Every finding on record at North Pointe Health & Rehabilitation

Based on observation, interview, record review, and facility policy review, the facility failed to reasonably accommodate residents' needs by ensuring call lights were accessible and within reach for three (3) of (15) sampled residents. Resident #10, #12 and #29.Findings Include:Record review of the facility's Dignity and Respect undated, revealed You have the right to dignity and respect in the care you receive and the settings you live in . It also means you have a right to expect care and a residential setting that: promotes your quality of life. aims to reach or maintain for you the highest achievable level of physical, mental and social well-being, consistent with a comprehensive assessment of your needs and your plan of care .Resident # 10On 08/11/2026 at 11:30 AM, during an observation, Resident #10 was observed sitting in the recliner. Resident #10 stated who is there? It is obvious Resident #10 has vision impairment. She states she uses call light when it is near, but if not, she just yells out for staff come sees what she needs.On 08/11/26 at 1:11 PM, an observation and interview with Resident #10 stated sometimes she drops the call light and must yell out for help. An observation of the call light revealed the call light was not in reach but wrapped around bed rail. She stated she sometimes gets frustrated when she does not have call light and must yell for help. She stated they do not always place call light within reach of her. On 08/12/26 at 1:28 PM, in an interview and observation with Certified Nursing Assistant (CNA)# 2 confirmed the call light was not within reach and was wrapped around the bed rail. She stated she forgot to make sure it was in reach. She stated she usually lets Resident #10 know that call light is within reach. She stated that when Resident #10 yells out for help the staff goes to see what she needs.Record review of Resident #10 admission Record revealed an admission date of 4/20/26 with diagnoses that included of unqualified visual loss, both eyes.Record review of Resident #10's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 7/21/26 revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicates moderate cognitive impairment.Resident # 12On 08/12/26 during random observations of call lights revealed Resident #12 was in the wheelchair close to the window. The call light was observed on the opposite side of the bed and wrapped around bed rail and was not in reach.On 08/13/26 at 11:48 AM, during an observation revealed Resident #12 was in the wheelchair close to the window. The call light was observed on the opposite side of the bed and wrapped around bed rail and was not in reach.On 08/13/2026 at 11:50 AM, an observation revealed Resident #12 sitting in a wheelchair on the right side of the bed. The call light was observed wrapped around the bed rail and was not in reach. CNA#3 confirmed the call light was not in reach and unwrapped it and placed it on the wheelchair. She stated she assisted resident in the wheelchair and forgot to give the resident the call light. She stated residents could get injured if call lights are not in place. She stated that call light should always be in reach for all residents to use for assistance.Record review of Resident #12's admission Record revealed an admission date of 1/13/25 and diagnoses that included unspecified abnormalities of gait and mobility and unspecified lack of coordination.Record review of Resident #12's MDS with an ARD of 6/17/26, revealed a BIMS score of 14, indicating the resident was cognitively intact.Resident # 29On 08/11/26 at 07:50 AM, an observation of Resident #29 was sitting in the recliner eating breakfast. The call light was observed on the opposite side of the room wrapped around the bed rail with the cord for the bed remote. On 08/11/2026 at 9:09 AM, in an interview and observation, Resident #29 stated they do not always give her call light when they place her in the recliner. An observation revealed the call light was wrapped around bed remote and attached to the bed on the opposite side of the chair where the resident was sitting. Resident #29's daughter who was at the bedside untangled the call light and gave it to the resident. The residents' daughter confirmed that the call light was not in reach and was difficult to untangle. She stated call lights should be in reach.On 08/13/2026 at 1:22 PM, in an interview with Corporate Compliance Nurse who was also acting as the Director of Nursing (DON), stated residents call light should be in reach. She stated she expects staff to answer call lights in a timely manner and place them in reach. She started residents trying to get help without call lights could fall. She stated she expects staff to follow policy, care plans and assessments.Record review of Resident #29's admission Record revealed an admission date of 01/20/26 with diagnoses that included unspecified osteoarthrosis, unspecified site and unspecified abnormalities of gait and mobility.Record review of Resident #29's MDS with an ARD of 7/22/26 revealed a BIMS score of 12 which indicated moderate cognitive impairment.

Based on observation, interview, record review, and facility policy review, the facility failed to identify, document, and accommodate food preferences and failed to ensure a resident knew that a substitute meal was available for one (1) of (15) sampled residents. Resident #33.Findings Include:Record review of the facility policy Tray Identification Cards Tickets undated revealed, .Special needs, request and preferences of each individual resident is documented .During Resident Council meeting at 10:21 AM on 08/11/26, Resident #33 revealed that the dietary staff consistently gave her meals that she did not like, for example, she stated she absolutely hates tuna fish. She said she has not asked them for a substitute, she just simply does not eat her lunch that day.On 08/11/2026 at 10:32 AM, in an interview with Resident #33 she stated sometimes she gets food on her tray that she dislikes. She stated they gave her tuna the other day and she does not like tuna. She stated she was admitted here earlier this year, and no one has come around asking her about likes and dislikes relating to food. She stated did not know she could get something else to eat.On 08/12/26 at 11:58 AM, during an observation of lunch is being served in the dining room revealed various unsampled residents' meal tickets were marked N/A (not applicable) for likes and dislikes.On 08/12/26 at 2:37 PM, in an interview with the Certified Dietary Manager (CDM) he stated he visits new admissions within 1-2 hours after admission to discuss dietary like and dislikes. He stated he does it only once unless there is a problem then he will adjust likes and dislikes. He stated it is important to find out, and document residents' likes and dislikes, so they can have a choice of what they want to eat. He stated when residents are served food they do not like they can lose weight. On 08/12/26 at 3:55 PM, during an interview with the CDM, he stated that he added a dislike of black pepper to Resident #33 meal ticket today because someone told him she does not like black pepper. He stated he should have done a one on one with her to confirm all of Resident #33 likes and dislikes.On 08/13/2026 at 1:32 PM, in an interview with Nursing Home Administrator (NHA) stated the CDM should review likes and dislikes upon admission and quarterly. She stated there is a possibility of Resident #33 not eating at all, weight loss and a decline in health. She stated her expectations are for residents to have their food choices. She stated it's very important that they receive what they like to eat and enjoy eating. She stated she expects the CDM to accommodate residents' food needs and choices.Record review of Resident #33's admission Record revealed an admission date of 01/08/26 with diagnoses that included anxiety disorder.Record review of Resident #33's Order Summary Report revealed an order 1/8/26 for NAS (No Added Salt) diet, Regular texture, Regular liquids consistency.Record review of Resident #33's Minimum Data Set (MDS)with an Assessment Reference Date (ARD) of 7/7/26 revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicates cognitively intact.Record review of Resident #33's meal ticket dated 08/11/26 for breakfast, lunch and dinner revealed N/A for likes and dislikes.Record review of Resident #33's meal ticket given on 8/12/26 revealed black pepper as a dislike.

Based on observation, interview, record review, and facility policy review, the facility failed to follow infection prevention guidelines when performing perineal/incontinent care for one (1) of two (2) care observations during survey. (Resident #8).Findings include: Record review of the facility policy Perineal Care Policy revised 1/2010 revealed, It is the policy of this facility to provide perineal cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition.4. Always change gloves when moving from a dirty to a clean environment.On 8/13/26 at 10:29 AM, Certified Nursing Assistant (CNA) #1 was observed providing incontinent care for Resident #8. The resident's brief contained urine and a small amount of feces (bowel movement). CNA #1 removed the resident's brief, turned the resident onto her side, and cleaned bowel movement from the resident's buttocks while wearing gloves. CNA #1 then turned the resident onto her back and performed urinary perineal care while wearing the same gloves used to clean the bowel movement. CNA #1 did not change gloves or perform hand hygiene between cleaning the resident's buttocks and urinary perineal area.During an interview on 8/13/26 at 10:36 AM, CNA #1 confirmed she cleaned bowel movement from Resident #8's buttocks before performing urinary perineal care while wearing the same gloves. CNA #1 stated staff should clean the perineal area first and proceed from clean to dirty areas to prevent transferring bacteria from bowel movement to the urinary perineal area. CNA #1 stated bacteria transferred to the urinary perineal area could cause a urinary tract infection. CNA #1 further stated gloves should be changed when moving from one area to another because wearing the same soiled gloves could result in cross-contamination.During an interview on 8/13/26 at 11:19 AM, the Interim Director of Nursing (IDON) stated CNA #1 should have cleaned the urinary perineal area before cleaning the resident's buttocks to follow the practice of moving from clean to dirty areas. The IDON stated CNA #1 should have removed the contaminated gloves, performed hand hygiene, and applied clean gloves before moving from the resident's buttocks to the urinary perineal area. She stated the failure could transfer bacteria, including Escherichia coli, to the resident's urinary perineal area and cause a urinary tract infection. She stated staff were expected to provide care according to infection prevention practices and facility policies.During an interview on 8/13/26 at 12:42 PM, the Infection Preventionist (IP) stated CNA #1 should have changed gloves and performed hand hygiene before moving from the resident's buttocks to the urinary perineal area. The IP stated CNA #1 should have cleaned the urinary perineal area before cleaning the resident's buttocks to reduce the risk of a urinary tract infection. The IP stated staff were expected to follow perineal care procedures and hand hygiene recommendations to prevent infection. A record review of Resident 8's Progress Notes revealed the resident was treated for a Urinary Tract Infection (UTI) on 5/22/2026. A record review of Resident #8's admission Record revealed she was admitted on [DATE] with diagnoses that included Alzheimer's disease.A record review of the Minimum Data Set (MDS) with an Assessment Reference Date of 5/29/26 revealed a Brief Interview for Mental Status (BIMS) score of 00 which indicates severe cognitive impairment.A record review of Inservice Records dated 6/22/26 revealed the CNA #1 attended an in-service and skills competency on perineal/incontinent care.

Based on observation, staff interview, record review, and the facility policy review, the facility failed to implement a care plan for enhanced barrier precautions (EBP) by failing to wear the proper Personal Protective Equipment (PPE) while providing care for one (1) of 17 resident care plans reviewed. Resident #2 Findings include: A record review of the facility's policy Care Plans- Comprehensive dated 10/2016 revealed . An individualized (person centered) comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, and mental and psychological needs is developed for each resident . Policy Interpretation and Implementation 1. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his//her family or resident representative, develops and maintains a comprehensive care plan for each resident that identifies the highest level functioning the resident may be expected to attain . A record review of Resident #2's Comprehensive Care Plan revealed an individual care plan initiated 4/1/24, Focus .has abscess to right buttock and is receiving wound care .Interventions .Use EBP When: Dressing/Bathing, Transferring, Changing Linens, Assisting With Toileting/Incontinence Care, Accessing Indwelling Medical Devices, Providing Wound Care, Any Other High-Contact Resident Care Activities . A record review of Resident #2's admission Record revealed the facility admitted the resident on 4/7/22 with current diagnoses including Chronic Obstructive Pulmonary Disease. A record review of the Order Summary Report with active orders as of 6/18/25 revealed a Physician's Order, dated 5/20/25, for Enhanced Barrier Precautions (EBP) related to a history of ESBL (Extended Spectrum Beta-Lactamase) resistance infection. A record review of Resident #2's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/11/25 revealed Section H indicated the resident was always incontinent of bowel and bladder. During an observation on 06/18/25 at 09:55 AM, Certified Nurse Aide (CNA) #2 provided incontinence care to Resident #2 without wearing a gown as required by EBP. During an interview on 06/18/25 at 11:50 AM, CNA #2 explained the green sticker by the resident's name on the door indicated she required EBP and she confirmed that she did not wear a gown while providing incontinence care. She stated the PPE that is required for a resident on EBP includes gloves and a gown. During an interview on 06/19/25 at 10:45 AM, Registered Nurse (RN) #2 explained the purpose of the care plan is for the staff to know how to care for the residents per the physician orders. She expects all staff to follow the care plans while providing care for the residents. During an interview on 06/19/25 at 11:20 AM, the Director of Nursing (DON) explained she expects all staff to follow EBP as ordered and care planned to protect the resident and the staff members from any spread of infections.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's right to be free from physical restraints by not identifying and documenting the use of a soft belt as a restraint for one (1) of seventeen (17) sampled residents, Resident #36. Findings included: A review of the facility's policy titled Physical Restraint, dated 2/20/2012, revealed, .Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Policy Interpretation and Implementation 1. Restraints will only be used after other alternatives have been tried unsuccessfully, and only with the informed consent from the resident, physician and/or responsible party .Order of Restraints Least Restrictive to Most Restrictive .Soft belts are RESTRAINTS under any circumstance . On 6/16/25 at 1:30 PM, during an observation, Resident #36 was observed sitting in a wheelchair with a Velcro soft belt secured across her lap. The resident was unable to remove the belt upon request. On 6/16/25 at 1:40 PM, during an interview with Certified Nursing Assistant (CNA) #1, she explained that the soft belt was applied to prevent the resident from sliding and falling out of the wheelchair. CNA #1 confirmed that Resident #36 could not remove the belt on her own. On 6/16/25 at 1:55 PM, during an interview with Registered Nurse (RN) #1, she stated that the soft belt was used to keep Resident #36 from sliding out of her high-back wheelchair and was applied each morning, removed at lunch when the resident went to bed for a nap, and then reapplied in the afternoon until bedtime. RN #1 confirmed the soft belt was released every two (2) hours to assist with toileting and peri care. On 6/17/25 at 11:05 AM, during an interview with the Director of Nursing (DON), she acknowledged that Resident #36 was unable to remove the soft belt upon request and confirmed the device had not been previously identified or documented as a restraint. She stated the facility would begin pre-restraint evaluations, obtain physician's orders and representative consent, ensure documentation, and provide staff in-service training on identifying and documenting restraints. On 6/19/25 at 10:50 AM, during an interview with the Administrator, she stated the soft belt was used to prevent the resident from sliding out of her wheelchair. The Administrator confirmed the resident could not remove the soft belt on request but stated the facility did not consider it a restraint because the resident lacked the mental capacity to understand or remove it. A record review of the admission Record revealed the facility admitted Resident #36 on 10/22/23 with current diagnoses including Alzheimer's Disease. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/12/25 revealed Resident #36 had a Brief Interview for Mental Status (BIMS) score of 00 which indicated her cognition was severely impaired. A record review of Resident #36's medical record revealed there was no documentation identifying the soft belt as a restraint or supporting evaluations, orders, consent, or monitoring.

Based on staff interview, record review, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) regarding an anticoagulant medication for one (1) of 17 sampled residents reviewed for MDS accuracy, Resident #2. Findings included: A review of the facility's policy titled MDS Assessment, dated 5/2006, revealed, .It is the policy of this facility to follow the RAI (Resident Assessment Instrument) process as set forth by CMS (Centers for Medicare and Medicaid Services) protocol .The facility will follow directions per federal and state guidelines for resident assessment protocol and will refer to the MDS RAI manual . A review of the Resident Assessment Instrument (RAI) Manual 3.0, Version 1.19.1, dated October 2024, revealed, .N0415: High-Risk Drug Classes .Do not code antiplatelet medications such as aspirin .as N0415E, Anticoagulant . A record review of Resident #2's admission Record revealed the facility admitted the resident on 4/7/22 with current diagnoses including Chronic Obstructive Pulmonary Disease and Hypertension. A record review of the Order Summary Report with active orders as of 5/1/25 revealed Resident #2 had a Physician's Order, dated 1/10/2024, for Aspirin EC (Enteric Coated) Tablet Delayed Release 81 milligrams (mg), one tablet by mouth daily for Essential (Primary) Hypertension. There were no active orders for an anticoagulant medication. A record review of Resident #2's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/11/25 revealed Section N0415 was coded to indicate that the resident received an anticoagulant medication. On 6/18/25 at 9:12 AM, during an interview and record review with Registered Nurse (RN) #3, she reviewed the physician's orders and the MDS dated [DATE] for Resident #2 and confirmed the resident was not on an anticoagulant medication during the MDS lookback period. RN #3 acknowledged the MDS had been coded in error and explained that the resident was receiving aspirin, which should have been coded as an antiplatelet. On 6/19/25 at 12:15 PM, during an interview with the Administrator and the Director of Nursing (DON), they both confirmed that their expectation was for all MDS assessments to be coded accurately to reflect each resident's condition and treatment.

Based on observation, staff interview, record review, and facility policy review, the facility failed to implement an ongoing resident-centered activities program that incorporated the resident's interests for one (1) of seventeen (17) sampled residents, Resident #22. Findings included: A review of the facility's policy titled Activity Program, dated 1/21/22, revealed: .An ongoing program of activities is designed to meet the needs of each resident . Policy Interpretation and Implementation 1. Our activity program is designed to encourage restoration to self-care and maintenance of normal activity which is geared to the individual resident's needs. 2. Activities are scheduled daily . 3. Our activity program consists of individual, and small and large group activities which are designed to meet the needs and interests of each resident . 7. Residents are encouraged, but not forced, to participate in scheduled activities . A review of the facility's document titled Resident Behavioral Objectives, undated, revealed: .Stimulate resident curiosity and alertness through meaningful activities . On 6/16/25 at 1:32 PM, during an observation on the 200 Hall, Resident #22 was observed sitting in her room with her chair facing the window. She was confused and unable to speak but attempted to smile and express words. There were no organized activities occurring at the time. On 6/16/25 at 1:38 PM, during an observation, a daily activity schedule was posted, listing rest and digest at 1:00 PM and group activity and snacks at 2:00 PM. However, there was another activity calendar, a monthly calendar for June 2025 that indicated ball toss was scheduled at 10:00 AM and bowling at 2:00 PM. These calendars were located at the station on the hall. On 6/17/25 at 2:01 PM, during an observation in the main dining room, several residents were participating in a bowling activity. The monthly calendar for June that was posted indicated movie and popcorn at 10:00 AM and Bingo at 2:00 PM. On 6/17/25 at 2:16 PM, during an observation, Resident #22 was observed sitting in her chair in her room, almost asleep, and smiled when spoken to. On 6/17/25 at 2:30 PM, during an observation on the 200 Hall, three (3) staff were sitting with residents in the common area. A snack tray with lemonade and water and boxed snack cakes was observed at the nurse's station. No activities were occurring. On 6/17/25 at 2:40 PM, during an interview with Certified Nurse Aide (CNA) #3, she stated there was no set activity schedule on the hall. She explained the three (3) CNAs just wing activities and Resident #22 rarely comes out of her room or participates. CNA #3 added that when the resident's family visits, they may take her outside, but this is not often, and no daily routine is followed. On 6/17/25 at 2:50 PM, during an interview with CNA #4, she stated she had done puzzles and coloring activities earlier and had taken some residents to the theater room for popcorn. She confirmed that Resident #22 did not participate in those activities. On 6/17/25 at 2:55 PM, during an interview with CNA #5, she stated that although most staff on the unit were consistent and tried to provide activities daily, there was no consistent activity schedule followed. She stated some residents participate in facility-wide activities, but Resident #22 does not, unless accompanied by family. On 6/18/25 at 7:30 AM, during an observation, Resident #22 was observed dressed and sitting in a bedside chair facing the window. On 6/18/25 at 10:00 AM, during an observation, Resident #22 remained in her room, with no staff interaction observed. Six (6) residents were in the common area. At 10:06 AM, CNA #3 initiated ring toss with residents. Another CNA was giving a shower, and the third CNA was off the unit. Resident #22 remained in her room, uninvolved. The posted schedule listed group activity/devotion at 10:00 AM, while the main activity schedule listed card games. On 6/18/25 at 11:05 AM, during an observation, six (6) residents were watching TV with CNA #3. Licensed Practical Nurse (LPN) #2 entered to perform a blood sugar check. Resident #22 remained in her room with no staff interaction observed. During an interview, LPN #2 stated she did not stay on the unit and rarely saw Resident #22 involved in activities. On 6/18/25 at 11:55 AM, during an observation, Resident #22 was assisted to the dining room. At the nurse's station, three different activity schedules were observed. CNA #3 stated she was unsure why there were multiple colors and thought they were just for decoration. She said the schedules were for ideas and were not followed or updated. On 6/18/25 at 2:20 PM, during an observation, Resident #22 remained in her room while three (3) CNAs were in the common area with other residents. On 6/18/25 at 3:15 PM, during an interview with CNA #6, she stated she worked the 200 Hall evening shift with three (3) CNAs. She said the nurse checks in periodically. Resident #22 comes out occasionally but mostly stays in her room watching TV. CNA #6 stated there was no set evening activity schedule. On 6/19/25 at 10:23 AM, during an interview with the Director of Nursing (DON), she stated Resident #22 had experienced a decline and was less active. She acknowledged not being aware that Resident #22 had no activity interaction and stated staff were expected to encourage interactions. The DON acknowledged that residents with dementia need consistency and confirmed that several daily schedules were available on the unit and expected to be followed to promote interaction. On 6/19/25 at 12:20 PM, during an interview with the Administrator, she stated her expectation was for all residents to have the opportunity and encouragement to participate in scheduled activities. A record review of the admission Record revealed the facility admitted Resident #22 on 3/4/25 with diagnoses including Unspecified Dementia. A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/11/25 revealed Section B0700 indicated the resident rarely or never had the ability to express ideas or wants and only sometimes understood others. Section C revealed a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident's cognition was severely impaired. Section F noted that very important activities included having books, newspapers, and magazines to read, listening to music, and going outside for fresh air when weather permitted. Other somewhat important preferences included being involved in group activities and doing favorite pastimes.

Based on observation, interview, record review, and facility policy review, the facility failed to follow Enhanced Barrier Precautions (EBP) when a Certified Nurse Aide (CNA) did not wear a gown while providing incontinent care for one (1) of two (2) residents reviewed for care, Resident #2. Findings included: A review of the facility's policy titled Enhanced Barrier Precautions, revised 8/7/24, revealed, .It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms (MDRO). Definitions: 'Enhanced barrier precautions' (EBP) refer to an infection control intervention designed to reduce transmission of multi-drug resistant organisms that employs targeted gown and gloves use during high contact resident care activities .Policy Explanation and Compliance Guidelines . 2. Initiation of Enhanced Barrier Precautions: a. The facility will have the discretion in using EBP for residents who do not have a chronic wound or indwelling medical device and are infected or colonized with an MDRO that is not currently targeted by CDC (Centers for Disease Control) .4. High-contact resident care activities include: .d. Providing hygiene .f. Changing briefs or assisting with toileting . On 6/18/25 at 9:55 AM, during an observation, CNA #2 provided incontinent care to Resident #2, who was incontinent of bowel and bladder. CNA #2 did not wear a gown during the care. On 6/18/25 at 11:50 AM, during an interview with CNA #2, she confirmed that the green sticker by the resident's name indicated EBP. She acknowledged that she did not wear a gown or gloves during the care and confirmed that Personal Protective Equipment (PPE) was required to protect the resident from infection. On 6/18/25 at 12:05 PM, during an interview with Licensed Practical Nurse (LPN) #1, she explained that the facility continued EBP for Resident #2 due to a history of frequent urinary tract infections with ESBL (Extended Spectrum Beta-Lactamase). She reported that staff had been educated and had completed incontinence care check-offs. She stated staff were expected to follow EBP at all times when providing care. On 6/19/25 at 11:20 AM, during an interview with the Director of Nursing (DON), she stated she expected all staff to follow EBP as ordered to protect both the resident and staff from the spread of infection. A record review of Resident #2's admission Record revealed the facility admitted the resident on 4/7/22 with current diagnoses including Chronic Obstructive Pulmonary Disease. A record review of the Order Summary Report with active orders as of 6/18/25 revealed a Physician's Order, dated 5/20/25, for Enhanced Barrier Precautions (EBP) related to a history of ESBL resistance infection. A record review of Resident #2's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/11/25 revealed Section H indicated the resident was always incontinent of bowel and bladder.

Based on observation and staff interview, and facility policy review the facility failed to ensure a dietary staff member wore a hair restraint (beard) while checking food temperatures and preparing meal trays in the food service area, during one (1) of two (2) kitchen observations. Findings included: A review of the facility's document titled Personal Hygiene, dated 2010, revealed, Hair Care. Hair completely restrained including beard restraints . On 6/17/25 at 10:50 AM, during an observation and interview in the kitchen, the Certified Dietary Manager (CDM), who had a beard and mustache, was observed checking food temperatures and preparing resident trays in the food service area without wearing a beard restraint. The CDM acknowledged he was not wearing a hair restraint for his facial hair while handling the food. He confirmed that failing to cover facial hair could result in physical contamination of food. He stated he would begin wearing his beard restraint whenever handling food. On 6/19/25 at 7:50 AM, during an interview with the Administrator, she acknowledged the CDM had not been wearing a beard restraint while in the food service area. The Administrator stated she was aware that the CDM did not wear a hair restraint when checking the food temperature and preparing meal trays and she expected all dietary to wear hair restraints as required.

Based on observation, interview, Safety Data Sheet review, and facility policy review, the facility failed to ensure a hazardous cleaning agent was not left unattended on the hallway that was accessible to any resident for one (1) of four (4) facility hallways. This deficient practice had the potential to affect any of the 51 residents who reside in the facility, who may be confused and wander around the facility as documented on the Resident Census and Resident Matrix (The Centers for Medicare and Medicaid Services (CMS) 802 form. Findings include: Review of the facility's policy, Hazardous Chemical Storage, dated 01/2017, revealed, .Environmental services shall maintain all hazardous chemicals in a safe, clean, and locked location when not in use. All hazardous chemicals shall be in control of facility personnel while being used . Record review of the Super Sani-Cloth Germicidal Wipes Safety Data Sheet, revised 6/3/2020, revealed, .Hazard(s) identifications .serious eye damage/eye irritation .Specific target organ toxicity (single exposure) .Flammable liquids . Precautionary Statements - Storage Store locked up . An observation on 01/08/24 at 11:11 AM, revealed a container of Super Sani-Cloth Germicidal Disposable Wipes (Purple Top) was stored on the vital sign equipment on the 100 Hall in a walk-through area that was accessible to the residents. An observation on 01/08/24 at 11:15 AM, revealed another container of Sani-Cloth Wipes on an end table located on the 100 hallway outside of a resident's room which was accessible to the residents. During an observation and interview on 01/10/24 at 11:15 AM, the Regional Consultant observed the container of the Sani-Cloth Wipes on the 100 Hall on an end table located outside a resident's room. The Regional Consultant stated that the wipes should not have been left unattended. In an interview with the Administrator on 01/10/24 at 11:20 AM, she stated the Sani Cloth Wipes were stored in areas that were considered high contact and required frequent cleaning with the cloths. She confirmed that the facility's policy stated that hazardous chemicals would be maintained in a locked storage area.

Based on observation, interviews, record review and facility policy review, the facility failed to ensure food was distributed and secured under professional standards. The facility also failed to cover, date, and label food items in the refrigerators and freezer and failed to ensure the refrigerator and freezer temperatures were appropriate to prevent the possible spread of food borne illness for 52 of 52 residents. Findings Include: Review of the facility's policy Monitoring Temperatures of Cooked Food with a revised date ,d+[DATE] revealed the temperature of cooked foods will be monitored to ensure that the foods are not in the danger zone (above 41 degrees Fahrenheit (F) and below 135 degrees F for more than six (6) hours and 1. Cooked foods after being cooked to the required minimum internal temperature, will be held on hot holding equipment that will keep the food at a minimum of 135 degrees F or higher. 2. The temperature of each potentially hazardous food will be taken at the following times: a. When the cooking process is completed. b. When the food is placed in the holding equipment. c. After food has been in the holding equipment for two (2) hours. d. When the storage process begins. e. Two (2) hours after the storage process began. f. Four (4) hours after the storage process began. 3. Cooking and holding temperatures should be recorded on the Food Holding Temperature Log. These logs should be maintained in a notebook in the serving area. 4. Storage temperature should be recorded on the Cooked Food Storage Temperature Log. These records should be maintained in a notebook near the refrigeration equipment. 5. All parts of reheated cooked foods must reach 165 degrees F for 15 seconds. Foods are discarded after being reheated once. 6. Prepackaged ready to eat foods must be heated before serving to 135 degrees before holding for service. Review of the facility's policy Food Storage Labeling with a revised date of ,d+[DATE] revealed the facility will ensure the safety and quality of food by following good storage and labeling procedures, and 1. All food items that are not in their original container must be labeled with the common name of the food. 2. Food held for longer than 24 hours must be labeled, and date marked to indicate the use by date 4. Suggested labeling includes: common name and date of expiration or use by date . 8. Monitoring storage temperatures a. a thermometer is kept in all storage areas. b. Temperatures in food storage units are monitored daily. c. Documentation of time and temperature is recorded on the appropriate form. On [DATE] at 10:20 AM, during the initial tour of the kitchen, the State Surveying Agency (SSA) observed a Refrigerator/Freezer Temperature Log with a date of [DATE]. The log was visibly located on the outside wall of the walk-in refrigerator and freezer. There was no Refrigerator/Freezer Temperature Log visible for the sliding door (reach-in) refrigerator. On [DATE] at 10:25 AM, during an interview with Dietary #2, the SSA asked to review the Refrigerator/Freezer Temperature Log for [DATE]. Dietary #2 stated that no one had checked the temperatures during August and there were no logs available to review for the current month. On [DATE] at 10:35 AM, during an interview with Dietary #4, she stated no one had checked the refrigerator or freezer temperatures this month (August) because there were no forms (Refrigerator/Freezer Temperature Log) in which to record the temperatures. The SSA asked who is responsible for providing the log to the dietary staff for recording purposes and she explained the previous dietary manager had always posted the blank log at the beginning of each month, but now there is no manager or team leader and she did not know who to ask for the blank forms. On [DATE] at 10:50 AM, during an interview with Dietary #3, she stated the staff has not had any temperature logs (Refrigerator/Freezer Temperature Log) for the month of August, and no one has checked the temperatures for the refrigerators or freezers. The SSA asked if there was a reason that no dietary staff had asked for a temperature log to record the refrigerator and freezer temperatures, and she replied that she had forgotten about recording the temperatures. On [DATE] at 11:00 AM, during an observation of the walk-in refrigerator, the SSA and Dietary #2 observed a container of food which appeared to be beans, that was not identified with a label or a date (received or use by), one container wrapped in clear plastic wrap of previously opened turkey lunch meat which was not identified with a label or date (received or use by), another container of turkey lunch meat which was sealed (not previously opened) but did not have an identifying date (received or use by), a container of white shredded cheese with no identifying label or date (received or use by), a container of salad dressing that was previously opened with no identifying date (received or use by), and six (6) cucumbers in a large clear plastic container which had no identifying date (received or use by). The cucumbers appeared soft and deformed, and had numerous white, molded areas. On [DATE] at 11:10 AM, the SSA asked Dietary #2, how long the cucumbers had been in the refrigerator and she replied that did not know. The SSA asked Dietary #2 to explain the procedure for storing and labeling food, and she stated all food items should be dated when opened and when received, and leftover food items should be labeled with the name of the item and the date when stored. She further explained food items should be discarded after seven (7) days of opening. Dietary #2 agreed the food items should have been labeled and dated and the cucumbers should have been discarded. On [DATE] at 11:15 AM, the SSA and Dietary #2 walked into the walk-in freezer and observed a container of whipped cream in which the plastic seal on the lid was not intact and there was no identifying date (received or use by) noted on the container. The SSA also observed a container of green vegetables, open to air with no covering, in which a large amount of ice had accumulated on the top layer of the open green vegetables. The SSA observed a container of 10 biscuits which was not identified with a label or date (received or use by). The SSA observed a container of hush puppies with no identifying label and no date (received or use by). On [DATE] at 11:20 AM, in an interview with Dietary #2, she agreed the items in the freezer should have been labeled and dated and the frozen green vegetables with ice accumulation should have been discarded. While reviewing the Food Temperature Log, the SSA noted there was no food temperatures recorded on [DATE] and [DATE] for the breakfast and lunch meals. The food temperatures for dinner were not recorded on [DATE], [DATE], [DATE], and [DATE]. The food temperatures for three (3) meals (breakfast, lunch, dinner) were not recorded on [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE], at 11:30 AM, the SSA asked Dietary #4 about the missing entries in the Food Temperature Log. She confirmed the food temperatures were not recorded on the Food Temperature Log since [DATE] and she stated she did not know why the entries have been omitted since that date. The SSA asked Dietary #4 if there are any other places in which food temperature documentation could be recorded other than the log, and she confirmed there were no other forms. She stated the food temperatures were either not checked or they were checked and not documented. She further stated the cooks are responsible for checking and recording the temperature of the food on the tray line. On [DATE] at 3:00 PM, during an interview with Administrator, she confirmed she is responsible for managing the dietary department since she is the Administrator and there is currently no Dietary Manager on staff. The Administrator admitted that she has helped in the kitchen but has not reviewed the Refrigerator/Freezer Temperature Log or the Food Temperature Log. She further stated she was not aware the dietary staff did not have a blank Refrigerator/Freezer Temperature Log to use for [DATE]. The Administrator also confirmed she was not aware of the issues related to labeling and dating of open containers of food in the refrigerators or freezers. The SSA asked the Administrator about the possibility of negative outcomes due to not checking food temperatures on the tray line and serving food items that are not labeled or dated. The Administrator stated it is important to check food temperatures prior to serving food to avoid anyone from getting food too hot or too cold, and to avoid serving undercooked food because the residents could get sick with food poisoning. On [DATE] at 3:30 PM, during an interview with the Director of Nursing (DON), she stated it is important to check the food line temperatures before serving food to the residents to ensure the food is not too hot or too cold and to make sure the food is thoroughly cooked. The SSA asked the DON about negative outcomes that can occur from serving undercooked food, and she stated residents could get food poisoning. She also confirmed the importance of dating food (in refrigerators and freezer) when received and opened, in order to avoid serving spoiled food that could cause gastrointestinal issues or food poisoning. On [DATE] at 3:55 PM, during a phone interview with the Registered Dietician (RD), she stated she was not aware of any missing entries in the Food Temperature Log or Refrigerator/Freezer Temperature Log. The SSA asked the RD about negative outcomes that can occur from not checking food temperatures on the tray line. She stated if food is not cooked to the correct temperature, someone could get food poisoning. She also confirmed that it is important to date food items when received and opened (in refrigerators and freezer), to ensure the food items are not expired because if someone consumed expired or spoiled food, they could get sick with food poisoning. [DATE] at 4:00 PM, during an interview with the Infection Preventionist (IP), she confirmed the purpose of dating food items when received and when opened (in refrigerators and freezer), is to ensure the facility does not serve spoiled or expired food that could make the residents sick. She stated serving spoiled or expired food can cause a resident to experience symptoms such as nausea, vomiting, and food poisoning. She further stated the purpose of checking the temperature of food before serving is to ensure the food is not too cold or too hot and to make sure the food is not undercooked. She further stated if a resident ate undercooked food, the resident could get food poisoning.

Based on interview, record review, policy review and facility investigation review, the facility failed to allow the Resident/Family the right to manage his or her financial affairs, for one (1) of five (5) residents reviewed, out of a total of 18 residents that received a government stimulus check, Resident #1. Findings include: Review of the State Agency's (SA) complaint MS # , received on 07/03/2020, Resident #1's daughter reported the resident's stimulus check was received by the facility and not given to the family to purchase items for Resident #1. The Complainant reported the facility informed her that they would be keeping the funds. A review of the facility's Protection of Money and Property policy, undated, revealed: You have the right to have your personal funds managed responsibly. You have the right to manage your own financial affairs, if you choose to. Or, you may request our assistance in managing personal funds. When we manage a resident's personal funds, we follow strict government guidelines and generally accepted accounting standards. During an interview, on 07/07/2020 at 9:00 AM, with Resident #1's Daughter #1 Power of Attorney (POA), stated she had talked with the facility's Office Manager regarding Resident #1's stimulus check. Daughter #1 stated the Office Manager told her Resident #1's stimulus money was put in a trust account, and that Daughter #1 could purchase anything her mother needed, and the facility would reimburse her. On 07/07/2020 at 9:30 AM, during an interview with Daughter #2 (Complainant and POA), she revealed, she was informed by her sister, Daughter #1, that the facility put Resident #1's stimulus money in a trust fund. Daughter #2 said she could not understand how two (2) facilities in Mississippi have different policies regarding the distribution of the residents' stimulus money. Daughter #2 stated she was concerned the facility was taking residents' money that could not speak up for themselves. Daughter #2 revealed she had not talked to the Director of Nursing (DON) nor the Administrator about her concerns. Interview on 07/07/2020 at 9:45 AM with the Office Manager said all the resident that receive stimulus money will go into their trust account and is used for the resident's needs. The family can buy things for the resident and the facility will reimburse them. The family can also ask the facility to order material for the resident and they will do that. The facility does not allow the resident trust account to go above 4000.00. The facility will notify the family so the family can get whatever the resident need. The facility did not notify the families about the stimulus money. The money deposited into the Residents trust account. If the family call and ask about the stimulus money the facility will let them know at that time where the money is located. During an interview, on 07/07/2020 at 2:00 PM, the Administrator (ADM) revealed the residents' stimulus money was deposited directly into the facility's account. The ADM stated the facility put the money in the resident's trust account. The Administrator stated the money was used for the resident. He stated the facility would allow the resident's Responsible Party (RP) to purchase what the resident needed. The ADM revealed the facility would reimburse the family out of the trust fund. The ADM stated the family could also allow the facility to purchase items for the resident's needs. He stated the facility would take the money out of the resident's trust fund. The ADM revealed the family was not notified the stimulus money had been placed in the resident's trust account. The ADM stated if the family called and asked, they are informed that the money had been placed in the resident's trust account. A review of the facility's Admission Record, revealed, Resident #1 was admitted by the facility on 04/22/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/12/2019, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of five (5), which indicated she had severe cognitive impairment.

Based on observation, staff interview, record review, and facility policy review, the facility failed to implement infection control practices to prevent potential cross contamination as evidenced by : (A) Failed to sanitize, and properly store nebulizer equipment for Resident #11; affecting one (1) of seven (7) residents observed during medication administration; and (B) Failed to perform hand hygiene between glove changes, and prior to touching clean items in the resident's room for Resident #4, for 1 of four (4) observations of care. Findings include: A review of the facility's policy titled, Procedure for Handwashing, revised 04/15, revealed: When to Wash Hands (at a minimum): After touching a resident, or handling his or her belongings, and after handling any contaminated items. A review of the facility's policy titled, Administering Medications through a Nebulizer, not dated, documented as follows: When treatment is complete, turn off nebulizer and disconnect T-piece, mouthpiece or mask, and medication cup. Wash and dry hands. Rinse and disinfect the nebulizer equipment according to facility protocol; Wash pieces with warm, soapy water, rinse with hot water; allow to air dry on a paper towel. Wash and dry hands. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. Review of the facility's policy titled, Wound Care, dated 01/15, revealed remove gloves, and clean hands with hand sanitizer before putting on clean gloves. Resident # 11 An observation during medication administration on 09/06/16 at 4:00 PM, revealed Licensed Practical Nurse (LPN) #1 administered a nebulized treatment to Resident # 11. LPN #1 poured the medication into the well (cup) of the nebulizer, and administered the treatment with a mask. Upon completion of the treatment LPN #1 placed the mask, and nebulizer cup into a plastic bag in the resident's room without sanitizing the equipment. The nebulizer cup was observed to have a liquid residue, and LPN # 1 said there were bubbles left in the cup from the medication. LPN #1 left the room without sanitizing the equipment. A review of Resident # 11's Order Summary Report for Active Orders as of 9/1/16, revealed an order dated 7/14/16, as follows: [MEDICATION NAME] Solution 1 vial inhale orally via nebulizer four times a day related to ASTHMA. During an interview on 09/08/16 at 9:10 AM, the Director of Nursing (DON) said LPN #1 had made her aware of not sanitizing the nebulizer equipment on 09/06/16. The DON said the nurse should have followed the facility's policy to rinse the mask, allow to air dry, and not leave droplets in the nebulizer. The DON said it was an infection control issue. During an interview on 09/08/16 at 12:10 PM, RN #1/Staff Development Nurse revealed she was responsible for Infection Control in the facility. RN #1 said the nebulized equipment should be stored clean to prevent cross contamination. Review of the facility's Face Sheet revealed the facility admitted Resident #11 on 10/14/14, with [DIAGNOSES REDACTED]. Review of Resident #11's Minimum Data Set (MDS), with an Assessment Reference Date of 03/21/16, identified Resident #11 with a BIMS (Brief Interview for Mental Status) Score of 13 (thirteen), which indicated cognition was intact. Further review of the MDS revealed the resident required limited to extensive assistance with all Activities of Daily Living (ADLs). Resident #4 Observation of wound care on 09/07/16 at 10:20 AM, with Registered Nurse (RN) #2 revealed she performed care to Resident #4's right heel. RN #2 washed her hands, and applied gloves before beginning the wound care. During the wound care, RN #2 changed gloves when going from dirty to clean. However, RN #2 did not wash, or sanitize her hands throughout the entire procedure. Upon completing the wound care, RN #2 took off her gloves, removed a clean pair of socks from Resident #4's drawer, and placed the socks on Resident #4's feet. RN #2 gathered up items used for the wound care, and placed them in a red biohazard bag without applying gloves. RN #2 exited the room without washing her hands. Interview on 09/08/16 at 2:05 PM, with RN #2 confirmed she did not perform handwashing while performing wound care for Resident #4. RN #2 stated, I knew I did something wrong as soon as I walked out of the room. I was just nervous. RN #2 revealed she failed to don gloves to remove the socks from the resident's feet, obtained clean socks from the drawer, and applied the socks to Resident #4's feet. RN #2 further revealed she has been in-serviced on wound care, and infection control. RN #2 revealed she was aware of the risk of cross contamination to potentially cause an infection by not washing her hands. A review of In-service Training records revealed RN #2 attended training related to Infection Control on 08/01/16. RN #2 received an individual in-service regarding a new job position for Wound Care, which included return demonstration on 07/20/16. On 05/26/16, RN #2 was one of the instructors that provided an individual in-service regarding wound care with demonstration. Interview on 09/08/16 at 12:20 PM, with RN #1/Staff Development Nurse revealed that in-services are provided to educate staff on wound care, and infection control. RN #1 revealed that during wound care, the nurse is expected to perform, good hand sanitation, and to always use barriers. RN #1 stated staff should, wash their hands before, during, and anytime after the procedure. A review of the facility's Face Sheet revealed the facility admitted Resident #4 on 12/11/14, with [DIAGNOSES REDACTED]. A review of the most recent Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 07/21/16, revealed Resident #4 scored 15 on the Brief Interview for Mental Status (BIMS), which indicated cognitively intact.

Based on group interviews, staff interviews, review of Resident Council minutes for the past twelve (12) months, review of the facility grievance records/logs, and review of the facility policy and procedures, the facility failed to resolve the concerns and grievances of the Resident council for five (5) of eight (8) residents that attended the group meeting for a census of 55 residents on 8/15/15. Findings Include: Review of the facility policy entitled Filing Grievances/Complaints, dated 1/2015, revealed, The disposition of all residents will be recorded on our facility's Resident Grievance/Complaint log. The policy also stated, The Resident Grievances/Complaint Log will be reviewed by the Quality Assurance Committee at least Quarterly. A Group Interview with the members of the Resident Council on 8/15/15 at 10:00 AM revealed five (5) of the eight (8) Resident Council members in attendance had issued complaints to the facility staff about the poor quality of the food served at the facility and about the alternate meal posted on the facility's television monitor was not available. The five (5) of the eight (8) residents stated the food at the facility was of poor quality and the facility had been notified of their concerns. The residents stated the facility had not worked toward improving the quality of the food that had been served to the residents. The members of the Resident Council all stated they were not allowed the privilege to plan a meal of the month for the residents. In an interview on August 15, 2015 at 11:00 AM with the facility Director of Nursing (DON) and the facility Administrator (ADM) revealed the residents had not planned a meal of the month, but this process will be instituted. The DON and ADM stated the residents would be allowed to plan a meal of the month. Review of the Resident Council minutes for the past twelve (12) months revealed there had been food complaints issued by the residents at the council meetings of 9/24/14; 02/26/15; 03/30/15; and 04/30/15. Review of the Resident Grievance Logs revealed there had been food complaints issued by residents and residents families on 7/15/15, 7/16/15; 8/10/15; and five (5) residents had each issued food concerns on 8/13/15. The concerns were referred by the Social Worker (SW) to the Dietary Manager (DM) on those documented dates, per the Grievance Log. In an interview with the Social Worker (SW) on 8/15/15 at 4:00 PM, the SW confirmed there had been food concerns and complaints issued by residents and their families and she had referred the concerns to the DM. The SW had documented the referrals on the Resident Grievance Log. In an interview with the DM on 8/15/15 at 4:30 PM she confirmed that she had been issued some concerns from residents and she tried to address their concerns in a positive manner. The Minimum Data Set (MDS) information submitted on each of the five (5) residents that attended resident council on 8/15/15 at 10:00 AM and issued food complaints revealed four (4) of the five (5) residents who had issued food concerns had Brief Interview of Mental Status (BIMS) scores of 15, which meant they had good cognitive skills for decision making. One (1) of the five (5) residents who issued food concerns had a BIMS scores of six (6), which meant moderate cognitive deficiencies and impaired decision making skills.

Complaint Investigation # Based on interviews and record review the facility failed to give the Responsible Party (RP) of Resident #2 a reason for discharge in writing in a manner the family understood and failed to assist in finding placement with another facility for one (1) of three (3) residents reviewed for admit, transfer and discharge. (Resident #2) The facility failed to provide a policy for discharge. The facility Administrator stated the facility used the Federal Regulations as the guideline for discharges. In a family meeting on 9/8/15 from 3:30 PM to 5:30 PM with four sons and one daughter, the family stated there was a first letter sent out by the facility to the Responsible Party (RP), that indicated their mother would be discharged from the facility on September 11, 2015 but this letter did not indicate the reason she was going to be discharged . In the last meeting with the facility on 9/4/15, the family stated the administrator had a second letter that gave a reason for the discharge but was not mailed to a working address and stated it was sent to an old address of the resident, not the same address used to send the first letter. They stated the second letter said the discharge was because the facility could not meet her needs, but the family stated the facility could not tell us what these needs were. The family also stated the only assistance they received from the facility regarding assisting in finding placement was to hand them a list of the local Nursing Home for them to call. In a review of a letter from the facility on 8/13/15, addressed to the RP, this letter indicated Resident #2 would be discharged from the facility on 9/11/15 and the Social Service Director would assist in finding suitable placement for Resident #2. In a review of a second letter from the facility on 8/20/15, addressed to the RP but with a different address than the first letter, revealed an addendum to the discharge for Resident #2 stating the decision to discharge still stood and cited the Federal Regulation, (I) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility. This letter indicated the facility had spoken to the District Ombudsman and gave a number where she could be reached. The facility admitted Resident #2 on 2/3/15 with the [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 7/29/15 indicated the Brief Interview for Mental Status Score of zero (0) which indicated Resident #2 was severely cognitively impaired. This assessment indicated Resident #2 had inattention, disorganized thinking all the time, and altered level of consciousness.

Based on observation, record review, interview, and facility policy review the facility failed to provide incontinent care in a manner to decrease the risk of infection for one (1) of three (3) incontinent care observations (Resident #2). Findings include: Review of the facility's policy entitled, "Perineal Care Policy", dated 1/2010, revealed: "4. Always change gloves when moving from a dirty to clean environment. B. Wash perineal area, wiping from front to back. Do not reuse the same wash cloth or water to clean the urethra and labia." Observation on 6/16/14 at 4:00 PM revealed Certified Nurse Aide (CNA) #1 and Licensed Practical Nurse (LPN) #1 assisted Resident #2 onto the toilet and performed incontinent care. LPN #1 removed Resident #2's wet brief. CNA #1 cleaned resident's buttocks then obtained clean disposable wipes to wash the resident's vaginal area. CNA #1 failed to wash hands or change gloves after cleaning the resident's buttocks and prior to cleaning the vaginal area. CNA #1 wiped vaginal area three times back to front with the same area of the wash cloth while the resident stood in a sit to stand lift. Interview with CNA #1 on 6/16/14 at 4:10 PM confirmed failure to wash hands and change gloves after cleaning buttocks and prior to cleaning vaginal area. CNA #1 confirmed wiping three (3) times using the same area of the wash cloth to clean vaginal area back to front. Interview with LPN #1 on 6/16/14 at 4:00 PM confirmed Resident #2's brief was wet. The facility admitted Resident #2 on 5/7/14. Review of the admission Minimum Data Set with Assessment Reference Date of 5/13/14 revealed Resident #2 was frequently incontinent of bowel/bladder and required assistance with personal hygiene.

Based on observation, record review, staff interview and facility policy review, the facility failed to provide incontinent care by qualified person as directed in the care plan for one (1) of three (3) care observations (Resident #2). Findings include: Review of the facility's policy entitled, "Following the Care Plan Policy", dated 1/2011, revealed: "All employees will be trained upon hire and be required to follow the care plan." Review of Resident #2's care plan for bladder incontinence, dated 5/13/14, and Visual/Kardex Report revealed, "Incontinent: Check the resident every 2 (two) hours and as required for incontinence. Wash, rinse and dry perineum." Observation on 6/12/14 at 4:00 PM revealed Certified Nurse Aide (CNA) #1 provided incontinent care for Resident #2. CNA #1 failed to cleanse Resident #2 in manner to prevent potential for Urinary Tract Infection. CNA #1 used the same area of wash cloth to wipe Resident #2's vaginal area three times back to front. Interview with CNA #1 on 6/16/14 at 4:10 PM confirmed she used the same area of the washcloth to wipe Resident #2's vaginal area three (3) times from back to front. Interview with Director of Nursing on 6/16/14 at 6:55 PM confirmed CNAs were in-serviced and were required to complete a return demonstration on peri-care. Review of the facility's training records revealed an in-service sign in sheet dated 5/25/14 with the documented content of Peri-care signed by CNA #1. Review of the facility's document entitled "General Orientation for Newly Hired Employees" revealed CNA #1 received training on Personal Care by viewing a 12 minute DVD on 4/22/14. The document was signed by CNA #1. The facility did not provide documentation of a skills check off or return demonstration. The facility admitted Resident #2 on 5/7/14. Review of the admission Minimum Data Set revealed Resident #2 was frequently incontinent of bowel/bladder and required assistance with personal hygiene.

Based on observation, record review, staff interview and facility policy review, the facility failed to prevent the potential for cross contamination for one (1) of three (3) topical medication applications. LPN #1 failed to use a barrier and placed a medication tube and box on Resident #1's bathroom counter top and on top of medication cart, then returned it to the medication drawer. Findings include: Review of the facility's policy entitled, "Infection Control Treatment Barriers", dated 5/2012, revealed: "Barriers will be used to maintain clean technique and prevent cross contamination of infection and germs when treatments are being administered." Observation on 6/16/14 at 4:25 PM revealed LPN #1 assisted Resident #1 to toilet and performed perineal care prior to applying [MEDICATION NAME] cream to the resident's rectum. LPN #1 removed the [MEDICATION NAME] cream and placed the tube and box on Resident #1's bathroom countertop without using a barrier. LPN #1 placed the tube back in the box without disinfecting either item. LPN #1 placed the box on the top of the medication cart without a barrier then placed it in the medication drawer with other resident's medications and stock medications. Interview with LPN #1 on 6/16/14 at 4:30 PM confirmed placing the medication box and tube on Resident #1's countertop and on top of medication cart without a barrier. LPN #1 confirmed Resident #1 was ambulatory without assistance, toileted self, but required reminding to wash hands, due to confusion. The facility admitted Resident #1 on 5/8/14. Review of the admission Minimum Data Set with Assessment Reference Date of 5/14/14 revealed Resident #1 required limited assistance with toileting.