Every finding on record at Northside Health Care

Based on observation, interviews, record review, and review of a facility policy titled, Notification of Patient/Resident Change, the facility failed to ensure the physician was notified when Resident Identifier (RI) #1 and RI #9 tested positive for COVID-19. This affected two of three residents sampled for testing positive for COVID-19. Findings included: Review of a facility policy titled, Notification of Patient/Resident Change, with an effective date of 11/01/2016, revealed, The center will consult the resident's physician, nurse practitioner or physician assistant, and if known notify the patient/resident's legal representative or an interested family member when there is: . (B) Acute illness or a significant change in the resident's physical, mental or psychosocial status . (C) A need to alter treatment . Review of an Admission Record revealed the facility admitted RI #1 on 06/29/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission Minimum Data Set (MDS) dated [DATE] revealed RI #1 had a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. Review of Progress Notes, dated 07/11/2022 at 12:36 PM, revealed RI #1 tested positive for COVID-19 and was moved to isolation. Review of a Progress Note, dated 07/11/2022 at 4:56 PM, revealed RI #1's family member was notified of the positive COVID test and room change. There was no documentation to indicate the physician was consulted regarding the resident's positive COVID-19 test. Review of a Progress Note, dated 07/16/2022 at 11:06 AM, revealed the facility received a call from Employee Identifier (EI) #7, facility Physician. The note indicated RI #1 had called the physician's answering service complaining of being short of breath. The note indicated staff went to assess the resident and confirmed RI #1 was short of breath. The nurse contacted EI #7 and received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The note further indicated that EI #7 voiced a complaint that no one had informed him of the resident's positive COVID test obtained on 07/11/2022. During an interview on 09/12/2022 at 2:00 PM, EI #7 confirmed the facility did not notify him that RI #1 tested positive for COVID-19, which caused a delay in treatment. RI #9 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed RI #9 had a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. Review of Progress Notes, dated 07/06/2022 at 11:56 AM, revealed RI #9 tested positive for COVID-19 and was moved to isolation. Review of a Progress Note, dated 07/06/2022 at 4:03 PM, indicated RI #9 had diminished breath sounds and an increased respiratory rate. A Registered Nurse (RN) performed a COVID test, and the test was positive. The resident was moved to a private room for isolation. There was no documentation to indicate the physician was notified of the positive COVID-19 test until 07/08/2022 at 6:53 PM, when the notes indicate the resident had an elevated temperature of 102.3 degrees Fahrenheit and a decreased level of consciousness. The physician provided staff with treatment orders for RI #9 upon notification. During an interview on 09/12/2022 at 4:35 PM, EI #2, the Interim Director of Nursing (DON), stated the physician should be notified of any resident condition changes. EI #2 stated positive COVID tests should be reported to the physician, even if the resident did not complain of any COVID symptoms. EI #2 stated the notification should be documented in the Progress Notes. EI #2 confirmed not notifying the physician of a change in condition could cause a delay in treatment which could cause the resident to become more ill. During an interview on 09/13/2022 at 11:17 AM, EI #1, the Administrator, stated all changes in residents' condition should be reported to the physician and documented in the chart. EI #1 confirmed a lack of notification to the physician could result in the resident not receiving proper care.

Based on interviews, medical record review, and a review of a facility policy titled, Notification of Patient/Resident Change, the facility failed to provide evidence that Resident Identifier (RI) #6's sponsor/family was notified when RI #6's medication, [MEDICATION(S)] (an antibiotic) was discontinued on 01/24/2022. This deficient practice affected RI #6, one of three sampled residents reviewed for notification. Findings Include: A review of the facility's policy titled, Notification of Patient/Resident Change, with an effective date of 11/01/2016 revealed: . The center will . notify the patient/resident's legal representative or . family member when there is: . (C) A need to alter treatment significantly . a need to discontinue an existing form of treatment . RI #6 was admitted to the facility on [DATE] with admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] RI #6's February 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order start date, 01/06/2022, was RI #6's day of admission and the end date was 01/24/2022. On 02/09/2022 at 10:34 AM an interview was conducted with RI #6's sponsor/family. The sponsor was asked if she was notified about the medication [MEDICATION(S)] being discontinued. The sponsor said no, she was not notified that [MEDICATION(S)] was discontinued. On 02/09/2022 at 5:14 PM an interview was conducted with Employee Identifier (EI) #1, RN (Registered Nurse), DON (Director of Nurses). EI #1 was asked what was the facility's policy about the change in treatment. EI #1 said, notify the resident and legal representative. EI #1 was asked if she considered a medication being discontinue a change in treatment. EI #1 said yes. EI #1 was asked should a representative be notified. EI #1 said yes. EI #1 was asked should the representative have been notified when the doctor discontinued RI #6's [MEDICATION(S)] on 01/24/2022. EI #1 said, I would think so. EI #1 was asked to review the nurses note for documentation of notification. EI #1 said, she did not see anything in the nurses notes. EI #1 was asked according to the nurses note was the representative notified. EI #1 said, no. On 02/10/2022 at 2:25 PM an interview was conducted with EI #2, RN, ADON (Assistant Director of Nurses). EI #2 was asked when was RI #6 prescribed [MEDICATION(S)]. EI #2 said on 01/06/2022. EI #2 was asked when was the [MEDICATION(S)] discontinued. EI #2 said on 01/24/2022. EI #2 was asked who discontinued the medication order. EI #2 said she did, after the doctor gave the order to stop the [MEDICATION(S)]. EI #2 was asked did she notify the resident's family/representative when the [MEDICATION(S)] was discontinued on 01/24/2022. EI #2 said no, the family was not notified when the [MEDICATION(S)] was discontinued on 01/24/2022. EI #2 was asked if a medication being discontinued was a change in treatment. EI #2 said yes, it was a change in treatment.

Based on interviews, medical record review and a facility policy titled, Weight Loss Intervention, the facility failed to ensure nutritional recommendations made by Employee Identifier (EI) #3 Registered Dietician (RD) on 02/02/2022, were addressed for Resident Identifier (RI) #6. The facility further failed to document RI #6's meal intake for nine days in January of 2022. This deficient practice affected RI #6, one of three residents sampled for weight loss. Findings Include: A facility policy titled Weight Loss Interventions, with an effective date of 3/16/2021 documented . PURPOSE To ensure adequate nutrition for those at risk for weight loss, . PROCEDURE . 3. When factors contributing to poor appetite have been identified, appropriate interventions will be implemented . 4.The CNA (Certified Nursing Assistant) will document on the Flow Sheet, the percentage of consumption of each meal. RI #6 was admitted to the facility on [DATE]. RI #6's Nutritional Assessment completed and signed by EI #3 RD on 02/01/2022, documented a recommendation for 60 milliliters of Medplus supplement to be given to RI #6 twice a day for added calories and protein. On 02/09/22 at 11:00 AM EI #3 RD was asked if she was familiar with RI #6. EI #3 said she did an admission assessment on RI #6 on 01/28/22. EI #3 was asked about the findings of her admission assessment. EI #3 said, RI #6 had some weight loss after admission and she recommended Medplus 60 milliliters for 90 days. EI #3 was asked what was her expectations of the facility for her recommendations. EI #3 said she gave the recommendations to the facility and they were to give them to the physician and if he agreed, he would sign off on them. On 02/09/22 at 3:45 PM an interview was conducted with EI #4, MDS Coordinator. EI #4 was asked to explain the RD recommendation process. EI #4 said the RD visits the facility every Tuesday, she emails the recommendations to him weekly, and he presented them to the MD (Medical Director). A follow-up interview was conducted on 02/10/22 at 3:32 PM with EI #4 and he was asked when he received the RD recommendations for RI #6. EI #4 said, on 02/02/22 and the doctor did not visit that week. EI #2 was asked would this weight loss for RI #6 have been a concern to notify the doctor by phone, since the doctor did not visit in person that week. EI #4 said yes, he could have. EI #4 was asked if the doctor should have been notified. EI #4 said yes the doctor should have been notified. An interview was conducted with EI #5, Medical Doctor at 4:52 PM per phone. EI #5 was asked if he was the medical doctor for RI #6. EI #5 said, yes he was and he had been the doctor at the facility for 15 or [AGE] years and he was always available by phone. RI #6's Care Plan with a focus area of potential nutrition problem, with a print date of 02/08/2022, documented an intervention to monitor intake and record each meal. RI #6's meal intake documentation was reviewed. There was not any amount of intake recorded for 01/22/2022 through 01/30/2022. On 02/09/22 at 2:15 PM EI #6 Licensed Practical Nurse (LPN), was asked how ADL's (Activity of Daily Living) were documented. EI #6 said, CNA's chart ADL's on kiosk. EI #6 was asked what was documented. EI #6 said, meals, bathing and behaviors. EI #6 was asked if there was no documentation did that mean ADL's were not performed. EI #6 said if there was no documentation, the care could have happened it was just not documented. EI #6 was asked what evidence there would be for ADL's. EI #6 said they chart just in the computer. EI #6 was asked to review the RI #6's documentation report for meals, and if the facility's policy had been followed. EI #6 said, no. On 02/11/22 at 10:07 AM EI #1, Director of Nursing (DON) was asked where should meal intake be documented. EI #1 said there were kiosks on the halls and the CNA's were responsible for putting in the documentation on the percentage resident's ate. EI #1 was asked to review RI #6's ADL for meal intake and if there was documentation for meal intake for 01/22/2022 through 01/30/2022 for each meal. EI #1 said, No. EI #1 was asked should there be documentation of RI #6's meal intake for each shift. EI #1 said, the CNA's should document meal intake. EI #1 was asked who was responsible for ensuring the CNA's documented the meal intake per shift. EI #1 said, the charge nurse on that shift and if they have any issues they contacted her. EI #1 was asked if she was informed by the charge nurse on that unit, that RI #6's meal intakes were not documented. EI #1 said, she was not informed. EI #1 was asked what was the importance of documenting RI #6's meal intake. EI #1 said knowing what percentages the resident ate. EI #1 was asked if the facility's weight loss intervention policy was followed for documentation meal percentage consumed. EI #1 said, no the policy was not followed.

Based on interviews, record review and review of a facility policy titled Falls, the facility failed to ensure a fall care plan was developed for Resident Identifier (RI) #5, a resident who triggered for falls on their Admission Minimum Data Set (MDS) Care Area Assessment (CAA) Summary, dated 01/03/2022. This deficient practice affected RI #5, one of three residents sampled for falls. Findings include: Review of a facility policy titled Falls, dated 02/2017, revealed the following: Purpose To establish a process that identifies risk and establishes interventions to mitigate the occurrence of falls Process On admission . · When the risk is identified the intervention it is documented on the care plan . RI #5 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #5's Admission MDS assessment, with an Assessment Reference Date of 01/03/2022, revealed under the CAA Summary RI #5 triggered the care area of Falls, and there was a decision made to care plan for falls. On 02/10/2022 at 4:29 PM, the surveyor conducted an interview with Employee Identifier (EI) #2, the ADON (Assistant Director of Nursing). The surveyor asked EI #2, when looking at RI #5's Admission MDS assessment under the CAA Summary, did RI #5 trigger to be care planned for falls. EI #2 said yes. When asked to show the surveyor where the fall care plan had been developed, EI #2 said there was not a fall care plan developed. The surveyor asked EI #2 what was the rationale for developing a care plan specific to the resident. EI #2 said to let staff know the resident was at risk for falls. On 02/11/2022 at 12:26 PM, the surveyor conducted an interview with EI #1, the DON (Director of Nursing). EI #1 said she did not know a fall care plan had not been developed for RI #5. When asked why should residents be care planned for falls if they triggered for falls on the CAA Summary, EI #1 said so everyone was aware the resident was at a risk for falls. This deficiency was cited as a result of the investigation of complaint/report number AL 689.

Based on observations, interviews, review of the (YEAR) Food Code, and a facility policy titled, Tray Line and Meal Service Temperatures, dietary staff failed to ensure: 1) the temperatures of food items on the tray line were checked prior to service; 2) thermometers were accurately calibrated prior to use; 3) staff did not handle ready-to-eat food with bare hands; 4) staff washed their hands prior to the application of gloves; and 5) food found to be below recommended temperatures, was reheated to 165 degrees Fahrenheit (F) prior to service. These deficient practices had the potential to affect 87 residents for whom meals were prepared and served at the time of this survey. According to the facility's RESIDENT CENSUS AND CONDITIONS OF RESIDENTS form, the census at the time of the survey was 90. Findings Include: 1) A facility policy titled, Tray Line and Meal Service Temperatures, with an effective date of 08/01/12, specifies: .Temperatures of food items held on the service line will be recorded . All hot food must be held at temperatures above 135 degrees F; . All cold foods will be held at or below 41 degrees F . PR[NAME]EDURE 1. Food temperatures will be taken prior to the start of each meal at the service line . On 10/16/19 at 5:10 p.,m., the temperature of the pureed, and alternate food items had not been checked. The surveyor questioned the staff about the temperatures of the pureed food items. The pureed Chicken Cordon Bleu was 80 degrees, pureed broccoli was 105 degrees, and the pureed yams were 120 degrees. Each pureed food item was below the recommended levels. On 10/16/19 at 5:15 p.m., the pureed food was returned to the stove top for reheating, as were individual portions of Chicken Cordon Bleu. The temperature of one pan of broccoli without cheese (which the evening Cook, Employee Identified (EI) #3, said was for a lactose-free resident) was not checked, nor was a carton of milk, chopped chicken, or the alternatives of beef patties with gravy, rice and green beans. On 10/16/19 at 5:45 p.m., EI #3, began serving the alternative food items (beef patties with gravy, rice and green beans) without having checked the temperatures. On 10/16/19 at 5:50 p.m., the surveyor asked the facility's Certified Dietary Manager (CDM), EI #5, which foods should have been checked for temperatures prior to the meal service. EI #5 responded, everything. When asked why staff should have checked all the food temperatures, EI #5 stated the milk might not be cold enough, and the food might not be hot enough. On 10/17/19 at 9:44 a.m., the surveyor asked the evening Cook, EI #3, how often she checked food temperatures on the tray line. EI #3 said she checked the food items once every night before serving the food. EI #3 stated she was nervous last night, and upset because the foods were not hot enough. 2) A facility policy titled, Tray Line and Meal Service Temperatures, dated 08/01/12, directs staff as follows: .PR[NAME]EDURE: . 2. Each facility must have a pocket thermometer to utilize for taking food temperatures. Thermometers may be tested for accuracy of hot foods by immersing in boiling water (212 degrees F) . Immersing in a 50/50 ice and water slush until the reading stabilizes tests accuracy for cold foods. Adjust the unit to 32 degrees F . On 10/16/19 at 4:50 p.m., the surveyor observed three thermometers sitting in a glass of water with a small amount of ice. The dial heads on the thermometers registered 22 degrees F, 22 degrees F, and 32 degrees F. On 10/16/19 at 5:00 p.m., EI #3 removed the three thermometers from the ice water and inserted them into three pans of food on the steam table. The surveyor questioned EI #3 about the two thermometers registering only 22 degrees, however EI #3 continued to use them. On 10/16/19 at 5:10 p.m., EI #3 replaced the thermometers into the glass of melted ice water. EI #3 commented, They're only 60 degrees F. I have to let them go down. The temperature on each of the three thermometers did not reach 32 degrees, but registered a variety of temperatures when EI #3 pulled them out of the water and inserted each into three pans of pureed food. EI #4, the Consultant CDM, checked the temperature of the reheated Chicken Cordon Bleu. EI #5 commented she thought the thermometer was broken. EI #4 adjusted the thermometer in the melted ice water to 32 degrees F. On 10/16/19 at 5:34 p.m., EI #4, sanitized each of three additional thermometers obtained, and placed them into the glass of water without ice. A calibration to 32 degrees F in a 50/50 mix of ice and water to ensure accuracy was not observed by the surveyor. On 10/17/19 at 9:10 a.m., the surveyor asked EI #5 how was staff to calibrate the thermometers. EI #5 explained the staff was to place thermometers in ice water, and ensure it was 32 degrees F. 3) The (YEAR) FOOD CODE mandates the following: 3-301.11 Preventing Contamination from Hands . (B) . FOOD EMPLOYEES may not contact exposed, READY-TO-EAT FOOD with their bare hands and shall use suitable UTENSILS such as deli tissue, spatulas, tongs, single-use gloves, or dispensing EQUIPMENT . On 10/16/19 at 4:55 p.m., the evening Cook, EI #3, positioned left-over biscuits inside the [NAME]ot Coupe blender, contacting the biscuits using her ungloved (bare) hand. EI #3 then placed her ungloved fingers inside a clean Dinex bowl before portioning the pureed bread into the bowl. On 10/16/19 at 5:50 p.m., the surveyor asked EI #5 what potential problem could result from the handling of biscuits with bare hands, as EI #3 did when she pureed them tonight. EI #5 responded, contamination. On 10/17/19 at 9:44 a.m., the surveyor questioned EI #3 about the handling of the biscuits with her bare hand, and asked EI #3 how she was supposed to handle ready-to-eat food. EI #3 responded, they were supposed to wear gloves. When asked why gloves should be worn, EI #3 stated they were told to do it. In response to the surveyor's comment about the placement of her bare fingers inside the bowl in which she placed the pureed bread, EI #3 stated, she guess her hand went inside the bowl when she picked it up. 4) The (YEAR) FOOD CODE mandates the following: .2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms . immediately before engaging in FOOD preparation including working with exposed FOOD . and: . (H) Before donning gloves to initiate a task that involves working with FOOD; . On 10/16/19 at 5:36 p.m., the Consultant CDM, EI #4, removed a pan of reheated Chicken Cordon Bleu from the convection oven. EI #4 removed her left glove, and applied a new glove without first washing her hand. EI #4 then picked up several portions of Chicken (with her left hand) and checked the temperatures of each (150 degrees F). On 10/16/19 at 5:55 p.m., the surveyor asked EI #4 what she should do when she regloved. EI #4 responded, wash hands. 5) The (YEAR) Food Code mandates the following: .3-403.11 Reheating for Hot Holding. (A) . TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the FOOD reach a temperature of at least .(165 F) for 15 seconds . During the 10/16/19 supper tray line observation, several pans of food were found to be less than 135 degrees F, including Chicken Cordon Bleu, Pureed Chicken, Pureed Yams and Pureed Broccoli and Cheese. Each pan of food was reheated but failed to reach 165 degrees F. On 10/16/19 at 5:21 p.m., the CDM (EI #5) removed pureed broccoli from the gas burner. The temperature was 100 degrees F. At 5:22 p.m., EI #5 removed pureed yams from the gas burner. The temperature was 125 degrees F. The temperature of the reheated pureed chicken was 110 degrees F. At 5:27 p.m., EI #4 removed a pan of Chicken Cordon Bleu from the convection oven. The temperature registered 160 degrees F. The cook. EI #3, served the chicken. At 5:31 p.m., EI #4 checked the reheated pureed broccoli, finding it to be 148 degrees F. At 5:32 p.m., EI #4 checked the reheated pureed yams, at 150 degrees F. At 5:34 p.m., the temperature of the reheated pureed chicken was 150 degrees. On 10/16/19 at 5:50 p.m., the surveyor asked the facility CDM, EI #5, at what temperature was the food supposed to be served. EI #5 explained food was to be served above 135 degrees F and reheated to 165 degrees.

Based on observation, interviews, record review and review of the Assure Platinum Glucometer Study Guide, the facility failed to ensure a medication nurse, Employee Identifier (EI) #1, wore gloves while performing a finger stick blood glucose test on Resident Identifier (RI) #61 on 10/16/19, during the evening medication pass observation. Findings Include: Review of an undated Assure Platinum Glucometer Study Guide, revealed the following: BLOOD GLUCOSE TESTING Obtaining a Drop of Blood Note . We advise healthcare professionals to wear gloves during blood testing . RI #61 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. RI #61's Order Summary Report for 10/2019, revealed RI #61 was to receive blood glucose testing before meals and at bedtime. On 10/16/19 at 3:50 p.m., the surveyor observed EI #1 gather supplies to check RI #61's blood sugar. After washing her hands, EI #1 wiped the third finger on RI #61's left hand with an alcohol prep. EI #1 removed a glucometer from a plastic bag, placed a glucometer strip in the glucometer, pricked RI #61's finger with the lancet, then placed the blood on the strip. EI #1 did not wear gloves during this procedure. On 10/16/19 at 4:09 p.m., the surveyor conducted an interview with EI #1. The surveyor asked EI #1 what should she have done before pricking RI #61's finger with the lancet. EI #1 said she should have put gloves on. The surveyor asked EI #1 why should she have gloved. EI #1 said to protect herself and RI #61. On 10/17/19 at 12:45 p.m., the surveyor conducted an interview with EI #2, the RN (Registered Nurse)/Director of Clinical Education. The surveyor asked EI #2 how should the nurses perform a finger stick blood sugar. EI #2 said the nurse would wash her hands, apply gloves and explain to the resident what was going on and what the nurse was about to perform. The surveyor asked EI #2 why should gloves be applied. EI #2 said blood borne pathogens could be transmitted to others. The surveyor asked EI #2 what kind of concern would that be when gloves were not worn. EI #2 said infection control.

Based on observations, interviews, review of the (YEAR) U.S. (United States) Public Health Service Food Code and review of facility policies titled Dry Storage, Dietary Food Handling and Water Temperature for Dishwashing Machines, the facility failed to ensure: (1) dented cans were not stored with other canned goods; (2) an opened jar of jelly had a use by date on it; (3) a container of barbeque sauce did not have sauce on the outside of the container; (4) the tips of the thermometers were not touching the bottom of the glass and the thermometer was not submerged under water during calibration; (5) a cook did not place the handle of the tong on top of a pan of rolls after she touched the handle with her bare hands; (6) grease was not on top of the oven; (7) dust like particles were not on the back of the oven fan and on a book above the toaster; (8) plate warmers and covers were air dried; and (9) a cook did not place her bare hands on the inside of plate covers. These deficient practices were observed on two of three days of the survey, and had the potential to affect all 88 residents receiving meals from the dietary department. Findings Include: (1) Review of a facility policy titled Dry Storage, with an effective date of 01/01/17, documented: . PR[NAME]EDURE . 9. Damaged cans will be identified for removal . On 09/04/18 at 4:30 p.m., the surveyor observed the following dented can goods on a rack in the dry storage area with other canned foods: 1) Four, 6.56 pound cans of Spaghetti sauce. One of the four cans had a dent on the side of the can; 2) 11, 48 ounce cans of chicken and dumplings. One of the 11 cans had a dent on the side of the can; 3) Six, seven pound five ounce cans of baked beans. Two of the six cans had a dent on the side of the can; and 4) Three, 6.56 pound cans of Marinara sauce. One of the three cans had a dent on the side of the can. On 09/04/18 at 5:26 p.m., the surveyor shared with Employee Identifier (EI) #8, the Dietary Manager (DM) the observations of the dented canned goods stored with the other canned goods. The surveyor asked EI #8 where should the dented cans be stored. EI #8 said on the bottom shelf in the pantry. On 09/06/18 at 12:12 p.m., the surveyor conducted an interview with EI #8. The surveyor asked EI #8 what was the potential for harm when dented cans were stored with the other canned food items. EI #8 said you do not want to use the dented canned goods because it could be hazardous to the food, depending on where the dent in the can was. (2) A review of the (YEAR) U.S. Public Health Service Food Code documented: . 3-5 LIMITATION OF GROWTH OF ORGANISMS OF PUBLIC HEALTH CONCERN . 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking . (B) . FOOD prepared and PACKAGED by a FOOD PR[NAME]ESSING PLANT shall be clearly marked, the the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES . On 09/04/18 at 4:25 p.m., the surveyor observed a four pound jar of opened grape jelly with the date of 8/28/18 on the jar. There was no use by date on the jar. On 09/04/18 at 5:26 p.m., the surveyor asked EI #8 what did the date of 08/28/18 on the jelly represent. EI #8 said the date it was opened. The surveyor asked EI #8 should there be a use by date on the jelly. EI #8 replied yes. On 09/06/18 at 12:12 p.m., the surveyor conducted an interview with EI #8. The surveyor asked EI #8 why should there be a use by date on opened food items. EI #8 said so employees would know when the food item was opened and the food item would not get reused after the date that was on the food item. (3) On 09/04/18 at 5:17 p.m., the surveyor observed in the Walk-in-Cooler. A container of barbeque sauce with sauce on the outside of the container. On 09/05/18 at 10:23 a.m., the surveyor observed the sauce to remain on the outside of the container of barbeque sauce. On 09/06/18 at 11:54 a.m., the surveyor asked EI #8 what was on the outside of the barbeque sauce container. EI #8 said sauce. The surveyor asked EI #8, when placed back in the cooler how should the container be. EI #8 said wiped down and clean. When asked why should the container be wiped down and cleaned, EI #8 said if there was stuff on the outside of the container, it could contaminate the other products if they were rubbed up against the container of barbeque sauce. (4) On 09/05/18 at 10:38 a.m., the surveyor observed five thermometers in a glass of ice water. Two of the thermometer tips were touching the bottom of the glass and one thermometer was submerged under water. On 09/05/18 at 11:08 a.m., the surveyor conducted an interview with EI #6, the morning cook. The surveyor asked EI #6 how should the thermometers be positioned when in the glass of ice water. EI #6 said on the calibrator/wrench. The surveyor asked EI #6 should the tip of the thermometer be touching the bottom of the glass. EI #6 said no. The surveyor asked EI #6 should the thermometer be submerged under the water. EI #6 said no. On 09/06/18 at 12:12 p.m., the surveyor conducted an interview with EI #8, the DM. The surveyor asked EI #8 how should the dietary staff calibrate the thermometer before it is used. EI #8 said with the little wrench. EI #8 said the thermometers should not be submerged in the ice water nor touching the bottom of the glass. The surveyor asked EI #8 what was there a potential for when the thermometer is not calibrated correctly and the tip of the thermometer touches the bottom of the glass. EI #8 said the thermometer would not read the food temperatures correctly. (5) Review of a facility policy titled Dietary Food Handling, with an effective date of 01/01/ 17, documented: . PR[NAME]EDURE . 12. Utensils . must be handled in such a way as to avoid touching surfaces with which food . will come in contact . On 09/05/18 at 11:40 a.m. - 11:55 a.m., the surveyor observed EI #6, the morning cook, using a red handled tongs to pick up rolls and place the rolls on the residents' plates. Each time EI #6 placed the tongs back in the bowl of rolls, the handle of the tongs, which EI #6 handled with her bare hands, was placed on top of the rolls in the bowl. On 09/05/18 at 11:58 a.m., the surveyor conducted an interview with EI #6. The surveyor asked EI #6 how should the handle of the tongs being used to pick up rolls be positioned when it is place back in the bowl of rolls. EI #6 said down in the bowl. The surveyor asked EI #6 should the handle of the tongs be touching the rolls in the bowl. EI #6 said no. The surveyor asked EI #6 what would that be considered when the handle that has been touched is placed back in the bowl touching the rolls. EI #6 said contamination. On 09/06/18 at 12:12 p.m., the surveyor conducted an interview with EI #8, the DM. The surveyor asked EI #8 how should the handle of the tongs being used to serve rolls be positioned when placed back in the bowl/container of rolls. EI #8 said you would place the tongs on the side of the bowl, where it is not touching the rolls. The surveyor asked EI #8 what would there a potential for when the handle of the tongs touched the rolls. EI #8 replied contaminating the food. (6) On 09/05/18 at 11:29 a.m., the surveyor observed the top of the oven with grease on it. On 09/06/18 at 7:45 a.m., the grease remained on top of the oven. On 09/06/18 at 11:59 a.m., the surveyor asked EI #8 what was on top of the oven. EI #8 said grease from the fryer. On 09/06/18 at 12:12 p.m., the surveyor conducted an interview with EI #8. The surveyor asked EI #8 how often was the top of the oven cleaned. EI #8 said it should be wiped down every evening or night. The surveyor asked EI #8 what was there a potential for when grease was left on top of the oven. EI #8 said the grease could be hazardous and if the fans came on, the grease would blow off. (7) On 09/05/18 at 12:00 p.m., the surveyor observed dust looking particles on the fan on the back of the oven. On 09/05/18 at 12:01 p.m., the surveyor observed dust looking particles on top of a book above the area where the toaster was located. On 09/06/18 at 7:46 a.m., the dust looking particles remained on the fan on the back of oven. On 09/06/18 at 07:47 a.m., the dust looking particles remained on the book above the area where the toaster was located. On 09/06/18 at 12:00 p.m., the surveyor asked EI #8 what did it look like was on the fan on the back of the oven. EI #8 said dust or it might be grease. On 09/06/18 at 12:01 p.m., the surveyor asked EI #8 what did it look like was on the book above the area where the toaster was located. EI #8 replied dust from the ceiling. On 09/06/18 at 12:12 p.m., the surveyor conducted an interview with EI #8. The surveyor asked EI #8 what was there a potential for when dust is on the fan on the back of the oven and on other items in the kitchen. EI #8 said the dust could blow off and get in anything, such as clean pans. (8) A review of the (YEAR) U.S. Public Health Service Food Code documented: . 4-9 PROTECTION OF CLEAN ITEMS . 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried . On 09/06/18 at 8:53 a.m., the surveyor observed EI #7, another cook, remove 10 lid covers from the dish rack and stacked the covers on the drying rack. On 09/06/18 at 8:59 a.m., the surveyor observed EI #7 remove nine lid covers from dish rack and stack the covers on the drying rack. On 09/06/18 at 09:02 a.m., the surveyor observed EI #7 stack 18 plate holders on the drying rack. On 09/06/18 at 09:04 a.m., the surveyor observe EI #7 stack 10 lid covers on the drying rack. On 09/06/18 at 9:12 a.m., the surveyor observed EI #7 stack 18 plate holders on the drying rack. On 09/06/18 at 09:16 a.m., the surveyor observed EI #7 stack 10 lid covers on the drying rack. On 09/06/18 at 9:35 a.m., the surveyor showed EI #8, the DM, the plate holders and lid covers that had been stacked by EI #7. The surveyor asked EI #8 was that considered air drying. EI #8 replied no ma'am On 09/06/18 at 12:12 p.m., the surveyor conducted an interview with EI #8. The surveyor asked EI #8 how were items in the kitchen air dried. EI #8 said items are placed on a drying rack, left there until they were dry, then stacked. The surveyor asked EI #8 should items be stacked before being air dried. EI #8 said items should be dried before they were stacked. The surveyor asked EI #8 what was there a potential for when items were stacked before air dried. EI #8 said a lid that was not air dried could drip water in the food. (9) On 09/06/18 at 8:59 a.m., the surveyor observed EI #7, remove nine lid covers from the dish rack. EI #7's hands touched the inside of the lid covers. On 09/06/18 at 9:04 a.m., the surveyor observed EI #7 removed 10 lid covers from the dish rack. EI #7's hands touched the inside of the lid covers. On 09/06/18 at 9:16 a.m., the surveyor observed EI #7 remove 10 lid covers from the dish rack. EI #7's hands touched the inside of the lid covers. On 09/06/18 at 12:03 p.m., the surveyor conducted an interview with EI #7. The surveyor shared with EI #7 that the surveyor observed, when she removed the lid covers from the dish rack, her hands touched the inside of the lid covers. The surveyor asked EI #7 what was that a potential for. EI #7 replied cross contamination. On 09/06/18 at 12:12 p.m., the surveyor conducted an interview with EI #8, the DM. The surveyor asked EI #8, how should the lid covers be handled when being removed from the dish rack. EI #8 said the lid covers should be touched from the back. The surveyor asked EI #8, when touched on the inside, what was that considered. EI #8 said staffs hands would be contaminating the inside of the lid covers.

Based on observation, interviews, record review, and review of PERRY & POTTER, 9th Edition, Clinical Nursing Skills & Techniques, the facility failed to ensure Resident Identifier (RI) #3's nebulizer face mask and reservoir cup were rinsed and dried after receiving a nebulizer treatment from a Licensed Practical Nurse (LPN). This affected 1 of 1 resident observed receiving a nebulizer treatment and 1 of 6 nurses observed during medication administration pass. Findings Include: A review of PERRY & POTTER 9th Edition, Clinical Nursing Skills & Techniques, Chapter 21, Page 564, documented .When medication is completely nebulized .Rinse nebulizer cup .Dry completely .Proper storage reduces transfer of microorganisms . RI #3 was admitted to the facility on [DATE]. RI #3's Order Review Report for (MONTH) (YEAR) documented a [DIAGNOSES REDACTED]. RI #3's (MONTH) (YEAR) Medication Administration Record [REDACTED]. On 09/05/2018 at 08:01 a.m., Employee Identifier (EI) #1, an LPN, was observed administering RI #3's nebulizer treatment. The surveyor observed EI #1 place RI #3's nebulizer face mask and reservoir cup in a plastic bag without rinsing or drying it. On 09/05/2018 at 02:41 p.m., an interview was conducted with EI #1, a LPN. EI #1 was asked what she did with the nebulizer face mask and reservoir cup after RI #3 finished the breathing treatment. EI #1 replied that she placed the nebulizer face mask and reservoir cup in a plastic bag without rinsing and cleaning. EI #1 was asked what the facility's standard of practice of care for the nebulizer face mask and reservoir cup was, after giving a resident a breathing treatment. EI #1 stated that you should rinse and dry the nebulizer face mask and reservoir cup prior to placing it in the plastic bag. EI #1 was asked why she did not rinse and dry the nebulizer face mask and reservoir cup after giving the nebulizer breathing treatment to RI #3. EI #1 stated that she forgot to do it. EI #1 was asked if there was wet moisture in the nebulizer face mask and reservoir cup that was placed in the plastic bag. EI #1 replied yes. EI #1 was asked how this could affect the resident if the nebulizer face mask and cup were put back in a plastic bag, without rinsing and drying. EI #1 stated that it could cause an infection or make the resident sick. On 09/05/2018 at 03:09 p.m., an interview was conducted with EI #2, an LPN, Infection Control Preventionist. EI #2 was asked what standard of practice does the facility follow regarding care of the nebulizer face mask and reservoir cup, after a resident has finished with a breathing treatment. EI #2 stated that you should rinse and dry the nebulizer face mask and reservoir cup, prior to placing it in the plastic bag. EI #2 was asked why you should rinse and dry the nebulizer face mask and reservoir cup prior to putting both items back in a plastic bag. EI #2 replied that it could cause bacteria and microorganisms to grow on the face mask or in the nebulizer cup. EI #2 further stated that this could cause the resident to contract an infection.

Based on observation, interview, and medical record review, the facility failed to ensure a care plan was developed for RI (Resident Indentifier) #241, a resident who required the use of Oxygen (O2). This deficient practice affected RI #241, one of three sampled residents who required the use of O2. Findings include: RI # 241 was re-admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 09/6/18 at 7:55 a.m., the surveyor observed the resident with O2 on. On 0 9/6/18 at 3:11 p.m., a review of RI #241's care plans revealed the facility had not developed a care plan to address RI #241's O2 use. On 09/06/2018 at 4:08 p.m., an interview was conducted with EI (Employee Identifier) #5, Director of Nurses (DON). EI #5 was asked if RI #241 used O2. EI #5 said, Yes. EI #5 was asked if RI #241 had a care for the use of O2. EI #5 said, No. EI #5 was asked what was the rationale for having a care plan. EI #5 said, To provided the care (he/she) requires.

Based on observation, interviews and record review, the facility failed to ensure Resident Identifier (RI) #55's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 08/20/18, reflected RI #55 was receiving [MEDICAL TREATMENT] services. This deficient practice affected RI #55, one of 40 residents whose MDS assessments were reviewed. Findings Include: RI #55 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of RI #55's Quarterly MDS assessment, with an ARD of 08/20/18, did not identify RI #55 as having received [MEDICAL TREATMENT] services during this assessment period. A review of RI #55's (MONTH) (YEAR) Physician order [REDACTED].> . [MEDICAL TREATMENT] @ (at) (name of [MEDICAL TREATMENT] center) Tues (Tuesday)/Thur (Thursday)/Sat (Saturday) . 09/05/18 at 08:45 a.m., the surveyor conducted an interview with RI #55. RI #55 shared with the surveyor he/she went to [MEDICAL TREATMENT] on Tuesdays, Thursdays and Saturdays. At this time, the surveyor observed an AV (Arteriovenous) graft to RI #55's left upper arm. 09/06/18 at 02:38 p.m., the surveyor conducted an interview with Employee Identifier (EI) #9, a Registered Nurse/MDS Coordinator. The surveyor asked EI #9 how long had RI #55 been a resident at the facility. EI #9 said for four years. When asked if RI #55 was receiving [MEDICAL TREATMENT] services, EI #9 said RI #55 was. The surveyor asked EI #9 how long had RI #55 been receiving [MEDICAL TREATMENT] services. EI #9 said as far as she remembered RI #55 had been receiving [MEDICAL TREATMENT] services. When the surveyor asked EI #9 if RI #55 was coded as receiving [MEDICAL TREATMENT] services on his/her Quarterly MDS assessment with the ARD of 8/20/18, EI #9 replied RI #55 was not. The surveyor asked EI #9 should RI #55 be coded as receiving [MEDICAL TREATMENT] services. EI #9 replied yes. When asked if the Quarterly 08/20/18 MDS assessment was accurate, EI #9 replied no.

Based on observation, interview, and review of the facility policy titled Refrigerated Storage, the facility failed to ensure raw beef shoulder, raw pork tenderloin, and open sandwich meat were not stored in the same container in the walk-in cooler, creating the potential for cross-contamination. This had the potential to affect 89 of 92 residents in the facility, identified by the facility as receiving meals from the dietary department. Findings include: Review of the facility's policy titled Refrigerated Storage, effective 06/01/2013, revealed the following: .PROCEDURE . 3. If it is necessary to store fresh and cooked food in the same refrigerator, the cooked foods should be . stored above the fresh foods. 4. Raw meats, poultry, and fish . each type of meat placed in a separate pan . On 08/15/2017, during the initial tour of the kitchen at 6:37 p.m., a plastic bin containing multiple types of meat was observed in the walk-in cooler. Dietary staff identified the meats as an uncooked beef shoulder, uncooked pork tenderloin, and multiple packages of luncheon meat. Two of the luncheon meat packages were loosely wrapped in an open paper sandwich bag. On 08/17/2017 at 10:25 a.m., Employee Identifier (EI) #1, the Dietary Manager, said raw meats should be stored on the bottom shelf of the walk-in cooler in a pan. She explained the raw beef and pork should have been in separate containers to prevent potential contamination. EI #1 also said the luncheon meat should be stored in a separate container because if it was open, it could make someone sick.

Based on record review, interviews, and review of the job description for the Vice President of Quality Management and Clinical Services, corporate staff failed to ensure a policy was developed and/or the facility procedure was revised for side rail use. This had the potential to affect all 57 of 92 residents in the facility, identified as utilizing side rails. Findings include: Cross Reference F323. Review of an undated job description for the Vice President of Quality Management and Clinical Services, Corporate Office, revealed the following: . KEY RESPONSIBILITIES . 4. Develops policies and procedures . A facility-provided list identified 57 residents in the facility utilizing side rails. When asked for a facility policy related to the use of side rails, Employee Identifier (EI) #4, the Director of Nursing Services, provided a signed document indicating the facility did not have a policy on side rails. This document also indicated the facility did not obtain informed consent/authorization prior to using side rails, unless it was considered a restraint. During an interview with EI #6, the Director of Clinical Operations (corporate), on 08/17/2017 at 2:00 p.m., EI #6 said they only obtained informed consent for side rails if it was considered a restraint. When asked if the facility had a policy addressing side rails and the requirements related to side rail use, EI #6 said no, not unless it was a restraint. When asked why not, EI #6 said she did not know what to say, and that it must have slipped by them with the recent regulatory changes. EI #6 said the Support Center was responsible for developing facility policies. EI #7, Senior Support Staff/Vice President of Quality Management and Clinical Services, was interviewed on 08/17/2017 at 2:35 p.m When asked who was responsible for developing policies, EI #7 said the committee (corporate level) was responsible for completing a lot of the policy development. EI #7 said they were in the process of addressing all the recent regulatory changes. EI #7 said she did see where the regulatory changes related to side rail use were currently effective, but said they must have missed it. When asked how staff would know what should be done if there was no policy related to side rail use, EI #7 said the facility's procedure needed to be revised to add more steps to address entrapment and informed consent requirements.

Based on observations, record review, and interviews, the facility failed to ensure: 1) the residents and/or their representatives were informed of the risks and benefits related to the use of side rails prior to installation; and 2) Resident Identifier (RI) #8 did not have a full side rail up on the room/exit side of the bed on 08/15/2017 and a fall mat was placed at the bedside. These failures affected RI #s 1, 2, 3, 8, 10, and 11, six of six residents reviewed for side rail use, and had the potential to affect all 57 of 92 residents residing in the facility, identified by the facility as using side rails. Findings include: 1) A facility-provided list identified 57 residents in the facility utilizing side rails. When asked for a facility policy related to the use of side rails, Employee Identifier (EI) #4, the Director of Nursing Services, provided a signed document indicating the facility did not have a policy on side rails. This document also indicated the facility did not obtain informed consent/authorization prior to using side rails, unless it was considered a restraint. RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1's Annual Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 08/29/2016, indicated RI #1 had short and long term memory problems with moderately impaired skills for daily decision making. This assessment also indicated RI #1 was totally dependent on one person for bed mobility and transfers. RI #1's EVALUATION FOR USE OF SIDE RAIL(S) ., dated 08/29/2016, indicated RI #1 required 3/4 side rails up times two at all times when in bed due to weakness, balance deficit, and to improve bed mobility. RI #1's medical record did not contain documentation of informed consent for the use of side rails. There was no evidence the risks and benefits of side rail use were discussed. During an interview with Employee Identifier (EI) #4, the Director of Nursing Services, on 08/16/2017 at 3:20 p.m., EI #4 said RI #1's side rail had been implemented in October 2012. When asked if any alternatives had been attempted prior to using the side rails, EI #4 said they had started RI #1 with a 1/2 rail. EI #4 also said they did not have an informed consent/authorization for RI #1's side rail because she was under the impression they only needed that if it was a full rail or a restraint. RI #2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #2's quarterly MDS Assessment, with an ARD of 06/05/2017, indicated RI #2 was cognitively intact and was totally dependent on one person for bed mobility and transfers. RI #2's EVALUATION FOR USE OF SIDE RAILS(S) ., dated 06/05/2017, indicated RI #2 required 3/4 side rails up times two at all times when in the bed due to weakness, balance deficit, and to improve bed mobility. RI #2's medical record did not contain documentation of informed consent for the use of side rails. There was no evidence the risks and benefits of side rail use were discussed. On 08/15/2017 at 7:05 p.m., RI #2 was observed in bed with side rails up times two. RI #3 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #3's yearly MDS, with an ARD of 08/04/2017, indicated RI #3 had short and long term memory impairment and moderately impaired daily decision making skills. This assessment also indicated RI #3 was totally dependent on one person for bed mobility and transfers. RI #3's EVALUATION FOR USE OF SIDE RAILS(S) ., dated 08/09/2017, indicated RI #3 required the use of 3/4 side rails up times two at all times when in the bed due to weakness and balance deficit. RI #3's medical record did not contain documentation of informed consent for the use of side rails. There was no evidence the risks and benefits of side rail use were discussed. RI #3 was observed in bed with 3/4 side rails up times two on 08/16/2017 at 8:15 a.m RI #8 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #8's Significant Change in Status Minimum Data Set Assessment, with an Assessment Reference Date of 05/03/2017, indicated RI #8 had moderately impaired cognition and required limited assistance of one person for bed mobility. RI #8's most recent EVALUATION FOR USE OF SIDE RAIL(S) ., dated 05/08/2017, indicated RI #8 required the use of 3/4 side rails up times two at all times when in bed related to weakness, balance deficits, and to improve bed mobility. RI #8's medical record did not contain documentation of informed consent for the use of side rails. There was no evidence the risks and benefits of side rail use were discussed. During the initial tour of the facility on 08/15/2017 beginning at 7:03 p.m., RI #8 was observed in bed with one full side rail up on the room side of the bed. During an interview with Employee Identifier (EI) #4, the Director of Nursing Services, on 08/16/2017 at 3:20 p.m., EI #4 said RI #8's side rails had been implemented upon admission on 12/31/2014. EI #4 also said they did not have an informed consent/authorization for RI #8's side rail. RI #10 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #10's quarterly MDS, with an ARD of 07/17/2017, indicated RI #10 had severely impaired cognition and required extensive assistance of one person for bed mobility and transfers. RI #10's most recent EVALUATION FOR USE OF SIDE RAIL(S) ., dated 07/17/2017, indicated RI #10 required the use of 3/4 side rails up times two at all times when in bed related to weakness, balance deficits, and to improve bed mobility. RI #10's medical record did not contain documentation of informed consent for the use of side rails. There was no evidence the risks and benefits of side rail use were discussed. RI #11 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #11's yearly MDS, with an ARD of 06/12/2017, indicated RI #11 had short and long term memory impairments and moderately impaired daily decision making skills. This assessment also documented RI #11 was totally dependent on one person for bed mobility and transfers. RI #11's most recent EVALUATION FOR USE OF SIDE RAIL(S) ., dated 06/12/2017, indicated RI #11 required the use of 3/4 side rails up times two at all times when in bed related to weakness, balance deficits, and to improve bed mobility. RI #11's medical record did not contain documentation of informed consent for the use of side rails. There was no evidence the risks and benefits of side rail use were discussed. On 08/15/2017 at 7:05 p.m. and on 08/16/2017 at 8:05 a.m. RI #11 was observed in bed with full side rails up times two. EI #8, Licensed Practical Nurse, was interviewed on 08/17/2017 at 8:05 a.m EI #8 said she was responsible for completing all side rail evaluations in the facility. When asked if she discussed side rail use with family, EI #8 said they discuss what was used when in the hospital. When asked if she discussed the risks involved in the use of side rails, EI #8 said they did not get that detailed when discussing it. When asked if she obtained informed consent prior to initiating side rails for residents, EI #8 said she was not informed of the need for that. In a follow-up interview with EI #8 on 08/17/2017 at 1:50 p.m., EI #8 was asked to clarify what she did discuss with residents and/or representatives related to side rails. EI #8 said they just discuss how to use the side rail and why it was needed. She further stated she had never discussed the risks involved with using side rails. During an interview with EI #6, the Director of Clinical Operations, on 08/17/2017 at 2:00 p.m., informed consents were requested for the use of RI #s 1, 2, 3, 8, 10 and 11's side rails. The facility failed to provide this as requested prior to the end of the survey on 08/17/2017 at 5:15 p.m 2) RI #8 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #8's Significant Change in Status Minimum Data Set Assessment, with an Assessment Reference Date of 05/03/2017, indicated RI #8 had moderately impaired cognition and required limited assistance of one person for bed mobility. RI #8's comprehensive care plans included an intervention dated 01/11/2016 for .fall mat to right side of bed . due to risk of falls. RI #8's most recent EVALUATION FOR USE OF SIDE RAIL(S) ., dated 05/08/2017, indicated RI #8 required the use of 3/4 side rails up times two at all times when in bed related to weakness, balance deficits, and to improve bed mobility. During the initial tour of the facility on 08/15/2017 beginning at 7:03 p.m., RI #8 was observed in bed with one full side rail up on the room side of the bed; no fall mat was noted. Employee Identifier (EI) #2, Licensed Practical Nurse (LPN), was interviewed on 08/15/2017 at 7:47 p.m When asked why RI #8 had a full side rail, EI #2 said RI #8's bed was provided by hospice, and added that the facility did not normally use full side rails. EI #2 was unsure how long RI #8 had been using a full side rail. When asked what RI #8's Care Guide said , EI #2 said fall mat at bedside. When asked if the fall mat was in place, EI #2 went to RI #8's room and located the fall mat under the bed, instead of beside it. EI #5, RI #8's Certified Nursing Assistant, was interviewed on 08/15/2017 at 8:20 p.m EI #4 said she had been assigned to RI #8 for the last two nights and admitted while she cared for RI #8 the full side rail was used and the mat was not place at bedside. When asked why it was important to follow the resident's care plan, EI #5 said if the care plan was not followed, things could happen, such as a fall or climbing over the side rail. During an interview with EI #4, the Director of Nursing Services, on 08/16/2017 at 3:20 p.m., EI #4 said per the resident assessment, RI #8 should have had 3/4 side rails. EI #8 also stated per the care plan, a fall mat should have been placed at the bedside when in bed. When asked why that was important, EI #4 said safety from a fall. EI #4 went on to explain they did not generally use full side rails, but hey must have missed RI #8's because the rails were adjustable.

Based on observations, record review, and interviews, the facility failed to ensure Resident Identifier (RI) #8's interventions of 3/4 (three quarter) side rails up times two and a fall mat at bedside were implemented. This affected one of six residents sampled for falls and side rails and one of 17 residents for whom care plans were reviewed. Findings include: RI #8 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #8's Significant Change in Status Minimum Data Set Assessment, with an Assessment Reference Date of 05/03/2017, indicated RI #8 had moderately impaired cognition and required limited assistance of one person for bed mobility. RI #8's comprehensive care plans included an intervention dated 01/11/2016 for .fall mat to right side of bed . due to risk of falls. RI #8's most recent EVALUATION FOR USE OF SIDE RAIL(S) ., dated 05/08/2017, indicated RI #8 required the use of 3/4 side rails up times two at all times when in bed related to weakness, balance deficits, and to improve bed mobility. During the initial tour of the facility on 08/15/2017 beginning at 7:03 p.m., RI #8 was observed in bed with one full side rail up on the room side of the bed; no fall mat was noted. Employee Identifier (EI) #2, Licensed Practical Nurse (LPN), was interviewed on 08/15/2017 at 7:47 p.m When asked what RI #8's Care Guide said, EI #2 said fall mat at bedside. When asked if the fall mat was in place, EI #2 went to RI #8's room and located the fall mat under the bed, instead of beside it. EI #5, RI #8's Certified Nursing Assistant , was interviewed on 08/15/2017 at 8:20 p.m EI #5 said she had been assigned to RI #8 for the last two nights and admitted that while she cared fro RI #8 the full side rail was used and the mat was not placed at bedside. EI #5 said RI #8's care plan was not followed. When asked why it was important to follow the resident's care plan, EI #5 said if the care plan was not followed, things could happen, such as a fall or climbing over the side rail. EI #3, the Care Plan Coordinator, was interviewed on 08/17/2017 at 8:40 a.m EI #3 confirmed RI #8 required the use of 3/4 side rails per the resident assessment, and said if a full rail was being used, the care plan was not followed. EI #3 also stated RI #8 should have a mat at bedside to help prevent injury in the event of a fall. EI #3 said the care plan was not followed if the fall mat was not at the bedside.

Based on observation, record review and interviews, the facility failed to ensure Resident Identifier (RI) #8's Care Guide was updated to reflect the need for 3/4 (three quarter) side rails up times two per the resident assessment. This affected one of 17 residents for whom care plans were reviewed. Findings include: RI #8 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #8's Significant Change in Status Minimum Data Set Assessment, with an Assessment Reference Date of 05/03/2017, indicated RI #8 had moderately impaired cognition and required limited assistance of one person for bed mobility. RI #8's most recent EVALUATION FOR USE OF SIDE RAIL(S) ., dated 05/08/2017, indicated RI #8 required the use of 3/4 side rails up times two at all times when in bed related to weakness, balance deficits, and to improve bed mobility. However, RI #8's current Care Guide (used by staff to know what care is needed) indicated RI #8 required 1/2 (one half) rails. During the initial tour of the facility on 08/15/2017 beginning at 7:03 p.m., RI #8 was observed in bed with one full side rail up on the room side of the bed. Employee Identifier (EI) #2, Licensed Practical Nurse (LPN), was interviewed on 08/15/2017 at 7:47 p.m When asked why RI #8 had a full side rail, EI #2 said RI #8's bed was provided by hospice , and added that the facility did not normally use full side rails. EI #2 was unsure how long RI #8 had been using a full side rail. When asked what RI #8's Care Guide said in regards to side rails, EI #2 said 1/2 (one half) side rails. On 08/17/2017 at 8:40 a.m., EI #3, the Care Plan Coordinator, said RI #8's care guide should have been updated after the EVALUATION FOR USE OF SIDE RAIL(S) . was completed, indicating the need for 3/4 side rails times two. EI #3 said it was important to update care guides to provide the best care for the residents.

Based on record review and interviews, the facility failed to ensure individualized care plan approaches were developed to address Resident Identifier (RI) #2's need for 3/4 (three quarter) side rails up times two. This affected one of 17 residents for whom care plans were reviewed. Findings include: RI #2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #2's quarterly Minimum Data Set (MDS) Assessment, with an Assessment Reference Date of 06/05/2017, indicated RI #2 was cognitively intact and was totally dependent on one person for bed mobility and transfers. RI #2's EVALUATION FOR USE OF SIDE RAILS(S) ., dated 06/05/2017, indicated RI #2 required 3/4 side rails up times two at all times when in the bed due to weakness, balance deficit, and to improve bed mobility. However, RI #2's undated Care Guide, did not indicate RI #2's need for side rails. RI #2's falls care plan, with an onset date of 12/23/2011, included an intervention of . May use bedside rails to promote independence with bed mobility .; however, this care plan did not address what size side rail RI #2 required or when the side rails should be used. During an interview with Employee Identifier (EI) #4, the Director of Nursing Services, on 08/16/2017 at 3:20 p.m., EI #4 said for the majority of residents with side rails, the care plans were more generalized, not individualized. EI #3, the Care Plan Coordinator, was interviewed on 08/17/2017 at 4:27 p.m EI #3 said neither RI #2's Care Guide or Care Plan indicated the size of side rail the resident required. When asked why not, EI #3 said she did not know, but explained the purpose of the care plans was to provide individual care for the residents.

Based on observation, record review and interview, the facility failed to ensure licensed staff washed hands prior to wound care after entering the resident's room with supplies. This affected RI (Resident Identifier) #2. The facility further failed to ensure a Licensed Practical Nurse (LPN) did not stack medication cups containing pills and administer them to RI #12 and #13, two residents observed during medication pass. These deficient practices affected 3 of 16 sampled residents with infection control concerns. Findings Include: 1.) A review of the facility Skills Handbook (pg.169) revealed: . SKILL 7-1 Hand Hygiene .3 If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in the following clinical situations: a Before .direct contact with patients . After contact with inanimate objects . RI #2 was readmitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. A review of RI #2's 14 day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/09/2016, revealed a Brief Interview for Mental Status (BIMS) score of 9, which is indicative of moderate cognitive impairment. A review of RI #2's August 2016 Physician order [REDACTED]. On 08/24/2016 at 1:15 p.m., Employee Identifier (EI) #1, LPN/Treatment Nurse, was observed washing her hands twice prior to leaving the room to retrieve another supply for the treatment table. Upon returning to RI #2's room, EI #1 put gloves on and proceeded with wound care without washing her hands. On 08/24/2016 at 4:05 p.m., an interview was conducted with EI #1. EI #1 was asked about the facility policy on controlling infection and she responded, anytime you touch anything you need to wash your hands or use hand sanitizer. EI #1 was asked what would be the potential harm of not washing her hands when she returned to RI #2's room. The response was, infection. On 08/25/2016 at 2:05 p.m., an interview was conducted with EI #2, LPN/Infection Control Nurse. When asked what had the facility done to prevent infections. The nurse responded proper handwashing and proper perineal care. The question was asked when should nurses wash hands during wound care and the nurse responded, when entering a room, when touching dirty and before touching clean or if the hands become soiled. EI #2 was asked, when EI #1 left the room to gather more supplies, why were hands not washed when she re-entered RI #2's room. EI #2 responded she did not know why and once the staff member re-entered the room, hands should have been washed. EI #2 was asked what the potential for harm was in not washing hands after returning with more supplies before restarting wound care. EI #2 responded spread of germs. 2) RI #13 was readmitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. A review of RI #13's quarterly MDS, with an ARD of 05/30/2016, revealed a BIMS of 15 which indicated intact cognition. On 08/23/2016 at 4:30 p.m., EI #3, LPN prepared medication for RI #13 and stacked cups containing pills, one inside the other, and administered them to RI #13. RI #12 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #12's annual MDS with an ARD of 07/25/2016, revealed a BIMS of 15, which is indicative of intact cognition. On 08/23/2016 at 4:40 p.m. EI #3 prepared medication for RI #12 and stacked cups containing pills, one inside the other, and administered them to RI #12. On 08/24/2016 at 4:30 p.m., an interview was conducted with EI #3 regarding medication pass on 08/23/2016. EI #3 was questioned how she practiced controlling the spread of infection during the medication pass. EI #3 responded, to take precautions like handwashing. EI #3 was asked, when placing medications into a medicine cup, what was done to control the spread of infection. EI #3 replied, by not touching the inside of the medicine cup and not touching the medication. EI #3 was asked about stacking medication cups. EI #3 responded that she had forgotten about that one and understood the theory. EI #3 was asked what was the potential harm in stacking plastic cups of medication. EI #3 responded, contamination and the spreading of germs. On 08/25/2016 at 2:10 p.m., an interview was conducted with EI #2, LPN/Infection Control Nurse. EI #2 was asked how the staff were trained to prevent infection while preparing medications and handling medication cups. EI #2 responded, by training to was hands between residents. EI #2 was asked how the nurse should have carried multiple pill cups into a residents room. EI #2 responded, to use the pink trays on the medicine cart. EI #2 was asked why the nurse stacked the pill cups instead of using the pink tray. EI #2 responded, I do not know why. EI #2 was asked what was the harm in stacking medicine cups. EI #2 replied, a cup on a dirty surface would contaminate a pill when stacked on top of another cup of pills.

Based on observations, interviews, and record reviews, the facility failed to ensure: 1. A Licensed Practical Nurse (LPN) did not stack medication cups during a medication pass observation on 9/01/2015. Also, an LPN did not multitask with gloves during medication pass. 2. The LPN did not multitask with gloves while cleaning the secretions from around the tracheotomy area on 9/01/15. This affected RI (Resident Identifier) #4, one of sixteen residents sampled. Findings include: A review of the Centers for Disease Control and Prevention recommendations with most recent update of November 9, 2011, revealed: .Protocol for Hand Hygiene and Glove Use Observations. Recommendations Hand hygiene. 3. Examples of situations when hand hygiene is indicated: 1. Before and after direct patient contact 2. After completing tasks at one patient station before moving to another station. 6. After contact with items/surfaces at patient stations. Glove use 1. In general, gloves should be worn prior to contact with patients at the treatment station and potentially contaminated surfaces (e.g (example given)., dialysis machine, environmental surfaces). Gloves should always be changes between patients and between clean and contaminated sites on the same patient. A review of an undated facility document titled, Hand Hygiene Care Audit, revealed: .5. Hand washing is done for at least 20 seconds and the faucet is turned off with a separate paper towel. 1. A review of the medical record for RI #4 revealed RI #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #4's most recent Quarterly MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 7/27/2015, revealed RI #4 had short and long term memory problems and had severe cognitive impairment for daily decision making. RI #4 required total assistance with all ADLs (Activities of Daily Living). RI #4 was always incontinent of bowel and had an indwelling catheter. On 9/01/2015 at 12:00 PM, the following was observed during a medication pass observation: EI (Employee Identifier) #3, an LPN, was observed to set up a medication to administer to RI #4 via Gastrostomy tube. EI #3 set up a liquid medication in a medication cup on a small pink tray. EI #3 was not observed to sanitize the tray. EI #3 stacked three medication cups. One of the medication cups had a liquid medication and the other two cups were empty. EI #3 entered the bathroom with the set up of the medication on the tray. EI #3 washed her hands and applied gloves. RI #4 was congested and secretions were observed to bubble around the (Tracheotomy) trach and trach collar. EI #3 lifted the trach collar, then obtained a feeding syringe from a new plastic package. EI #3 placed the feeding pump on hold and checked the Gastrostomy ([DEVICE]) for placement. EI #3 un-stacked the medication cups and poured water into a medication cup. EI #3 administered the medication via [DEVICE] and flushed the tube with one of the medication cups that was stacked on top of each other. EI #3 threw the feeding syringe away, washed her hands and documented on the MAR (Medication Administration Record). Throughout the observation, EI #3 was observed to multitask with her gloves. 2. On 9/01/2015 at 12:20 PM, EI #3 was observed to clean the trach area of RI #4. RI #4 was observed to cough up copious amounts of frothy white secretions from the midline trach. The secretions were observed to bubble out of the trach into the trach collar and down into the corrugated tubing. Secretions were also observed on the towel that was lying on the chest of the resident. RI #4 also had secretions running down the side of the mouth. EI #3 entered the resident's room with a bag of supplies. She had a glove in her right hand that she used to close the blinds in RI #4's room. EI #3 washed her hands and applied gloves. One of the gloves was used to close the blinds. EI #3 turned the faucet on and off with her gloved hands to wet a wash cloth. EI #3 cleaned the copious secretions from around the trach area with the wet cloth. EI #3 went to the chest of drawers, opened a drawer and obtained a plastic bag. EI #3 removed the gloves, washed her hands and applied gloves. EI #3 opened the bathroom door and turned the faucet on and off with her gloved hands. She wet a wash cloth and cleaned the trach area and upper chest with the wet wash cloth. EI #3 went to RI #4's closet with the same gloved hands and obtained a clean trach collar, opened it and put the trach collar on top of the resident's bed side table. The bed side table was not sanitized or covered with a barrier. EI #3 then washed her hands and applied the trach collar and new corrugated tubing that was on the bedside table. An interview was conducted with EI #3 on 9/02/15 at 2:45 PM. The surveyor asked EI #3 what she was taught regarding hand washing and changing of gloves during a [DEVICE] medication administration. EI #3 said she was taught to wash her hands before and after the medication pass. The surveyor asked EI #3 if she was taught to stack medications cups while administrating [DEVICE] medications. EI #3 stated, No ma'am. You can't do that. The surveyor shared the observation of the medication pass on 9/01/15 for RI #4, and asked what was the concern when medication cups were stacked. EI #3 stated, Contamination. The surveyor asked EI #3 if she sanitized the pink tray that was used during the medication pass. EI #3 said she could not remember if she did or did not. The surveyor shared the observation when EI #3 multitasked with gloves during the [DEVICE] medication pass and then asked what was the concern. EI #3 stated, Cross Contamination. The surveyor shared the above observation on 9/01/15 at 12:20 PM, when EI #3 multitasked with her gloved hands while cleaning the copious amounts of secretions from around RI #4's trach. The surveyor asked EI #3 what was the concern. EI #3 stated, Contamination, cross contamination. I knew I had placed the trach collar on the table but it was already done. It is a concern. It is a big issue with infection control. An interview was conducted on 9/02/15 at 2:10 PM, with EI #5, the Infection Control Coordinator of the facility. The surveyor asked EI #5 how were nurses trained to wash their hands during medication pass for a resident receiving [DEVICE] medications. EI #5 stated, Upon entering the room, wash hands put on gloves, check placement .I am going to finish my final flush, clean the area and wash my hands. The surveyor shared the above observations regarding the multitasking during medication pass and the multitasking with gloved hands while cleaning of the trach area for RI #4. EI #5 stated, The concern would be the washing of the hands and not changing gloves between tasks. Spreading germs and possible infection would be a concern.

Based on observations, interviews, and record reviews, the facility failed to ensure: 1) RI (Resident Identifier) #13 was instructed to rinse their mouth with water after being administered [MEDICATION NAME] Diskus on 9/01/2015. 2) The correct dose of a Nicotine patch was administered to RI #14 on 9/02/2015. This affected RI #13 and RI #14, two of ten residents observed for medication pass and resulted in a 7.4% Medication Error Rate. Findings include: 1)A review of a document titled, HIGHLIGHTS OF PRESCRIBING INFORMATION, for [MEDICATION NAME] Diskus, with a revision date of 7/2014, revealed, . WARNINGS AND PRECAUTIONS . · [MEDICAL CONDITION][MEDICATION NAME] infection of the mouth and pharynx may occur. Monitor patients periodically. Advise the patient to rinse his/her mouth with water without swallowing after inhalation to help reduce the risk (5.4) . A review of the medical record for RI #13 revealed the resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #13's Quarterly MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 8/17/2015, revealed, RI #13 had a BIMS (Brief Interview for Mental Status) score of 14 out of a possible score of 15, indicating RI #13 was cognitively intact for daily decision making. RI #13 required extensive assistance with transfers, dressing and bathing. On 9/01/15 at 4:45 PM, a medication pass was observed for RI #13 by EI (Employee Identifier) #4, an LPN (Licensed Practical Nurse). EI #4 was observed to give the resident the [MEDICATION NAME] Diskus and asked RI #13 to inhale the Diskus. EI #4 then returned the Diskus to the medication cart, but failed to have the resident rinse their mouth after the medication was administered. 2) A review of the medical record for RI #14 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #14's Admission MDS, with an ARD of 7/13/2015, revealed, RI #14 had a BIMS score of 4 out of a possible score of 15. This score indicated that RI #14 had severe cognitive impairment for daily decision making. RI #14 required extensive assistance with transfers, walking, dressing, and personal hygiene. A review of the physician's orders [REDACTED].>21 MG (milligrams)/24 HR (hour) PATCH. APPLY ONE PATCH DAILY. REMOVE OLD PATCH BEFORE APPLYING NEW PATCH. On 9/02/2015 at 8:55 AM, a medication pass was observed with EI #3, an LPN, for RI #14. EI #3 was observed to apply a Nicotine Patch 14 mg to RI #14's upper left back, after removing the old patch from the upper right back. On 9/03/2015 at 9:00 AM, an interview was conducted with EI #3. EI #3 was asked what was the process for administering [MEDICATION NAME] Diskus to a resident. EI #3 stated, she administered it by holding it to their mouth and telling them to blow out and then telling them to inhale deeply. EI #3 stated after she was finished administering the medication, she would offer them water to rinse their mouth. EI #3 was asked what was the concern when a resident did not rinse their mouth after [MEDICATION NAME] was administered. EI #3 stated, it (the [MEDICATION NAME]) had a bad taste and the residue was left in their mouth. EI #3 also stated, it could cause sores, ulcers, anything in their mouth, and fungus. EI #3 was asked what was the dose of the Nicotine Patch for RI #14. EI #3 stated, it was the two step the resident's family brought the patches in. EI #3 stated the family had been advised to titrate the dose. EI #3 was asked what was the dose on hand of the Nicotine Patches in the medication cart for RI #14. EI #3 stated, the dose on the MAR (Medication Administration Record) was 21 mg. EI #3 stated the facility did not change the dose to titrate down to 14 mg. EI #3 was asked who checked the orders for the Nicotine Patches. EI #3 stated, the Unit Managers, but she was ultimately responsible. EI #3 stated, with this particular situation there was not a big risk. She stated if the resident was getting the 21 mg patch, it might have been a concern because the resident might have a craving for cigarettes, but the resident did not. An interview was conducted on 9/03/2015 at 10:55 AM, with EI #6, the Director of Nursing. The surveyor asked EI #6 what was the concern when a resident did not rinse their mouth after [MEDICATION NAME] Diskus was administrated. EI #6 stated, That is a precaution you can take to prevent Thrush. The surveyor asked EI #6 what was the concern when a resident did not receive the correct dose of a nicotine patch. The surveyor gave the example of a resident who was ordered 21 mg, but was administered 14 mg. EI #6 stated, Well, you put them at risk for withdrawals.

Based on an observation, interviews, and record reviews, the facility failed to ensure a Certified Nursing Assistant (CNA): 1. Completely removed stool from RI (Resident Identifier) #4 while providing incontinence care on 9/01/15, and; 2. Cleaned the front and back of the resident's perineal areas during the incontinence care observation. This affected RI #4, one of two residents observed for incontinence care, and a resident with an indwelling catheter who was at risk for developing a UTI (Urinary Tract Infection). Findings Include: A review of, POTTER & PERRY. Fundamentals of Nursing.7th Edition, revealed: .page-878.39-2.Perineal Care. 3. Apply clean gloves, and assess genitalia for signs of inflammation, skin breakdown, or infection. Discard gloves. Perform hand hygiene. 6. Prepare necessary equipment and supplies. 7.Assemble supplies at bedside. 8. Raise bed. 9. Apply clean gloves. 15. Provide Perineal care. B. Male Perineal care. (2) Fold lower corner of bath blanket up between client's legs and onto abdomen. Wash and dry client's upper thighs. (3) Gently raise penis, and place a bath towel underneath. Gently grasp shaft of penis. (4) Wash tip of penis at urethral meatus first. (6) Wash shaft of penis. (7) Gently cleanse scrotum. (8) Fold bath blanket back over client's perineum, and assist client in turning to side-lying position. 16. If client has had urinary or bowel incontinence, apply thin layer of skin barrier containing [MEDICATION NAME] or zinc oxide over anal and perineal skin. A review of an undated facility document titled, Peri (Perineal) Care Audit Tool revealed: Action. 11. If Foley catheter present, must wash catheter tube first before starting the peri care. Washes from the meatus up the tube about 6 inches x2 (times two) with changing position of cloth. Does hold tube in place with your other hand to stabilize the tube and it won't get tugged on during washing. (Apply leg strap). A review of the medical record for RI #4 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #4's most recent Quarterly MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 7/27/2015, revealed, RI #4 had short and long term memory problems and had severe cognitive impairment for daily decision making. RI #4 required total assistance with all ADLs (Activities of Daily Living). RI #4 was always incontinent of bowel and had an indwelling Foley catheter. A review of RI #4's care plan with a problem onset date of 2/20/2015 revealed: RI #4 uses an indwelling catheter/at risk for developing an UTI. On 9/1/2015 at 3:15 PM, the following was observed during incontinence care for RI #4. Employee Identifier (EI) #1, (CNA), washed her hands, applied gloves, obtained a basin of water, and a wash cloth. EI #1 wet the wash cloth and sprayed it with a perineal wash. RI #4 had a moderate amount of soft brown formed stool. EI #1 wiped between the buttocks fold three times. EI #1 changed the position of the wash cloth with each wipe, but stool was observed on the wash cloth with every wipe. EI #1 dried the buttocks fold. EI #1 washed and dried her hands and applied gloves. Both CNAs turned the resident, changed the draw sheet, and put a wedge in place for the resident. The surveyor requested for the resident to be wiped to assure that the resident was clean. Stool was observed on the wash cloth when EI #1 wiped the resident from front to back. EI #1 did not clean RI #4's penis, the front of the perineal area, or the scrotum. The CNAs did not check the front of the perineal area to see if the areas needed cleaning. RI #4's catheter was not checked or cleaned. The only area cleaned was between the buttocks fold. Stool was not completely removed from the resident's bottom. On 9/2/2015 at 11:40 AM, EI #1 was interviewed. The surveyor asked EI #1 how did she provide incontinence care for RI #4 during the observation when stool was present. EI #1 stated, I don't understand. The surveyor asked EI #1 how did she make certain the resident was completely cleaned, and all of the stool was removed from the perineal area. EI #1 stated, We washed and dried RI #4. RI #4 looked clean. RI #4 had another bowel movement, we cleaned RI #4 up again. The surveyor asked EI #1 when did she clean RI #4's right and left buttock during the incontinence care observation. EI #1 stated, When I washed RI #4, I cleaned both sides. The surveyor asked EI #1 when did she clean RI #4's scrotum and surrounding areas of the scrotum during the incontinence care observation. EI #1 stated, I wiped and cleaned the area. The surveyor asked EI #1 when did she clean the front of the resident's perineal area during the incontinence care observation. EI #1 stated, I had did (done) the cath (catheter) care before, I had gone in then to see if RI #4 had a bowel movement. The catheter care before then, I'm not sure how long. It was probably an hour earlier. The surveyor asked EI #1 what was the concern when stool was not completely removed from a resident during incontinence care. EI #1 stated, Infection. The surveyor asked EI #1 what was the concern when the front of the resident was not cleaned, and the scrotum and surrounding areas were not cleaned during incontinence care when stool was present. EI #1 stated, Skin breakdown. The surveyor asked EI #1 if she checked the front of the perineal area to assure RI #4 did not require catheter care or cleaning due to the bowel movement. EI #1 stated, No ma'am, was nervous. I get real nervous. On 9/2/2015 at 3:00 PM, an interview was conducted with EI #2, a CNA and a member of the staff development team for training the CNAs at the facility. EI #2 was asked how were staff members trained to provide incontinence care for a male resident. EI #2 said the staff members were trained to get a set up of five to six wash cloths, three towels, a bed basin, and perineal wash. She said they were trained to provide incontinence care together. EI #2 said staff were taught to have a dirty person and a clean person. The clean person should wet the wash cloth and spray it with perineal wash. EI #2 stated they would change gloves and wash their hands. The clean person did not touch anything dirty. The clean person would clean the stomach area and thigh sections using a clean section of the wash cloth every time and pat dry. EI #2 continued to describe the process of cleaning the penis in a circular motion. If the resident was not circumcised the foreskin was to be pulled back. She said once they are done they use a clean section of the wash cloth and wash the shaft of the penis. EI #2 described the process of cleaning all the way down the catheter. She added that hand washing and glove changes were to be done and staff were to dry the resident. After that process staff were to get a clean portion of the wash cloth and clean the scrotum and dry the resident. EI #2 said the bottom was cleaned by using different sections of the wash cloth to clean both sides of the buttock by wiping away from the perineal area. She said hands should be washed, pat the resident dry and then apply the moisture barrier. The surveyor shared the above incontinence care observation with EI #2 and asked what was the concern with the care. EI #2 stated, I would be concerned about the resident. If stool is left it could cause skin breakdown. An interview was conducted with EI #5, a Licensed Practical Nurse and the facility's Infection Control Coordinator, on 9/2/2015 at 2:10 PM. The surveyor discussed the above incontinence care observation and asked what the concern was regarding the observation. EI #5 stated, The concern was not providing correctly, and not ensuring the resident was completely clean before finishing the incontinence care.