Every finding on record at Northway Health and Rehabilitation, LLC

Based on interviews, record review, and review of facilities Resident Handbook and the facility's document titled Resident - These are YOUR Rights, the facility failed to ensure residents had reasonable access to personal funds/petty cash after business hours and on the weekends. This affected Resident Identifier (RI) #64. Further affected RI #43, RI #55, RI #6, RI #81, RI #28, RI #69, RI #34, RI #85, RI #26, and RI #76 who attended Resident Council Group meeting on 04/16/2024 and reported they were unable to access funds on the weekends. This had the potential to affect all residents who have a Resident Trust Account established with the facility. Findings include: A review of the Resident Handbook revealed the following: . Personal Funds . no personal account withdrawals may can be made after the close of business hours or on weekends. You should anticipate your cash needs for weekend and withdraw funds accordingly on Friday before the business office closed . A review of undated facility document titled Resident- These are YOUR Rights documented . You have the right to your money. RI #43 was admitted to the facility on [DATE]. RI #43's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/12/2024 noted a Brief Interview for Mental Status (BIMS) of 15/15 which indicated no cognitive impairment. RI #64 was admitted to the facility on [DATE]. RI #64's Quarterly MDS with an ARD of 03/18/2024 noted a BIMS score of 15/15 which indicated no cognitive impairment. RI #55 was admitted to the facility on [DATE]. RI #55's Annual MDS with an ARD of 03/18/2024 noted a BIMS score of 15/15 which indicated no cognitive impairment. RI #6 was admitted to the facility on [DATE]. RI #6's Quarterly MDS with an ARD of 03/18/2024 noted a BIMS score of 6/15 which indicated cognitive impairment. RI #81 was admitted to the facility on [DATE]. RI #81's Quarterly MDS with an ARD of 01/08/2024 noted a BIMS score of 15/15 which indicated no cognitive impairment. RI #28 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #28's Quarterly MDS with an ARD of 03/04/2024 noted a BIMS score of 6/15 which indicated cognitive impairment. RI #69 was admitted to the facility on [DATE]. RI #69's Quarterly MDS with an ARD of 03/11/2024 noted a BIMS score of 15/15 which indicated no cognitive impairment. RI #34 was admitted to the facility on [DATE]. RI #34's Quarterly MDS with an ARD of 03/04/2024 noted a BIMS score of 15/15 which indicated no cognitive impairment. RI #85 was admitted to the facility on [DATE]. RI #85's Annual MDS with an ARD of 01/15/2024 noted a BIMS score of 15/15 which indicated no cognitive impairment. RI #26 was admitted to the facility on [DATE]. RI #26's Quarterly MDS with an ARD of 02/05/2024 noted a BIMS score of 6/15 which indicates cognitive impairment. RI #76 was admitted to the facility on [DATE]. RI #76's Quarterly MDS with an ARD of 03/18/2024 noted a BIMS score of 15/15 which indicated no cognitive impairment. On 04/14/2024 at 1:58 PM during initial tour RI #64 stated personal money withdrawals were not available on the weekends due to the business office not being open. On 04/16/2023 at 3:00 PM Resident Council meeting was held with RI #43, RI #55, RI #6, RI #81, RI #28, RI #69, RI #34, RI #85, RI #26 and RI #76 were in attendance. When the group was asked how personal funds were accessed on the weekends and after hours, residents stated personal funds were not accessible on the weekends due to the business office not being open. On 04/16/2023 at 3:29 PM during further interview, RI #64 stated the business office was only open Monday through Friday. RI #64 said even when money was in his/her account he/she could not get it when the business office was closed and they made the business hours very clear. On 04/16/2024 at 3:55 PM an interview was conducted with RI #43. RI #43 reported he/she was unable to access funds on the weekend. RI #43 said he/she used his/her funds for snacks from vending and if he/she did not get cash on Friday he/she was unable to access funds on the weekend to purchase snacks. On 04/16/2024 at 4:16 PM an interview was conducted with the Financial Specialist Assistant (FSA) and when asked about how residents are made aware of how to access personal money on the weekend, the FSA stated it was on the nurses' station and that they were made aware of this by word of mouth. Other than word of mouth, the FSA was uncertain how this was communicated to residents. The FSA reported it was difficult to keep up with the checks and balances when residents withdraw funds outside of business hours. When asked why it was important for residents to have reasonable access to personal funds outside of business hours, the FSA stated it was very important; therefore, residents were given more money on Fridays before the close of business hours. The FSA stated this was why she tried to get them to get personal money on Fridays. On 04/16/2024 at 4:36 PM the Financial Specialist (FS) was interviewed and asked how residents accessed personal funds after hours. The FS stated according to policy petty cash funds were locked up on nurses' cart. The FS further stated that when residents funds initially started coming to the facility, they (residents) were made aware that they could obtain personal funds through business office during the week. When asked why it was important that residents have reasonable access to personal funds after hours, FS stated it was their money to do as they desired, and residents should have access to funds at all times.

Based on observations, interviews and the facility's Residents Rights, the facility failed to ensure rooms on three of five halls were not found in need of repair. This deficient practice affected seven residents' rooms on three halls. Findings Include: The facility's undated Residents Rights, documented, These are YOUR Rights: YOU have the right .to live in a safe, clean, comfortable and homelike environment. On 04/14/2024 at 1:18 PM, surveyor observed Resident Identifier (RI) #56's closet was missing a door. On 04/14/2024 at 4:09 PM, surveyor observed RI #100's wall behind bed with scraped paint. On 04/14/2024 at 4:25 PM, surveyor observed RI #67's wall behind bed with scraped paint. On 04/15/2024 at 8:28 AM, surveyor observed RI #18's wall behind bed with scraped paint and chipped paint and hole in the wall on the side of bed. On 04/15/2024 at 10:56 AM, surveyor observed dark stain and no caulking at base of RI #9's toilet. On 04/15/2024 at 9:00 AM, surveyor observed stained ceiling tile and wall at foot of RI #103's bed scuffed and peeling. On 04/14/2024 at 8:45 AM, surveyor observed a hole in RI #35's wall under the sink. On 04/17/2024 at 11:29 AM surveyor and Maintenance Director (MTD) made observations of the noted concerns in residents' rooms. Observed RI #100's wall behind bed. The MTD stated the wall had scraped paint. An observation was made of RI #67's wall behind bed, maintenance stated had scraped paint behind his/her bed. An observation was made of a hole under the sink in RI #35's room. An observation was made of a brown stained on ceiling tile, the wall scuffed and peeling in RI #103's room. An observation was made of RI #56's room which had a missing closet door. An observation was made of scraped paint and wall with hole in the wall behind the bed in RI #18's room. An observation was made of the toilet in RI #'9's bathroom. The MTD stated the toilet had a red-brownish stain around the base and missing caulking. An interview was conducted with the MTD on 04/17/2024 at 11:50 AM. The MTD stated the walls behind the bed that had scraped paint, the hole under the sink, the missing closet door, the holes in the walls, the stained ceiling and the red/brownish base of the toilet that needed caulking did not look good and needed to be repaired.

Based on observations, interviews and a facility policy titled, Hand Hygiene, the facility failed to ensure: 1) staff sanitized their hands on 04/14/2024 while passing meal trays on Station 4. The facility further failed to ensure staff performed hand hygeine while assisting Resident Identifer (RI) #1 and RI #47 with their meal. This deficient practice affected residents residing on two of five halls, including RI #1 and RI #47. 2) staff followed Standard Precautions and properly disinfected the glucometer after routine testing of blood glucose. This affected RI #73, one of two residents observed for blood glucose testing. Findings Include: A facility policy titled, Hand Hygiene, with an effective date of 06/11/2020, documented, PURPOSE: To provide guidelines to employees for proper and approriate hand washing techniques that will aide in the prevention of the transmission of infections. III. Hand Hygiene . The following is a list of some situations that require hand hygiene. Before and after . handling food . Before and after assisting a resident/guest with meals . On 04/14/2024 at 5:12 PM, surveyor observed the dinner meal cart on hall. Certified Nursing Assistant (CNA) #13 was observed as she sanitized her hands, took dinner tray off meal cart and took into room came back to the meal cart, retrieved another tray. CNA #13 passed three meal trays before she sanitized her hands again. CNA #12 walked up to the meal cart and began to pass trays. She passed four trays then sanitized her hands. An interview was conducted with CNA #12 on 04/14/2024 at 5:18 PM. CNA #12 stated she washed her hands before she began passing trays. CNA #12 admitted she did not perform hand hygiene between passing each tray and stated she should have. CNA #12 stated the concern of not performing hand hygiene between each tray was passing bacteria. An interview was conducted with CNA #13 on 04/14/2024 at 5:24 PM. CNA #13 admitted she only sanitized her hands after passing the third tray. CNA #13 stated the concern of not performing hand hygiene after passing each tray was the possibilty of contamination. 47408 On 04/14/2024 at 5:17 PM CNA #18 obtained trays and proceeded to assist two residents, RI #47 and RI #1 with their meal at the same time and without performing hand hygiene. At 5:18 PM CNA #18 was observed as she got up, picked up a soiled tray from another resident, and continued to assist RI #47 and RI #1 without performing hand hygiene. Next, CNA #18 washed her hands, escorted a resident out of dining room, and resumed assisting RI #1 and RI #47 with their dinner meals without performing hand hygiene. An interview was conducted with CNA #18 on 04/16/2024 at 10:19 AM. CNA #18 said that she did not perform hand hygiene between trays and assisted RI #1 and RI #47 with their dinner meal on 04/14/2024 simultaneously. CNA #18 stated it was not possible to perform hand hygiene while assisting two residents with their meals at the same time. CNA #18 stated the concern of not performing hand hygiene while passing trays and assisting with feeding two residents at the same time is cross-contamination. An interview was conducted with the Director of Nursing (DON) on 04/17/2024 at 12:11 PM. The DON stated staff should perform hand hygiene after passing each tray. The DON stated the concern of not performing hand hygiene between each tray was possible cross-contamination. The DON also stated staff should never feed two residents at the same time. She stated the concern of feeding two residents at the same time was cross-contamination. 2) On 04/15/2024 at 3:47 PM, surveyor observed MAC #12, obtain a blood glucose level for RI #73. Afterwards, MAC #12 left RI #73's room and placed the used barrier tray which contained the glucometer on the med cart. MAC #12 cleaned the glucometer with tissue paper and hand sanitizer. The glucometer was then placed on the med cart. An interview was conducted with MAC #12 on 04/15/2024 at 4:00 PM. MAC #12 said she should have thrown the used barrier away instead of bringing it out of RI #73's room. She also said that she cleaned the glucometer with hand sanitizer. MAC #12 stated there were Clorox wipes on the cart, but stated she usually just wiped off the glucometer with hand sanitizer. MAC #12 stated the concern of bringing a used barrier from resident's room and placing on medication cart was cross-contamination. An interview was conducted with The DON on 04/17/2024 at 12:15 PM. The DON stated it was never acceptable to take a used barrier from a resident's room and place it on the medication cart. She stated glucometers were to be cleaned with Clorox wipes, never hand sanitizer. She stated the concern was cross-contamination and infection control.

Based on interviews, record review, review of the facility's investigation titled Verification of Investigation, and review of facility policy Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, the facility failed to ensure Licensed Practical Nurse (LPN) #6, did not misappropriate Resident Identifier (RI) #43's Percocet and Lyrica after signing the medication as administered. This was cited as a result of investigation of complaint/report number AL00045405, and affected one of one residents reviewed for misappropriation of resident property. Findings Include: Review of a facility policy Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, with an effective date of 05/01/2023 documented PURPOSE: . All of our resident/guest(s) have a right to be free from . misappropriation of resident/guest property. The Policy also prohibits the misappropriation of resident/guest property. D. Misappropriation of Resident/Guest Property. Misappropriation of resident/guest property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident/guest(s) belongings or money without the resident/guest(s) consent. The facility's investigation of the incident titled Verification of Incident documented . On the morning of Monday 08/28/2023 (RI #43) reported to the charge nurse not receiving medication on the 3 p - 11p shift. He/she was interviewed by the Director of Nursing and repeated the same allegation . Stated had pain medication due at 10:00 PM realizing had not received it around 11:30 PM asked the nurse on duty she stated could not give it as the 3 - 11 shift nurse had signed it out. OUTCOME OF INVESTIGATION: . As a part of the investigation, a review of the Electronic Medical Record (EMR) and a printed narcotic log stated all medications scheduled during the 3 - 11 pm shift were signed out as given by Nurse (LPN #6). Nurse was contacted by phone and stated . passed all medication scheduled . The administrator reviewed the camera system . While counting . medication cart, LPN #6 is seen punching seven pills from the narcotic box into one cup and signing the medication log. LPN #6 is witnessed placing the medication in her right hand and transferring it to a personal pill bottle, and then to her purse. RI #43 was admitted to the facility on [DATE] with diagnoses of Pain and Neuropathy. Review of RI #43's August 2023 Physician Orders documented . Lyrica Capsule Three Times a Day DX (Diagnosis) Neuropathy .Percocet 10-325 Milligram 1 Tablet every 8 hours DX Pain . Review of RI #43's Controlled Drug Record for Oxycodone (Percocet) indicated the medication signed out on 08/27/2023 at 9:00 PM by LPN #6. Pregabalin (Lyrica) indicated it was signed out by LPN #6 on 08/27/2023 at 8:00 PM. On 04/14/2024 at 1:40 PM during an interview with RI #43 when asked if any nurses did not give medications as scheduled, RI #43 said one did. When asked how long he/she went without pain medication, RI #43 said a few hours. RI #43 denied increased pain when the pain medication was not administered. On 04/15/24 at 10:37 AM during an interview with (Registered Nurse) RN #4, she said she came on shift at 11:00 PM, counted with LPN #6 and all counts were correct. She said it was around midnight when she went into RI #43's room, he/she said he/she did not get pain medications, RN #4 said she would check on it. She said she looked in the record it was signed out as administered. On 04/15/2024 at 11:23 AM during an interview with the oncoming nurse LPN #5, she recalled RI #43 telling her he/she did not get pain medication the evening before. She said she told the Director of Nursing (DON) because it was unusual. She said RI #43 was alert, oriented and aware of medications administered. LPN #5 said RI #43 said he/she did not receive the Lyrica or the Percocet. On 04/16/2024 at 8:34 AM during an interview with the DON, she said RN #4 told the morning nurse, LPN #5, RI #43, said he/she did not get medication for pain at 10:00 PM, she checked the books found it signed as administered. The next morning RI #43 told LPN #5 the nurse on 3 to 11 did not give his/her pain medication. The DON said LPN #5 said RI #43 was alert, and oriented. The DON said she told the Administrator, and they started an investigation. The DON said the Administrator watched the camera footage. The DON said RI #43 said did not get Lyrica and Percocet, those medications were signed out as administered. The DON said they called LPN #6 to come to the facility, she said she could not, she said she gave it to RI #43, she said she gave all the medications. The Administrator said he watched the video and wrote down her actions. The Administrator said he could not tell which resident's medications she was pulling while she was in the cart and could only tell she was in the narcotic drawer. LPN #6 was observed taking the medication cup around the nurses' station and poured the medication into her personal prescription bottle. On 04/16/2024 around 2:00 PM during a phone interview with the previous Administrator, he said he was made aware of RI #43 not receiving medication on the evening before shift after the morning nurse told the DON, what RI #43 told that morning. He said the medication was signed out as administered. He said because RI #43 was alert, and the nurses knew him/her he thought to look on camera. He said he documented a timeline according to the camera footage. He said he saw LPN #6 was pushing medications in a cup and hid it under the binder. He said they did a review of the medications that were signed out by LPN #6 and recalling by memory not sure, he thought he saw her punching out seven, that may not have been exact. The Administrator said they could be sure of RI #43's by him/her saying he/she did not get his/hers. They could only validate RI #43 not receiving his/her pain medications as he/she told two nurses. The Administrator said after watching the video they saw some concerns, and called her back with no answer, she was terminated although she never returned calls or returned to the facility. The Administrator said it was abuse by misappropriation when the nurse did not give scheduled pain medication, however signed them out as given, and the timeline from watching the video indicated she punched pills and did not give to a resident. The Administrator said the concern with LPN #6 misappropriating RI #43's medication was abuse, and the nurse being untrustworthy. He said during her orientation she was presented with the policy on abuse and went through a week of orientation; he said the event was her first shift out of orientation. On 04/16/2024 at 4:09 PM during a follow-up interview with the DON, she said it was misappropriation of resident property when a nurse signed out a resident's medication, but did not administer it to the resident. The DON said they could only determine RI #43 had medication misappropriated as LPN #6 took medication from the narcotic box, signed it out as administered and never administered it to the resident. The DON said the facility determined the misappropriation when RI #43 told the nurses he/she had not received pain medication on the evening shift, although it was signed out as given. On 04/17/2024 at 9:26 AM during an interview with the Regional Nurse she it was misappropriation of property when a nurse signed out a resident medication, but did not administer the medication. She said the only medication determined misappropriated was RI #43's as RI #43 told two nurses he/she did not receive it.

Based on interview, record review, review of a facility policy Pre-Admission Screening Resident Review, and review of Resident Identifier (RI) #103's PASRR (Preadmission Screening and Resident Review), the facility failed to ensure RI #103's PASRR was accurately marked with an admission diagnosis of Bipolar Disorder, which indicated a Level II was indicated. This affected one of two residents sampled for PASRR. Findings Include: A review of a facility policy titled Pre-admission Screening Resident Review, with a revised date of 06/2009 documented . 4. The nursing facility is responsible for ensuring that a level I screening is completed, submitted and has a Level I Determination on or before nursing home admission . Process for PASRR . 3. Nurse Consultants and Case Managers will review Level I and/or Level II Determination during medical records audits for newly admitted or readmitted residents. 4. QA Nurses will review Level I and/or Level II Determinations as part of their audit of the admissions process. On 04/15/2024 at 2:15 PM a review of RI #103's PASRR which was signed on 09/15/2023 did not indicate resident had a Major Mental Illness of Bipolar Disorder. Based on the results there was no need for a Level II. The PASRR review revealed only a Level I and no diagnoses were selected or marked on the screening form. RI #103 was admitted to the facility on [DATE] with a diagnosis of Bipolar Disorder. A review of RI #103's diagnoses sheet included Bipolar Disorder with onset date of 10/27/2023. On 04/15/2024 at 3:00 PM during an interview with Social Services staff, when she was asked what was the facility's process to identify residents needing a Level I or Level II. She said they looked at the diagnoses and medications, marked diagnoses and medications on the screening form, then submitted it to the screening office. When asked what the date of onset for RI #103's Bipolar Disorder, she said 10/27/2023 which was the date RI #103 admitted to that facility. She was asked if Bipolar Disorder should be marked on the PASRR, she said yes she would have marked it. She said Social Service was responsible for ensuring the PASRR was accurate if a resident was admitted from another facility. She said the PASRR not having Bipolar Disorder marked or selected resulted in an inaccurate PASRR. She said the concern in the PASRR not updated to include Bipolar Disorder was not having accurate diagnosis.

Based on interviews, record review, and review of the facility policy titled Medication Administration Documentation for Medication Administration, facility failed to ensure Resident Identifier (RI) #43's Medication Administration Record (MAR) was accurate. On 08/27/2023 Licensed Practical Nurse (LPN) #6 documented the administration of Lyrica and Percocet in RI #43's medical record and did not administer the medications to RI #43. This affected RI #43, and was cited as a result of investigation of complaint/ report number AL00045405. Findings Include: Review of a facility policy Documentation for Medication Administration with an effective date of 04/2020 documented . Procedures 1. The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. RI #43 was admitted to the facility on [DATE] with diagnoses of Pain and Neuropathy. Review of RI #43's August 2023 Physician Orders documented . Lyrica Capsule Three Times a Day DX (Diagnosis) Neuropathy . Percocet 10-325 Milligram 1 Tablet every 8 hours DX Pain . Review of RI #43's August 2023 Medication Administration Record (MAR) indicated Percocet and Lyrica was documented as administered by LPN #6 on 08/27/2023. An interview was conducted with RI #43 on 04/14/2024 at 1:40 PM. RI #43 stated one nurse did not give him/her medication as scheduled around 10:00 PM on 08/27/2023. An interview was conducted with Registered Nurse (RN) #4 on 04/15/2024 at 10:37 AM. RN #4 stated she went into RI #43's room around midnight, and he/she stated he/she did not get his/her pain medication. RN #4 stated she reviewed the record and confirmed that it was signed out as administered. An interview was conducted with LPN #5 on 04/14/2024 at 11:23 AM. She stated she became aware of RI #43 not getting pain medication on second shift on 08/27/2023 when RI #43 told her. She stated she told the DON because RI #43 was alert and oriented and it was unusual. A telephone interview was conducted with the Former Administrator on 04/16/2024 at 2:00 PM. He stated LPN #6 did not administer RI #43 his/her scheduled pain medication on 08/27/2023, however signed them out as given. He stated it was inaccurate documentation. An interview was conducted with The Director of Nursing (DON) on 04/16/2024 at 4:09 PM. The DON stated RI #43's medication was signed out by LPN #6 on the Medication Administration Record (MAR) and it was not given to him/her on 08/27/2023. The DON stated it was falsifying the records when LPN #6 signed out medication and she did not administer the medications. An interview was conducted with the Regional Nurse on 04/17/2024 at 9:26 AM. She stated RI #43's medications was signed out on both the narcotic sheet and MAR on 08/27/2023 as given. The Regional Nurse stated it was falsifying the records when LPN #6 signed out medication and she did not administer the medications.

Based on an interview and a review of a policy titled, Federal Rights of Resident/Guest(s) the facility failed to ensure mail was delivered to residents on Saturday. This affected 13 residents who attended the Resident Council Meeting on 04/17/2024 and had the potential to affect all residents in the facility. Findings Include: A review of a policy titled, Federal Rights of Resident/Guest(s) with an effective date of November 28, 2016, documented the following: .(g)(8) The resident/guest has the right to . receive mail . On 04/16/2024 at 3:15 PM during the Resident Council Meeting, 13 residents reported mail was not delivered to them on Saturday. Residents reported that mail received by the facility on Saturday would be passed out to them on Monday. On 04/16/2024 at 4:18 PM an interview was conducted in the Social Services Director (MSW). The MSW said that mail delivered by the Postman to the facility on Saturday was placed in the Activity Director's box and given to the residents on Monday. On 04/16/2024 at 4:27 PM an interview was conducted with the Activity Director (AD). The AD stated she worked Monday through Friday and did not work on Saturday or Sunday. The AD stated she was responsible for passing out mail to the residents when it was delivered to the facility. When asked about the residents' mail on Saturday she said the staff who work placed the delivered mail in her box and she delivered it to the residents on Monday when she returned to work. When asked if any staff delivered mail to residents on Saturday, she stated that, to her knowledge, no staff delivered mail to residents on the weekend. In response to whether residents should receive mail on the weekend, she said that very few residents received mail on Saturday, and if they did, they were aware they would receive it on Monday. An interview was conducted with the Director of Nursing (DON) on 04/17/2024 at 2:43 PM. The DON said that residents should receive their delivered mail on Saturday because it was their personal mail and they should receive it in a timely manner. When asked what was the concern of residents not receiving mail on Saturday she said they could miss greetings from family or important information.

Based on interviews, record review, review of facility policies titled, Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation and Medication Administration Procedures Controlled Medication Administration, review of the facility's investigative file and review of information from the Alabama Department of Public Health's (ADPH) Online Reporting System, the facility failed to ensure Resident Identifier (RI) #1 did not have missing narcotic medication, [MEDICATION(S)] 10 mg (milligrams). Employee Identifier (EI) #4, the LPN (Licensed Practical Nurse) and EI #3 LPN failed to conduct a physical count of the narcotics upon the exchange of the narcotic keys on 01/25/2022. The missing narcotics were discovered by EI #4, the LPN assigned to care for RI #1 on the 11 PM - 7 AM shift. This deficient practice affected RI #1, one of three residents reviewed for misappropriation of resident property. Findings Include: A review of a facility policy titled Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, with an effective date of 02/08/2018, revealed the following: . PURPOSE: . All of our resident/guest(s) have the right to be free from . misappropriation of resident . property. The facility has established procedures that enable it to . educate all if its employees . to help prevent instances of . misappropriation of resident . property . D. Misappropriation of resident . property means the deliberate misplacement . of a resident . belongings . without the resident . consent. Acts that may constitute the misappropriate of resident . property include, but are no limited to: . theft of a resident . medication . RI #1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of another facility policy titled Medication Administration Procedures Controlled Medication Administration, dated 04/2020, revealed the following: . Policy Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal and state laws and regulations. Procedures . 6. At each shift change, or upon change in authorized nurse, a physical inventory of all controlled medications is conducted by two licensed nurses and is documented on an audit record . A review of RI #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This controlled medication had a start date of 11/24/2020. A review of an ADPH Online Facility Reported Incident dated 01/25/2022, revealed the following: . Incident Type . Misappropriation of Resident Property . Narrative summary of incident: On today it was discovered that a card of [MEDICATION(S)] 10mg was missing, along with the Narcotic Sheet. An immediate investigation occurred which found the medication was present during the 7a-3p shift. During the Narcotic Count at shift change, it was present in the Narcotic box. The 3-11 nurse stated the medication was given as scheduled during the shift. The 3-11 nurse counted the Medication cart with . (EI #3) at 11:20pm due to the 11p-7a calling off. Nurse . (EI #3) stated there were no discrepancies during the medication count. Nurse . (EI #3) held the keys to the medication cart until On-call Nurse, . (EI #4) came into the building to relieve her at approximately 1:00am. Once . (EI #4) came into the building, the nurses both stated they did not count with each other. Nurse . (EI #3) and . (EI #4) have been suspended pending investigation . Review of a facility form titled CONFERENCE REPORT for EI #3, dated 02/08/2022, revealed the following: . NATURE OF VIOLATION: . -On the morning of 1/25/22 at approximately 1:00am, . (EI #3) failed to perform medication count with incoming LPN . (EI #4). CORRECTIVE ACTION NECESSARY: (EI #3) . will be re-educated on the process of counting the Medication Cart at shift change and Chain of Command. Review of a facility form titled CONFERENCE REPORT for EI #4, dated 02/08/2022, revealed the following . NATURE OF VIOLATION: . -On the morning of 1/25/22 at approximately 1:00am, . (EI #4) failed to perform medication count with out going LPN . (EI #3). CORRECTIVE ACTION NECESSARY: (EI #4) . will be re-educated on the process of counting the Medication Cart at shift change and Chain of Command. On 05/11/2022 at 11:26 AM, the surveyor conducted an interview with EI #4, the LPN assigned to care for RI #1 on the 7 AM - 3 PM shift on 01/24/2022, and on 01/25/2022 . The surveyor asked EI #4 what was the procedure facility nurses used to ensure narcotic medications were accounted for. EI #4 said when nurses come in, the narcotic box is opened, the going off nurse will tell the nurse coming on how many cards of narcotics there should be. EI #4 said the nurse coming on then counts the cards of narcotics. EI #4 said the second part to that would be the off going nurse will look at the Controlled Drug Record and say the name of the resident, the name and strength of the narcotic, and the number of pills on the card and the nurse coming on will confirm this. EI #4 said this was done when she left after her 7 AM - 3 PM shift was over with on 01/24/2022. When asked who she received the keys to the narcotic box from when she returned to work on 01/25/2022 at 1:00 AM, EI #4 said EI #3. The surveyor asked EI #4 what should have been done before she accepted the keys to the medication cart. EI #4 said she should have counted the narcotics before she accepted the keys. The surveyor asked EI #4 when did she discover RI #1's [MEDICATION(S)] 10 mg pills were not in the narcotic box. EI #4 said when she was about to give RI #1's scheduled 6 AM dose. EI #4 said she looked in all three medication carts and could not find the [MEDICATION(S)] pills. EI #4 said at that time she notified EI #2, the former DON (Director of Nursing). The surveyor asked EI #4 what type education/in-services were done after the narcotics were found to be missing. EI #4 said she got sent home, and nurses were educated on counting narcotics and the process for the record keeping of narcotic medications. On 05/11/2022 at 3:50 PM, the surveyor conducted a telephone interview with EI #3, the LPN holding the narcotic keys for EI #4 on 01/25/2022. When asked which nurse she gave the narcotic keys to before she left on 01/25/2022, EI #3 said EI #4. The surveyor asked EI #3 when did she and EI #4 count the narcotics on the medication cart that had RI #1's [MEDICATION(S)] 10 mg pills. EI #3 said they did not count the cart. The surveyor asked EI #3 what was the procedure facility nurses followed to ensure narcotics were accounted for. EI #3 said nurses were supposed to count the narcotics before they left. When asked why this was not done before she gave EI #4 the keys, EI #3 said, to be honest nurses do trust each other and since she had counted with EI #5, she and EI #4 did not count the narcotics. When asked should she and EI #4 have recounted the narcotics, EI #3 said yes. The surveyor asked EI #3 what type education/in-service was done when this incident occurred. EI #3 said EI #2 wrote her up and the nurses received an inservice about counting the narcotic medications. On 05/11/2022 at 5:23 PM and on 5/12/2022 at 12:59 PM, unsuccessful attempts were made to contact EI #2. On 05/14/2022 at 1:10 PM, EI #2 contacted the surveyor and a telephone interview was conducted. The surveyor asked EI #2 who made her aware RI #1 had missing narcotics and what did she do when she became aware. EI #2 said EI #4 notified her and she immediately went to the floor and started an investigation. EI #2 said the sheet you log the narcotics on and the narcotics were gone. EI #2 said EI #4 had worked the 7 AM - 3 PM shift and came back on the 11 PM - 7 AM shift. EI #2 said EI #3 counted the narcotics with the 3 PM - 11 PM nurse and they both said the [MEDICATION(S)] was there. EI #2 said EI #4 took the keys from EI #3 when she got to work and they did not count the narcotics. EI #2 said when EI #4 got ready to give RI #1's medications that morning, the narcotics were not on the medication cart. EI #2 said about 86 [MEDICATION(S)] pills were missing. When asked where should narcotic medications be kept at all times, EI #2 said on the medication cart in the locked box. The surveyor asked EI #2 what was the procedure nurses followed to ensure narcotics were accounted for. EI #2 said nurses should count at any change of custody of the keys. EI #2 said from the facility's investigation this procedure was not followed. When asked, according to the facility's Controlled Medication Administration policy when should a physical inventory of controlled medications be done, EI #2 said at any change of custody of the keys. The surveyor asked EI #2, when RI #1's [MEDICATION(S)] 10 mg pills were missing, what would it be considered. EI #2 said diversion or misappropriation. On 05/12/2022 at 5:06 PM, the surveyor conducted an interview with EI #1, the facility's Administrator. When asked about the facility's Controlled Medication Administration policy and what should occur at shift change, or upon change in the authorized nurse, EI #1 said the physical inventory of all controlled medications should be conducted by two nurses and documented on an audit form. The surveyor asked EI #1, from the facility's investigation, was this done. EI #1 said EI #3 just held the keys until EI #4 came in around 1:00 AM. EI #1 said when EI #4 came, the two nurses did not count the narcotics. When asked what the facility had put in place to ensure this would not recur, EI #1 said everyone involved was drug tested , all the narcotic medication were reconciled, RI #1 was ordered a new card of Narcotics, RI #1 did not miss a dose of his/her narcotics because it was pulled from the STAT (emergency use) box, there was now a new log in narcotic sheet the nurses were using and also a new medication cart had been purchased. EI #1 said this incident was reported to the ADPH the same day it occurred. When asked what category the incident was reported under, EI #1 said misappropriation of resident property. ******************************************************** Once RI #1's narcotic medications were found to be missing the following corrective actions were implemented: On 01/25/2022, RI #1's medication card of [MEDICATION(S)] 10 mg was noted to be missing when EI #4 was preparing the resident's 6:00 AM medications. On 01/25/2022, EI #4 searched the medication carts, and the [MEDICATION(S)] was not located. On 01/25/2022, EI #2 was notified of the missing narcotics and too searched the medication carts, and the [MEDICATION(S)] was not located. An immediate audit of all Medication Carts in facility was initiated to ensure no other residents were affected. No discrepancies were noted. On 01/25/2022, the Medical Director was notified and a new card was ordered and billed to the facility. RI #1 did not miss any medication because the narcotic medication was pulled from the STAT medications. EI #3 and EI #4 were placed on suspension. On 01/25/2022, the incident was reported to ADPH as well as law enforcement. From 01/26/2022 through 01/28/2022, urine drug test were done on all nurses working the mediation cart, all urinalysis performed returned with no discrepancies. From 01/25 through 02/09/2022, the Pharmacy Consultant was notified, a new narcotic card and record keeping process was initiated, and the licensed nurses were in-serviced on chain of command protocols regarding narcotics and in-serviced on counting narcotics, along with narcotic cards at the change of each shift. On 02/09/2022, EI #3 and EI #4 were provided one on one in-service education & training on how controlled substance counts should be conducted at shift change and hand off/transfer of narcotic keys. Charge Nurses were audited QD (every day) times 4 weeks, then Q Week times 90 days, then were to be re-evaluated thereafter. Signature of Narcotic sign out book vs. (verses) electronic MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . ******************************************************** After review of the facility's investigation file, in-service/education records, staff and resident interviews, review of the facility's monitoring audits records, and ensuring the facility's corrective actions were being implemented, past non-compliance was cited. On 05/12/2022, the surveyor observed narcotic matchbacks, and the unit manager observing/monitoring how the licensed nurses were performing change of shift narcotic counts. This deficiency was cited as a result of the investigation of complaint/report number AL 710.

Based on observation, interviews, medical record review, and a review of POTTER AND PERRY's, FUNDAMENTALS OF NURSING, the facility failed to ensure a licensed nurse: 1) did not lay the insulin pen, needles, [MEDICATION NAME], and alcohol swabs on Resident Identifier (RI) #90's bedside table without first laying a barrier down; Further, while administering medications to RI #90, the licensed nurse stored medications and supplies in her pocket, and used scissors from her pocket to cut up a used [MEDICATION NAME], then returned them to the pocket without cleaning or disinfecting them; and 2) did not stack medication cups, each containing medication, on top of each other, after the cups had been placed on the medication cart, prior to administering medication to RI #63. These failures affected two of six residents and two of three nurses observed during medication pass observations. Findings Include: A review of POTTER AND PERRY's, FUNDAMENTALS OF NURSING, NINTH EDITION, CHAPTER 29, page 443 revealed: Infection Prevention and Control . Reservoir, a reservoir is a place where microorganisms survive, multiply, and await transfer to a susceptible host. Humans can transmit microorganisms . inanimate objects can also be reservoirs for infectious organisms. 1) RI #90 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/23/19 at 8:01 a.m., the surveyor observed Employee Identifier (EI) #1, a Licensed Practical Nurse, do the following while administering medications to RI #90: 1. store medications and injections supplies in her pocket prior to drug administration; 2. lay RI #90's insulin pen, needles, alcohol swabs, and [MEDICATION NAME] on RI #90's bedside table without first laying a protective barrier. She then returned the insulin pen to the medication cart; and 3. cut up RI #90's [MEDICATION NAME], that had been removed from his/her body, and return the scissors to her pocket without first cleaning or disinfecting them. An interview was conducted on 5/23/19 at 9:00 a.m. with EI #1. EI #1 was asked, what should be done before laying the insulin pen, diabetic supplies, and [MEDICATION NAME] on the resident's over bed table EI #1 stated, Clean area, paper towel. EI #1 was asked, what should be done after cutting up RI #90's [MEDICATION NAME] before placing the scissors back in her pocket. EI #1 stated, Clean them. EI #1 further stated she was not supposed to store medications and supplies in her pockets. EI #1 was asked what the potential for harm was with these concerns. EI #1 stated, Infection control. 2) RI #63 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 5/22/19 at 4:20 p.m., the surveyor observed EI #2, Licensed Practical Nurse,stack medication cups on top of each other, each containing RI #63's medication, after the cups had been placed on the medication cart, prior to administration. An interview was conducted on 5/23/19 at 3:23 p.m. with EI #3, a Registered Nurse/Director of Nursing/ Infection Control Officer. EI #3 stated medication cups with medicines in them should not be stacked on top of each other after placing them on the medication cart. EI #3 was asked, what was the potential for harm. EI #3 stated, Infection Control.

Based on observation, interview, the facility's policy for Insect and Rodent Control, and the (YEAR) Food Code, the facility failed to ensure the tile coving along the juncture of the floor/floor sink and the wall in the chemical/mop closet was not cracked and did not have holes, which allowed the potential for pests to enter the kitchen and for moisture to seep behind the walls. This had the potential to affect all residents receiving meals from the facility, 91 of 93 residents. The facility's policy for Insect and Rodent Control, dated (MONTH) 1, 2002, included the following: . Purpose: To prevent the spread of bacteria that may cause food borne illnesses. Process: . f. Cracks in walls, floors, along baseboards or ceilings should be reported to maintenance for repair. The (YEAR) Food Code by the United States Public Health Service and the Food and Drug Administration, included the following: . 6-201.13 Floor and Wall Junctures, Coved, and Enclosed or Sealed. (B) The floors in FOOD ESTABLISHMENTS in which water flush . methods are used shall be provided with drains and be graded to drain, and the floor and wall junctures shall be coved and SEALED. 6-202.15 Outer Openings, Protected. (A) . a FOOD ESTABLISHMENT shall be protected against the entry of insects and rodents by: (1) Filling or closing holes and other gaps along floors, walls, and ceilings; . 6-501.11 Repairing. PHYSICAL FACILITIES shall be maintained in good repair. During the initial tour of the kitchen on 06/05/18 at 6:52 PM, the ceramic tile coving in chemical/mop closet at the right-hand corner of the floor/floor sink was observed to have a hole at the base, which was approximately one inch to one and one-half inches high and three inches across. On 06/06/18 at 3:17 PM, the chemical/mop closet was viewed with Employee Identifier (EI) #2, the Dietary Manager. In addition to the hole seen on 06/06/18, a second, smaller hole in the tile coving along the back wall was observed. Also, numerous cracks in the tile coving were observed. EI #2 verified this area was also the service sink (a floor sink style with a short ledge about one-third way into the closet to create a sink depression and the floor gradually graded down to a drain that was flush to the floor). It was also determined with EI #2 that the back wall of the chemical/mop closet adjoined an interior stairwell. When asked the problem with having large holes in the wall/tile coving of the floor sink in the chemical/mop closet, EI #2 said, Potential for pests. When asked if a request had been made to repair this area, EI #2 said, No. On 06/06/18 at 3:20 PM, the chemical/mop closet was viewed with EI #3, the Registered Dietitian. EI #3 agreed there was a potential for pests due to the holes in the tile coving. When asked if there could be a potential for water seepage behind the walls due to the holes and cracks in the tile coving surrounding the floor drain/sink, the RD said the potential was there. On 06/06/18 at 5:09 PM, EI #3 said the Maintenance Director had measured the two openings in the tile coving of the chemical/mop closet today as requested. EI #3 said the first hole was four inches wide and the second hole was two inches wide.

Based on interview, the facility's policy for Master Meal Schedule, and the facility's Schedule of Meals, the facility failed to ensure the period between the facility's scheduled meal times for supper and breakfast did not exceed fourteen hours. The facility also failed to request or receive approval from the Resident Council for the period between the facility's scheduled meal times for supper and breakfast to exceed fourteen hours. This had the potential to affect all residents receiving meals from the facility, 91 of 93 residents. The facility's policy for Master Meal Schedule, dated (MONTH) 23, 2012, included the following: . Standard: According to federal regulations, three meals should be served at regularly scheduled times. No more than a 14-hour span between supper and breakfast should occur. Residents are encouraged to express preferences for self-directed mealtimes including options to normal/regular mealtimes. On 06/05/18, Employee Identifier (EI) #1, the Administrator, provided a copy of the facility's Schedule of Meals for residents, dated (MONTH) 2012, to the surveyors. This document was reviewed on 06/06/18 at 09:25 AM and the following was revealed: a.) The schedule documented supper for Station 2 was started at 4:00 PM and that breakfast for Station 2 was started at 7:00 AM, which was a 15 hour overnight time span between the two meal services. (Note: On the original document, the start time for supper had been altered with a black pen to create a zero over the first number for minutes, changing the time from 4:30 PM to 4:00 PM.) b.) The schedule documented supper for North. Hts (Northern Heights, the dementia unit) was started at 4:40 PM and that breakfast for North. Hts was started at 7:10 AM, which was a 14 hour 30 minute overnight time span between the two meal services. c.) The schedule documented supper for Dining Room was started at 4:50 PM and that breakfast for Dining Room was started at 7:20 AM, which was a 14 hour 30 minute overnight time span between the two meal services. d.) The schedule documented supper for Station 4 was started at 5:00 PM and that breakfast for Station 4 was started at 7:30 AM, which was a 14 hour 30 minute overnight time span between the two meal services. e.) The schedule documented supper for Station 1 was started at 5:10 PM and that breakfast for Station 1 was started at 7:40 AM, which was a 14 hour 30 minute overnight time span between the two meal services. f.) The schedule documented supper for Station 3 was started at 5:20 PM and that breakfast for Station 3 was started at 7:50 AM, which was a 14 hour 30 minute overnight time span between the two meal services. On 06/06/18 at 9:51 AM, EI #2, the Dietary Manager, provided a current copy of the Schedule of Meals, dated (MONTH) (YEAR). The start times for meals on this document were the same as the one dated (MONTH) 2012, except the start time for supper for Station 2 was 4:30 PM. This schedule revealed the period of time between the evening meal and breakfast for each resident area was 14 hours and 30 minutes. On 06/06/18 at 9:51 AM, EI #2 was asked if the Resident Council or any resident group had given approval for the time period between supper and breakfast to be more than 14 hours. EI #2 said she was not aware of any approval being given by the residents. EI #3, the Registered Dietitian was present during this conversation. EI #3 also said she was not aware of any approval being given by the residents. On 06/06/18 at 9:51 AM, EI #1 was asked if he had any knowledge or documentation of the residents giving approval for a time period greater than 14 hours between supper and breakfast. EI #1 said no. A Resident Council meeting was held on 06/06/18 at 3:30 PM with a surveyor and four residents. When asked about the issue, these residents said no approval had been asked for or given to allow a time period greater than 14 hours between supper and breakfast for the regular schedule. On 06/07/18 at 4:03 PM, EI #2 was asked, how could a resident be negatively affected if the period of time between supper and breakfast was more than 14 hours. EI #2 said, They could be a little hungry. On 06/07/18 at 4:06 PM, EI #3 was asked, how could a resident be negatively affected if the period of time between supper and breakfast was more than 14 hours. EI #3 said, They could possibly get hungry.

Based on observation, interviews and record review, the facility failed to ensure Resident Identifier (RI) #24's Admission Minimum Data Set (MDS) assessment, dated 04/02/18, reflected RI #24 had a [MEDICAL CONDITION]. This affected RI #24, one of 42 sampled residents whose MDS assessments were reviewed. Findings Include: RI #24 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #24's Admission MDS assessment, with an Assessment Reference Date (ARD) of 04/02/18, revealed RI #24 was not coded as having a [MEDICAL CONDITION]. 06/06/18 04:29 PM Resident # 24 raised gown & said Someone needs to see about this. [MEDICAL CONDITION] bag VERY full of gas & stool. Staff LPN notified. On 06/07/18 at 11:28 a.m., the surveyor conducted an interview with Employee Identifier (EI) # 4, the RN (Registered Nurse), MDS Coordinator. The surveyor asked EI # 4 did RI #24 have a [MEDICAL CONDITION]. EI # 4 said RI #24 did. The surveyor asked EI # 4 how long had RI #24 had the [MEDICAL CONDITION]. EI # 4 said RI #24 had the [MEDICAL CONDITION] on admission to the facility. The surveyor asked EI # 4 was the [MEDICAL CONDITION] coded on RI #24's 04/02/18 Admission MDS assessment. EI # 4 said, no it was miscoded. The surveyor asked EI # 4 should it have been. EI # 4 said yes. The surveyor asked EI # 4 was this an accurate MDS assessment. EI # 4 said, it was an omission as far as the [MEDICAL CONDITION] and section H was not accurate. On 06/07/18 at 2:51 p.m., the surveyor conducted an interview with EI # 5, the Restorative LPN (Licensed Practical Nurse). The surveyor asked EI # 5 did she code under the Bowel & (and) Bladder section on RI #24's 04/02/18 Admission MDS assessment. EI # 5 said yes. The surveyor asked EI # 5 did RI #24 have a [MEDICAL CONDITION]. EI # 5 said yes. The surveyor asked EI # 5 how long had RI #24 had the [MEDICAL CONDITION]. EI # 5 said since admission. The surveyor asked EI # 5 was the [MEDICAL CONDITION] coded on RI # 24's 04/02/18 Admission MDS assessment. EI # 5 said no. The surveyor asked EI # 5 should it have been. EI # 5 said yes. The surveyor asked EI # 5 was this an accurate MDS assessment. EI # 5 said no.

Based on observation, interview, and document review of 2013 Food Code, the facility failed to ensure an air gap existed between the drain of the three-compartment sink and the floor drain. The facility further failed to ensure two drains from the dishwasher area did not extend into the floor drain by one inch, so that no air gap existed. This was observed on two of three days of the survey. This had the potential to affect 99 of 104 residents receiving meals from the kitchen. Findings include: The 2013 Food Code of the United States Public Health Service and the Food and Drug Administration included the following: . 5-402.11 Backflow Prevention. (A) . a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. During a kitchen observation on 6/20/17 at 5:30 p.m., the 3-compartment sink did not have an air gap. The drains of the three sinks were connected by a horizontal long pipe and all then drained into one vertical pipe, which was connected by a rubber collar with a metal ring tied to a pipe coming out of concrete from the floor. Further observation revealed the dishwasher area had two drain pipes without air gaps. The two drain pipes extended into an open floor drain. On 6/21/17 at 7:55 a.m., the sinks were being filled for the 3-compartment sink to be used and there were pots and pans in the wash and rinse sinks. At 8:00 a.m., on 6/21/17, Employee Identifier (EI) #11, the Dietary Manager, was asked where was the air gap for the 3-compartment sink, which was being used to wash pots and pans at that moment. EI #11 looked at the 3-compartment sink and said, I don't know. I know what you are talking about. EI #11 then said the Maintenance Director should be asked the question. At 8:05 a.m., on 6/21/17, EI #4, the Maintenance Director was interviewed. EI #4 said he had been at the facility for two months. At the 3-compartment sink, EI #4 was asked where the air gap to prevent backflow was located. EI #4 said it should be where the black rubber bladder was located, which was being held in place by the metal tie between the sink drain and the drain pipe cemented in the floor. When asked what was preventing any potential backflow from the sewer into the 3-compartment sink, EI #4 said he thought gravity would prevent it. At the dishwasher, EI #4 was asked to measure how far the two drain pipes extended down into the open floor drain from the top edge of the floor drain. Upon measuring, EI #4 found the two drain pipes from the dishwasher area were extending one inch into the floor drain.

Based on observations, interviews, record reviews, review of a facility policy titled Standard Precautions and review of Potter and Perry's Fundamentals of Nursing, the facility failed to ensure: 1) a Certified Nursing Assistant (CNA) did not use the same pair of gloves used to clean Resident Identifier (RI) #5 during incontinent care on 06/21/17, to place a clean brief on RI #5 then pull up the resident's pants, 2) a Licensed Practical Nurse (LPN) did not place gloves in the pocket of her uniform on 06/21/17, then administering a nebulizer treatment and rinse RI #16's tube feeding syringe using the gloves from her pocket, and 3) Laundry staff: 1. wore Personal Protective Equipment (PPE) while loading soiled linens and towels into a washer; 2. washed her hands after removing a soiled glove in the dirty area and before returning to the clean area; 3. placed a dirty bib which fell to the floor and was picked up and folded, then stacked with the other clean bibs; and 4. stored residents clothing items in a manner to prevent contamination. These deficient practices affected RI #5, one of one resident observed for incontinent care, one of two nurses observed administering a tube feeding and nebulizer treatment, and had the potential to affect 89 residents whose clothing was laundered by the facility and 104 residents whose linens were laundered by the facility. Findings Include: 1) A review of Potter & (and) Perry's FUNDAMENTALS OF NURSING eighth Edition, Copyright 2013 Chapter 39, Hygiene revealed . o. Provide perineal hygiene. wash . p. Remove soiled gloves and discard . q. wash back. (5) clean buttocks and anus, . remove contaminated gloves. and perform hand hygiene . RI #5 was admitted to the facility 07/01/84, and readmitted to the facility 10/27/16, with [DIAGNOSES REDACTED]. On 06/21/17 at 9:00 a.m., Employee Identifier (EI) #6, a CNA was observed performing incontinent care for RI #5. EI #6 cleaned RI #5's front side first, then turned RI #5 to the side and cleaned the buttocks area. EI #6 placed the clean brief, with the same gloves on, and pulled up RI #5's pants and assisted RI #5 back to the wheelchair while wearing the same soiled gloves. On 06/22/17 at 8:00 a.m., an interview was conducted with EI #6. EI #6 was asked what was the policy on glove use and changing during incontinent care. EI #6 replied she should change after she cleaned and before she put on the clean brief. EI #6 was asked if she used the same soiled gloves she cleaned RI #5 with to place the clean brief and pull up RI #5's pants, then assist RI #5 to the wheelchair. EI #6 replied yes. EI #6 was asked what was the harm in touching the clean brief with the same gloves used to clean the resident. EI #6 replied contamination. On 06/22/17 at 12:00 p.m., an interview was conducted with EI #1, the Director of Nursing/ Infection Control Nurse. EI #1 was asked what was the policy for incontinent care related to glove use and changing gloves. EI #1 replied they were to DON gloves prior to starting and change during the incontinent care when going from soiled to clean. EI #1 was asked when should a CNA perform incontinent care, then with the same soiled gloves on place the clean brief, pull up the resident's pants and assist them to the wheelchair. EI #1 replied never. EI #1 was asked what was the harm in the CNA placing the clean brief with same soiled gloves on. EI #1 replied contamination. 2) RI #16 was admitted to the facility on [DATE], and readmitted on [DATE], with a [DIAGNOSES REDACTED]. RI #16's June 2017 Physician order [REDACTED].> . [MEDICATION NAME] 2.5 MG (milligram)/0.5 ML (milliliters) SOL (solution) FOR NEBULIZER EVERY 4 HOURS . [MEDICATION NAME] BR ([MEDICATION NAME]) 0.02% (percent) SOLN FOR INHALATION 2.5 ML EVERY 4 HOURS . On 06/21/17 at 4:15 p.m., the surveyor observed a medication nurse, EI #10, remove her gloves after administering medications to RI #16. EI #10 put additional gloves in the pocket of her uniform then washed her hands at a sink in the resident's room. EI #10 removed a pair of gloves from the pocket of her uniform, gloved, then repositioned and covered RI #16. EI #10 removed a nebulizer mask from RI #16's drawer and placed [MEDICATION NAME] and [MEDICATION NAME] solutions in the reservoir of RI #16's nebulizer. EI #10 placed the nebulizer mask over RI #16's face and turned on the nebulizer. EI #10 removed her gloves and washed her hands. EI #10 then removed another pair of gloves from the pocket of her uniform and gloved. EI #10 next rinsed RI #16's syringe, dried the syringe with a paper towel and placed the syringe back in a plastic bag. On 06/22/17 at 2:52 p.m., the surveyor conducted an interview with EI #10. The surveyor asked EI #10 were the pockets of a uniform considered dirty or clean. EI #10 replied, Dirty. EI #10 said she did not know why she had placed the gloves in the pocket of her uniform. The surveyor asked EI #10 what would placing gloves in the pocket of the uniform be considered. EI #10 replied, Contamination. On 06/22/17 at 3:15 p.m., the surveyor conducted an interview with EI #1, the Director of Nursing/Infection Control Nurse. The surveyor asked EI #1 should the nurses place gloves in the pockets of their uniforms. EI #1 replied, No. The surveyor asked EI #1 what was it considered when this was done or what was there a potential for when this was done. EI #1 replied, It's contamination. 3) A review of facility policy Standard Precautions with an effective date of Dec. 1, 2009 revealed Purpose: It is the intent of this facility that: 1) all resident blood, body fluids . will be considered potentially infectious, 2) Standard Precautions will be used for all residents. I. Gloves - gloves should be worn whenever exposure to . is planned or anticipated .Urine Feces Saliva Mucus membranes Wound drainage . III. Gowns/Aprons (fluid resistant) - should be worn when there is potential for soiling clothing with blood/body fluids. X. Linen - soiled linen should be handled as little as possible. Gloves should be worn to handle linen wet with . PERSONAL PROTECTIVE EQUIPMENT (PPE) . III. PPE available includes gloves, gowns or aprons . 1. On 6/21/17 beginning at 9:31 a.m, surveyor observed EI #2 on the dirty side of the laundry room without PPE gear. During EI #2's laundry task at 9:34 a.m., the surveyor observed EI #2, laundry aide, placing soiled linens from a bag into the washer. No PPE was used. On 6/21/17 at 10:00 a.m., an interview was conducted with EI #2, laundry aide. EI #2 was asked if she should have on an apron and gloves when she placed the soiled linens into the washer. EI #2 replied yes she should have had on gloves but they do not use aprons. EI #2 was asked why were aprons not used when placing soiled linens and clothing items into washers. EI #2 said she did not know but they should be used. EI #2 was asked what was the potential for harm in not using gloves when placing dirty clothing or linens into the washers. EI #2 replied you can catch diseases and infections. On 6/21/17 at 4:35 p.m., an interview was conducted with EI #3, Housekeeping/Laundry Supervisor. EI #3 was asked what was the facility procedure for laundry staff when placing dirty or soiled linens and clothing into the washers. EI #3 replied first they were to have their gloves on and sort at all times; second after loading the washer they were to take the gloves off and wash their hands and put on new gloves and start the machine then take the gloves off and wash their hands. EI #3 was asked if staff should have on gloves and an apron when placing soiled/dirty linens and towels in the washer. EI #3 replied sure. EI #3 was asked why; he replied to protect themselves. EI #3 was asked when should PPE gear be used. EI #3 replied when they are washing soiled linens and clothing and when loading the washer. EI #3 was asked what does PPE consist of; EI #3 replied gloves and an apron. On 6/21/17 at 5:51 p.m., an interview was conducted with EI #1, Infection Control RN(Registered Nurse), DON (Director of Nursing). EI #1 was asked why should gloves and aprons be used when a laundry staff dumps a bag of dirty soiled linens, towels into a washer. EI #1 said infection control and prevents contamination. EI #1 was asked what was the potential harm of a laundry staff to dump a bag of soiled/dirty linens and towels into a washer without PPE gear such as aprons. EI #1 said she (staff) could spread contamination. 2. EI #2 was observed on 6/21/17 at 9:36 a.m., in the dirty area of the laundry room. EI #2 placed on gloves and placed dirty linens and towels from the dirty bin into a washer. EI #2 with her soiled gloves, pressed the washer cycle, took her gloves off and returned to the clean area of the laundry room without washing her hands. On 6/21/17 at 10:00 a.m., an interview was conducted with EI #2. EI #2 was asked when she put on her gloves and sorted the dirty linens and towels in the washer what did she do then. EI #2 replied she pulled her gloves off. EI #2 was asked if she washed her hands, she replied she thought she did. EI #2 was asked when was she to wash her hands during the laundry. EI #2 replied when she comes into the laundry room she puts on her gloves and pulls in the dirty bins and sorts the laundry. EI #2 went on to add once she placed the laundry in the washer she should take off the gloves and wash her hands, then turn on the washer. EI #2 was asked what was she to do before entering the clean area of the laundry. EI #2 replied wash my hands. An interview was conducted with EI #3 at 4:35 p.m., on 6/21/17, he was asked when should laundry staff wash their hands. EI #3 replied when they get finished loading and unloading the washer, and when going into the clean area. On 6/21/17 at 5:51 p.m., an interview was conducted with EI #1. EI #1 was asked why should laundry staff wash their hands after placing dirty linens and or clothing items into a washer. EI #1 explained to prevent the spread of infection. EI #1 was asked what was the potential harm for a laundry staff member to place soiled items into a washer and return to the clean area of the laundry room without washing their hands. EI #1 explained it could be contamination. 3) On 6/21/17 at 9:19 a.m., the surveyor observed EI #2 had folded and placed a dirty bib that had fell to the floor on the stack with the clean bibs. On 6/21/17 at 10:00 a.m., the surveyor conducted an interview with EI #2. EI #2 was asked when a bib fell to the floor while she was folding it what did she do. EI #2 replied she probably picked it up and folded it. EI #2 was asked when she picked up the bib off the floor and placed it on the table with the other clothes were those items then contaminated. EI #2 replied yes. On 6/21/17 at 5:51 p.m., an interview was conducted with EI #1, Infection Control Nurse. EI #1 was asked when a clean item on the clean side of the laundry room falls to the floor what should the laundry staff have done. EI #1 explained the item is considered dirty and it should go into the dirty linen. EI #1 was asked should laundry staff pick up items from the floor, fold it and continue to place clean folded items on top of it. EI #1 replied no. EI #1 was asked why. EI #1 explained because once the item fell to the floor it was considered dirty so it should not have been picked up and placed with clean items. 4. On 6/21/17 at 9:37 a.m., the surveyor observed in a clothing closet clothing on the lower rack, the sleeves of shirts touching the floor. At 9:51 a.m., the surveyor and EI #2, laundry aide, observed 5 clothing items on the floor in the station 1 and 2 clothing closet. On 6/21/17 at 4:05 p.m., the surveyor observed with EI #3 one red shirt on the floor and the sleeves of another shirt touching the floor under the bottom rack. On 6/21/17 at 4:35 p.m., an interview was conducted with EI #3. EI #3 was asked why were some of the clean clothing items that were labeled and ready for the residents on the floor in the station 1 and 2 closet. EI #3 replied he did not know. On 6/21/17 at 5:51 p.m., an interview was conducted with EI #1, Registered Nurse/ Director of Nursing/Infection Control Nurse. EI #1 was asked why should laundry staff wash their hands after placing dirty linens or clothing items into a washer. EI #1 replied to prevent the spread of infection if it were present. EI #1 was asked why should gloves and aprons be used when laundry staff dumps a bag of dirty soiled linens and towels into a washer. EI #1 replied infection control and prevents contamination. EI #1 was asked when a clean item on the clean side falls to the floor what should the laundry staff do. EI #1 replied it is considered dirty so it should go into the dirty linen if she has a barrel. EI #1 was asked once a an item that fell to the floor was picked up when should the laundry staff wash their hands. EI #1 replied after she places it back in the dirty she should wash her hands and return to the clean side. EI #1 was asked should the laundry staff pick up the item from the floor and fold it and continue folding clean items and placing them on the other clean items. EI #1 replied because once that item has fallen to the floor it is considered dirty so the laundry staff should not have placed it with the other clean items. EI #1 was asked what was the potential for harm for a laundry person to place sorted soiled items into the washer with gloved hands then taken the gloves off and returned to the clean area without washing her hands. EI #1 replied it could be contaminated. EI #1 was asked what was the potential for harm of a laundry staff to dump a bag of soiled/dirty linens and towels into a washer without PPE gear. EI #1 replied she could spread contamination.

Based on observation, interview, and a review of facility's policy titled, Garbage and Refuse (DS.V.38), the facility failed to ensure one door of one of two dumpsters was not left open on 6/20/2017. This affected one of two dumpsters at the facility. Findings include: The facility's policy titled, Garbage and Refuse (DS.V.38) with an effective date of 2/1/2002, documented . PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses. STANDARD: Garbage and refuse containers should be free from cracks or leaks and covered when not in use . PROCESS: . e. Refuse containers and dumpsters kept outside the facility should have tightly fitting lids and should be kept covered when not being loaded . The 2013 Food Code of the United States Public Health Service and the Food and Drug Administration included the following: . 5-501.15 Outside Receptacles. (A) Receptacles . for REFUSE . used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall . have tight-fitting lids, doors, or covers. During an observation of the dumpster area on 6/20/2017 at 2:46 p.m., with Employee Identifier (EI) #11, the Dietary Manager, and EI #12, the Registered Dietitian, the door of one dumpster was open. EI #12 was interviewed on 6/20/2017 at 3:05 p.m., When asked what was the problem with the dumpster door being left open, EI #12 said, Potential for attracting rodents.

Based on observation, interview, review of a facility policy titled Menu Changes (DS.III-22), and review of the facility's pre-panned menu for 06/21/2017, the facility failed to ensure the pureed menu was followed during the lunch meal on 6/21/17. The facility served pureed pineapple for dessert, not pureed fruit crisp as listed on the menu. This affected 8 of 8 residents receiving pureed meals. Findings include: The facility's policy titled Menu Changes (DS.III-22) with an effective date of 4/29/2015, documented . PURPOSE: Cycle menus are designed to meet the daily food allowance requirements . for residents. STANDARD: The cycle menu should be followed whenever possible. When situations arise that prevent adherence to the menu, the Dietary Manager should select food replacements what are of similar nutritive value. PROCESS: a. Menu changes should be indicated on the menu, prior to meal service by Dietary Manager or R.D. (Registered Dietician) . On 6/20/2017 at 4:30 p.m., Employee Identifier (EI) #12, the Registered Dietitian, had provided a copy of the facility's pre-planned Pureed Menu for Week 2, Day 11, which was to be served on Wednesday, 6/21/2017. The menu for lunch included, Pureed Fruit Crisp. During a kitchen observation on 6/21/2017 at 11:05 a.m., EI #13, a Dietary Aide was observed portioning pureed pineapple from a container labeled as Pineapple Pureed into individual dishes. The surveyor checked the menu to see if any change had been noted, but none was seen. The trayline for lunch on 6/21/2017 began at 11:20 a.m., A pureed test tray was prepared at 12:28 p.m. on the trayline. Tray delivery service to the residents was completed by 12:46 p.m., The test tray was sampled at 12:47 p.m., and the items on the pureed tray were: pureed chicken tenders, mashed potatoes, pureed green beans, pureed bread, pureed pineapple as dessert, 2% milk, tea, and water. EI #11, the Dietary Manager, was interviewed on 6/21/2017 beginning at 1:30 p.m., EI #11 was asked why pureed pineapple was served instead of pureed fruit crisp. EI #11 said it was an oversight. EI #11 said 8 pureed meals were served for lunch on 6/21/2017. When asked if the menu had been followed, EI #11 said, No.

Based on observation, interviews, record review and review of a facility policy titled Capillary Blood Sampling, the facility failed to ensure the medication nurse, Employee Identifier (EI) #8, discarded a used lancet in the manner to prevent someone from being stuck by the lancet. On 06/21/17, during the evening medication pass observation, EI #8 discarded a used lancet in the trash can in Resident Identifier (RI) #3's room after checking RI #3's blood glucose level. This deficient practice has the potential to affected anyone handling the trash in RI #3's trash can. Finding Include: Review of a facility policy titled Capillary Blood Sampling, with an effective date of November 1, 2001, documented: . STANDARD: . Lancets should be handled as a used needle. PROCESS: . 6. Discard the lancet into the sharp's container . RI #3 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. RI #3's June 2017 Physician order [REDACTED].> . CBG (Capillary Blood Glucose) BID (twice a day) @ (at) 630 (6:30 a.m.) & (and) 430PM (4:30 p.m.) . On 06/21/17 at 3:49 p.m., the surveyor observed EI #8 use a lancet to check the blood glucose level of RI #3. After checking RI #3's blood glucose, EI #8 rolled the used alcohol prep, lancet and glucometer strip into her gloves and place the gloves in a cup. EI #8 then placed the cup in the trash can in RI #3's room. On 06/22/17 at 3:00 p.m., the surveyor conducted an interview with EI #8. The surveyor read back the above observation and asked EI #8 did she place the lancet in the trash can on yesterday. EI #8 replied, Yes. The surveyor asked EI #8 why she placed the lancet in the trash can. EI #8 said she was nervous, not thinking and she knew better. The surveyor asked EI #8 what was there a potential for when placing a used lancet in a trash can. EI #8 replied, Someone getting stuck with it. A resident could go in the garbage can and get it out. Housekeeping handling it may have got stuck with it. On 06/22/17 at 3:15 p.m., the surveyor conducted an interview with EI #1, the Director of Nursing. The surveyor asked EI #1 where are used lancets suppose to be placed. EI #1 replied, In the sharp's container. The surveyor asked EI #1, when not placed in the sharp's container, what could occur. EI #1 replied, Someone could stick themselves.

Based on record review and interview, the facility failed to ensure: 1) Resident Identifier (RI) #3's 05/27/2017, Quarterly Minimum Data Set (MDS) assessment accurately assessed the resident as not having a foley catheter; and 2) RI #17's 04/06/2017, Quarterly MDS assessment accurately reflected RI #17 was receiving hospice services. This affected RI #3 and 17, two of 20 residents whose MDS's were reviewed. Findings Include: 1) RI #3 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. RI #3's Physician order [REDACTED]. . D/C (discontinue) FOLEY CATHETER . A Quarterly MDS assessment with an Assessment Reference Date (ARD) of 05/27/17, assessed RI #3 as having an indwelling or condom catheter during this assessment period. On 06/22/17 at 3:44 p.m., the surveyor conducted an interview with EI #5, the MDS Coordinator. The surveyor asked EI #5 did RI #3 have a Foley Catheter at this time. EI #5 said no. The surveyor asked EI #5 when was RI #3's Foley Catheter discontinued. EI #5 said the Foley Catheter was discounted on 05/04/17. The surveyor asked EI #5 should it be captured on RI #3's 05/27/17 Quarterly MDS that the Foley Catheter had been discontinued. EI #5 replied, It should have. The surveyor asked EI #5 was this an accurate assessment. EI #5 said no it was not. 2) RI #17 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #17's January 2017 Physician order [REDACTED]. RI #17's Quarterly MDS with an ARD of 04/06/17, assessed the resident as having a BIMS (Brief Interview for Mental Status) of 8. In section O, K2: Treatment: hospice care-while resident was unchecked. On 06/22/17 at 3:03 p.m., the surveyor conducted an interview with EI #5. EI #5 was asked how long she had been the MDS Coordinator. EI #5 replied, nine years. EI #5 was asked, when a medical doctor orders and a resident is admitted to Hospice, should it be reflected on the MDS. EI #5 replied, yes. EI #5 was asked why should it be reflected on the MDS. EI #5 replied, because of the MDS coding. At 3:07 p.m., the MDS Coordinator was asked to review RI #17's 04/06/17 Quarterly MDS. After reviewing the MDS EI #5 replied, it looks like a coding error had occurred. EI #5 was asked why was this an error on the 04/06/17 MDS. EI #5 replied, it was an oversight. EI #5 was asked why should Hospice be checked on RI #17's 04/06/17 Quarterly MDS. EI #5 replied, because it lets them know that RI #17 continued to receive Hospice service and the MDS should be accurate.

Based on observations and interviews, the facility failed to ensure Room Locators (RL) #'s 1-5 were free of exposed bolts/screws at the commode base, commode base were free of dirt like substance, resident room faucet did not leak, resident bathroom floors were free of dirt like substance, bathroom door closed with ease, window seal did not leak and bathroom door knob was secure. This affected five of 57 rooms located on stations one, two and three of the facility. 3 of 3 stations located in the facility. Findings Include: RL #1: Observations were made on 06/20/2017 at 1:57 p.m. and 06/21/2017 at 11:24 a.m. of the bathroom with dirt like substance; observations were made on 06/21/2017 at 11:20 a.m. and 06/22/2017 at 8:44 a.m. of Side B window seal with a white spread with brown stains. On 06/22/2017 at 8:46 a.m. both surveyor and Housekeeping/Laundry Supervisor observed the white bed spread on Side B's window seal. On 06/22/2017 at 1:56 p.m. Maintenance Supervisor observed water on Side B's window blinds, the spread had been removed. RL #2: Observations were made on 06/20/2017 at 1:59 p.m., and 06/21/2017 at 11:25 a.m., of the bathroom door sticking and difficult to open and close; observations were made on 06/20/2017 at 2:00 p. m., and 06/21/2017 at 11:27 a.m., of the base of commode with dirt like substance on both sides. RL #3: Observations were made on 06/20/2017 at 1:48 p.m., and 06/21/2017 at 11:12 a.m., of the resident room faucet continuously dripping water and the commode base observed with dirt like substance on both sides. RL #4: Observations were made on 06/20/2017 at 2:30 p.m., and 06/21/2017 at 4:00 p.m., of the bathroom door knob hanging loosely and commode base screws sticking up with no cover. RL #5: Observation made on 06/20/2017 at 4:57 p.m., 06/21/2017 at 12:32 p.m. and 06/22/2017 at 8:40 a.m., of commode screws sticking up uncovered on both sides. On 06/22/2017 beginning at 8:42 a.m., and ending at 9:06 a.m., EI (Employee Identifier) #3, Housekeeping/Laundry Supervisor, observed the above housekeeping concerns along with the surveyor. On 06/22/2017 at 9:06 a.m., an interview was conducted with EI #3. EI #3 was asked why resident bathroom floors should be free of black dirt like substance. EI #3 replied, It's suppose to be clean because their suppose to be in a clean homelike environment. EI #3 was asked why commode base should be free of black dirt like build up. EI #3 explained they should be clean at all times. EI #3 was asked who was responsible for ensuring bathroom floors and commode base were clean and free of dirt like build up. EI #3 said Me. EI #3 was asked how often he conducted rounds in the facility. EI #3 said every three days out of the week, 15 rooms out of the week. EI #3 was asked when should housekeeping clean floors and commode base. EI #3 said every day. EI #3 was asked why there was dirt like substance on the bathroom floors and commode base. EI #3 said it was probably overlooked and housekeeping did not perform her duties. EI #3 was asked what was the potential harm of resident bathroom floors and commode base having dirt like build up. EI #3 explained it could affect the resident's health. On 06/22/2017 beginning at 1:51 p.m., and ending at 2:18 p.m., EI #4, Maintenance Supervisor, observed the above maintenance concerns. On 06/22/2017 at 2:20 p.m., an interview was conducted with EI #4. EI #4 was asked how long had he been in his position. EI #4 said two months. EI #4 was asked who was responsible for repairing needed repairs. EI #4 said maintenance. EI #4 was asked how maintenance knew when there was a needed repair required. EI #4 said the facility's work order system. EI #4 was asked how often maintenance made rounds. EI #4 said daily. EI #4 was asked why resident bathroom doors should be easy to open and close. EI #4 said for easier access. EI #4 was asked why window seals should be free of leaks. EI #4 explained, to keep from damaging the paint. EI #4 was asked why faucets should be free of leaks. EI #4 explained it should not be leaking and further explained it could cause slips and falls if not contained. EI #4 was asked why bathroom door knobs should be sturdy and not loose in resident's rooms. EI #4 said for safety. EI #4 was asked why there should be caps on commode base screws. EI #4 explained so they (residents) would not be harmed and it looked good in appearance. EI #4 was asked what was the potential harm of commode base screws sticking up without caps. EI #4 said, skin tears and punctures. EI #4 was asked what was the potential harm of bathroom door knobs fitting loosely in resident rooms. EI #4 explained slips and falls with opening door knobs that are loose. EI #4 was asked what was the potential harm of bathroom doors sticking and being difficult to open and close. EI #4 explained they can hurt themselves trying to pull the door. EI #4 was asked what was the potential harm for window seals to leak. EI #4 said puddle of water. EI #4 was asked what was the potential harm of resident rooms having water leaking from the sink faucet. EI #4 explained it was a potential for falls.

Based on observation, interviews, record review and review of a facility policy titled Medication Administration Procedures Respiratory Therapy, the facility failed to ensure a medication nurse, Employee Identifier (EI) #7, remained with Resident Identifier (RI) #22 during the administration of RI #22's nebulizer treatment on 06/22/17. The facility further failed to ensure RI #22 had been evaluated to self administer the nebulizer treatment. This affected RI #22, one of two residents observed receiving a nebulizer treatment and EI #7, one of five medication nurses observed during the medication administration observation. Finding Include: A facility policy titled Medication Administration Procedures Respiratory Therapy, dated 03/11, documented: . Policy Respiratory therapy is administered via (by way of) nebulizers in a safe and accurate manner . Procedures . The resident should be evaluated for self administration. RI #22 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. An Annual Minimum Data Assessment with an Assessment Reference Date of 03/31/17, assessed RI #22 as scoring a 6 on the Brief Interview for Mental Status indicating RI #22 had severely impaired cognition. RI #22's June 2017 Physician order [REDACTED].> . [MEDICATION NAME] BR ([MEDICATION NAME]) 0.02% (percent) SOLN (solution) PER (via way of) NEBULIZER Q (every) 4 HRS (hours) . On 06/22/17 at 9:30 a.m., the surveyor observed RI #22 laying in bed with the Head of the Bed elevated receiving a nebulizer breathing treatment. There was no nurse observed in the room at this time. On 06/22/17 at 11:51 a.m., the surveyor conducted an interview with EI #7, the medication nurse assigned to administer RI #22 the nebulizer treatment. The surveyor asked EI #7 had RI #22 been assessed to self administer the nebulizer treatment. EI #7 said she was not sure. The surveyor asked EI #7 what was the facility's procedure nurses used when administering a nebulizer treatment. EI #7 replied, We are suppose to stay at the bedside unless they (the resident) are care planned to self administer. On 06/22/17 at 3:15 p.m., the surveyor conducted an interview with EI #1, the Director of Nursing/Infection Control Nurse. The surveyor asked EI #1, where should the nurse be when a nebulizer treatment is being administered. EI #1 replied, In the room with the patient. The surveyor asked EI #1 had RI #22 been evaluated to self administer the nebulizer treatment. EI #1 replied, No Ma'am.