Every finding on record at Oakview Manor Health Care Center

Based on observations, interviews, record review, and facility policy review, the facility failed to maintain a urinary catheter bag in a manner to prevent potential contamination and urinary tract infections when Resident 86's urinary catheter bag was observed on the floor on five occasions on three of the four days of the survey. This affected Resident #86, one of three residents reviewed with catheters. Findings included: Review of a facility policy titled, Urinary Catheter Care, dated 07/02/2007, revealed, . PURPOSE: Urinary catheter care helps prevent urinary tract infections . PROCESS: . Catheter tubing and drainage bags are kept off the floor to prevent contamination . Review of a Face Sheet revealed the facility admitted Resident #86 on 10/28/2021 and readmitted the resident on 03/03/2022 with diagnoses that included Urinary Retention and Gross Hematuria (visible blood in the urine). Review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/27/2023, revealed Resident #86 had a Brief Interview for Mental Status (BIMS) score of seven, which indicated Resident #86 had severe cognitive impairment. The MDS indicated Resident #86 was totally dependent on staff for toilet use and had an indwelling catheter. Review of Resident #86's Care Plan, initiated 01/30/2023, revealed Resident #86 required a suprapubic catheter due to urinary retention. The Care Plan directed staff to secure the resident's urinary catheter bag to their thigh and maintain the drainage bag below the level of the bladder. The Care Plan also indicated Resident #86 liked to keep their urinary catheter bag in the garbage can. Review of Resident #86's June 2023 Physician Orders revealed an order, dated 10/04/2022, that indicated the resident utilized a suprapubic catheter for a diagnosis of Urinary Retention. On 07/10/2023 at 10:25 AM, the surveyor observed Resident #86's urinary catheter bag on the floor. On 07/11/2023 at 2:56 PM, the surveyor observed Resident #86's urinary catheter bag on the floor. On 07/11/2023 at 3:43 PM, the surveyor observed Resident #86's urinary catheter bag hanging from the side of the trash can with the bag touching the floor. On 07/12/2023 at 10:21 AM, the surveyor observed Resident #86's urinary catheter bag hanging from the side of the trash can with the bag touching the floor. On 07/12/2023 at 2:47 PM, Resident #86's urinary catheter bag was observed on the floor. In an interview with Licensed Practical Nurse (LPN) #2 on 07/12/2023 at 2:52 PM, she revealed the urinary catheter bag should never be on the floor. In an interview with Registered Nurse (RN) #3 on 07/12/2023 at 2:53 PM, she revealed the urinary catheter bag should not be on the floor. In an interview with LPN #5 on 07/13/2023 at 8:59 AM, she revealed urinary catheter bags should be hanging off the side of the bed and the bag should not touch the floor. In an interview with the Director of Nursing (DON) on 07/13/2023 at 9:14 AM, she stated urinary catheter bags should not be on the floor. She went on to add the staff acknowledged this issue should have been taken care of a while ago. In an interview with the Administrator on 07/13/2023 at 10:52 AM, she revealed the urinary catheter bag should not be on the floor.

Based on observations, interviews, and a review of facility policies titled FOOD TEMP LOG POLICY & PR[NAME]EDURE, and Cleaning Dishes / Dish Machine, the facility failed to ensure: 1.) the holding temperature of all foods on the steam table were measure before beginning tray-line service and the holding temperature of fried chicken was at least 135 degrees Fahrenheit and 2.) four pans were not wet and stacked in a manner that prevented air-drying. This was observed on 11/13/19 during the supper meal and had the potential to affected 127 of 127 residents receiving meals from the kitchen. Findings Include: 1.) A facility policy titled: FOOD TEMP LOG POLICY & PR[NAME]EDURE dated 09/18/12 revealed Food temperatures will be taken . when placed on the serving line for all meal service . On 11/13/19 at 4:38 PM during a kitchen observation, the Surveyor noted that no holding temperatures were measured before the beginning of the supper meal plating. At 5:26 PM, 45 meals were plated and had left the kitchen. The Surveyor intervened and asked Employee Identifier (EI) #4, Dietary Manager who was performing cook duties, how did he know the food on steam table was held at the correct temperature before the tray line started. EI #4 replied, staff checked the temperature of all foods immediately after cooking and before transfer to the steam table. EI #4 measured temperatures of all foods on the steam table at that time. The holding temperature of the fried chicken was 125 degrees Fahrenheit. Food service resumed without the fried chicken being removed or re-heated. On 11/13/19 at 5:32 PM, an interview was conducted with EI #5, Dietary Manager. EI #5 was asked, when should the temperature of foods be measured. EI #5 replied, food temperatures should be measured once when the food was finished cooking to ensure it reached appropriate temperature; and then again on the steam table prior to beginning food service line. EI #5 was asked, who was responsible for checking the temperatures. EI #5 replied, the cook. EI #5 was asked, what was the potential harm to residents when food holding temperatures were not measured before beginning tray service line. EI #5 replied, bacteria grew more rapidly when foods were held below 135 degrees Fahrenheit, measuring the temperature ensured foods were held above 135 degrees Fahrenheit. EI #5 added, not measuring holding temperatures could also affect the palatability of foods. On 11/14/19 at 12:37 PM, an interview was conducted with EI #4. EI #4 was asked, who was responsible for measuring temperatures of foods. EI #4 replied, the cook and himself, the Dietary Manager. EI #4 was asked, when were temperatures measured. EI #4 replied, food temperatures were measured after staff cooked the food and before the tray-line started. EI #4 was asked, why were food temperatures measured before starting the tray-line. EI #4 replied, holding temperatures were measured to ensure food was at the correct temperature. EI #4 was asked, when should foods prepared in the kitchen be served from the steam table before the holding temperatures of foods were measured. EI #4 replied, never. EI #4 was asked, what was the potential harm to residents when holding temperatures were not measured before serving. EI #4 replied, bacteria could grow when foods were not held at temperatures greater than 135 degrees Fahrenheit and it could affect the temperature of food when it reached resident. 2.) A facility policy titled: Cleaning Dishes / Dish Machine with a year date of 2013 revealed . Procedure: . 9. Allow the dishes to air dry on the dish racks. On 11/13/19 at 4:15 PM, two small metal pans and two large pans were observed on a shelf stacked in a manner that prevented air-drying. The two pair of pans were separated by the Surveyor and wetness was noted on the inside and outside of the pans. On 11/13/19 at 5:32 PM, EI #5, Dietary Manager was asked to check the metal pans stacked on the shelf. EI #5 was asked, were the pans stacked in a manner that prevented air-drying. EI #5 replied, yes, they were stacked together. EI #5 was asked, were those pans visibly wet. EI #5 replied, yes. EI #5 was asked, what was the potential harm to residents when metal food service pans were wet and stacked in a manner that prevented air-drying. EI #5 replied, bacteria grew more rapidly in moist conditions and increased the risk of food-borne illness. On 11/14/19 at 12:37 PM an interview was conducted with EI #4. EI #4 was asked, how was cookware dried and stored. EI #4 replied, pans should be tilted to the side to allow air-drying. EI #4 was asked, when should pans be moist and stacked together. EI #4 replied, never, that was wet nesting. EI #4 was asked, what was the harm to residents when pans were moist and stacked together. EI #4 replied, bacteria could grow.

Based on observation, interviews, a review of a facility policy Perineal Care, and a facility Laboratory Report, the facility failed to ensure the Certified Nursing Assistant (CNA) did not use the same soiled gloves she had on to place a clean brief on Resident Identifier (RI) #54, a resident with a history of Urinary Tract Infections [MEDICAL CONDITION]. This was observed on 11/13/19 and affected one of two residents observed for incontinent care. Findings Include: A review of a facility policy titled Perineal Care with a revised date of (MONTH) 2010 revealed Purpose The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections . RI #54 was admitted to the facility on [DATE]. A [DIAGNOSES REDACTED]. A review of a facility Laboratory Report revealed PR[NAME]EDURE CULTURE URINE . COLLECTED 10/30/19 . Organisms Identified Escherichia coli 11/01/19 . A review of a Physician order [REDACTED]. On 11/13/19 at 4:14 PM, the surveyor observed incontinent care for RI #54 provided by Employee Identifier (EI) #2, CNA and EI #3, CN[NAME] Both CNAs gathered the needed supplies, washed their hands, and put on gloves. EI #3 placed the barrier on the over the bed table and the supplies on top of the table. Both CNAs prepared RI #54. EI #2 cleaned the front area of RI #54 wiping four times using a clean wipe each time. EI #3 assisted to turn RI #54 to the left side. EI #2 removed her gloves, sanitized her hands, and put on a clean pair of gloves. EI #2 wiped the buttock area three times using a clean wipe each time. EI #2 picked up the clean brief and placed it under RI #54 with the same gloves she had on to clean the buttocks area. On 11/13/19 at 4:23 PM, during an interview, the surveyor asked EI #2 to recap how she performed the incontinent care. EI #2 replied, she cleaned the front, changed gloves after sanitizing her hands, turned the resident, wiped the buttock area, and then placed the clean brief. EI #2 was asked when should you wash or sanitize your hands. EI #2 replied, between cleaning the buttock and placing the clean brief. EI #2 was asked if she washed or sanitized her hands after cleaning the buttock area before placing the clean brief. EI #2 replied, no. EI #2 was asked why she did not wash her hands and put on clean gloves before placing the clean brief. EI #2 replied, she kind of forgot to. EI #2 was asked what was the harm in her using the same gloves to place a clean brief after cleaning a resident's buttock area. EI #2 replied, spreading germs and infection control. On 11/14/19 at 10:27 AM, an interview was conducted with EI #1, the Staff Development and Infection Control Registered Nurse. EI #1 was asked when should staff change gloves during incontinent care. EI #1 replied, they should wash their hands and put on gloves when starting; after cleaning they should wash their hands and put on clean gloves; then before placing anything clean like the brief. EI #1 was asked when should the CNA use the same gloves she had on to clean a resident, then place the clean brief. EI #1 replied, the CNA should not use the same gloves she had on to clean a resident; she should remove her gloves wash her hands, put on clean gloves, and then place the clean brief. EI #1 was asked what would the harm be in the CNA using the same soiled gloves to place a clean brief on a resident. EI #1 replied, possible spread of infection.

Based on observations, interviews and a review of facility policies and a document titled, Dishware and Glassware Safety, Tray Line Temp Log, and FOOD TEMPT LOG POLICY & (and) PR[NAME]EDURE, the facility failed to ensure : 1. residents were not served food on chipped plates and 2. a second temperature was taken for the egg rolls, a temperature was taken of the orient vegetables and the second batch of chicken. This had the potential to affect 125 of 125 residents who received meals from the kitchen. Findings Include: 1) A review of a policy titled, Dishware and Glassware Safety, with a date of 2013 revealed: .Procedure: 1. Chipped or cracked .or china are discarded immediately. On 11/14/2018 at 11:56 a.m., the surveyor observed EI #9, the cook putting food in a chipped plate. The survyor observed 14 chip plates under a table in the dish room with utensils on top of the table. On 11/14/18 at 12:33 p.m., EI #6 brought 8 plates from the dishroom. The surveyor observed 5 chipped plates in the stack. On 11/15/2018 at 9:39, an interview was conducted with EI #6. EI #6 was asked why were plates chipped at the tray line. EI #6 replied, a failure to ensure all chipped items was removed before service. EI #6 was asked why should residents not be served food on chipped plates. EI #6 replied, they could become further chipped, food can become contaminated with foreign material and the resident can become injured. EI #6 was asked what was the facility policy on chipped plates at the tray line. EI #6 replied, they should be removed from service and not used. EI #6 was asked where were the chips located on the plates. EI #6 replied, around the rims of the plates. EI #6 was asked who was responsible for making sure residents were not served food on chipped plates. EI #6 replied, dietary staff. On 11/15/2018 at 9:55 a.m., the surveyor conducted an interview with EI #9. EI #9 was asked why were plates chipped at the tray line. EI #9 replied, she had no idea. EI #9 stated from being handle rough when coming out of the dish machine. EI#9 was asked why should residents not be served food on chipped plates. EI #9 replied, it was a danger, pieces could get in their food and if they handle their own plate they could get scratch. EI #6 was aked where were the chips located on the plate. EI #9 replied, on the back and side of the plate at the rim 2) A review of a facility policy titled, FOOD TEMPT LOG POLICY & PR[NAME]EDURE, with a date of 9/18/12 revealed: Food temperatures will be taken before the meal is placed on the serving line to insure the food is cooked and has reached the appropriate temperature .each time the tempts are taken they are to be documented on the Daily Food Temp Log Sheet .All temperatures will be recorded immediately onto the temp log. A review of a document titled, Tray Line Temp Log, with a date of Nov (YEAR), at the lunch meal revealed no temperature for the alternate egg rolls, and orient vegetable. The second batch of chicken was not recorded on the log. Only the first batch of chicken was recorded on (MONTH) 14, (YEAR) temperature log. The first batch of chicken was recorded at 180 degrees. On 11/14/2018 at 11:13 a.m. during the lunch meal, EI (Employee Identifier) EI #9, the cook was taking temperatures of the foods on the tray line. EI #9 took the temperature of the alternate egg rolls and the temperature was not hot enough. EI #9 stated that she would get back with the surveyor regarding the temperature. EI #9 did not go back and take a second temperature of the Egg Rolls. EI #9 did not take the temperature of the alternate Orient Vegetables/Broccoli and EI #9 did not take the temperature of the second batch of chicken. At 11:46 a.m. ,the second batch of chicken was in two baskets up in the fryer. At 11:49, EI # 8, kitchen manager, dropped more chicken in the fryer. EI #8 took the chicken from the fryer basket and put it in a medium square pan and placed it in the stove oven. EI #8 did not take the temperature before putting the chicken in the stove. At 12:30 the cook took the second batch of chicken which was in a medium square pan from the oven and placed it in the pan on the steam table. EI #9 did not take the temperature of the chicken. On 11/15/2018 at 10:02 a.m., an interview was conducted with EI #9. EI #9 was asked what was the temperature of the orient vegetable/broccoli and egg rolls at the tray line. EI #9 replied, the egg rolls were not up to temperature and she should have taken them off the line. EI #9 further stated the first temperature of the egg rolls was around 110 degree. EI #9 was asked did she take the temperature of the egg rolls the second time. EI #9 replied, no ma'am. EI #9 was asked what was the temperature of the orient vegetable /broccoli. EI #9 stated she did not recall. EI #9 was asked did she take the temperature of the vegetable /broccoli. EI #9 replied, she could not remember. EI #9 was asked who was responsible for taking the temperatures of food at the tray line. EI #9 replied, the cook. EI #9 was asked why was it important that all food temperatures were taken at the tray line. EI #9 replied, so it would be at the correct temperature before serving the food. EI #9 was asked when should food temperatures be taken at the tray line. EI #9 replied, right as they put them on the line or before putting them on the line. EI #9 was asked what was the temperature of the second batch of chicken. EI #9 replied, she could not tell the surveyor. EI #9 stated that the surveyor would need to talk with EI #8, kitchen manager. EI #9 was asked did she take the temperature of the second batch of chicken. EI #9 replied, no ma'am. EI #9 was asked did she take the temperature of the second batch of chicken before putting it in a pan on the tray line. EI #9 replied, no ma'am. EI #9 was asked what was the potential harm to the residents when food temperatures were not taken at the tray line. EI #9 replied, they (residents) could get sick and the temperature not being up was not the proper procedures. On 11/15/2018 at 9:51 a.m., the surveyor conducted an interview with EI #8. EI #8 was asked what was the temperature of the second batch of chicken. EI #8 replied, he did not take the temperature of the chicken. EI #8 was asked what was the potential harm to the residents when food temperatures were not taken at the tray line. EI #8 replied, it was a potential for them to get sick, and bacteria grow on the foods not held at the proper temperature.

Based on observation, interview and a review of a facility policy titled, Waste Disposal, the facility failed to ensure: the dumpster doors were closed on two of three dumpster's on site. This had the potential to affect all resident residing at the facility. Findings Included: A review of a facility policy titled, Waste Disposal, with a date of 2013 revealed, .Procedure: .2. Trash will be deposited into a sealed container outside the premise. On 11/13/18 at 10:52 a.m., the surveyor observed three dumpster's on site. Dumpster number two doors was opened at the front side and back side of the dumpster. Dumpster number three door was opened at the back side of the dumpster. There was food debris on the front side of dumpster number three. On 11/15/18 at 9:50 a.m., the surveyor conducted an interview with (Employee Identifier) EI #6, Dietary Manager. EI #6 was asked what was the facility policy regarding keeping the dumpster doors closed. EI #6 replied, the dumpster should be closed at all times. EI #6 was asked what dumpster doors were opened. EI #6 replied, the center dumpster doors had two doors opened which was number two, and the last dumpster number three had one door opened. EI #6 was asked why were the dumpster doors open. EI #6 replied, the nursing home and dietary staff failure to ensure dumpster doors were closed. EI #6 was asked who was responsible for keeping the doors closed. EI #6 replied, dietary. EI #6 was asked why was it important to keep the dumpster doors closed. EI #6 replied, to help keep down on rodents, pest control and offensive odors.

Based on record review, interview, review of a facility abuse reportable to the State Agency and review of the facility policy titled Abuse, Neglect and Exploitation, Misappropriation of Resident Property, the facility failed to ensure two allegations of abuse were reported to the State Agency within the required two hour reporting time frame. This affected two of three allegations reported to the state agency. Findings Include: A review of a facility policy titled Abuse, Neglect and Exploitation, Misappropriation of Resident Property with an implementation date of 11/28/17 revealed . Policy Explanation and Compliance Guidelines: .The components of the facility abuse prohibition plan . :VII. Response and Reporting of Abuse . The DON, Administrator or designee will contact the State Agency to report any alleged abuse, this will be done immediately but no later than 2 hours after allegation of abuse, . 1) A review of an Online Incident Reporting System Report revealed An incident report has been submitted at 10/15/2018 5:49 PM . resident involved . Date and Time of incident 10/13/18 7:00 PM . Resident Identifier (RI) #123 was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. On 11/14/18 03:20 PM an interview was conducted with Employee Identifier (EI) #1, Director Of Nursing, referring to the incident reported to the State Agency. EI #1 was asked what type of incident was this. EI #1 replied, physical abuse. EI #1 was asked what was the time and the date the alleged abuse occurred. EI #1 replied, 10/13/18 at 7:00 PM. EI #1 was asked when was the incident reported to the State Agency. EI #1 replied, on 10/15/18 at 5:49 PM. EI #1 was asked what was the policy for the time frame for reporting abuse. EI #1 replied, within 2 hours. EI #1 was asked if the policy for reporting an allegation of abuse was followed. EI #1 replied, no. EI #1 was asked what was the potential for harm in not reporting an allegation of abuse in the required time frame. EI #1 replied, there really was no harm, actions were taken it was only not reported timely. 2 ) A review of an Online Incident Reporting System Report revealed, Name(s) of resident (s) involved .Date and Time of incident 10/29/18 at 6:15 PM . An incident report has been submitted .10/30/18 at 9:19:41 AM . RI # 89 was admitted to facility on 2/26/97 with a [DIAGNOSES REDACTED]. RI #180 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 11/14/18 at 3:30 PM, an interview was conducted with EI #1, DON. EI #1 was asked what type of incident was this, referring to the incident reported to the State Agency. EI #1 replied, physical. EI #1 was asked what was the time and date the incident occurred. EI #1 replied, 10/29/18 at 6:15 PM. EI #1 was asked when was the incident reported to the State Agency. EI #1 replied, 10/30/18 at 9:19 AM. EI #1 was asked what was the policy for the time frame for reporting abuse. EI #1 replied, within 2 hours. EI #1 was asked if the incident was abuse. EI #1 replied, yes physical. EI #1 was asked if the policy for reporting an allegation of abuse followed. EI #1 replied, no. EI #1 was asked what was the potential for harm in not reporting an allegation of abuse in the required time frame. EI #1 replied, there was no potential for harm; they took appropriate actions, but just did not follow the policy in reporting.

Based on record review and interviews the facility failed to ensure the Quarterly Minimum Data Set ((MDS) dated [DATE] for Resident Identifier (RI) #123 accurately reflected RI #123 transfer status. This affected one of 32 residents who were reviewed for MDS accuracy. Findings Include: A review of RI #123's Quarterly MDS assessment, with Assessment Review Date (ARD) of 11/08/2018 revealed that his/her transfer status was supervision on self-performance and setup help only on support provided. RI #123 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. On 11/15/2018 at 10:10 AM, an interview was conducted with Employee Identifier (EI) # 11, Certified Nursing Assistant. EI #11 was asked what were her duties. EI #11 stated, activity of daily living, feeding, and general assistance to residents. EI #11 was asked how often she was assigned to care for RI #123. EI #11 stated that it varied but she was familiar with RI #123. EI #11 was asked if RI #123 could transfer to the wheelchair from the bed without assistance. EI #11 replied, no. EI #11 was asked what was the transfer status in regards to assistance for RI #123. EI #11 replied, 2-person assist. EI #11 was asked why was it necessary to be a 2-person assist for RI #123. EI #11 replied, safety. On 11/15/2018 at 10:20 AM an interview was conducted with RI #123. RI #123 was asked how did he/she transfer from the bed to the wheelchair. RI #123 stated, Very slowly and asked for help. RI #123 was asked how many staff members were required to assist with transferring from the bed to the wheelchair. RI #123 replied that it was usually two. RI #123 stated that his/her legs would give out if he/she put any weight on them. On 11/15/2018 at 1:15 PM, an interview was conducted with EI #12, Registered Nurse, MDS Coordinator. EI #12 was asked what was the general purpose of Minimum Data Set (MDS) assessments. EI #12 replied, to give an overview of the residents' care and needs. EI #12 was asked when was the last MDS assessment completed for RI #123. EI #12 replied, 11/8/18. EI #12 was asked what was coded for RI #123's transfer status. EI #12 replied, self performance was coded as supervision. EI # 12 was asked did the MDS accurately reflect the assistance that RI #123 required in getting from the bed to the wheelchair during the observation period for the MDS. EI #12 replied, no sir, she did not believe so. EI #12 was asked what was the possible negative consequence of the MDS being coded inaccurately. EI #12 replied that if the MDS was the only thing to go by then it could lead to an injury.

Based on observation, interview, record review and review of the facility policies titled, Handwashing/Hand Hygiene, Personal Protection Equipment - Gloves and Instillation of Eye Drops, the facility failed to ensure: 1. a Certified Nursing Assistant (CNA) washed her hands between glove changing while assisting with incontinent care for Resident Identifier (RI) #41 and 2. two licensed staff washed their hands after giving by mouth medication to RI #52 and RI #71, before putting on gloves to administer eye drop medication. This affected one of one resident's observed for incontinent care and two of four nurses observed for medication pass. Findings Include: 1) A review of a facility policy titled Hand Hygiene, revised date (MONTH) (YEAR), revealed: Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. The facility policy titled, Personal Protection Equipment - Gloves revised date (MONTH) 2008, revealed, . 8. Wash your hands after removing gloves. RI #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/13/18 at 2:26 PM Employee Identifier (EI) #13 and EI #3, CNAs were observed providing incontinent care for RI#41. Both CNAs washed their hands and put on gloves. EI #13 removed the brief, wiped the front area of RI # 41. EI #13 turned RI #41 to the side and wiped the buttock area. EI #13 removed her gloves and washed her hands and placed a clean brief then turned RI #41 to the back position. EI #3 removed the soiled brief. EI #3 changed her gloves without washing her hands then continued to place and secure the clean brief. On 11/14/18 at 2:00 PM, an interview was conducted with EI #3, CNA. EI #3 was asked what was the policy for washing hands with glove changes, while performing incontinent care for residents. EI #3 replied, they were supposed to wash their hands before they start then put on gloves. EI #3 continued saying to wash hands every time they changed gloves and when the task was completed. EI #3 was asked if she washed her hands between the glove change. EI #3 replied, no. EI #3 was asked what was the potential for harm in not washing hands between glove changes. EI #3 replied, infection control and they could spread germs. On 11/14/18 at 4:41 PM an interview was conducted with EI #2, Registered Nurse, Infection Control. EI #2 was asked what was the policy on washing hands when changing gloves during incontinent care. EI #2 replied, wash hands put on gloves, then wash before and after each glove change. EI #2 was asked when should staff change gloves without washing their hands. EI #2 replied, never. EI #2 was asked what would the harm be in not washing hands between glove changes. EI #2 replied, spread of infection. 2) A Review of a revised date (MONTH) 2010, facility policy titled Instillation of Eye Drops revealed: . The purpose of this procedure is to provide guidelines for instillation of eye drops to treat medical conditions, eye infections and dry eyes . Steps in the Procedure 2. Perform hand hygiene. 3. Put on gloves . RI#52 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of RI #52's (MONTH) (YEAR) Physician orders [REDACTED]. On 11/14/18 at 8:09 AM, EI #5 Licensed Practical Nurse (LPN) was observed giving RI #52's morning medication. EI #5 gave the by mouth medications. EI #5 put on gloves without washing her hands and administered the eye drop medication. EI #5 removed the gloves and washed her hands and put eye drops back into the medication cart. On 11/14/18 at 3:17 PM, an interview was conducted with EI #5. EI #5 was asked, what was the policy on washing hands before instilling eye drops, EI#5 stated, she was suppose to wash her hands or use hand sanitizer before and after putting on gloves, make sure to put the drops on clean surface and make sure you don't touch eye the. EI #5 was asked if she washed her hands before putting on gloves. EI#5 replied, no. EI #5 was asked why did she not wash her hands. EI#5 replied, I forgot. EI#5 was asked what was the potential harm in not washing her hands before putting on gloves and instilling eye drops. EI #5 replied, it could cause infection. RI #71 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of RI #71's (YEAR) (MONTH) Physician order [REDACTED]. On 11/14/18 at 4:24 PM, the surveyor observed EI #4 LPN knock on the door and explained to RI #71 what she would be given. EI #4 washed her hands and instilled eye drop x 1 and removed the gloves. RI #71 was taking the by mouth medication while EI#4 waited for next eye drop. EI #4 did not wash hands before putting on a clean pair of gloves. EI#4 put on gloves, loaded the [MEDICATION NAME] treatment and removed the gloves. EI #4 did not wash her hands. EI#4 put on clean gloves and instilled the second eye drop in the other eye and then started the breathing treatment. EI#4 removed her gloves and did not wash her hands. On 11/14/18 at 4:45 PM, an interview was conducted with EI #4. EI #4 was asked what was the policy on washing hands after removing gloves. EI#4 replied to sing the song happy birthday for 30 seconds. EI #4 was asked if she washed her hands after she removed her gloves. EI #4 replied,I don't recall. EI #4 was asked, why did she not wash her hands. EI# 4 replied, I forgot. EI #4 was asked what was the potential harm in not washing her hands, EI#4 replied, It can cause contamination and transfer infections. On 11/15/18 09:44 AM, an interview was conducted with EI#2 Infection Control Nurse. EI#2 was asked what was the policy on administering eye drops. EI #2 replied, do hand hygiene, put on gloves, administer the eye drops and wash hands after completing. EI#2 was asked when should a nurse give by mouth medication, then without washing their hands put on gloves and administer the eye drops. EI#2 replied, Never. EI # 2 was asked, what was the potential for harm with putting on gloves without washing hands and administering the eye drops. EI#2 replied, Transmission of infections.

Based on observations, interviews and a review of the Food Code U.S. Public Health Service and FDA (Food and Drug Administration) 2013, the facility failed to assure: 1. the facility followed correct manual dishwashing procedures concerning the three compartment sink, correct water temperature and chemical concentration, 2. effective cleaning/sanitizing of utensils and equipment to prevent the potential growth of food borne organisms, a. dinnerware and sectional plates were cleaned to sight/touch (machine dishwashing), b. a tea urn/spigot was cleaned every 24 hours. The spigot was observed with a brown solid build-up and 3. hot foods were maintained at 135 degrees Fahrenheit (F) or above when held on the tray line. The above practices posed the potential for food contamination and compromised food safety. This had the potential to affect 124 residents who received meal trays from dining services. Findings Include: 1. A review of the manufacturer QUAT SANITIZER TECHNICAL DATA SHEET revealed .General Information: >Quat use solutions must be a minimum of 75 Degrees F. as required by the EPA (Environmental Protection Agency) registration. There is no upper temperature limit for Quat use solutions. If the use solution is not at a minimum of 75 Degrees F. we can not make sanitizing claims .> Quat test strips should be read at room temperature (75 Degrees F), higher temperatures will result in inaccurate readings. (A limit of the test strip, not the product). On 02/06/2018 at 3:45 PM, manual dishwashing (three compartment sink - pots/pan) was observed. The method for sanitizing was the use of the chemical, Quaternary Ammonia. On 02/07/2018 at 9:00 AM, manual dishwashing was observed. Signage had water fill designation on the sink used to wash vs (versus) the sink to sanitize. The Certified Dietary Manager, Employee Identifier (EI) #4 measured the water temperature in the third sink (sanitizing). The temperature that registered on the thermometer was 66 degrees F. A record review of the monitoring log documentation for the 3 COMPARTMENT SINK revealed facility staff was not monitoring the temperature of the water which held the chemical. Staff monitored and documented the temperature of the middle sink used for rinsing. Seventeen of seventeen opportunities on the log revealed 120 degree F for the rinse. No data was recorded for the water temperature mixed with the chemical. 2. (a) A record review of the 2013 Food Code by the United States Public Health (USPHS) and the Food and Drug Administration (FDA) included the following: .4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch . 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried . On 02/07/2018 at 09:58 AM, an observation was made of clean/sanitized sectional plates awaiting transport to the trayline. Four of four sectional plates were stacked (not inverted). All four contained food debris or was badly stained. An interview at this time with the CDM, EI #4 revealed the first line aide failed to monitor dishes for adequate cleaning. EI #4 was asked what was the potential risk for failure to monitor. EI #4 responded, there was a potential for food borne illness or bacterial growth. 2. (b) A record review of the 2013 Food Code by the USPHS and the FDA included the following: .Frequency 4-602.11 Equipment Food-Contact Surfaces and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be cleaned: (E) .surfaces of UTENSILS and EQUIPMENT contacting food that is not TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cleaned: .(2) At least every 24 hours for iced tea dispensers . An observation on 02/06/2018 at 9:20 AM, was made of a five gallon tea urn container (one of three). A request was made for the CDM, EI #4 to disassemble the faucet/spigot. EI #4 broke the faucet down from the dispenser into one part. The surveyor requested the tea urn be broken down further. EI #4 complied and a brown area encircled the top internal area (faucet seat cup). Upon seeing the internal part, EI #4 said, it's (it is) dirty. During an interview on 02/06/2018, after the above observations, EI #4 was asked what was the risk factor for failure to effectively clean daily. EI #4 stated there was potential for cross-contamination. 3. A record review of the 2013 Food Code by the USPHS and the FDA included the following: 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) .TIME/TEMPERATURE CONTROL FOR SAFETY FOOD SHALL BE MAINTAINED. (1) At 57 degrees C (135 degrees F) or above . On 2/07/2018 at 11:35 AM, hot holding temperatures were monitored on the tray line steamtable. There were approximately 15 hot items on the steamtable. The documented plating time was scheduled to begin at 11:25 AM. A request was made for the cook to measure the holding temperature of two entrees which had been held since 11:12 AM. Potentially hazardous food, pureed chicken, was measured at 120 degrees F and the beef patties were measured at 130 degrees F. EI #4 said the hot holding temperature should be at 135 degrees F.

Based on observation, interviews and the facility's document titled, Resident Rights the facility failed to ensure residents who ate in the dining room did not have plate covers/domes on the dining table and that domes were not filled with debris (paper trash). This was observed on two of three days during the survey. This deficient practice affected one resident in the Main dining room and nine of nine residents in the South Wing dining room. Finding Include: A review of a facility document titled, Resident Rights with an implementation date of 11/28/16, revealed the following: .Resident Rights 1.The resident has the right to a dignified existence, self-determination .5. Respect and dignity. The resident has a right to be treated with respect and dignity, .9. Safe environment. The resident has a right to .clean, comfortable and Homelike environment . On 02/07/18 at 11:55 a.m., the surveyor observed residents who required feeding assistance. The surveyor also observed plate domes (plate covers) removed and stacked on tables. The domes were used to hold debris. 02/08/18 at 08:15 a.m., the surveyor observed dining in the dining room on the South Wing, nine residents were in the dining room. Plate covers were on tables used to hold sugar packet paper, straw cover paper, jelly and butter wrappers and pull back tabs from juices. 02/08/18 01:25 p.m., the surveyor observed dining in the Main dining room with one resident eating at table. The plate cover on the table was used for debris. On 02/08/18 at 1:30 p.m. an interview was conducted with EI (Employee Identifier) #3, a CNA (Certified Nursing Assistant). EI #3 was asked if the staff normally left the lid top on the table turned up with debris in them. EI #3 said the lid was left on the table turned up. EI #3 was asked what was put in the lid top. EI #3 said whatever they took off of the tray. EI #3 was asked if she would want to eat a meal at the table with trash in the lip cover on the table. EI #3 said there was no where else to put the paper and there was no space/extra tables. EI #3 was asked if she considered that to be a good dining experience for residents with the plate lid on the table with debris in it. EI #3 said no residents had complained. EI #3 was asked if she had asked residents if they wanted the plate cover (lid) to be on top of the table. EI #3 said, no. EI #3 further stated the lids had been on the table turned up with debris in them since last year when she started to work on day shift. On 02/08/18 at 4:10 p.m., an interview was conducted with EI #1, ADON (Assistant Director of Nurses). EI #1 was asked should plate cover/domes remain on the table during dining with debris in them while residents were eating. EI #1 said, no. EI #1 was asked what should the staff do with the plate cover lids during dining. EI #1 said remove them from the table. EI #1 was asked would that be considered a dignity issues for residents. EI #1 said, Possible

Based on interview and record review, the facility failed to ensure RI (Resident Identifier) #86's Minimum Data Set (MDS) assessments dated 11/2/17 and 11/16/17, were accurately coded for [MEDICAL TREATMENT]. This affected one of four residents whose MDS assessments were reviewed for [MEDICAL TREATMENT]. Findings Include: RI #86 was originally admitted to the facility on [DATE] and re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #86's physician orders [REDACTED].[MEDICAL TREATMENT] ON T-TH-SAT (Tuesday-Thursday-Saturday) @ (at) 12N (Noon) AT DAVITA OZARK . A review of RI #86's 14 day MDS with an ARD (Assessment Reference Date) of 11/02/2017, revealed [MEDICAL TREATMENT] was unchecked. A review of RI #86's Quarterly MDS with an ARD of 11/16/17, revealed [MEDICAL TREATMENT] was unchecked. An interview was conducted on 2/8/18 at 5:15 p.m. with EI (Employee Identifier) #2 RN (Registered Nurse)/MDS Coordinator. EI #2 was asked if RI #86 had a physician order [REDACTED].#2 said, Yes. EI #2 was asked if RI #86's 14 day and Quarterly MDS's were coded for receiving [MEDICAL TREATMENT]. EI #2 said, No. EI #2 was asked if RI #86's 14 day and Quarterly MDS's should have been coded for receiving [MEDICAL TREATMENT]. EI #2 said, Yes Ma'am . EI #2 was asked why was it important to code the MDS accurately. EI #2 said it helped to establish a plan of care for the resident.

Based on a review of a facility policy titled, Departmental (Respiratory Therapy)- Prevention of Infection, observations, record reviews and interviews, the facility failed to ensure RI (Resident Identifier) #113's nebulizer mask and tube were stored in a bag and dated. This was observed on two days of the survey and affected one of one sampled resident requiring nebulizer treatment. Findings Include: A review of a facility policy titled, Departmental (Respiratory Therapy)-Prevention of Infection with a revised date of October 2010, revealed the following: .Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol: . 3. After completion of therapy: . 7. Store the circuit in plastic bag, marked with date . RI #113 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #113's physician orders [REDACTED]. On 02/06/2018 at 4:16 p.m., an observation was made of RI #113's nebulizer mask and tubing lying on top of RI #113's bedside table with no barrier and not stored in a bag and labeled. On 02/07/2018 at 11:02 a.m., an observation was made of RI #113's nebulizer tubing attached to the nebulizer and hanging behind RI #113's dresser, behind the television touching the floor. At 11:15 a.m, the surveyor had EI (Employee Identifier) #8, LPN (Licensed Practical Nurse) to observe the location of RI #113's nebulizer tube. On 02/07/2018 at 11:39 a.m., an interview was conducted with EI #8, LPN. EI #8 was asked how were nebulizer masks and tubes to be stored when not in use. EI #8 explained the mask and tube were to be taken apart from the nebulizer and placed in a bag. EI #8 was asked when she observed RI #113's nebulizer tube, where was it located. EI #8 said it was behind RI #113's television which was on top of his/her dresser. EI #8 was asked should it have been behind the dresser. EI #8 said no. EI #8 was asked why should it have been stored in a bag. EI #113 said to prevent the resident from getting a bacteria. On 02/08/2018 at 3:45 p.m., an interview was conducted with the Infection Prevention Nurse, EI #9, RN (Registered Nurse). EI #9 was asked how should nebulizer masks and tubes be stored. EI #9 explained both should be stored in a sealed bag and dated. EI #9 was asked why should both be stored in that manner. EI #9 explained to keep both from getting dirty and to keep the resident from getting an infection. EI #9 was informed of the surveyors observations of RI #113's nebulizer mask and tube not being stored in a bag and dated. EI #9 was asked what was the potential harm for a resident's nebulizer mask and tube to be left out and not stored in a sealed bag and labeled. EI #9 said infection.

Based on observation and interview, the facility failed to ensure waste was properly contained in dumpsters and maintained in a manner to prevent the harborage and feedings of pests. This deficient practice had the potential to affect all 131 residents who reside in the facility. Findings Include: The 2013 Food Code by the United States Public Health Service (USPHS) and the Food and Drug Administration (FDA) included the following: . 5-501.15 Outside Receptacles. (A) Receptacles and waste handling units for REFUSE . used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers. (B) Receptacles and waste handling units for REFUSE . shall be installed so that accumulation of debris and insect and rodent attraction and harborage are minimized and effective cleaning is facilitated . On 2/07/2018 at 9:35 AM, three dumpsters were observed. Observed beneath the sliding doors were dark streaks of a liquid build-up. Inside, the walls were covered with food debris adhering to the surface. At the above time, the Certified Dietary Manager (CDM) Employee Identifier (EI) #4, was asked what was the potential for risk because of lack of cleaning. EI #4 said there was a potential for attracting pests.

Based on record reviews and interviews the facility failed to ensure: 1) a food item was sealed after use, 2) items in the freezer and dry storage were labeled with the name of the item on the bag; and 3) food temps on the tray line were recorded. This had the potential to affect 127 of 130 residents served meals from the kitchen. Findings Include: 1) Review of a facility document titled, Preventing Cross-Contamination When Storing Food with no revised date revealed: .Wrap or cover food before storing it. On 12/06/2016 at 10:41 a.m., the surveyor observed a 42 ounce box of Quick Oaks opened and not sealed at the top. On 12/08/2016 at 9:54 a.m., the surveyor conducted an interview with (Employee Identifier) EI # 2, the dietary manager. EI #2 was asked what items on the shelf was not sealed properly. EI #2 relied, Oatmeal. EI #2 was asked why was it not sealed properly. EI #2 replied, he could not answer that. EI #2 was asked who was responsible for sealing items after use. EI #2 replied, each individual that opened the item should be the one that sealed it. EI #2 was asked why should items be sealed after use. EI #2 replied, items should be sealed to help prevent cross contamination. EI #2 was asked what was the facility's policy on sealing food items after use. EI #2 replied, all items should be stored in proper storage bags or containers and labeled and dated. EI #2 was asked what was the potential harm when food items were not sealed. EI #2 replied, cross contamination. 2) A review of a document titled FOOD CODE Public Health Service . 2013 U. S. DEPARTMENT OF HEALTH AND HUMAN SERVICES without a date revealed: . Labeling . (B) Label information shall include: (1) The Common name of the FOOD . On 12/06/2016 at 10:10 a.m., the surveyor observed a large container of food with no name on the container in dry storage. At 10:12 a.m., the surveyor observed Ham in the freezer in a zip lock bag labeled with date only. On 12/08/2016 at 10:00 a.m., the surveyor conducted an interview with EI #2. EI #2 was asked what item was in dry storage with no name on it. EI #2 replied, brown sugar. EI #2 was asked what item was in the freezer with no name on the bag. EI #2 replied, Ham. EI #2 was asked who was responsible for labeling food items. EI #2 replied, whichever cook or aide was using it would be responsible for it. EI #2 was asked why should food items be labeled. EI #2 replied, to help identify the item so it would not be grabbed by mistake. EI #2 was asked did the brown sugar or ham have a name on the bag identifying what it was. EI #2 replied, no. EI #2 was asked what was the potential harm when food items were not labeled correctly. EI #2 replied, staff grabbing and preparing the wrong item. 3) A review of a facility document titled, Food Temperatures with no date revealed: Policy . 4. The temperature will be taken and recorded for all items at all meals. A review of a facility document titled,Tray Line Temp Log for the month of December revealed the log had no dates recorded in the Wednesday slots for December 7th. On 12/07/2016 at 11:00 a.m, the surveyor observed the cook calling out the food temperatures but she did not write the temperatures of the food items down. On 12/08/2016 at 10:06 a.m., an interview was conducted with EI #2. EI #2 was asked what was the facility policy on recording food items on the tray line. EI #2 replied, take the temperature and record in the temperature tray line book. EI #2 was asked what was the potential harm when food temperatures were not written down. EI #2 replied, if there was an issue and anyone got sick they would have proof the food was in the proper temperature zone. On 12/08/2016 at 10:23 a.m., the surveyor conducted an interview with EI #3, the cook. EI #3 was asked did she write the tray line temperatures down on 12/07/2016. EI #3 replied, no ma'am. EI #3 was asked why not. EI #3 replied, she just got caught up. EI #3 was asked what was the facility policy on recording food items on the tray line. EI #3 replied, take temperatures of the food as soon as they are on the line and periodically. EI #3 was asked should she have written the food temperature down on 12/07/2016. EI #3 replied, yes, ma'am. EI #3 was asked what was the potential harm when food temperatures were not written down. EI #3 replied, a safety hazard.

Based on record review, observation and interview the facility failed to ensure a Certified Nursing Assistant (CNA) cleaned Resident Identifier (RI) #15's, a resident with a history of Urinary Tract Infection [MEDICAL CONDITION], perineal area during incontinent care on 12/07/2016. This affected one of one residents observed for incontinent care. Findings Include: A facility policy titled: Perineal Care with a revised date of October 2010, revealed: . The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Steps in the Procedure . 9. For a . resident: . b. Wash perineal area, wiping from front to back. (1) Separate . and wash area downward from front to back. RI #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #15's Quarterly Minimum Data Set (MDS) with an assessment Reference Date (ARD) of 10/19/2016 revealed RI #15 had a Brief Interview for Mental Status (BIMS) of 8, which indicated the resident was moderately impaired for daily decision making. The MDS further revealed that RI #15 was always incontinent of bowel and bladder. A review of a Microbiology Report with a result date of 12/05/2016 at 7:51 a.m., revealed RI #15's urine was found to have an Escherichia coli colony count greater than 100,000 Colony Forming Units/milliters. A review of RI #15's December 2016 Physician Orders revealed: Order Date . 12/06/2016 . [MEDICATION NAME] 100 MG (Milligrams) Capsule 1 CAPSULE PO (By Mouth) BID (Twice Daily) X (Times) WEEK . During an observation of incontinent care on 12/07/2016 at 8:56 a.m., Employee Identifier (EI) #4 CNA rolled RI #15 to the right. The surveyor asked EI #4 what was in the bedpan and EI #4 said Booboo. Stool remained on RI #15's rectal and buttocks area. EI #4 wiped from the rectum up toward the back and down the center of RI #15's buttock then rolled RI #15 supine (back). EI #4 failed to clean RI #15's perineal area. After completing RI #15's incontinent care, EI #4 was asked was all the stool wiped off of RI #15's buttock area. EI #4 replied I thought I did. EI #4 was asked what was the potential harm in not cleaning all the feces off of the buttocks and rectal area. EI #4 said the resident could get a rash and the stool could go in the perineal area then the resident would get a UTI. EI #4 was asked did she clean RI #15's perineal area correctly. EI #4 said apparently not. EI #4 was asked why should the perineal area be cleaned correctly. EI #4 said to make sure there is no BM (Bowel Movement) left on the resident because it can cause an infection. On 12/08/2016 at 3:15 p.m., an interview was conducted with EI #1, the RN (Registered Nurse) Infection Control Nurse. EI #1 was asked what was the facility's policy on incontinent care. EI #1 said to clean the perineal area. EI #1 was asked why should stool not be left on the skin or rectal area. EI #1 said it could cause infection, skin breakdown and odor.

Based on observation, record review and interview, the facility failed to ensure a CNA (Certified Nursing Assistant), during RI (Resident Identifier) #15's incontinent care on 12/07/2016, washed her hands after removing soiled gloves and before touching the clean linen and clean brief with the soiled gloves. This affected one of one resident observed for incontinent care. Findings Include: A review of a facility policy titled, Handwashing/Hand Hygiene with a revised date of June 2010 revealed: . This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation .7. Hand hygiene is always the final step after removing and disposing of personal protective equipment.8. The use of gloves does not replace handwashing/hand hygiene. RI #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #15's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/19/2016 revealed RI #15 had a Brief Interview for Mental Status (BIMS) of 8, which indicated the resident was moderately impaired for daily decision making. The MDS further revealed that RI #15 was always incontinent of bowel and bladder. On 12/07/2016 at 8:56 a.m., during an observation of incontinent care, (EI) Employee Identifier #4 was observed cleaning stool from RI #15. EI #4 then changed her gloves and did not wash her hands before applying clean gloves. EI #4 touched the clean brief and clean linen with soiled gloves. After completing RI #15's incontinent care EI #4 was asked did she wash her hands after removing the soiled gloves. EI #4 said no. EI #4 was asked if she used hand sanitizer. EI #4 said no. EI #4 was asked did she put clean gloves on and did not wash her hands, then touch clean linen and a clean brief. EI #4 said yes. On 12/08/2016 at 3:15 p.m., EI #1 the RN (Registered Nurse) Infection Control Nurse was asked when should hands be washed during incontinent care. EI #1 said after changing gloves. EI #1 was asked what the facility's policy was on handwashing and gloving. EI #1 said to wash hands after taking gloves off. EI #1 was asked why should clean linen/brief not be touched with dirty gloves. EI #1 said to not contaminate the clean.

Based on observations and interviews, the facility failed to ensure five nursing and two housekeeping staff members knocked on resident doors, or otherwise obtained permission prior to entering each resident's room on 10/19/15 and 10/20/15. This affected Resident Identifier (RI) #s: 1, 3, 13, 16 and 17 on two of five residential units. Findings included: A facility policy titled, Dignity (undated) documented: . Standard: . Respect resident's private space and property (e.g. (for example) . knocking on doors and requesting permission to enter .). 1) During the initial tour on 10/19/15 at 3:12 PM, a housekeeper, Employee Identifier (EI) #4 entered the room of RI #13 without first knocking. On 10/22/15 at 8:35 AM, during a phone interview, the housekeeper confirmed she had not first knocked prior to entering RI #13's room on 10/19/15. EI #4 explained the resident's door was open and she had gone into the room to collect the trash. When asked what she should do before entering a room, EI #4 stated if the door was closed, she would knock; if not, she would go on inside. When asked to explain the facility's policy prior to entering a resident's room, EI #4 stated they were supposed to knock on the door, identify themselves, and ask the resident if they would like their room cleaned. The surveyor asked what potential harm or issue could result in not first receiving permission before entering a room. EI #4 explained they could upset the resident. EI #4 stated this was where the residents lived (their home); they were supposed to show them respect. 2) On 10/20/15 at 8:32 AM, a housekeeper (EI #5) walked into the room of RI #16 without first knocking. As she entered the room, EI #5 merely announced, Housekeeping. EI #5 did not first seek the resident's permission to enter. On 10/21/15 at 3:19 PM during an interview, EI #5 affirmed she had not asked for RI #16's permission prior to entry on 10/20/15; she had merely identified herself as housekeeping as she walked into the room. EI #5 explained the facility policy was to knock on the resident's door, ask for permission to come in and let them know who you are. EI #5 stated the potential harm, or resulting issue of not getting the resident's permission was it invaded their privacy. 3) During a medication administration on 10/20/15 at 9:14 AM, EI #3, a Licensed Practical Nurse (LPN) removed a medicated patch from her medication cart, and without knocking or otherwise seeking permission, walked into the room of RI #3. On 10/21/15 at 2:28 PM, during an interview, the surveyor asked the LPN (EI #3) what she should have done prior to entering the room of RI #3. The LPN stated she should have knocked; that she just walked into the resident's room and told RI #3 she had his/her medication. When asked what the facility policy stated in regard to entering residents' rooms, EI #3 explained the staff was to first knock and address oneself. EI #3 was asked what potential harm it could cause when walking into a resident's room without first gaining permission. EI #3 replied it could frighten the resident, causing then to bump their hand making a skin tear. 4) On 10/20/15 at 12:50 PM, the surveyor observed another LPN (EI #9) walk into the room of RI #1 without first knocking. RI #1 was in the process of eating lunch. On 10/21/15 at 11:41 AM during an interview, the surveyor asked EI #9 what should be done prior to entering a resident's room. EI #9 stated she should knock. When asked if she had knocked on RI #1's door the previous day (10/20/15), EI #9 responded no, explaining the resident was looking back so she just went on into the room. EI #9 stated the facility policy was to knock and make oneself known prior to entering each resident's room. EI #9 was asked what was the potential harm or issue that could arise if permission was not given to enter a resident's room. EI #9 stated the resident could be startled, or feel violated if staff did not knock before entering. 5) On 10/20/15 at 12:53 PM, a Certified Nursing Assistant, (CNA), EI #6, entered the room of RI #16 to remove the (finished) lunch tray. EI #6 did not knock or verbally request permission prior to entering the resident's room. On 10/20/15 at 12:57 PM, the CNA (EI #6) then entered RI #3's room to collect the remains of the resident's lunch tray, without first knocking. On 10/21/15 at 3:10 PM, the surveyor asked EI #6 what she should have done prior to entering the residents' rooms. EI #6 responded she should have knocked on the door. When asked if she had knocked, EI #6 could not recall. EI #6 was asked what the facility policy was on gaining entrance to a resident's room. EI #6 explained the facility's policy was to knock on the resident's door and wait to see whether the resident said, Come in. EI #6 was asked what issue could arise if permission was not first given by a resident to enter their room. EI #6 replied this was a dignity issue. 6) On 10/20/15 at 1:09 PM, two CNAs (EI #7 and EI #8) entered the room of RI #17 without first knocking or otherwise gaining permission. The CNAs asked RI #17 only if he/she was finished with the meal. On 10/22/15 at 8:45 AM, during a phone interview, the surveyor asked EI #8 (CNA) what she should do before entering a resident's room. EI #8 stated she should knock on the door. When asked why she did not knock on RI #17's door on 10/20/15, EI #8 explained because the resident was looking at her. EI #8 was asked to explain the facility's policy before entering a resident's room. EI #8 explained the policy was to knock and ask permission to enter. EI #8 was asked what was there a potential for, if permission was not gained before entering a resident room. EI #8 replied it was not abiding by the resident's privacy and rights. On 10/22/15 at 11:17 AM, during an interview, the surveyor asked the second CNA (EI #7) what she should have done before entering RI #17's room. EI #7 replied, knock on the door. When asked if she had knocked, EI #7 stated, I should have but she did not know why she had not. EI #7 was asked what was the facility policy on entering a resident room. EI #7 replied the facility policy was to knock on the resident's door, present yourself, and tell what you were in the room for. EI #7 was asked what was there a potential for, if permission was not gained before entering a resident's room. EI #7 replied the resident might not want them in the room; they might be getting dressed. On 10/22/15 at 11:23 AM, the Director of Nursing (EI #1) was asked what the facility's policy was, prior to entering a resident's room. EI #1 responded, Knocking. EI #1 was asked what was there a potential for when not gaining permission to enter a resident room. EI #1 stated privacy would be compromised if permission was not first obtained.

Based on observations, interviews and record review, the facility failed to ensure the medication nurses: 1) consistently signed the electronic and/or paper Medication Administration Record (MARs) after administering medications; 2) immediately signed the narcotic book after preparing narcotic medications; 3) maintained confidentiality of a resident's medication list; 4) correctly administered eye drops to the left and right conjunctiva of a resident; and 5) followed physician's orders [REDACTED]. This affected Resident Identifier (RI) #s 3 and #5, two of five residents and three of four nurses observed during the medication administration observation on 10/20/15. Findings Include: A. A facility policy titled Oral Medication Administration with an effective date of June 14, 2007, documented: . PROCESS: . j) Crush medication, if indicated . q) Administer medication . t) Return to medication cart, cleanse hands, and document medication administration with your initials in the appropriate space on the Medication Administration Record (MAR) . A review of Potter and Perry, Fundamentals of Nursing, Eight Edition, copyright date of 2013, p. 586 documented: . Right Documentation . After administering a medication, indicate which medication was given on the patient's MAR . 1a) On 10/20/15 at 9:03 AM, during the medication administration observation, Employee Identifier (EI) #3, a Licensed Practical Nurse (LPN), was observed pulling a medicine cup out of the top of the medication cart after opening it. EI #3 stated she had already prepared the medicine for RI #3 while the surveyor was in the resident's room. EI #3 identified the medicines in the medicine cup and showed the surveyor the e-MAR where she had signed the e-MAR as having already administered the medication for RI #3. On 10/20/15 at 9:32 AM, during the medication administration observation, EI #3 administered the medication to RI #3. EI #3 gel sanitized her hands and pushed the medication cart to the next room, without first signing off the paper MAR for RI #3. RI #18 was seated in the doorway of his/her room and EI #3 prepared RI #18's medication at the resident's request. On 10/21/15 at 2:50 PM, the surveyor asked EI #3 why she signed off the e-MAR before administering the medication. EI #3 stated, I am told I can sign the paper MAR when I am done (with the complete med pass). EI #3 further stated, We can sign the e-MAR when pulling (the medication) up and the paper MAR anytime. EI #3 was asked when did she sign off the paper MAR. EI #3 replied at the end of her med pass. EI #3 was asked when should she have signed off the e-MAR and the paper MAR. EI #3 replied the e-MAR, right at the time she was dispensing the med; and the paper MAR, when she had administered the med. EI #3 was asked what issue could arise by signing off the e-MAR before administering the medication. EI #3 replied, with the e-MAR, they could refuse and she would have already signed the MAR off indicating they took it. EI #3 was asked what issue could arise by not signing off the paper MAR after administering the medication. EI #3 replied it would seem as if she had not given the medication or the resident could say that they did not get it. EI #3 said another nurse could check and say she had not given it and could give it to the resident again possibly causing an overdose. On 10/22/15 at 11:23 AM, the surveyor conducted an interview with EI #1, the Director of Nursing (DON). EI #1 was asked when should the e-MAR be signed off. EI #1 replied after the medication was given. EI #1 was asked if it was acceptable practice to sign off the e-MAR before giving the medication. EI #1 replied they can click it was prepared, and then come back and click it was administered. EI #1 was asked was it also acceptable practice to sign off the paper MARs at the end of the med pass. EI #1 stated, No. EI #1 was asked to explain the facility policy for signing off the electronic and paper MARs. EI #1 explained each resident's MAR was to be signed off after administering the medicine, whether electronic or paper. EI #1 was asked what the potential harm might be when a nurse signed off the e-MAR before giving the medications and when a nurse failed to sign off the paper MAR after administering medication. EI #1 replied, for the e-MAR they might get distracted and forget to administer the med; for the signing of the paper MAR, others might think the medication had not been given, and the record would not be accurate. 1b) RI #5 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 08/19/15 assessed RI #5 under Section K - Swallowing/Nutritional Status, as having a feeding tube. RI #5's physician's orders [REDACTED]. . [MEDICATION NAME] 150 MG (milligrams)/15 ML (milliliters) GIVE 2 TEASPOONS (100MG) BY tube TWICE DAILY . [MEDICATION NAME] 5 MG TABL (tablet) GIVE 1 TABLET BY tube OR PER TUBE TWICE DAILY @ (at) 5AM AND 5PM . On 10/20/15 at 4:09 PM, the surveyor observed a medication nurse, EI #15, pour up 10 cc's (cubic centimeters) of [MEDICATION NAME] and initial in the appropriate space on the MAR before administering the medication. EI #15 opened the prepackaged [MEDICATION NAME], placed the tablet in a medication cup and initialed in the appropriate space on the MAR before administering the medication. On 10/20/15 at 6:33 PM, the surveyor conducted an interview with EI #15. The surveyor asked EI #15 when should the MAR be signed when administering medications. EI #15 said she signs the MAR as she prepares the medications so she would know she did not miss a medication. EI #15 said she signed RI #5's MAR before she administered RI #5's medications. On 10/22/15 at 12:21 PM, the surveyor asked EI #2, an RN (Registered Nurse) Unit manager, what was the facility's policy concerning administering medications. EI #2 replied, To prepare the medication, take to room, come back and sign the MAR if the resident took all of their medication. B. A facility policy titled Controlled Medication Administration, dated 08/2001 documented: POLICY: Medications included in the Drug Enforcement Administration (DEA) classifications as controlled substances are subject to special handling, storage, disposal, and record keeping in the Facility . PROCEDURE: . when a controlled medication is administered, the licensed nurse administering the medication immediately enters . the . information on the Controlled Medication Accountability Record: . 2) On 10/20/15 at 9:03 AM, during the medication administration, EI #3 pulled a medicine cup out of the top of the med cart after unlocking it. EI #3 identified one of the medications in the medicine cup as [MEDICATION NAME] 10 mg, to be given to RI #3. On 10/20/15 at 9:14 AM, during the above observation, EI #3 pulled a [MEDICATION NAME] out the narcotic lock box, picked up the medicine cup, and walked into RI #3's room. After administering the medications, and without signing the MARs, EI #3 pulled the med cart to the next (RI #18's) room. RI #18 was sitting in the doorway of the room and asked for his/her medications. EI #3 prepared RI #18's medication, opened the locked narcotic box, and took out the controlled medications: [MEDICATION NAME] 1 mg, [MEDICATION NAME] 150 mg, [MEDICATION NAME] 10 mg, and a [MEDICATION NAME] Patch. EI #3 did not immediately sign off the narcotics on the Controlled Substance Inventory Record sheet. On 10/20/15 at 9:35 AM, EI #3 administered the oral medications to EI #18, applied the [MEDICATION NAME] to the resident's left upper chest (after removing the old patch), and placed the old patch in the sharps container. EI #3 gel sanitized her hands and proceeded to the next resident's room. On 10/20/15 at 9:39 AM, the surveyor conducted a brief interview with EI #3. EI #3 was asked if she had a narcotic sign-out book. EI #3 replied yes. EI #3 was asked after she pulled the narcotics out of the lock box did she sign off RI #18's narcotics. EI #3 stated, Not yet. I am about to. EI #3 was asked when did she sign off for RI #3's narcotics. EI #3 replied right before she walked into RI #3's room. The surveyor asked EI #3 to show where she had signed off the narcotics for RI #3. EI #3 proceeded to show the surveyor RI #3's Controlled Substance Inventory Record sheet. Neither the [MEDICATION NAME] nor the [MEDICATION NAME] had been signed off as given. On 10/21/15 at 2:13 PM, the surveyor conducted another interview with EI #3. EI #3 was asked why she did not sign the narcotics off after pulling them from the narcotic box. EI #3 replied she had been told she could sign off after she gave the rededication. EI #3 was asked when should (the Controlled Substance Inventory Record sheet) be signed off. EI #3 stated, I would say as soon as you pop it out. EI #3 was asked if it was an acceptable practice to not sign out a narcotic after pulling it from the narcotic box. EI #3 explained she felt it was acceptable if she gave the narcotic medication and signed it directly afterwards. EI #3 was asked what was the facility's policy on narcotic administration. EI #3 replied her understanding was she could sign it (narcotic) after taking it out, or give it, then sign it (narcotic) out before going on to another resident. EI #3 was asked what issue or potential harm could arise if narcotics were not signed out after removing them immediately from the narcotic box. EI #3 explained if she had an emergency and had to leave, another nurse could say she (EI #3) had not given the narcotic; that nurse could then give the medication again. On 10/22/15 at 11:23 AM, the surveyor asked EI #1, the Director of Nursing (DON), when should a narcotic be signed off on the Controlled Substance Inventory Record sheet after pulling it from the locked box. EI #1 stated, Immediately. When asked, EI #1 stated the facility policy on narcotic administration was to check the physician's orders [REDACTED]. EI #1 was asked what potential harm could result if a licensed nurse did not sign out for a narcotic on the Controlled Substance Inventory Record sheet after pulling the narcotic from the locked box. EI #1 stated, Possible diversion. C. A review of Potter and Perry, Fundamentals of Nursing, Eight Edition, copyright date of 2013, p. 349, documented: . Confidentiality Nurses are legally and ethically obligated to keep information about patients confidential . Only staff directly involved in a patient's care have legitimate access to the records . 3) A review of RI #18's medical record revealed physician's orders [REDACTED]. . [MEDICATION NAME] 1 MG (MILLIGRAM) TABLET . GIVE 1 TABLET BY MOUTH 4 TIMES A DAY . [MEDICATION NAME] 10/325 MG GIVE ONE TABLET BY MOUTH 4 TIMES A DAY FOR PAIN . [MEDICATION NAME] 3 MG TABLET GIVE 1 TABLET BY MOUTH AT BEDTIME (SLEEP) [MEDICATION NAME] 100 MG TABLET . GIVE 1 BY MOUTH EACH NIGHT AT BEDTIME (SLEEP) MILK OF MAGNESIA GIVE 30 ML (MILLILITERS) BY MOUTH DAILY AS NEEDED FOR CONSTIPATION . On 10/20/15 at 9:30 AM, the following was observed during a medication pass observation. After reviewing RI #18's medications via (by way of) the paper and electronic MARs, EI #3 left the medication cart in the hallway. The paper MAR was open to public view. Facility staff, and other residents were observed in the vicinity. On 10/21/15 at 2:44 PM, the surveyor questioned EI #3 about the above occurrence (on 10/20/15), when EI #3 left the medication cart unattended. When asked which resident EI #3 was about to give medications to at that time, EI #3 replied, RI #18. The surveyor asked how EI #3 had left the paper MAR. EI #3 stated she had left the paper MAR exposed. EI #3 explained she had gotten worked up because it was her first time with the State. The surveyor asked EI #3 what issue could arise with leaving the MAR exposed. EI #3 replied, the resident, family, sponsor or anyone could look at the medications. On 10/22/15 at 11:23 AM, the surveyor conducted an interview with EI #1. EI #1 was asked what should have been done with the MARs if the nurse walked away from them. EI #1 stated, They should be secured, covered. EI #1 was asked should a MAR ever be left open, exposing a resident's medication? EI#1 stated, No ma'am. EI #1 was asked to explain the facility's policy regarding confidentiality of MARs. EI #1 replied they were to be covered. EI #1 was asked what was it a potential for if MARs are left uncovered. EI #1 replied others could see confidential information. D. A facility policy titled Eye Ointment/Drops Administration, dated June 1, 2013 documented: PURPOSE: To administer opthalmic ointment/drops into and around the eye in a safe and accurate manner. PROCESS: . j) Pull down the lower eyelid gently with index or middle finger. Instruct resident to look upward . k) Administer medication into the space between the lower eyelid and the eye . 4) On 10/20/15 at 9:03 AM, during the medication administration observation, EI #3 administered opthalmic drops ([MEDICATION NAME]) to the eyes of RI #3. EI #3 pulled the right (upper) eyelid upward, placed one drop in the eye, and took her gloves off. EI #3 donned a clean pair of gloves, pulled RI #3's left (upper) eyelid upward, and placed one drop in the left eye. The eye drops were not placed in the lower conjuctival sac. On 10/22/15 at 1:42 PM, the surveyor asked EI #3 how eye drops were to be administered. EI #3 replied, wash hands and put on gloves; it is easier to put them (eye drops) in the punctum (tear duct). EI #3 explained the medication would flow down (into the the cavity of the eye) and not wipe off with a tissue. EI #3 further explained, if she was going to place a drop in the other eye, she would wash her hands and put on more gloves. EI #3 was asked how she had administered RI #3's [MEDICATION NAME] eye drops. EI #3 explained she had pulled down the lower lid and put it in the punctum. EI #3 was asked was it acceptable practice pull the eyelid upward to administer eye drops. EI #3 replied no. EI #3 was asked the potential harm when administering eye drops and the eyelids were pulled upward. EI #3 explained if she were to pull the eyelid up, the eye drop would not go into the eye. On 10/22/15 at 11:13 AM, the surveyor asked the DON (EI #1) how eye drops should be administered. EI #1 explained the drops should be administered in a private location, wash hands, put on gloves, pull the lower lid downward, encourage the resident to look up and administer the drops, remove gloves and wash hands. EI #1 was asked if it was acceptable practice to pull the upper eyelid upward when administering eye drops. EI #1 stated, No. The surveyor asked why eye drops were administered in the lower conjuctiva sac. EI #1 stated it was to ensure the dose was contained on (in) the eye. E. A review of Potter and Perry, Fundamentals of Nursing, Eight Edition, copyright date of 2013, p. 1031 documented: . Administering Enteral Feedings . 3 Verify health care provider's order for formula, rate, route, and frequency . 5) A review of RI #5's care plan titled Potential for weight loss . with a Problem Onset date of 12/22/2014, revealed the following approach: . * . Administer tube feeding as ordered . RI #5's physician's orders [REDACTED]. . [MEDICATION NAME] 1.2 @ (at) 60CC/HR (hour) X (times) 23HRS VIA (by way of) PUMP . On 10/21/15 at 9:15 AM, the surveyor observed RI #5 sitting in a Rock-n-go chair in the dayroom. RI #5's tube feeding was observed by the surveyor to be off at this time. On 10/21/15 at 12:16 PM, RI #5 remained in the Rock-n-go chair in the dayroom. RI #5's tube feeding remained off. On 10/21/15 at 2:22 PM, the surveyor conducted an interview with EI #16, the LPN assigned to care for RI #5 on 10/21/15 on the 7-3 shift. The surveyor shared with EI #16 the surveyor's observations of RI #5's tube feeding being turned off from 9:15 AM - 12:16 PM (a period of three hours). The surveyor asked EI #16 why was RI #5's tube feeding off. EI #16 replied, I didn't know it was turned off. EI #16 said RI #5 had a 1:00 PM flush and she reconnected the tube feeding at that time. The surveyor asked EI #16 why RI #5 was receiving the tube feeding. EI #16 replied RI #5 had gotten to a point where the resident would not eat. On 10/22/15 at 12:21 PM, the surveyor conducted an interview with EI #2, an RN Unit manager. The surveyor asked EI #2, did RI #5 have physicians order for the resident's tube feeding to infuse continuously (x23 hours). EI #2 said RI #5 did. The surveyor shared with EI #2, the surveyor's observations of RI #5's tube feeding being turned off from 9:15 AM - 12:16 PM. The surveyor asked EI #2 why RI #5's tube feeding was off. EI #2 said she understood RI #5 was brought to the dayroom and the nurse had disconnected the tube feeding, but did not bring the tube feeding to the day room. The surveyor asked EI #2 were the physician orders [REDACTED]. EI #2 replied, At that time it was not.

Based on observations, interviews and record review, the facility failed to ensure: 1) a Licensed Practical Nurse (LPN) medication nurse applied Resident Identifier (RI) #18's [MEDICATION NAME] in the privacy of the resident's room, and 2) the LPN medication nurse closed RI #18's Medication Administration Record [REDACTED] This affected one of five residents observed during the morning medication pass on 10/20/15. Findings Include: 1) RI #18 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #18's medical record revealed physician's orders [REDACTED]. [MEDICATION NAME] 25 MCG (MICROGRAMS)/HR (HOUR) PATCH . APPLY 1 PATCH TO CLEAN, DRY SKIN ONCE EVERY 72 HOURS (ROTATE SITES). On 10/20/15 at 9:35 AM, the surveyor observed Employee Identifier (EI) #3, a Licensed Practical Nurse pulled RI #18 to the doorway of RI #18's room. As EI #3 stood in the hall by the doorway, she placed a [MEDICATION NAME] to EI #18's left upper chest. Other residents and staff members were ambulating in the hallway. On 10/21/15 at 2:44 PM, the surveyor conducted an interview with EI #3. EI #3 was asked, when applying RI #18's [MEDICATION NAME] where was she and RI #18. EI #3 stated in RI #18's doorway. EI #3 was asked where she applied the patch. EI #3 replied to RI #18's upper right shoulder area. EI #3 was asked why she applied the patch on RI #18 while he/she was in the doorway and as she stood in the hall. EI #3 replied, I figured because (RI #18) was in the room, although technically I was semi out in the hall. EI #3 was asked if it was an acceptable practice for a licensed nurse to apply a [MEDICATION NAME] to a resident's upper chest while the resident was in the doorway of their room, while the nurse was standing in the hall right outside the door. EI #3 replied no. EI #3 was asked, what was the facility's policy on applying a patch. EI #3 replied the facility's policy was to move the resident into the room for dignity purposes. EI #3 also stated she should have taken RI #18 further into the room. EI #3 was asked what was the potential harm to a resident when a patch was applied in public view. EI #3 stated, Dignity; had RI #18 been a she and EI #3 had put it on the chest like that, a breast could have been exposed. On 10/22/15 at 11:23 AM, the surveyor conducted an interview with EI #1, the Director of Nursing (DON). EI #1 was asked what should be provided when applying a patch to the upper chest of a resident. EI #1 stated, Privacy. EI #1 was asked should a [MEDICATION NAME] be applied as the resident is sitting in the doorway with the nurse standing in the hall. EI #1 stated, No. EI #1 was asked what the facility policy on administering a [MEDICATION NAME] was. EI #1 replied, check the physician's orders [REDACTED]. 2) A review of RI #18's medical record revealed physician's orders [REDACTED]. . [MEDICATION NAME] 1 MG (MILLIGRAM) TABLET . GIVE 1 TABLET BY MOUTH 4 TIMES A DAY . [MEDICATION NAME] 10/325 MG GIVE ONE TABLET BY MOUTH 4 TIMES A DAY FOR PAIN . [MEDICATION NAME] 3 MG TABLET GIVE 1 TABLET BY MOUTH AT BEDTIME (SLEEP) [MEDICATION NAME] 100 MG TABLET . GIVE 1 BY MOUTH EACH NIGHT AT BEDTIME (SLEEP) MILK OF MAGNESIA GIVE 30 ML (MILLILITERS) BY MOUTH DAILY AS NEEDED FOR CONSTIPATION . On 10/20/15 at 9:30 AM, EI #3 walked away from the medication cart leaving the above medications on the paper and electronic MARs exposed to public view. Facility staff and other residents were observed on the hall. On 10/21/15 at 2:44 PM, the surveyor conducted an interview with EI #3. EI #3 was asked on 10/20/15, to which resident were you about to give medications when you left the medication cart unattended. EI #3 replied RI #18. EI #3 was asked how was the paper MAR indicated [REDACTED]. EI #3 was asked what issue could arise with leaving the MAR indicated [REDACTED]. On 10/22/15 at 11:23 AM, the surveyor conducted an interview with the DON, #1. EI #1 was asked what should have been done with the MAR indicated [REDACTED]. EI #1 stated, They should be secured, covered. EI #1 was asked should a MAR indicated [REDACTED]. EI #1 stated, No ma'am. EI #1 was asked if it was an acceptable practice for a licensed nurse to leave a MAR indicated [REDACTED]. EI #1 was asked to explain the facility's policy on maintaining the privacy of MARs. EI #1 replied you cover them. EI #1 further stated others could see confidential information.

Based on interviews and record review the facility failed to ensure: 1) the bowel status of Resident Identifier (RI) #13 was coded accurately on the Annual Minimum Data Set (MDS) assessment dated [DATE], and 2) the as needed mitten restraints were coded accurately on the 07/28/15 Quarterly MDS assessment and on the 09/18/15 Discharge assessment of RI #6. This affected RI #3 and #13, two of twenty-four sampled residents whose MDS assessments were reviewed. Findings Included: A review of a facility policy titled, Resident Assessment Instrument, dated April 2010 documented: . Policy Interpretation and Implementation. . Certify Accuracy of Resident Assessment . 7. All persons who have completed any portion of the MDS Resident Assessment Form MUST sign such document attesting to the accuracy of such information. 1) RI #13 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. An Annual MDS assessment with an Assessment Reference Date (ARD) of 07/20/15, assessed RI #13 as being totally dependent on staff for bathing and was always incontinent of bowel and bladder. On 10/21/15 at 11:54 AM, the surveyor conducted an interview with Employee Identifier (EI) #12, the MDS Coordinator. The surveyor asked EI #12 who was responsible for the coding of the MDS. EI #12 replied each discipline did their own section on the MDS. The surveyor asked EI #12 who did Section H - Bowel and Bladder. EI #12 said the Restorative Nurse did. EI #12 was asked by the surveyor to review Section H of RI #13's 10/12/15 Quarterly MDS assessment, 07/20/15 Annual MDS assessment and 09/02/14 Annual MDS assessment. EI #12 said on RI #13's 10/12/15 Quarterly MDS assessment it was checked that RI #13 had an ostomy. On the 07/20/15 Annual MDS assessment, the ostomy was unchecked. On the 09/02/14 Annual MDS assessment it was checked that RI #13 had an ostomy. The surveyor asked EI #12 should RI #13's 07/20/15 Annual MDS assessment be checked for the ostomy. EI #12 replied, Yes Ma'am. EI #12 said RI #13 has had the [MEDICAL CONDITION] the entire time. The surveyor asked EI #12 what was the facility's policy on coding the MDS. EI #12 replied, It must be coded accurately and timely according to the schedule. The surveyor asked EI #12 what was the potential harm or issue that could arise from the MDS not being coded accurately. EI #12 replied, Costing the facility civil money penalties and not reflecting accurate care to the resident. On 10/21/15 at 12:21 PM, the surveyor conducted an interview with EI #13, the Licensed Practical Nurse Restorative Nurse. The surveyor asked EI #13 who was responsible for coding Section H (Bowel and Bladder) of the MDS. EI #13 replied, Me. The surveyor asked EI #13 to review RI #13's 09/02/14, 07/20/15 and 10/12/15 MDSs. The surveyor asked EI #13 was RI #13's 07/20/15 MDS coded accurately. EI #13 replied, No, not for the bowel part. The surveyor asked EI #13 why the MDS was not coded accurately. EI #13 replied, I don't know. It is a mistake. EI #13 said she knew RI #13 had a [MEDICAL CONDITION]. The surveyor asked EI #13 what was the facility's policy on coding the MDS. EI #13 replied, It is supposed to be accurate. The surveyor asked EI #13 what issue could arise if the MDS was not coded accurately. EI #13 replied, The care wouldn't be correct. 2) RI #6 was re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of RI #6's most recent physician orders, dated 09/01/15 and 10/01/15, revealed order(s) stating hand mittens to be applied to both hands during ADL (Activity of Daily Living) care only & (and) to be removed when care is complete. Observation of RI #6's current Care Plan revealed a revised plan on 11/25/14, which included hand mittens to be applied to both hands during ADL care only and to be removed when care completed. According to the Quarterly MDS assessment, with reference date of 07/28/15 and the Discharge MDS with a reference date of 09/18/15, under Section P - Restraints, . P0100F: Restraints in chair/out of bed: limb restraint . is coded as 0. Not used. An interview was conducted on 10/22/15 at 11:00 AM with EI #14, MDS/Care Plan Coordinator. EI #14 was asked if RI #6 used restraints, and she stated, Yes, during ADL care. When asked what type of restraint was used, EI #14 stated hand mittens. EI #14 was asked to show on the Quarterly MDS dated [DATE] and on the Discharge MDS dated [DATE], where it was coded for RI #6 to have restraints. RI #14 stated it was not coded on either MDSs and should have been. When asked if the assessments done on 07/28/15 and 09/18/15 were accurate assessments, EI #14 replied, not section P. When asked what was the potential harm or negative outcome for an inaccurate MDS assessment, EI #14 replied the resident's careplan would be inaccurate.