Every finding on record at Roanoke Rehabilitation & Healthcare Center

Based on observations, interviews, and policy review the facility failed to ensure food service employees washed their hands before they put on clean gloves. This deficient practice had the potential to affect all residents who received food from the kitchen. Findings included: Review of the facility's policy titled, Hand and Single Use Glove Sanitation Practices, revised in October 2017, indicated . Facility employees shall follow sanitary practices when handling food to prevent the spread of foodborne illness . The policy specified food service employees wash their hands after the following activities, . viii. Touching garbage or trash can . xii. Before putting on gloves and after removing gloves . On 09/19/2023 beginning at 11:21 AM, the surveyor observed Cook #1 pick gloves up off the floor and apply new gloves without washing her hands. Cook #1 then proceeded to make a turkey sandwich for a resident. After the turkey sandwich was made, Cook #1 removed her gloves and applied clean gloves without washing her hands. Cook #1 was noted to touch the lid of the trash can when she placed her gloves in the trash can. Cook #1 then removed a container of ham from the refrigerator and without washing her hands, she put on clean gloves and started to remove ham from the container. During an interview on 09/19/2023 at 1:33 PM, Cook #1 stated staff should wash their hands every time they touched something that could cause cross contamination. She stated staff should wash their hands if they dropped anything on the floor and whenever they changed their gloves. During an interview on 09/20/2023 at 9:40 AM, the Dietary Manager (DM) stated staff should wash their hands anytime they entered the kitchen, touched the trash, went to the bathroom, or picked items up off the floor that were dropped. She stated it depended on the situation if staff should wash their hands with each glove change but indicated if they contaminated their hands, they should wash their hands before applying new gloves but indicated on the serving line, staff could not do that. During an interview on 09/20/2023 at 10:31 AM, the Administrator stated he expected staff to wash their hands every time they changed their gloves, when they touched the trash, and when they picked things up off the floor.

Based on record review, document review, and interviews, the facility failed to complete a quarterly Minimum Data Set (MDS) for one of one sampled resident reviewed for resident assessments. Findings included: A review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2019, specified, . The Quarterly assessment is an OBRA [Omnibus Budget Reconciliation Act] non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored . A review of Resident #16's Face Sheet indicated the facility admitted the resident on 01/06/2015. A review of Resident #16's medical record, revealed the last completed Minimum Data Set (MDS) was a quarterly MDS with an Assessment Reference Date (ARD) of 04/10/2023. During an interview on 09/19/2023 at 10:55 AM, the MDS Coordinator indicated the July 2023 quarterly MDS for Resident #16 had not been completed. She confirmed the last MDS completed for Resident #16 had an ARD of 04/10/2023. During an interview on 09/19/2023 at 2:18 PM, the Director of Nursing (DON) stated her expectation was for MDS assessments to be completed timely. According to the DON, other staff had sections of the MDS to complete, but the MDS Coordinator was the person responsible to ensure all the assessments were completed timely. During an interview on 09/20/2023 at 2:37 PM, the Administrator stated all MDS assessments should be done within the timeframe given due to the fact the assessments were important because staff needed a clear picture on the care to be provided to the residents.

Based on interviews, record review, and policy review, the facility failed to ensure staff transcribed wound care orders for one (Resident #154) of 16 sampled residents. The failure to transcribe the wound care orders resulted in staff not performing wound care as ordered. Findings included: The facility policy titled, Admission of a Resident, effective on 02/01/2004 indicated, . Purpose: The admission process is intended to obtain all the information possible about the resident for the development of [the] comprehensive plan of care and to assist the resident in becoming comfortable in the facility . The facility policy titled, Wound and Skin Care Protocols, dated October 2010, specified, . Objectives: To maintain skin integrity and promote wound healing. General Policy: These protocols are designed as a guide to the prevention and/or treatment of impaired skin integrity. They are intended to serve as a tool in the appropriate management of preventative skin care and the management of actual impaired skin. Physician orders will always have precedent over the following guidelines . A review of Resident #154's Face Sheet indicated the facility admitted the resident on 07/21/2023 with an admit diagnosis to include malignant neoplasm (cancerous tumor) of the floor of the mouth. Per the Face Sheet, the resident was hospitalized in a local hospital from 07/07/2023 to 07/21/2023. A review of an Order Requisition, for Resident #154 dated 07/21/2023 from the discharging hospital indicated, Wound care to right neck as follows: Pack with dry 4x4 gauze. Wrap with kerlix [bandage roll] 3 times to help dressing remain in place. Secure with tape. Perform dressing change twice daily. A review of Resident #154's medical record revealed no evidence of the transcription of a wound care order for the resident until 07/23/2023. The order dated 07/23/2023 indicated to change the dressing around the surgical site above the tracheostomy collar, clean with Normal Saline, apply a nonadherent dressing, cover with a 4x4 gauze, wrap rolled gauze, and secure with tape. A review of Resident #154's 5-day Minimum Data Set with an Assessment Reference Date of 07/25/2023 indicated the resident had a surgical wound(s), received surgical wound care, and application of dressings. During an interview on 09/18/2023 at 6:48 AM, Licensed Practical Nurse (LPN) #6 stated she cared for Resident #154 once while the resident resided in the facility. According to LPN #6, she did not remember if the resident had a bandage on. In an interview on 09/18/2023 at 3:32 PM, LPN #5 stated she had no orders for wound care to be performed for Resident #154. LPN #5 stated the nurse who performed the resident's admission, should have contacted the doctor to get wound care orders. According to LPN #5, if she was the admission nurse, she would have called the doctor to get an order for wound care. During an interview on 09/19/2023 at 8:37 AM, Registered Nurse (RN) #4 stated if the resident came from the hospital, the orders would carry over from the hospital or the admission nurse would call to the physician to get orders. During an interview on 09/19/2023 at 10:08 AM, the Director of Nursing (DON) stated the order from the hospital physician was in the hospital paperwork, and she assumed the admitting nurse did not see the order. During an interview on 09/19/2023 at 2:08 PM, the physician stated the expected the facility to follow the hospital discharge orders. The physician stated he did not recall the facility asking about wound care orders; however, there were usually wound care orders included in the hospital summary. According to the physician, he read the discharge summary from the hospital, noted the hospital did send wound care orders, and wrote new orders on 07/23/2023 for wound care. In a follow-up interview on 09/20/2023 at 3:26 PM, the DON stated if Resident #154 had a wound, the nurse should have called for wound care orders. The DON stated she expected the nurse to assess the wound area and get orders to do wound care to prevent infection. During an interview on 09/20/2023 at 3:31 PM, the Administrator stated he expected the nurses to assess the resident and contact the physician for orders.

Based on interviews, discussion during the resident group meeting, review of the facility's Admission Agreement, and review of scheduled mail delivery days and times through the United States Postal Service (USPS) website, the facility failed to ensure mail was delivered to residents on Saturdays. This deficient practice had the potential to affect all 54 out of 54 residents residing in the facility. Findings Include: A review of the facility's, ADMISSION AGREEMENT, with a revised date of 10/08/2014, revealed: . RESIDENT'S RIGHTS .13. Resident rights .(i) Mail. The resident has the right to privacy in written communication, including the right to- (1) send and promptly receive mail that is unopened, . On 03/02/22 at 10:45 AM a group meeting was held with nine residents present. All nine residents confirmed that they do not receive mail on Saturdays. Resident Identifier (RI) #30 stated the facility's Business Office was not open on Saturdays so there was no one to get the mail from the post office. According to RI #30, the mail that should be delivered on Saturdays is held and delivered on Mondays instead. On 03/02/22 at 5:34 PM, an interview was conducted with Employee Identifier (EI) #5, Activity Director. EI #5 was asked if the postal service delivered mail to the facility on Saturdays. EI #5 said yes, they used to deliver it on Saturdays, but because the facility's Business Office is closed on Saturdays, they currently hold the mail until Monday. EI #5 was asked if the residents' mail was delivered on Saturdays. EI #5 said no. EI #5 was asked what days were the residents' mail delivered to them. EI #5 said Mondays-Fridays. EI #5 stated, everything that came for residents was put in her box, and then she delivers it to the residents, Mondays through Fridays. On 03/02/22 at 05:58 PM an interview was conducted with EI #1, the Administrator. EI #1 was asked if the postal service delivered mail to the facility on Saturdays. EI #1 said, no. EI #1 was asked why was the mail not delivered to the facility on Saturdays. EI #1 said it had always been delivered Mondays through Fridays. EI #1 was asked if residents had a right to receive mail on Saturdays. EI #1 said, yes, they do. Review of the USPS website (https://tools.usps.com/find-location.htm) confirmed the post office that services the facility does have mail delivery hours scheduled on Saturdays.

Based on observations, interviews and review of facility policies, titled STORAGE OF REFRIGERATED FOODS, STORAGE OF FROZEN FOOD and FOOD SERVICE OPERATIONAL STANDARDS FOR PURCHASING, RECEIVING, COOKING AND STORAGE OF FOOD, the facility failed to ensure that all food items in the kitchen cooler/freezer were labeled with an open and use by date, and that food items were discarded when the use-by-date was exceeded. This had the potential to affect 49 of 49 residents who received meals from the kitchen. Findings include: Review of facility's policy titled STORAGE OF REFRIGERATED FOOD, with a revised date of 10/17, revealed: POLICY: The facility ensures the quality and safety and sanitation of refrigerated foods through accepted storage practices. PROCEDURE: .5. All opened foods are labeled with common name of food, date stored and use- by date . Review of facility's undated policy titled STORAGE OF FROZEN FOOD revealed: POLICY: The facility ensures the quality and safety of frozen food through accepted storage practices. PROCEDURES: .4. Frozen foods are dated when received .7. Frozen foods that are stored in opened containers or packages are labeled with common name of food, the date stored and the use-by or expiration date .10. Frozen foods are used or discarded on or before the use-by or expiration date. Review of facility's policy FOOD SERVICE OPERATIONAL STANDARDS FOR PURCHASING, RECEIVING, COOKING AND STORAGE of FOOD, with a revised date of 10/17, revealed: POLICY: The facility receives, stores, prepares, distributes and serves food under sanitary conditions to prevent the spread of food borne illness and to reduce those practices that result in food contamination and compromised food safety. PROCEDURE: . 3. Storage . g. Foods should be labeled before being stored in the refrigerator or freezer. i. Label all items PHF/TCS (Potentially Hazardous Food/ Time/Temperature Control for Safety Food) items not in their original containers and all leftover foods. ii. Include the common name of food iii. Ready to eat TCS foods must be date marked if held longer than 24 hours. A ready to eat TCS food can be stored for only 7 days if it is held at 41 degrees F or lower. The date mark indicates the date of preparation or the discard date .iv. Commercially processed foods will have a use by date. This use by date should be followed . On 02/28/2022 at 6:35 PM a tour of the kitchen was conducted with Employee Identifier (EI) #7, Cook. The reach-in cooler was observed to have a cup filled halfway with fluid with no label. EI #7 stated the fluid in the cup was milk. The surveyor also observed the following items in the reach-in cooler: an opened bag of Cole slaw mix with received date of 2/17/22 (no use-by-date), a container of sliced cheese with a use-by-date of 02/19/22, a container of provolone cheese with a use-by-date of 2/25/22, a container of sliced tomatoes with a use-by-date of 2/27/22, and a container of parmesan cheese with a use by date of 2/11/22. In the reach-in freezer the following items were observed: a bag of hot dogs with a sticker stating received 2/10/22, an open bag of hush puppies with no label, and an open bag of chicken patties with no label. EI #7 was questioned throughout the initial tour of the kitchen on 02/28/2022 at 6:35 PM. EI #7 said the bag of coleslaw, hot dogs, hushpuppies and chicken patties should have been labeled with an open date and a use-by-date. EI #7 stated items should be labeled so facility staff knows when to discard food , so as not to serve bad food. EI #7 also admitted that sliced cheese, provolone cheese, tomatoes and parmesan cheese should have all been discarded by the use-by-date. EI #7 stated, foods should be discarded because food can grow bacteria and it could cause residents to get sick. An interview was conducted with EI #8, Dietary Manager, on 03/03/2022 at 9:41 AM. EI #8 stated, 49 residents received trays from the kitchen. When asked who was responsible for labeling food that goes into the cooler and freezer; EI #8 stated, she was responsible for labeling food as it came in, but the cooks/aides were if they used or opened the food. EI #8 stated, cooks/aides are also responsible for labeling leftovers. EI #8 stated that foods are labeled when received and when they are opened. EI #8 stated labels should have the name of the food, the open date and the use-by-date. EI #8 stated, leftovers should be labeled because they need to be used within 7 days. EI #8 stated, the milk in a cup, bag of coleslaw, hotdogs, hush puppies and chicken patties should have had a label identifying the food, as well as the open dates and use-by-dates. EI #8 admitted that the sliced cheese with a use-by-date of 02/19/22, tomatoes with a use-by-date of 02/27/22, provolone cheese with a use-by-date of 02/25/22 and parmesan cheese with a use-by-date of 02/11/22, should have been discarded. EI #8 admitted that the facility's policies were not followed, and stated the potential harm in not following the facility's policy is potential dangerous food spoilage and potential resident sickness.

Based on interview, medical record review, and review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure Resident Identifier (RI) #1's discharge Minimum Data Set (MDS) was signed off as completed by a Registered Nurse (RN). This deficient practice affected one of 16 sampled residents whose MDS assessments were reviewed. Findings include: A review of the CMS, Long-Term Care Resident Assessment Instrument 3.0 User's Manual, dated of October 2019, revealed: .09. Discharge Assessment-Return Not Anticipated . Must be completed .within 14 days after the discharge date . RI #1 was admitted to the facility on [DATE] and discharged on [DATE]. Review of RI#1's discharge MDS assessment revealed, . STATUS: Open . discharge date [DATE] . On 03/03/22 at 10:50 AM, an interview was conducted with Employee Identifier (EI) #4, MDS Coordinator. EI #4 was asked when RI #1 was discharged from the facility. EI #4 said 01/17/22. EI #4 was asked if she completed a discharge assessment on 01/17/22. EI #4 said, no, Section Z of the MDS assessment (where the nurse signs off on the assessment as completed) had not been signed and closed. EI #4 was asked when should a discharge assessment for RI #1 have been completed. EI #4 said on 01/31/22. EI #4 was asked why was the discharge assessment not completed for RI #1 when he/she discharged on [DATE]. EI #4 said she was not sure. EI #4 was asked when should a discharge assessment be completed when a resident is discharged . EI #4 said 14 days after discharge.

Based on observation, interviews, record review and review of the facility policy titled Eye Ointment/Drops Administration, the facility failed to ensure a licensed staff member did not place the eye drop bottle in her pocket after giving Resident Identifier (RI) #25 scheduled eye drops. This was observed on 3/2/22 and affected one of two residents observed receiving eye drops during medication administration. Findings include: A review of the facility policy titled Eye Ointment/Drops Administration, with an effective date of February 1, 2004, revealed: . PROCESS . 11. Administer medication .14. Replace medication cap 15. Return to medication cart . RI #25 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #25 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of RI #25's March 2022 Physician orders revealed . [MEDICATION(S)] EYE DROPS -GIVE 1 GTT (DROP) TO RIGHT EYE TID (three times a day) . On 3/02/22 at 4:27 PM, Employee Identifier (EI) #3, Registered Nurse (RN), was observed giving RI #25's scheduled medications. EI #3 administered RI #25's eye drops, replaced the cap and placed the bottle in her uniform pocket. EI #3 then returned to the medication cart, removed the eye drop bottle form her pocket, and placed it back inside the medication cart. On 3/02/22 at 4:35 PM, an interview with EI #3, RN, was conducted. EI #3 was asked, where she put the eye drop bottle when she finished giving the medication. EI #3 replied, in her pocket. EI #3 was asked where she should have put the eye drop bottle when finished. EI #3 replied, on the table on a barrier. EI #3 was asked if her pocket was clean. EI #3 replied, considerably not, and further stated her pocket could have been contaminated. On 3/03/22 at 3:51 PM, an interview was conducted with EI #2, RN/Infection Preventionist. EI #2 was asked what was the policy for the eye drop bottle once they had been administered. EI #2 replied, staff should clean it, replace the cap and place it on a barrier on the table. EI #2 was asked when should a licensed nurse give the eye drop, replace the cap on the bottle, then put the bottle in her pocket. EI #2 replied, never, they should not put medication in their pocket. EI #2 was asked, what would be the potential harm in a nurse placing a resident's eye drop medication in her pocket. EI #2 replied, it would create a risk for germs from the pocket getting on the eye drop bottle, then back to the resident, and could cause infection.

Based on observation, record review, staff interview, review of the facility document entitled, Novel Coronavirus Prevention and Response, the facility COVID-19 Resident Monitoring Log and Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to 1) ensure transmission based precautions were implemented and full personal protective equipment (PPE) was used when caring for one (1) of one (1) residents under investigation for COVID-19, who ultimately tested positive (Resident #4); 2) failed to ensure staff wore all recommended COVID-19 personal protective equipment (PPE) when transferring a resident who was COVID-19 positive (Resident #6); 3) failed to ensure staff did not wear the same personal protective (PPE) equipment when entering rooms of resident's who were COVID-19 positive (non-sampled Residents A, B, C, D, E and F) then the room of a resident who was COVID-19 negative (Resident #1) while collecting meal trays; 4) failed to ensure residents who were COVID-19 negative or who were readmitted and on a 14 day quarantine were not housed on or admitted to the COVID-19 positive isolation unit (Resident #1, #2 and #3); and 5) failed to ensure staff wore all recommended COVID-19 PPE when providing care to a readmitted resident with unknown COVID-19 status (Resident #5). These failures in infection control practices occurred during a COVID-19 pandemic and had the potential to affect other residents in the facility through the development and transmission of COVID-19 and other communicable diseases. It was determined the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm impairment or death to residents. The Director of Nursing, Administrator (via telephone) and Restorative Nurse were made aware the Immediate Jeopardy existed on July 16, 2020 at 7:49 p.m. Immediate Jeopardy was removed on July 17, 2020 at 12:15 p.m., after an acceptable removal action plan was received and after further observations, staff interview, and review of training and logs were conducted to verify the immediate correction. The facility remained out of compliance at a lower scope and severity of E, for deficiencies at F880. The findings include: 1) Resident #4 was admitted [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #4 also had a [MEDICAL CONDITION]. Review of the residents Vital Signs Record revealed the following temperatures over 99.9 degrees F (Fahrenheit) since 6/27/20: 100.9 Axillary on 6/27/20 12:55 a.m. 101.8 Generic on 7/9/20 at 5:54 p.m. 102.4 Oral on 7/11/20 at 11:19 p.m. 102.5 Generic on 7/12/20 at 7:05 a.m. 103.1 Generic on 7/13/20 at 3:24 p.m. 102.3 Generic on 7/14/20 at 7:18 p.m. Review of the Nursing Note dated 7/15/20 at 3:31 p.m. revealed that at 2:00 p.m. the resident's temperature was 101.1 degrees Fahrenheit. Review of the Nursing Note dated 7/16/20 at 2:49 a.m. revealed the resident's temperature at 6:00 p.m. was 99.5 and the resident refuses to take Tylenol as ordered for fever. At 10:00 p.m. the resident's temperature was 99.6 but the resident continued to refuse Tylenol for fever. Review of the Physician Orders revealed an order dated 7/13/20 for a COVID-19 swab. Further review revealed there were no orders for transmission based precautions from 6/27/20 through 7/16/20. Review of the Nursing Notes from 6/27/20 through 7/16/20 revealed Resident #4 frequently refused his nebulizer treatments. The resident did receive [MEDICAL CONDITION] care daily and good cough effort was routinely documented in regards to the resident's ability to remove secretions. Review of the undated facility COVID-19 Resident Monitoring Log revealed Resident #4's COVID-19 swab was completed on 7/13/20. During an interview with the Director of Nursing on 7/16/20 at 2:00 p.m., she said that there was one resident in the facility who had COVID-19 test results still pending (Resident #4). An observation on 7/16/20 at 5:49 p.m. revealed Resident #4 was in a private room. The door to the room was open and the resident was observed in bed. An isolation kit containing PPE was not present by his door or near his room. During an interview with Nurse #1 on 7/16/20 at 5:51p.m., she stated Resident #4 was not on transmission based precautions. During an interview with Nurse #2 on 7/16/20 at 5:53 p.m., she stated the facility did not place residents on transmission based precautions for a fever or when COVID-19 test results were pending. She said the practice was to wait for a positive test result before initiating transmission based precautions. Nurse #2 said Resident #4 was not on transmission based precautions and staff just wore their mask when entering the resident's room. Nurse #2 was aware Resident #4 had been tested for COVID-19 but she unaware of the test results. During an interview with the Director of Nursing, Administrator (on the telephone) and Restorative Nurse #1 on 7/16/20 at 7:05 p.m., the Administrator stated that the facility practice for when a resident had a fever was to increase the frequency of vital signs monitoring from every 8 (eight) hours to every 4 (four) hours and test for COVID-19. If the test was positive transmission based precautions with full PPE (cloth gowns, gloves, face shield and N95 mask) would be initiated. The facility had N95 and KN-95 masks available for staff and had implemented mask reuse procedures to extend the supply. The facility did not have a respiratory program in place for fit testing. Resident #4 had been having fevers over 100 degrees Fahrenheit (a symptom of COVID-19) and had a COVID-19 swab test completed on 7/13/20. The test results were still pending at the time of the survey. A telephone interview with the Director of Nursing on 7/28/20 at 11:25 a.m. revealed the test result was COVID-19 positive. Resident #4 also had a [MEDICAL CONDITION] and orders for aerosol generating procedures. Review of the undated facility COVID-19 Resident Monitoring Log revealed the facility had 26 in-house residents that were COVID-19 positive. There were also 32 staff that tested positive for COVID-19. Review of the facility policy entitled, Novel Coronavirus Prevention and Response dated 3/29/20 revealed, Staff will 'Think COVID-19' when a resident or employee exhibits the following symptoms and epidemiologic risk: fever or cough/shortness of breath AND has had close contact with a laboratory confirmed COVID-19 patient within 14 days of symptom onset. Further review of this policy revealed the following procedure when COVID-19 is suspected: a. Notify physician, Director of Nursing, Infection Preventionist, and family. b. Place resident in a private room if possible, with the door closed. Residents with similar symptoms can be cohorted. e. Implement standard, contact, and airborne precautions (droplet precautions if no airborne isolation room available). Wear gloves, gowns, goggles/face shields, and masks (respirators, including N95 masks) upon entering room and when caring for the resident. f. Avoid aerosol-generating procedures (i.e. nebulizer treatments) as possible. 2) Resident #6 was admitted [DATE] with [DIAGNOSES REDACTED]. On 6/26/20 she tested positive for COVID-19. On 7/17/20 at 11:15 a.m. cloth isolation gowns were observed in bins in the hallway of the COVID-19 isolation unit. There were also laundry bins observed in the hall with a sign that read, Attention CNA's the isolation gowns need to be put in a water soluble bag inside of a red bag to be washed daily . On 7/17/20 at 3:00 p.m. Certified Nursing Assistant #1 (CNA #1) and CNA #2 were observed exiting Resident #6's room. Neither CNA was observed wearing or carrying a gown. CNA #1's face shield was pushed back on her head and not covering her face or N95 mask. During an interview with CNA #1 on 7/17/20 at 3:01 p.m., she stated she had helped CNA #2 transfer Resident #6 using the stand-up lift. She confirmed both she and CNA #2 did not wear a gown while providing this care to Resident #6. CNA #1 indicated she was aware Resident #6 was COVID-19 positive and cloth gowns should be worn along with the N95 mask, face shield and gloves when providing care to residents with COVID-19. She said she did not wear the gown because it was close to change of shift when CNA #2 had asked for help and they were trying to transfer the resident quickly, prior to leaving. CNA #1 stated that while she was in the room close to the resident she did have her face shield pulled down over her face and mask. During an interview with the Director of Nursing, Administrator (on the telephone) and Restorative Nurse #1 on 7/16/20 at 7:05 p.m., the Administrator indicated she expected staff to wear a cloth gown in addition to a mask, face shield and gloves when providing care to COVID-19 positive residents. She also said she expected CNA #1 and #2 to wearing a gown when transferring Resident #6. A facility policy and procedure regarding the use of cloth gowns when caring for residents with COVID-19 was requested but not provided during the survey. A facility policy and procedure regarding the Personal Protective Equipment staff were to use for COVID-19 positive residents on the COVID-19 isolation unit was requested but not provided during the survey. 3) On 7/16/20 at 5:29 p.m. CNA #3 was observed wearing a yellow cloth isolation gown. She was also wearing an N95 mask and face shield. CNA #3 entered room [ROOM NUMBER] and picked up a meal tray which she then placed on the meal cart. CNA #3 then entered room [ROOM NUMBER] and picked up a meal tray which she placed on the meal cart. Next she entered Resident #1's room to pick up his meal tray and brought it out to the hall and placed it on the meal cart. While in Resident #1's room CNA #3 was wearing the same personal protective equipment that she wore in the previous two rooms. Review of the undated facility COVID-19 Resident Monitoring Log revealed the residents in room [ROOM NUMBER] were COVID-19 positive (unsampled Residents A, B and C) as were the residents in room [ROOM NUMBER] (unsampled Residents D, E and F). Resident #1 was listed as COVID-19 negative. During an interview on 7/16/20 with CNA #3 she stated that she was aware Resident #1 was COVID-19 negative and the residents in room [ROOM NUMBER] and #5 were COVID-19 positive. She stated this was her first time working on the COVID-19 isolation unit but she had been educated prior to her shift and was told that the cloth gowns were only to be used in rooms of residents who were COVID-19 positive. CNA #3 said she should not have worn the same gown, or face shield that she used for COVID-19 positive residents, in Resident #1's room because he was not COVID-19 positive. During an interview with the Director of Nursing, Administrator (on the telephone) and Restorative Nurse #1 on 7/16/20 at 7:05 p.m., the Administrator indicated they had already identified a concern on the COVID-19 Isolation Unit with staff wearing the cloth isolation gowns that they wore in the rooms of COVID-19 positive residents in the rooms of residents who were not COVID-19 positive. To resolve this she said they had made the room signage more clear; provided disposable gowns in an isolation kit outside the door of a readmitted resident whose COVID-19 status was unknown (Resident #3) on 7/15/20; and were planning to create a COVID-19 isolation unit exclusively for residents who were COVID-19 positive instead of having the mixed unit they had at the time of the survey. The Administrator acknowledged that at the time of the survey there were two residents who were COVID-19 negative (Resident #1 and #2) and one readmitted resident (Resident #3) who was on a 14 day quarantine, housed within the defined plastic barriers of the COVID-19 Isolation unit. All 26 of the facilities residents who were COVID-19 positive were housed on this unit as well. 4) Resident #1 was readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #1 tested negative for COVID-19 on 6/26/20 but his room was located behind the plastic barrier that defined the COVID-19 isolation unit and separated it from the rest of the facility. A 7/16/20 Nursing Note (Late Entry for 7/13/20) revealed will ambulate in hall. On 7/16/20 at 11:45 a.m. Resident #1 was observed outside his room. He was not wearing a mask. He was redirected to return to his room by the Director of Nursing (DON). During an interview with the Therapy Director on 7/16/20 at 1:53 p.m., she stated that Resident #1 was known to wander and it was an ongoing challenge to ensure he stayed in his room. On 7/16/20 at 3:10 p.m. Resident #1 was observed outside his room in the hall on the COVID-19 isolation unit. He was wearing a mask that was covering his mouth but not his nose. After a few minutes the resident returned to his room. Resident #2 was admitted [DATE] with [DIAGNOSES REDACTED]. Resident #2 tested negative for COVID-19 on 6/26/20 but her room was located behind the plastic barrier that defined the COVID-19 isolation unit and separated it from the rest of the facility. Resident #3 was admitted [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #3 tested negative for COVID-19 prior to being readmitted to the facility on [DATE] and was on a 14 day quarantine. His room was located behind the plastic barrier that defined the COVID-19 isolation unit and separated it from the rest of the facility. During an interview with the Director of Nursing (DON) on 7/16/20 at 2:00 p.m., she stated they (the facility) were in the process of moving the plastic barriers on the COVID-19 isolation unit to create a separate area for readmitted residents. The DON said some room changes had been initiated recently to get ready to make the unit smaller. She added that plans had been in place to move the plastic barriers that week to ensure the rooms of the two residents who did not have COVID-19 (Resident #1 and #2) and the readmitted resident on the unit (Resident #3) were no longer on the COVID-19 isolation unit. She did not know why this had not been done yet as she had been out of the facility for two weeks and just returned. During an interview with the Infection Preventionist (IP) on 7/16/20 at approximatley 3:00 p.m., she stated she had not been involved in the decision making regarding putting the COVID-19 positive residents on the same hall as two residents who were not COVID-19 positive. She indicated the decision had been Corporate driven. The IP stated both Resident #1 and #2 had a private room and a room change would be too disruptive for them, and not in their best interest. The IP was also the family member of Resident #2 and said she did not want Resident #2 moved despite the room being on the COVID-19 isolation unit. The IP revealed the original plan was to have the back hall (Rooms 8 - 22) designated as the COVID-19 care unit but she came back to work one day and the COVID-19 isolation unit was on the front hall (Rooms 1 - 7 and 101 - 112). The IP indicated she was aware the facility had a plan to move the plastic barriers defining the COVID-19 care unit so the readmitted residents would be in a separate area at the back of the hall but did not know why the barriers had not been moved yet. The IP also said that she had not been involved in developing or implementing any of the plans for responding to COVID-19 in the facility because she had been busy working on the medication cart to cover for staff who were out sick with COVID-19. Review of the CDC guidance entitled, Responding to Coronavirus (COVID-19) in Nursing Homes revealed, Facilities that have already identified cases of COVID-19 among residents but have not developed a COVID-19 care unit, should work to create one unless the proportion of residents with COVID-19 makes this impossible . Ideally the unit should be physically separated from other rooms or units housing residents without confirmed COVID-19. Depending on facility capacity (e.g., staffing, supplies) to care for affected residents, the COVID-19 care unit could be a separate floor, wing, or cluster of rooms. Assign dedicated HCP (Health Care Personnel) to work only on the COVID-19 care unit. At a minimum this should include the primary nursing assistants (NAs) and nurses assigned to care for these residents. Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options include placement in a single room or in a separate observation area so the resident can be monitored for evidence of COVID-19. 5) Resident #5 was readmitted [DATE] with [DIAGNOSES REDACTED]. The resident was readmitted to room [ROOM NUMBER] which was not on the COVID-19 isolation unit, but was a private room. Review of the Physician Orders revealed there were no admission orders [REDACTED]. The resident also had an unproductive cough first documented on 7/8/20 which continued to be present through 7/16/20. On 7/16/20 at 11:00 a.m. an isolation kit containing PPE was observed outside the door of the resident's room. On 7/16/20 at 6:55 p.m., CNA #3 was observed donning a disposable gown and gloves. She was already wearing an N95 mask. During an interview at this time CNA #3 indicated she was planning to provide personal care for the resident. She entered the room without donning eye protection. Upon inquiry, she said she did have a face shield but she did not need to use it in Resident #5's room as it was only to be used for residents who were COVID-19 positive. Restorative Nurse #1 was present during this observation and interview. During an interview with Restorative Nurse #1 on 7/16/20 at 6:58 p.m., she confirmed that Resident #5 was on a 14 day quarantine due to being readmitted after a hospital admission. She also confirmed facility staff should wear full PPE (gown, gloves, mask and eye protection) when caring for residents on quarantine. A facility policy regarding the 14 day quarantine for readmitted residents and the PPE required when caring for these residents was requested but not provided during the survey. Review of the CDC guidance entitled, Responding to Coronavirus (COVID-19) in Nursing Homes revealed, Newly admitted or readmitted residents should still be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE. The recommended COVID-19 PPE . includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. Removal Plan: The facility provided an acceptable removal action plan on July 17, 2020 at 11:30 a.m. that read: 1. On July 16, 2020 the barrier in the hallway was moved back to be across from room [ROOM NUMBER] to room [ROOM NUMBER] removing Rooms 4 (Resident #2), 6, and 7 (Resident #1) from the COVID unit. Residents in quarantine were moved to be located in rooms [ROOM NUMBER]. These rooms were labelled clearly as quarantine rooms. On July 17, 2020 another barrier was created separating rooms 110, 111 and 112 from the COVID Isolation Unit creating a divided Quarantine Unit. This barrier will ensure clear separation of residents with unknown COVID status (Quarantine Unit - Transmission Based Precautions) and COVID positive residents (COVID Isolation Unit). Residents will be removed from the Quarantine unit if they receive a positive COVID 19 PCR nasal swab and placed on the COVID Isolation Unit immediately upon notification of the results. If the resident is a new admission or readmission and has been at the building for 14 days and received a negative COVID swab collected no sooner than day 10 they will be transferred out of the Quarantine Unit. Resident #2 and Resident #1 will be immediately placed on 14 day transmission based precautions and quarantined due to possible exposure. 2. On July 16, 2020, education was provided to all staff on duty regarding the proper PPE that should be used in COVID Isolation Rooms versus the proper PPE that should be used in Quarantine Rooms. Isolation Rooms will be clearly labeled along with a list of approved PPE for the room. Quarantine Rooms will be clearly labelled along with a list of approved PPE for the room. All off duty staff will be in serviced prior to the start of their next shift by DON/designee. Therapy staff, facility staff and all other staff, i.e., hospice, if applicable, will receive all training related to changes specified in the Removal Plan before being allowed to work their nest shift. 3. On July 16, 2020, licensed staff on duty were in serviced by DON/Designee that when a resident presents possible symptoms of COVID19 they will be placed on in quarantine on transmission based precautions immediately. The licensed nurse will write the order for the quarantine precautions immediately after symptoms identified. All licensed staff not on duty will be in service before the start of there next shift by the DON/Designee. 4. On July 16, 2020 all on duty staff were educated on the location of their 2 face shields and how to differentiate them. Face shields labeled with a Q are to be used only on residents located in Quarantine Rooms. Face shields labeled with a C are to be used only on residents located in Isolation Rooms. All off duty staff will be in serviced prior to start of their next shift by DON/Designee. On July 17, 2020 all staff on duty were educated that between different quarantine residents they are to sanitize the face shield utilizing bleach wipes located in the sitting room with the face shield bags. Bleach wipes are also located on medication carts and at the nurses station. 5. Resident #4 was relocated to room [ROOM NUMBER] in the Quarantine area due to pending COVID19 results. Resident #5 was relocated to room [ROOM NUMBER] in the Quarantine area due to recent new admission. Both rooms have the Quarantine Room signage which lists appropriate PPE to be worn. Each room on the Quarantine Unit and COVID 19 Isolation unit will have a box of surgical masks located in each room. 6. The two staff members who did not wear a gown when transferring Resident #6 will each receive one on one education in regards to appropriate PPE usage. 7. Quarantine Rooms are rooms of residents that are new or readmissions and residents that have displayed new COVID like symptoms. Quarantine Precautions include the use of disposable gowns for each resident, face shields, N95 masks with surgical masks over the N95 mask and gloves. 8. Isolation Rooms are rooms with laboratory confirmed COVID 19. The COVID-19 Isolation Precautions include the use of face shield, N95 mask with surgical mask to be changed between each resident in the room, washable gowns will be used and gloves. 9. On July 17, 2020 all housekeeping, laundry and therapy staff were educated on the difference between Quarantine Rooms and Isolation Rooms along with the appropriate PPE for each room and disinfection required of the PPE. Validation of the removal plan was completed on July 17, 2020 at 12:15 p.m., after the Federal Surveyor verified corrective actions taken by the facility had been implemented. This included observations, staff interviews, review of training logs and training materials to verify the immediate corrective actions were in place.

Based on observation, interview, medical record review, and review of the facility's policy titled, Bath - Shower or Tub, the facility failed to ensure Resident Identifier (RI) #43 was not exposed while being transported back to his/her room after a shower on 5/8/19. This affected one of sixteen residents sampled. Findings Include: A review of the facility's policy titled, Bath - Shower or Tub, with an Effective Date of (MONTH) 1, 2004 revealed: . PURPOSE: Shower and tub baths promote cleanliness and comfort for the resident. PR[NAME]ESS: b) Drape the resident and transport to the bath area. c) Assist the resident the bath or shower keeping them draped . e) Assist resident out of the tub or shower and into the chair . h) Dress the resident RI #43 was readmitted to the facility with [DIAGNOSES REDACTED]. On 5/8/19 at 10:15 AM, two surveyors observed RI #43 in shower chair, being wheeled from the whirlpool room to his/her room, with right side of buttocks and thigh exposed. Nursing staff and male and female residents were present in the hallway when resident was wheeled past them. On 5/9/19 at 2:27 PM, an interview was conducted with Employee Identifier (EI) #5, a Certified Nursing Assistant (CNA). EI #5 was asked, if she had cared for RI #43 yesterday and if she had taken him/her back to his/her room after his/her shower. EI #5 replied, yes. EI #5 was asked, how should a resident be transported to ensure he/she is not exposed. EI #5 replied, everything should be covered. EI #5 was asked, was RI #43 completely covered when he/she was returned to his/her room after him/her shower. EI #5 replied, from my knowing, she/he was. Surveyor explained to EI #5 that RI #43's right buttock and thigh were visible and uncovered during his/her transport back to his/her room. EI #5 was asked how would the resident/family feel if they knew he/she was exposed. EI #5 replied, not happy at all. EI #5 was asked, why had she transported RI #43 down the hall with him/her not completely covered and male and female residents present in the hallway. EI #5 replied, she did not know why they did not catch it.

Based on record review and interview, the facility failed to ensure Resident Identifier (RI) #53 did not fall off the bed in (MONTH) 2019 when only one Certified Nursing Assistant (CNA) was assisting with bed mobility. This affected one of one sampled resident reviewed for falls. Findings include: RI # 53 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. RI #53's quarterly Minimum Data Set Assessment, with an Assessment Reference Date of 7/17/18 documented RI #53 was cognitively intact, required extensive assistance of two people for bed mobility, and had impaired range of motion on both sides to both upper and lower extremities. RI #53's comprehensive care plans included a care plan for Requires extensive to total assist with ADL's (Activities of Daily Living) related to [MEDICAL CONDITION], h/o (history of)[MEDICAL CONDITION](cerbrovascular accident), spinal cord injury ., onset date 10/06/16. This care plan included the following approach: .4/10/18 Two people in room when care being provided . RI #53's Departmental Notes for 9/2/18 documented RI #53 fell from the bed when one CNA was assisting with changing the bed sheets. Employee Identifier (EI) #7, the CNA caring for RI #53 at the time of the fall, was interviewed on 5/09/19 at 4:25 PM. EI #7 said she recalled the incident in (MONTH) when RI #53 fell off the bed. EI #7 said RI #53 had an air mattress and it went flat, and the resident slid off the bed. When asked what other staff were present in the room with her, EI #7 said no one. EI #7 said the fall could have been prevented had she used two people for the care.

Based on observation, interview, record review, and review of a facility policy titled Urinary Catheter Care, the facility failed to ensure a licensed nurse did not wipe Resident Identifier (RI) #49 from back to front multiple times up to his/her catheter. This affected one of three residents sampled for catheters. Findings include: Review of the facility policy titled Urinary Catheter Care, effective 2/01/04, revealed the following: PURPOSE: Urinary catheter care helps to prevent urinary tract infection. STANDARD: Catheter care should be provided each time perineal care is provided . PR[NAME]ESS: . II. Catheter Care a) Wash perineal area per policy b) Cleanse area of catheter insertion well using soap and water . c) Wash the catheter itself by holding on to the catheter at the insertion site; wash with one stroke downward . d) Rinse perineal area well and rinse the catheter by holding on to the insertion site; rise with one stroke downward . RI # 49 was admitted to facility on 4/4/18 and re-admitted [DATE] with [DIAGNOSES REDACTED]. RI #49's annual Minimum Data Set assessment, with an Assessment Reference Date of 4/01/19, indicated RI #49 had an indwelling urinary catheter. On 5/08/19 at 10:15 AM, Employee Identifier (EI) #1, Licensed Practical Nurse (LPN)/Treatment Nurse, and EI #4, LPN, were observed preparing to perform wound care on RI #49. When they rolled RI #49 over onto his/her right side, staff noted a yellowish-brown bowel movement on RI #49's rectum. EI # 1 wiped from back to front, wiping multiple times from backside up to and over the catheter, with noted yellowish brown substance on the wipe . EI #1, LPN/Treatment Nurse, was interviewed on 5/08/19 at 10:40 A.M. EI #1 was asked how residents were supposed to be cleaned. EI #1 answered, front to back. When asked how she had cleaned the bowel movement from RI #49, EI #1 said back to front, because she got turned around on her direction. EI #1 said wiping back to front and and wiping over the catheter could cause an infection. EI #2, the Infection Control Nurse, was interviewed on 5/08/19 at 2:52 PM. When asked about the facility policy for cleaning bowel movement from a resident with a catheter, EI #2 said from the catheter, you should wipe away from the body. EI #2 said wiping back to front and over the catheter with a soiled wipe could result in an infection.

Based on observation, record review, interviews, review of a facility policy titled Administering Medications via Nasogastric / Gastrostomy Tube and review of the manufacturer's protocol for use Enteral Feeding Tube DeCloggers, the facility failed to ensure: 1) Licensed staff did not allow the tip of the DeClogger to come in contact with Resident Identifier (RI) #34's bed linens, prior to insertion into the gastrostomy tube; 2) Licensed staff rinsed and dried RI #34's syringe and plunger, and placed into a labeled bag after mediction administration via gastrostomy tube; 3) Licensed staff mixed crushed medications with water prior to administering to RI #34 via gastrostomy tube; and 4) Licensed staff used the DeClogger device to unclog RI #34's gastrostomy tube in accordance with the manufacturer's protocol for use. These failures affected RI #34, one of one resident observed during administration of medications per gastrostomy tube. Findings include: A review of the facility's policy titled, Administering Medications via Nasogastric / Gastrostomy tube with an effective date of (MONTH) 1, 2004, revealed: . PURPOSE: To provide proper administration of medication, via feeding tube, when the resident is unable to take medications by mouth. PR[NAME]ESS: . 3. Prepare medications as ordered. All medications should be prepared directly before entering room. This includes crushing. Crushed medications should be administered immediately after mixing with at least 5 cc's (cubic centimeters) of H2O (water). 9. Rinse, dry and store a 60 cc syringe in a plastic bag. Note: Give medications separately, flushing between with approximately 5 cc' s' of water, . Review of the manufacturer's protocol for use for the Enteral Feeding Tube DeClogger, revised 2/12/14, revealed the following: .Protocol for use of the DeClogger Purpose To maintain or achieve patency of gastric and/or jejunostomy enteral tubes. Policy . the DeClogger will also be used to achieve patency of a tube that has become clogged with semi-solid formula . Protocol . INSTRUCTIONS .1. Determine the size of the gastric . tube. CAUTION: Verify that the tube has not been modified . 2. Select appropriate size DeClogger . . 4. Insert the DeClogger to reach the blockage and slowly rotate two times in a clockwise direction then reverse and rotate two times in a counter-clockwise direction while removing it. Do not attempt to force the DeClogger through the entire blockage. 5. Repeat step 4 until the stop disk of the DeClogger is reached without difficulty . RI # 34 was admitted to facility on 1/25/16 and readmitted on [DATE] with a [DIAGNOSES REDACTED]. On 5/08/19 at 4:41 PM, Employee Identifier (EI) #6, Licensed Practical Nurse (LPN), was observed administering RI #34's medications via gastrostomy tube. Prior to administering the medications, EI #6 attempted to flush the tube with water; however, the water would not flow by gravity. EI #6 obtained a DeClogger device from the hall storage. As EI #6 opened the DeClogger packaging (while it was layed across RI #34's bed), she allowed the tip of the device to come into contact with RI #34's bed linens, prior to inserting the device into RI #34's gastrostomy tube. EI #6 then inserted the DeClogger device into RI #34's gastrostomy tube, all the way to the handle, and thrust the device in and out of the tube. EI #6 then took RI #34's crushed medication and poured it directly into the tube without first mixing it with water. After administering all medications, EI #6 did not rinse and dry RI #34's syringe was not rinsed, dried, and return to a labeled bag. EI # 6, LPN, was interviewed on 5/09/19 at 11:14 AM. When asked to explain the policy on use of the DeClogger device, EI #6 said as far as she knew, there was no policy on that. EI #6 said another nurse had shown her how to use it several years prior. EI #6 was asked to explain how she was shown to use the device. EI # 6 said she observed the nurse remove the DeClogger from the packaging, insert the DeClogger into tube, and pull the DeClogger up and down to clear the blockage, then discard the device. The surveyor then asked EI #6 how she had used he DeClogger device to remove the clog in RI #34's tube. EI #6 said she moved the DeClogger in and out of the tube, then flushed it. When asked what the manufacturer's instructions for use specified should be done, EI #6 said she would have to look at them. EI #6 was then asked why she would use a device without knowing what the instructions said. EI # 6 said that was what they always do, and said she had used the same type of device about 20 other times. After discussing the manufacturer's instructions for use, EI #6 was asked why she had not followed them. EI #6 said she did not realize she had not. When asked what the risk was of using the DeClogger device in a manner other than instructed on the package, EI #6 said resident harm. EI #6 was then questioned regarding steps that should be taken to maintain infection control when using the DeClogger device. EI #6 said when opening the packaging, the device should not touch anything. EI #6 said if a DeClogger device touches a resident's bed it should immediately be discarded. When asked the potential harm in allowing the tip of the device to touch the bed linens, EI #6 said it could cause infection. EI #6 was then questioned regarding the facility's policy on administering medications via gastrostomy tube. EI #6 said once the medications are crushed, they should be mixed with water prior to administration. EI #6 admitted she had poured RI #34's crushed medications into the tube without mixing with water first. EI #6 explained, if crushed medications are not mixed with water prior to administering, it could cause the tube to clog. EI #6 then stated, after administering medications via tube, the syringe should then be rinsed and dried to prevent infection.

Based on observation, interviews, and a review of the facility's policy titled, [MEDICAL CONDITION] Care, the facility failed to ensure a licensed nurse washed her hands before applying sterile gloves and providing [MEDICAL CONDITION] care for Resident Identifier (RI) #43. This had the potential to affect one of one resident observed for [MEDICAL CONDITION] care. Findings Include: A review of the facility's policy titled [MEDICAL CONDITION] Care, with a revised date of 5/2011, revealed: . POLICY: [MEDICAL CONDITION] care is to be done daily . PR[NAME]EDURE: . 3. Thoroughly wash hands before and after each aspiration, toilet or other attention to [MEDICAL CONDITION]. RI #43 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/15/18 at 11:10 a.m., the surveyor observed Employee Identifier (EI) #1, a Licensed Practical Nurse, did not wash her hands before putting on gloves and providing [MEDICAL CONDITION] care. An interview was conducted on 5/17/18 at 11:58 a.m. with EI #1. EI #1 was asked what should be done before putting on gloves and providing [MEDICAL CONDITION] care. EI #1 stated, Go wash hands. EI #1 was asked what was the potential for harm. EI #1 stated, It creates a risk for infection. A phone interview was conducted on 5/17/18 at 3:56 p.m. with EI #2, a Registered Nurse/Infection Control. EI #2 was asked what should be done before putting on sterile gloves and providing [MEDICAL CONDITION] care. EI #2 stated, Wash your hands before putting on sterile gloves or any gloves. EI #2 was asked what was the potential for harm in not washing hands before applying sterile gloves. EI #2 stated, Infection.

Based on observation and interview, the facility failed to ensure Resident Identifier (RI) #3, #10, #25, and #36 had the required eighty feet of living space for a multiple resident room. This affected four of fifty nine residents residing in the facility. Findings Include: RI # 3 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #10 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #25 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During the facility's recertification survey, 5/15/18 at 10:27 a.m., it was noted that four residents occupied room # 21. The beds were too close to the closet doors, limiting the space available to fully open the closet doors. On 5/17/18 at 4:45 p.m. Employee Identifier (EI) #3, the Maintenance Director, measured room [ROOM NUMBER] to be 18 feet 5 inches X 15 feet 2.5 inches. This would give each resident in room [ROOM NUMBER] approximately 70 feet of living space. An interview was conducted on 5/17/18 at 5:00 p.m. with EI #4, the Administrator. EI #4 was asked if anyone had said anything to her about getting a waiver for room [ROOM NUMBER]. EI #4 stated, No one has ever said. EI #4 was asked why did the other large room in the facility have only three residents occupying them instead of four. EI #4 stated, That's the way it 's always been. EI #4 said rooms #21 and #22 normally had four residents at one time in both rooms. (room [ROOM NUMBER] currently has two residents).

Based on an interview and review of a facility policy titled, Abuse, Neglect and Exploitation the facility failed to ensure an allegation of abuse was reported to the State Agency within in the required time frame. On 12/14/16 at 12:00 AM, Resident Identifier (RI) #16 informed a Certified Nursing Assistant (CNA) that she had been abused by being pinched 30 times. This allegation of physical abuse was not reported to the State Agency until two days after the allegation of abuse was made by RI #16. This affected RI #16, one of one sampled residents who made an allegation that he/she had been physically abused. Findings include: A review of a facility policy titled, Abuse, Neglect and Exploitation with a revised date of 12/20/16 revealed the following: . Procedure: . 3 . the event will be reported .via (by way of) the Online Incident Reporting System . not later than twenty-four (24) hours . On 12/14/16, RI #16 reported an allegation of physical abuse to a CNA. According to the ADPH (Alabama Department of Public Health) Online Incident Reporting System, this allegation was not reported by the facility until December 16, 2016 8:38:16 AM. On 3/30/2017 at 12:00 p.m., an interview was conducted with EI (Employee Identifier) #1, DON (Director of Nursing)/Abuse Coordinator. EI #1 was asked what was the facility policy and procedure for reporting alleged occurrences of abuse to the State Agency. EI #1 said they had two hours to report it. EI#1 also said, We know it changed from 24 hours to two hours. EI#1 was asked was the alleged physical abuse reported within the required time frame to the ADPH/state agency. EI#1 replied, I don't think it was reported within the required time frame. EI#1 was asked what was the potential harm in not reporting incidents of alleged abuse to ADPH/State Agency within the required time frame. EI #1 replied, It could be potential harm to the resident.

Based on an interview and review of a facility policy titled, Abuse, Neglect and Exploitation, the facility failed to follow their Abuse, Neglect and Exploitation, policy and procedure by failing to report an allegation of physical abuse within in the required time frame. On 12/14/16 at 12:00 AM, Resident Identifier (RI) #16 informed a Certified Nursing Assistant (CNA) that she had been abused by being pinched 30 times. This allegation of physical abuse was not reported to the Alabama Department of Public Health (ADPH)/State Agency until two days after the allegation of abuse was made by RI #16. This affected RI #16, one of one sampled residents who made an allegation that he/she had been physically abused. Findings include: A review of a facility policy titled, Abuse, Neglect and Exploitation with a revised date of 12/20/16 revealed the following: . Procedure: . 3 . the event will be reported .via (by way of) the Online Incident Reporting System . not later than twenty-four (24) hours . On 12/14/16, RI #16 reported an allegation of physical abuse to a CNA. According to the ADPH (Alabama Department of Public Health) Online Incident Reporting System, this allegation was not reported by the facility until December 16, 2016 8:38:16 AM. On 3/30/2017 at 12:00 PM., an interview was conducted with Employee Identifier (EI) #1, Director of Nursing (DON)/Abuse Coordinator. EI #1 was asked what was the facility policy and procedure for reporting alleged occurrences of abuse to the State Agency. EI #1 said they had two hours to report it. EI#1 also said, We know it changed from 24 hours to two hours. EI#1 was asked was the alleged physical abuse reported within the required time frame to the ADPH/state agency. EI#1 replied, I don't think it was reported within the required time frame. EI#1 was asked what was the potential harm in not reporting incidents of alleged abuse to ADPH/State Agency within the required time frame. EI#1 replied, It could be potential harm to the resident.

Based on observations, interview and a review of a facility policy titled, DIRECTOR OF MAINTENANCE JOB DESCRIPTION, the facility failed to ensure Room Locator (RL) #1, RL #2, and RL #3, were free of chipped paint, nails in walls, holes in walls and visible nails in the base of a toilet exposed without a cover. This affected practice affected one of five rooms located on the middle hall and two of ten rooms located on the B Hall. Findings include: A review of a facility policy titled, DIRECTOR OF MAINTENANCE JOB DESCRIPTION, dated 05/03 revealed the following: General Purpose: .ensuring that the facility is maintained in a safe, comfortable condition . On 03/28/2017, from 3:19 PM - 3:28 PM, observations were made of the following: (3:25 PM) RL #1: Bed A side baseboard with caulking loose and scuffed paint. The ceiling had peeling paint. Bed B had nails in wall, with nail holes. Bed C's ceiling and peeling paint. (3:19 PM) RL #2's bathroom had screws sticking up on the base of the toilet and not covered. (3:28 PM) RL #3's bathroom wall had chipped paint in front of the toilet and sink On 03/30/2017 at 9:10 AM, an interview was conducted with EI #4. EI #4 was asked why should resident's walls be free of scuffed and or chipped paint and small holes. EI #4 said to prevent infestation of bugs. EI #4 was asked why should the base of toilets not have nails sticking up with no covers. EI #4 said residents could hit themselves on them. EI #4 was asked what was the potential harm for walls to have chipped paint, base of toilets to have nails sticking up without covering and nails left in walls and holes in the walls. EI #4 said nails could tear a resident's skin, peeling paint from the ceiling could fall on the resident's bed. EI #4 further explained nails sticking out of walls could result in a resident cutting their skin.

Based on record review, interview and a review of a facility policy titled,Resident Assessment Instrument the facility failed to ensure a significant change Minimum Data Set (MDS) was done for Resident Indentifer (RI) #13, when admitted to hospice. This deficient practice affected RI #13, one of three residents reviewed for hospice services. Findings include: A review of a facility policy titled, Resident Assessment Instrument, with a revised date of 10/2013, revealed: STANDARD: . VI. Significant Change in Status Assessment a) Asignificant change is defined, according to federal regulations, as a decline or improvement in the resident's status that 1) is not self limiting, 2) impacts more than one area of the resident's health status, and 3) requires interdisciplinary review or revision of the care plan . RI #13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the PHYSICIAN/PRESCRIBER form, dated 12/09/2016, revealed, Admit to Life . Hospice. The Licensed Practical Nurse (LPN)/Careplan Coordinator, Employee Identifier (EI) #2 was interviewed on 03/30/2017 at 12:00 PM. EI #2 was asked what assessment is done when a resident is admitted to hospice. EI #2 stated significant change is done. EI #2 stated the facility completed an annual assessment on 12/18/16, but should have completed a significant change assessment instead.

Based on record reveiw, observation and interview, the facility failed to ensure a Certified Nursing Assistant (CNA), Employee Identifier (EI) # 3, separated the perineum and clean Resident Identifier (RI) #6, in a manner to prevent the potential for Urinary Tract Infections. This affected RI #6, one of sampled residents observed during incontinence care. Finding Include: RI #6 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE], assessed RI #6 as being frequently incontinent of bowel and bladder. On 03/29/2017 at 3:05 PM, a CNA, EI #3 was observed providing incontinence care for RI #6. EI #3 failed to separate the perineum and clean RI #6. When asked why she failed separate the perineum. EI #3 stated, she forgot. When asked why it was important to clean a resident's perineum, EI #3 stated it prevents Urinary Tract Infections and yeast infections.

Based on observations, record review and interview, the facility failed to ensure a container of tea and a container of fruit punch were discarded by the use by date. This had the potential to affect all residents receiving meals from the kitchen. On 3/15/16 at 11:40 AM, during the initial tour of the kitchen, the surveyor observed a partially filled container labeled unsweetened tea dated 3/9/16 with a use by date of 3/12/16. Also observed, was a partially filled container labeled fruit punch dated 3/10/16 with a use by date of 3/13/16. A facility document titled FOOD STORAGE LABELING , with a revised date of 2/15, revealed the following: Policy: The facility will ensure the safety and quality of food by following good storage and labeling procedures. . PROCEDURE: . 4. Suggested labeling includes: . b. Date of preparation or Use By Date . On 3/17/16 at 11:40 AM, an interview was conducted with facility's Dietary Manager (DM), EI #5. When asked what was the facility's policy regarding labeling and use by dates, EI # 5 stated the use by date is three days after an item is opened. EI #5 was asked if she observed on 3/15/16 a container of tea with a use by date of 3/12/16 and a container of fruit punch with a use by date of 3/13/16. EI #5 stated yes, she did. EI #5 also stated the potential harm of using items past the use by date would be food poisoning.

Based on observation, interview and record review, the facility failed to ensure the safety of Resident Identifier (RI) #9 by staff remaining with him during toileting. As a result of the Certified Nursing Assistant (CNA) not being with the resident, he fell to the floor in the bathroom, hitting his head on the wall, and sustaining an injury that required five staples to the back of the head. This affected 1 of nine sampled residents reviewed for falls. Findings include: RI #9 was originally admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. Review of RI #9's fall investigations revealed a fall on 6/21/11 at 1200 PM in the resident's bathroom. The investigation indicated the resident was taken to the toilet by a staff member who then stepped out of the bathroom. The resident was found on the bathroom floor after a nurse heard a noise and went searching for where the sound came from. No injuries noted other than a small 1 x 1 abrasion to the right elbow. The corrective action taken to prevent a reoccurrence was for CNA to stay with resident while toileting. Review of the resident's care plan for falls reflected the approach of the CNA to stay with resident at all times during toileting was added on 6/21/11. Also on 6/21/11 the facility inserviced staff, including EI #3, to stay with the RI #9 at all times while toileting and not to leave him unattended related to his inability to follow commands and risk of falling. RI #9's Quarterly Minimum Data Set (MDS) assessment, reference date of 12/12/11 reflected a BIMS (Brief Interview Mental Status) score of 6, suggesting severe impairment. RI #9's functional status reflected the resident required one person extensive assistance for transferring and locomotion on unit. RI #9 also required extensive assistance of one person for toilet use. The resident was also coded for functional limitation in range of motion on both sides of his upper and lower extremities. Mobility devices coded were walker and wheel chair. The MDS also reflected the resident having falls since admission or prior assessment. The facility continued the care plan for at risk for falls related to unsteady gait, his episodes of confusion and thinks he can ambulate without assistance. The goal was for the resident to have no fall related injuries, target dates of 12/13/11 and 3/13/12. Review of the resident's fall investigations revealed another fall occurred on 1/26/2012 at 7:55 PM in the resident's bathroom. The investigation indicated the CNA heard the bed alarm sounding and went to answer the alarm promptly. The CNA noted the resident walking to the bathroom without assist. The CNA then assisted the resident to the toilet and then went to turn off the bed alarm. Upon going back to the resident's bathroom, she found the resident in the floor. The CNA called for help. Also documented in the 1/26/2012 investigation was a laceration noted to the residents head near the crown measuring approximately 3 centimeters. Upon assessment, the pupils were noted to be unequal with right larger than left. Orders received to send to emergency room for evaluation and possible treatment. The facility's corrective action taken to prevent a reoccurrence was staff educated related to following plan of care and profile: staff to remain with resident while toileting. The attending License Practical nurse documented the the area was through the epidermis and required stitches. A review of the hospital emergency room outpatient record was conducted. The record reflected RI #9 arrived at 20:50 (8:50 PM) on 1/26/12. The chief complaint was an open wound of the scalp. There was treatment of [REDACTED]. Discharge Instructions/ Plan: staples removed in 7 days... Bactroban ointment times 7 days and Tylenol 500 milligrams for pain. The hospital Pertinent History documentation reflected Chief Complaint: Fall; lac (laceration) to posterior scalp approx (approximately) 2" ; 1 side weakness. On 2/23/12 at 4:10 PM, RI #9 was observed in his room, with his room mate, sitting in his wheel chair with the restraint belt attached. On 2/24/2012 at 8:40 AM, the emergency room Physician EI # 5 that treated RI #9 was interviewed. At that time when he was asked why the wound was closed with staples, he stated the wound could be approximated better. When asked why the staples were used he answered it would depend on the extent of the wound such as the size and depth. EI # 5 was asked what could have happened without stitches or staples and he stated, the wound could "get infected or bleeding can reoccur. The old(er) people don't do so good." On 2/24/12 at 12:00 PM, EI #3 was interviewed. EI #3 was RI #9's CNA the night of his 1/26/12 fall. EI #3 was asked about the fall. She said the light came on and the alarm was going off. EI #3 said she and two other CNAs were on the hall at the time. EI #3 was asked how long it took her to respond to the alarm. EI #3 said it took about seven minutes because they were putting other residents to bed. EI #3 was asked to describe what she saw when she entered the resident's room. She said when she entered the room the resident was standing between the dresser that held the TV and the footboard of RI #9's roommate bed. RI #9 had his left hand on the dresser. The CNA said the resident's hands were shaking and she told RI#9 he was going to fall. EI #3 said she asked RI#9 what was he trying to do and he replied he was trying to go to the bathroom. EI #3 then took her gait belt off and put it on RI #9 and assisted him to the toilet. She said after seating RI #9 on the toilet she told him to seat there and she watched the resident to make sure he was not going to get off the toilet. EI #3 then said she went to turn the alarm off and she heard a noise before she could cut the alarm off. The CNA said she went back to the bathroom and found the resident on the floor and called for help. The two other CNAs came in to assist EI #3. EI #3 explained the resident had hit the edge of the wall (corner) and was lying on the floor, with his head against the wall corner at the bottom. EI #3 said when she got the resident up she noticed a gash in the back of his head. She said the gash was only bleeding a little until the resident started moving. The CNA was asked what was the resident's mental status at that time. She said the resident was more confused when the ambulance came, the resident kept saying he didn't drink anything.