Every finding on record at NHC Healthcare, Mcminnville

Based on facility policy review, observations, and interviews, the kitchen failed to store refrigerated food in a safe manner to prevent cross-contamination and failed to ensure refrigerated foods were dated to ensure expired foods were discarded, which had the potential to affect 111 of 111 residents. The findings include: Review of the facility's policy titled, Refrigerator and Freezer Storage, dated ,d+[DATE], showed .all items are to be stored at least 6 [inches] off floor of walk-in units .Leftovers will be placed in .approved containers, covered, labeled .dated . Observation of the walk-in cooler with the Certified Dietary Manager (CDM) on [DATE] at 8:05 AM, showed Four 5-pound containers of Pulled Pork stored on the floor of the walk-in cooler. Observation of the walk-in cooler with the CDM on [DATE] at 8:05 AM, showed the following items were not labeled and dated: Three individual bowls of apple sauce Three individual bowls of chocolate pudding One individual bowl of salad Observation of the walk-in freezer with the CDM on [DATE] at 8:08 AM, showed One ,d+[DATE] full bag of french-fries not labeled or dated. Observation of the reach-in freezer with the CDM on [DATE] at 8:11 AM, showed One ,d+[DATE] lemon pie not labeled or dated. Observation of the reach-in cooler with the CDM on [DATE] at 8:13 AM, showed One ,d+[DATE] full container of cottage-cheese not dated. During an interview on [DATE] at 12:05 PM, the CDM stated all refrigerated and freezer food items were to be dated and stored properly. The DM confirmed the food items had not been stored and dated per the facility policy for refrigerator and freezer storage. Review of the manufacturer's guidelines titled, Ready Care, undated, showed .frozen shake .nectar consistency .Shelf life: 1 year from production date in frozen state. Once thawed, refrigerate for up to 14 days . During an observation on [DATE] at 7:30 AM, on the 400-hall medication cart, showed five 4-oz cartons of nectar thickened liquid supplement stored at room temperature. During an interview on [DATE] at 7:35 AM, Licensed Practical Nurse (LPN) #1 stated the nectar thickened liquid cartons were pulled from the unit refrigerator to use during medication administration. LPN #1 stated as referenced on the product label, the thickened liquids should be stored on ice or in the refrigerator. During an interview on [DATE] at 7:45 AM, the Director of Nursing (DON) stated the thickened liquid supplement should not be stored at room temperature during medication administration. DON confirmed the thickened liquid supplement was not stored per manufacturer guidelines. During an interview on [DATE] at 7:50 AM, the Certified Dietary Manager (CDM) stated the nectar thickened liquid supplements are stored in the freezer upon arrival to the facility and then placed in unit refrigerators for the floor staff to use during medication administration. CDM stated per manufacturer guidelines, the thickened liquid supplement should be stored in the refrigerator or on ice to maintain temperature during medication administration.

Based on facility policy review, record review, observation, and interview the facility failed to revise the comprehensive care plan for 1 resident (Resident #99) related to an indwelling urinary catheter of 6 residents reviewed for indwelling urinary catheters. The findings include: Review of the facility's policy titled, Patient Care Plans, dated November 2023, showed .Care plans are updated as needed but are reviewed completely by the interdisciplinary team on a quarterly bases within 7 days of the completion of the clinical .assessment .new problems are handled as they arise and are to be added to the current care plan . Resident #99 was admitted to the facility on [DATE] with diagnoses including Adult Failure To Thrive, Hypertension, Chronic Kidney Disease, and Atrial Fibrillation. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #99 was cognitively intact and had an indwelling urinary catheter. Review of the Comprehensive Care Plan dated 12/7/2023, showed Resident #99 had an indwelling urinary catheter, and the diagnosis was Stage III Pressure Ulcer. Review of the current Physician's Orders showed an indwelling urinary catheter diagnosis of .Neuromuscular dysfunction of bladder . During an observation on 12/13/2023 at 7:15 AM, in the residents room with the Wound Care Nurse showed Resident #99 had an indwelling urinary catheter and the resident did not have a Stage III pressure ulcer. During an interview on 12/13/2023 at 8:25 AM, MDS Coordinator #2 stated the diagnosis for the indwelling urinary catheter for Resident #99 was Stage III pressure ulcer. During an interview on 12/13/2023 at 9:50 AM, the Director of Nursing (DON) stated the diagnosis for Resident #99's indwelling urinary catheter was a neurogenic bladder. The DON confirmed Resident #99 did not have a Stage III Pressure Ulcer and the care plan had not been revised to include the diagnosis of neurogenic bladder.

Based on review of the facility policy, observation, and interview, the facility failed to label, date, correctly store resident foods, and discard expired food items, potentially affecting 105 of 105 residents residing in the facility. The findings include: Review of the facility policy titled, Safety & Sanitation Best Practice Guidelines revised ,[DATE] showed .Foods will be stored in their original container or .wrapped tightly in moisture-proof film, film, foil .Clearly labeled with the contents and the use by date . Observation and interview on [DATE] at 10:38 AM, with the Dietary Manager (DM), in the walk-in refrigerator, revealed 65 half pint whole milk cartons with an expiration date of [DATE], and 9 chicken tenders in a plastic container with no open date or expiration date. The DM confirmed the milk was expired, the chicken tenders were unlabeled, and available for resident use. Observation and interview on [DATE] at 10:45 AM, with the DM, in the walk-in freezer revealed a box of 160 sausage links and a 12 pound box of whole hog sausage patties open to air. The DM confirmed the sausage links and sausage patties were stored incorrectly, open to air, and available for resident use. During an interview on [DATE] at 1:15 PM, the Registered Dietician stated all open foods were to be labeled, dated, and expired foods were to be discarded.

Based on medical record review, review of the Resident Assessment Instrument (RAI) Version 3.0 Manual, review of the Minimum Data Set (MDS) and interview the facility failed to complete a timely quarterly assessment for 1 resident (#4) of 3 residents reviewed for MDS assessments of 32 sampled residents. The findings include: Medical record review revealed Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the RAI Version 3.0 Manual Chapter 2: Assessments for the RAI revealed .The next non-comprehensive assessment is due within 92 days after the ARD (Assessment Reference Date) of the most recent .assessment . Medical record review for Resident #4 revealed an annual MDS had been completed with an ARD date of 10/9/18. Further review revealed a quarterly MDS assessment had not been completed 1/2019. Interview with the MDS Coordinator, Licensed Practical Nurse on 2/27/19 at 8:45 AM, in the MDS office, confirmed the quarterly assessment had not been completed timely for Resident #4.

Based on medical record review, observation, and interview, the facility failed to implement a comprehensive care plan, for pain management, for 1 Resident (#103) of 12 residents reviewed for pain of 36 residents sampled. The facility's failure to implement the pain management care plan on 2 occasions between 5/4/18 and 5/7/18 resulted in an increase in pain and harm to the resident. The findings included: Medical record review revealed Resident #103 was admitted to the facility on [DATE], on Palliative care, (specialized medical care for people with serious illness. This type of care is focused on providing relief from the symptoms and stress of a serious illness. The goal is to improve quality of life for both the patient and the family.) with [DIAGNOSES REDACTED]. Medical record review of the 30 day Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Further review revealed the resident had moderate pain and received routine and PRN (as needed) pain medication. Medical record review of the resident's care plan dated 4/24/18 revealed .risk for alteration in comfort/pain .administer medications as ordered .via PCA pump (Patient Controlled [MEDICATION NAME], method of allowing a person in pain to administer their own pain medication) . Review of the (MONTH) (YEAR) Medication and Treatment Administration Record Report revealed .[MEDICATION NAME] (a pain medication) PCA 1MG (milligram) HOUR PRN 0.5 MG BOLUS (as needed single dose of a drug given all at once) Q (every) 20 MIN (minutes)DO NOT EXCEED 4MG .Continued review revealed on 5/7/18 the order changed to .[MEDICATION NAME] 2MG HOUR WITH PRN 1MG BOLUS Q 20 MIN DO NOT EXCEED 4MG . and on 5/8/17 the order changed to .[MEDICATION NAME] 2MG HOUR WITH PRN 1MG BOLUS Q 20 MIN DO NOT EXCEED 5MG . Continued review revealed on 5/7/18 . [MEDICATION NAME] (a pain medication) 100 MG/5ML (milliliter) SOLUTION 0.5ML-1 ML (10MG-20MG) BY MOUTH EVERY HOUR AS NEEDED FOR PAIN . Review of a Nurse's Note dated 5/7/18 at 10:50 AM revealed .Pt (patient) stated this AM that current resting pain level @ (at) 7/10 (7 on a 0-10 scale with 10 being the worst pain) MD (Medical Doctor)notified. N/O (nursing order) to (increase) continuous infusion to 2 mg per hour and 1 mg boluses q (every) 20 min . Review of the PCA Pump Flow Sheet revealed on 5/4/18 Resident #103's level of pain was 4/10, on 5/5/18 4/10 and 6/10, on 5/6/18 5/10 and 7/10 and on 5/7/18 7/10 and 6/10. Interview with Resident #103 and a family member on 5/7/18 at 2:30 PM, in the resident's room, revealed the resident and the family member stated the PCA pump ran out on 5/4/18 and the facility had no replacement available. Interview with Resident #103's family member on 5/8/18 at 8:49 AM, in the resident's room, confirmed the PCA pump ran out again on 5/7/18 at 3:30 PM and was not restarted until 7:30 PM. Further interview revealed .he was having a lot of pain in his bottom . Interview with Licensed Practical Nurse (LPN) #1 on 5/9/18 at 10:14 AM, in the 100 hallway, confirmed on 5/7/18 .his pain pump ran out between 3 - 4 (PM) . Further interview confirmed no extra pump was available. Interview with Resident #103 on 5/9/18 at 10:43 AM, in the resident's room, confirmed when the PCA pump ran out of medication the first time, Resident #103 was asked ifthe pain was worse and stated .Yeah it probably was . Further interview confirmed the pain was worse the second time the PCA medication ran out stating .it got bad . Continued interview confirmed the resident stated .it (PCA pump replacement) needs to be on hand at all times . The resident further stated he was very upset, and if it had happened once, it should not have happened again. Interview with Assistant Director of Nursing (ADON) #1 on 5/9/18 at 1:23 PM, in the station 3 activity/dining room, confirmed the PCA pump medication ran out on 5/7/18 at approximately 3:00 PM, and the facility did not receive the pain medication from the pharmacy until approximately 6:30 PM or 7:00 PM. Further interview confirmed the resident received 4 doses of [MEDICATION NAME] between 3:30 PM to 10:00 PM and confirmed the 4th dose was given after the PCA pump had been restarted to get his pain .back under control . Continued interview confirmed the [MEDICATION NAME] was .not what his body is used to . Further interview confirmed ADON #2 was notified of the first occurrence on 5/4/18 and ADON #1 was notified of the second occurrence on 5/7/18. Interview with ADON #2 on 5/9/18 at 2:30 PM, in the class room, confirmed she was notified on 5/4/18 at 7:15 PM the PCA pump was empty and no extra pump was available in the medication room. Further interview confirmed the medication arrived at the facility approximately 9:30 PM to 10:00 PM on 5/4/18. Continued interview confirmed ADON #2 did not assess the Resident #103's pain level while the PCA pump was empty. Interview with the Director of Nursing (DON) on 5/9/18 at 2:42 PM, in the conference room, confirmed she was aware on 5/4/18 the PCA pump had run out. Further interview confirmed she spoke with the pharmacy on the morning of 5/7/18 regarding the pump running out of medication with no replacement immedicately available on 5/4/18, and the dosage increase ordered the morning of 5/7/18. Continued interview revealed .I don't know (the reason the pump ran out of medication again later that evening) . Further interview revealed the DON had not discussed either occurrence with the resident or the family member. Interview with Resident #103's family member on 5/9/18 at 4:41 PM, in the resident's room, revealed prior to admission to the facility the resident had experienced uncontrolled pain. Further interview confirmed the PCA pump was .his crutch . Continued interview confirmed the resident became anxious when the pain medication was unavailable and continues to worry it will happen in the future and his pain will not be controlled. The facility's failure to implement the pain management care plan resulted in an increase in pain and harm to the resident.

Based on medical record review, observation, and interview, the facility failed to ensure physician ordered pain medication was available for 1 Resident (#103) of 1 resident on Patient Controlled [MEDICATION NAME] (PCA) pump (method of allowing a person in pain to administer their own pain medication) of 12 residents reviewed for pain. The facility's failure to ensure the pain medication was available on 2 occasions between 5/4/18 and 5/7/18 resulted in an increase in pain and harm to Resident #103. The findings included: Medical record review revealed Resident #103 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the 30 day Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Further review revealed the resident had moderate pain and received routine and PRN (as needed) pain medication. Medical record review of the resident's care plan dated 4/24/18 revealed .risk for alteration in comfort/pain .administer medications as ordered .via PCA pump . Review of the (MONTH) (YEAR) Medication and Treatment Administration Record Report revealed .[MEDICATION NAME] (a pain medication) PCA 1MG (milligram) HOUR PRN 0.5 MG BOLUS (as needed single dose of a drug given all at once) Q (every) 20 MIN (minutes)DO NOT EXCEED 4MG .Continued review revealed on 5/7/18 the order changed to .[MEDICATION NAME] 2MG HOUR WITH PRN 1MG BOLUS Q 20 MIN DO NOT EXCEED 4MG . and on 5/8/17 the order changed to .[MEDICATION NAME] 2MG HOUR WITH PRN 1MG BOLUS Q 20 MIN DO NOT EXCEED 5MG . Continued review revealed on 5/7/18 . [MEDICATION NAME] (a pain medication) 100 MG/5ML (milliliter) SOLUTION 0.5ML-1 ML (10MG-20MG) BY MOUTH EVERY HOUR AS NEEDED FOR PAIN . Review of a Nurse's Note dated 5/7/18 at 10:50 AM revealed .Pt (patient) stated this AM that current resting pain level @ (at) 7/10 (7 on a 0-10 scale with 10 being the worst pain) MD (Medical Doctor)notified. N/O (nursing order) to (increase) continuous infusion to 2 mg per hour and 1 mg boluses q (every) 20 min . Review of the PCA Pump Flow Sheet revealed on 5/4/18 Resident #103's level of pain on a 0-10 scale with 10 being the worst pain was 4/10, on 5/5/18 4/10 and 6/10, on 5/6/18 5/10 and 7/10 and on 5/7/18 7/10 and 6/10. Medical record review of the Medication and Treatment Administration Record Report dated (MONTH) (YEAR) revealed the resident received 4 doses of [MEDICATION NAME] on 5/7/18 at the following times: 3:30 PM, 4:39 PM, 6:41 PM, and 8:27 PM. Observation and Interview with Resident #103, and a family member, on 5/7/18 at 2:30 PM, in the resident's room, revealed the resident lying in the bed with a PCA pump at the bedside. Further interview revealed the resident and his family stated the PCA pump ran out on 5/4/18 and the facility had no refill available. Interview with Resident #103's family member on 5/8/18 at 8:49 AM, in the resident's room, confirmed the PCA pump ran out again on 5/7/18 at 3:30 PM and was not restarted until 7:30 PM. Continued interview revealed the resident received sublingual (under the tongue) [MEDICATION NAME] while the pump was not infusing and was also given a dose of [MEDICATION NAME] once after the pump was restarted because he was in so much pain. Further Interview revealed .he was having a lot of pain in his bottom . Interview with Certified Nursing Assistant (CNA) #1 on 5/9/18 at 9:04 AM, in the 100 hallway, confirmed Resident #103's PCA pump ran out on 5/7/18. Continued interview revealed .Someone was supposed to deliver it at 4:30 PM and it was not here yet when I left at 7:00 PM .He was in pain . Interview with Licensed Practical Nurse (LPN) #1 on 5/9/18 at 10:14 AM, in the 100 hallway, confirmed on 5/7/18 .his pain pump ran out between 3 - 4 (PM) . Further interview confirmed no extra pump was available at the facility. Continued interview revealed the pharmacy was notified for a STAT (rush) delivery because normal delivery time was 00:00 to 2:00 AM. Continued interview confirmed this was the second time the PCA pump ran out of pain medication and none was available to replace. Interview with Resident #103 on 5/9/18 at 10:43 AM, in the resident's room, confirmed when the PCA pump ran out the first time the pain was worse and stated .Yeah it probably was . Further interview confirmed the pain was worse the second time the PCA ran out stating .it got bad . Continued interview confirmed the resident stated .it needs to be on hand at all times . The resident further stated he was very upset, and if it had happened once, it should not have happened again. Interview with LPN #2 on 5/9/18 at 12:39 PM, in the Nursing Secretary's Office at Station 2, confirmed the PCA pump was empty when she came on shift on 5/4/18 at 7:00 PM. Continued interview revealed the medication was received approximately 9:30 PM or 10:00 PM on 5/4/18. Interview with Registered Nurse (RN) #1 on 5/9/18 at 1:03 PM, in the station 3 activity/dining room, confirmed there was no extra pump kept in the medication room. Further interview revealed Resident #103's normal pain level with use of the PCA pump was .when he is using it 0 . Interview with Assistant Director of Nursing (ADON) #1 on 5/9/18 at 1:23 PM, in the station 3 activity/dining room, confirmed the PCA pump medication ran out on 5/7/18 at approximately 3:00 PM, and the facility did not receive the pain medication from the pharmacy until approximately 6:30 PM or 7:00 PM. Further interview confirmed the resident received 4 doses of [MEDICATION NAME] between 3:30 PM to 10:00 PM and confirmed the 4th dose was given after the PCA pump had been restarted to get his pain .back under control . Continued interview confirmed the [MEDICATION NAME] was .not what his body is used to . Further interview confirmed ADON #2 was notified of the first occurrence on 5/4/18 and ADON #1 was notified of the second occurrence on 5/7/18. Interview with ADON #2 on 5/9/18 at 2:30 PM, in the class room, confirmed she was notified on 5/4/18 at 7:15 PM the PCA pump was empty and no extra pump was available in the medication room. Further interview confirmed the medication arrived at the facility at approximately 9:30 PM to 10:00 PM on 5/4/18. Continued interview confirmed ADON #2 did not assess the resident's pain level while the pump was empty. Interview with the Director of Nursing (DON) on 5/9/18 at 2:42 PM, in the conference room, confirmed she was aware on 5/4/18 the PCA pump was empty. Further interview confirmed she spoke with the pharmacy on the morning of 5/7/18 regarding the pump running out of medication on 5/4/18 and the dosage increase ordered the morning of 5/7/18. Continued interview revealed .I don't know (the reason the pump ran out again later that evening) . Further interview revealed the DON had not discussed either occurrence with the resident or the family member. Interview with Resident #103's family member on 5/9/18 at 4:41 PM, in the resident's room, revealed prior to admission to the facility the resident had experienced uncontrolled pain. Further interview confirmed the PCA pump was .his crutch . Continued interview confirmed the resident became anxious when the pain medication was unavailable and continues to worry it will happen in the future and his pain will not be controlled.

Based on medical record review, review of facility documentation and interview, the facility failed to accurately assess 1 resident (#105) out of 3 residents reviewed for falls of 36 sampled residents. The findings included: Medical record review revealed Resident #105 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's Post Falls Investigation dated 3/30/18 revealed Resident #105 experienced a fall on 3/29/18 in the resident's room. Medical record review of the Minimum Data Set ((MDS) dated [DATE] revealed, .resident had any falls since admission . 0 (indicating none) . Interview with the MDS Coordinator on 5/9/18 at 8:30 AM, at the 400 unit nurse's station, confirmed the 4/14/18 MDS for Resident #105 was inaccurate for falls.

Based on medical record review, observation and interview, the facility failed to post an isolation precaution sign on the door of 1 Resident (#82) of 1 resident on isolation precautions of 36 sampled residents. The findings included: Medical record review revealed Resident #82 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a physician order [REDACTED].ISOLATION (separation of those known to be infected with a contagious disease to prevent further infections) PT (patient) IN PRIVATE ROOM WITH ALL CARE AND TREATMENT PROVIDED IN ROOM . Medical record review of the resident's care plan dated 4/20/18 revealed .Need for isolation precautions .Maintain isolation per protocol . Observation during the initial tour of Resident #82's room on 5/7/18 at 11:05 AM, in the 100 hallway, revealed no precaution sign on the door and a bedside table, not labeled, in the hallway beside the resident's door. Observation of CNA #3 on 05/07/18 at 12:19 PM, in the100 hallway, obtain a gown and gloves from the bedside table, beside the resident's door, and put on the gown and the gloves to deliver the resident's lunch. Interview with Certified Nursing Assistant (CNA) #2 on 5/8/18 at 10:12 AM, in the rehab dining room, confirmed there should be a sign on the door to see the nurse before entering. Further interview confirmed a precaution sign was not on the door on 5/7/18. Interview with the Director of Nursing (DON) on 5/9/18 at 2:42 PM, in the conference room, confirmed the facility failed to post an isolation precaution sign on the resident's door to notify staff and visitors of the isolation precautions.

Based on review of facility policy, medical record review, facility documentation, observation, and interview, the facility failed to provide assistance for toileting for 1 resident (#31) of 2 residents reviewed for incontinence care of 28 residents sampled. The findings included: Review of the facility policy Bowel and Bladder Guidelines, undated, revealed .a resident who is incontinent of bowel and bladder receives appropriate treatment and services . Medical record review revealed Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident scored a 3 (severe cognitive impairment) on the Brief Interview of Mental Status (BIMS). Continued review revealed the resident required extensive assistance with toileting and was always incontinent of urine. Medical record review of a Nursing Summary Report dated 4/15/17 revealed the resident did not have any excoriation or pressure ulcers. Observation of Resident #31 on 4/17/17 at 11:40 AM, in the resident's room, revealed a strong odor was present. Observation and interview with Resident #31 on 4/18/17 at 9:03 AM, in the resident's room, revealed the resident was lying in bed and a strong odor was present. Interview with the resident revealed she had urinated and the staff rolled up a blanket and placed it between the resident's upper thighs. Further interview revealed the .the nurses do it to catch the urine . Observation and interview with Certified Nursing Assistant (CNA) #2 and Licensed Practical Nurse (LPN) #1 on 4/18/17 at 9:20 AM, in the resident's room, confirmed the strong odor was urine. Observation and interview with the Director of Nursing (DON) on 4/18/17 at 9:30 AM, in the resident's room, confirmed the strong odor was urine and the rolled up blanket was not to be used. Interview with the DON on 4/19/17 at 11:42 AM, in the conference room, confirmed the facility failed to provide ADL care for Resident #31 and failed to follow facility policy.

Based on facility policy review, observation and interview, the facility failed to prevent debris accumulation in the walk-in freezer and walk-in refrigerator condenser fan grates and ceiling areas, thereby, possibly contaminating food stored in these units; failed to prevent the walk-in freezer from developing ice build-up; failed to dispose expired food and prevent it from being available for resident use; failed to maintain the dish machine wash temperature at the manufacturer's recommended minimum temperature of 160 degrees Fahrenheit (F) in 2 separate observations of 6 consecutive cycles each observation; failed to maintain cold food at or less than 41 degrees F on the resident tray line; failed to maintain food preparation and storage equipment in a sanitary manner; and failed to maintain the sanitizer level in the 3 compartment sink at 150-400 parts per million per the manufacturer's recommendation. The findings included: Review of the facility policy entitled Safety & Sanitation Best Practices Guidelines dated 1/2011, revealed .Danger Zone: Temperatures above 41 degrees F (Fahrenheit) .allow the rapid growth of pathogenic microorganisms that could cause food borne illness .Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) Food: Food that requires time/temperature control for safety to limit growth of pathogens .Ex (Example) Milk, dairy products, eggs . Further review revealed .Holding (of food): .Cold food must be kept at a minimum of 41 degrees or lower . Further review revealed .Serving (the food): .Cold food should be held at 41 degrees or lower throughout the serving process . Observation and interview on 4/11/16 at 9:12 AM in the dietary department, with the Dietary Manager (DM) present during the observation, revealed the walk-in freezer and walk-in refrigerator condenser fan grates and the ceiling area in front of the grates had an accumulation of hanging black and/or white debris. Further observation in the walk-in freezer revealed a heavy accumulation of ice down the pipe from the condenser unit to a pan stored on the top shelf of a rack. Further observation revealed the pan was filled with ice from the condenser unit. Further observation in the walk-in refrigerator revealed two 5 pound containers labeled Protein Salad. One container was 2/3 empty and had an expiration date of 12/17/15 and the second unopened container had an expiration date of 3/10/16. Further observation revealed 1 flat (approximately 2 dozen) uncovered fresh eggs stored in the walk-in refrigerator that could be contaminated by the debris on the condenser fan grate and ceiling. Interview with the DM confirmed both walk-in units had an accumulation of hanging debris on the condenser fan grates and ceiling area, fresh eggs were uncovered and could be contaminated by the debris from the condenser fan grate and ceiling debris, there was ice built-up in the freezer, and the 2 containers of Protein Salad were expired and available for resident use. Observation and interview on 4/11/16 at 9:30 AM and on 4/12/16 at 1:38 PM in the dietary department, with the DM present during the observation, revealed the dish machine was in operation. Observation of the posted manufacturer's recommendation revealed the minimum wash temperature was 160 degrees F. Observation on 4/11/16 at 9:30 AM and on 4/12/16 at 1:38 PM, of 6 consecutive operations of the machine each day observed, revealed the wash temperature was 148 degrees F each operation and the wash gauge never moved. Further observation revealed the dietary staff removed the cleaned dishes and placed them in a storage unit. Interview with the DM confirmed the dish machine failed to reach a minimum of 160 degrees F per the manufacturer's recommendation, for the wash temperature for each operation observed on both days. Further observation on 4/11/16 at 9:30 AM and on 4/12/16 at 1:38 PM revealed the top of the dish machine was covered with debris and rust which could contaminate the cleaned dishes. Observation on 4/11/16 from 11:27 AM to 11:55 AM in the dietary department, with the DM present, revealed the resident mid-day meal service was in operation. Further observation revealed the morning cook obtaining the temperatures of the eclairs (a food containing dairy products), stored on a rack by the tray line, was 45 degrees F. Further observation revealed there were 4 full size sheet pans of eclairs stored on the rack. Further observation revealed the dietary staff continued to place the eclairs onto individual resident trays in 2 resident delivery carts after the temperature was obtained. Interview with the DM on 4/11/16 at 11:55 AM in the dietary department, by the resident tray line, confirmed the facility failed to maintain cold food at or less than 41 degrees F and continued to serve it to the residents. Observation and interview on 4/12/16 beginning at 1:43 PM in the dietary department, with the DM present during the observation, confirmed the facility failed to maintain sanitary food preparation and storage equipment by the following: 1. Toaster conveyor and spill pan had a heavy accumulation of crumbs. 2. Ice maker intake filter grate had an accumulation of sticky dusty debris. 3. 2 heat lamps, located next to the fryer, exterior surfaces had an accumulation of greasy residue. 4. Grill trough and waste slot had a greasy residue and food debris present. 5. Grill and range top spill pan were filled with food debris and liquid. 6. Grill spill pan handle had an accumulation of sticky dusty residue. 7. Grill back splash had an accumulation of greasy residue. 8. The 4 gas range burners had a very heavy accumulation of blackened debris present. 9. Can opener base, slot, and area by the blade had a very heavy accumulation of blackened sticky debris. 10. Can opener blade had shavings present that could fall into the food. 11. 2 stacked convection ovens interior and racks, including the doors, had an accumulation of blackened debris. 12. 11 full size sheet pans, stacked and stored on a rack and ready to use, exterior outer corners had a very heavy accumulation of blackened debris. 13. 21 full size steam table pans, stacked and stored on a rack and ready to use, exterior outer corners had a very heavy accumulation of blackened debris. 14. Rack, next to the 3 compartment sanitizer sink, used to store cleaned ready to use steam table pans, lids, pitchers and various items, was covered with an accumulation of sticky dusty debris. 15. Large Robo Coup (food blender) base exterior had an accumulation of sticky dusty debris. 16. Can rack, in the dry goods store room, was covered with a very heavy accumulation of greasy dusty debris. 17. 7 racks with total of 13 shelves, in the dry goods storage room, had a very heavy accumulation of greasy dusty debris and food debris. Observation and interview on 04/12/16 at 1:53 PM, with the DM and the evening cook present during the observation, in the dietary department revealed the 3 compartment sink was set up and in use by the evening cook. Observation revealed the posted manufacturer's recommended sanitizer level was 150-400 parts per million for a Quaternary sanitizer. Observation revealed the evening cook washing, rinsing and sanitizing various items. Further observation revealed numerous items were on the drying shelf next to the sanitizer sink. Further observation revealed the evening cook checked the sanitizer level and the test strip did not change. Observation of a new unopened test strip pack used to do a second sanitizer level test revealed the test strip did not change. Interview with the evening cook and the DM confirmed the test strip did not change and the facility could not verify the sanitizer was effective in the 3 compartment sink.

Based on facility policy review, observation and interview, the facility failed to provide food at a palatable temperature on the 400 hall for 1 of 2 meal observations. The findings included: Review of the facility policy entitled Safety & Sanitation Best Practices Guidelines dated 1/2011, revealed .Danger Zone: Temperatures above 41 degrees F (Fahrenheit) .allow the rapid growth of pathogenic microorganisms that could cause food borne illness .Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) Food: Food that requires time/temperature control for safety to limit growth of pathogens .Ex (Example) Milk, dairy products, eggs . Further review revealed .Holding (of food): .Cold food must be kept at a minimum of 41 degrees or lower . Further review revealed .Serving (the food): .Cold food should be held at 41 degrees or lower throughout the serving process . Observation on 4/11/16 from 11:27 AM to 11:55 AM in the dietary department, with the Dietary Manager (DM) present, revealed the resident mid-day meal service was in operation. Further observation revealed the morning cook obtaining the temperatures of the eclairs (a food containing dairy products), stored on a rack by the tray line, was 45 degrees Fahrenheit (F). Further observation revealed there were 4 full size sheet pans of eclairs stored on the rack. Further observation revealed the dietary staff continued to place the eclairs onto individual resident trays in 2 resident delivery carts after the temperature was obtained. Further observation revealed the fried breaded fish was 153 degrees F, fries were 150 degrees F, and the slaw was 40 degrees F. Interview with the DM on 4/11/16 at 11:55 AM in the dietary department, by the resident tray line, confirmed the facility failed to maintain cold food at or less than 41 degrees F and continued to serve it to the residents. All eclair desserts were removed from the delivery carts and tray line and placed in the walk-in refrigerator. Observation on 4/11/16 beginning at 11:59 AM on the 400 hall revealed the open resident delivery cart contained 11 resident trays, no facility staff present and 2 call lights were activated. Further observation at approximately 12:02 PM revealed 2 dietary staff employees placing 2 resident trays onto the cart (for a total of 13 trays) and shut the cart door. Further observation revealed 1 housekeeper (HK) #1 answering the 2 call lights then delivering trays to a total of 3 individual resident rooms from 11:59 AM to 12:05 PM. Further observation at 12:10 PM revealed a dietary staff member delivering the eclair dessert to the residents rooms. Further observation revealed Certified Nurse Aide (CNA) #4 delivering and assisting residents with eating from 12:05 PM to 1:07 PM. Further observation revealed CNA #5 came on the 400 hall at 12:08 PM , provided personal care to a resident, then started delivering and providing eating assistance to residents from 12:26 PM to 1:09 PM. Further observation revealed CNA #5 left the 400 hall and went to the dining room to assist a 400 hall resident (usually ate in room) with eating. Further observation revealed CNA #1 came on the 400 hall at 1:09 PM, delivered 1 resident tray at 1:12 PM and provided eating assistance. Further observation at 1:12 PM revealed 1 tray was left on the cart and it was for the resident already eating and being assisted in the dining room by CNA #5. In summary, the 400 hall resident meal service was from 11:59 AM to 1:12 PM,1 hour and 13 minutes, for 12 trays. Observation on 4/11/16 at 1:15 PM on the 400 hall revealed the DM taking temperatures of the unserved resident tray remaining on the 400 cart as follows: fried breaded fish was 83 degrees F (dropped 70 degrees), fries were 83 degrees F (dropped 67 degrees), slaw was 65 degrees F (increased 25 degrees) and eclair was 54 degrees F. Interview with the DM on 4/11/16 at 1:15 PM on the 400 hall at the resident delivery cart confirmed the food temperatures obtained from the unused resident tray were not acceptable. Further interview revealed the eclairs removed from the 2 delivery carts and the eclairs from the rack on the tray line were initially placed in the walk-in refrigerator but the temperature was not decreasing fast enough to serve. Further interview revealed the eclairs were then moved to the walk-in freezer and served when the temperature reached 40 degrees. Interview on 4/11/16 at 2:59 PM with the DM and Registered Dietitian (RD), in the RD office, revealed 13 residents always eat in their room at lunch on the 400 hall. Interview with the Director of Nursing on 4/13/16 at 3:50 PM in the Classroom confirmed the 400 hall had 12 residents requiring eating assistance from the facility staff.

Based on observation and interview, the facility dietary department failed to maintain the dish machine wash temperature at the manufacturer's recommended minimum 160 degrees Fahrenheit (F); failed to maintain the exterior and interior of the dish machine in a safe operating condition; and failed to maintain 1 of 3 trash can lids in a safe operating manner. The findings included: Observation and interview on 4/11/16 beginning at 9:30 AM and on 4/12/16 beginning at 1:38 PM, with the Dietary Manager (DM) present during the observation, in the dietary department, revealed the dish machine was in operation. Observation of the posted manufacturer's recommendation revealed the minimum wash temperature was 160 degrees F. Further observation of 6 consecutive operations of the machine on each day observed, revealed the wash temperature was 148 degrees F each operation and the wash gauge never moved. Further observation on both days revealed the top of the dish machine was covered with rust; and the exterior and interior surfaces, the interior curtains and heating coils were white with calcium deposits. Interview with the DM confirmed the dish machine failed to reach a minimum of 160 degrees F per the manufacturer's recommendation for the wash temperature for each operation observed on both days. Further interview confirmed the facility failed to maintain the exterior and interior of the dish machine in a safe operating condition. Observation and interview on 4/11/16 beginning at 9:30 AM and at 11:20 AM and on 4/12/16 beginning at 1:38 PM, with the DM present during the observations, confirmed 1 of 3 trash can lids, stored in the dish room area, had a cracked lid and approximately 1/2 of the lid's lip was missing making it impossible to seal the trash can properly.

Based on facility policy, observation and interview, the facility failed to maintain sanitary conditions in one of one kitchen and failed to document the monitoring of temperatures for one of one walk-in refrigerator and one of one walk-in freezer. The findings included: Review of the untitled facility policy revealed, "...HAIR NETS OR CAPS MUST BE WORN AT ALL TIMES IN THE KITCHEN. (COMPLETELY COVERING THE HAIR)..." Observation and interview during the initial tour of the kitchen, with the Dietary Manager on 3/30/15, at 9:20 AM, revealed one walk-in refrigerator and one walk-in freezer. Further observation revealed the freezer and refrigerator both had internal and external temperature thermometers. When the Dietary Manager was asked for documentation of the monitoring of the freezer and refrigerator temperatures, she replied "We check the temperatures everyday but we don't record the temperatures." Further interview confirmed the facility failed to maintain temperature control logs for the walk-in refrigerator and walk-in freezer. Continued observation during initial tour revealed Dietary Staff #1 during food preparation, with her hair exposed from her forehead to mid-crown. Interview with the Dietary Manager, on 3/30/15, at 11:30 AM, in her office, confirmed Dietary Staff #1 had failed to completely cover her hair while in the kitchen. Continued interview confirmed the facility had failed to maintain sanitary conditions in the kitchen.

Based on medical record review, observation, and interview, the facility failed to ensure the bed brakes were functional for one (#29) of three residents reviewed for accidents of thirty-two residents reviewed. The findings included: Resident #29 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident transferred and ambulated with supervision, and had experienced two falls without injury since the prior assessment. Medical record review of the Fall Risk Evaluation dated May 21, 2013, revealed the resident was at high risk for falls Medical record review of a Post Falls Nursing Assessment revealed the resident experienced a fall on December 20, 2013, at 10:30 p.m., while ambulating without assistance. Continued review of the Post Falls Nursing Assessment revealed the intervention put into place was to have maintenance repair the bed brakes. Observation on January 29, 2014, at 7:50 a.m., revealed the resident lying on the bed feeding self the breakfast meal. Interview on January 28, 2014, at 5:20 p.m., with the Administrator, in the conference room, revealed the Administrator had spoken with the nurse who was present at the time of the resident's fall on December 20, 2013, and confirmed the bed had rolled due to the bed brakes did not work, and maintenance had repaired the bed brakes after the resident's fall.

Based on medical record review, review of a facility investigation, and interview, the facility failed to allow the choice of having no male caregivers providing personal care for one resident (#7) of twelve residents reviewed. The findings included: Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident was severely impaired for daily decision making, required extensive assistance for all Activities of Daily Living (ADL's) and was incontinent of bowels. Medical record review of the care plan dated February 2012 revealed the resident preferred female caregivers for personal care. Review of a facility investigation dated February 13, 2013, revealed a male Certified Nurse Aide (CNA) had showered the resident and the resident had alleged the male CNA inserted his finger into the resident's rectum. Review of a facility investigation and the Administrator's statement (no date) of the alleged incident on February 13, 2013, revealed "...approximately six months prior, the patient's son had requested no male CNAs (provide personal care). The center complied until a recent return from the hospital..." Interview with the resident's daughter on November 5, 2013, at 2:33 p.m., by telephone revealed the son and resident had requested no male caregivers provide personal care prior to the incident and the resident "never wanted males to see...naked." Interview with the Director of Nursing on November 5, 2013, at 4:15 p.m., in the conference room revealed the resident was a "no male caregiver" and after a hospitalization the "no male caregiver" was not continued. Continued interview confirmed the facility had failed to allow the resident a choice of having no male caregivers providing personal care. C/O #

Based on observation and interview, the facility failed to provide sanitary storage of food and equipment. The findings included: Observation of the dietary department on July 30, 2012, from 10:00 a.m. until 11:15 a.m., revealed: 1. Two seven pound cans of Pork and Beans were dented and were available for use; 2. Eight wet pans stored under the steamer were wet and were available for use; 3. A box of crackers opened and not labeled with date when opened; 4. A stand up mixer had food debris on the lip and top of the machine and was available for use; 5. A dirty ice cream scoop had dried Pimento Cheese on it and was available for use; 6. Four wet ladles were found in the drawer available for use; 7. The bottom plate warmer holder had crumbs under the three lids that were falling onto the plate warmers that were available for use; 8. The sanitizer section of the three compartment sink tested at 75 p.p.m. (parts per million) instead of the required 200 p.p.m. The staff continued to use this section of the sink for sanitizing the pots and pans. Interview with the dietary manager on July 30, 2012, at 11:15 a.m., in the dietary department, confirmed dented cans were to be removed from stock, the ladles and pans needed to dry completely before being stored for use, all open food was to be labeled with the date and closed completely prior to storage, the stand up mixer was to be cleaned completely after each use before storage, the ice cream scoop used for Pimento Cheese was to be cleaned prior to storage, the bottom plate warmer storage container was to be clean from debris at all times, and the three compartment sink sanitizer section was to be kept at the acceptable sanitizer level at all time. Continued observation of the dietary department on July 31, 2012, from 8:00 a.m. to 9:35 a.m., revealed: 1. Two staff bottle drinks were found in the first floor dietary freezer; 2. The floor in the dishwasher section of the main dietary department had free standing water on it without a Wet Floor Sign present. Interview with the dietary manager on July 31, 2012, at 9:40 a.m., in the dietary department, confirmed the staff drinks were not to be in the dietary freezer, and there needed to be a Wet Floor Sign in the dishwasher area of the kitchen.

Based on medical record review, observation, and interview, the facility failed to maintain infection control measures for four resident's (#10, #14, #B, #12) of twenty-four residents reviewed, The findings included: Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation of catheter care for resident #10 on July 31, 2012, revealed the Certified Nursing Assistant (CNA) #2 had donned gloves after washing hands. CNA #2 proceeded to draw the curtains, close the blinds, turn the resident, remove the resident's soiled brief, perform catheter care,, and put away supplies with the same pair of dirty gloves. Interview with CNA #2 on July 31, 2012, at 1:53 p.m., confirmed the CNA had proceeded with catheter care and clean-up with the same pair of soiled gloves. Observation of resident #10 during medication pass conducted on July 31, 2012, at 11:00 a.m., on the 300 corridor, revealed Licensed Practical Nurse (LPN) #3 withdrew six units of [MEDICATION NAME] R (short acting insulin used for the treatment of [REDACTED]. Continued observation revealed LPN #3 entered the resident's room, and administered the injection. Interview with LPN #3 on July 31, 2012, at 11:25 a.m. in the 300 hallway corridor confirmed the medication was withdrawn from the medication vial without cleansing the vial prior to accessing it with the sterile needle. Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) dated , June 23, 2012, revealed the resident was severely cognitively impaired, and dependent for activities of daily living. Observation of Resident #14 on July 30, 2012, at 11:40 a.m., in the resident's room, during initial tour, revealed the resident lying supine on the bed. Observation revealed a dislodged gauze dressing, above the resident's left temple. Continued observation revealed, beneath the dislodged dressing a golf ball sized black tumor extending upward from the resident's temple exposed to open air. Yellow drainage was visible on the dislodged dressing. Medical record review of the Physician's Recapitulation Orders dated July 2012, revealed orders to keep the tumor site covered with gauze dressings, and to change the dressings daily, and as needed when soiled. Interview with LPN #2, on July 30, 2012, at 11:45 a.m., in the resident's room, confirmed the dressing on the resident's head did not cover the tumor. Resident B was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation of Resident B during the medication pass on July, 31, 2012, at 11:20 a.m., revealed LPN #3 failed to wash the hands prior to donning gloves and administering three units of subcutaneous [MEDICATION NAME] R ( short acting insulin used to treat elevated blood sugar levels) to the resident. Interview with LPN #3 on July 31, 2012, at 11:25 a.m., in the hallway outside the resident's room, confirmed the hands were not washed prior to donning gloves and administering the injection. Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set, dated dated dated [DATE], revealed the resident required extensive assistance with decision making, total assistance with personal hygiene, extensive assistance with all activities of daily living, and was incontinent of bladder and bowel. Observation on August 1, 2012, at 7:58 a.m., in the resident's room, revealed Certified Nursing Assistant (CNA) #3 providing hygiene care following an episode of bowel and bladder incontinence. While performing perineal care, the CNA removed the soiled linens, placed linens in a plastic bag, cleaned the resident's perineal area front to back, positioned resident on left side, and rolled the soiled bed pads under the resident's buttocks. CNA #3 placed two clean pads under the resident's buttocks. Continued observation, at that time, revealed a pillow fell to the floor. CNA #3 picked the pillow up from the floor, placed it on a chair, touched the rail of the bed, touched the resident, and continued with hygiene care without changing gloves. Interview with CNA #3 on August 1, 2012, at 8:15 a.m., in the hall, confirmed the soiled gloves were not removed before applying the clean pads, picking the pillow off floor, touching the bed rail and the resident. Continued interview confirmed appropriate infection control was not maintained.

Based on medical record review and interview, the facility failed to ensure accuracy of the Minimum Data Set (MDS) for Urinary Continence for one resident (#5) of twenty-four residents reviewed. The findings included: Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the quarterly MDS dated [DATE], revealed the resident was always continent of urine. Interview with the MDS Coordinator on July 31, 2012, at 1:39 p.m., in the 400 wing activity room, confirmed the MDS assessment failed to indicate the resident had a [MEDICATION NAME] and the MDS assessment was inaccurate.

Based on medical record review, observation, facility policy review, and interviews, the facility failed to follow accepted standards of practice for ensuring an indwelling peripheral catheter is changed in a timely manner, failed to follow a physician's orders [REDACTED]. The findings included: Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of nurse's notes from July 15, 2012, through August 1, 2012, revealed no documentation of the date of the initial placement or date of a peripheral INT (an indwelling intravenous (I.V.) catheter placed in a vein to administer medications or fluids) being changed. Observation on July 31, 2012, at 7:40 a.m., in the resident's room, revealed an INT taped to the resident's right forearm with no date on the tape indicating the date of placement in the resident's arm or when changed last. Review of facility policy, I.V. Dressing and Cannula Site Care, revealed "...8. Standard peripheral I.V. access sites should be changed every 72 hours unless specified by a physician's orders [REDACTED]. Interview on July 31, 2012, at 8:30 a.m., with Licensed Practical Nurse (LPN) #3 in the 300 Hallway, confirmed the dressing of the INT had no date indicating the day the INT was placed. Continued interview with LPN #3 confirmed the facility policy is to date the dressing of the INT to ensure the INT is changed every 72 hours per facility policy. Interview on August 2, 2012, at 8:50 a.m., with the Director of Nursing (DON), at 300 Unit Nurse's Station, confirmed the facility failed to date the dressing of the resident's INT, and failed to follow the facility's policy by ensuring the dressing of the INT is dated upon insertion. Medical record review of the physician's recapitulation orders signed and dated July 25, 2012, revealed "O2 (oxygen) @ (at) 2 LPM (liters per minute) BNC (by nasal cannula) PRN (as needed) SOB (shortness of breath)." Medical record review of a nursing note dated July 30, 2012, at 10:15 a.m., revealed: "Con't (continue) on O2 at 2-3 LPM BNC." Observation on July 30, 2012, at 2:45 p.m., in the resident's room, revealed the resident lying in the bed, receiving oxygen by nasal cannula at 2.5 liters per minute. Observation on July 31, 2012, at 7:40 a.m., in the resident's room, revealed the resident lying in the bed, receiving oxygen by nasal cannula at 2.5 liters per minute. Interview on July 31, 2012, at 8:30 a.m., with LPN #3, in the resident's room, confirmed the resident was receiving oxygen via nasal cannula at 2.5 liters per minute and the physician's orders [REDACTED]. Observation of the medication pass, on July 30, 2012, at 8:50 a.m., on the 200 hallway revealed, Licensed Practical Nurse (LPN) #4 prepared a dose of [MEDICATION NAME] 100 mg (milligram) oral tablet and administered the tablet to resident #A. Medical record review of the Physician's Recapitulation Orders dated July 2012, revealed, "[MEDICATION NAME] 100 mg (milligram) PO (orally) every HS (bedtime) Depression..." Interview with LPN #4 on July 30, 2012 at 10:15 a.m., in the 200 hall nursing station, confirmed the medication was to be given at bedtime daily and the medication was administered during the morning medication pass.

Based on medical record review, observation, facility policy review, and interview, the facility failed to provide appropriate incontinence care for one (#12) of twenty-four residents reviewed. The findings included: Resident #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set, dated dated dated [DATE], revealed the resident required extensive assistance with decision making, total assistance with personal hygiene, extensive assistance with all activities of daily living, and was incontinent of bladder and bowel. Observation on August 1, 2012, at 7:58 a.m., in the resident's room, revealed Certified Nursing Assistant (CNA) #3 providing hygiene care following an episode of bowel and bladder incontinence. While performing perineal care, the CNA removed the soiled linens, cleaned the resident's perineal area front to back, turned the resident to the left side, and cleaned the rectal area front to back. Continued observation, at that time, revealed visible stool on the wash cloth. CNA #3 obtained a clean wash cloth, rinsed and dried the rectal area front to back, leaving a small amount of feces on rectal area. CNA #3 positioned the resident on back and applied a clean gown. Review of the facility's Perineal Policy revealed, "Spray soiled and /or odorous areas (or wet washcloth) with product. Gently wipe clean with washcloth, using one area of washcloth for each cleansing stroke. Repeat as necessary, using as many washcloths as needed..." Interview with CNA #3 on August 1, 2012, at 8:15 a.m., in the hall, confirmed feces was left on the resident's rectal area and perineal care was not performed appropriately.