Every finding on record at Opp Health and Rehabilitation, LLC

Based on observation, interviews, and a review of the facility policies titled Food Receipt and Storage and Food Cooking and Serving Temperatures, the facility failed to ensure: 1) a medium box of opened patty sausage was sealed, a clear plastic bag of french toast, a bag of hash browns, and a half a bag of frozen biscuits in the freezer had a used by date, and 2) the temperature was taken on the second and third pan of ribs, a second pan of seasoned greens, and a second pan of rice. This had the potential to affect 48 of 96 residents who received a regular diet from the kitchen. Findings Include: 1) A review of a facility policy titled Food Receipt and Storage, with an effective date of [DATE], revealed: PURPOSE: Foods should be received and stored properly to prevent food borne illnesses. PROCESS: . II. Storage of Foods: . k. Open food items should be covered, labeled, and dated; . On 2/24/20 at 3:20 PM, the surveyor and the dietary manager made an observation of the freezer. The surveyor observed a medium box of patty sausage that was opened and not sealed, a clear plastic bag of 8 to 10 French toast pieces, with no use by date, and a clear bag of 12 to 15 hash browns with no use by date. Further observation revealed a half of bag of biscuits with no use by date. On 2/26/20 at 3:36 PM, an interview was conducted with Employee Identifier (EI) #3, Certified Dietary Manager. EI #3 was asked, who was responsible for labeling and dating open food items in the freezer. EI #3 replied, all employees that use items out of the freezer. EI #3 was asked, where was the label on the French toast, hash browns or the biscuits on 2/24/20, during the observation of the freezer. EI #3 replied, no ma'am, there was not one. EI #3 was asked, why were the French toast, hash browns and biscuits not labeled or had a use by date. EI #3 replied, perhaps who used them got in a rush and forgot. EI #3 was asked, when should food items in the freezer be labeled after they are opened. EI #3 replied, immediately. EI #3 was asked, what was the potential concern with the food when there was no label or a use by date. EI #3 replied, staff would be unaware of possible spoilage and could make somebody sick. EI #3 was asked, when should food items be put in the freezer open and not closed. EI #3 replied, never. EI #3 was asked when was the box of patty sausage opened. EI #3 replied, they were opened on 2/24/20. EI #3 was asked, why was the box of patty sausage open in the freezer. EI #3 replied, she did not know, she guessed they forgot and were in a hurry. EI #3 was asked, what was the facility policy on labeling, dating, and closing opened food items. EI #3 replied, all items should be labeled and dated immediately after use or opening them. 2) A review of a facility policy titled Food Cooking and Serving Temperatures with an effective date of [DATE] revealed: PURPOSE: Safe and sanitary food handling practices include effective control of food temperatures, in order to prevent food borne illnesses. PROCESS: . III. General Guidelines . b. (When replenishing or batching items to the steamtable new products should not be mixed with existing product, and the temperature of the new product should be recorded. On 2/26/20 at 11:52 AM, the surveyor observed the tray line. EI #5, dietary aide, was observed bringing out a second pan of ribs for the tray line. There was no observation of the temperature taken. EI #5 then brought a second pan of greens to the tray line, there was no temperature taken. At 12:01 PM, EI #5 brought out a second pan of rice to the tray line, there was no temperature taken. At 12:13 PM, EI #5 brought out the third pan of ribs to the tray line, there was no temperature taken. On 2/27/20 at 10:31 AM, EI #4, the breakfast cook was interviewed. EI #4 was asked, who was responsible for checking the temperatures on food at the tray line. EI #4 replied, the server. EI #4 was asked, when were the temperatures taken on the second and third pan of ribs, the second pan of greens and second pan of rice. EI #4 replied, she did not know. EI #4 was asked, where were the second pan and third pan of ribs, the second pan of greens, and the second pan of rice sent. EI #4 replied, to the residents who were on regular diets. EI #4 was asked, how many residents where fed from the second and third pans of ribs, the second pan of greens, and the second pan of rice. EI #4 replied, half of the residents had all ready been fed. EI #4 was asked, why were the temperatures not taken on the second and third pan of ribs, the second pan of greens, or the second pan of rice. EI #4 replied, she forgot to take the temperatures. EI #4 was asked, when should temperatures be taken of food on the tray line. EI #4 replied, before the cook brings it out to the trayline, it should be taken before it gets on the tray line. EI #4 was asked, should the temperatures be taken on foods that were brought out when the food runs out on the tray line. EI #4 replied, yes ma'am. EI #4 was asked, what was the facility policy on checking food temperatures on the tray line. EI #4 replied, she knew it was not suppose to drop below red line because it would be in the danger zone and could cause a bacteria and [MEDICAL CONDITION]. EI #4 was asked, what were some concerns in not checking the temperatures on the tray line. EI #4 replied, she did not want anyone to get sick or anything happen to the residents or the workers. On 2/27/20 at 1:16 PM, an interview was conducted with EI #5, dietary aide. EI #5 was asked, who was responsible for taking the temperature of foods at the tray line. EI #5 replied, it usually was tempted before handing to her by the cook. EI #5 was asked, what were the temperatures taken on the second and third pan of ribs, the second pan of greens, and the second pan of rice when it was brought to the tray line. EI #5 replied, she did not know; she did not see any one check the temperatures of the food. EI #5 was asked, why was the temperatures not taken on the second and third pan of ribs, the second pan of greens, and the second pan of rice. EI #5 replied, she did not know. EI #5 was asked, when should the temperatures be taken. EI #5 replied, when food was first prepared, right before serving, and each time before it was replenished. EI #5 was asked what were some concerns in not taking temperatures of foods on the tray lines. EI #5 replied, the food may not be hot or cold enough and make people sick. On 2/27/20 at 1:54 PM, an interview was conducted with EI #3, the Certified Dietary Manager. EI #3 was asked, who was responsible for checking temperatures on the tray line. EI #3 replied, the breakfast cook at breakfast and lunch and the float cook during supper. EI #3 was asked, what would be the reason for the food items not being tempted on the tray line. EI #3 replied, just forgot. EI #3 was asked, how would she know if the cook checked the temp before the food came out to the tray line. EI #3 replied, it would be documented. EI #3 was asked, if the temperatures on the second and third pans of ribs, the second pan of greens, and the second pan of rice was documented. EI #3 replied, no it was not. EI #3 was asked, how often should temperatures be taken at the tray line. EI #3 replied, when it was first put out on the tray line and each time it had been replenished. EI #3 was asked, what was the facility policy on tempting foods on the tray line. EI #3 replied, it should be tempted on the first round before serving, then each time when it was replenished. EI #3 was asked, what was the potential concern in not tempting foods at the tray line. EI #3 replied, food-borne illness. EI #3 was asked, how many residents were fed on a regular diet from the kitchen. EI #3 replied, 96. EI #3 was asked, how many would have been served from the second and third pan of ribs, the second pan of greens, and the second pan rice. EI #3 replied, half of 96 (48).

Based on observations, interviews and a review of the the (YEAR) Food Code, facility staff failed to ensure: 1) expired milk was discarded by the use by date and 2) the dish machine rinse temperatures were maintained at recommended temperatures (no greater than 194 degrees Fahrenheit). This had the potential to affect 169 residents for whom meals were prepared and served at the time of this survey. Findings included: 1. On [DATE] at 4:21 PM, the pantry refrigerator located on Hall 2 was observed to have an 8-oz carton of fat free skim milk with a stamped best by date of [DATE]. 2. The (YEAR) U.S. Food and Drug Administration Food Code mandates under ,[DATE].112 (A) Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures the following: . in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 194 degrees F (Fahrenheit) . The Food Code annex, explains further: When the sanitizing rinse temperature exceeds 194 degrees F at the manifold, the water becomes volatile and begins to vaporize reducing its ability to convey sufficient heat to utensil surfaces. On [DATE] at 09:25 AM, three dietary staff members were in the latter stages of processing dishes and flatware from the breakfast meal. Of eight total cycles of dish washing observed, the rinse temperatures exceeded the 194 degree F maximum temperature during five cycles. These temperatures were observed and confirmed by the Certified Dietary Manager (EI #12) and dietary staff member, EI #11. On [DATE] at 9:35 AM, the surveyor asked EI #12 why rinse temperatures above 194 degrees F were a problem. EI #12 explained that above 194 degrees, sanitizing was counter-acted. The surveyor then asked the staff member (EI #11), responsible for documenting the dish machine temperatures, if the rinse water could get too hot. EI #11 replied, yes, and stated 190 degrees was too hot. When asked why, EI #11 did not know.

Based on observation, interviews, record reviews and review of facility policies titled: Perineal Care and Urinary Catheter Care, the facility failed to ensure: 1. a Certified Nursing Assistant (CNA) cleaned Resident Identifier (RI) #114, a resident with a history of Urinary Tract Infections [MEDICAL CONDITION], from front to back of the perineal area, during catheter and incontinent care; and 2. the catheter tubing was not dragging on the floor as RI #114 and RI #27 propelled their wheelchairs on and off the unit. This affected one of one residents observed for catheter and incontinent care, and two of two residents with catheter tubing observed on the floor. Findings Include: A facility policy titled Perineal Care with an effective date of 12/08/06 revealed the PURPOSE: Good perineal care helps prevent infection, irritation and skin breakdown. PR[NAME]ESS: . II. b) Turn the resident on his/her side and wipe from front to back wiping from . area to rectum extending over the buttocks . 1) RI #114 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of a facility form Physician order [REDACTED]. 3/15/19 . [MEDICATION NAME] 500 milligrams . BID (two times a day) [MEDICAL CONDITION] . 3/11/19 . FOLEY CATHETER .TO CLOSED URINARY DRAINAGE BAG . ([MEDICAL CONDITION]) . A review of a hospital laboratory report revealed . PR[NAME]EDURE --- CULT URINE .ORDERED 3/13/19 . CULTURE -CATH URINE .Specimen Comments . E COLI Escherichia coli . A review of another hospital laboratory report revealed .PR[NAME]EDURE --- CULT URINE .ORDERED 4/04/19 . CULTURE -CATH URINE .Organisms Identified .Escherichia coli . On 5/21/19 at 9:01 AM, the surveyor observed Employee Identifier (EI) #4, CNA performing catheter and incontinent care for RI #114. After preparing for the task, EI #4 cleaned the front of the perineal area without any issues. EI #4, with clean gloves, then turned RI #114 to the left side and wiped the left buttock from back to front. EI #4 wiped the right buttock in the same manner, back to front. EI #4 wiped the middle, in a back to front direction. EI #4 removed her gloves and washed her hands, put on new gloves and placed the clean brief. The surveyor asked EI #4 to recap when she wiped the resident's buttock area. As EI #4 was moving her hands she replied, Oh my, I wiped toward the opening instead away. The surveyor asked EI #4 which direction did she wipe. EI #4 replied, from the back down to the opening. The surveyor asked EI #4 if that was the right way to wipe. EI #4 replied, no. On 5/21/19 at 11:47 AM, another interview was conducted with EI #4, CNA. EI #4 was asked what was the policy on which direction to wipe during incontinent care. EI #4 replied, she was supposed to wipe down in front and on the back side she was suppose to wipe up. EI #4 was asked which way did she wipe the buttock area as she was cleaning the resident. EI #4 replied, she wiped from the back down to the opening, which was toward the opening and the wrong way. EI #4 was asked what would the risks be in wiping a resident in a back to front direction. EI #4 replied, spread infection. On 5/21/19 at 3:19 PM, an interview was conducted with EI #2, Licensed Practical Nurse / Staff Development/ Infection Control Nurse. EI #2 was asked what was the policy for wiping a resident during incontinent care. EI #2 replied, front to back. EI #2 was asked when should the CNA wipe in a back to front direction. EI #2 replied, never. EI #2 was asked what would the risk be in the CNA wiping in a back to front direction. EI #2 replied, UTI's, wounds and infections. 2) A review of a facility policy titled Urinary Catheter Care with an effective date of 12/1/06 revealed . Urinary Catheter care helps to prevent urinary tract infection. PR[NAME]ESS: I. General . i) Catheter tubing and drainage bags are kept off the floor to prevent contamination . RI #114 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 5/21/19 at 11:30 AM, the surveyor observed RI #114 up in a wheelchair self propelling in the hall to the main dining room. The surveyor observed the catheter tubing dragging on the floor. At 11:40 AM, the resident propelled to the main dining room. The surveyor observed the catheter tubing still dragging the floor. At 12:00 PM, RI #114 was eating lunch in the dining room; the catheter tubing remained on the floor. At 12:40 PM, RI #114 was observed propelling self back to the unit from the dining room. The catheter tubing was observed to still be dragging on the floor. On 5/21/19 at 12:45 PM, the surveyor observed RI #114, with EI #3 LPN, propelling the wheelchair on the unit. The surveyor asked EI #3 what was observed with the catheter. EI #3 replied, the tubing was dragging the floor. EI #3 was asked if the tubing was to be on the floor or dragging the floor. EI #3 replied, no. EI#3 was asked what would the harm be in the catheter tubing dragging the floor, or on the floor. EI #3 replied, infection control and the tubing would be picking up germs. On 5/21/19 at 3:19 PM, the Infection Control Nurse (EI #2) was asked how should catheter tubing hang when a resident was in a wheelchair. EI #2 replied, the tubing was to be looped and placed in a privacy bag. EI #2 was asked when should the catheter tubing drag the floor. EI #2 replied, never. EI #2 was asked what would the harm be in catheter tubing dragging on the floor. EI #2 replied, it could pick up bacteria that could introduce infection in the urinary tract. 3) RI #27 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 04/30/19, the Physician ordered for RI #27, the placement of a Foley Catheter (with leg bag) for a [DIAGNOSES REDACTED]. On 05/19/19 at 10:55 AM, RI #27 was observed propelling his/her wheelchair down the hallway. The catheter tubing extended out from the resident's pant leg and drug along the floor, beneath the wheel chair, as the resident moved down the hall. On 05/21/19 at 3:41 PM, the above observation was discussed with the Registered Nurse Supervisor, Employee Identifier #5. The surveyor asked what concern would this situation pose to RI #27. EI #5 replied, Infection. When asked if RI #27 had a history of [REDACTED].#5 stated the resident had them chronically.

Based on observations, interviews, record reviews and review of facility policies titled: Oxygen Administration and Nebulizer, the facility failed to ensure: 1. the humidifier bottle and nasal cannula for Resident Identifier (RI) #370 were dated to show that they were changed in a timely manner, and 2. the masks for nebulizer treatments for RI #371 and RI #370 were not lying on top of the bedside table. The nebulizer machine was also left uncovered. This affected two of five residents observed for oxygen administration and nebulizer treatments. Findings Include: A review of a facility policy titled, OXYGEN ADMINISTRATION with an effective date of (MONTH) 8, 2005 revealed: Purpose: To administer high purity oxygen for the treatment of [REDACTED]. . Process . 11. Cannulas and masks should be changed weekly . A review of a facility policy titled, NEBULIZER with a revised date of (MONTH) 1, 2004, revealed: . Process . V. After completion of therapy . e). store in plastic bag. A. RI #370 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Physician orders [REDACTED].#370 revealed the order for oxygen (O2) at 2 liters per minute per nasal cannula as needed for shortness of breath and low O2 (below 92%) saturations. The PO also revealed an order dated 5/12/19 for Iprat-Albut per nebulizer. On 05/19/19 at 11:28 AM, RI #370 was observed resting in bed. An oxygen concentrator was observed with oxygen running through a nasal cannula. The cannula was lying on the bed beside the resident. No dates were observed on the nasal cannula or humidifier bottle. Also observed was a treatment mask lying on the bedside table beside the breathing treatment machine (nebulizer), uncovered (not in a bag). On 05/19/19 at 12:50 PM, the surveyor asked Licensed Practical Nurse (LPN), Employee Identifier (EI) #14 if RI #370 had an order for [REDACTED].#14 was asked did the humidifier bottle for RI #370's oxygen concentrator have a date on it. EI #14 replied, no it did not. EI #14 was asked did the nasal cannula have a date on it. EI # 14 replied, no. EI #14 was asked should the humidifier and cannula be dated. EI #14 replied, yes. EI #14 was asked how do you know when the humidifier and cannula were replaced. EI #14 replied, if not dated, you do not know. EI #14 was asked, who was responsible for changing the humidifier and cannula EI #14 replied, 10 pm to 6 am nurses on Saturday night. EI #14 was asked, what was the potential harm of not having the humidifier and cannula with a date labeled on them. EI #14 replied, infection. EI #14 was asked where the mask was. She replied not in a bag, lying on the bedside table uncovered. EI #14 was asked who was responsible for placing the mask in a bag when finished with the treatments. She replied the LPNs. EI #14 was asked what the potential harm was in leaving the mask on top of the bedside table. She replied, infection control. B) RI #371 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A Physician order, dated 05/18/19, revealed the order, Iprat-Albut . per nebulizer . On 05/19/19 at 10:33 AM, RI #371 was resting in bed, confused but alert. The surveyor observed a breathing treatment machine on the bedside table with the mask placed on top of the machine. On 05/19/19 at 12:41 PM, the surveyor asked LPN (EI #3) if RI #371 received breathing treatments. EI #3 replied, yes. When asked where the mask should be placed between treatments, EI #3 replied, in a Ziploc bag. EI #3 was asked, where the mask was at that time. EI #3 replied, sitting on top of the machine. EI #3 was asked, who was responsible for placing the mask in a bag when done with the treatment. EI #3 replied, the nurse. The surveyor asked why the mask was lying on the bedside table and not in a bag. EI #3 responded, Oversight. When asked what potential harm could result in leaving the mask uncovered on top of the machine on the bedside table, EI #3 replied, germs and infection control. On 5/22/19 at 9:06 AM, the surveyor interviewed EI #2, Staff Development/ Infection Control Nurse. EI #2 was informed that on the initial tour of facility on Sunday (MONTH) 19, the nasal cannula and humidifier bottle were observed in EI #370's room, neither of which were dated. Additionally, RI #370's and #371's nebulizer masks were lying uncovered on top of the nebulizer machines on the bedside tables. EI #2 was asked, what was the policy on changing and dating the cannula and humidifier bottles. EI #2 replied, they were changed weekly, on Saturday nights during the 10 pm to 6 am shift. EI #2 was asked, who was responsible for changing these. EI #2 replied, the LPN Charge Nurse. EI #2 was asked why was it important to change these. EI #2 replied, infection. EI #2 was asked, why was it important to put dates on the cannula's and humidifiers. EI #2 explained you would not know when they were last changed. EI #2 was asked, why it was important to keep these masks covered. EI #2 replied, infection control.

Based on observation, interviews, record review and review of a facility policy, Perineal Care, the facility failed to ensure a Certified Nursing Assistant (CNA) wiped a resident with a history of Urinary Tract Infections, Resident Identifier (RI) #53's, buttocks in an upward direction during the provision of pericare. This was observed on 7/24/18 and affected one of one residents observed for pericare. Findings Include: A review of a facility policy Perineal Care with an effective date of (MONTH) 1, 2010 revealed PURPOSE: Good perineal care helps prevent infection, . PR[NAME]ESS: .II. b) Wash the anal area, moving upward toward the back. RI #53 was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. A review of a facility report dated 7/3/18 of a Urinalysis revealed: .BACTERIA 2+ the report further indicated . CULTURE .Pseudomonas aeruginosa Organism identified 07/05/18 . On 7/24/18 at 3:32 PM Employee Identifier (EI) # 2, CNA was observed performing perineal care for RI # 53. EI #2 cleaned the front side of RI #53 then assisted to turn to the left side. EI #2 wiped the buttocks area of RI #53 in a downward direction. EI #2 wiped the buttocks area three times going from the back towards the urinary opening. EI #2 washed her hands put on new gloves and placed the clean brief. On 7/24/18 at 3:40 PM an interview was conducted with EI #2, CNA. EI #2 was asked what was the policy on the direction to wipe the buttocks area during perineal care. EI #2 replied, wipe from the legs up toward the back. EI #2 was asked which way did she wipe. EI #2 replied, from the hips down toward the urine opening. EI #2 was asked if that was the correct way. EI #2 replied, no. EI #2 was asked what was the risk for wiping toward the urinary opening. EI #2 replied, if the resident had a bowel movement it could get in that area and cause an infection. On 7/26/18 at 10:18 AM an interview was conducted with EI #1, Licensed Practical Nurse. EI #1 was asked what was the policy on wiping the buttocks during the provision of perineal care. EI #1 replied, the staff should wipe the buttocks area in an upward direction away from urinary opening. EI #1 was asked if it would be an acceptable practice for staff to wipe the buttocks area in a downward motion. EI #1 replied, no. EI #1 was asked what would the harm be in wiping the buttocks in a downward direction. EI #1 replied, infections.

Based on observation, interviews and a review of a facility policy titled, Hand Hygiene, the facility failed to ensure a Certified Nursing Assistant (CNA) washed her hands after removing her gloves after providing assistance to Resident Identifier (RI) #123 and washed her hands prior to assisting RI #88 with his/her bread. This had the potential to affect two of 16 residents observed during a meal. Findings Include: A review of a facility policy titled, Hand Hygiene with a effective date of 9/1/2017 revealed: PURPOSE: To provide guidelines to employees for proper and appropriate hand washing techniques that will aide in the prevention of the transmission of infections III Hand Hygiene .when coming on duty, . Before and after assisting a resident . with meals. RI #88 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #88's Annual Minimum Data (MDS) with an (ARD) Assessment Reference Date of 5/16/2018 revealed RI #88's cognitive skills for daily decision making were severely impaired. RI #123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #123's most recent MDS, dated [DATE], the resident had short/long term memory deficit and severely impaired for decision making. On 7/24/18 at 12:41 p.m, (Employee Identifier) EI #3, CNA, entered RI #123's room. She put on gloves, pulled the resident up in his/her bed. She pulled her gloves off and did not wash her hands. She then turned the crank at the bottom of RI #123's bed with her bare hands and left the room without washing her hands. EI #3 then entered RI #88's room with the resident's food tray. She was helping the resident set up his/her meal. She touched RI #88's slice of white bread with her bare hands and opened the resident's milk carton with her bare hands. EI #3 did not wash her hands or place gloves on her hands prior to handling the resident's bread or milk carton. On 7/24/18 at 12:53 p.m., the Surveryor conducted an interview with EI #3. EI #3 was asked did she wash her hands after pulling RI #123 up in the bed. EI #3 replied, she did not immediately. EI #3 was asked why not. EI #3 replied there was a problem with RI #88. EI #3 was asked what did the facility policy say regarding when she should wash her hands. EI #3 replied, wash hands after every interaction with a resident. EI #3 was asked did she touch RI #88's bread and milk. EI #3 replied, apparently she did. EI #3 was asked did she crank RI #123's bed. EI #3 replied, she rolled up his bed. EI #3 was asked when pulling off her gloves should she have washed her hands or sanitizer her hands. EI #3 replied, if a sink was available, other wise she should sanitize her hands. EI #3 was asked was a sink available. EI #3 replied, a sink was available. EI #3 was asked what was the potential harm to the resident when staff did not wash their hands after rolling the resident bed and pulling the resident up in bed. EI #3 replied, infection control, and the spreading of germs that she may have had on her hands prior to cranking the bed. EI #3 was asked did she go from room to room passing out the resident's trays and not sanitize her hands. EI #3 replied, yes she did. EI #3 was asked what task did she perform last after leaving RI #123's room. EI #3 replied, cranked his/her bed. EI #3 was asked did she wash her hands after leaving RI #123's bed. EI #3 replied, she did not. On 7/25/18 at 9:27 a.m., the surveyor conducted an interview with EI #4, CNA/Supply Clerk. EI #4 was asked did EI #3 sanitize her hands after cranking RI #123's bed. EI #4 replied, no ma'am. EI #4 was asked should she have washed or sanitized her hands after cranking the bed. EI #4 replied, yes ma'am before and after. EI #4 was asked what was the potential harm to the resident when staff do not wash their hands after cranking a bed and passing out trays. EI #4 replied, an infection could appear. On 7/26/18 at 12:13 p.m., the surveyor conducted an interview with EI #1, Infection Control Nurse/Staff Development Prevention. EI #1 was asked when should CNAs wash their hands. EI #1 replied, when coming on duty, going off duty, and when gloves were on hands, when touching food, resident contact care and coughing or sneezing. EI #1 was asked should a CNA wash her hands after touching the bed crank on a bed and proceeding to another resident's room to help set up a meal. EI #1 replied, yes ma'am, she went from one resident to another. EI #1 was asked why was it important that CNAs wash their hands. EI #1 replied, to prevent the spread of infection and to keep the residents safe. EI #1 was asked what was the potential harm when staff did not wash their hands after touching a bed crank and proceeding to set up another resident meal and touching the resident food. EI #1 replied, the spreading of infection to the resident, other residents and themselves.

Based on observation, interview and a review of facility policy titled, Cleaning of Miscellaneous Equipment and Utensils, and Food Receipts and Storage, the facility failed to ensure: 1. vents over the stove were free of dust and grease like substance and vents in the cooler were free of dust, 2. a cup was not in the thickener bin, 3. pulled pork, diced ham and chicken were labeled with an opened and used by date and 4. a plate on the tray line was not dirty. This was observed on one of four days of the survey and had the potential to affect 154 of 162 residents who receive meals from the kitchen. Findings Include: 1) A review of a facility Policy titled, Cleaning of Miscellaneous Equipment and Utensils with an effective date of March 17, 2016 revealed: .30. Hood Filter over Stove: (monthly) . On 6/12/2017 at 4:50 p.m., the surveyor observed the vents over the stove with dust and a grease like substance. On 6/14/2017 at 3:00 p.m., the surveyor conducted an interview with (Employee Identifier ) EI #11, Dietary Assistant. EI #11 was asked what vents had dust in them. EI #11 replied, vents over the range. EI #11 was asked what was in the vents in the cooler. EI #11 replied, dust. EI #11 was asked why was there dust in the cooler vents. EI #11 replied, maintenance had not cleaned them. EI #11 was asked what was the substance in the vents over the stove. EI #11 replied, grease and dust combined. EI #11 was asked when were the stove vents cleaned last. EI #11 replied, February 2017. EI #11 was asked when were the vents in the cooler cleaned last. EI #11 replied two months ago. EI #11 was asked what did the facility policy say regarding the cleaning of the vents over the stove. EI #11 replied, clean the hood every six months, and in between as necessary. EI #11 was asked what was the potential harm when vents in the cooler had a moderate amount of dust in them and meat was stored under the vents. EI #11 replied, particles and dust could get in the food. EI #11 was asked what was the potential harm when vents under the stove hood were dirty and cooking equipment was located under the vents. EI #11 replied, it could possibly get in the food. EI #11 was asked how much dust was on the vents in the cooler. EI #11 replied, a moderate amount. EI #11 was asked how much dust and substance was on the vents in the stove hood. EI #11 replied, pretty dirty. On 6/14/2017 at 4:37 p.m., an interview was conducted with EI #7, Maintenance Staff. EI #7 was asked who was responsible for cleaning the filter over the stove. EI #7 replied, maintenance. EI #7 was asked what was the potential harm when filter vents have dust and a grease like substance on them and the stove was located under the vents. EI #7 replied, a fire hazard. EI #7 was asked who was responsible for cleaning the vents in the cooler. EI #7 replied, maintenance. EI #7 was asked when were they cleaned last. EI #7 replied, he could not tell the surveyor. EI #7 was asked what was the potential harm when there was a moderate amount of dust in the vents in the cooler and food was located under the vents. EI #7 replied, sanitary issues. EI #7 was asked how much dust was in the cooler vents. EI #7 replied, moderate. 2) A review of a facility policy titled, Cleaning of Miscellaneous Equipment and Utensils with an effective date of March 17, 2017 revealed: 23. Ingredient Bins: .Place scoops in covered containers or plastic zip lock bags . On 6/12/2017 at 4:20 p.m., the surveyor observed a cup in a thickener bin. On 6/14/2017 at 3:03 p.m., the surveyor conducted an interview with EI #11. EI #11 was asked what was in the thickener bin. EI #11 replied, a cup. EI #11 was asked why was it there. EI #11 replied, they were using it to dip out thickener and did not remove it. EI #11 was asked what did the facility policy say regarding a cup in the thickener bin. EI #11 replied, it was not allowed. EI #11 was asked why should cups not be left in thickener bins. EI #11 replied, possible contamination. EI #11 was asked when should a cup be removed from the thickener bin. EI #11 replied, it should never be left in the bin. EI #11 was asked what was the potential harm when a cup was left in the thickener bin and the thickener was prepared for the resident to consume. EI #11 replied, it could cause bacteria. 3) A review of a facility policy titled, Food Receipt and Storage with an effective date of August 21, 2013 revealed: .k. Open food items should be covered, labeled, and dated . On 6/12/2017 at 4:50 p.m., the surveyor observed pork, dice ham and chicken tenders in the freezer out of the original container. There was no use by date on any of the items. On 6/14/2017 at 3:10 p.m., an interview was conducted with EI #11. EI #11 was asked what items in the freezer were out of the original container with no use by date. EI #11 replied, dice ham, pulled pork and chicken tenders. EI #11 was asked why was there no use by date on the food items. EI #11 replied, whoever put them back forgot to date them. EI #11 was asked what did the facility policy say when food items were taken out of the original container and were opened. EI #11 replied, label and date with a use by date. EI #11 was asked when should food items be labeled. EI #11 replied, when they were out of their original container and they were placed back in storage, freezer or cooler. EI #11 was asked who was responsible for labeling food items. EI #11 replied, the person who pulled or use the item. EI #11 was asked why should food items be labeled. EI #11 replied, they need to be labeled to be sure nothing would be used that would cause a illness. EI #11 was asked what was the potential harm when food items were not labeled and cooked to serve to the residents. EI #11 replied, illness. 4) On 6/13/2017 at 11:10 a.m., the surveyor observed the cook on the tray line. The cook pulled a sectional plate to put food on it. The plate had a red spot in it. The plate was on top of eleven more plates. On 6/14/2017 at 3:13 p.m., an interview was conducted with EI #12, the Dietician. EI #12 was asked did he see a spot in the plate. EI #12 replied yes. EI #12 was asked what was the spot. EI #12 replied, he did not know. EI #12 was asked who was responsible for making sure plates were clean. EI #12 replied, the dishwasher. EI #12 was asked why should food not be put in a plate with a spot in it. EI #12 replied it could be a biological contaminant. EI #12 was asked what was the potential harm when resident food was put on a plate with a spot. EI #12 replied, physical or biological contaminant. On 6/15/2017 at 9:30 a.m., the surveyor conducted an interview with EI #11. EI #11 was asked what was her position in the dish room on 6/14/2017. EI #11 replied, she was pulling clean dishes. EI #11 was asked did she observe a spot in a sectional plate. EI #11 replied, no ma'am. EI #11 was asked what was the facility policy regarding dirty dishes. EI #11 replied, if staff was in the dish room pulling dishes and observed a dirty dish they would give it back to the washer. EI #11 was asked who was responsible for making sure dishes were clean. EI #11 replied, the washer and the person pulling the dishes in the dish room. EI # 11 was asked what was the potential harm when residents were served food on dirty plates. EI #11 replied, biological bacteria. On 6/15/2017 at 9:37 a.m., an interview was conducted with EI #13, the Cook. EI #13 was asked what was the spot in a plate on 6/13/2017. EI #13 replied, grit corn. EI #13 was asked why was it there. EI #13 replied, it did not come off in the wash. EI #13 was asked who was responsible for making sure plates were clean. EI #13 replied, the dishwashers and people who work in the dish room. EI #13 was asked did she put food in the plate with the spot. EI #13 replied, yes she did. EI #13 was asked what did the facility policy say regarding putting food on a dirty plate. EI #13 replied, they did not feed people on dirty dishes. EI #13 was asked why should she not put food on a plate with a spot on it. EI #13 replied, they could put the resident's health at risk. EI #13 was asked what was the potential harm when residents food was put on a plate with a spot in it. EI #13 replied, they could get food borne illness infection.

Based on observation and interview the facility failed to ensure: 1. linen did not touch the floor while laundry staff was folding, 2. laundry staff failed to wash hands after throwing an item into the trash can and returned to pull clean clothes out of the dryer, 3. residents clothes did not touch laundry staff clothing while hanging residents clothes on hangers and 4. laundry staff did not sweep the bottom of the dryer with lint and dust flying in the air and clean sheets in a bin that was not covered. This was observed on one of four days of the survey and had the potential to affect 126 residents whose clothes were laundered by the facility and 162 residents whose linens were laundered by the facility. Findings Include: 1) On 6/13/2017 at 8:32 a.m., the surveyor observed laundry staff folding sheets. The sheets were hitting the floor as laundry staff folded the sheets. On 6/13/2017 at 9:30 a.m., the surveyor conducted an interview with (Employee Identifier) EI #4, laundry staff. EI #4 was asked when should they wear (Personal Protective Equipment) PPE in the laundry room. EI #4 replied, when pulling dirty items from barrels to place in the washer. EI #4 was asked while folding a sheet did it touch the floor. EI #4 replied, yes, ma'am. EI #4 was asked why should linen not touch the floor. EI #4 replied, because it needed to be clean when they put it on the resident's bed. EI #4 was asked what was the potential harm when residents' linens touched the floor and the sheet was put on the resident bed. EI #4 replied, dirty and contaminated. On 6/13/2017 at 9:35 a.m., the surveyor conducted an interview with EI #5, Housekeeping and Laundry Supervisor. EI #5 was asked when should staff wear PPE in the laundry room. EI #5 replied, when separating and handling anything dirty. EI #5 was asked while EI #4 was folding a sheet did the sheet touch the floor. EI #5 replied, yes ma'am. EI #5 was asked why should linen not touch the floor. EI #5 replied, germs, contamination. EI #5 said the floor was dirty and the sheet was clean. EI #5 was asked what was the potential harm when linen touched the floor and the sheet was put on the resident's bed. EI #5 replied, contamination. 2) On 6/13/2017 at 8:32 a.m., the surveyor observed one laundry staff pulling clothes out of the dryer. The staff person pulled a paper item from the clean clothes in the dryer and went to the trash can to put the item in the trash can. The staff person lifted the trash lid put the item in and went back to folding clothes. On 6/13/2017 at 9:43 a.m., the surveyor conducted an interview with EI #6, laundry assistant. EI #6 was asked when should PPE be worn in the laundry room. EI #6 replied, when separating clothes on the dirty side. EI # 6 was asked what did she put in the trash can. EI #6 replied, a diaper sticker. EI #6 was asked what did she do after putting the item in the trash can. EI #6 replied, she was separating and pulling clothes out of the dryer. EI #6 was asked did she wash her hands. EI #6 replied, no ma'am. EI #6 was asked why not. EI #6 replied, she did not think about it. EI #6 was asked when should she wash her hands. EI #6 replied, everytime she separated clothes on the dirty side, went to the bathroom and when she touched the trash can. On 6/13/2017 at 9:35 a.m., an interview was conducted with EI #5. EI #5 was asked when should staff wash their hands. EI #5 replied, after handling dirty linen or something else dirty. 3) On 6/13/2017, after completing the dryer task at 8:32 a.m., EI #6 started hanging clothes. As EI #6 was hanging clothes on a hanger, the resident clothes was touching her clothes. On 6/13/2017 at 9:35 a.m., an interview was conducted with EI #5. EI #5 was asked why should resident clothes not touch the laundry worker's clothes. EI #5 replied, germs, something can be on them, staff could have sneezed. EI #5 said what was on staff could get on the resident's clothing. EI #5 was asked what was the potential harm when residents' clothes touched staff clothing. EI #5 replied, germs. EI #5 was asked did a resident shirt touch a worker's clothes while hanging up the residents' clothes. EI #5 replied, yes ma'am. On 6/13/2017 at 9:43 a.m., an interview was conducted with EI #6. EI #6 was asked why should residents clothes not touch the staff clothing while hanging clothes. EI #6 replied, contamination. EI #6 was asked did a resident's shirt touch her clothes while hanging clothes on a rack. EI #6 replied, yes ma'am. EI #6 was asked what was the potential harm when resident clothes touch staff clothing. EI #6 replied, germs. 4) On 6/13/2017 at 8:32 a.m., the surveyor observed EI #4 sweeping the bottom of the lint filter. As the worker was sweeping dust and lint was flying in the air. An uncovered bin with clean linen was in the room. On 6/13/2017 at 9:30 a.m., an interview was conducted with EI #4. EI #4 was asked what was flying in the air while he was sweeping the dryer. EI #4 replied, lint from cleaning two dryers. EI #4 was asked while sweeping the dryer bottom did he have on PPE. EI #4 replied, no. EI #4 was asked what barrel of clothes was uncovered while sweeping. EI #4 replied, sheets. On 6/13/2017 at 9:35 a.m., an interview was conducted with EI #5. EI #5 was asked what was flying in the air while a laundry worker was sweeping the bottom of the dryer. EI #5 replied, lint. EI #5 was asked what barrel of clothes was uncovered while a worker was sweeping. EI #5 replied, a buggy of sheets. On 6/15/2017 at 10:40 a.m., an interview was conducted with EI #2, infection control (Register Nurse) RN. EI #2 was asked why should linen not touch the floor in the laundry room. EI #2 replied, because the floor could have some kind of germs or it could be soiled. EI #2 said the floor was not clean at all and there was a risk for infection control to be broken. EI #2 was asked why should resident clothes not touch staff clothes in the laundry room. EI #2 replied, there was possible contamination. EI #2 replied, they were touching numerous other residents' clothing and it could be clean or dirty clothing they were touching. EI #2 was asked who was responsible for training staff about infection control in laundry. EI #2 replied, a combination of the Infection Control Nurse, DON (Director of Nursing) and Staff Development. EI #2 was asked what was the potential harm when staff was sweeping the bottom of the dryer and lint and dust was flying in the air and clean linen and clothes were uncovered. EI #2 replied, spreading of any type of contaminates. EI #2 was asked when should staff wash their hands in laundry. EI #2 replied, before and after handling any linen. EI #2 was asked what was the potential harm to the resident when staff was pulling clothes from the dryer and lifted the trash lid and went back to pulling clothes out of the dryer. EI #2 replied potential contaminates from the trash can to the clean laundry.

Based on observations and interview, the facility failed to ensure Room Locators (RL) #'s 1-14 were free of exposed bolts/screws at the commode base, free of stained ceiling tile, baseboards were secured and light fixture in the resident bathroom was not missing. This affected RL #1 through RL #14 on three of four halls in the facility. Findings Include: RL #1: Observation was made on 06/12/2017 at 5:10 p.m. of the bathroom with exposed commode screws on both sides of the base. RL #2: Observation was made on 06/12/2017 at 5:44 p.m. of the bathroom with exposed commode screws on both sides of the base. RL #3: Observation was made on 06/12/2017 at 5:39 p.m. of the bathroom with exposed commode screws on both sides of the base. RL #4: Observation was made on 06/12/2017 at 5:26 p.m. of Side B with detached baseboard next to bathroom; ceiling tile stain on Side B; at 5:28 p.m. an observation was made of the bathroom with exposed commode screw on the left side of the base. RL #5: Observation made on 06/12/2017 at 5:20 p.m. of the bathroom with exposed commode screws on both sides of the base. RL #6: Observation was made on 06/12/2017 at 5:04 p.m. of the bathroom with exposed screws on both sides of the commode. RL #7: Observation was made on 06/12/2017 at 5:00 p.m. of the bathroom with exposed screws on both sides of the commode. RL #8: Observation was made on 06/12/2017 at 4:55 p.m. of the bathroom with exposed screws on both sides of the commode. RL #9: Observation was made on 06/12/2017 at 4:55 p.m. of the bathroom with exposed screws on both sides of the commode. RL #10: Observations were made on 06/12/2017 at 4:30 p.m. and on 06/13/2017 at 8:10 a.m. of the bathroom with exposed screws on both sides of the commode. RL #11: Observations were made on 06/12/2017 at 4:35 p.m. and on 06/13/2017 at 8:10 a.m. of the bathroom with exposed screws on both sides of the commode. RL #12: Observations were made on 06/12/2017 at 4:55 p.m. and 06/13/2017 at 11:40 a.m. and 06/14/2017 at 2:25 p.m. of the bathroom with exposed screws on both sides of the commode. RL #13: Observations were made on 06/12/2017 at 4:35 p.m., 06/13/2017 at 11:42 a.m. and on 06/14/2017 at 2:29 p.m., of the bathroom with exposed screws on both sides of the commode. RL #14: Observations were made on 06/12/2017 at 4:30 p.m., 06/13/2017 at 11:46 a.m. and on 06/14/2017 at 2:45 p.m., of the bathroom with exposed screws on both sides of the commode. On 06/15/2017 beginning at 9:04 a.m. and ending at 9:57 a.m., EI (Employee Identifier) #10, Maintenance Director, observed the above concerns along with the surveyor. EI #10 stated some of the commode bolts were from an inch to two inches long in height. On 06/15/2017 at 10:00 a.m. an interview was conducted with EI #10. EI #10 was asked what she observed in some of the residents bathrooms. EI #10 said, Caps were missing on the commode bolts. EI #10 was asked should bolts being an inch to two inches long be covered. EI #10 replied, Yes, the two inch should be cut off and a cap placed on them. EI #10 was asked why should two inch bolts be cut off and capped. EI #10 replied, Because someone could get hurt on them. EI #10 was asked how often rounds were made for needed repairs. EI #10 explained it was her third day on the job and did not know prior to her starting. EI #10 was asked what would cause brown stains in ceiling tiles. EI #10 stated, Roof leak. EI #10 was asked why ceiling tiles should be free of brown stains. EI #10 explained the roof should not leak. EI #10 was asked who was responsible for ensuring inch to two inch long commode bolts were cut and capped. EI #10 said, Maintenance. EI #10 was asked why they were not. EI #10 said she did not know. EI #10 was asked why light bulbs in bathroom ceilings should have light fixtures/covers. EI #10 replied, Because they could be hit and broken and it looked better. EI #10 was asked why baseboards should be attached to the walls. EI #10 explained it could make someone fall. EI #10 was asked what was the potential harm of inch to two inch long commode bolts not being cut and capped. EI #10 said, Someone could get hurt on it. EI #10 was asked what was the potential harm of ceiling light bulbs in resident bathrooms not having a cover/light fixture. EI #10 said they could break. EI #10 was asked what was the potential harm of baseboards not being attached to the wall. EI #10 replied, Someone could trip over and fall.

Based on, medical record review, a review of a facility policy titled,Person Centered Care Plans, observations and interview, the facility failed to ensure Resident Identifier (RI) # 2's grip strips were implemented as outlined in RI #2's Care Plans for Falls. This affected one of five residents whose Fall Care Plans were reviewed. Findings Include: A review of a facility policy titled, Person Centered Care Plans with an effective date of November 28, 2016 revealed the following: .STANDARD: .the facility develops a comprehensive person centered plan of care for each resident .that includes measurable objectives .to meet .needs that are identified . RI #2 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #2's most recent quarterly Minimum Data Set (MDS) with a Assessment Reference Date (ARD) of 04/26/2017, revealed RI #2 had a Brief Interview for Mental Status(BIMS) score of 3, which indicated the resident was severely impaired cognitively for daily decision making. A review of RI #2's Care Plan for falls revealed the following: Problem Onset: .Potential for falls .Approaches .2/6/17-APPLY GRIP STRIPS IN FRONT OF CHAIR . Approaches . 2/7/17- APPLY GRIP STRIPS BESIDE BED. On 06/14/2017 at 3:19 p.m., and 06/15/2017 at 10:23 a.m., observations were made of RI #2's room and found there were no grip strips applied in front of the resident's chair nor were there grip strips observed on RI #2's bedside. On 06/15/2017 at 10:28 a.m., an interview was conducted with EI (Employee Identifier) # 9, Registered Nurse (RN) Unit Manager. EI #9 made an observation of RI #2's room. EI #9 was asked did she see any grip strips in RI #2's room. EI #9 replied, No they are not. EI #9 was asked to review RI #2's Care Plan for falls. EI #9 was asked what RI #2's interventions were for falls. EI #9 said, Grip strips on bedside and in front of (his/her) chair. EI #9 was asked were they there when she made her observation. EI #9 replied, No ma'am. EI # 9 was asked why not. EI #9 said, They waxed (his/ her) floor last week. EI #9 was asked who was responsible for ensuring the interventions such as grip strips were implemented. EI #9 said she was. EI #9 was asked was RI #2's Care Plan for falls regarding the use of grip strips followed. EI #9 said, Not today. EI #9 was asked why should the grip strips have been in front of RI #2's chair and on the bedside. EI #9 replied, To prevent falls. EI #9 was asked why were the grip strips implemented as an intervention for RI #2. EI# 9 stated, Because (he/she) gets up on (his/her) own and to prevent (his/her) from slipping. EI #9 was asked what was the potential harm of RI #2 not having grip strips as indicated on his/her Care Plan in front of his/her chair and the bedside. EI #9 explained he/she could fall.

Based on interviews, observation, medical record review and review of a facility policy titled, Pharmacy Services the facility failed to ensure the labeling on Resident Identifier (RI) #16's medication of Chlordiazepoxide 5 mg (milligrams) had an order changed refer to MAR (Medication Administration Record) label on the medication card indicating the medication frequency had been changed from Q 8 hrs (every eight hours) to BID (twice a day). This affected one of five residents observed for a medication pass. Findings Include: A review of a facility policy titled, Pharmacy Services, with a date of 03/2011 revealed the following: .Procedures . E. (1) Labels are permanently affixed to the prescription container b. Improperly or inaccurately labeled medications should be addressed. If the physician's directions for use change, the nurse may place an order changed refer to MAR indicated [REDACTED]. On 06/14/2017 at 8:00 a.m., the following information was observed on a medication card during a medication pass on RI #16, .CHLORDIAZEPOXIDE 5 MG CAPSL (Capsule) . Give 1 CAPSULE BY MOUTH EVERY 8 HOURS . A review of RI #16's June 2017 Physician order [REDACTED]. CHLORDIAZEPOXIDE 5 MG CAPSULE GIVE ONE CAPSULE PO (BY MOUTH ) BID . A review of RI #16's June 2017 MAR indicated [REDACTED].CHLORDIAZEPOXIDE 5 MG CAPSULE GIVE ONE CAPSULE PO BID . On 06/14/2017 at 3:00 p.m. an interview was conducted with EI #1 the Director of Nursing. EI #1 was asked what was the facility's policy and procedure on labeling of medication card when a medication dose, time or frequency is changed. EI #1 said flag the card, use dot system or change of record sticker and notify pharmacy. EI #1 was asked what the frequency or schedule of RI #16's Chlordiazepoxide 5 mg should be according to the physician orders. EI #1 stated, Says 5 mg cap give 1 cap po BID. EI #1 was asked what the labeling instruction says on RI #16's Chlordiazepoxide 5 mg medication. EI #1 replied, Q 8 hrs. EI #1 was asked was there a sticker or dot on the label indicating a frequency change. EI #1 stated, No. EI #1 was asked what was the harm in not having the correct labeling on a medication that did not match the physician orders. EI #1 replied there was not a sticker indicating but nurses still need to check the right dose.

Based on observation and interviews, the facility failed to ensure that the humidifier in Room Locator (RL) #15 was free of dust and exposed wires. This affected one of two humidifiers observed in the facility. Findings Include: On 6/12/2017 at 5:10 p.m., the surveyor observed an Energy Star Humidifier in RL #15 plugged into an outlet with exposed white, green, and black wires and dust on the front vents. On 6/13/2017 at 8:53 a.m., the surveyor observed the humidifier in RL #15 plugged into the outlet with exposed white, green, and black wires and dust on the front vents. On 6/14/2017 at 7:35 a.m., the surveyor observed the humidifier in RL #15 plugged into the outlet with exposed white, green, and black wires and dust on the front vents. On 6/14/2017 at 3:30 p.m., an interview was conducted with Employee Identifier (EI) #7 Assistant Maintenance Supervisor. EI #7 was asked what he saw on the humidifier. EI #7 said, I see exposed white, green, and black wires, not good. Dust in vent. EI #7 was asked how often the humidifiers were supposed to be cleaned. EI #7 responded, I would say about once a month. EI #7 was asked when was the last time the humidifier was serviced or inspected. EI #7 stated, I could not tell you. EI# 7 was asked what was the potential for harm in having exposed wires and dust on the humidifier. EI #7 stated, Electrical shock and allergies [REDACTED].>On 6/14/2017 at 4:00 p.m., an interview was conducted with EI # 8; Floor Tech. EI #8 was asked what he could see on the humidifier and EI #8 responded, Wires and dust. EI #8 was asked how often should the humidifiers be serviced and cleaned and EI # 8 replied, Mostly every day. EI #8 was asked when was the last time the humidifier was cleaned and serviced. EI #8 responded, We emptied the water couple days ago. EI #8 was asked what the potential harm was in having exposed wires and dust build up on vents to a humidifier. EI #8 stated, Electrical shock.

Based on observation, record reviews, and interviews, the facility failed to ensure RI (Resident Identifier) #4 was provided privacy by pulling a privacy curtain between two residents during incontinence care for RI #4. This was observed on one of two residents observed for incontinence care. Findings include: A review of POTTER & PERRY Fundamentals of Nursing, 7th Edition, page 877, Chapter 39 revealed: Perineal Care . Step 7. Pull curtain around client's bed, or close door. Rational . Maintains client's privacy . A review of a facility's document titled: Perineal Care, with an effective date of October 1, 2010, revealed, PURPOSE: . PROCESS: I. General A) Explain procedure to the resident, screen for privacy . A review of the medical record for RI #4, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The review of RI #4's Significant Change MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 06/03/2016, revealed RI #4 had severe cognitive impairment for daily decisions making. RI #4 was also coded as always incontinent of bowel and bladder. An observation of incontinence care for RI #4 was performed on 8/03/2016 at 4:05 p.m., by EI (Employee Identifier) #1, a CNA (Certified Nursing Assistant), and assisted by a second CNA, EI #2. The 2 CNAs entered RI #4's room to provide incontinence care. After the completion of the incontinence care, EI #2 pulled the privacy curtain between the two residents. At that time, the surveyor asked EI #2 when was the privacy curtain pulled between the two residents. EI #2 replied just now. EI #2 also replied it should have been pulled before they started the incontinence care. An interview was conducted on 8/03/2016 at 6:10 p.m. with EI #1. EI #1 was asked how does she provide privacy for a resident when she provided incontinence care. EI #1 stated she should pull the privacy curtain around the resident and close the blinds. EI #1 was asked how did she provide privacy for RI #4 during the above incontinence observation. EI #1 stated the curtain was supposed to be pulled between her/him and the other resident. EI #1 was asked what was the concern when privacy was not provided for RI #4 during incontinence care. EI #1 responded, indecent exposure. An interview was conducted with EI #2, on 8/04/2016 at 11:35 a.m. The surveyor shared the observations and asked EI #2 what was the concern regarding not pulling the privacy curtain between two residents while incontinence care was provided. EI #2 responded because it was a patient and it gives the best quality of care that staff can give, it gives them (resident) peace of mind that the care given by staff was private, and staff taking care of them without having the other patient watching what staff was doing. An interview was conducted with EI #5, the Staff Development Nurse, on 8/04/2016 at 10:58 a.m. EI #5 was asked how were staff trained on providing privacy for a resident. EI #5 responded privacy curtains were closed, blinds were closed, and the doors were closed. On 8/04/2016 at 11:09 a.m., an interview was conducted with EI #6, the DON (Director of Nursing). EI #6 was asked how were staff trained on providing privacy for a resident. EI #6 responded EI #5 (Staff Development Nurse) was the main educator. EI #6 replied they shadow staff and it depended on the employee's job title. EI #6 was asked during incontinence care how should dignity/privacy be maintained. EI #6 responded, blinds should be closed, the curtains pulled, and the doors shut.

Based on observations, interviews, and record review, the facility failed to ensure: 1) A sink was not missing caulking at the upper back of the sink, and the sink was secured on two of three survey days. This affected AL (Area Locator) #1. 2) A bathroom door frame was not found with missing paint and rusted areas on two of three survey days. This affected AL #1. 3) A toilet seat surface was not found with worn and missing paint on two of three survey days. This affected AL #1. 4) A toilet was not found with rust at the base of the bowl and not secure. This affected AL #2 and was observed on three of three survey days. The above was observed on one of four halls. Findings Include: A review of a facility document, with an effective date of March 1, 2010, revealed: PREVENTATIVE MAINTENANCE MANUAL . Policy Title: Preventive Maintenance Strategy . PURPOSE: The Facilities Maintenance Department's major goal is to schedule and perform preventive maintenance for all equipment and the facility physical plant, so that breakdown or failure is avoided. STANDARD: All essential mechanical, electrical, and resident care equipment should be maintained in a safe operating condition, through an effective preventive maintenance program. Preventive maintenance should be performed by the facility maintenance department. Three types of maintenance may be identified: 1. Preventive Maintenance - maintenance done on a scheduled routine basis with the emphasis on prevent maintenance problems, rather that correcting existing problems. It will lower the rate of failures, decrease severity of failures, increase efficiency, protect assets, and add to safety. 1, 2 and 3) An observation was made at 4:15 p.m. on 8/2/2016 of a worn toilet seat with paint missing in AL (Area Locater) #1. The sink moved and was not secured to the wall. The door frame had missing paint and rusted areas. 1, 2 and 3) An observation was made at 10:40 a.m. on 8/3/2016 in AL #1. The sink moved and was not secured to the wall. The door frame had missing paint and rusted areas. 1, 2 and 3) An observation as made at 6:15 p.m. on 8/3/2016 in AL #1. The sink moved and was not secured to the wall. The door frame had missing paint and rusted areas. An interview was conducted with EI #1, a CNA (Certified Nurse Assistant), on 8/3/2016 at 6:15 p.m EI #1 was asked to describe the sink area, toilet seat, and the door frame of AL #1. EI #1 stated the back of the sink was pulling away from the wall and rust was on the door frame close to the toilet. The toilet seat was missing paint on the left side of the seat. EI #1 was asked how were concerns in resident's room reported. EI #1 stated they were written in a maintenance book and the charge nurse was notified. EI #1 was asked what was the concern with the above observations in AL #1. EI #1 said the sink could fall from the wall and break. A resident could hit their leg on the door frame, could be cut, and the toilet seat could crack or splinter, causing an injury to the resident. An interview was conducted with EI #3, the Maintenance Supervisor, at 8:05 a.m. on 8/4/2016. EI #3 was asked who was responsible for the maintenance of the residents' restrooms. EI #3 said the Maintenance department. EI #3 was asked when was the last time he provided maintenance to the restroom fixtures in AL #1. EI #3 stated yesterday afternoon, after being made aware of the issues. EI #3 was asked what was the potential harm for a resident if their sink is loose and wobbles when touched. EI #3 answered, the sink was secure because the screws were tight. He indicated the caulking had come loose. An interview was conducted with EI #4, the Administrator, at 11:20 a.m. on 8/4/2016. EI #4 was asked who was responsible for the maintenance of residents room. EI #4 answered the Maintenance Department, supervisor, and assistant. EI #4 was asked what was the concern of a sink not secured to the wall and wobbly, a toilet seat with a worn area missing paint, and a door frame missing paint with rusted areas near the toilet. EI #4 replied there was a possibility of the sink falling. There could be a splinter from toilet seat and the resident could possibly be scratched from the door frame. 4) On 8/02/2016 at 11:32 am, an observation was made of AL #2. The toilet was rusted and not secured at the base. On 8/03/2016 at 10:16 a.m., an observation was made of AL #2. The toilet was rusted and not secured at the base. On 8/04/2016 at 9:22 a.m., an observation was made of AL #2. The toilet was rusted and not secured at the base. On 8/03/2016 at 8:13 a.m., an interview was conducted with EI #1. EI #1 was asked if she provided care for the residents in AL #2. EI #1 responded yes. The surveyor and EI #1 walked to AL #2 and the toilet bowl was observed. EI #1 was asked what was the concern for a resident when the toilet wobbled when used. EI #1 responded they (resident) could fall. EI #1 was asked how did she report problems in resident's rooms. EI #1 said she told the charge nurse and wrote in the concern in the maintenance book. On 8/04/2016 at 9:22 a.m., an interview was conducted with EI #3, the Maintenance Supervisor. EI #3 was asked who was responsible for the maintenance in the residents' rooms and bathroom. EI #3 responded, maintenance. EI #3 was asked how maintenance was notified if there was a concern in a resident's room or bathroom. EI #3 stated maintenance log books were kept at each nurses station. EI #3 was asked to describe how the facility routinely checked for environmental issues in residents' rooms and bathrooms. EI #3 responded rounds were made every morning. The surveyor and EI #3 walked into AL #2 and the concern was observed by EI #3. EI #3 was asked what was the concern when a toilet was not secured. EI #3 stated it would not turn over.

Based on observations, interviews, and record reviews, the facility failed to ensure a licensed nurse observed during medication pass: 1. Did not handle a medication capsule with her bare hands. 2. Did not close the privacy curtain with gloved hands prior to administering G (Gastrostomy)- Tube medications. These deficient practices affected (Resident Identifier), RI #16, and one of eight licensed nurses observed during medication pass. Findings include: A review of Potter and Perry, Fundamentals of Nursing Seventh Edition, with a copyright date of 2009, Chapter 35, page 721. revealed: .Medication Administration . STEPS . h. To prepare tablets or capsules . Do not touch medication with fingers . Rationale Maintain clean technique required of medication administration. A review of Potter and Perry, Fundamentals of Nursing Seventh Edition, with a copyright date of 2009, Chapter 34, page 655, revealed: .The CDC (Centers for Disease Control and Prevention) recommends the following: .2. If hands are not visibly soiled, use an alcohol-based waterless antiseptic agent for routinely decontaminating hands in the following clinical situations: . e. After contact with inanimate objects (including medical equipment) in the immediate area of the client . The review of a facility document titled, Infection Prevention & Control Manual, with the effective date of [DATE], revealed: PURPOSE: To provide guidelines to employees for proper and appropriate hand washing techniques that will aide in the prevention of the transmission of infections. STANDARD: Hand washing should be performed between procedures with residents based upon the principle that all blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucus membranes may contain transmissible infectious agents. A review of RI #16's medical record revealed the resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #16's MDS (Minimum Data Set), with the ARD (Assessment Reference Date) of 6/23/16, revealed RI #16 had long and short term memory problems and was severely impaired for daily decision making skills. During a medication administration observation on 8/02/16 at 4:30 p.m., Employee Identifier (EI) #7 was observed to prepare medications for RI #16. EI #7 opened a capsule with her bare hands prior to administering the medication to RI #16 via [DEVICE]. EI #7 then washed her hands, applied gloves, and then pulled the privacy curtain. EI #7 proceeded to administer medications via [DEVICE]. On 8/02/16 at 4:45 p.m., an interview was conducted with EI #7. The surveyor asked EI #7 how she opened the capsule for RI #16. EI #7 said she opened it with her bare hands. She stated she should have used gloved hands. The surveyor asked EI #7 if she used gloved hands to pull the curtain prior to administering medications to RI #16. EI #7 stated she should have pulled the curtain and then applied her gloves. An interview was conducted on 8/04/16 at 7:50 a.m., with EI #5, the Staff Development Nurse of the facility. EI #5 was asked how should a nurse open a capsule prior to administration of the medication to a resident via [DEVICE]. EI #5 stated, I would say in my opinion, I know you can't touch meds (medications) . I would have to say with gloves. The surveyor asked EI #5 what was the concern when the privacy curtain was closed with gloved hands and then [DEVICE] medications were administered. EI #5 said she would make sure curtains were pulled and blinds were closed, wash her hands and administer medications. She stated she would also use hand sanitizer, and put her gloves on. An interview was conducted on 8/04/16 at 9:40 a.m., with EI #6, the Director of Nursing of the facility. EI #6 was asked how should a nurse open a capsule prior to administration of the medication to a resident via [DEVICE]. EI #6 said it would be proper to wear gloves. The surveyor asked EI #6 what was the concern when the privacy curtain was closed with gloved hands and then [DEVICE] medications were administered. EI #6 stated, Contamination.

Based on an observation, interviews, and record reviews, the facility failed to ensure the CNA (Certified Nursing Assistant) provided incontinence care in a manner to prevent the potential for cross contamination. This affected RI (Resident Identifier) #6, one of two residents observed for incontinence care. Findings include: A review of the facility's policy and procedure titled, Perineal Care, with an effective date of October 1, 2010, revealed: PURPOSE: Good perineal care helps prevent infection, irritation and skin breakdown. STANDARD: Residents who are incontinent of urine or feces should receive perineal care as needed. Residents should receive perineal care during routine baths or showers. PROCESS:. II. Female Resident a) Wash the pubic area first. Separate the labia and wash downward on each side of the labia using different corners of the wash cloth. Wash downward in the middle over the urethra and vaginal openings. Always wash downward toward the anus to prevent the spread of infection. b) Wash the anal area, moving upward toward the back. Rinse, dry and inspect the perineal area and then the anal area. A review of the medical record for RI #6 revealed RI #6 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #6's Annual MDS Minimum Date Set), with an ARD Assessment Reference Date)of 07/22/2015, revealed, RI #6 had short and long term memory problems and had moderate cognitive impairment. RI #6 was always incontinent of bowel and bladder and was totally dependent on staff for toileting. RI #6 was coded as requiring extensive two person assistance with bathing, dressing, and bed mobility. An observation of incontinence care for RI #6 was done on 08/05/15 at 9:30 AM, by EI (Employee Identifier) #6, a CNA. EI #6 wiped the front of RI #6's perineal area from top to bottom on the right side, the left side, and then down the middle of the perineal area. EI #6 used a different disposable wipe with each stroke, but she did not open RI #6's labia while cleaning the front of the perineal area. RI #6 was turned to the right side. RI #6 had expelled a large amount of dark brown stool. EI #6 cleaned the stool off of RI #6's bottom by wiping from back to front toward the front of the resident's perineal area. EI #6 cleaned the right buttocks twice, then the left buttocks twice with separate disposable wipes from back to front. EI #6 wiped three times with separate disposable wipes between the buttocks fold from back to front. EI #6 wiped between the buttock fold three times with separate wipes, until all of the stool was removed from the buttocks fold. EI #6 then wiped from back to front in the labia area twice while removing stool from the area. EI #6 cleaned the resident by wiping a total of nine times from back to front during the incontinence care observation. An interview was conducted on 08/05/2015 at 10:40 AM, with EI #6. EI #6 was asked how the staff were taught to provide perineal care for a female resident. EI #6 stated they were taught to go side to side, middle, and across the front, then clean each buttock and the top of the buttock. The surveyor asked EI #6 when did she open the labia while cleaning the front of RI #6's perineal area. EI #6 stated that she didn't open the labia. She stated she knew the labia was supposed to be opened to clean it. She indicated she was nervous. EI #6 was asked what direction she wiped while cleaning the stool off of the bottom of RI #6's buttock. EI #6 stated that she could not remember. EI #6 then demonstrated, and said she went back to front. EI #6 was asked what the potential negative outcome would be when a resident was cleaned from back to front, toward the labia, especially when stool was removed from the resident's bottom. EI #6 replied UTIs (Urinary Tract Infections) and infection. An interview was conducted on 08/06/2015 at 11:15 AM, with EI #1 the DON (Director of Nursing), and Infection Control Coordinator of the facility. The surveyor asked EI #1 how staff were trained to provide incontinence care for a female resident. EI #1 replied a nurse from Staff Development did the training. She stated the staff development nurse taught incontinence care like it was a sterile procedure. EI #1 was asked how the staff members were taught to clean stool off of the bottom of a resident and what direction they should wipe. EI #1 stated the staff members were taught to wipe away from the direction of the vagina. The surveyor asked what the concern would be if the labia was not opened while cleaning the front of a female resident. EI #1 answered infection or the potential for infection. EI #1 was asked what the concern would be when a resident was cleaned from back to front while removing stool from a resident's bottom. EI #1 stated it increased the potential for infection when the resident was not wiped properly.

Based on observations, interviews, and record reviews, the facility failed to ensure staff members practiced infection control guidelines for a resident on contact isolation with a [DIAGNOSES REDACTED]. This affected RI (Resident Identifier) #18, one of one residents for isolation precautions. Findings include: A review of a facility policy titled, INFECTION PREVENTION & (and) CONTROL MANUAL . 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, excretions and secretions other than sweat will be considered potentially infectious; 2) Standard Precautions will be used on all residents. PERSONAL PROTECTIVE EQUIPMENT (PPE) I. PPE is provided to all employees. Each employee is responsible for knowing where the equipment is kept in the department. II. The type of protective barriers (s) should be appropriate for the procedure being performed and the type of exposure anticipated. III. PPE available includes gloves, gowns or aprons, masks and eye protection (or face shields), and . A review of a facility policy titled, INFECTION PREVENTION & CONTROL MANUAL . Contact Precautions, with an effective date of Dec. 1, 2009, revealed, .PURPOSE: It is the intent of this facility to use contact precautions in addition to Standard Precautions for resident known or suspected to have serious illnesses easily transmitted by direct contact or by contact with items in the resident's environment. II. GLOVES AND HAND HYGIENE Hand hygiene should be completed prior to donning gloves. A. Gloves should be worn when entering the room and while providing care for the resident. C. Gloves should be removed before leaving the resident's room and hand hygiene should be performed immediately. D. After glove removal and hand hygiene, hands should not touch potentially contaminated environmental surfaces or items. III. GOWNS A gown should be donned prior to entering the room or resident's cubicle. A. The gown should be removed before leaving the resident's room. B. After removal of the gown, clothing should not contact potentially contaminated environmental surfaces. VI. CONTACT PRECAUTIONS MAY BE CONSIDERED FOR (EXAMPLES); Multi-drug resistant organisms (e.g. {example gratia}, MRSA, VRE {[MEDICATION NAME] Resistant [MEDICATION NAME]}) . A review of a facility policy titled, INFECTION PREVENTION & CONTROL MANUAL Section: Precautions, Policy Title: Multidrug Resistant Organism (MDROs), with an effective date of Dec. 1, 2009 revealed, .Purpose: To prevent transmission of Multi-drug resistant organisms (MDROs). Policy: Prevention, containment and eradication measures including use of contact precautions are indicated to prevent the spread of resistant microorganisms that have been identified within a facility. I. GENERAL MEASURES: A. Prevention and control of MDROs within this facility is considered a resident safety measure. II. ISOLATION PRECAUTIONS (for residents with known or suspected MDRO infection/colonization): Standard precautions shall be used during all resident encounters. C. Contact Precautions shall be considered for residents infected or colonized with an MDRO. A review of the current medical record for RI #18 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Discharge Summary from the hospital for RI #18, with a discharge date of [DATE], revealed, REASON FOR ADMISSION: Wound Infection. BRIEF HISTORY/PHYSICAL: See History and Physical for full details. (RI #18) comes back in with a wound infection of the right hip. HOSPITAL COURSE: . (RI #18) did grow staph in (the) blood stream . A review of Physician order [REDACTED]. A review of a care plan for RI #18 dated 7/23/15, revealed, Problem/Need(:) Isolation R/T (related to) MRSA RT (right) HIP SURGICAL WOUND with an intervention of CONTACT ISOLATION AS ORDERED. An observation was made during the initial tour of the facility on 8/04/15 at 7:41 AM of RI #18's room and surrounding doorway. Upon exiting the room, two large red trash cans with red bags in them were noted. No sign was found to alert persons entering the room that isolation precautions were in effect. The black cart outside the room had gloves on the second shelf and a small bottle of hand sanitizer on the top shelf. Inside the doors of the bottom shelf was a box of red disposal bags. No sign or other identifying markings were found on the cart to indicate isolation precautions were in effect. An observation was made on 8/04/15 at 12:07 PM of RI #18's room and doorway. No sign or warning of isolation precautions was noted. A visitor was observed entering and exiting the room. The plain black cart remained outside the resident's room. An observation was made on 8/04/15 at 2:41 PM of RI #18 in bed (seen from the open door). There was no sign on the resident's door regarding isolation precautions. The plain black cart outside the resident's room was noted to have 1 box of gloves and an empty meal tray on it. An observation was made on 8/04/15 at 6:08 PM from the open doorway of RI #18 in bed. A visitor was seated in a chair next to the resident's bed. The visitor was not wearing any PPE. There were no signs present to indicate isolation precautions were in effect. During this observation, EI (Employee Identifier) #4, a CNA, (Certified Nursing Assistant), entered RI #18's room. Prior to entering RI #18's room, EI #4 donned a pair of gloves outside of the room that were on the cart outside of RI #18's room. EI #4 did not wash her hands prior to donning the gloves and entering RI #18's room. An observation was made on 8/05/15 at 7:44 AM of a sign on the door of RI #18's room that read, (Name of facility) Please check at Nurses Station Before entering Room. An interview was conducted on 8/04/15 at 6:11 PM with EI #4. EI #4 was asked if RI #18's room was on isolation. She answered, Yes, MRSA of hip. EI #4 was asked if there were any signs up to indicate isolation precautions. She answered, No Ma'am there are red buckets. EI #4 was asked where were the buckets located and she answered, Inside the room. A subsequent interview was conducted with EI #4 on 8/06/15 at 10:45 AM. EI #4 was asked what precautions were in place. She answered no contact, wear gloves and red bags. EI #4 indicated linen was in one red bag and garbage was in the other. EI #4 stated hand sanitizer was on the cart. EI #4 was asked when should hand sanitizer be used. She answered before and after going in (the room). EI #4 was asked what the facility's policy indicated should be in place for a resident with MRSA of the wound and blood. EI #4 answered, The sign was supposed to be up and it wasn't. EI #4 was asked if there was anything else indicated. She answered, Protected going in and out, so you glove up. No contact. Could be apron. EI #4 was asked if staff should depend on visualizing barrels with red bags inside a room to know that a patient was on isolation and she answered, No. When asked how staff and guests should be alerted regarding isolation, EI #4 referred to her previous answer that a sign was supposed to be up. EI #4 was asked what supplies should be available outside of RI #18's room. She answered gloves, hand sanitizer, red bags, and aprons. EI #4 was asked what PPE she used when entering RI #18's room on 8/04/15 at 6:11 PM. She answered gloves. When asked why, EI #4 stated to protect herself from getting something. EI #4 was asked what could be the potential negative outcome of staff and guests entering and exiting RI #18's room with no precautions in place or PPE in use. EI #4 answered it could spread the infection. An interview was conducted with EI #2, a Licensed Practical Nurse (LPN), on 8/06/15 at 11:14 AM. EI #2 was asked what was the reason for isolation precautions for RI #18. She answered (RI #18) had MRSA on right hip surgery. EI #2 was asked what precautions were in place. She answered contact isolation. EI #2 was asked what the facility's policy indicated should be in place for a resident with MRSA of the wound and blood. She answered before going into the room, wash hands, put on isolation gear, gloves and a gown. EI #2 then stated be sure not to take anything into the room because staff can't bring it back out. EI #2 was asked how should staff and guests be alerted regarding isolation precautions. She answered staff from report. Guests, there should be a sign on the door to check with the Nurse before entering. EI #2 was asked what supplies should be available outside of RI #18's room. She answered there should be gloves, gowns, at least hand sanitizer. EI #2 was asked what could be the potential negative outcome of staff and guests entering and exiting RI #18's room with no precautions in place or PPE in use. EI #2 answered it could spread throughout the facility or to self. Guests could spread it to the public. An interview was conducted with EI #3, a CNA, on 8/06/15 at 11:22 AM. EI #3 was asked what was the reason for isolation precautions for RI #18. She answered (RI #18) had an infection in (RI #18's) hip. EI #3 was asked if she knew what kind of infection. She answered, I have no idea. EI #3 was asked if this was discussed at shift change. She answered, Yes ma'am. EI #3 was asked what she had been told about the infection. She answered all she had been told was a blood culture had been done but they didn't tell what kind of infection it was. EI #3 was asked what the sheet used during shift change indicated. She answered, It says contact. EI #3 was asked what precautions were in place and she answered gloves and hand sanitizer. EI #3 was asked what the facility's policy indicated should be in place for a resident with MRSA of the wound and blood. She answered wash her hands, put gloves on, if clothes are going to touch the resident, staff should put a gown on. EI #3 was asked how should staff and guests be alerted regarding isolation precautions. She answered a sign on the door. EI #3 was asked what supplies should be available outside of RI #18's room. She answered gloves, gowns, mask, hand sanitizer, red and clear bags. EI #3 was asked what supplies did she use prior to entering RI #18's room on 8/06/15 and she answered gloves. When asked why, EI #3 answered (RI #18) was on isolation. EI #3 was asked if she used any other PPE. She answered, No Ma'am. EI #3 was asked what could be the potential negative outcome of staff and guests entering and exiting RI #18's room with no precautions in place or PPE in use. EI #3 answered it could spread to other people. The guest could spread it to other people. An interview was conducted with EI #1, the Director of Nursing/Infection Control Nurse, on 8/06/15 at 11:25 AM. EI #1 was asked why was RI #18 on isolation. She answered, I believe (RI #18) has MRSA of the wound. RI #18 actually has MRSA of the wound and blood. EI #1 was asked what isolation precautions were in place for RI #18. She answered MRSA of the wound was contact precautions. EI #1 was asked what does the facility policy indicate should be in place for a resident with MRSA of the wound. She answered contact precautions. EI #1 was asked if staff should depend on visualizing barrels with red bags inside a room to know that a patient was on isolation. She answered no and that a report was given to staff. The LPNs give reports. LPN give reports to CNAs. The family and staff were aware. EI #1 was asked how the room of a resident with MRSA would be identified. She answered staff, family, dietary, and housekeeping, . were all aware. EI #1 indicated they (facility) used to (post signs) before HIPPA (Health Insurance Privacy Portability Act). They could post signs on the doors, but since HIPPA's guidelines were enforced, the facility had to be very cautious about things posted. EI #1 was asked what supplies should be available outside RI #18's room. EI #1 answered they could have a cart beside any isolation room. The cart would have Isogel (hand sanitizer), gloves, special laundry bags, and they may put gowns on in case there was drainage or bleeding from the wound. EI #1 indicated gowns would be optional. The gowns would be available in case they were needed if the drainage started. EI #1 was asked what could be the potential negative outcome of guests and staff entering and exiting RI #18's room with no precautions in place or PPE in use. EI #1 stated contact isolation was having basically gloves on hand for (RI #18's) situation. EI #1 further stated, Potential for spread. EI #1 was asked why was the sign placed on the door on 8/05/15. She answered someone must have noticed it and put it up. She indicated they like to have it there.

Based on an observation, interviews, and record review, the facility failed to ensure a dietary staff member on the tray line, on 9/17/14, washed hands and donned a clean pair of gloves, after picking up an item off of the floor prior to resuming plating food. This had the potential to affect 164 residents served meals from the kitchen. Findings include: A review of the FOOD CODE U.S.(United States) PUBLIC HEALTH SERVICE FDA (Food and Drug Administration) 2013 revealed, Chapter 2 2-3 entitled, "PERSONAL CLEANLINESS ... 2.301.14 When to Wash ... (H)Before donning gloves to initiate a task that involves working with FOOD; and (I)After engaging in other activities that contaminate the hands." On 9/17/14 at 12:22 PM, during an observation of the lunch tray line, a plastic soup bowl lid fell to the floor. EI (Employee Identifier) #9, a dietary staff member that was plating food, stopped plating food, picked up the lid off of the floor and then resumed plating food without washing her hands and changing gloves. On 09/18/14 at 9:20 AM, an interview was conducted with EI #9. EI #9 was asked what the purpose of wearing gloves was while plating food. EI #9 stated, "So you won't contaminate it (food) with your hands." EI #9 was asked when gloves were supposed to be changed. EI #9 stated, "Every use just about, like when ... taking out trash and ... come back in ... take gloves off." EI #9 also stated, "If you're in the serving line and you have to go back and make a sandwich you take them off, touching raw meat, after vegetables, everything." EI #9 was asked when should hands be washed. EI #9 stated, "Before you plate it (food), then put on gloves and serve." EI #9 was then asked if she removed her gloves and washed her hands after she picked up a plastic lid off of the floor. EI #9 stated, "No." EI #9 was asked why not. EI #9 stated, "I wasn't thinking." EI #9 was asked what the potential negative outcome would be for residents if gloves were not changed and hands were not washed while plating food after an item was removed from the floor. EI #9 stated, "They may get sick, bacteria." On 09/18/2014 at 9:35 AM, an interview was conducted with EI #10, the Dietary Manager. EI #10 was asked how many trays were served from the kitchen at any one meal. EI #10 stated, "164 in house." EI #10 was asked what were employees taught on the purpose of wearing gloves and when should gloves be changed. EI #10 stated, "To, you know, not to have bare hand to food contact, when you do something, ..., when you're doing this and you do something else ..." EI #10 was asked what the potential negative outcome was for residents if an employee, while plating food, picked up an item off of the floor and resumed plating food without washing their hands and changing gloves. EI #10 stated, "Infection control of course, germs getting on food."

Based on observations, interviews, and record reviews, the facility failed to ensure: 1) A CNA (Certified Nursing Assistant) opened the labia and spread the buttocks for RI (Resident Identifier) #10 during incontinence care 2) A CNA checked and cleaned the front of the perineal area while providing incontinence care for RI #6. 3) A CNA changed gloves and washed her hands after removing stool from RI #14 during incontinence care, and checked and cleaned the front of RI #14's perineal area. CNAs did not change gloves and wash their hands between providing incontinence care, repositioning and covering RI #14. 4) A CNA did not clean RI #8's bottom, by wiping in a back and forth motion during incontinence care. CNAs did not change gloves and wash their hand between providing incontinence care, transferring, and making the bed for RI #8. This affected RI #(s) 6, 8, 10, and 14, four of four residents observed for incontinence care. Findings include: A review of, "POTTER & PERRY... Fundamentals of Nursing...7th Edition...reprint 2009," revealed: "...page- 878 and 879...39-2...Perineal Care... 3. Apply clean gloves, ... Perform hand hygiene... 15. Provide Perineal care Wipe in direction from perineum to rectum (front to back). Repeat on opposite side using separate section of washcloth. Rinse and dry thoroughly... 17. Remove clean gloves, dispose in proper receptacle, and perform hand hygiene. 18. Assist client in assuming a comfortable position, and cover with sheet. Raise side rails appropriately. ..." A review of the facility's document with an effective date of October 1, 2010, revealed: "Section: Basic Care Procedures Policy Title: Perineal Care ... PURPOSE: Good Perineal care helps prevent infection, irritation and skin breakdown ... PROCESS: II. Female Resident a) Wash the pubic area first. Separate the labia and wash downward on each side of the labia using a different corner of the wash cloth. Wash downward in the middle over the urethra and vaginal openings. Always wash downward toward the anus, to prevent the spread of infection. b. Wash the anal area, moving upward toward the back. ... III. Male Resident a) Wash the penis from the urethra opening or tip of the penis and then wash the scrotum ... Pull back the foreskin on uncircumcised males and clean under it. Return the preskin. b) Turn resident onto side. Wash, rinse and dry the anal area, moving upward toward the back. ..." A review of the facility's policy on Infection Prevention with an effective date of December 2009 revealed: "Section: General Infection Prevention & Control Policies... Policy Title: Hand Hygiene. ... PURPOSE: To provide guidelines to employees for proper and appropriate hand washing techniques that will aide in the prevention of the transmission of infections. STANDARD: Hand washing should be performed between procedures with residents based upon the principle that all blood, body fluids, secretions, excretions, (except sweat) non-intact skin, and mucous membranes may contain transmissible infectious agents. ..." 1. A review of RI #10's medical record revealed the resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #10's Annual MDS (Minimum Data Set), with an ARD(Assessment Reference Date) of 8/1/14, revealed RI #10 was severely impaired for cognitive decision making skills. This MDS also indicated RI #10 required extensive to total assistance with all ADLs (Activities of Daily Living). RI #10 was incontinent of bowel and bladder. On 09/17/14 at 8:55 AM, an observation was made of incontinence care for RI #10. The incontinence care was performed by EI #3, and assisted by EI #4, both CNAs. EI #3 removed the brief from the front of RI #10. EI #3 used disposable wipes and wiped the right groin in a downward motion and discarded the wipe, then wiped the left groin in a downward motion, and discarded the wipe. EI #3 wiped the lower portion of RI #10's abdomen from right to left, and discarded the wipe. EI #3 did not open the labia for RI #10. RI #10 was rolled on to the left side and EI #3 wiped RI #10's left buttock in an upward motion, then the right buttock in an upward motion. The brief was then completely removed and another brief placed. RI #10 was rolled to the right side, and EI #4 pulled the brief to that side. The brief for RI #10 was secured. EI #3 did not open, or clean between RI #10's buttocks. The resident was placed on the left side and a wedge was placed. On 9/17/14 at 12:43 PM, an interview was conducted with EI #3. EI #3 was asked when she last had training for incontinence care, and she replied, "Three weeks ago." EI #3 was asked how had she was instructed to provide perineal care. EI #3 stated, "Wipe one time on one side, throw wipe away, do the other side the same way, and then clean the center downward. Turn them (residents) over, wipe one cheek, throw away (wipe), wipe the other cheek and throw away. Then wipe across the sacrum and throw (wipe) away. Then put the diaper on." The surveyor asked if the labia should be separated and cleaned. EI #3 stated, "Yes ma'am." EI #3 was asked why, and she replied, "You don't know what's in between there. If they have peed (urinated), you do it too. You have to keep them clean." The surveyor asked if the buttocks should be separated and the anal area cleaned, and EI #3 replied, "Yes ma'am." EI #3 was asked why, and EI #3 stated, "To make sure you get everything clean. If they are not cleaned, they could get a rash." EI #3 was asked how she cleaned RI #10 during the above observation. EI #3 stated, "I didn't do it right. The other CNA was supposed to hand me the wipes. I guess we were nervous. ..." EI #3 was asked what the potential harm was of not separating the labia and buttocks and cleaning, when providing incontinence care. EI #3 stated, "It's not done right. It could have been something left there. They might get a rash, just like a baby." On 9/18/14 at 11:25 AM, an interview was conducted with EI #8, the Infection Control Nurse. The surveyor asked EI #8 if the labia and buttocks should be separated and the areas cleaned, during incontinence care. EI #8 stated, "Yes. To prevent infection." EI #8 was asked what could be the potential harm of not separating the labia during incontinence care, and she replied, "Infection and skin issues." EI #8 was asked what could be the potential harm of not separating the buttocks during incontinence care, and she responded, "Excoriation and skin problems." 2) A review of the medical records revealed RI #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Annual MDS for RI #6, with an ARD of 9/3/14, revealed a BIMS (Brief Interview for Mental Status) score of 3 out of a possible 15 points. This indicated RI #6 was severely impaired of cognitive skills for daily decision making. RI #6 required total assistance with all ADLs. RI #6 was always incontinent of bowel and bladder. On 9/17/14 at 8:57 AM, incontinence care for RI #6 was observed. EI #11 and EI #16, both CNAs, entered the room and turned RI #6 to the right side. EI #11 took a disposable wipe and wiped the middle of the buttocks in an upward motion and disposed of the wipe. EI #11 then took another wipe and wiped the right side of the resident's buttocks. EI #11 took another clean wipe and wiped the left side of the buttocks. A new adult brief was placed on RI #6. Staff failed to check and clean the front of RI #6's perineal area. An interview was conducted on 9/17/14 at 3:05 PM, with EI #12, a Licensed Practical Nurse. EI #12 was asked to explain the steps for performing incontinence care. EI #12 stated, "Turn them on their back, wipe the middle downwards, then the farthest away from you, then the closest to you. Roll them and put the clean diaper underneath them. Remove the dirty out and fasten the diaper. Turn to side, wipe up the middle, wipe the other side, and then wipe the side closest to you." EI #12 was asked if it was important to perform perineal care when doing incontinence care. She stated, "Yes." EI #12 was asked what potential harm could happen to residents if perineal care was not performed when doing incontinence care. EI #12 stated, "You run the risk of the bacteria from the bottom side getting into the urethral area. You also run into skin issues." An interview was conducted on 9/18/14 at 9:00 AM, with EI #11. EI #11 was asked to explain the steps for performing incontinence care. EI #11 stated, "When washing the front you spread the labia and wash the center downwards, and then one side and then the other." EI #11 was asked if it were important to do perineal care when doing incontinence care. EI #11 stated, "Yes." EI #11 was asked what potential harm could happen to a resident when perineal care was not done during incontinence care. EI #11 stated, "You can cause infection if you don't start from front to back." An interview was conducted on 9/18/14 at 11:25 AM, with EI #8. EI #8 was asked was it important to wash the perineal area when performing incontinence care. EI #8 stated, "Of course." EI #8 was asked what potential harm could happen to a resident when perineal care was not done while performing incontinence care. EI #8 stated, "You can cause infection if you don't start from front and then go to the back." 3) A review of RI #14's medical record indicated RI #14 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #14's most recent Quarterly MDS, with an ARD of 9/10/14, indicated RI #14 had long and short term memory problems and was severely impaired for decision making skills. This MDS also indicated RI #14 was totally dependent on staff for bathing, toilet use, personal hygiene, dressing, and eating. RI #14 was incontinent of bowel and bladder. An observation of incontinence care for RI #14 was done on 9/17/14 at 9:00 AM, by EI #17, a CNA. The adult brief was removed from RI #14. A moderate amount of stool was observed on the resident. EI #17 cleaned the stool off of the resident using a different personal wipe with each stroke until the stool was removed. A second CNA assisted EI #17 to turn RI #14. The CNAs did not wash their hands or change their gloves. The CNAs did not check or clean the front of RI #14's perineal area. The CNAs applied the adult brief and positioned the resident on the left side and applied a hand splint to RI #14's hand. RI #14 was positioned with a wedge and a pillow. The CNAs then removed their gloves and washed their hands. An interview was conducted with EI #17 on 9/17/14 at 12:15 PM. EI #17 was asked when she washed her hands and changed gloves after cleaning stool from the bottom of RI #14. EI #17 stated, "After I finished with RI #14's care." The surveyor asked EI #17 what the concern was when hands were not washed, and gloves were not changed after cleaning stool off of a resident. EI #17 stated, "Germs and infections." The surveyor asked EI #17 how she was taught to provide incontinence care for a resident. EI #17 stated, "I clean from front to back. You can use as many wipes as you want, just don't wipe from back to front because of UTI(s) (Urinary Tract Infections) and other infections." The surveyor asked EI #17 when did she clean the front of RI #14's perineal area, during the above observation. EI #17 stated, "I don't think I did." The surveyor asked why not. EI #17 stated, "You just had me nervous, I know how to do it." The surveyor asked EI #17 what the concern was when the front of the perineal area was not cleaned during incontinence care. EI #17 stated. "The same things, infection and smells from urine." 4) A review of RI #8's medical record revealed, RI #8 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a Significant Change MDS, with an ARD of 8/4/14, indicated RI #8 had long and short term memory problems and was severly impaired for daily decision making. RI #8 required extensive assistance for mobility, dressing, eating and personal hygiene. RI #8 was totally dependent on staff for toilet use and bathing. RI #8 was coded as always incontinent of bowel and had a catheter. On 9/17/14 at 9:40 AM, the surveyor observed EI #16, a CNA, provide incontinence care for RI #8. EI #16 and a second CNA had gloves on when the surveyor entered the room. The CNAs opened the adult brief on RI #8. EI #16 wiped the front of RI #8's perineal area from front to back, on the right side, the left side and then down the middle with a different personal wipe with each stroke. EI #16 did not open the labia. Both CNAs turned RI #8 to the left side. EI #16 wiped RI #8's bottom in a back and forth motion. The adult brief was removed and a clean brief was applied. The CNA(s) did not wash their hands or change their gloves. An interview was conducted with EI #16 on 9/17/14 at 11:50 AM. EI #16 was asked how she was taught to provide incontinence care for a female resident. EI #16 stated, "Actually I take one wipe, go across throw away, go down each side with a different wipe, then turn them over. I go from front to back, throw away, then get another wipe, and go across the top and throw the wipe away." The surveyor asked EI #16 how she cleaned RI #8 during incontinence care, during the above observation. EI #16 stated, "I went across the top of the perineal area, then I took another wipe and went down the sides with a different wipe. I then wiped down the middle with another wipe." The surveyor asked EI #16 when did she open the labia of RI #8 during the incontinence care. EI #16 stated, "I didn't open it wide, but I did open it." The surveyor asked EI #16 how she cleaned RI #8's bottom during the incontinence care. EI #16 stated, "From front to back, then I took the wipe and wiped the top." The surveyor shared the above observation with EI #16, when she wiped RI #8's bottom in a back and forth motion. EI #16 stated, "Oh, now that you mentioned that, I think I did. That was my first time with a surveyor watching me." The surveyor asked EI #16 what the concern was when a resident was not properly cleaned during incontinence care. EI #16 stated, "Well, if you wipe the wrong way, infections could be a problem."

Based on observations, interviews and document reviews, the facility failed to ensure: 1) Staff knocked prior to entering residents' rooms, as observed on 2 of 3 survey days. This had the potential to affect RI(Resident Identifier) #'s 26, 27, 28, and 29, four of thirty-one sampled residents. 2) Staff pulled the privacy curtains completely around the bed while providing incontinence care for RI #10, one of four residents observed for incontinence care. Findings include: 1) A review of the facility's document titled, "(Named Facility) Resident Handbook," dated 2008, revealed, "...Privacy You have the right to personal privacy, including privacy in accommodations, medical treatment, written and telephone communications, personal care, visits, ..." A review of the medical records revealed RI #26 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Significant Change of Status MDS (Minimum Data Set) for RI #26 with an ARD (Assessment Reference Date) of 7/13/2014, revealed a BIMS (Brief Interview for Mental Status) score of 5 out of a possible 15 points. This indicated RI #26 was severely impaired for decision making skills. This MDS also indicated RI #26 required limited to extensive assistance with ADL(s) (Activities of Daily Living). A review of medical records revealed RI #27 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of RI #27's MDS, with an ARD of 9/01/2014, revealed RI #27's cognitive skills were severely impaired for daily decision making, and RI #27 had short and long term memory problems. This MDS also revealed RI #27 required extensive assistance with ADLs but could feed self, after meals were set up. On 9/16/2014 at 3:45 PM, EI (Employee Identifier) #1, a CNA (Certified Nursing Assistant), was observed to enter the room of RI #26 and 27 without knocking. Both residents were in the room. A review of medical records revealed RI #28 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Quarterly MDS, with an ARD of 7/10/2014, revealed RI #28 was severely impaired for cognitive skills for decision making, and had short and long term memory problems. This MDS also revealed RI #28 was totally dependent on staff for all ADLs. On 9/17/2014 at 8:20 AM, EI #2, a Licensed Practical Nurse, entered RI #28's room without knocking, and washed her hands. RI #28 was in the room. A review of the medical records revealed RI #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Quarterly MDS, with an ARD of 7/17/2014, revealed RI #29 was severely impaired for cognitive decision making skills. This MDS also indicated RI #29 required extensive to total assistance with all ADLs. On 9/17/2014 at 8:44 AM, EI #7, a Restorative Aide, entered RI #29's room without knocking. This resident was in the room. On 9/17/2014 at 3:30 PM, an interview was conducted with EI #2. EI #2 was asked what the facility's policy was on privacy and dignity. EI #2 stated, "You're always supposed to knock on the door before entering. Introduce yourself and explain what you're doing to the resident. Pull the curtain before you do anything and make sure the door is shut." EI #2 was asked why she did not knock prior to entering RI #28's room to wash her hands on 9/17/2014. EI #2 stated, "Because I was nervous and you were there. I know to do all those things." EI #2 was asked why it was important to knock prior to entering a residents' room, and she replied, "To let them know you're gonna be entering and you're there." On 09/18/2014 at 10:23 AM, an interview was conducted with EI #8, the Director of Nursing. EI #8 was asked what the facility's policy was on privacy and dignity. EI #8 stated, "They (residents) all have a right to privacy and dignity. ..." EI #8 was asked why it was important to knock prior to entering a resident's room. EI #8 stated, "... Knock or announce yourself, letting them know you're entering." EI #8 was asked what the potential harm was of not knocking prior to entering a residents' room. EI #8 replied, "Knocking, that's just respect. Knocking or announcing." 2) A review of medical records revealed RI #10 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #10's Annual MDS, with an ARD of 08/01/2014, revealed RI #10 was severely impaired for cognitive decision making skills. This MDS also indicated RI #10 required extensive to total assistance with all ADLs. On 09/17/2014 at 8:55 AM, an observation was made of incontinence care for RI #10. The incontinence care was performed by EI #3, and assisted by EI #4 and EI #5, all CNAs. During this observation, all CNAs donned gloves. EI #3 closed the door and elevated RI #10's bed. EI #3 removed the pillows from under RI #10's legs. EI #3 was on the right bed side and EI #4 was on the left. EI #5 was at the foot of the bed and pulled the privacy curtain only partially around bed, prior to her leaving the room, leaving the other two CNA's to provide the incontinence care. On 9/17/2014 at 1:05 PM, an interview was conducted with EI #3. EI #3 was asked if the privacy curtains should be pulled completely around the bed when providing incontinence care, and EI #3 replied, "Yes ma'am." EI #3 was then asked why. EI #3 stated, "If somebody's in the room, they could see. It's their (resident's) privacy. ..." EI #3 was asked why the curtains were not pulled completely around the bed while providing incontinence care for RI #10 on 9/17/14 at 8:55 AM. EI #3 stated, "Y'all caught us off guard and we were nervous." EI #3 was asked what the potential harm was of not pulling the curtains completely around the bed when providing care. EI #3 stated, "We didn't give them their privacy they should have gotten. It could have hurt their feelings and we had them exposed." During an interview on 9/18/2014 at 10:23 AM, EI #8 was asked why it was important to pull the privacy curtains completely around the resident's bed during incontinence care. EI #8 replied, "Dignity of that resident. Making them feel secure and safe. We always want them to feel that way, because it's their home." EI #8 was asked what the potential harm was of not pulling the privacy curtains completely around the bed. EI #8 stated, "Someone else coming by and seeing the exposure or invasive care, if it's a semi-private room. Humility would also be possible."