Every finding on record at South Health and Rehabilitation, LLC

Based on interviews, record reviews, facility document review, Resident #14's emergency department medical records, and the facility's policy titled Person Centered Care Plans the facility failed to ensure staff implemented the care plan for transfers with a mechanical lift for Resident #14. Specifically, on 04/11/2023 Certified Nursing Assistant (CNA) #1 and CNA #2 failed to implement Resident #14's care planned intervention for transfers with mechanical lift, which resulted in the resident having arm pain while being transferred without the use of the mechanical lift and being lowered to the floor. The incident resulted in a left humerus fracture and numerous rib fractures. This deficient practice affected Resident #14, one of three residents reviewed for falls. Findings included: A review of a facility policy titled, Person Centered Care Plans, effective 08/15/2018, indicated, .STANDARD . the facility develops a comprehensive person centered plan of care for each resident/guest that includes measurable objectives and timetables to meet a resident/guest(s) medical, nursing and mental/psychosocial needs that are identified in the comprehensive assessment and based upon the resident/guest(s) goals and preferences . PROCESS .I. Assessment and Person Centered Care Plan Process . f) Upon completion of baseline care plan or comprehensive care plan and when reviewed quarterly/significant change, the MDSC [Minimum Data Set Coordinator] will ensure care plan intervention(s) are entered into Care Guide ADLs [Activities of Daily Living]/Intervention in the electronic medical record that are considered outside of routine care. This will provide the CNA with individualized information needed to meet the resident's care needs . A review of Resident #14's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/07/2023, indicated the resident was admitted to the facility on [DATE]. The resident had active diagnoses that included Cerebrovascular Accident (transient ischemic attack or a stroke), Dislocation of Right Internal Hip Prosthesis, and Anxiety Disorder. Further review revealed the resident's Brief Interview for Mental Status (BIMS) score was 15, which indicated the resident was cognitively intact. The MDS indicated the resident had no delirium or behaviors. Per the MDS Resident #14 required total staff assistance for transfers and toilet use. A review of Resident #14's Care Plan, with a start date of 07/02/2021, revealed the resident had the potential for falls related to impaired mobility. An intervention, initiated on 09/01/2022, indicated the resident transferred with two-person assistance using a mechanical lift. A review of the Verification of Investigation document signed by the Administrator on 04/19/2023, revealed on 04/11/2023 at approximately 6:30 AM, CNA #1 and CNA #2 transferred Resident #14 with two-persons' assistance when the resident's care plan indicated the use of a mechanical lift was required. Further review revealed, CNA #1 acknowledged she and CNA #2 transferred the resident with two-person assistance and did not use a mechanical lift. CNA #1 reported the staff lowered the resident to the floor when the resident complained of pain and then lifted the resident from the floor with a mechanical lift pad to transfer the resident to the wheelchair. CNA #2 reported he did not know how the resident should transfer and was following the direction of CNA #1. The investigation included an interview with Resident #14 who reported that he/she told CNA #1 and CNA #2 that he/she could not transfer without the use of the mechanical lift. The resident stated the CNAs told him/her, We are going to transfer you the fast way. The resident said that while they were transferring him/her there was a pop in his/her arm and a sharp pain. When the resident's arm started hurting the CNAs lowered the resident to the floor. The CNAs then put a mechanical lift pad under him/her and lifted him/her into the chair without the mechanical lift. During a follow up interview, CNA #2 confirmed Resident #14 told the CNAs that they required a mechanical lift before they transferred the resident, but CNA #2 did not see anything wrong with just transferring them. CNA #2 reported the CNAs manually lifted the resident off the floor by lifting the mechanical lift pad underneath him/her. The ALLEGATON DISPOSITION section of the Verification of Investigation revealed, . All information provided points to [Resident #14's] fracture occurring during the improper transfer . A review of the hospital emergency department Radiology Results, dated 04/11/2023 at 3:26 PM, revealed Resident #14 sustained a fracture of the left humeral neck, subluxation [a partial dislocation] of the humeral head with a small humeral head impaction fracture, and numerous minimally angulated posterior rib fractures. During an interview on 08/20/2023 at 10:49 AM, Resident #14 stated they had a fall once at approximately 6:50 AM when the resident wanted to transfer to the wheelchair for an early appointment with an outside provider. Resident #14 stated they informed CNA #1 from the night shift that they transferred via mechanical lift, but CNA #1 said they would transfer the resident quickly and did not use the mechanical lift. Resident #14 said the CNAs transferred him/her under his/her arms. Resident #14 stated they fell during the transfer and screamed in pain. Resident #14 stated CNA #1 and the second CNA rolled the resident on the floor to place a mechanical lift pad under the resident and lifted the resident to the wheelchair manually and did not use the mechanical lift. The resident stated it was determined there was a shoulder fracture and rib fractures. During an interview on 08/23/2023 at 4:14 PM, Licensed Practical Nurse (LPN) #3 stated the resident had always used the mechanical lift to transfer, and it was on their care plan. During an interview on 08/23/2023 at 2:51 PM, the Administrator indicated the transfer status for a resident was shown on the CNA care plan in the CNA charting system. The staff referenced that before every shift and as needed during the shift. The Administrator stated CNA #1 and CNA #2 should have known Resident #14's transfer status by reviewing the documentation and known because the resident informed them; the resident told them to get the lift, and they should have reviewed the documentation to verify it and to ensure that was the accurate way to transfer the resident. The Administrator stated they should have transferred the resident via mechanical lift, as that was indicated on the CNA care plan. This deficient practice was cited as a result of complaint/intake #AL00043925. During the survey, no current failed practice related to F656-Develop/Implement Comprehensive Care Plan was identified; thus, past non-compliance was cited.

Based on interviews, record reviews, facility document review, Resident #14's emergency department medical records, the facility's policies titled Lifting Devices and Incidents and Accidents, and a report submitted by the facility to the Alabama Department of Public Health Online Incident Reporting System the facility failed to ensure Resident #14 was transferred from his/her bed to their wheelchair with a mechanical lift in accordance with the resident's plan of care and facility policies which resulted in an accident. Specifically, on 04/11/2023 Certified Nursing Assistant (CNA) #1 and CNA #2 failed to transfer Resident #14 in accordance with the plan of care and the resident's voiced need to be transferred by the mechanical lift, also known as a Hoyer lift. While being transferred, Resident #14 complained of having arm pain and the staff lowered him/her to the floor. The facility further failed to ensure CNA #1 and/or CNA #2 reported the incident per facility policy to the nursing staff before the resident was transferred from the floor to the wheelchair resulting in the resident being moved unnecessarily before the resident's condition was assessed. The incident resulted in a left humerus fracture and numerous rib fractures. This deficient practice affected for one (Resident #14) of five resident reviewed for accidents. Findings included: A review of a facility policy titled, Lifting Device, effective 05/16/2014, revealed, . PURPOSE . A lifting device may be used to assist in lifting and repositioning residents per plan of care . A review of a facility policy titled, Incidents and Accidents, effective 11/10/2014, revealed, .PURPOSE . The resident/guest environment remains as free of accident hazards as possible, however, when an accident occurs, prompt response and reporting occurs . PROCESS . I. Handling Accident Occurrences .a) The resident/guest should not be moved unnecessarily until condition has been accessed . A review of Resident #14's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/07/2023, indicated the resident was admitted to the facility on [DATE]. The resident had active diagnoses that included Cerebrovascular Accident (transient ischemic attack or a stroke), Dislocation of Right Internal Hip Prosthesis, and Anxiety Disorder. Further review revealed the resident's Brief Interview for Mental Status (BIMS) score was 15, which indicated the resident was cognitively intact. The MDS indicated the resident had no delirium or behaviors. The resident required total staff assistance for transfers and toilet use. The MDS indicated Resident #14 did not walk. A review of Resident #14's Care Plan, with a start date of 07/02/2021, revealed the resident had the potential for falls related to impaired mobility. An intervention, initiated on 09/01/2022, indicated the resident transferred with two-person assistance using a mechanical lift. On 04/12/2023 the facility submitted an initial report to the State Survey Agency via the Alabama Department of Public Health Online Incident Reporting System. This report indicated Resident #14 was transferred by CNA #1 and CNA #2 with two-persons' assistance when the resident's plan of care dictated that he/she should be transferred with use of a Hoyer lift. The CNA's reported they did not know his/her transfer orders. On 04/12/2023 after the resident returned to the facility, Resident #14 reported he/she informed the CNAs of his/her transfer status prior to them attempting the transfer and they transferred him/her anyways. A review of the Verification of Investigation document signed by the Administrator on 04/19/2023, revealed on 04/11/2023 at approximately 6:30 AM, CNA #1 and CNA #2 transferred Resident #14 with two-persons' assistance when the resident's care plan indicated the use of a mechanical lift was required. Further review revealed, CNA #1 acknowledged she and CNA #2 transferred the resident and did not use a mechanical lift. CNA #1 reported the staff lowered the resident to the floor when the resident complained of pain and then lifted the resident from the floor with a mechanical lift pad to transfer the resident to the wheelchair. CNA #2 reported he did not know how the resident should transfer and was following the direction of CNA #1. Further review of the facility investigation revealed the charge nurse, Licensed Practical Nurse (LPN) #3, reported she did not know about the incident until Resident #14 was in the wheelchair. Resident #14 reported that he/she told CNA #1 and CNA #2 that he/she could not transfer without the use of the mechanical lift. The resident stated the CNAs told him/her, We are going to transfer you the fast way. The resident said that during the transfer there was a pop in his/her arm and a sharp pain. When the resident's arm started hurting the CNAs lowered the resident to the floor. The CNAs then put a mechanical lift pad under him/her and lifted him/her into the chair without the mechanical lift. CNA #2 later confirmed Resident #14 told the CNAs that he/she required a mechanical lift before they transferred the resident, but CNA #2 did not see anything wrong with just transferring them. CNA #2 reported the CNAs manually lifted the resident off the floor by lifting the mechanical lift pad underneath him/her. The ALLEGATON DISPOSITION section of the Verification of Investigation revealed, .Both [Resident #14] and [CNA #2] reported that [Resident #14] informed the staff members of [his/her] hoyer lift transfer orders. They then chose to transfer [him/her] that way despite [his/her] information . All information provided points to [Resident #14's] fracture occurring during the improper transfer . A review of LPN #3's written statement dated 04/11/2023 indicated Resident #14 reported to her that two CNAs hurriedly tried to transfer him/her from the bed to the wheelchair without using the Hoyer lift resulting in him/her falling and popping his/her left shoulder. The statement also indicated that Resident #14 reported while he/she was on the floor the CNAs placed a pad underneath him/her and lifted him/her from the floor to the wheelchair causing lots of pain. A review of the hospital emergency department Radiology Results, dated 04/11/2023 at 3:26 PM, revealed Resident #14 sustained a fracture of the left humeral neck, subluxation [a partial dislocation] of the humeral head with a small humeral head impaction fracture, and numerous minimally angulated posterior rib fractures. According to the Departmental Notes, dated 04/12/2023 at 2:03 AM, the resident returned from the hospital on 04/11/2023 at 11:44 PM with a sling on their left arm. During an interview on 08/20/2023 at 10:49 AM, Resident #14 stated they had a fall once at approximately 6:50 AM when the resident wanted to transfer to the wheelchair for an early appointment with an outside provider. Resident #14 stated he/she informed CNA #1 from the night shift that they transferred via mechanical lift, but CNA #1 said they would transfer the resident quickly. Resident #14 said the CNA did not use the mechanical lift. Resident #14 stated they fell during the transfer and screamed in pain. Resident #14 stated CNA #1 and the second CNA rolled him/her while on the floor to place a mechanical lift pad under him/her and then lifted him/her to the wheelchair manually without the use of the mechanical lift. The resident stated it was determined there was a shoulder fracture and rib fractures. Resident #14 said he/she did not know why the CNAs did not use the mechanical lift. During a follow-up interview on 08/23/2023 at 3:36 PM, Resident #14 stated they told CNA #1 she needed to get a lift to transfer him/her because the resident could not stand and walk. The resident stated CNA #1 said, they were going to do it the quick way, and lifted the resident without the mechanical lift. During an interview on 08/21/2023 at 7:36 AM, LPN #3 stated she was the charge nurse on the night shift on 04/10/2023. LPN #3 stated she was charting at the end of her shift the morning of 04/11/2023 when CNA #4 from the day shift reported the resident was crying and did not want to go to their appointment because of pain. LPN #3 stated she went to the resident's room to assess his/her pain, but the resident refused to allow a full assessment. LPN #3 stated she called her supervisor, Registered Nurse (RN) #5, and returned to the resident's room with her phone on speaker so RN #5 could speak to the resident about going to the appointment. LPN #3 stated the resident described the incident and how the CNAs had transferred the resident to their wheelchair by hand and did not use the mechanical lift, and the resident had a fall. LPN #3 stated she then ran to attempt to catch CNA #1 and CNA #2, but they had already left the building and did not answer text messages or phone calls. During a follow-up interview on 08/23/2023 at 4:14 PM, LPN #3 stated the resident had always used the mechanical lift to transfer, and it was on their care plan. She stated it was not appropriate to transfer a resident from the floor by manually lifting them with a mechanical lift pad; a mechanical lift should be used. During an interview on 08/22/2023 at 2:48 PM, Registered Nurse (RN) #5 stated she was the supervisor the morning of 04/11/2023. She stated Resident #14 transferred using a mechanical lift and had for approximately the past year because the resident was so heavy and could not stand. During an interview on 08/22/2023 at 7:31 AM, CNA #4 stated she worked with Resident #14 on the day shift on 04/11/2023, and the resident complained of arm pain. CNA #4 stated she did not know anything had happened to the resident and reported the pain to LPN #3. She stated Resident #14 used a mechanical lift to transfer, and CNA #1 and CNA #2 should have checked the resident's care plan and transferred the resident properly. CNA #4 stated it was unacceptable to lift any resident under their arms if the resident was assessed to need a mechanical lift. During an interview on 08/23/2023 at 2:51 PM, the Administrator stated CNA #1 and CNA #2 should have known Resident #14's transfer status by reviewing the documentation on the CNA care plan. When the resident informed the CNAs to get the lift, they should have reviewed the documentation to verify it and to ensure that was the accurate way to transfer the resident. The Administrator stated they should have transferred the resident via mechanical lift, as that was what was indicated on the CNA care plan. During an interview on 08/24/2023 at 3:41 PM, the Administrator was asked why the facility substantiated neglect at the conclusion of the investigation. The Administrator read the Allegation Disposition section on the Verification of Investigation form. The Administrator stated, due to the information collected during the investigation, the allegation of abuse, neglect will be indicated for the resident and both CNAs involved. Both Resident #14 and CNA #2 reported that Resident #14 informed the staff members of his/her Hoyer lift transfer orders. They then chose to transfer him/her that way despite his/her information. Resident #14's arm began hurting during said transfer and Resident #14 was found to have a fracture that afternoon. All information provided points to Resident #14's fracture occurring during the improper transfer and his/her injury being a result of the CNAs neglect to follow his/her proper care orders. This deficient practice was cited as a result of complaint/intake #AL00043925. During the survey, no current failed practice related to F689-Free of Accident Hazards/Supervision/Devices was identified; thus, past non-compliance was cited.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure that one (Resident #63) of three sampled residents who self-administered medications was assessed as safe and appropriate to self-administer medications. Findings included: A review of the facility's policy titled, Self Administration of Drugs, effective 11/01/2001, revealed, .Residents will not be permitted to self-administer medications, unless so ordered by the attending physician, and approved by the care planning team . A review of Resident #63's Face Sheet revealed the facility admitted Resident #63 on 03/30/2023 with diagnoses that included Neuropathy, Conjunctivitis, and Gastro-esophageal Reflux Disease. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/22/2023, revealed Resident #63 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. According to the MDS, Resident #63 was independent with supervision for all activities of daily living (ADLs), except bathing, for which the resident required physical assistance of one person. A review of Resident #63's Care Plan, initiated on 03/31/2023, revealed there was no care plan for the resident to self-administer medications. A review of Resident #63's August 2023 Physician Orders revealed there was no order for the resident to self-administer medications. Observation on 08/20/2023 at 11:47 AM revealed Resident #63 was in their room. A medication cup with one blue pill was observed on the table next to Resident #63's bed. During an interview at that time, Resident #63 stated that the nurses would leave medication at the bedside if the resident was sleeping when they came in to give medications. Observation on 08/21/2023 at 7:34 AM revealed Resident #63 was in bed and a medication cup containing six pills was on the resident's bedside table. During an interview at that time, Resident #63 stated a nurse brought the medication but could not remember which nurse. The resident said the nurses knew the resident liked to sleep, so they just left the medications at the bedside. Resident #63 stated that the nurses knew the resident would take the medications when they woke up. In an interview on 08/21/2023 at 8:04 AM, Licensed Practical Nurse (LPN) #14 stated she took Resident #63's medications into the resident's room, but Resident #63 was in the bathroom. LPN #14 stated Resident #63 was alert and oriented, so she left the medications at the bedside. LPN #14 stated that she should not have left the medication at the bedside and should have stayed and watched the resident take the medications. LPN #14 stated the risk in leaving the medications was that another resident could come into the room and take the medication. LPN #14 stated the following medications were in Resident #14's medication cup at the bedside: - amlodipine (a medication used to treat high blood pressure) 10 milligrams (mg) - potassium chloride (KCl) 10 milliequivalents - omeprazole (a medication used to treat heartburn) 20 mg - meloxicam (a nonsteroidal anti-inflammatory medication) 15 mg - loratadine (an antihistamine)10 mg - gabapentin (an anti-seizure and nerve pain medication) 600 mg In an interview on 08/23/2023 at 8:45 AM, Registered Nurse (RN) #13, the Unit Manager, stated Resident #63 did not self-administer medications. RN #13 stated that if Resident #63 was going to self-administer medications, the resident would have to demonstrate appropriate self-administration, and it would have to be care planned. RN #13 stated that leaving Resident #63's medication at the bedside was unacceptable. In an interview on 08/23/2023 at 10:56 AM, the Regional Quality Assurance (QA) Nurse stated the nurse should stay and watch the resident take the medication to ensure that it was taken correctly. The Regional QA Nurse stated her expectation was that staff should contact the physician and complete an assessment to ensure the resident was safe to self-administer medications if they were going to allow a resident to self-administer medications.

Based on interviews, review of Resident Identifier (RI) #1's medical record, the facility's PROTOCOL FOR EMERGENT CARE, FUNDAMENTALS OF NURSING NINTH EDITION, a facility policy titled Cardio Pulmonary Resuscitation (CPR), and a facility reported incident received by the Alabama State Survey Agency, the facility failed to honor the end-of-life wishes of RI #1, a resident with an Advanced Directive and a DNR (Do Not Resuscitate) Code Status. Code status describes what type of intervention a health care facility will provide should a resident stop breathing and/or their heart stops beating. DNR means when a resident stops breathing and/or their heart stops beating, staff are not to initiate emergency medical services, Cardiopulmonary Resuscitation, in an attempt to revive the resident. During the 11:00 PM to 7:00 AM shift on [DATE], RI #1 was found unresponsive with no pulse or respirations by Employee Identifier (EI) #6, Certified Nursing Assistant (CNA), and EI #3, Licensed Practical Nurse (LPN). EI #3 and EI #4, another LPN, then initiated CPR on RI #1, in an attempt to revive the resident. EI #3 and EI #4 did not check RI #1's code status prior to initiating CPR. This deficient practice placed RI #1, one of eight sampled residents reviewed for advance directives and code status, in immediate jeopardy, as the failure of facility staff to honor a resident's end-of-life wishes is likely to cause serious injury, serious harm, serious impairment, or death. On [DATE] at 12:53 PM, the Administrator and Director of Nursing (DON) were provided a copy of the immediate jeopardy template and notified of the findings at the immediate jeopardy level in the area of Resident Rights, F578-Request/Refuse/Discontinue Treatment/Formulate Advance Directives. Beginning [DATE] until [DATE], the facility implemented corrective actions to correct the identified deficient practice and prevent recurrence; thus immediate jeopardy past non-compliance was cited. Findings include: On [DATE] at 2:51 PM, the Alabama State Survey Agency received a facility reported incident which indicated staff found RI #1 unresponsive on [DATE] at 4:50 AM. This report documented EI #3 started chest compressions without checking RI #1's code status. The report further documented RI #1 had a DNR in place. The facility's policy titled Cardio Pulmonary Resuscitation (CPR), with an effective date of [DATE], documented: . PURPOSE: To circulate blood containing oxygen to vital organs pending the arrival of emergency medical services (EMS) to a resident/guest who experiences cardiac arrest (cessation of respirations and /or pulse) in accordance with the resident/guest(s) advance directives or in the absence of advance directives or a Do Not Resuscitate (DNR) order . A review of the facility's undated PROTOCOL FOR EMERGENT CARE, documented: .A staff member should access E-chart (electronic health record) immediately and verify the identification of the resident/guest .and if there is an order for DNR. This order will appear as one of the first orders when sorting by order type . FUNDAMENTALS OF NURSING NINTH EDITION, with a copyright date of 2017, Chapter 23, titled Legal Implications in Nursing Practice, page 305, documented: . Advance Directives include living wills, health care proxies, and durable powers of attorney for health care .They are based on values of informed consent, patient autonomy over end-of-life decisions, truth telling, and control over the dying process . Health care providers perform CPR when needed unless there is a DNR order in the patient's chart . RI #1 was readmitted to the facility on [DATE], with diagnoses of Hypertensive Heart Disease with Heart Failure and Cirrhosis of the Liver. Review of RI #1's medical record revealed a document titled ALABAMA CERTIFICATE OF HEALTH CARE DECISION SURROGATE. This document was signed, dated and notarized on [DATE], and indicated a family member of RI #1 was the .judicially-appointed guardian of the resident ., with the authority to make health care decisions for RI #1. RI #1's Alabama Portable Physician Do Not Attempt Resuscitation Order, No/CPR/Allow Natural Death, signed by the RI #1's designated health care surrogate on [DATE], documented: . After consultation with the attending physician, I hereby direct that resuscitative measures be withheld from the patient/resident in the event of cardiopulmonary cessation. I believe that this decision conforms as closely as possible to what the patient/resident would have wanted . During an interview on [DATE] at 9:08 AM, RI #1's designated health care surrogate indicated she had come down a few months prior and met with RI #1 and RI #1's physician, to discuss RI #1's health condition. RI #1's designated health care surrogate confirmed RI #1 was a DNR, which was consistent with his/her end-of-life wishes. EI #7, RI #1's physician, was interviewed on [DATE] at 12:30 PM. EI #7 reported he became aware staff had performed CPR on RI #1 when he arrived at the facility around 8:00 AM on [DATE]. EI #7 said he went to the DON to inform him RI #1 was a DNR. EI #7 indicated he and the DON then reviewed the chart and confirmed RI #1's code status was listed as DNR. Review of RI #1's [DATE] PHYSICIAN ORDERS, revealed an order dated [DATE] for .No CPR .DNR . A review of a facility document titled Verification of Investigation, summarizing the facility's investigation into the incident, documented that EI #6, CNA, and EI #3, LPN, went into RI #1's room and found him/her unresponsive around 4:50 AM on [DATE]. EI #3 was then assisted by EI #4, another LPN, and chest compressions were initiated, without checking RI #1's code status. RI #1 had a DNR order in place. Paramedics arrived promptly and called time of death at 5:06 AM. Review of the EMS run report, dated [DATE], indicated the facility contacted EMS on [DATE] at 4:51 AM. EMS arrived at the patient (RI #1) at 5:00 AM. The Narrative Section documented the following: . RESPONDED EMERGENCY ON A CARDIAC ARREST . LAST SEEN ALIVE AT 0300 (3:00 AM), CHECKED JUST BEFORE 0500 (5:00 AM) AND FOUND UNRESPONSIVE, .CPR INITIATED BY NH (Nursing Home) STAFF . PT (patient) UNRESPONSIVE, PULSELESS, APNEIC (not breathing) . EMS pronounced RI #1 deceased , with a time of death listed as 5:06 AM. An interview was conducted with EI #6, the CNA, on [DATE] at 10:40 AM. EI #6 was asked if she worked with RI #1 on [DATE]. EI #6 stated she was assigned to work with RI #1 on [DATE]. EI #6 explained she asked EI #3 to assist with patient care for RI # 1. EI #6 stated when they walked into RI #1's room he/she was found unresponsive. EI #6 stated EI #3 checked RI #1's pulse and breathing. EI #6 stated EI #3 told her to get help, and then the crash cart was brought into the room. On [DATE] at 9:00 AM an interview was conducted with EI #3, LPN. EI #3 explained she was asked to assist with resident care for RI #1 on [DATE]. According to EI #3, when she and EI #6, CNA, went into RI #1's room around 4:50 AM, RI #1 was unresponsive. EI #3 stated she told EI #6 to go get help. EI #3 stated within seconds the crash cart arrived. According to EI #3, EI #4, LPN, assisted her in placing RI #1 on the backboard and chest compressions were started. EI #3 said compressions continued until EMS arrived, and then they took over. EI #3 was asked about RI #1's code status. EI #3 stated RI #1 was a DNR, and she did not check the code status prior to initiating CPR. EI #3 explained, in the moment, everything was moving so fast and she forgot to check the code status, but acknowledged she should have. When asked the importance of knowing a resident's code status prior to initiating CPR, EI #3 stated to honor the resident's end-of-life wishes. A review of EI #4's statement from the investigation file dated [DATE], documented: . (EI #3) requested I call the paramedics around 4:50 am on [DATE]. After I called the paramedics I assisted in the code with (EI #3) . Upon the paramedics arrival, they took over and called time of death at 5:06am. I assumed that (EI #3) had checked code status prior to code . An interview was conducted with EI #2, Registered Nurse (RN)/Director of Nursing (DON), on [DATE] at 11:30 AM. EI #2 was asked about the incident on [DATE] involving RI #1. EI #2 stated RI #1, who had a DNR, was found unresponsive by staff, who initiated CPR without checking RI #1's code status first. EI #2 stated nurses are trained to check code status prior to initiating CPR, to ensure residents' end-of-life wishes are honored. An interview was conducted with EI #5, RN, Staff Development on [DATE] at 11:40 AM. EI #5 stated she became aware of the incident involving RI #1 on [DATE] when she arrived at work around 7:30 AM. EI #3 said she was told RI #1 expired and CPR was initiated, even though RI #1 was a DNR. EI #5 stated EI #3 told her everything happened so fast that the code status was not checked. EI #5 was asked what was the importance of checking a resident's code status prior to administering CPR, and EI #5 said to honor the resident's end-of-life wishes. This deficiency was cited as a result of complaint/report number AL00042248. ************************* The facility took immediate actions to correct the non-compliance by: - On [DATE] the facility identified that EI #3 initiated CPR on RI #1 when he/she had an active DNR. - On [DATE] an investigation was initiated, the event was reported to ADPH (Alabama Department of Public Health), the two LPNs involved were suspended pending the investigation. - EI #3 and EI #4 received one on one education about emergency care protocols on [DATE]. - On [DATE] education of all licensed nurses was initiated. Education was completed on [DATE]. - On [DATE] mock codes were initiated and continued on [DATE] to include all licensed nurses. - On [DATE] a review of all DNRs in the building was completed by EI #2, DON. - On [DATE] an emergency Quality Assurance and Performance Improvement (QAPI) meeting was completed related to Emergency Protocols. Monitoring was established that the facility would complete mock codes upon hire and quarterly with all licensed nurses and as needed when codes occur. ************************* After review of documentation supporting the above corrective actions, including the facility's investigation file, in-service/education records, QAPI documentation, and staff interviews, the survey team verified the facility implemented corrective actions from [DATE] to [DATE], thus immediate jeopardy past non-compliance was cited.

Based on observation and interview, the facility failed to ensure three expired mighty shake supplements in the milk cooler were discarded. This deficient practice had the potential to affect up to three residents receiving mighty shake supplements. Findings Include: On [DATE] at 11:15 AM, the surveyor observed three 4-ounce mighty shake supplements in the milk cooler with a use by date of [DATE]. At this time, Employee Identifier (EI) #1, the Acting Dietary Manager, was asked what was the date on the mighty shakes. EI #1 said [DATE]. EI #1 was asked was that the use by date. EI #1 said yes. EI #1 was asked what should have been done with the expired might shake supplements. EI #1 said they should have been discarded. EI #1 was asked what was the potential harm with expired mighty shakes still being in the cooler. EI #1 said the potential harm was that they could be served to a resident.

Based on observations, interviews, review of medical records, review of a facility policy titled, Continuous Positive Airway Pressure ([MEDICAL CONDITION]) Administration, and review of a manufacture's documents titled, 1800 [MEDICAL CONDITION] Patient Education Booklet and . (name of company), User Manual, the facility failed to ensure: 1 [NAME] Resident Identifier (RI) #3 had an order to clean his/her [MEDICAL CONDITION] and/or Bilevel Positive Airway Pressure ([MEDICAL CONDITION]) machine, 1 B. RI #3's oxygen was applied on 09/11/19 to keep his/her oxygen saturation greater than 92 percent (%), and 2. RI #4 had evidence to ensure his/her [MEDICAL CONDITION] was being cleaned per the manufacture's guidelines. These deficient practices affected RI #3 and RI #4, two of two residents sampled for [MEDICAL CONDITION] and [MEDICAL CONDITION] use. Findings Included: A review of the facility policy and procedure titled, Continuous Positive Airway Pressure ([MEDICAL CONDITION]) Administration, with effective date (MONTH) 15, (YEAR), revealed: Process . 6. Mask/nasal pillows and flexible tubing should be washed, per manufacturer guidelines, with mild soap and water; rinse thoroughly; air dry. A review of a manufacturer guidelines titled, 1800 [MEDICAL CONDITION] Patient Education Booklet, revealed: . Humidifier Maintenance. The humidifier chamber . should be emptied out entirely after each use . if not dried out daily . will breed bacteria . may cause upper respiratory infections . Mask and Tubing Maintenance . should be cleaned daily with . baby shampoo and warm water . hang it to drain/dry but keep it out of direct sunlight . A manufacturer user manual titled, (name of company) , . page 24 Cleaning the Tubing . clean the flexible tubing before first use and daily . in a solution of warm water and a mild detergent. Rinse thoroughly. Air dry. 1 [NAME]) RI #3 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 9/10/19 at 9:21 am, observed in RI #3 was the resident's [MEDICAL CONDITION] mask, dated 9/10/19. The connector tubing was observed in a plastic bag, also dated 9/10/19, on the the feeding pole with small droplets of water in the bag at that time. A review of RI #3's medical record revealed no order to clean his/her [MEDICAL CONDITION] machine prior to RI #3's discharge to the hospital on [DATE], for [DIAGNOSES REDACTED]. Additional review of RI #3's medical record revealed no order to clean his/her [MEDICAL CONDITION] machine when he/she returned from the hospital on [DATE]. Further review of RI #3's medical record revealed no order to clean his/her [MEDICAL CONDITION] machine when RI #3 was changed to the [MEDICAL CONDITION] on 09/09/19. 1 B.) Review of RI #3's Physician Orders For the month of: (MONTH) 2019, revealed: 7/30/19 . Oxygen @ 2 L/MIN (liters per minute) per NC (Nasal Cannula) PRN (as needed) for shortness of breath . Room air during the day when awake keep oxygen sat (saturation) @ (at) 92% or greater . 9/10/19 Continuous pulse oximetry when in room/resp (respiratory) monitor . On 09/11/19 at 11:32 a.m., the surveyor entered RI #3's room and observed RI #3 sitting in a wheelchair beside his/her bed with a pulse oximeter attached to his/her left hand, third finger. The surveyor observed the pulse oximeter screen without illumination and went out of the room and asked Employee Identifier (EI) #5, Licensed Practical Nurse (LPN), to accompany surveyor to RI #3's room. When in the room the surveyor asked EI #5 if the pulse oximeter was on and EI #5 said let her see if it was on his/her finger good. EI #5 then pressed the power button and the pulse oximeter illuminated an oxygen saturation of 94-95%. On 09/11/19 at 11:37 a.m., an interview was conducted with EI #5, LPN. EI #5 was asked was RI #3's pulse oximeter off. EI #5 said yes. EI #5 was asked how often did it cut off. EI #5 replied about every 20 minutes. EI #5 was asked, if the pulse oximeter cut off every 20 minutes was that considered continuous oxygen saturation monitoring. EI #5 answered no. On 09/11/19 at 4:01 p.m., the surveyor observed staff push RI #3 from the hallway into his/her room, put him/her to bed and provide incontinence care and leave RI #3's room. RI #3's pulse oximeter was observed on the overbed table beside the bed without being applied/attached to RI #3. On 09/11/19 at 5:06 p.m., the surveyor observed EI #4, LPN, enter RI #3's room to administer medications. Upon entering the room, RI #3 was lying in the bed on his/her left side. A pulse oximeter was observed on the overbed table, not attached to RI #3. The Surveyor asked EI #4 what was RI #3's O2 saturation. EI #4 said she would put it on and check it. EI #4 placed the pulse oximeter at 5:31 p.m. The surveyor asked EI #4 to read RI #3's O2 saturation. EI #4 responded 70%. EI #4 then applied RI #3's oxygen at two liters. On 09/11/19 at 6:33 p.m., an interview was conducted with EI #4, LPN. EI #4 was asked what did RI #3's physician's order say regarding his/her pulse oximeter. EI #4 said that it should be on when he/she was in his/her room and when in bed. EI #4 was asked what time did she come to work. EI #4 replied about 3:05 p.m. EI #4 was asked where was RI #3 when she reported to work. EI #4 stated in the hallway outside room [ROOM NUMBER]. EI #4 was asked what was RI #3's O2 sat at 5:31 p.m. during medication pass. EI #4 said 70. EI #4 was asked when was RI #3 supposed to wear oxygen. EI #4 replied 2 liters per nasal cannula for periods of shortness of breath. EI #4 was asked when should RI #3's pulse oximeter and oxygen have been applied. EI #4 stated the pulse oximeter should have been applied once RI #3 was put to bed. EI #4 was asked why was it not applied. EI #4 replied she did not have an excuse for it. EI #4 was asked how would she have known that RI #3 had been put to bed and it was not on. EI #4 stated usually when she did a check. When the surveyor explained that she had watched incontinence care for RI #3 and he/she had been put back to bed at 4:01 p.m., EI #4 stated the pulse oximeter should have been applied at 4:02 p.m. EI #4 was asked what was the concern with RI #3's pulse oximeter not being put on when he/she was back in the room and back in bed. EI #4 responded low O2 saturation. EI #4 was asked what could low O2 saturation cause. EI #4 said shortness of breath. EI #4 was asked what did RI #3's orders said about his O2 saturation being addressed. EI #4 answered less than 92%. EI #4 was asked since RI #3's O2 saturation was 70, should his/her O2 have been applied earlier. EI #4 answered yes. On 09/12/19 at 3:39 p.m., an interview was conducted with EI #3, Registered Nurse (RN)/Unit Manager/Infection Control. EI #3 was asked when should a [MEDICAL CONDITION] or [MEDICAL CONDITION] be cleaned. EI #3 said once a week. EI #3 was asked what did the facility policy say about cleaning the [MEDICAL CONDITION] and [MEDICAL CONDITION]. EI #3 replied to follow the manufacturer's guidelines. EI #3 was asked what did the manufacturer's recommendations say about cleaning the [MEDICAL CONDITION] and [MEDICAL CONDITION]. EI #3 read, the [MEDICAL CONDITION] mask and tubing should be cleaned daily with fragrance free baby shampoo and warm water and other soaps can be used, just make sure there are no moisturizers or heavy fragrance due to leaks and life of mask. EI #3 was asked what did RI #3's order say about cleaning his/her [MEDICAL CONDITION] and/or [MEDICAL CONDITION]. EI #3 answered it did not say anything because there was no order. EI #3 further stated that she put in a physician's order with a date and time for it to fire on the Medication Administration Record [REDACTED]. EI #3 said she put it in this morning. EI #3 was asked was the policy for cleaning the [MEDICAL CONDITION]/[MEDICAL CONDITION] being followed. EI #3 said it was not. EI #3 was asked what was the concern with not cleaning [MEDICAL CONDITION]'s and [MEDICAL CONDITION]'s per manufacture's recommendations. EI #3 answered sinus infection, respiratory infection and probably pneumonia. 2.) RI # 4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of RI # 4's medical record revealed no evidence to show that RI # 4's [MEDICAL CONDITION] machine was being cleaned. On 09/11/19 at 05:05 PM, an interview with RI #4 was conducted regarding the C-PAP machine observed on the resident's bedside dresser. The surveyor asked RI #4 if they used the [MEDICAL CONDITION] as ordered. RI #4 replied they did not use the [MEDICAL CONDITION], in fact had not used the [MEDICAL CONDITION] in over a month. RI #4 was asked how often was their [MEDICAL CONDITION] cleaned by staff. RI #4 replied that in the almost 2 years that they had been at the facility, their [MEDICAL CONDITION] had been cleaned by staff maybe five times. RI #4 continued to state that they wanted to have family bring them detergent to clean the [MEDICAL CONDITION] themselves and staff told them that they could not do that. RI #4 was asked if it was their choice to not use the [MEDICAL CONDITION]. RI #4 stated yes and no, that they would use the [MEDICAL CONDITION] if it was cleaned properly because they sleep better when they use the [MEDICAL CONDITION] nightly. On 09/12/19 at 03:30 PM, an interview with EI #6, RN, was conducted. EI # 6 was asked how would they clean a [MEDICAL CONDITION] machine. EI #6 stated, they would rinse out the hose, they would dry the hose, and wipe out the mask. EI #6 was asked how would they dry the hose. EI #6 stated they would use a paper towel. EI #6 was asked when should they clean a [MEDICAL CONDITION] machine. EI #6 stated, they should clean the [MEDICAL CONDITION] machine once a week and whenever it got dirty. EI #6 was asked if they had cleaned any residents [MEDICAL CONDITION] machine and EI #6 stated no, they had not. EI #6 was asked what would be the potential harm in not cleaning a [MEDICAL CONDITION] machine as ordered. EI #6 stated that the resident could possibly get an infection. EI #6 was asked where would they document if they had cleaned a [MEDICAL CONDITION] machine. EI #6 replied that they would put in a nursing note that they had cleaned the [MEDICAL CONDITION]. On 09/12/19 at 3:45 PM, an interview with EI # 7 RN, was conducted. EI #7 was asked how would they clean a [MEDICAL CONDITION] machine. EI #7 replied that they would wash the mask and tubing with warm water and a mild soap, they would rinse thoroughly, then hang to air dry. EI #7 was asked when should they clean a C-PAP machine. EI #7 stated, the [MEDICAL CONDITION] machine should be cleaned once a week and as needed. EI #7 was asked if they had cleaned any residents [MEDICAL CONDITION] machine and EI #7 first stated no, then added they had recently cleaned RI #3's [MEDICAL CONDITION] machine. EI #7 was asked where they documented that they had cleaned RI #3's C-PAP machine. EI #7 replied they did not document the cleaning. EI #7 was asked, why did they clean RI #3's [MEDICAL CONDITION] machine, EI #7 responded that by looking at the C-PAP, they noticed it was soiled. EI #7 was asked what would be the potential harm in not cleaning a [MEDICAL CONDITION] machine as ordered. EI #7 stated that the resident could possibly get a respiratory infection. On 09/12/19 at 3:39 p.m., an interview was conducted with EI #3, RN/Unit Manager. EI #3 was asked did RI #4 have an order for [REDACTED].#3 was asked what day and time was it to be cleaned. EI #3 replied it was just weekly. EI #3 was asked how would the nurses know what day and time it was to be cleaned since the order did not specify the day of the week or shift. EI #3 stated it was just a verbal thing not written anywhere to clean on Saturday, day shift. EI #3 was asked where was RI #4's cleaning documented. EI #3 answered it was not being documented because it did not fire to the MAR (Medication Administration Record). EI #3 was asked how could she ensure the cleaning was being done without documentation. EI #3 answered just the trust of the nurses and knowing they had to do it.

Based on observation, interviews, medical record review, review of Potter and Perry, Fundamentals of Nursing, Ninth Edition the facility failed to ensure Certified Nursing Assistants (CNAs): 1. did not wash down from the anus when providing incontinence care for Resident Identifier (RI) #3, 2. did not pick up a hand roll from a dirty pad and place it on RI #3's bed linen, 3. did not touch RI #3's bed linen wearing same gloves worn when removing a soiled pad during incontinence care, and 4. did not place a garbage bag containing soiled items used during RI #3's incontinence care on the floor in RI #3's room. These deficient practices affected RI #3, one of one residents observed for incontinence care. Findings Included: A review of Potter and Perry, Fundamentals of Nursing, Ninth Edition, Unit V, Foundations for Nursing Practice, Chapter 29, Infection Prevention and Control, page 459, revealed the following: .Table 29-6, Centers for Disease Control . Standard Precautions . for Use with All Patients . Perform hand hygiene before, after, and between direct contact with patients. Perform hand hygiene after contact with . body fluids, mucous membranes, . excretions, . after contact with inanimate surfaces or articles in a patient room; and immediately after gloves are removed. Wear gloves when touching . body fluids, .excretions, . Remove gloves and perform hand hygiene . when going from a contaminated to a clean body site. RI #3 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 09/11/19 at 4:01 p.m., the surveyor observed staff provide incontinence care for RI #3. As RI #3 was lying on their side, Employee Identifier (EI) #9 was observed wiping RI #3's buttocks and anus in a downward motion, while removing urine and smears of feces from RI #3. EI #8 was observed picking up a hand roll from a dirty pad and placing it on RI #3's covers and removing a dirty pad from under RI #3 and then helped to position and touched RI #3's covers while wearing those same soiled gloves. EI #10 was observed placing a plastic garbage bag containing the soiled items used during incontinence care on the floor in RI #3's room. On 09/11/19 at 6:09 p.m., an interview was conducted with EI #10, CN[NAME] EI #10 was asked what should be done with the used supplies after incontinence care of a resident. EI #10 said they should be disposed of supplies in a garbage bag and place in soiled linen barrel. EI #10 was asked where did she place the garbage bag containing soiled items from RI #3's completed incontinence care. EI #10 stated she placed it on the floor, but she knew she was not supposed to. EI #10 was asked what was the concern with placing the garbage bag containing soiled items on the floor. EI #10 answered, infection control. On 09/11/19 at 6:15 p.m., an interview was conducted with EI #9, CN[NAME] EI #9 was asked how should she wipe the buttocks when providing incontinence care. EI #9 said up away from the anus. EI #9 was asked how did she wipe RI #3's buttocks when providing incontinence care. EI #9 stated she wiped down. EI #9 was asked what was the concern with wiping in the wrong direction when providing incontinence care. EI #9 answered, infection. On 09/11/19 at 6:33 p.m., an interview was conducted with EI #8, CN[NAME] EI #8 was asked when should she change gloves and wash her hands when providing incontinence care. EI #8 said when she went in and after each care she gave she should change gloves and wash her hands. EI #8 was asked did she change her gloves and wash her hands after removing the pad from RI #3. EI #8 replied, no. EI #8 was asked what she did when the roll of gauze fell on RI #3's dirty pad. EI #8 stated she took it and put it at the bottom of the bed. EI #8 was asked what was the concern with something taken from the dirty pad being laid on the bed linen. EI #8 said cross contamination. EI #8 was asked what was the concern with not changing gloves and washing her hands after touching a dirty pad. EI #8 replied cross contamination. EI #8 was asked what was the concern with cross contamination. EI #8 answered, infection control.

Based on interviews, medical record review and review of a facility policy titled, Change in Medical Condition of Resident/Guest(s), the facility failed to notify Resident Identifier (RI) #5's family when RI #5 was transferred to a local hospital for treatment on 08/19/19. This affected RI #5, one of one resident sampled for notification. Findings Included: A review of a facility policy titled, Change in Medical Condition of Resident/Guest(s), with an Effective Date: (MONTH) 28. (YEAR), revealed: . Notification of . interested family member should occur promptly according to federal regulations, when there is a change in the resident/guest(s) condition. Change in condition is defined as: . A significant change in the resident/guest(s) physical, mental or psychosocial status (i.e., a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications) . A decision to transfer or discharge the resident/guest from the facility . RI #5 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 09/11/19 at 12:15 p.m., RI #5 asked to speak with the surveyors. RI #5 stated he/she had been transferred to the hospital on [DATE] and his/her Sister had not been notified of the transfer. A review of RI #5's medical record revealed no documentation on 08/19/19 that RI #5's family had been notified of his/her transfer to the hospital when he/she experienced a low blood sugar requiring treatment. On 09/12/19 at 11:57 a.m., an interview was conducted with Employee Identifier (EI) #2, Registered Nurse (RN)/Director of Nursing. EI #2 was asked was there any documentation in RI #5's medical record that his/her family had been notified during RI #5's transfer to the hospital on [DATE]. EI #2 said no. EI #2 was asked why was RI #5's family not notified. EI #2 stated during her investigation, she had determined that two nurses had been involved in RI #5's care and they had each assumed that the other had contacted the family. She further stated that she had counseled them regarding not notifying RI #5's Sister. EI #2 was asked what was the concern with the Sister not being notified. EI #2 answered, the resident's family should be notified of any change in condition.

Based on interviews, medical record review, review of a facility document titled, Alabama Department of Public Health Online Incident Reporting System, and review of a facility policy titled, Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, the facility failed to report an allegation of abuse to the State Agency within the regulatory two-hour time frame for allegations of abuse. This deficient practice affected Resident Identifier (RI) #5, one of one resident reviewed for abuse reporting. Findings Included: A review of a facility policy titled, Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, with an Effective Date: (MONTH) 8, (YEAR), revealed: . The facility's Policy requires that it report all instances of abuse . as required by state and federal law . IV. (d) Each employee has an obligation to immediately report any incident or allegation that could constitute an instance of abuse . to the Administrator, Director of Nursing or the Department Supervisor. If the report is made to the DON (Director of Nursing) or his or her Department Supervisor, that individual will notify the Administrator. V. If the facility receives an allegation or suspects that an employee may have committed an act of abuse, . the facility shall remove the employee from any resident/guest contact pending investigation. VI. The Administrator/Designee will report to the State Agency and all other required agencies, per regulations. All allegations of abuse . must be reported within 2 hours. RI #5 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 09/11/19 at 12:15 p.m., RI #5 asked to speak to the surveyors. RI #5 then asked the surveyors if they were there to investigate what happened to him/her. RI #5 stated he/she had reported a nurse to the DON because the nurse had stabbed him/her with an injection of insulin after it was refused by the resident. RI #5 further stated that he/she had told the nurse that he/she was not feeling right and did not want the insulin. RI #5 stated the nurse said, 'You're not a doctor' and stabbed him/her with the insulin. RI #5 further stated that his/her blood sugar dropped to 33 and he/she passed out and was sent out to the hospital for two days. RI #5 said that the DON had talked to him/her because he/she refused to take medication from the nurse since returning to the facility and the DON asked if he/she would like a room change so a different nurse would be responsible for giving his/her medication instead of moving the nurse as he/she suggested. A review of a facility document titled, Alabama Department of Public Health Online Reporting System, with Date/Time Submitted: Wednesday, (MONTH) 11, 2019, 1:48 PM, documented: . Select Category: Physical Abuse . Date and time of incident or alleged incident: 08/19/2019 Time: 11:30 AM . On 09/12/19 at 11:57 a.m., an interview was conducted with Employee Identifier (EI) #2, Registered Nurse (RN)/DON. EI #2 was asked when did she first speak to RI #5 about his/her concern. EI #2 said, late Monday evening, around 5:15 p.m. EI #2 was asked what did RI #5 tell her at that time. EI #2 stated RI #5 told her that a nurse gave him/her insulin after he/she told the nurse not to and he/she would not be taking any more medication from that nurse. EI #2 was asked why was RI #5 transferred to the hospital on [DATE]. EI #2 replied because he/she had low blood sugar. EI #2 was asked was that the same day that RI #5 tried to refuse his/her insulin. EI #2 stated that was the day. EI #2 was asked what was the concern with the nurse giving medication after it had been refused. EI #2 stated that the nurse went against the resident's wishes. EI #2 was asked what was it considered if any resident care was forced on a resident. EI #2 replied if they do not want it, then it can be considered abuse. EI #2 was asked how should any allegation of abuse be handled. EI #2 said, it should be reported to the abuse coordinator which was EI #1, the Administrator. EI #2 was asked did she report RI #5's allegation of abuse to EI #1. EI #2 replied, not immediately. EI #2 was asked when did she report it to EI #1. EI #2 stated she had a conversation with him about RI #5 seeming depressed and that he/she had some concerns, but she did not tell him there was abuse. EI #2 was asked when was that conversation. EI #2 said when they got there on Tuesday morning she had started talking to him, but she had not told him it was abuse. EI #2 was asked when should RI #5's allegation have been reported to the Administrator. EI #2 replied soon after RI #5 told her on Monday, 09/09/19 at 5:15 p.m., after she finished talking to RI #5 she should have called EI #1 so that it could have been reported. EI #2 was asked was RI #5's allegation of physical abuse reported according to State and Federal guidelines. EI #2 answered no. On 09/12/19 at 12:46 p.m., an interview was conducted with EI #1, Administrator /Abuse Coordinator. EI #1 was asked who was the abuse coordinator in the facility. EI #1 said he was. EI #1 was asked when did he become aware of an allegation of physical abuse regarding RI #5. EI #1 replied when he spoke to Surveyors on 09/11/19 about 1:20 p.m. EI #1 was asked when should he have been made aware of the allegation. EI #1 replied immediately after EI #2 had the conversation with RI #5 on Monday night, 09/09/19, she should have called him and reported it to him so he could have reported it immediately to the State Agency. EI #1 was asked was RI #5's allegation of abuse reported according to State and Federal guidelines. EI #1 answered, no.

Based on observation, interview, record review, and review of a facility policy titled, Continuous Positive Airway Pressure ([MEDICAL CONDITION]) Administration, the facility failed to clean Resident Identifier (RI) #4's [MEDICAL CONDITION] machine weekly as ordered This deficient practice affected 1 of 2 residents sampled with [MEDICAL CONDITION] machines. Findings Included: A review of the facility's Policy and Procedure titled, Continuous Positive Airway Pressure ([MEDICAL CONDITION]) Administration, effective date (MONTH) 15, (YEAR), revealed: Process . 6. Mask/nasal pillows and flexible tubing should be washed, per manufacturer guidelines, with mild soap and water; rinse thoroughly; air dry. RI #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of RI #4's medical record revealed Physician Orders, dated 08/01/19, to clean the [MEDICAL CONDITION] machine weekly. RI #4's medical record provided no evidence to show the machine was cleaned as ordered. On 09/10/19 at 11:00 AM, an observation of a [MEDICAL CONDITION] machine on RI #4's bedside dresser was made. The mask was bagged and dated for 09/10/19. RI #4 was asked if the [MEDICAL CONDITION] was theirs and RI #4 stated that was their [MEDICAL CONDITION] machine and staff came in earlier that morning and placed the mask in a bag. RI #4 further stated that they did not know why the staff bagged the mask because it had not been in a bag for over a month. On 09/11/19 at 5:05 PM a second interview with RI #4 was conducted. The surveyor asked RI #4 if they used the [MEDICAL CONDITION] as ordered. RI #4 replied they did not use the [MEDICAL CONDITION], in fact had not used the [MEDICAL CONDITION] in over a month. RI #4 was asked how often was their [MEDICAL CONDITION] cleaned by staff. RI #4 replied that in the almost 2 years that they had been at the facility, their [MEDICAL CONDITION] had been cleaned by staff maybe five times. RI #4 continued to state that they wanted to have family bring them detergent to clean the [MEDICAL CONDITION] themselves and staff told them that they could not do that. RI #4 was asked if it was their choice to not use the [MEDICAL CONDITION]. RI #4 stated yes and no, that they would use the [MEDICAL CONDITION] if it was cleaned properly because they sleep better when they use the [MEDICAL CONDITION] nightly. On 09/12/19 at 3:30 PM, an interview with EI #6, a Registered Nurse (RN), was conducted. EI #6 was asked how would they clean a [MEDICAL CONDITION] machine. EI #6 stated, they would rinse out the hose, they would dry the hose, and wipe out the mask. EI #6 was asked how would they dry the hose, EI #6 stated they would use a paper towel. EI #6 was asked when should they clean a [MEDICAL CONDITION] machine. EI #6 stated, they should clean the [MEDICAL CONDITION] machine once a week and whenever it got dirty. EI #6 was asked if they had cleaned any residents [MEDICAL CONDITION] machine and EI #6 stated no they had not. EI #6 was asked what would be the potential harm in not cleaning a [MEDICAL CONDITION] machine as ordered. EI #6 stated that the resident could possible get an infection. EI #6 was asked where would they document if they had cleaned a [MEDICAL CONDITION] machine. EI #6 replied that they would put in a nursing note that they had cleaned the [MEDICAL CONDITION]. On 09/12/19 at 3:45 PM, an interview with EI #7 RN, was conducted. EI #7 was asked how would they clean a [MEDICAL CONDITION] machine. EI #7 replied that they would wash the mask and tubing with warm water and a mild soap, they would rinse thoroughly, then hang to air dry. EI #7 was asked when should they clean a [MEDICAL CONDITION] machine. EI #7 stated, the [MEDICAL CONDITION] machine should be cleaned once a week and as needed. EI #7 was asked if they had cleaned any residents [MEDICAL CONDITION] machine. EI #7 first stated no, then added they had recently cleaned RI #3's [MEDICAL CONDITION] machine. EI #7 was asked where they documented that they had cleaned RI #3's C-PAP machine. EI #7 replied they did not document the cleaning. EI #7 was asked, why did they clean RI #3's [MEDICAL CONDITION] machine, EI #7 responded that by looking at the [MEDICAL CONDITION], they noticed it was soiled. EI #7 was asked what would be the potential harm in not cleaning a [MEDICAL CONDITION] machine as ordered. EI #7 stated that the resident could possible get a respiratory infection.

Based on observation, interviews, and review of a facility policy titled, Hand Hygiene, the facility failed to ensure that a licenced staff performed hand hygiene after removing gloves. This affected one of three nurses observed during medication pass. Findings include: Review of a facility policy titled, Hand Hygiene, with an effective date of (MONTH) 1,2017, revealed, PURPOSE: To provide guidelines to employee 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 resident/guest(s) based upon the principle that all blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucus membranes may contain transmissible infectious agents. PR[NAME]ESS: . III. Hand Hygiene. Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene. After removing gloves . On 5/20/19 at 8:44 a.m., an observation was made of Employee Identifier (EI) #2, Licensed Practical Nurse (LPN), applying gloves to give a nasal spray. After administering the nasal spray, one glove was removed, and the nasal spray was taken out of the room. The other glove was then removed, and new gloves were applied to clean the top of the nasal spray. After cleaning the top of the spray, EI #2 removed her gloves, placed the nasal spray back in the medication cart, and then went to wash her hands. On 5/20/19 at 9:06 a.m., an interview was conducted with EI #2, LPN. EI #2 was asked, what should be done after removing gloves. EI #2 replied, wash your hands. EI #2 was asked if she had done that. EI #2 said she had not. EI #2 was asked, what was the potential concern of not performing hand hygiene after removing your gloves. EI #2 replied, infection control. On 5/20/19 at 9:47 a.m., an interview was conducted with EI #1, Infection Control Nurse. EI #1 was asked, what should be done after removing gloves. EI #1 replied, wash your hands. EI #1 was asked, what was the potential concern of not doing hand hygiene after removing gloves. EI #1 replied, spreading of infection.

Based on observation, interview, and review of a facility policy titled, Oxygen Administration, the facility failed to ensure: 1) Resident Identfier (RI) #28's oxygen tubing and humidifier bottles were changed weekly; and 2) RI #s 29, 68, and 71's nasal cannula tubing were dated. This affected four of seven sampled residents requiring the use of oxygen. Findings include: Review of a facility policy titled, Oxygen Administration, effective date (MONTH) 8, 2005, revealed, . PR[NAME]ESS: . 11. Cannulas and masks should be changed weekly . 1) RI #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An observation was made on 05/18/19 at 11:45 a.m. of RI #28's oxygen tubing and humidifier bottle; both were dated 04/29/19. An interview was conducted with Employee Identfier (EI) #1, Infection Control Nurse, on 05/20/19 at 9:18 a.m EI #1 was asked, who was responsible for labeling and changing out oxygen tubing and humidifier bottles. EI #1 replied, the eleven to seven shift does it on Sunday nights. EI #1 was asked, how often should oxygen tubing be changed. EI #1 replied, we change it weekly and as needed. EI #1 was asked, how often should the humidifier bottle be changed. EI #1 replied, we change it weekly and as needed. EI #1 was asked, what was the potential concern of this not being done weekly. EI #1 said she would say infection. 2) RI #29 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED].>Shortness of Breath and Cerebral Infarction. On 5/19/19 at 7:40 a.m., the Surveyor observed RI #29 receiving oxygen per nasal cannula. There was no date or time on the nasal cannula tubing, green connection tubing, or tubing connecting the water bottle to the concentrator. RI #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/18/19 at 3:01 p.m., the Surveyor observed RI #68 receiving oxygen per nasal cannula. There was no date on the nasal cannula tubing, and no date on the tubing from the concentrator to the water bottle. RI #71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/18/19 at 3:06 p.m., the Surveyor observed RI #71 receiving oxygen per nasal cannula. There was no date on the cannula tubing or the tubing from the concentrator to the water bottle. On 5/20/19 at 10:16 a.m., and interview was conducted with EI# 3, Registered Nurse (RN). EI#3 was asked, how often does the facility change the nasal cannula tubing and the tubing running from the concentrator to the water bottle. EI#3 replied, it is changed weekly. EI#3 was asked, what documentation verifies those two tubes were changed. EI#3 replied, the tubing should be dated. EI#3 was asked, how would someone know if the tubing had been changed if there was no date on either tubing, including nasal cannula and tubing from the concentrator to the water bottle. EI#3 replied, they would not know. EI#3 was asked, what was the potential harm for not dating the oxygen tubing. EI#3 replied, the harm would probably be infection.

Based on observation, interviews, record review, and review of Potter and Perry, Fundamentals of Nursing, Ninth Edition, the facility failed to ensure a Licensed Nurse changed gloves and washed her hands after touching Resident Identifier (RI) #47's catheter bag, before she cleaned RI #47's sacral wound. This affected RI #47, one of one resident observed for wound care. Findings include: RI #47 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Potter and Perry, Fundamentals of Nursing, Ninth Edition, Unit V, Foundations for Nursing Practice, Chapter 29, Infection Prevention and Control, p.459, Table 29-6, revealed: Perform hand hygiene after contact with .wound dressings; after contact with inanimate surfaces or articles in a patient room . On 05/17/18 at 8:48 a.m., during wound care observation for RI #47, Employee Identifier (EI) #2, Licensed Practical Nurse (LPN)/Treatment Nurse, was observed picking up RI #47's catheter bag wearing gloves. EI #2 then cleaned RI #47's sacral wound without changing gloves and washing her hands. On 05/17/18 at 2:34 p.m., an interview was conducted with EI #2. EI #2 was asked did she clean RI #47's sacral wound wearing the same gloves she was wearing when she picked up his/her catheter bag to move it to the other side of the bed. EI #2 said she did. EI #2 was asked what was the concern with potentially introducing bacteria into the wound bed. EI #2 answered it could affect wound healing.

Based on observations, interviews, record review, and review of Potter and Perry, Fundamentals of Nursing, Ninth Edition and review of facility policies titled, Enteral Tube Administration and Respiratory Therapy, the facility failed to ensure licensed staff: 1. washed her hands before and after applying gloves to administer Resident Identifier (RI) #59's handihaler and cleaned the mouthpiece of RI #59's handihaler before storing it in the medication cart, and 2. changed her gloves and washed her hands after touching the faucet handles during RI #20's gastrostomy tube medication administration and did not store RI #20's syringe and tubing in plastic bags after rinsing them, causing moisture to collect in the bags. This affected RI #59 and RI #20, two of four residents observed for medication pass observations and two of four nurses observed during medication pass. Findings Include: A review of Potter and Perry, Fundamentals of Nursing, Ninth Edition, Unit V, Foundations for Nursing Practice, Chapter 29, Infection Prevention and Control, page 459, revealed the following: .Table 29-6, Centers for Disease Control . Standard Precautions . for Use with All Patients . Perform hand hygiene before, after, and between direct contact with patients. Perform hand hygiene after contact with . body fluids, mucous membranes, . excretions, . after contact with inanimate surfaces or articles in a patient room; and immediately after gloves are removed. Wear gloves when touching . body fluids, .excretions, . Remove gloves and perform hand hygiene . when going from a contaminated to a clean body site. 1.) A review of a facility policy titled, Respiratory Therapy, dated 03/11, documented: .F. Wipe mouthpiece with damp paper towel or gauze sponge. RI #59 was admitted to the facility on [DATE]. On 05/16/18 at 8:47 a.m., during medication pass observations, Employee Identifier (EI) #3, Licensed Practical Nurse (LPN), was observed to apply gloves without washing her hands, take RI #59's medication from the package and put it in a handihaler. EI #3 then removed her gloves and did not wash her hands. EI #3 returned to medication cart to sign out medications and stored the handihaler in the cart without cleaning the mouthpiece. On 05/17/18 at 2:06 p.m., an interview was conducted with EI #3, LPN. EI #3 was asked when should she wash her hands when using gloves. EI #3 said before and after. EI #3 was asked did she wash her hands before applying gloves to administer RI #59's inhaler. EI #3 said no. EI #3 was asked did she clean the mouthpiece of RI #59's inhaler before storing it back in the medication cart drawer. EI #3 replied, no. EI #3 was asked what was the concern with not washing her hands before applying and after removing her gloves and not cleaning RI #59's handihaler. EI #3 answered infection control. 2.) A review of a facility policy titled, Enteral Tube Administration, dated 03/11, revealed: .9. Rinse, dry and store syringe in a plastic bag. RI #20 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 05/16/18 at 9:04 a.m., during medication pass observations, EI #4, LPN, was observed to obtain water from the sink while wearing gloves and then administer the remaining flush to RI #20's gastrostomy tube wearing those same gloves. EI #4 was then observed rinsing RI #20's syringe and tubing in the sink and placing them back into plastic bags with water in the bags. On 05/16/18 at 10:24 a.m., EI #4 was asked to accompany the surveyor into RI #20's room to look at the plastic bags containing the tubing and syringe. EI #4 was asked was there water in the bags. EI #4 said yes, she must not have dried them good. EI #4 was asked what was the concern with water in the plastic bags. EI #4 replied bacteria. EI #4 was asked what was the concern with rinsing the tubing in the sink. EI #4 said germs. EI #4 was asked what was the concern with germs and bacteria. EI #4 answered infection control. On 05/17/18 at 2:44 p.m., an interview was conducted with EI #1, Registered Nurse (RN)/Unit Manager/Infection Control Coordinator. EI #1 was asked when should a nurse wash her hands when wearing gloves. EI #1 said prior to and after. EI #1 was asked should a nurse clean a handihaler before storing it in the medication cart after administration for a resident. EI #1 said yes. EI #1 was asked should a nurse store a syringe in a plastic bag leaving moisture in the bag. EI #1 said no. EI #1 was asked what was the concern with these things. EI #1 answered infection control and bacteria breeding in the moisture.

Based on observations, staff interviews, a review of the facility's policy titled, Dietary Service Manual and a review of the 2013 Food Code, the facility failed to ensure dry goods container lids were properly secured and the refrigerator door rubber seal was not loose. This had the potential to affect 71 of 72 residents receiving meals from the dietary department. Findings Include: The facility's policy titled, Food Receipt and Storage, with an effective date of August 21, 2013 documented: Process: . II. Storage of Foods: . k. opened dry goods should be kept in tightly sealed containers. A review of the 2013 Food Code U.S. (United States) Public Health Service FDA (Food and Drug Administration) page 132, revealed the following: . 4-5 MAINTENANCE AND OPERATION (A) EQUIPMENT shall be maintained in a state of repair . (B) EQUIPMENT components such as doors, seals and hinges . shall be kept intact and adjusted . On 03/28/2017 at 7:40 a.m., the following observations were made during the initial tour: 1. One Rice container was not sealed; 2. One container wide noodles was not sealed; 3. One container dry lima beans was not sealed; 4. One container spaghetti pasta was not sealed; 5. One container of pinto beans was not sealed; 6. One container of elbow pasta was not sealed; 7. One container of grits was not sealed; and 8. One container of oatmeal was not sealed. On 03/28/17 at 8:00 a.m., the following observation was made during initial tour: The reach in refrigerator, labeled Thaw Box, had a rubber seal that was separated and hanging loose from the door. On 03/30/2017 at 10:06 a.m., an interview was conducted with Employee Identifier (EI) #2, Dietary Manager. EI #2 was asked why it was important to keep food containers sealed. EI #2 replied when containers were not sealed, they could get pests, products could go bad and residents could get sick. The surveyor asked what was the potential for harm when the rubber seal on the door did not close properly. EI #2 stated people could get sick from pest and germs.

Based on observation of Resident Identifier (RI) #15's Broda chair, job descriptions of the Director of Maintenance and Housekeeping Technician and staff interviews, the facility failed to ensure RI #15's Broda chair was free of a build up of dried debris and a black colored substance. This affected one of 15 sampled residents who used a Broda, wheelchair or geri chair. Findings Include: The facility's job description titled, Director of Maintenance with a review date of 06/30/03 documented: GENERAL PURPOSE To provide direction and support for the Maintenance department, to include . maintenance of the physical plant to include . departmental equipment . B. Departmental Functions .7. Conduct at least weekly departmental compliance rounds. . 19. Conduct preventive maintenance programs . d. Inventory & (and) Planning Functions . 4. Make periodic inspections of supplies and equipment to ensure that adequate levels are maintained . The facility's job description titled, Housekeeping Technician with a review date of 06/30/03 documented: GENERAL PURPOSE . Standard Requirements . 4. Support, cooperate with, and implement specific procedures and programs for: a. report and/or correct . equipment repair and maintenance needs. . ESSENTIAL JOB FUNCTIONS . 12. m. Cleans wheelchairs, geri chairs and other equipment as scheduled . RI #13 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 03/28/17 at 7:40 a.m. the left and right arm rests on RI #13's geri chair were observed taped with black tape that was torn and peeling and the foam on the left arm rest was exposed RI #14 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #14's Quarterly Minimum Data Set ((MDS) dated [DATE], documented RI #14 had long and short term memory loss and was severely impaired in cognitive skills for daily decision making. The MDS also assessed RI #14 required total assistance from staff for all Activities of Daily Living (ADL) including transfers and locomotion on and off the unit. On 03/28/17 at 10:15 a.m., RI #14 was observed sitting in a Broda chair. The frame of the chair was coated with dried debris and a black colored substance. On 03/29/17 at 8:40 a.m., Employee Identifier (EI) #14, Maintenance Director, was asked who was responsible for cleaning the wheelchairs. EI #14 replied that was between maintenance and housekeeping and they get cleaned by pressure washing every three months. EI #14 was asked when was the last time wheelchairs were washed. EI #14 replied before Thanksgiving 2016. EI #14 was asked how he was made aware wheelchairs needed to be cleaned. EI #14 replied there was a maintenance log book at each nursing station and sometimes the residents would tell him. EI #14 was asked what would be a concern to a resident with a wheelchair with a build up of dried debris. EI #14 replied residents would not like it and it could make them feel like they had no dignity or pride. On 03/30/17 at 2:55 p.m., EI #15, Administrator, was asked who was responsible for ensuring wheelchairs were being cleaned. EI #15 replied that would be him. EI# 15 was asked if the process for cleaning wheelchairs was working. EI #15 replied no. EI #15 was asked what would be a concern to a resident with a wheelchair with a build up of dried debris. EI #15 replied it could be an infection control issue.

Based on observations, a review of the facility policy titled, Oxygen Administration, medical record review and staff interviews, the facility failed to ensure RI (Resident Identifier) #8's Oxygen flow rate was maintained at 2L (liters) during two of three days of the survey. This affected RI #8, one of one sampled residents who was prescribed Oxygen. Findings Include: The facility's policy titled, Oxygen Administration with an effective date of December 8, 2005, documented: PURPOSE: To administer high purity oxygen for the treatment of [REDACTED]. . PROCESS: . 6. Turn the unit on to the desired flow rate and assess for proper functioning . 8. check oxygen flowmeter for correct liter flow . RI #8 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #8's Minimum Data Set (MDS) with an Assessment Reference date of 12/26/16, documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated RI #8's cognition was intact. In Section 0-Special Treatments, Procedures and Programs, it was documented RI #8 used oxygen while a resident in the facility. On 03/28/17 at 8:45 a.m., RI #8's Oxygen flow rate was observed set at 3L. On 03/29/17 at 1:50 p.m., RI #8's Oxygen flow rate was observed at 3 1/2L. RI #8 was asked if she/he changed the Oxygen flow rate. RI #8 replied no. On 03/29/17 at 3:35 p.m., Employee Identifier (EI) #11, Registered Nurse/Unit Manager, was asked to verify the Oxygen flow rate on RI #8's concentrator. EI #11 looked at the level and replied 3 1/2 liters. EI #11 reviewed RI #8's physician's orders and an order dated 03/24/17, documented Oxygen at 2L. EI #11 was asked if the physician's order was followed. EI #11 replied not for the 2 liters. EI #11 was asked what would be a concern. EI #11 replied respiratory distress. On 03/30/17 at 3:30 p.m., EI #1, Director of Nurses, was asked who was responsible for monitoring Oxygen flow rates and how often. EI #1 replied the Unit Manager and every shift. EI #1 was informed of the two observations of RI #8's Oxygen flow rates on 03/28/17, set at 3L and on 03/29/17, set at 3 1/2 L. EI #1 was asked why was it on the wrong setting. EI #1 replied the orders were not read. EI #1 was asked if the physician's order was followed if the order prescribed Oxygen at 2 L and it was set on the other levels. EI #1 replied it was not.

Based on medical record review, a review of facility policies titled, Nursing Assessments and Resident Assessment Instrument (RAI), and staff interviews, the facility failed to ensure an accurate weight was documented on RI (Resident Identifier) #5's Annual MDS (Minimum Data Set) dated 12/19/16. This affected one of 17 sampled residents whose MDS's were reviewed. Findings Include: The facility's policy titled, Nursing Assessments with an effective date of November 28, 2016 documented: PURPOSE: The facility conducts, a comprehensive, standardized assessment of each resident/guest's functional capacity necessary to develop a person centered care plan and to modify the care plan and care/services based on the resident/guest's status . The facility's policy titled, Resident Assessment Instrument (RAI) with an effective date of October 29, 2015 documented: PURPOSE: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop a plan of care. . PROCESS: 1. c) It is suggested the individual interdisciplinary team members be responsible for the following sections of the MDS: Dietary Manager/Registered Dietician-K . Section K of the MDS includes swallowing and nutritional status. RI #5 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #5's Annual MDS dated [DATE], documented a Brief Interview for Mental Status score of 15, which indicated RI #5's cognition was intact. In Section K- Swallowing/Nutrition, RI #5's weight was documented to be 205 pounds. A review of RI #5's Weight Change History documented the last weight of 205 pounds on 10/10/2014. On 03/30/17 at 3:35 p.m., Employee Identifier (EI) #1, Director of Nurses (DON), was asked who was responsible for Section K on RI #5's 12/19/16 Annual MDS. EI #1 replied EI #2, Dietary Manager. EI #1 was asked where was the weight of 205 obtained from. EI #1 replied she did not know. EI #1 was asked why a weight was used from 2014. EI #1 replied she did not know. EI #1 was asked if that was an accurate assessment if a weight from 2014 was documented on a 2016 assessment. EI #1 replied no. EI #1 was asked what would be a concern of an inaccurate assessment. EI #1 replied it would not be accurate and it could affect a lot of other things. On 03/30/17 at 3:45 p.m., an interview with EI #2, Dietary Manager, was conducted. EI #2 was asked where she obtained the weight for RI #5 for Section K. EI #2 replied from the resident's weights.

Based on observation, medical record review, a review of the facility's policies titled, Urinary Catheter Care and Catheterization .Resident/Guest, and staff interviews, the facility failed to ensure RI #3's foley catheter was not observed to have sediment and dark colored urine on 03/28/2017 and 03/29/2017. RI #3 is a resident identified by the facility as having a history of UTI (Urinary Tract Infection). This affected one of three residents with foley catheters. Findings Include: A review of the facility's policy titled, . Urinary Catheter Care . with an effective date of July 12, 2011, revealed the following: . PURPOSE: Urinary catheter care helps to prevent urinary tract infection. c) Check the urine for unusual appearance (color, consistency) . A review of the facility's policy titled, Catheterization .Resident/Guest with a revision date of 03/30/2017, revealed the following: . the standard is changing as needed (PRN) for obstruction, . and excessive sediment. RI #3 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #3's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed RI #3 Brief Interview for Mental Status (BIMS) score of 15, indicating RI #3's cognition was intact. The MDS under Section G revealed RI #3 was totally dependent for all Activities of Daily Living (ADLs). The MDS assessed RI #3, under Section H, as having an indwelling catheter. A review of RI #3's Care Plan revealed the following: . Goal: I WILL NOT HAVE COMPLICATIONS R/T (RELATED TO) FOLEY CATHETER . AEB (AS EVIDENCED BY) NO UTI . Interventions: . 3. OBSERVE FOR SIGNS AND SYMPTOMS OF INFECTIONS ( . URINE . COLOR, SEDIMENT IN URINE) . A review of RI #3's Urinalysis with a date of 12/21/2016 revealed: .Pseudomonas .Abnormal . On 03/28/2017 at 3:30 p.m., RI #3's Foley catheter was observed to have sediment in the tubing and dark colored urine. On 03/29/2017 at 9:30 a.m., RI #3's Foley catheter was observed to have sediment in the tubing and dark colored urine. On 03/30/2017 at 8:10 a.m., RI #3's Foley catheter was observed to have sediment in the tubing and dark colored urine. On 03/29/2017 at 4:26 p.m., an interview was conducted with Employee Identifier (EI) #1, Director of Nursing (DON). EI #1 was asked what should staff do if the catheter was cloudy with sediment in the tubing and with dark colored urine. EI #1 said the CNA (Certified Nursing Assistant) should report the findings to the charge nurse. On 03/30/2017 at 9:10 a.m., a phone interview was conducted with EI #5, Licensed Practical Nurse (LPN)/Unit Manager. EI #5 was asked if she had received any report about RI #3's catheter. EI #5 said she had not and no one had said anything about the catheter. EI #5 was asked when was the last time she assessed the Foley catheter. EI #5 said she had not assessed the catheter that week. On 03/30/2017 at 3:15 p.m., a interview was conducted with EI #13, the Nurse Practitioner. EI #13 was asked how often should the Foley catheter be assessed. EI #13 said daily. EI #13 said she or the nurse should be notified of cloudy urine. EI #13 was asked if sediment could potentially clog the catheter. EI #13 said yes it could. EI #13 was asked when was she made aware of any abnormalities with RI #3's catheter. EI #13 said she had not been notified that week.

Based on observation, staff interviews and medical record review, the facility failed to ensure a Licensed Practical Nurse (LPN) did not leave RI (Resident Identifier) #19's EMAR (Electronic Medication Administration Record) open to public view. This affected one of five residents observed during medication administration. The facility further failed to ensure staff provided privacy during an observation of incontinent care on 03/29/2017, based on a review of a facility policy titled, Perineal Care, and staff interviews. This affected RI #3, one of two residents observed during incontinent care. Findings Include: 1. RI #19 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 03/28/17 at 4:10 PM, the following was observed during medication administration: EI #6, LPN, dispensed medications to administer to RI #19. At 4:16 PM, EI #6 walked away from the medication cart, RI #19's EMAR was open and the following was observed: resident's name, allergies [REDACTED]. On 03/28/17 at 4:19 PM, during an interview with EI #6, the surveyor asked what should be done with a resident's information on the EMAR. EI #6 stated policy and procedure was to have the screen closed, but that was not what she had done. EI #6 also stated policy and procedure had not been followed because anyone could have seen the resident's information. On 03/30/17 at 8:35 AM, during an interview with EI #1, Director of Nursing (DON), the surveyor asked when should a resident's EMAR information be left unattended and open for view when the nurse was not at the medication cart. EI #1 stated never, because that is a HIPAA (Health Insurance Portability and Accountability Act) violation. 2. A review of the facility's policy titled, . Perineal Care . with an effective date of October 1, 2010, revealed the following: . PROCESS: . a) . screen for privacy . RI #3 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #3's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed RI #3's Brief Interview for Mental Status (BIMS) score of 15, indicating RI #3's cognition was intact. The MDS ,under Section G, assessed RI #3 as being totally dependent for all Activities of Daily Living (ADLs). The MDS further assessed RI #3 under Section H as having an indwelling catheter. On 03/29/2017 at 9:30 a.m., during an incontinent care observation, the privacy curtain was open. There was a knock on the door and EI #1 opened the door and RI #3's buttocks were exposed. An interview was conducted on 03/29/2017 at 10:00 a.m., EI #9, Certified Nursing Assistant (CNA), was asked why was the privacy curtain not closed during the incontinent care of RI #3. EI #9 said, I forgot. EI #9 was asked why should the privacy curtain have been closed. EI #9 said she should have pulled it before she started doing anything for the resident to provide privacy and dignity.