous observations when she entered RI #1's room. EI #2 said there was no difference in that observation and the previous two. EI #2 was asked, based on her nursing judgment, why she administered the [MEDICATION NAME] at that time. EI #2 said the previous two times she entered RI #1's room, she thought that the resident would lay down, relax and go to sleep, but he did not. On 8/20/14 at 10:15 AM, an interview was conducted with EI #1, DON (Director of Nursing). EI #1 was asked what was RI #1's [DIAGNOSES REDACTED].#1 said confusion. EI #1 was asked when the last dose of [MEDICATION NAME] injection had been administered to RI #1. EI #1 said 8/19/14 at 5:21 AM. EI #1 was asked what behaviors was RI #1 displaying at the time the [MEDICATION NAME] was administered. EI #1 said around 4:30 AM, RI #1 became restless, swinging legs over the side of the bed and swatting at staff. EI #1 was asked if she felt the [MEDICATION NAME] injection was appropriate. EI #1 said yes, after they tried to redirect and that did not work, she felt it was needed to get RI #1 to calm down. EI #1 was asked when she looked at the psych medication policy, was the [MEDICATION NAME] injection necessary. EI #1 said she felt like with RI #1's prior behavior from the hospital and the resident's last admission at the facility, it was necessary. EI #1 was asked how was staff to redirect behavior. EI #1 said that staff watched videos on customer service, monthly inservices, redirection techniques and alerting the charge nurse. EI #1 was asked, based on RI #1's care plan, what behavior should RI #1 exhibit in order for the prn [MEDICATION NAME] to be administered. EI #1 said if RI #1 was going to hurt themselves, another resident or employee, or if RI #1 was unable to be redirected, she felt it was appropriate to give the [MEDICATION NAME]. On 8/20/14 at 11:45 AM, a telephone interview was conducted with EI #3, CNA (Certified Nursing Assistant). EI #3 was asked when she was a sitter for RI #1 on 8/18/14 on the 11 PM to 7 AM shift, what behaviors were exhibited by RI #1. EI #3 said RI #1 was very agitated, threw the covers back, pushed her back and had feet out of the bed trying to get up. EI #3 was asked to describe how RI #1 pushed her back. EI #3 stated that RI #1 told her to move because he could walk. EI #3 was asked what she did at that time. EI #3 said she asked RI #1 if the resident wanted to get up, talked to the resident and tried to reason with the resident. She said she then called the nurse, EI #2, down to the room and they went through the same procedure. EI #3 said she and EI #2 were afraid RI #1 was going to fall. EI #3 was asked if any other techniques were tried with RI #1. EI #3 said she checked RI #1 to see if the resident was wet or needed something to drink. EI #3 stated, "RI #1 said just leave me alone." EI #3 was asked on the day that that the [MEDICATION NAME] injection was given if she felt that RI #1 was more agitated or uncooperative. EI #3 said both. EI #3 was asked to explain how RI #1 was being uncooperative. EI #3 said RI #1 sat back on the bed and tried to scoot. EI #3 stated "RI #1 said just leave me alone, I can do it and I don't need your help." EI #3 said the more she tried talk to RI #1, the more agitated and uncooperative the resident became. EI #3 was asked what was the main reason for administering the [MEDICATION NAME] to RI #1. EI #3 said because RI #1 was agitated and uncooperative. EI #3 was asked after receiving the [MEDICATION NAME] injection, how did RI #1 respond. EI #3 stated that RI #1 went back to sleep. On 8/20/14 at 3:30 PM, a second interview was conducted with EI #1, DON. EI #1 was asked was it appropriate to administer [MEDICATION NAME] based on prior behavior. EI #1 said no, we base it on what we see here. EI #1 was asked what was the potential harm in administering a [MEDICATION NAME] injection without a sufficient reason. EI #1 said people handle the medication differently; it is different for each person.

Based on observation, interview, and record review, the facility failed to ensure that licensed staff administered crushed medication for RI (Resident Identifier) #17 and eye drops for RI #16 in a manner to prevent cross contamination. This affected two of six residents observed during medication pass. The facility further failed to ensure licensed staff washed their hands while administering eye drops for RI#16 in a manner to prevent cross contamination. This affected one of six residents observed during medication administration. The facility further failed to ensure licensed staff did not contaminate RI #5's over bed table during wound care. This affected one of two observations of wound care. Findings Included: A review of the facility's policy and procedure titled, "Hand Hygiene" with an effective date of 12/1/2009, revealed "PURPOSE: To provide guidelines to employees for proper and appropriate hand washing techniques...STANDARD: Hand washing should be performed between procedures with residents..." A review of the facility's policy and procedure titled, "Dressings - Clean" with an effective date of 12/15/2010 revealed "...PROCESS: ...3. A disposable cloth...is placed on the overbid table to establish a clean field...15. Discard disposable items and gloves into appropriate trash receptacle..." A review of the facility's policy and procedure titled, "Preparation for Medication Administration" dated 3/2011 revealed "...Policy... Medications are administered as prescribed in accordance with good nursing principles and practices..." A review of the facility's policy and procedure titled, "Medication Administration" dated 3/2011 revealed "...Procedures...6. Cleanse hands with soap and water...after direct contact with resident...then administering...ophthalmic...medications..." A review of the facility's policy and procedure titled, "Medication Administration Procedures Eye Drops" dated 3/11, revealed "...Policy Ophthalmic solutions are to be administered into and around the eye in a safe and accurate manner. Procedures...2. Obtain a clean barrier and place on the over bed table... 4. Remove the cap and place it on the barrier..." 1.) RI #17 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #17's most recent quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 4/18/2014 revealed, that RI #17 had a BIMS (Brief Interview for Mental Status) score of 11 which indicated moderately impaired daily decision making ability. RI #17's MDS further revealed that she had signs and symptoms of a possible swallowing disorder that included coughing or choking when swallowing medications. On 4/30/2014 at 4:25 PM EI (Employee Identifier) #1, LPN (Licensed Practical Nurse) was observed crushing medication for RI #17. Three pill crush pouches were used for crushing three different pills. EI #1 opened each pouch of crushed medication by placing her bare finger inside each pouch. On 4/30/2014 at 4:35 PM and interview was conducted with EI #1. EI #1 was asked how she usually opens pill pouches. EI #1 demonstrated that she opens the pouch by touching the outside of the pouch. EI #1 was asked why she opened the pouch with her bare fingers inside the pouch. EI #1 stated that she did not know that she did. EI #1 was asked what would be the harm in touching the inside of the pouch. EI #1 stated, "Contamination." On 4/30/2011 at 10:00 AM an interview was conducted with EI #3, DON (Director Of Nurses). EI #3 was asked what was the facility policy for administering crushed medications from a pill pouch. EI #3 stated to use fingers to open the pouch but not put fingers inside the pouch, if so they would have to start over. EI #3 was asked if the nurse should have done it that way. EI #3 stated that the nurse should have started over if her fingers were placed inside the pouch. EI #3 was asked what was the harm in touching the inside of the pouch. EI #3 stated, " infection control". 2.) RI #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #16's Annual MDS (Minimum Data Set), dated 3/7/2014, revealed RI #16 had moderately impaired cognitive skills for daily decision making. The MDS further revealed that RI #16 had severely impaired vision. On 5/1/2014 at 8:45 AM EI (Employee Identifier) #4, LPN (Licensed Practical Nurse), was observed during medication pass administering three different types of eye drops for RI #16. EI #4 placed the eye drop bottle caps onto the over bed table without a barrier. After administration of the last eyedropper EI #4 removed her gloves and did not wash her hands. EI #4 then placed the three eye drop bottles back into the medication cart, handed a staff member a resident's cigarette package out of the cart, assisted RI #16 to activities, assisted another resident with a hearing aide, and then washed her hands. On 5/1/2014 at 10:30 AM an interview was conducted with EI #4. EI #4 was asked what was the facility's policy and procedure for handwashing during medication pass. EI #4 stated to wash your hands before, after, and between eye drops or fingersticks. EI #4 was asked how she should have washed her hands after administering eye drops. EI #4 stated to wash hand in between all drops and after drops. EI #4 was asked why she did not wash her hands after administrating the last eye drop for RI #16. EI #4 stated she thought she did and it was just a mistake. EI #4 was asked what was the harm in not washing her hands after eye drop administration and she stated, "Cross contamination." EI #4 was asked what was the facility policy for handling eye bottle caps. EI #4 stated that the bottle caps should be placed on a clean surface. EI #4 was asked how she handled the bottle caps and she stated that she did not remember. EI #4 was asked what was the harm in placing the bottle caps on the over bed table and she stated "Cross contamination." On 5/1/2014 at 10:00 AM an interview was conducted with EI #3, DON (Director Of Nursing). EI #3 was asked what was the facility's policy and procedure for administration of eye drops and placement of the bottle caps. EI #3 stated that the caps should be placed on a drape or barrier. EI #3 was asked if EI #4 should have done it that way and she stated yes. EI #3 was asked what was the harm in not placing the bottle caps on a drape or barrier. EI #3 stated, "Infection control, whatever is on the surface can go in the bottle and be transmitted in the eyes." EI #3 was asked what was the facility's policy for handwashing during eye drop administration. EI #3 stated between eye drops and after administration. EI #3 was asked if EI #4 should have done it this way and she stated yes. EI #3 was asked what was the harm in not doing it that way. EI #3 stated infection control and contamination of the next bottle of drops. 3.) RI #5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #5 quarterly Minimum Data Set (MDS), dated [DATE] revealed RI #5's BIMS (Brief Interview for Mental Status) score was a 12, which indicated moderately impaired daily decision-making skills. The MDS further revealed that RI #5 had dressings to her feet. On 5/1/2014 at 11:10 AM EI #5, RN (Registered Nurse), was observed providing wound care for RI #5. EI #5 placed tongue blades that had been used for measuring RI #5's wounds directly onto RI #5's over bed table. EI #5 removed the tongue blades from RI #5's over bed table without sanitizing the table. RI #5's lunch tray was then brought in and placed on the over bed table. On 5/1/2014 at 11:49 AM an interview was conducted with EI #5. EI #5 was asked what was the facility policy and procedure for cleaning areas used for treatment supplies after wound care. EI #5 stated that RI #5's over bed table was clean. EI #5 was asked how would that surface be cleaned after wound care. EI #5 stated that she would use a disinfectant wipe. EI #5 was asked if she wiped the over bed table. EI #5 stated, "No, the surface was clean and had a barrier." EI #5 was asked why did she place the tongue blades directly onto the overbed table. EI #5 stated, "I should have placed them on the barrier." EI #5 was asked what was the harm in placing the tongue blades used for measuring wounds on the over bed table and not cleaning it afterward. EI #5 stated that the table could be contaminated. On 5/1/2014 at 10:05 AM an interview was conducted with EI #3, DON. EI #3 was asked what was the facility policy for placing used wound care items on a surface. EI #3 stated that a barrier is needed. EI #3 was asked if the nurse should have done it that way. EI #3 stated yes. EI #3 was asked what the harm was in not doing it that way. EI #3 stated contamination of the surface the item was put on.

Based on observation, interviews, and record review, the facility failed to ensure RI (Resident Identifier) #3 was checked and changed for incontinence every two hours as planned. This was observed on 4/9/2013 during a continuous 4 hour observation. This affected 1 of 3 residents sampled for bowel and bladder concerns. Findings include: RI #3 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/10/2013 revealed Section G- Functional Status Toilet Use as total dependence upon staff. Section H- Bladder and Bowel further revealed RI #3 was always incontinent of bladder and bowel. Review of RI #3's care plan titled "Frequently incontinent of bowel and bladder..." with a problem onset date of 6/17/2011 revealed a goal of "Resident not to have complications r/t (related to) incontinence x (times) 90 days AEB (as evidenced by): no skin problems". Care plan further revealed an approach "... resident checked q (every) 2 hr (hour) with incontinence care provided..." The surveyor observed RI #3 continuously on 4/9/2013 from 2:30 PM to 6:28 PM. At 2:30 PM on 4/9/2013 RI #3 was observed in her room in her geri-chair sitting straight up with a pillow behind her head and one in her lap. At 2:38 PM on 4/9/2013 a CNA (Certified Nursing Assistant) entered RI #3's room and pulled the curtain. The surveyor immediately knocked on the door and received permission to enter. The CNA stated the resident was not wet. The CNA then repositioned RI #3 up in the geri-chair, reclining her back with a pillow behind her head and replaced the pillow under her arm. The Surveyor made a continuous observation of RI #3 on 4/9/2013 from 2:38 PM to 3:12 PM. Another CNA, Employee Identifier (EI) #1, entered the room and asked the resident how she was doing and immediately exited. The Resident did not respond. On 4/9/2013 at 3:15 PM EI #1 entered the room and filled in the staffing board and left. The Resident was still in the same position. The Surveyor made a continuous observation of RI #3 on 4/9/2013 from 3:15 PM to 4:05 PM. EI #1 entered the resident's room and pulled the curtain. The surveyor immediately knocked on the door and received permission to enter. EI #1 stated she was going to stand RI #3 and reposition her. The surveyor observed the CNA stand RI #3 and reposition the resident. RI #3 was never checked for incontinence. The Resident was placed back in her geri-chair, sitting straight up with a pillow behind her head and under her arms. The surveyor continued to make observations of RI #3 from 4:05 PM to 4:18 PM when EI #1 assisted RI #3 to the main dining room and arrived at 4:21 PM. The surveyor made continuos observations of RI #3 from 4:21 PM to 5:19 PM when RI #3 received her supper tray. At this time RI #3 was still seated in the same position. RI #3 finished her meal at 5:51 PM. At 5:54 PM RI #3 was assisted from the main dining room to the hall where she resided. RI #3 arrived on the hall at 5:56 PM. The Surveyor observed EI #1 stand RI #3 and reposition her. RI #3 was placed back in her geri-chair with a pillow behind her head and under her arms. The surveyor made continuous observations of RI #3 from 5:56 PM to 6:28 PM when EI #1 assisted RI #3 to her room. Two Surveyors knocked on the door and received permission to enter. EI #1 stated she was getting the resident ready for bed. At 6:32 PM the second surveyor remained in RI #3's room to observe incontinent care. The surveyor asked EI #1 if RI #3 was wet. EI #1 stated, "She is wet." EI #1 explained the lines on the diaper turn blue when the diapers are wet. EI #1 also stated, "She has two blue lines." In an interview on 4/9/2013 at 6:44 PM, EI #1 was asked how often RI #3 was supposed to be checked and changed for incontinence. EI #1 stated, "Every two hours." EI #1 was asked when the last time she had checked RI #3 for incontinence prior to 6:28 PM. EI #1 replied, "Around 2:30 PM." EI #1 was asked what the potential harm could be if RI #3 was not checked and changed in a timely manner. EI #1 stated, "If she stays wet too long there is the potential for breakdown." In an interview on 4/11/2013 at 8:13 AM, EI #2, RN (Registered Nurse)/ DON (Director of Nursing), was asked how often residents should be checked and changed. EI #2 replied, "Every hour or when the light goes off and I like for them to go in even sooner than that, maybe even every thirty minutes but at least every hour." EI #2 was asked what potential harm could result if a resident was not checked and changed within the required time frame. EI #2 replied, "It could absolutely cause skin issues, redness, breakdown." EI #3 was asked who was responsible for checking and changing residents, and EI #2 answered, "The CNAs are responsible but the LPNs (Licensed Practical Nurse) and RNs will assist if a call light goes off." When asked why residents should be checked and changed, EI #2 replied, "We want to make sure we prevent any skin issues and especially if they are incontinent they are kept clean and dry and repositioned timely."