Every finding on record at Southern Springs Healthcare Facility

Based on interviews, review of the facility's policy titled, Abuse Prevention, and the Alabama Department of Public Health online Incident Reporting System, the facility failed to ensure Employee Identifier (EI) #2, Admissions Coordinator did not exploit Resident Identifier (RI) #1 for personal gain by becoming the beneficiary on RI #1's life/burial insurance policy (face value of $20,000). This deficient practice affected RI #1; one of three sampled residents reviewed for exploitation. Findings include: The facility's policy titled, Abuse Prevention with a revised date of [DATE], revealed, POLICY: . to promote a dignified existence for all residents; free from . exploitation . Exploitation- means taking advantage of a resident for personal gain through the use of manipulation, intimidation, threats and/or coercion. RI #1 was readmitted to the facility on [DATE]. and expired in the facility on [DATE]. The Alabama Department of Public Health Online Incident Reporting System form dated [DATE], documented, . Narrative summary of incident: (NAME OF GUARDIAN) AND RESIDENT REPRESENTATIVE OF (NAME OF RI #1), CALLED ADMINISTRATOR [DATE] INQUIRING AS TO IF FACILITY HAD A LIFE INSURANCE POLICY ON (NAME OF RI #1). EXPLAINED THAT WE DO NOT DO THAT. SHE THEN ASKED IF FACILITY WAS AWARE THAT (NAME OF EI #2) HAD A LIFE INSURANCE POLICY ON (NAME OF RI #1) WHERE SHE WAS THE BENEFICIARY. FACILITY WAS NOT AWARE OF SUCH AND TOLD HER THAT I WOULD BEGIN AN INVESTIGATION. TODAY, WHEN (NAME OF EI #2) WAS INTERVIEWED SHE STATED THAT SHE HAD PAID (NAME OF RI #1)'S POLICY PREMIUMS TO PREVENT IT FROM LAPSING AND CONFIRED THAT SHE WAS THE BENEFICIARY. SHE WAS TOLD IMMEDIATELY THAT WAS INAPPROPRIATE . On [DATE] at 9:48 AM, a phone interview was conducted with RI #1's Guardian ad litem (appointed) who has kids for RI #1. She stated she became aware EI #2 was the beneficiary of RI#1's policy when she was going through some paperwork and saw a suspicious piece of paper and called the insurance company. The Guardian stated EI #2 has not done anything for RI #1's kids since RI #1's death and she has not spoken with EI #2. On [DATE] at 10:21 AM, a phone interview was conducted with EI #2, (2nd Former Admission Coordinator). EI #2 stated she had been knowing RI #1's family for years. EI #2 said RI #1's dad was paying the premium on the policy but had died that year and no one was paying the premium and the policy was about to lapse. EI #2 stated she called RI #1 in the office and asked him/her about the policy and was told that sisters had a policy on him/her. They (EI #2 and RI #1) called and verified that sister indeed had a policy. EI #2 stated RI #1 asked her if she would pay for the policy just in case his/her sisters fall through. EI #2 stated she asked RI #1 was he/she sure because policy was about to lapse, and they needed to let the insurance company know that he/she will pay it. EI #2 stated she told RI #1 that he/she would have to sign, and he/she stated no problem because he/she knew she would make sure everything would be taken care of. EI #2 stated she became the beneficiary and she started paying for the policy. EI #2 stated the amount of the policy was $20,000 and she had cashed it in. She admitted she had not done anything for RI #1 children at this time and she had paid off the balance of the funeral. A second phone interview was conducted with EI #2 on [DATE] at 4:30 PM. EI #2 stated she started paying the premium of RI#1s policy in May. She stated all RI #1 had to do to make her the beneficiary was to sign the beneficiary form. EI #2 admitted she did not talk to anyone at the facility about RI #1 wanting her to start paying the premium on the policy and becoming the beneficiary until after RI #1's death and funeral. EI #2 admitted she never told family she had an insurance policy on RI #1 and there were several opportunities to let them know. She stated RI #1's guardian called the facility and spoke with her and asked if the facility had a policy on RI #1. EI #2 stated she informed RI #1's Guardian the facility does not do such things like that, and she was going to call her because she had something to talk to her about. EI #2 stated the reason she did not say anything to Guardian at that time about her having a policy was because she had a family member in the office. She stated she did not tell the family the date of RI #1's death because there were other people in the room. EI #2 stated she went to the funeral to inform family of the policy; however, she did not get around to it. EI #2 stated RI#1's guardian was rude to her when she tried to talk with her. EI #2 admitted after the funeral she did not try to reach out to family anymore because she felt RI #1's sisters and guardian were on the same accord. EI#2 stated she finally contacted the funeral home in February, and she paid the balance of $5,500 owed on RI #1's funeral. EI #2 stated reflecting back she guess her becoming beneficiary of RI #1's policy could be considered financial abuse. On [DATE] at 3:44 PM, a phone interview was conducted with EI #3, (1st Former Admission Coordinator/Marketing). EI #3 said she became aware EI #1 had a policy on RI #1 when she told her it was something weighing heavy on her heart. EI #3 stated, EI #2 asked should she do anything for RI #1's daughters. EI #3 told her to talk with EI #1, Administrator but she did not report this to Administrator. EI #3 stated she remember RI #1 coming into the office and EI #2 talking with him/her about a policy lapsing. EI #3 said RI #1 stated he/she didn't think he/she needed it because his/her sisters had a policy. EI #3 said EI #2, and RI #1 call his/her sister and verified she indeed had a policy on RI #1. The Admission Coordinator (EI #3) stated that was the last she knew of the concerns or conversation of the policy. EI #3 stated a facility staff member becoming beneficiary of a resident's policy could be considered taking advantage of a resident. EI #3, went on to say she knew RI #1 loved his/her daughters and would have wanted to make sure they were taken care of. On [DATE] at 5:14 PM, an interview was conducted with EI #4, Registered Nurse (RN)/ MDS Coordinator. EI #4 stated EI #2 mentioned to her after the funeral that she was the beneficiary of RI #1's policy. EI #4 stated EI #2 said RI #1 suggested that she become the beneficiary since she was paying the policy. EI #4 stated RI #1 was able to make competent decisions, however admitted that it was inappropriate for a staff member to become beneficiary of a resident's policy. EI #4 said at the time EI #2 told her about the policy, she (EI #4) did not see it as abuse. On [DATE] at 3:36 PM, a phone interview was conducted with funeral director. The funeral director stated EI #2 came to the funeral home and never disclosed she was in possession of a policy for RI #1. The funeral director said EI #2 finally reached out to him months later to notify him about the policy she had on RI #1. The funeral director stated at that time there was still a balance owed ($5,500) on RI #1's funeral which EI #2 paid. On [DATE] at 6:00 PM, an interview was conducted with EI #1, Administrator. She stated she became aware of EI #2 being beneficiary of RI #1's policy when his/her guardian called to asked if facility had a policy on RI #1. The Administrator stated she was then told that EI #2 had a policy on RI #1. The Administrator (EI #1) stated guardian informed her she found some papers in RI #1's belonging. EI #1 stated she went to talk to EI #2, and she admitted she was paying the premium on a policy for RI #1 and was the beneficiary. EI #1 stated EI #2 said she did it because she thought she was helping RI #1. EI #1 stated her concern was EI #2 was not upfront with the family when they came to pick up RI #1's things from facility and at the funeral. EI #1 stated even though RI #1 was competent to make decision, staff are not to become beneficiary of anything. EI #1 stated EI #2 was aware of the abuse policy pertaining to exploitation and part of her job was to review resident's rights with resident/families upon admission. EI #1 stated EI #2 made promises to RI #1 in exchange for being the beneficiary of his/her policy. This definition fits exploitation. ************************* Once the allegation of exploitation was reported to the facility's Administrator, the following corrective actions were implemented EI #2 was placed on suspension on [DATE]. EI #2 turned in her resigned effective [DATE]. On [DATE], the facility initiated an investigation into the allegation; the facility was able to substantiate the allegation of exploitation. Around [DATE], the Administrator began an audit of all admission files for all in-house residents and any files that were in the buildings for residents that may have been discharged (where EI #2 was designated power of attorney, any guardianship papers, insurance papers. On [DATE], held training with Service, Activities, and Business Office personnel regarding handling of residents' funds, the abuse policy and procedure- specifically the exploitation definition. ************************* After review of the facility's investigation file, in-service/education records and staff interviews, the facility implemented corrective actions from [DATE] to [DATE], thus past non-compliance was cited. This deficiency was cited because of the investigation of complaint/report number AL00042370.

Based on record review and interview the facility failed to ensure the anticoagulation medication for Resident Identifier (RI) #31 was coded on the Quarterly Minimal Data Set ((MDS) dated [DATE]. RI #31 was admitted to the facility 8/2/18 and readmitted [DATE] with a [DIAGNOSES REDACTED]. A review of RI #31's (MONTH) 2019 Physician order [REDACTED].APIXABAN (Eliquis) 5 MG (milligrams) tablet give one tablet PO (by mouth) BID (two times a day) This medication was indicated for acute [MEDICAL CONDITION] of the right lower extremity. A review of RI #31's (MONTH) 2019 Physician order [REDACTED].APIXIABAN tablet 5 MG give one tablet PO BID . A review of RI #31's Quarterly MDS, with an Assessment Reference Date of 2/3/19, revealed under Section N . Medications Received Anticoagulant . not checked as resident receiving. On 4/24/19 at 12:00 PM, an interview was conducted with EI # 6, Registered Nurse (RN) MDS Coordinator. The surveyor and EI #6 reviewed the MDS dated [DATE] and EI #6 was asked if RI #31 was currently receiving an anticoagulation medication. EI #6 replied, yes Eliquis. EI #6 was asked how long the resident had been receiving the Eliquis. EI #6 replied, since 9/14/18. EI # 6 was asked when the MDS was completed on 2/3/19, was RI #31 receiving the Eliquis. EI #6 replied, yes. EI #6 was asked if the anticoagulation medication was coded on the 2/3/19 MDS. EI #6 replied, no. EI #6 was asked if the Eliquis should have been coded on the MDS. EI #6 replied, yes. EI #6 was asked who was responsible for coding the anticoagulation medication on the MDS. EI #6 replied, she was. EI #6 was asked if the MDS dated [DATE] was an accurate assessment. EI #6 replied, no, not that part. EI #6 was asked what was the risk in the MDS not coded accurately. EI #6 replied, no harm to the resident, it was only not accurately coded for those that review the record.

Based on observation, record review, interview and review of facility policies titled, Medication Administration Oral Medications and Medication Administration NG/G Tube, the facility failed to ensure : 1. Licensed staff did not handle the scoop inside the Questran Powder medication with her bare hand then return the scoop inside the container when preparing the medication for Resident Identifier (RI) #45; 2. Licensed staff did not touch the inside of the crush medication bag with his bare hand during medication pass for RI #99, and 3. Licensed staff did not place RI #55's eye drop medication on the glove box in the bathroom without a barrier, while he washed his hands and then place the top of the eye drop container on the resident bedside table while he administered the medication without a barrier, then returned the top to the eye drop container. This affected two of five licensed staff observed for medication pass; one of one resident observed for medication by mouth, one of one resident observed for medication by gastrostomy tube and one of two residents observed for eye drop medication. Findings Include: 1. A review of a facility policy titled, MEDICATION ADMINISTRATION ORAL MEDICATIONS with a reviewed date of 2/2013 revealed: .PR[NAME]EDURE: .6.Do not touch medication with fingers or hands . RI # 45 was readmitted to the facility 4/1/19 with [DIAGNOSES REDACTED]. A review of a Physician order [REDACTED]. On 4/24/19 at 8:43 AM the surveyor observed Employee Identifier (EI) #4, Licensed Practical Nurse (LPN) prepare and give medications to RI #45. Among the medications EI #4 prepared was Questran Powder light. EI #4 opened the container of Questran Powder and took the scoop, that was inside the container, with her bare hand and placed one scoop full in a medication water cup. EI #4 then returned the scoop to the inside of the container, on top of the remaining Questran Powder. On 4/24/2019 at 9:36 AM, an interview was conducted with EI #4. EI #4 was asked where was the scoop for the Questran Powder stored. EI #4 replied, inside container. EI #4 was asked how should she handle the scoop stored inside a medication container. EI #4 replied, with gloves. EI #4 was asked if she wore a glove to handle the scoop. EI #4 replied, no. EI #4 was asked what was the harm in not wearing gloves to handle the scoop stored inside the medication containers. EI #4 replied, contamination. 2. A review of a facility policy MEDICATION ADMINISTRATION NG/G TUBE (Nasogastric/gastrostomy) with a revised date of 1/2017 revealed: . PR[NAME]EDURE: .2. Wash hands. Prepare medication and supplies. 4 Apply gloves. Explain procedure to resident. 5. Check tube placement . RI # 99 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of RI #99's Physician order [REDACTED]. Tylenol 10 CC (cubic centimeters) [MEDICATION NAME], . [MEDICATION NAME] 10 MG (milligram Tablet, . [MEDICATION NAME] 32.4 MG Tablet, . [MEDICATION NAME] ([MEDICATION NAME] Acid) . Give 10 cc by Tube . On 4/24/19 at 4:05 PM, the surveyor observed EI #5, LPN prepare RI #99's medication. EI #5 prepared the following medication to be given by gastrostomy tube: [MEDICATION NAME] ([MEDICATION NAME] acid) liquid 10 cc, Tylenol ([MEDICATION NAME]) Liquid 10 cc, [MEDICATION NAME] 32.4 mg Tablet and [MEDICATION NAME] 10 mg tablet. EI #5 prepared the liquid medication. EI #5 took a medication crush bag and placed each tablet in a separate bag and crushed each tablet. EI #5 was observed putting his finger in each of the medication crush bags after crushing the tablet as he opened the bag to place each crushed tablet in the medication cups. EI #5 took the medication in the resident's room, washed his hands and put on gloves. EI #5 then pulled the privacy curtain, turned off the feeding pump, checked for tube placement, administered the medications and then flushed water in the tube, with the same gloves he touched the privacy curtain and feeding pump with. On 4/24/19 at 4:40 PM, an interview was conducted with EI #5, LPN. EI #5 was asked what was the practice on crushing medication. EI #5 replied, he should place the medication in a bag and crush it. EI #5 was asked how should he handle the bag. EI #5 replied, he should touch only the outside. The surveyor explained observing him touching the inside of the bag when he opened the bag to pour the medication in the medication cup. EI #5 was then asked if he should have touched the inside of the bag. EI #5 replied, no. EI #5 was asked what was the harm in touching the inside of medication crush bag. EI #5 replied, contamination. EI #5 was asked when should he put on gloves then close the privacy curtains and administer the medications, with the same gloves he touched the privacy curtain and feeding pump. EI #5 replied, he should not. EI #5 was asked what was the harm in touching the inside of a medication crush bag with his bare hand and touching the privacy curtain with the same gloves, then give medications. EI #5 replied, cross contamination. 3. RI #55 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of RI #55's (MONTH) 2019 Physician order [REDACTED].Artificial Tears to Both Eyes 1 Drop in Each Eye tid (Three times a day) For Dry Eyes . On 4/24/19 at 4:29 PM, EI #5 was observed preparing Artificial Tears eye drops for RI #55. EI #5 took the Artificial Tears bottle from the medication cart and entered the resident's bathroom. EI #5 placed the bottle of Artificial tears in the bathroom on top of a glove box, without a barrier, and washed his hands. EI #5 put on gloves, removed the top from the eye drop bottle and placed it on RI #55's bedside table, without a barrier. EI #5 administered one drop to each eye. EI #5 then picked up the top from the bedside table and placed it back on the Artificial Tears eye drop bottle. EI #5 removed his gloves, washed his hands and returned the medication to the medication cart. On 4/24/19 at 4:40 PM, an interview was conducted with EI #5. EI #5 was asked what was the procedure on where to place an eye drop bottle while washing your hands. EI #5 replied, on a barrier. EI #5 was asked where did he put the eye drop bottle while he washed his hands. EI #5 replied, on top of the glove box in the bathroom. EI #5 was asked what was procedure on where to place the top of eye drop container while he administered the drops. EI #5 replied, he placed it on RI #55's bedside table. EI #5 was asked if he placed the top on a barrier. EI #5 replied, no. EI #5 was asked should the top have been placed on a barrier. EI #5 replied, yes. EI #5 was asked what was the harm in placing the eye drop container on the glove box in the bathroom and the top for the eye drop container on the resident table without a barrier. EI #5 replied, contamination from the glove box and from the table to the top and the container of the eye drop bottle. On 4/25/19 at 11:04 AM, an interview was conducted with EI #1, Director Of Nursing, in the absence of the infection control nurse. EI #1 was asked what was the best practice for handling the scoop that was inside a medication container. EI #1 replied, put gloves on to remove it. EI #1 was asked should a nurse handle the scoop with bare hands. EI #1 replied, no. EI #1 was asked what was the harm in the nurse handling the scoop with a bare hand. EI #1 replied, contamination. EI 31 was asked where should the nurse place an eye drop container while in the bathroom washing their hands. EI 31 replied, on a barrier. EI #1 was asked when should a nurse place a container of eye drops on the glove box in the bathroom. EI #1 replied, they should not without a barrier. EI #1 was asked what was the harm in placing a container of eye drops on the glove box in the bathroom without a barrier. EI #1 replied, possible contamination with bathroom-feces, urine, or other. EI #1 was asked where should the nurse place the top of the eye drop container while administering the drops. EI #1 replied, anywhere, with a barrier. EI #1 was asked when should the nurse place the top on the bedside table without a barrier. EI #1 replied, never. EI #1 was asked what was the harm in placing the eye drop container/top without a barrier. EI #1 replied, contamination. EI #1 was asked how should a nurse handle the crush bag when crushing medication. EI #1 replied, near the bottom or center of the bag on the outside. EI #1 was asked when should a nurse touch the inside of a bag for crushing medications. EI #1 replied, never. EI #1 was asked what was the harm in the nurse touching the inside of the bag medication was crushed in. EI #1 replied, contamination.

Based on observations, interviews and a review of facility policies titled, Cleaning Instructions: Food Preparation Appliances, and Handwashing Guidelines-Dietary Employees, the facility failed to ensure: 1) crumbs were not in the bottom of the mixer bowl; 2) the bottom of the Robo Coupe blender was free of water; and 3) a dietary staff member washed her hands when entering the kitchen. This had the potential to affect 95 of 105 residents who received meals from the kitchen. Findings Include: 1) A review of a facility policy titled, Cleaning Instructions: Food Preparation Appliances, with no date revealed: Policy: It is the policy of this facility to handle small food preparation appliances, such as blenders, food processors, and mixers, will be cleaned and sanitized following each use . On 05/22/18 at 4:09 p.m., during the initial tour of the kitchen, the surveyor observed a mixer bowl with crumbs in the bottom of it and around the protective covering of the mixer. On 05/24/18 at 2:22 p.m., the surveyor conducted an interview with Employee Identifier (EI) #3, the Dietary Manager. EI #3 was asked what was inside of the mixer bowl. EI #3 replied, a few crumbs. EI #3 was asked why were crumbs in the mixer bowl. EI #3 replied, it was an oversight. EI #3 was asked who was responsible for making sure the mixer bowl was cleaned. EI #3 replied, the person that used it. EI #3 was asked what did the facility's policy say regarding the cleanliness of equipment. EI #3 replied, after they used the equipment it was supposed to be properly washed, sanitized and air dried. EI #3 was asked what was the potential harm when dirty equipment was used to prepare food for the residents. EI #3 replied, it could cause cross contamination. 2) On 05/22/18 at 4:09 p.m., during the initial tour of the kitchen, the surveyor observed the Robo Coupe blender on the base with water in the bottom of it. On 05/24/18 at 2:28 p.m., the surveyor conducted an interview with EI #3. EI #3 was asked what was in the bottom of the Robo Coup blender. EI #3 replied, water. EI #3 was asked why was there water in the bottom of the Robo Coup blender. EI #3 replied, a dietary aide did not allow it to air dry. EI #3 was asked who was responsible for making sure the Robo Coup blender was free of water. EI #3 replied, the person who used it was responsible for washing it, sanitizing and allowing it to air dry. EI #3 was asked what did the facility's policy say regarding the cleanliness of equipment. EI #3 replied, it was supposed to be washed, sanitized and air dried. EI #3 was asked was the equipment put away for future use. EI #3 replied, it was. EI #3 was asked what was the potential harm when dirty equipment was used to prepare food for the residents. EI #3 replied, contamination. 3) A review of a facility policy titled, Handwashing Guidelines-Dietary Employees, with no date, revealed: Policy: Handwashing is necessary to prevent the spread of bacteria that may cause foodborne illnesses. Dietary employees shall clean their hands in a handwashing sink located within the kitchen that is specifically for handwashing. Procedures: . 6. Frequency of Handwashing: . a. Every time an employee enters the kitchen; . On 05/23/18 at 11:23 a.m., during the lunch meal tray line, when food temperatures were being taken, EI #4, a Dietary Aide came into the kitchen and did not wash her hands. EI #4 was observed by the three compartment sink with the tray cards. EI #4 left the kitchen and returned with the food carts. EI #4 did not wash her hands when re-entering the kitchen. On 05/24/18 at 2:34 p.m., an interview was conducted with EI #3. EI #3 was asked when should staff wash their hands in the kitchen. EI #3 replied, after using the bathroom; from one task to another; when touching any part of the body; when leaving the kitchen and coming back in; when changing gloves and when handling raw food products. EI #3 was asked how often should hands be washed when entering the kitchen. EI #3 replied, every time staff entered the kitchen staff were supposed to wash their hands. 05/24/18 at 02:45 pm., an interview was conducted with EI #4. EI #4 was asked when should she wash her hands in the kitchen. EI #4 replied, any time she finished something, and before she started something else she was supposed to wash her hands. EI #4 was asked how often should she wash her hands when entering the kitchen. EI #4 replied, every time she came into the kitchen she was supposed to wash her hands. EI #4 was asked what did the facility's policy say regarding washing hands in the kitchen. EI #4 replied, staff were supposed to wash their hands anytime they entered the kitchen and anytime they started something else. EI #4 was asked what was the potential harm to the residents when she did not wash her hands in the kitchen. EI #4 replied, her hands could pick up germs.

Based on interview, record review and review of a facility policy titled, Conducting an Accurate Resident Assessment, the facility failed to ensure Resident Identifier (RI) #59's Admission Minimum Data Set (MDS) assessment, dated 02/13/18, was coded for the [DIAGNOSES REDACTED].#59's use of the antidepressant medication [MEDICATION NAME]. This affected RI #59, one of 22 residents whose MDS assessments were reviewed. Findings Include: A review of a facility policy titled, Conducting an Accurate Resident Assessment, with a revised date of 11/17 revealed: Policy: The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, . RI #59 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #59's Admission MDS assessment, with an Assessment Reference Date (ARD) of 02/13/18, did not reveal the [DIAGNOSES REDACTED].#59's use of an Antidepressant was not coded. A review of RI #59's (MONTH) (YEAR) Physician order [REDACTED]. . [MEDICATION NAME] 10 MG (milligram) GIVE ONE CAPSULE PO (by mouth) QDAY (every day) . This order had a start date of 02/06/18. A review of RI #59's February, (MONTH) and (MONTH) Medication Administration Records (MARs) for (YEAR), were reviewed and indicated RI #59 had received [MEDICATION NAME] every day. On 05/24/18 at 8:55 a.m., Employee Identifier (EI) #5, a RN (Registered Nurse)/MDS Coordinator was asked if RI #59 was receiving an antidepressant medication. EI #5 replied, yes. EI #5 was asked what antidepressant was RI #59 receiving and when was it started. EI #5 replied, RI #59 was receiving [MEDICATION NAME] every day and it started on 02/06/18. EI #5 was asked should the [MEDICATION NAME] be coded on the MDS. EI #5 replied yes. EI #5 was asked if the [MEDICATION NAME] was coded on the MDS. EI #5 replied no. EI #5 was asked why was the [MEDICATION NAME] not coded on the MDS. EI #5 replied, it was an oversight. EI #5 was asked would RI #59's MDS be considered accurate if the antidepressant was not coded on the MDS. EI #5 replied no, not in the medication section.

Based on record review and interview, the facility failed to ensure Resident Identifier (RI) #63's Skin Breakdown care plan was revised after RI #63 was identified to have redness around his/her sacral area. This deficient practice affected RI #63, one of 22 sampled residents whose plans of care were reviewed. Findings Include: RI #63 was admitted to the facility on [DATE], and readmitted on [DATE], with a [DIAGNOSES REDACTED]. RI #63's physician's orders [REDACTED]. . 2) Clean reddened area around sacral area c (with) wound cleanser, apply TAO (Triple Antibiotic Ointment) & (and) cover c gauze pads & Duoderm qd (every day) . On 05/23/18 at 2:15 p.m., the surveyor reviewed RI #63's care plans. There was no care plan noted which addressed the redness to RI #63's sacral area or the use of a Duoderm dressing to the area. On 05/23/18 at 2:24 p.m., the surveyor conducted an interview with Employee Identifier (EI) #2, the Treatment Nurse. The surveyor asked EI #2 did RI #63's Skin Breakdown care plan address the redness and use of the Duoderm to his/her sacral area. EI #2 looked at RI #63's care plans and stated, No Ma'am. When asked should there be a care plan addressing the redness, EI #2 replied yes. The surveyor asked EI #2 what would be the purpose of having a care plan to address the redness to RI #63's sacral area. EI #2 said so people would be aware that RI #63 had the redness and know what treatment was to be provided.

Based on observations, interview and review of a facility policy titled, (Name of Nursing Home) NURSING STAFFING LEVELS, the facility failed to ensure the nurse staff postings reflected the census on two of three days of the survey. This had the potential to affect all 106 residents residing in the facility. Findings Include: An undated facility policy titled, (Name of Nursing Home) NURSING STAFFING LEVELS, documented: . 2. Census: This is the total number of residents that are currently residing with this facility during that shift . On 05/22/18 at 4:12 p.m., the surveyor observed the nurse staff posting for the evening shift (3 p.m. - 11 p.m.). There was no census on the form. On 05/22/18 at 6:33 p.m., the surveyor again observed the nurse staff posting for the evening shift. There was no census on the form at this time. 05/23/18 at 4:25 p.m., the surveyor observed the nurse staff posting for the evening shift. There was no census on the form. On 05/24/18 at 12:25 p.m., an interview was conducted with Employee Identifier (EI) #1, the Staffing Coordinator. The surveyor asked EI #1 what was the resident census for the evening shift on 05/22/18. EI #1 said there was no census documented. When asked if the nurse staff posting for the evening shift on 05/22/18 was complete, EI #1 said no. EI #1 also acknowledged there was no census on the nurse staffing form for 05/23/18. The surveyor asked EI #1 why was it important that the staffing form be complete. EI #1 said because it showed there were sufficient amount of staff to take care of the residents. When asked who was responsible for completing the daily nurse staffing form, EI #1 said she was for the first shift, and the supervisors were for the evening and night shifts.

Based on interviews, medical record review and a review of a facility policy titled Care Plan, the facility failed to ensure the care plan was updated to reflect an intervention of Health shakes with meals ordered on [DATE]. This deficient practice affected Resident Identifier (RI) #8, one of 13 sampled residents whose care plans were reviewed. Findings include: A review of a facility policy titled, Care Plan with an effective date October 1998 and revised July 2017 documented the following: Policy: A comprehensive care plan shall be developed for each resident that includes objectives and goals ., Interventions should then be developed based on the care plan and should be individualized .#4. Care plans are revised as changes in the resident's condition dictate #6 Information that is developed as part of the Care Plan will be communicated to the appropriate departments in a variety of ways including .a copy of the care plan . RI # 8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED].Healthshake TID (Three times a day) with meals . A Diet Order dated 1/6/17 revealed: .Supplement Healthshakes TID with meals . A review of RI # 8's nutritional risk care plan dated 11/30/16 did not reveal an update to include the intervention of health shakes with meals. On 4/5/17 at 4:00 p.m., an interview was conducted with EI (Employee Identifier) #3, Care Plan Coordinator. The surveyor asked EI #3 when should the care plan be updated. EI #3 responded when the order was written. EI # 3 further stated a communication was also to be sent to dietary and the change should be written on the care plan. The surveyor ask should the care plan have been updated when RI #8's Healthshake was ordered. EI #3 responded yes. The surveyor ask why is it important to update the care plan. EI #3 responded, so staff can document what the resident gets on their tray and the nurses can keep up with the resident's nutritional supplement.

Based on observation, interviews and a review of a facility policy titled Weight/Nutrition Interventions, and the weigh change history document, the facility failed to ensure RI (Resident Identifier) #8, a resident at risk for weight loss received a Healthshake as ordered with his/her lunch meals on April 4 and 5th, 2017. This deficient practice affected one of seven sampled residents who received supplements with meals and whose meals were observed during the survey. The facility provided documentation indicating 44 residents received supplements with their meals. Findings include: A review of a facility policy titled, Weight/ Nutrition Interventions with an effective date of July 1998 and revised November 2015 documented the following: .2 .Orders are written and carried out by the nurse and Dietary if diet or supplements are modified. 5. Meal consumption as well as supplement consumption will be monitored by staff assigned to the resident . RI # 8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI # 8's most recent Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference date) of 2/20/17 documented RI # 8 was cognitively intact. A review of RI # 8's care plan dated 11/30/16 documented he/she was at nutritional risk due to decreased appetite. A review of RI #8's weight change history documented the following: 11/2/16 Weight 156 lbs. (pounds), 12/2/16 Weight 158.5 lbs, 1/2/17 Weight 150 lbs, 2/3/17 150.5 lbs, 3/1/17 Weight 144.5lbs , 4/4/17 Weight 149.5 lbs. A review of the physician's orders [REDACTED]. A Diet Order dated 1/6/17 revealed, Supplement Healthshakes TID with meals. On 4/4/17 at 12:15 p.m., RI # 8's lunch meal was observed. RI #8 received a regular no added salt diet to include chicken strips, mixed vegetables, rice, cornbread and cake. No Healthshake was observed on the tray. On 4/5/17 at 12:30 p.m., RI #8's, lunch meal was observed. RI #8 received a regular no added salt diet to include pork loin, baked beans, zucchini slices, cornbread and apple slices. No Healthshake was observed on the tray. On 4/5/17 at 12:30 p.m., an interview was conducted with RI #8. The surveyor ask the resident if he/she ever received a Healthshake with his/her meals. The resident stated his/her roommate gets one, not him/her The surveyor ask RI #8, if he/she had ever received a Healthshake. The resident stated, No. On 4/5/17 at 3:10 p.m., an interview was conducted with the EI # 2, (RN), Registered Nurse, Supervisor. The surveyor ask EI #2 who was responsible for putting the diet supplements on the resident's tray. EI #2 responded the kitchen staff. The Surveyor asked EI #2 what is the potential harm when a resident does not receive his/her supplement. EI # 2 responded he/she is not getting the supplement needed and that could potentially cause weight loss. On 4/5/17 at 3:30 p.m., an interview was conducted with EI #1, Director of Dietary. EI #1 was asked if RI #8 was supposed to receive a Healthshake with meals. EI #8 did not respond but provided a copy of the order as follows: Diet Order, Healthshake TID (three times per day) with meals. The surveyor asked EI #1 who was responsible for making sure the Healthshake is put on the resident's tray. EI #1 responded, I am. The surveyor asked if the kitchen was notified that RI #8 was to receive a Healthshake with all three meals. EI #1 responded, Yes, it was on a diet communication sheet. She further stated it some how fell through the cracks. It was not in the computer system. EI #1 stated she prints out the tray cards so staff will know to put the health shake on the tray. It was not on the tray card.

Based on observation, interview and a review of a policy titled Cleaning Instructions: Floors, the facility failed to ensure the drain under the vegetable sink in the kitchen was free of food and other debris. This deficient practice was observed on 4-4-17 and 4-5-17 and had the potential to affect 99 residents receiving meals from the kitchen. Findings Include: A review of an undated policy titled Cleaning Instructions: Floors documented the following: . Policy: It will be the policy .to maintain floors in a clean and sanitary condition .Procedure: .4. Floor drains will be kept covered .emptied as needed daily . On 4-4-17 at 11:25 a.m., the surveyor observed the drain under the vegetable sink with no cover. Debris was observed in the drain to include paper and food. On 4-5-17 at 1:05 p.m., the surveyor observed the drain under the vegetable sink to broken without a cover. Food was visible in the drain. An interview was conducted on 4/5/17 at 1:10 p.m. with Employee Identifier (EI) #1, Director of Dietary. EI #1 was asked how long the drain under the vegetable sink had been broken. EI #1 replied the top portion was not mounted to the drain. EI #1 explained the drain was cleaned once a week or as needed. EI # 1 was asked if food should be in the drain. EI #1 stated yes, its going to collect some but most should go down the pipe. EI #1 was asked if the drain should have trash in it. EI #1 replied no, but the staff had just finished cutting up cucumbers; so that is what is in there now. EI #1 was asked if the drain needed to be cleaned. EI #1 replied it should be emptied. EI #1 was asked why should the drain be cleaned or emptied. EI #1 replied it is part of the normal cleaning of the kitchen and old food is an infection control issue and can also cause pests.

Based on observation, interviews and record review, the facility failed to consistently prepare and serve pureed food in a soft, semi-formed texture on two of two days observed during the survey. This had the potential to affect 17 of 17 residents for whom a pureed diet was ordered. Findings included: The facility's Health Technology Diet Manual (2007 edition) describes preparation and consistency of the Pureed Diet as follows: . PREPARATION: All foods are prepared in a food processor or blender, with the exception of those foods which are normally in a soft and smooth state (such as puddings, ice cream, mashed potatoes, etc. (et cetera)). 1. Additional liquid is added in the form of broth, gravy, vegetable or fruit juices, or milk to achieve appropriate consistency (puddings, mashed potatoes) . During the 03/16/16 lunch tray line, the pureed meat (Mexican Beef Tips), pureed vegetable (Broccoli Cuts) and cake (Red Velvet) were each of a honey-thick liquid consistency. On 03/17/16 at 12:00 PM, the surveyor observed the pureed food served from the lunch trayline. The menu consisted of pureed Cornbeef Casserole, pureed Cabbage, pureed Cornbread, and Lime Pie (with the appearance of melted sherbet). The pureed food was of a consistency too thin to hold a form. At this time, the surveyor asked the Certified Dietary Manager, (Employee Identifier/EI) #5 to explain the runny appearance of the pureed food. EI #5 replied the pureed food should be formed. When asked how she monitored the staff to ensure food was prepared at the correct consistency, EI #5 stated she did dining room monitoring. EI #5 stated the pureed meat (on 03/17/16) should have had more thickener added. EI #5 explained the consistency of the pureed food should be of a pudding or scoop form (the utensil used to serve the pureed items) with more shape. The surveyor questioned EI #5 about the pureed Cabbage and Lime Pie prepared and served on the 03/17/16 tray line (also of a liquid consistency). EI #5 stated, It needs to be thicker. EI #5 confirmed the pie appeared runny, stating it usually gelled. Pureed food observed by both EI #5 and the surveyor in the assisted dining room, was served in sectional plates. The pureed food had no form, despite being served with a scoop. Each pureed food item was of a consistency such that it completely extended to the barrier of each section. On 03/17/16 at 12:50 PM, the cook (EI #6) was asked to describe the texture of the pureed Cabbage and Cornbeef Casserole. EI #6 stated the pureed food did fill the sections of the divided plates, but usually it was a little thicker. EI #6 stated she did not disagree that the pureed food could be thicker.

Based on observations, interview and record reviews, the facility failed to ensure wheelchair (w/c) and geri chair arm rest were not cracked, torn and rough to the touch in Room Locators (RL), #'s 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15. This affected five of six halls of the facility. Findings Include: The facility's job description titled, DIRECTOR OF MAINTENANCE JOB DESCRIPTION, documented: General Purpose: To plan, organize and direct the overall operation of the department in accordance with current federal, state and local standards, ensuring that the facility is maintained in a safe, comfortable condition. . Essential Job Functions: A. Maintenance Functions Duties: . assist in establishing and maintaining a preventive maintenance program; . ensure proper maintenance of the facility including . equipment . The facility's job description titled, Maintenance Assistant documented: . Purpose of Your Job Position The primary purpose of your job position is to maintain . facility, equipment in a safe and efficient manner . Duties and Responsibilities . Equipment . Functions Ensure that the facility and its equipment is properly maintained for resident comfort and convenience . On 03/15/16 beginning at 2:50 PM, during the initial tour the following observations were made: Room Locators #6- the right arm rest on the geri chair was torn. #7- the right and left w/c arms rest were cracked and rough to the touch. #8- the right and left w/c arms rest were cracked and rough to the touch. #9- the right and left w/c arms rest were cracked and rough to the touch. #10- the right and left w/c arms rest were cracked and rough to the touch. #11- the right arm rest was torn. #12- the right and left w/c arms rest were cracked and rough to the touch. #13- the right and left w/c arms rest were cracked and rough to the touch. #14- the front of an arm rest was torn off. #15- the right and left w/c arms rest were cracked and rough to the touch. On 03/17/16 at 12:15 PM, Employee Identifier (EI) #15, Director of Maintenance, was asked who was responsible to monitor w/c and geri chair arm rests for needed repairs. EI #15 replied maintenance and Occupational Therapy. EI #15 was asked how often was that done. EI #15 replied not everyday but regularly. EI #15 was asked where was the documentation. EI #15 replied there was no documentation. EI #15 was asked why there were still so many w/c and geri chair arms rests that were cracked and rough to the touch throughout the facility. EI #15 replied he could not tell me. EI #15 was asked what was the facility's policy about equipment. EI #15 replied keep them maintained. EI #15 was asked what could be the potential harm to a resident with fragile skin. EI #15 replied skin tears. EI #15 was asked what could be the potential harm to a resident on a blood thinner. EI #15 replied they could bleed.

Based on observations, record review and interviews, the facility failed to ensure Room Locator (RL) #1, #2, #3, #4 and #5 were free of an accumulation of black and yellow stains and residue. This was observed two days of the survey. This affected five of 30 rooms located on unit two of the facility. Findings Include: A review of a facility's policy titled, GENERAL CARE GUIDELINES, with a revised date of October 2004 revealed the following: . POLICY: It is the policy . to provide guidelines for staff to adhere to in regards to general areas of resident care. Guidelines: . 38. Environment is clean and neat to include . floors. During the initial tour on 03/15/2016 beginning at 3:20 PM, the following was observed: RL #1's bathroom floor tile located around the commode was observed with a yellow substance/residue; RL #2's bathroom floor tile located around the commode was observed with a yellow substance/residue; RL #3's bathroom floor tile at the base of the commode was observed with a yellow substance/residue; RL #4's bathroom floor tile was observed with black substance/residue behind the commode; and RL #5's bathroom floor tile in front of the commode was observed with a yellow substance/residue. On 03/17/2016 beginning at 8:55 AM, the surveyor and Employee Identifier (EI) #4, Housekeeping Supervisor/Director, observed RL #1, #2, #3, #4, and #5's bathroom. At 9:10 AM, EI #4 was asked what did he observe on RL #1's bathroom floor. EI #4 stated a yellow stain around the commode base and in front of the commode/toilet. EI #4 was asked what did he observe on RL #2's bathroom floor. EI #4 said there were stains at the back of the toilet. EI #4 was asked what color were the stains. EI #4 stated yellow. EI #4 was asked what did he observe in RL #3's bathroom. EI #4 stated black particles/residue in the corners and yellow stains. EI #4 was asked what did he observe in RL #4's bathroom. EI #4 stated stains in the back of the toilet/commode and at the baseboards. EI #4 was asked what color were the stains. EI #4 stated yellow. EI #4 was asked what did he observe in RL #5's bathroom. EI #4 explained stains were in front of the toilet and it looked like a wax build up. EI #4 was asked what color were the stains. EI #4 stated a brownish color. On 03/17/2016 at 9:10 AM, EI #4 was asked who was responsible for monitoring housekeeping and ensuring residents' bathroom floors were clean and free of stains and buildup. EI #4 replied, I am. EI #4 was asked how often housekeeping staff was monitored to ensure bathroom floors were cleaned on a consistent basis. EI #4 explained when he did rounds. EI #4 was asked why bathroom floors should be cleaned and free of a build up, black particles/residue and yellow stains. EI #4 explained those areas should be cleaned on a daily basis so residents could have a clean homelike environment. EI #4 was asked what was the potential harm in not having residents' bathroom floors free of build up and yellow and black stains/particles. EI #4 explained there was no harm but housekeeping should make sure all areas of the resident's rooms and bathrooms should be clean because it is their home.

Based on observations, interviews and document reviews, the facility failed to ensure Employee Identifier (EI) #17 (Licensed Practical Nurses/LPN)did not sign the MAR (Medication Administration Record) before she administered medication to Resident Identifier (RI) #1. The facility further failed to ensure EI #18 signed the MAR after she administered medication to an unsampled resident and EI #2 signed the TAR (Treatment Administration Record) after providing wound care for RI #9. These deficient practices affected two of the seven residents observed during Medication Administration and one of one resident observed during wound care. Findings include: A review of POTTER and PERRY, Fundamentals of Nursing, 8th Edition copy right 2013, Chapter 31 Medication Administration, page 584 and 586 documented: . Standards Standards are actions that ensure safe nursing practice. To prevent medication errors, follow the six rights of medication administration consistently everytime you administer medication. Many medication errors can be linked, in some way, to an inconsistency in adhering to these six rights: . 6. The right documentation . Right documentation. Nurses and other health care providers use accurate documentation to communicate with each other. After administering a medication, indicate which medication was given on the patient's MAR . to verify that is given as ordered. Record each medication on the patient's MAR as soon as you give medications to the patient. Inaccurate documentation such as failing to document giving a medication . leads to errors in subsequent decisions about patient care . A review of a facility's policy titled, Medication Administration Oral Administration, with a review date of February 2013 documented: . PROCEDURE: . 13. Record medication immediately after administration on the medication administration record (MAR). 1. On 03/17/16 at 8:45 AM: EI (Employee Identifier) #17, (License Practical Nurse/LPN/Charge Nurse) signed off for each medication as she dispensed them into the medication cup, before the medication was administered to RI #1. On 3/17/16 at 8:52 AM, EI #17 acknowledged that she signed the MAR before she administered the medication. EI #17 was asked what was the potential harm in signing out medication before giving. EI #17 replied that if they did not take the medication and she forgot to circle it, it would indicate the resident received the medication when they had not. On 03/17/16 at 1:43 PM, EI #19 was asked how she taught the nurses to sign the MAR. EI #19 stated, After they give the med. EI #19 was asked what was the facility's policy on signing the MAR. EI #19 stated, Immediately after they give the med. 2. On 03/17/16 at 9:26 AM, EI #18, an LPN, administered medications to an unsampled resident. After the administration of the medications, EI #18 washed her hands and pushed the medication cart to another resident's room. On 03/17/16 at 9:44 AM, EI #18 was asked when did she sign the MAR for the unsampled resident's medications. EI #18 stated, I didn't but I should have signed off after I gave it. the medications. EI #18 was asked if it was an acceptable practice of this facility to administer medications and not sign the MAR after giving the medications. EI #18 replied, No. 3. On 3/16/16 at 11:35 AM, EI #2 (LPN/Treatment Nurse) provided wound care to RI #9. After providing wound care to RI #9, EI #2 placed the soiled dressings into the proper receptacle and washed her hands. After the surveyor reviewed RI #9's TAR, EI #2 had not signed the TAR indicating wound care treatment. On 03/17/16 at 2:04 PM, EI #2 was asked when should the TAR be signed. EI #2 stated, Immediately after I finished. EI #2 was asked why did she not sign the TAR immediately after wound care. EI #2 replied she was nervous. EI #2 was asked if it was an acceptable practice of the facility to provide wound care to a resident and not sign the TAR. EI #2 was asked what the potential harm if the TAR is not signed after providing wound care to a resident. EI #2 said staff would not know the treatment had already been provided and the treatment could be repeated.

Based on observations, interviews and record reviews, the facility failed to ensure: 1. staff followed Resident Identifier (RI) #4's care plan for turning and repositioning, and checking and changing for incontinence, every two hours; 2. staff followed RI #13's care plan for removal of the lap buddy during lunch meal This affected two of 20 sampled residents whose care plans were reviewed. Findings Include: A review of the facility's policy and procedure titled, CARE PLANS-FOLLOWING, with a revised date of 03/2013, revealed the following: . PROCEDURE: . 6. Interventions on the care plan are should be followed . A review of the facility's policy and procedure titled, Incontinence, with a revised date of 06/2009, revealed the following: POLICY . residents are checked at least every 2 hours . 1) RI #4 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #4's current Quarterly Minimum Data Set ((MDS) dated [DATE] revealed RI #4 had short and long term memory problems with severe impairment in cognitive skills for daily decision making. The MDS documented RI #4 was totally dependent on staff for Activities of Daily Living (ADLs), and always incontinent of bowel and bladder, and was at risk for development of pressure ulcers. A review of RI #4's care plan titled, Dependent for daily decision . Requires total assistance with her/his daily care . with a problem onset date of 10/28/2015, revealed the following: . Approaches . Dependent for toileting needs. Check for incontinent episodes every 2 hours and prn (as needed) to keep . clean and dry . A review of RI #4's care plan titled, Potential for skin breakdown associated with impaired mobility . with a problem onset date of 10/28/15, revealed the following: . Assist . with turning, positioning, and bed mobility per turn schedule . A review of RI #4's turn schedule revealed a clock turn schedule with every two hour positioning changes from the door to the window. On 03/16/16, beginning at 10:35 AM, RI #4 was continuously observed until 2:15 PM. RI #4 was awake and alert, up to the geri-chair and positioned facing the door. RI #4 was not checked and changed until 2:15 PM, for three hours and forty minutes later. On 03/16/16 at 2:15 PM, Employee Identifier (EI) #7 (Certified Nursing Assistant/CNA) checked RI #4. EI #7 removed RI #4's brief and replied the resident had a moderate amount of urine and smears of bowel movement. The surveyor asked EI #7 to describe the inside of RI #4's brief. EI #7 stated the brief was discolored. On 03/16/16 at 2:20 PM, during an interview with EI #7, the surveyor asked how often should a resident be checked and changed. EI #7 replied every two hours. EI #7 stated she thought she had checked RI #4 at 11:00 AM. The surveyor informed EI #7 that she (EI #7) had not checked the resident at 11:00 AM. The surveyor asked had RI #4 been turned and repositioned every two hours. EI #7 replied no. On 03/16/16 at 5:10 PM, during an interview with EI #1 (Director of Nursing/DON), the surveyor asked who was responsible to check and change a resident and to turn and reposition. EI #1 replied the CNA that is assigned to that resident and every two hours. The surveyor asked what the longest time should a resident go without checking and changing. EI #1 stated not more than two hours. The surveyor asked what was the potential for harm when a resident is not checked and changed every two hours. EI #1 replied skin breakdown and possibly a Urinary Tract Infection. 2) RI #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #13's current Quarterly MDS dated [DATE] revealed RI #13 had short and long term memory problems with severe impairment in cognitive skills for daily decion making. The MDS documented RI #13 required extensive to total assistance of staff with ADLs. The MDS also documented RI #13 was not steady, only able to stabilize with staff assistance with moving from seated to standing position and surface to surface to surface transfer. The MDS documented RI #13 had Range of Motion limitations to bilateral upper and lower extremities. A review of RI #13's care plans revealed a care plan titled, Potential for falls and injury R/T (Related to): Impaired balance; [MEDICAL CONDITION] disorder; M.R. (Mental [MEDICAL CONDITION]) (Mental [MEDICAL CONDITION]) (Mental [MEDICAL CONDITION]) (Mental [MEDICAL CONDITION]) (Mental [MEDICAL CONDITION]) with cognitive deficits; Does not comprehend safety needs; Lap buddy; [MEDICAL CONDITION]'s; Jumps around in chair frequently and at intervals with a problem onset date of 11/25/2015. One of the goals was: .Will maintain safe surroundings to reduce the risk of falls and injury . Approaches . 15. Do not release lap buddy during meals due to constant moving about, and jumping around while in wheelchair. A review RI #13's March 2016 NURSING ASSISTANT PLAN OF CARE revealed the following: .THE FOLLOWING CARE WILL BE PROVIDED IN ACCORDANCE WITH THIS RESIDENT'S CARE PLAN. Under ADDITIONAL INTERVENTIONS this documentation identified: . WHEELCHAIR W/ (WITH) LAP BUDDY FOR POSITIONAL SUPPORT - DO NOT RELEASES DURING MEALS R/T JUMPING WHILING (while) BEING FED. RELEASE FOR AMBULATION AND TOILETING. Observations were made of RI #13 on 3/16/2016 at 12:50 PM. RI #13 was sitting in a wheelchair with a lap buddy in place. EI #13 (CNA) entered the room, removed the lap buddy and fed RI #13 the lunch meal. On 3/17/2016 at 11:45 AM, an interview with EI #13 revealed that she was told to remove the lap buddy during lunch. The surveyor asked where was that information documented. EI #13 said in the care plan. The surveyor asked was she aware that it was documented in the care plan not to remove RI #13's lap buddy during meals. EI #13 said she was not aware not to remove the lap buddy during meals. The surveyor asked did she follow the care plan. EI #13 said no. An interview with the Registered Nurse (RN) EI #14 on 3/17/16 at 12:35 PM. The surveyor asked who is responsible to follow a residents care plan. EI #14 said staff CNAs and nurses. The surveyor asked how do the CNAs know how to care for a specific resident. EI #14 said CNAs have care plans that they use. The surveyor asked should the CNA release the RI #13's lap buddy during meals. EI #14 said no because of his/her jumping around. The surveyor asked what could happen. EI #14 said it would be a safety issue.

Based on observations, interviews and record reviews, the facility failed to ensure Resident Identifier (RI) #7 and RI #20's toenails were trimmed on a regular basis. This affected two of five sampled residents for Activities of Daily Living (ADLs). Findings Include: 1) RI #7 was re-admitted to the facility on [DATE]. A review of RI #7's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/28/2015, indicated the resident was cognitively intact, with a Brief Interview for Mental Status score of 15. RI #7 was assessed as requiring extensive assistance with personal hygiene. On 03/16/2016 at 10:50 AM, RI #7 further explained his/her toenails were currently long, and had not been cut since December 2015, three months ago. On 03/16/2016 at 5:40 PM, an observation was made of RI #7's toe nails with EI #2, a License Practical Nurse (LPN/Treatment Nurse. The first four toe nails on the right foot were long and jagged. The great toe nail on the left foot was long and jagged. EI #2 was asked who would be responsible for cutting RI #7's toenails. EI #2 stated staff could cut RI#7's toe nails when assisting him/her with bathing. EI #2 was asked to observe and describe RI #7's toe nails. EI #2 stated they are long and jagged. EI #2 was asked what was the potential for harm when toenails are long and jagged. EI #2 explained RI #7 could scratch areas of skin. On 03/17/2016 at 1:34 PM, an interview was conducted by telephone with EI #3, Certified Nursing Assistant (CNA). EI #3 was asked was she familiar with RI #7. EI #3 stated yes. EI #3 acknowledged that when she gave the resident a bath his/her toenails were long and needed to be cut. 2) RI #20 was readmitted to the facility on [DATE]. RI #20's Annual MDS dated [DATE] documented a BIMS score of 12 out of 15 which indicated moderately impaired cognition. RI #20 required extensive assistance which personal hygiene. A care plan for RI #20 with a Nursing DX: (diagnosis) Self-care deficit Requires assistance with ADL's (Activities of Daily Living) . with a problem onset date of 02/18/16 documented: .Approaches . Assist with personal grooming . nail care . During the initial tour on 03/15/16 at 4:25 PM, RI #20 stopped the surveyor and stated he/she needed his/her toe nails cut. RI #20 took of the left shoe, and commented they (toe nails) hurt. RI #20's left great toe nail was long and thick. RI #20 further commented he/she told the facility but was told he/she would have to wait. On 03/16/16 at 10:15 AM, RI #20 was observed in his/her room. RI #20 commented they had cut the toe nails last night and they felt so much better. On 03/16/16 at 10:35 AM, EI #11, Occupational Therapist, stated the nurse had asked him to cut RI #20's toe nails. EI #11 was asked to describe RI #20's toe nails. EI #11 replied they were long, thick and mycotic (very thick). EI #11 was asked was he asked before yesterday to cut RI #20's toe nails. EI #11 replied no not before yesterday. On 03/16/16 at 4:30 PM, RI #20's sponsor stated the resident had complained for a couple of weeks about the toe nails. The sponsor further stated he had seen RI #20's toe nails two days ago and they were long.

Based on observations, interviews, and record reviews, the facility failed to ensure Resident Identifier (RI) #4 was not allowed to remain in the same position for three hours and forty minutes without being toileted and repositioned. RI #4 was identified by the facility as at risk for skin breakdown and had a history of [REDACTED]. This affected one of four residents who were monitored for position changes during the survey. Findings Include: A review of the facility's policy and procedure titled, INCONTINENCE, with a revised date of 06/2009, revealed the following: . POLICY: . residents are checked at least every 2 hours, changed and cleaned . A review of the facility's policy and procedure titled, DRESSING CHANGE, with a revised date of 07/2001, revealed the following: POLICY: Special precautions shall be taken to prevent the cross contamination of residents . RI #4 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #4's current Quarterly Minimum Data Set ((MDS) dated [DATE] revealed RI #4 had short and long term memory problems with severe impairment in cognitive skills for daily decision making. The MDS documented RI #4 was totally dependent on staff for Activities of Daily Living and always incontinent of bowel and bladder. A review of RI #4's care plan titled, Dependent for daily decision . Requires total assistance with her daily care . with a problem onset date of 10/28/2015, revealed the following: . Approaches . Dependent for toileting needs. Check for incontinent episodes every 2 hours and prn (as needed) to keep . clean and dry . A review of RI #4's care plan titled, Potential for skin breakdown associated with impaired mobility. admitted with skin deficits; Bowel and bladder incontinence; . with a problem onset date of 11/03/14, revealed the following: . Approaches . Treatment as ordered to help to maintain intact skin integrity, since . tends to have reoccurrences of areas in buttocks area . A review of RI #4's Body Audit dated 03/09/16, sent in with additional information on 03/21/16, revealed healed pink areas to the buttock and old pink area to the right thigh area. A review of the facility's RESIDENT CARE PLAN for RI #4, sent in on 03/21/16 as additional information, revealed the following: . 6/24/15 Clean open area to top of (right) buttock (with) wound cleanser, cover (with) [MEDICATION NAME] border change every 5-7 days, or until healed . On 03/16/16 beginning at 10:35 AM, RI #4 was awake and alert, up to the geri-chair and positioned facing the door. RI #4 was continuously observed from 10:35 AM until 2:15 PM. RI #4 was not checked and/or changed until 2:15 PM, three hours and forty minutes. On 03/16/16 at 2:15 PM, the following was observed: Employee Identifier (EI) #7 (Certified Nursing Assistant/CNA) checked RI #4. EI #7 removed RI #4's brief and replied the resident had a moderate amount of urine and smears of bowel movement. The surveyor asked EI #7 to describe the inside of RI #4's brief. EI #7 stated the brief was discolored. RI #4 had BM in the groin, vaginal area, rectal area and the buttock. RI #4 was observed to have old light colored areas to the buttock and inner thigh area. On 03/16/16 at 5:10 PM, during an interview with EI #1 (Director of Nursing/DON), the surveyor asked who was responsible to check and change a resident. EI #1 replied the CNA that is assigned to that resident and every two hours. The surveyor asked what was the longest time a resident should go without being checked or changed. EI #1 stated not more than two hours. The surveyor asked what was the potential for harm when a resident is not checked and changed every two hours. EI #1 replied skin breakdown. On 03/17/16 at 3:45 PM, during an interview with EI #9 (Registered Nurse/RN Supervisor, Unit I), the surveyor asked who was responsible for checking and changing a resident. EI #9 replied the CNA is responsible for checking and changing and it should be done every two hours and as needed.

Based on observation, interviews and record reviews, the facility failed to ensure; 1. a. Staff wiped Resident Identifier (RI) #4 till the resident was clean and free of stool; b. used the same area of the wash cloth only once; c. wiped the left buttock; d. wiped the rectal area with one consistent wipe; and e. checked and changed RI #4 every two hours. 2. A Certified Nursing Assistant (CNA) washed her hands and change her gloves after touching a pad soiled with urine and before touching clean linen and performing incontinent care for RI #9, a resident with a history of UTI's (Urinary Tract Infections), on 3/16/16. This affected RI #9, one of two residents observed during perineal and incontinence care. This affected RI #4 and RI #9, residents identified with a history of Urinary Tract Infection and two of two residents observed during incontinence care observation. Findings Include: A review of the facility's, PERINEAL CARE SKILLS CHECKLIST, without a date, revealed the following: . Separate labia with one hand and wash with the other, using gentle downward [MEDICAL CONDITION] from the front to back to prevent contamination . Use a clean section of the washcloth for each stroke . Turn the resident to . side . Clean . the anal area, starting at the posterior vaginal opening and wiping from front to back . A review of the facility's policy and procedure titled, INCONTINENCE, with a revised date of 06/2009, revealed the following: . POLICY: . residents are checked at least every 2 hours, changed . 1. RI #4 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #4's current Quarterly Minimum Data Set ((MDS) dated [DATE] revealed RI #4 had short and long term memory problems with severe impairment in cognitive skills for daily decision making. The MDS documented RI #4 was totally dependent on staff for Activities of Daily Living and always incontinent of bowel and bladder. A review of RI #4's care plan titled, Dependent for daily decision . Requires total assistance with her daily care . with a problem onset date of 10/28/2015, revealed the following: . Approaches . Dependent for toileting needs. Check for incontinent episodes every 2 hours and prn (as needed) to keep . clean and dry . A review of RI #4's turn schedule revealed a clock turn schedule with every two hour positioning changes from the door to the window. On 03/16/16, beginning at 10:35 AM, RI #4 was continuously observed until 2:15 PM. RI #4 was awake and alert, up to the geri-chair and positioned facing the door. RI #4 was not checked and changed until 2:15 PM. On 03/16/16 at 2:15 PM, Employee Identifier (EI) #7 (Certified Nursing Assistant/CNA) checked RI #4. The surveyor asked what type of incontinence episode had the resident had and how much. After removing RI #4's brief, EI #7 replied a moderate amount of urine and smears of bowel movement. The surveyor asked EI #7 to describe the inner aspect of RI #4's brief. EI #7 stated the brief was discolored. On 03/16/16 at 2:15 PM, the following was observed during incontinent care observation: EI #7 and EI #8 (CNA) washed their hands and applied gloves. EI #7 obtained a basin with soap and water. EI #7 placed wash cloths into the basin with soap and water. EI #7 obtained a wet wash cloth from the basin and wiped the right groin back and forth, flipped the wash cloth and wiped the left groin. EI #7's gloves touched the dark colored substance observed on the wash cloth. EI #7 did not change gloves. EI #7 obtained a clean wash cloth from the basin of soap and water and wiped the vaginal area. Stool was observed on the wash cloth and EI #7's gloved hands touched the inner area of the wash cloth that contained stool. EI #7 obtained a clean wash cloth from the basin of soap and water and wiped the vaginal opening. The surveyor asked EI #7 what was on the wash cloth. EI #7 replied BM (bowel movement). EI #7 obtained a towel and pat dried the groin and the vaginal area. A dark substance was observed on the towel and the surveyor asked what was on the towel. EI #7 replied BM. EI #7 did not wipe the vaginal area again. EI #7 and EI #8 repositioned the resident and EI #7 obtained a wash cloth from the basin with soap and water. EI #7 wiped the right hip multiple times without changing the position of the wash cloth. EI #7 obtained a wet wash cloth from the basin of soap and water and wiped the rectal multiple times, without changing the position of the wash cloth with each wipe. The last wipe to the rectal area, the wash cloth was observed with stool. EI #7 removed her gloves, washed her hands and applied clean gloves. EI #7 applied a clean pad and booties to both feet were applied. EI #7 did not wiped the left buttock. On 03/16/16 at 2:30 PM, during an interview with EI #7, the surveyor asked how many times should she wipe a resident. EI #7 replied till clean and that was what she had done when she wiped the vaginal areas and the groin area. The surveyor asked how many times should the same area of the wash cloth be used. EI #7 stated once and that was what she had done when she wiped the buttock. The surveyor asked when did she wipe the left buttock. EI #7 replied she had not. The surveyor asked did she ever loose contact with the rectal area when she wiped. EI #7 stated she did. The surveyor asked what was the potential for harm. EI #7 stated infection and breakdown. The surveyor asked EI #8 was the brief soiled to the left side. EI #8 stated yes. Repeat care was observed. EI #7 wiped the vaginal area, the groin, the left buttock and stated BM was on the wash cloth with each area wiped. On 03/16/16 at 5:10 PM, during an interview with EI #1 (Director of Nursing/DON), the surveyor asked who was responsible to check and change a resident. EI #1 replied the CNA that is assigned to that resident and every two hours. The surveyor asked what was the longest time a resident should go without being checked or changed. EI #1 stated not more than two hours. The surveyor asked what was the potential for harm when a resident is not checked and changed every two hours. EI #1 replied skin breakdown and the resident could possibly develop a Urinary Tract Infection. On 03/17/16 at 3:45 PM, during an interview with EI #9 (Registered Nurse/RN Supervisor, Unit I), the surveyor asked who was responsible for checking and changing a resident and how often should it be done. EI #9 replied the CNA is responsible for checking and changing and it should be done every two hours and as needed. 2. A review of a facility's policy titled, HAND HYGIENE revised August 2012, documented . Hand hygiene shall be practiced before and after resident contact (even if gloves are worn) . Hands should be washed . after handling . contaminated tissues or lines, and after handling items or work surfaces potentially contaminated with residents blood, excretions, or secretions . When going from dirty to a clean site, hands shall be washed or an alcohol hand rub applied . RI #9 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. RI #9's Annual Minimum Data Set with an assessment reference date of 12/20/2015, identified the resident as being totally dependent on the staff for toilet use and always incontinent of bowel and bladder. colony forming units per ml. During the provision of incontinent care on 3/16/2016 at 11:10 AM, EI #16, a CNA did not change her gloves or wash her hands after she touched an urine soaked incontinent pad. After touching the pad, EI #16 proceeded to get a clean wash cloth to perform incontinent care on RI #9. In an interview on 3/17/2016 at 1:01 PM, EI #16, a CNA acknowledged that she did not wash her hands or change gloves after she touched RI #9's incontinent pad that was soiled with urine. When asked what was the potential harm, EI #16 said you can cause infection that is the harm to the resident and myself. In an interview on 3/17/2016 4:11 PM, EI #9, a Registered Nurse (RN) was asked, when should staff change their gloves during incontinent care. EI #9 replied, whenever the gloves are soiled. EI #9 was asked what was the facility policy on changing gloves and hand washing during the provision of incontinence care. EI #9 responded, when ever your gloves become soiled take those off and wash your hands and apply more gloves. EI #9 was asked what potential harm to the resident can occur if hands are not washed or sanitized and the gloves are not changed when going from dirty to clean. EI #9 said it will cause them to have a UTI or Ecoli from BM (bowel movement).

Based on observation, interviews and record reviews, the facility failed to ensure the arm rests on Resident Identifiers (RI) #8's wheelchair (w/c) were not cracked and rough to the touch. RI #8 was identified by the facility facility to be on a blood thinner. This affected RI #8 one of six sampled resident's who used a wheelchair. Findings Include: A review of Plavix (Clopidogrel Bisulfate) Drug Information: Warning and Precautions-Prescribing computer print out from rx (prescription) list.com dated 03/22/16 revealed the following: . 2. Plavix can cause bleeding which can be serious and can sometimes lead to death. Plavix is a blood thinner medicine that lowers the chance of blood clots forming in you body. While you take Plavix: . you may bruise and bleed more easily . it will take longer for any bleeding to stop . RI #8 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #8's Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15 which indicated RI #8 was cognitively intact. The MDS documented RI #8 with limited range of motion in both upper and lower extremities. RI #8 used a wheelchair for mobility A review of RI #8's care plan titled, Potential for skin breakdown associated with limited mobility secondary to recent stroke with a problem onset date of 06/26/15 documented: . Approaches . Observe . skin daily when assisting with care . A review of RI #8's care plan titled, At risk for bruising and bleeding related to use of anticoagulant therapy/or medication with anticoagulant effect with a problem onset date of 06/26/15 documented: . Approaches . Anticoagulant as ordered . Report bleeding from any source to physician . On 03/17/16 at 12:15 PM, RI #8 was observed in his /her wheelchair. The left arm rest had cracked, open and jagged areas. The right arm rest outer edge was torn and jagged. On 03/17/16 at 12:15 PM, Employee Identifier (EI) #15, Director of Maintenance, was asked who was responsible to monitor w/c and geri chair arm rests for needed repairs. EI #15 replied maintenance and Occupational Therapy. EI #15 was asked how often was that done. EI #15 replied not everyday but regularly. EI #15 was asked where was the documentation to reflect w/c repairs. EI #15 replied there was no documentation. EI #15 was asked why there were still so many w/c and geri chair arms rests that were cracked and rough to the touch throughout the facility. EI #15 replied he could not tell me. EI #15 was asked what was the facility's policy about equipment. EI #15 replied keep them maintained. EI #15 was asked what could be the potential harm to a resident with fragile skin. EI #15 replied skin tears. EI #15 was asked what could be the potential harm to a resident on a blood thinner. EI #15 replied they could bleed. On 03/17/16 at 4:40 PM, during an interview with EI #1 (Director of Nurses/DON), the surveyor asked what was the potential for harm when a resident is on an Aspirin, an anticoagulant, a blood thinner and in a wheelchair with armrest that are torn, cracked and jagged. EI #1 replied potential for injury to the skin. The surveyor asked what type of injury. EI #1 stated skin tears, abrasions and maybe bruising.

Based on observation, interviews and record review, the facility failed to ensure Employee Identifier (EI) #16, a Certified Nursing Assistant (CNA) washed her hands and changed gloves after she touched Resident Identifier (RI) #9's urine soaked incontinent pad. Findings include: The facility's policy titled, HAND HYGIENE, revised August 2012, documented: POLICY: . Hand hygiene shall be practiced before and after resident contact (even if gloves are worn) . Hands should also be washed when obviously soiled, . after handling items or work surfaces potentially contaminated with residents blood, excretions, or secretions. RI #9 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #9's Annual Minimum Data Set (MDS) with an assessment reference date of 12/20/2015 identified RI #9's Brief Interview for Mental Status score was 6, indicating severe impairment in cognition. The MDS also documented RI #9 as being totally dependent on staff for toileting and always incontinent of bowel and bladder. During the provision of incontinent care on 03/16/2016 at 11:10 AM, EI #16 washed her hands and applied gloves. EI #16 touched RI #9's incontinent pad that was soiled with urine. After touching the soiled pad, EI #16 proceeded to get a clean wash cloth to perform incontinent care on RI #9. EI #16 did not change her gloves or wash her hands after she touched the incontinent pad that was soiled with urine. In an interview on 03/17/2016 at 1:01 PM, EI #16, a CNA acknowledged that she did not wash her hands or change gloves after she touched RI #9's incontinent pad that was soiled with urine. When asked what was the potential harm, EI #16 stated it could cause infection to the resident and herself. In an interview on 03/17/2016 at 4:11 PM, EI #9, a Registered Nurse (RN) was asked, when should staff change their gloves during incontinent care. EI #9 replied, whenever the gloves are soiled. When asked if it was acceptable for a CNA to touch a urine soaked incontinent pad then proceed to touch a clean wash cloth and pad, without washing their hands and changing gloves, EI #9 said, if the staff member touched dirty stuff then they should have taken those gloves off and washed their hands.