Every finding on record at Southland Nursing Home

Based on observation, interviews, review of Resident Identifier (RI) #14's medical record and the facility's policy titled NURSE CALL SYSTEM, the facility failed to ensure RI #14's call light was in reach. This deficient practice affected RI #14, one of 19 sampled residents. Findings include: The facility's policy, titled, NURSE CALL SYSTEM, last updated on 4/30/2013, revealed, . Policy: . Call light cords in the resident rooms will be located within the resident's reach . RI #14 was readmitted to the facility on [DATE]. On 4/20/2021 at 3:29 PM, RI #14 was observed in bed. The resident's call light was behind the bed frame handing down to the floor. The call light was not in RI #14's reach. On 4/21/2021 at 5:03 PM, RI #14 was observed in bed. The resident's call light was pinned to the back of the mattress. When asked where the call light was, RI #14 stated on the back somewhere. When asked if he/she could reach the call light, RI #14 said no. On 4/21/2021 at 5:14 PM, Employee Identifier (EI) #3, the Activity Coordinator was asked to observe RI #14's call light. EI #3 was asked, where was RI #14's call light. EI #3 replied, it was at the head of the resident's bed. When asked if RI #14 was able to reach the call light, EI #3 said no. EI #3 was asked, what the potential concern was of RI #14 not being able to reach the call light. EI #3 replied, that RI #14 would need help and not be able to reach the call light.

Based on observation, interviews, review of Resident Identifier (RI) #46's medical record and the facility's policy titled, Hand Washing Policy & Procedure, the facility failed to ensure Employee Identifier (EI) #2, a Licensed Practical Nurse (LPN) performed hand hygiene after she removed her gloves during medication administration. This deficient practice affected RI #46, one of four residents observed for medication administration. Findings include: The facility's policy titled, Hand Washing Policy and Procedure, last updated April 2020, documented, POLICY: Hand hygiene practices will promote resident safety and prevent infections. Every member of the facility must perform proper hand-washing techniques. HAND WASHING IS TO BE DONE AS INDICATED: . After . Taking off gloves . RI #46 was readmitted to the facility on [DATE] with a medical history to include a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During medication administration observation on 4/21/2021 at 3:34 PM, EI #2, an LPN washed her hands and applied gloves. EI #2 wiped RI #46's finger with an alcohol prep and pricked the resident's finger to obtain a blood sugar. After obtaining RI #46's fingerstick blood sugar, EI #2 removed her gloves and put on a new pair without performing hand hygiene. EI #2 then wiped RI #46's stomach with an alcohol prep and administered Insulin to the resident. In an interview on 4/21/2021 at 4:09 PM, EI #2, a LPN was asked, what should be done after gloves are removed. EI #2 replied, throw them in the garbage and wash your hands. EI #2 was asked, did she perform hand hygiene after taking the gloves off and putting on a new pair of gloves. EI #2 replied, no. When asked why not, EI #2 replied, she was supposed to wash her hands, but she was nervous and forgot. EI #2 was asked, what the potential harm was in not performing hand hygiene between changing gloves. EI #2 replied, germs. During an interview on 4/22/2021 at 2:01 PM, EI #1, the Infection Control Nurse was asked, what should be done after gloves are removed. EI #1 replied wash your hands. EI #1 was asked, what the potential concern was of not performing hand hygiene after removing gloves. EI #1 replied, possible transmission of infection.

Based on observation, record review, interviews, and a facility policy titled, PLANNED MENUS, the facility failed to ensure RI ( Resident Identifier ) #69 received a mechanical soft diet with chopped meat, as ordered by the physician. This was observed on 6/26/19 during the supper meal and affected one of four residents whose meals were observed. Findings include: A review of a facility policy titled, PLANNED MENUS, with an update of 2/21/2003 revealed: POLICY: . It is our intent to assure that the resident maintains acceptable parameters of nutritional status, . taking into account the resident's clinical condition or other appropriate intervention, . Planned Menus . A Therapeutic Diet is offered when ordered by a physician as part of treatment for [REDACTED]. or to provide food the resident is able to eat. RI #69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #69's (MONTH) 2019 Physicians Orders documented: . 3/14/19/ . MECH (Mechanical) SOFT WITH CHOPPED MEATS . On 06/26/19 at 5:15 p.m.,Surveyor observed EI (Employee Identifier) #1, CNA (Certified Nursing Assistant) feeding RI #69 his/her supper meal. RI #69's supper meal included a hamburger pattie, bun, french fries and super potatoes. EI #1 was asked what diet was RI #69 prescribed. EI #1 said, Her/His ticket says mechanical soft and chopped meat. EI #1 was asked if RI #69's meat was chopped. EI #1 said, No, it is not chopped. EI #1 was asked could the resident chew the meat. EI #1 said, No because she/he does not have any teeth, she/he gum it. On 6/26/19 at 5:40 p.m. EI #2, RN (Registered Nurse) accompanied the surveyor to RI #69's room. EI #2 was asked, according to the resident's meal ticket what diet should he/she be prescribed. EI #2 said, Mechanical soft, chopped meat. EI #2 was asked what type of meat was on the resident's tray. EI #2 said, whole meat, regular diet. EI #2 was asked why RI #69 was served regular meat instead of chopped meat. She replied she did not know, she would have to ask the kitchen. EI #2 was asked what was the potential concern with RI #69 receiving a regular diet instead mechanically soft diet with chopped meat. EI #2 said, the resident could get choked. On 6/27/19 at 1:09 p.m. an interview was conducted with EI #3, DM (Dietary Manager). EI #3 was asked what diet was RI #69 prescribed. EI #2 said regular with super potatoes he thought , he would have to look it up. EI #3 was asked to review RI #69 meal ticket which documented resident was prescribed a mechanical soft with chopped meat. EI #3 was asked if that was a regular diet or mechanical diet. EI #3 said, Yes, it is a mechanical diet. EI #3 was asked what was the menu for the supper meal on 6/26/19. EI #3 said hamburger patty, lettuce, tomato, and french fries. EI #3 was asked if the resident's hamburger patty should have been chopped. EI #3 said, Yes, it should have been chopped. EI #3 was asked should resident diet orders be followed. EI #3 said, Yes, it all times. EI #3 was asked what was the potential concern with RI #69 not receiving his/her prescribed diet of Mechanical Soft with chopped meat. EI #3 said possible choking.

Based on observations, interviews and review of the facility's policy titled, Food and Beverage Labeling Policy, the facility failed to ensure bags of food items in the walk in cooler and the chest freezer were labeled with an open and use by date after opening the bags. This had the potential to affect 52 of 52 residents receiving meals from dietary. Findings include: The facility's policy titled, Food and Beverage Labeling Policy, updated (MONTH) 14, (YEAR), documented: . Procedure - . If It Is A . Opened Item It Will Have Two Dates - A . Open Date And Discard Date, which is the Use By Date (UBD) . EVERYTHING HAS TO HAVE . AN OPENED DATE AND A DISCARD / USE BY DATE! . On 07/09/18 at 5:30 PM, during the tour of the kitchen the following observations were made: 1) The two door stand up refrigerator was observed to have an open bag with 2 chicken patties in it. There was no open date or use by date label on the bag. 2) The chest freezer was observed with 3 bags of opened items with no opened date or use by date. The bags contained coffee cake pieces, 5 cornbread muffins and cheese biscuits. EI # 2, dietary staff said the labels probably fell off. No labels were observed in the freezer; and 3) The walk in cooler was observed with bags of mixed shredded cheese, a cheese block and pieces, parmesan cheese and shredded carrots without opened and use by dates. On 07/09/18 at 5:45 PM, Employee Identifier (EI) #3, Assistant Dietary Manager, was shown and asked about the opened bags that had no opened and use by date labels. EI #3 said the bags were supposed to have an open date label, all bags opened were suppose to have open date labels. EI#3 further reported perishable items were to be used within seven days of opening.

Based on observation, interview, medical record review,and a review of the facility's policy titled, RESIDENT PRIVACY POLICY & (and) PR[NAME]EDURE, the facility failed to ensure a licensed nurse provided privacy while administering an injection to Resident Identifier (RI) #28. This affected one of five nurses observed during medication pass. Findings Include: A review of the facility's policy titled, RESIDENT PRIVACY POLICY & (and) PR[NAME]EDURE, updated 10/2011, revealed: . POLICY: It is the policy of this facility to care for residents in the manner and in an environment that maintains resident dignity and respect. PR[NAME]EDURE: . 4. Provide privacy by screening the resident. (The staff will examine and treat the resident in a manner that maintains the privacy of the resident's body) * Close all doors to the room (resident room door and bathroom door). RI #28 was re-admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 7/10/18 at 4:44 p.m., Employee Identifier (EI) #4, a Registered Nurse, did not shut the resident's room door, leaving him/her exposed as she gave an insulin injection into his/her abdomen. An interview was conducted on 7/1/18 at 4:30 p.m EI #4 was asked, what should be done before performing an invasive procedure/care to a resident. EI #4 stated, Explain what I am doing and then provide privacy. EI #4 was asked if she had done that. EI #4 stated, No. An interview was conducted on 7/11/18 at 5:15 p.m. with EI #5, the Infection Control Nurse. EI #5 was asked, what should be done before performing an invasive procedure/care to a resident. EI #5 replied, knock on the door, explain the procedure and provide privacy, close blinds and door, pull the curtain and have supplies.

Based on observation, interview, and a review of the facility's policy titled, Medication Storage, the facility failed to ensure that the locked medication box in the medication refrigerator was secured. This affected one of one of one medication refrigerator observed. Findings Include: A review of the facility's policy titled, Medication Storage, with an update of 1/2017, revealed: Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines 1. Narcotics and Controlled Substances: Schedule II drugs and back-up stock of Schedule III, IV and V medications are stored under double-lock and key. On 7/11/18 at 2:37 p.m. the surveyor observed the locked box in the medication refrigerator in Medication Room One was not attached to the inside of the medication refrigerator. Stock supplies of [MEDICATION NAME] were stored in the refrigerator locked box. An interview was conducted on 7/11/18 at 2:45 p.m. with Employee Identifier (EI) #6 ,a Registered Nurse/ the Director of Nursing. EI #6 was asked, besides being locked, what else should the locked box in the medication refrigerator be. EI #6 replied, attached. EI #6 was asked, what was the potential for harm. EI #6 replied, someone could get the medications.

Based on observation, interview, medical record review, a review of the facility's policy titled, HAND WASHING POLICY & (and) PR[NAME]EDURE, and a review of the facility's policy titled, Infection Control Policy and Procedures, the facility failed to ensure: 1) A licensed nurse washed her hands after taking gloves off, prior to putting on new gloves while administering medications. Further she did not wash her hands after returning to the medication cart to prepare medications for other residents or use a paper towel to turn off the water faucet. This licensed nurse also placed the glucometer and supplies directly on Resident Identifier (RI) #28's over bed table; and 2) a Certified Nursing Assistant (CNA) did not touch items in the resident's room, as well as clean items in the linen bag while providing incontinence care to RI #45. This had the potential to affect RI #28, one of ten residents observed during medication pass administration and RI #45, one of one sampled resident observed for incontinence care. Findings Include: A review of the facility's policy titled,Infection Control Policy and Procedures, with an update of 1/20/2016, revealed, GENERAL INFECTION CONTROL: Within the health-care setting, GENERALIZED INFECTION CONTROL PR[NAME]EDURES have been developed to minimize the risk of residents acquiring infection from contact with contaminated devices, objects, or surfaces or of transmission of an infectious agent from health-care workers to the residents. GENERAL INFECTION CONTROL: The following practices are considered to be the minimum standard. B. GLOVES will be worn for contact with any body substance . Wash your hands before applying gloves. A review of the facility's policy titled, HAND WASHING POLICY & PR[NAME]EDURE, with an update of 10/2017, revealed: POLICY: Hand hygiene practices will promote resident safety and prevent infections. PURPOSE: To prevent the spread of infection. HAND WASHING IS TO BE DONE AS INDICATED: Before: a) Direct resident care b) Before leaving any area and beginning work c) Before starting any procedure . After: g) Taking off gloves. HANDWASHING TECHNIQUE: 8. Turn off water with a towel (remember that germs are now on sink). 1) RI #28 was re-admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 7/10/18 at 4:03 p.m., Employee Identifier (EI) #5, a Registered Nurse, was observed putting on and removing gloves without washing her hands during medication pass administration. EI #5 was also observed returning to the medication cart after going into the medication room without washing her hands and then began preparing medications for the residents. EI #5 was observed laying the glucometer and other supplies directly on Resident Identifier (RI) #28's over bed table without using a barrier. EI #5 was also observed turning the water faucet off with her bare hands after washing her hands. An interview was conducted on 7/11/18 at 4:30 p.m. with EI #4. EI #4 was asked what should be done before putting gloves on and after taking gloves off. EI #4 stated, Wash your hands. EI #4 was asked if she had done that. EI #4 stated, No. EI #4 was asked what should be done before laying the glucometer and supplies on the resident's bedside table. EI #4 stated, Put a paper towel down or something. EI #4 was asked if she had done that. EI #4 stated, Not every time. EI #4 was asked, after going to the medication room and returning to the medication cart, what should be done before starting to prepare medications. EI #4 stated, I should have washed my hands. EI #4 was asked, in handwashing, how do you turn the water faucet off after washing your hands. EI #4 stated, With a paper towel. EI #4 was asked if she had done that. EI #4 stated, Not that I recall. An interview was conducted on 7/11/18 at 5:15 p.m. with EI #5, the Infection Control Nurse. EI #5 was asked, what should be done before putting gloves on and after taking gloves off. EI #5 replied, washing your hands. EI #5 was asked, what should be done before laying the glucometer and supplies on the resident's over bed table. EI #5 replied, placing a barrier. EI #5 was asked, in hand washing, how do you turn the faucet off after washing your hands. EI #5 replied, you get a paper towel to turn off the faucet. EI #5 was asked, after going elsewhere and returning to the medication cart, what should be done before starting to prepare medications for the residents. EI #5 replied, clean your hands. EI #5 was asked, what was the potential for harm. EI #5 replied, spreading bacteria. 2) EI #45 was re-admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 7/11/18 at 9:44 a.m. the surveyor observed EI #7, a Certified Nursing Assistant (CNA), touch the curtain and the bathroom door handle wearing the same gloves used to clean the buttocks of RI #45. EI #7 was also observed reaching into the clean linen bag wearing the same gloves use to clean RI #45's perineal area. An interview was conducted with EI #7 on 7/11/18 at 2:40 p.m. EI #7 was asked what should be done after cleaning the buttocks before touching the curtain or the door handle. EI #7 stated, Remove your gloves. EI #7 was asked if she had done that. EI #7 stated, No. EI #7 was asked, should you place a dirty, gloved hand into a bag of clean linen after cleaning the perineal area. EI #7 stated, No. EI #7 was asked if she had done that. EI #7 stated, Yes. EI #7 was asked what was the potential for harm. EI #7 stated, Contaminate it. An interview was conducted on 7/11/18 at 5:15 p.m. with EI #5, the Infection Control Nurse. EI #5 was asked, what should be done after cleaning the buttocks before touching the curtains and the door handle. EI #5 replied, take off gloves and wash hands. EI #5 was asked, should a dirty, gloved hand be placed in a bag of clean linen after cleaning the perineal area. EI #5 replied, no, of course not. EI #5 was asked what was the potential for harm. EI #5 replied, spreading bacteria.

Based on a review of a facility policy titled, Dented Can Policy, a review of a document titled, FOOD CODE, observations and interview, the facility failed to: 1. prevent potential bacterial contamination as evidenced by dented cans and 2. ensure staff prevented poor personal hygiene as evidenced by touching their skin without washing their hands and/ or changing gloves during Dinner Tray-line on 04/26/2017. This affected 67 residents receiving meals from the kitchen. Findings Include: 1. A review of a facility policy titled, Dented Can Policy with a date of 03/2013, revealed the following: Policy: .Cans that are dented are to be placed on the cart in Dietary Dry Storage . On 04/26/2017 at 3:44 p.m., and 3:45 p.m., an observation was made of two six pound 12 ounce cans of Pinto Beans and one six pound five ounce can of Fancy French Style Green Beans, and one six pound 10 ounce can of Pineapple Tid Bits with dents in the seams on the shelves in Dry Storage. On 04/27/2017 at 3:36 p.m., an observation was made of two six pound 12 ounce cans of Pinto Beans and one six pound five ounce can of Fancy French Style Green Beans, and one six pound 10 ounce can of Pineapple Tid Bits with dents in the seams, on the shelves in Dry Storage. On 04/27/2017 at 3:36 p.m., the Dietary Manager, EI (Employee Identifier) #4, made observations of the dented cans on the shelves and explained there was a cart dietary staff were to place dented cans on. On 04/27/2017 at 3:44 p.m., an interview was conducted with EI #4. EI #4 was asked why were the dented cans not on the cart, but on the shelves with other canned food items. EI #4 said she could not tell the surveyor why. EI #4 was asked should the dented cans have been placed on the cart instead of being on the shelves with other canned items. EI #4 replied, yes. EI #4 was asked why. EI #4 explained because they were to be in a designated area so they would not be used. EI #4 was asked what was the potential harm in using dented canned items. EI #4 explained if the can was dented the food item was contaminated on the inside. 2. A review of a document titled, Food Code revealed the following: U.S. Public Health Service FDA (Food and Drug Administration) 2013 .2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands .immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS . (A) After touching bare human body parts other than clean hands . On 04/26/2017 at 4:42 p.m., an observation was made of the cook with her bare fingers, scratch her chin and did not wash her hands after scratching her chin and before checking the dinner tray-line temperatures. An observation was made at 5:07 p.m. of another dietary worker during tray-line. The dietary worker rubbed her nose with her gloved hands and continued to place lids on top of residents trays without washing her hands or changing her gloves. On 04/27/2017 at 3:44 p.m., an interview was conducted with EI #4, Dietary Manager. EI #4 was asked why should dietary staff on tray-line wash their hands after scratching and/or touching their faces. EI #4 said because if they have touched an unsanitary area their hands need to be cleaned. EI #4 was asked what was the potential harm in dietary staff members not washing their hands after touching and/or scratching their skin. EI #4 explained that could spread contamination from anything that was on their face.

Based on observation, interview, medical record review and a review of a facility policy titled, INCONTINENT CARE POLICY & (and) PROCEDURE, the facility failed to ensure RI (Resident Identifier) #8, a resident totally dependent on staff for incontinence care, had a Care Plan with a specific approach on how often he/she was to be monitored for incontinent episodes. This affected RI #8, one of six sampled residents identified by the facility as being incontinent. Findings Include: The facility policy titled, INCONTINENT CARE POLICY & (and) PROCEDURE with a date of 06/13/16 revealed the following: Policy: Each resident will be assessed .to determine whether or not resident is incontinent . (2) .a.) Nursing Assistants will check residents for incontinence every two hours . RI #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #8's most recent quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/17/2017, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 9, which indicated RI #8 was moderately impaired for daily decision making. Further review of RI #8's MDS revealed the resident was totally dependent on staff for toilet use and was incontinent of bowel and bladder. A review of RI #8's Care Plan revealed the following: Problem Onset: .RESIDENT IS INCONTINENT OF BOTH BOWEL AND BLADDER HIGH RISK FOR SKIN BREAKDOWN; HX (history) OF . DECUBITUS . Approaches .INCONTINENT CARE AFTER EACH INCONTINENT EPSOIDE(EPISODE) . On 04/27/2017 RI #8 was continuously observed from 8:15 a.m. to 12:12 p.m. without being checked for incontinence and/or changed. On 04/27/2017 at 12:51 p.m., an interview was conducted with EI (Employee Identifier) #2, CNA (Certified Nursing Assistant). EI #2 was asked if she was assigned to RI #8 on 04/27/2017. EI #2 replied, Yes ma'am. EI #2 was asked how often was RI #8 to be checked and/or changed. EI #2 said every two hours. EI #2 was asked why should RI #8 be checked and/or changed every two hours. EI #2 replied, You don't want BM (Bowel Movement) or urine to sit on them too long. EI #2 was asked if RI #8 was able to let her know when he/she needed to be toileted. EI #2 replied, No ma'am. EI #2 was informed of the continuous observation made from 8:15 a.m. until 12:12 p.m. by the surveyor of RI #8 not being checked and/or changed. EI #2 was asked why. EI #2 said RI #8 normally pointed and that would let her know he/she needed to be changed. EI #2 was asked what was the potential harm of a resident that was incontinent of bowel and bladder not to be changed every two hours. EI #2 replied, They can get a UTI (Urinary Tract Infection) or bedsore. On 04/27/2017 at 4:16 p.m., an interview was conducted with EI #3, MDS Coordinator, RN (Registered Nurse). EI #3 was asked when reviewing the incontinent approaches on RI #8's Care Plan if it specified how often the CNA was to check and change the resident. EI #3 said it was not on the Care Plan but was on the CNAs ADL (Activity of Daily Living) book. EI #3 was asked should the check and change every two hours on the CNA's ADL book be specified on RI #8's Care Plan approach. EI #3 stated they had not been putting it on the Care Plan.

Based on observation, interview, record review and a review of a facility policy titled, INCONTINENT CARE POLICY & (and) PROCEDURE, the facility failed to ensure RI (Resident Identifier) #8, a resident with a history of pressure ulcers and a high risk for the development of pressure ulcers, was checked for incontinence and changed for a time period of three hours and 57 minutes. On 04/27/2017 RI #8 was continuously observed from 8:15 a.m. to 12:12 p.m. without being checked for incontinence or changed. This affected one of one sampled resident with a history of pressure ulcers. Findings Include: A review of a facility policy titled, INCONTINENT CARE POLICY & (and) PROCEDURE with a date of 06/13/2016 revealed the following: Purpose: 1. To cleanse and refresh the resident. 2. To help prevent problems such as skin excoriation, infection or pressure sores. (2) (Name of Facility) Skin Care Protocol will include: (a.) Nursing Assistants will check residents for incontinence every two hours . 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 03/17/2017, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 9, which indicated RI #8 was moderately impaired for daily decision making. Further review of RI #8's MDS revealed the resident was totally dependent on staff for toilet use and was incontinent of bowel and bladder. A review of a facility document titled, PRESSURE ULCER RISK EVALUATION had an entry dated 04/03/2017, which indicated RI #8 was a high risk for developing a pressure ulcer. A review of a facility document titled, RN (Registered Nurse) Admission Notes revealed RI #8 was admitted to the facility on [DATE], with a Stage 4 sacral pressure ulcer. This indicated the resident had a history of [REDACTED]. On 04/27/2017 RI #8 was observed continuously from 8:15 a.m. to 12:12 p.m. without being checked for incontinence or changed. On 04/27/2017 at 12:51 p.m., an interview was conducted with EI (Employee Identifier) #2, CNA (Certified Nursing Assistant). EI #2 was asked if she was assigned to RI #8 on 04/27/2017. EI #2 replied, Yes ma'am. EI #2 was asked how often RI #8 was to be checked and/or changed. EI #2 said every two hours. EI #2 was asked why should RI #8 be checked and/or changed every two hours. EI #2 replied, You don't want BM (Bowel Movement) or urine to sit on them too long. EI #2 was asked if RI #8 was able to let her know when he/she needed to be toileted. EI #2 replied, No ma'am. EI #2 was informed of the continuous observation made from 8:15 a.m. until 12:12 p.m. by the surveyor of RI #8 not being checked and/or changed. EI #2 was asked why. EI #2 said RI #8 normally pointed and that would let her know he/she needed to be changed. EI #2 was asked what was the potential harm of a resident that was incontinent of bowel and bladder not to be changed every two hours. EI #2 replied, They can get a UTI (Urinary Tract Infection) or bedsore. On 04/27/2017 at 7:43 p.m., an interview was conducted with EI #1, DON (Director of Nursing) RN. EI #1 was asked how often should an incontinent resident with a high risk for developing pressure ulcers be checked and changed. EI #1 said every two hours and PRN (as needed). EI #1 was asked why should they be checked and changed for incontinence. EI #1 stated to prevent worsening and infection. EI #1 was asked how often should RI #8, a resident with a high risk for developing pressure ulcers be checked and changed. EI #1 said every two hours and PRN. EI #1 was asked if RI #8 had any previous pressure ulcers. EI #1 said yes, RI #8 was admitted with a Stage 4 pressure ulcer. EI #1 was asked had it healed. EI #1 said yes. EI #1 was asked what was the risk of RI #8 developing a pressure ulcer if he/she was not checked and changed every two hours or PRN. EI #1 stated it was a definite risk. EI #1 was asked what was the potential harm of RI #8, a resident with a history of a Stage 4 pressure ulcer, not being checked and changed every two hours or PRN. EI #1 said he/she could have a reoccurrence.

Based on record review and interview, the facility failed to ensure Employee Identifier (EI) #1, a Registered Nurse (RN) Supervisor timely reported to the facility's administrator and State Agency an allegation of physical abuse. On 9/15/2016, EI #1 became aware of an allegation of abuse; however he did not report it to the administrator. After a State survey team entered the facility, the facility's administrator became aware of the allegation of abuse and reported it the State Agency on 9/21/2016, six days later. This affected Resident Identifier (RI) #1, one of four sampled residents. Findings include: The facility's policy titled SOUTHLAND NURSING HOME POLICY AND PROCEDURE FOR REPORTING ABUSE updated 01/2011, documented As employees of Southland Nursing Home, it is our duty and responsibility to maintain our residents' physical, mental, and psychosocial well being by ensuring their environment is free of abuse. Therefore, if we witness or are told (to include gossip) of abuse that has occurred, we MUST report the incident to the administrator IMMEDIATELY! . The administrator or her designee will report to other officials as established in following procedures as required by state law. This includes notification of the COMPLAINT UNIT of the Division of Health Care Facilities. ALL ALLEGATIONS AND ALL SUSPECTED cases of abuse will be reported to the DIVISION OF HEALTH CARE FACILITIES WITHIN 24 HOURS . PROCEDURE FOR REPORTING AND INVESTIGATION: 1. A complaint/report of abuse should be in writing, containing the name and address of the person filing the complaint, and describing in detail what the incident is. 2. A complaint/report of abuse should be REPORTED IMMEDIATELY to the Administrator of this facility, then to the Director of Nursing . RI #1 was admitted to the facility on [DATE] with an admit [DIAGNOSES REDACTED]. On 9/19/2016, the State Agency received a complaint which alleged a family member of RI #1 reported to a staff member (later identified as EI #1) that on 9/15/2016, she observed six bruises on RI #1 right arm that resembled finger and thumb prints. There were also bruises observed on RI #1's right thigh. The complainant felt as thought the bruises were due to abuse. In an interview on 9/21/2016 at 9:10 AM, a family member of RI #1 was asked, how she thought the bruises on RI #1 happened. RI #1's family member stated she thought someone grabbed RI #1 by the arm since the bruises were in the patten of finger prints. In a follow-up telephone interview on 9/23/2016 at 9:55 AM, RI #1's family member was asked to describe the bruises she saw on RI #1. She stated on 9/15/2016 around 2:00 PM, there were eight bruises that were located on the resident's right upper arm and right outer thigh. The bruises were yellow and purple in color and ranged from dime size to half-dollar size. According to RI #1's family member, after she reported the bruises to EI #1, the RN Supervisor, he (EI #1) told her that he did not know what happened but he was sure that no staff member had done anything intentional to RI #1. The family member stated EI #1 did not look at the bruises on RI #1's thigh, even though it was reported to him (EI #1); he (EI #1) only looked at the bruises on the resident's arm. During an interview on 9/21/2016 at 2:00 PM, EI #1, the RN Supervisor acknowledge being told by RI #1's family member on 9/15/2016 that she had observed bruises on RI #1. EI #1 stated he assessed the resident and noted some old bruises on RI #1's upper right arm. EI #1 did not assess the bruises that were observed on RI #1's right outer thigh. When asked if he reported to the administrator, EI #1 said no. In a follow-up telephone interview on 9/23/2016 at 10:30 AM, EI #1 (RN Supervisor) was asked, why he did not report it (an allegation of abuse) to the administrator. EI #1 stated oversight on his part and bad judgment. In an interview on 9/22/2016 at 12:30 PM, EI #4, the facility's Administrator, also the Abuse Coordinator, stated she was unaware of the allegation made by RI #1's family member on 9/15/2016 until the State Surveyors questioned the staff about body audit (on 9/21/2016). According to the Online Incident Reporting System Report, on 9/21/2016 at 11:05 AM, the facility's administrator (EI #4) reported an allegation of physical abuse to the State Agency regarding RI #1. The report listed the date and time of the alleged abuse as 9/15/2016 2:00 PM. The report indicated, RI #1 was injured and three staff members had been placed on administrative leave while the investigation was being conducted. This deficiency was cited as a result of the investigation of complaint/report number AL 675.

Based on record review and interview, Employee Identifier (EI) #1, a Registered Nurse (RN) Supervisor failed to document the condition of Resident Identifier (RI) #1's skin after it was bought to his attention that RI #1 was found with bruises on the right upper arm and right outer thigh. This affected RI #1, one of four sampled residents. Findings include: Chapter 16 titled Nursing Assessment page 217 of FUNDAMENTALS OF NURSING EIGHTH EDITION with a copyright date of 2013, documented . DATA DOCUMENTATION Data documentation is the last part of a complete assessment. The timely, thorough, and accurate documentation of facts is required in recording patient data. If you do not record an assessment finding or problem interpretation, it is lost and unavailable to anyone else caring for the patient . RI #1 was admitted to the facility on [DATE] with an admit [DIAGNOSES REDACTED]. On 9/19/2016, the State Agency received a complaint which alleged a family member of Resident Identifier (RI) #1 reported to a staff member (later identified as EI #1) that on 9/15/2016, she observed six bruises on RI #1 right arm that resembled finger and thumb prints. There were also bruises observed on RI #1's right thigh. In a telephone interview on 9/23/2016 at 9:55 AM, a family member of RI #1 was asked to describe the bruises she saw on RI #1. She stated on 9/15/2016 around 2:00 PM, there were eight bruises that were located on the resident's right upper arm and right outer thigh. The bruises were yellow and purple in color and ranged from dime size to half-dollar size. According to RI #1's family member, she reported the bruises to EI #1, the RN Supervisor. During an interview on 9/21/2016 at 2:00 PM, EI #1, the RN Supervisor acknowledge being told by RI #1's family member on 9/15/2016 that she had observed bruises on RI #1. EI #1 stated he assessed the resident and noted some old bruises on RI #1's upper right arm. EI #1 did not assess the bruises that were observed on RI #1's right outer thigh. In a follow-up interview on 9/22/2016 at 11:30 AM, EI #1 (RN Supervisor) was asked, did he document his assessment of RI #1's bruises. EI #1 stated he did not document it anywhere but he wished he had. This deficiency was cited as a result of the investigation of complaint/report number AL 675.

Based on record review and interviews, the facility failed to ensure their policy and procedure regarding reporting abuse was implemented. On 9/15/2016, Employee Identifier (EI) #1, a Registered Nurse (RN) Supervisor became aware of an allegation of abuse regarding Resident Identifier (RI) #1; however, it was not reported to the administrator and State Agency until 9/21/2016, six days later. This affected RI #1, one of fours sampled residents reviewed for abuse. Findings include: The facility's policy titled SOUTHLAND NURSING HOME POLICY AND PROCEDURE FOR REPORTING ABUSE updated 01/2011, documented As employees of Southland Nursing Home, it is our duty and responsibility to maintain our residents' physical, mental, and psychosocial well being by ensuring their environment is free of abuse. Therefore, if we witness or are told (to include gossip) of abuse that has occurred, we MUST report the incident to the administrator IMMEDIATELY! . The administrator or her designee will report to other officials as established in following procedures as required by state law. This includes notification of the COMPLAINT UNIT of the Division of Health Care Facilities. ALL ALLEGATIONS AND ALL SUSPECTED cases of abuse will be reported to the DIVISION OF HEALTH CARE FACILITIES WITHIN 24 HOURS . PROCEDURE FOR REPORTING AND INVESTIGATION: 1. A complaint/report of abuse should be in writing, containing the name and address of the person filing the complaint, and describing in detail what the incident is. 2. A complaint/report of abuse should be REPORTED IMMEDIATELY to the Administrator of this facility, then to the Director of Nursing . RI #1 was admitted to the facility on [DATE] with an admit [DIAGNOSES REDACTED]. On 9/19/2016, the State Agency received a complaint which alleged a family member of RI #1 reported to a staff member (later identified as EI #1) that on 9/15/2016, she observed six bruises on RI #1 right arm that resembled finger and thumb prints. There were also bruises observed on RI #1's right thigh. The complainant felt as thought the bruises were due to abuse. In an interview on 9/21/2016 at 9:10 AM, the RI #1's family member was asked, how she thought the bruises on RI #1 happened. RI #1's family member stated she thought someone grabbed RI #1 by the arm since the bruises were in the patten of finger prints. In a follow-up telephone interview on 9/23/2016 at 9:55 AM, RI #1's family member was asked to describe the bruises she saw on RI #1. She stated on 9/15/2016 around 2:00 PM, there were eight bruises that were located on the resident's right upper arm and right outer thigh. The bruises were yellow and purple in color and ranged from dime size to half-dollar size. According to the family member, after she reported the bruises to EI #1, the RN Supervisor, he (EI #1) told her that he did not know what happened but he was sure that no staff member had done anything intentional to RI #1. The family member stated EI #1 did not look at the bruises on RI #1's thigh, even though it was reported to him (EI #1); he (EI #1) only looked at the bruises on the resident's arm. During an interview on 9/21/2016 at 2:00 PM, EI #1, the RN Supervisor acknowledge being told by RI #1's family member on 9/15/2016 that she had observed bruises on RI #1. EI #1 stated he assessed the resident and noted some old bruises on RI #1's upper right arm. EI #1 did not assess the bruises that were observed on RI #1's right outer thigh. When asked if he reported to the administrator, EI #1 said no. In a follow-up telephone interview on 9/23/2016 at 10:30 AM, EI #1 (RN Supervisor) was asked, why he did not report it (an allegation of abuse) to the administrator. EI #1 stated oversight on his part and bad judgment. In an interview on 9/22/2016 at 12:30 PM, EI #4, the facility's Administrator, also the Abuse Coordinator, stated she was unaware of the allegation made by RI #1's family member on 9/15/2016 until the State Surveyors questioned the staff about body audit (on 9/21/2016). According to the Online Incident Reporting System Report, on 9/21/2016 at 11:05 AM, the facility's administrator (EI #4) reported an allegation of physical abuse to the State Agency regarding RI #1. The report listed the date and time of the alleged abuse as 9/15/2016 2:00 PM. The report indicated, RI #1 was injured and three staff members had been placed on administrative leave while the investigation was being conducted. This deficiency was cited as a result of the investigation of complaint/report number AL 675.

Based on observation, interview and record review, the facility failed to ensure the bird aviaries in the resident's library and on the Speciality Care Unit were free of a build up of black and white bird droppings in the bottom of the aviary, in the bird food and the water. This affected two of two aviaries observed in the facility. Findings Include: The facility manual titled Bird Manual no date documented: DAILY MAINTENANCE .WATER While the water may look fresh day to day, it must be changed daily. Bacteria can build up in water so daily changing of the water is important. REGULAR WEEKLY AVIARY UPKEEP Aviary cleaning should be done once each week. The bedding will have areas under branches, etc. where droppings have accumulated. The droppings can be removed with a kitty litter scoop . If excess droppings are on any of the greenery, you may remove theses soiled parts with scissors. In the manual on page 14, was a Daily Care Checklist that was provided to the facility to use. On 06/08/16 at 8:30 AM, the bird aviary on the Special Care Unit was observed with an accumulation of black and white bird droppings on top of the bird food on the floor and in the water bowls. The water bowls were observed with debris floating in the water. On 06/08/16 at 8:40 AM, the bird aviary in the resident's library was observed with an accumulation of black and white bird droppings on top of the bird food on the floor of the aviary. The water bowls were observed with debris floating in the water. The birds were not observed to go to the food or water. On 06/09/16 at 9:40 AM, Employee Identifier (EI) #1, Activity Director was asked who maintained the bird aviaries. EI #1 replied they have a individual who comes every three months to clean the aviaries. EI #1 was asked when was the last time he came and cleaned the aviaries. EI #1 replied April 2016. EI #1 was asked what was the policy in regards to cleaning the aviaries. EI #1 replied daily from now on. EI #1 was asked who was responsible to clean in between his visits and put in fresh water and food. EI #1 replied the Activity Staff. EI #1 was asked to describe what the bird aviary looked like on the Specialty Care Unit. EI #1 replied there was poop on the floor of the aviary and in the bird feeder. It was really dirty and needed to be cleaned. A review of a facility's letter dated 06/09/16 revealed the following: . (EI #14) (Activity Staff), ON SUNDAY CHECK LIST YOU WROTE THAT YOU CLEANED AND TOOK CARE OF THE BIRD CAGES. IS THAT CORRECT? (yes) WHAT EXACTLY DID YOU DO AS FAR AS THE CARE? Did water & (and) food Didn't clean window . Signed by EI #14 and dated 06/05/16, and Signed by EI #1 and dated 06/09/16.

Based on interviews and record reviews, the facility failed to ensure Range of Motion (ROM) assessments were completed for Active ROM, Passive ROM, and Active Assistive ROM for Resident Identifier's #4, #5, #6 and #7. This affected four of eight residents sampled for ROM. Findings Include: The facility's policy titled RANGE OF MOTION POLICY PROCEDURE, updated 01/18/2008, documented the following: POLICY: Range of Motion activities will be provided by the Certified Nursing Assistant (C.N.A.) daily with AM care . 3. A resident's physician along with the physical therapist and licensed nurse determines which type of ROM a resident should do . - Range of Motion Assessment form will be filled out. - Instructions: For each joint listed on the form, check whether ROM exercises are being done, . AROM (Active Range of Motion), PROM (Passive Range of Motion), or AAROM (Active Assisted Range of Motion) . 1) RI #4 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #4's Quarterly Minimum Data Set ((MDS) dated [DATE] documented RI #4 had long and short term memory loss and was severely impaired in cognitive skills for daily decision making. RI #4 required total assistance from staff with all Activities of Daily Living (ADL's). RI #4's Range of Motion Assessmenta dated 03/02/16 and 06/02/16, completed by Employee Identifier (EI) #7, Registered Nurse/RN Supervisor. There was no documentation to reflect assessments for AROM, PROM and AAROM. 2) RI #5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #5's Significant Change MDS dated [DATE] documented RI #5's Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated severely impaired cognition. RI #5 required extensive to total assistance from staff for ADL's such as bed mobility, transfers, dressing, bathing and personal hygiene. The MDS documented RI #5 had impairment in Functional Limitation in ROM in the lower extremities including; hips, knees, ankles and feet. RI #5's Range of Motion Record dated 06/06/16, completed by EI #7. There was no documentation to reflect EI #7 assessed RI #5 for AROM, PROM or AAROM. On 06/08/16 at 3:30 PM, EI #7 was asked what the ROM record was used to assess. EI #7 replied to get a baseline to determine if a resident is improving or declining with flexibility. EI #7 was provided a copy of RI #5's Range of Motion Record to review and was asked did this record document what type of ROM RI #7 was assessed for. EI #7 replied no it did not. EI #7 also stated it was policy to complete the ROM record by documenting the type of ROM Range, but that was not what she had done. EI #7 further replied policy had not been followed for documenting ROM assessed for RI #57 On 06/08/16 at 3:24 PM, during an interview with EI #7, RN Supervisor, the surveyor provided RI #5's ROM assessment/record to review and asked what type of exercise was performed, AROM, PROM or AAROM. After review the ROM assessment/record, EI #7 replied she could not tell which ROM was done. The surveyor asked was that policy to complete all sections. EI #7 stated yes. The surveyor asked what was the negative outcome when all sections are not completed. EI #7 stated that it does not give a complete picture of the resident. 3) RI #6 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #6's Quarterly MDS dated [DATE] documented RI #6's BIMS score of 4 out of 15, which indicated severely impaired cognition. RI #6 required extensive to total assistance from staff for ADL's such as bed mobility, transfers, dressing, bathing and personal hygiene. The MDS also documented RI #6 had impairment in Functional Limitation in ROM in the upper extremities including; hips, knees, ankles and feet. RI #6's Range of Motion Record sections dated; 03/02/16, which was completed by EI #10, RN, and 06/01/16, which was completed by EI #8, RN Supervisor. There was no documentation to reflect EI #8's or EI #10's assessment of RI #6 for AROM, PROM or AAROM. On 06/08/16 at 3:05 PM, surveyor provided EI #8 a copy of RI #6's ROM record for review and asked what type of documentation to reflect what type of ROM RI #6 was assessed for. EI #8 replied EI #1 there was no documentation to reflect what type of ROM assessment had been completed for RI #6. The surveyor asked what was the purpose of the ROM assessments/records. EI #8 replied to assess if the resident is declining or improving in ROM. 4) RI #7 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #7's Quarterly MDS dated [DATE] documented RI #7's BIMS score was a 10 out of 16, which indicated moderately impaired cognition. RI #7 required extensive to total assistance from staff for ADL's such as bed mobility, transfers, dressing, bathing and personal hygiene. The MDS also documented RI #7 had impairment in Functional Limitation in ROM in upper and lower extremities. RI #7's Range of Motion Record dated 02/15/16 and 05/31/16, which was completed by EI #7 and EI #8. There was no documentation to reflect EI #7 or EI #8 assessed RI #7 for AROM, PROM or AAROM. On 06/08/16 at 3:05 PM, EI #8 was provided a copy of RI #7 ROM record to review and was asked what type of ROM was assessed. EI #8 replied AROM. The surveyor asked where was the documentation to reflect the AROM. EI #8 stated she did not know and there was no documentation to indicate what type of ROM RI #7 had been assessed for.

Based on interview and record review, the facility failed to ensure reference checks were completed and documented prior to employee hire. This affected one of five personnel records reviewed. Findings Include: A review the facility's policy titled, (Name of Nursing Home) Abuse Policy and Procedure, without a date, revealed the following: . This facility will not knowingly employ and individual who has been convicted of abusing, neglecting, or mistreating individuals. 1. Screening- We will screen potential employees for a history of abuse, neglect or mistreating residents. This includes attempting to obtain information from previous employers and/or current employers . On 06/09/16 at 11:00 AM, during a record review of employee personnel files the following was revealed: Employee Identifier (EI) #13 (housekeeping assistant) who was hired May 05, 2016, did not have documentation to reflect references were checked for previous employers in her personnel file. On 06/09/16 at 12:05 PM, EI #6, (Human Resources), was asked when were employer reference checks done for EI #13. EI #6 replied 05/03/16. The surveyor asked what documentation did she have to reflect reference checks for EI #13's previous employers. EI #6 stated she did not have any documentation for EI #13's previous employer reference checks.

Based on observation, interview and record review the facility failed to ensure a brownish colored glue on the floors was cleaned as assigned on a daily basis. The glue was observed in gaps between tiles and smeared on the floor. This affected Room Locators (RL) #1 and RL #2. Findings Include: The facility document titled . Checklist Janitor, Effective 5/23/13 . documented: .OTHER ASSIGNED DUTIES - Daily clean glue off Dementia Unit floors. On 06/08/16 at 8:15 AM, in RL #1 the tile in the floor had several gapped seams and a build up of a brownish colored substance was observed in the gaps and smeared on the top of the tile. In RL #2 the tile had several gapped areas throughout the room and a build up of a brownish colored substance was observed in the gaps. On 06/09/16 at 10:00 AM, Employee Identifier (EI) #2, Environmental Supervisor, was asked who was responsible to clean the floors in the residents rooms on the Dementia Unit. EI #2 replied the janitor. EI #2 was asked to describe what was on the floor in between the tiles. EI #2 stated it was a tar glue that came up between the tiles. EI #2 was asked who should notify you if the floors needed to be deep cleaned. EI #2 replied the janitor.

Based on observation, interview and record review, the facility failed to ensure a Certified Nursing Assistant (CNA): 1. used the same area of the washcloth only once; 2. wipe resident until no stool is observed on the washcloth; 3. wipe from front to back; 4. did not reuse a contaminated washcloth to clean another area; and 5. wiped the vaginal opening. This affected RI #7, a resident identified by the facility with a history of Urinary Tract Infections [MEDICAL CONDITION], and one of one resident observed during incontinence care. Findings Include: A review of the facility's .INCONTINENT CARE POLICY & (AND)PROCEDURE, updated 11/09 revealed the following: POLICY: Each resident will be assessed by the RN (Registered Nurse) or LPN (Licensed Practical Nurse) charge nurse upon admission to determine whether or not the resident is incontinent . PURPOSE: . 2. To help prevent problems such as skin excoriation, infection or pressure sores. EQUIPMENT: . (2) . b.) After each episode of incontinence, the nursing assistants will cleanse perineum and buttocks with soap and water wiping with wet wash cloth using separate sections of the wash cloth with each wipe from front to back to clean resident, then rinse well with wash cloth using separate section of wash cloth with each wipe using same method (change wash cloth at any point it becomes soiled). Procedure: . If stool is present, . Cleanse using separate section of the wash cloth with each wipe, rinse using separate section of wash cloth with each wipe . Place soiled wash cloth in separate bag . Female Perineal Care: . 2. Separate labia . to expose . vaginal orifice (opening).wash downward from pubic area toward rectum in one smooth stroke. Use separate section of clothfor each stroke . Cleanse thoroughly . Rinse the perineal area using separate section of wash cloth with each wipe . .After Either Procedure: -Remove Gloves and Discard - Wash Hands -Change Gloves Apply clean pad or brief as needed - Apply incontinent product,- cream or ointment or gel. RI #7 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #7's Quarterly Minimum Data Set ((MDS) dated [DATE] documented RI #7's Brief Interview for Mental Status score of 10 out of 15, which indicated moderately impaired cognition. RI #7 required total assistance from with toileting. The MDS documented RI #7 was always incontinent of bladder and bowel. On 06/09/16 at 10:25 AM, the following was observed during incontinent care on RI #7. Employee Identifier (EI) #9, Certified Nursing Assistant/CNA, EI #11 (CNA) and EI #12 (CNA), washed their hands, and applied gloves. EI #9 removed RI #7's brief and the surveyor asked what type incontinent episode had RI #7 had. EI #9 stated a small BM (bowel movement and medium amount of urine. RI #7 was assisted on her right side. EI #9 obtained a soapy washcloth wiped the rectal area. EI #9 then obtained a wash cloth from a basin with soapy water and wiped RI #7's left buttock in a circular motion without changing the position of the washcloth. EI #9 then rinsed RI #7's left buttock in the same circular motion. EI #9 then obtained the same wet soapy washcloth used to wipe RI #7's buttock and wiped the inner aspect of the right buttock from front to back and then front. RI #7 was positioned on her back. EI #9 obtained a wet soapy washcloth and wiped the right groin, stool was observed on the washcloth. EI #9 obtained another wet soapy washcloth and wiped the left groin, stool was observed on the washcloth. EI #9 repeated the wipe with a wet washcloth to rinse the right and left groin and stool was observed on the washcloth. EI #9 obtained a wet soapy wash cloth and wiped the left labia, separated the vaginal opening, stool was observed in the vaginal opening. EI #9 flipped the wash cloth and wiped the right labia. EI #9 repeated the labia wipes with a wet wash cloth. EI #9 obtained a towel and patted the areas dry. EI #9 removed a clean brief and her soiled gloves touched the inner aspect of the brief, and placed the clean brief underneath the resident. EI #9 then applied ointment to her soiled gloved hands and applied to RI #7's buttocks. EI #9 did not change her gloves after cleaning RI #7 and before applying a clean brief. On 06/09/16 at 10:40 AM, during an interview with EI #9, the surveyor asked how many times should the same area of the washcloth be used. EI #9 replied once but that was not what she had done every time. The surveyor asked how many times should the same area be wiped. EI #9 replied until BM is gone and that was what she had done. The surveyor asked what direction should a resident be wiped. EI #9 replied from to back and that was what she had done. EI #11 stated that was not how EI #9 wiped every time she wiped the resident. EI #12 also stated EI #9 did not wipe the resident until there was no BM left on the resident. EI #11 and EI #12 stated EI #9 had also reused a soiled washcloth to clean another area. The surveyor asked EI #9 when did she wipe the entire right buttock. EI #9 stated she thought she had. EI #12 stated EI #9 did not wipe the entire right buttock. The surveyor asked what should be done after cleaning a resident and before applying a clean brief. EI #9 stated to remove gloves and wash hands but that was not what she had done. The surveyor asked what was the potential harm. EI #9 stated infection, UTIs and skin breakdown. EI #9 also stated the resident care should be repeated. On 06/09/16 at 10:50 AM, during the repeat observation of incontinent care, EI #9 wiped RI #7's groin and the inner thigh area. The surveyor asked what was on the washcloth. EI #9 stated urine. EI #9 wiped the vaginal opening and stated stool was on the washcloth.

Based on observation, interviews and record reviews, the facility failed to ensure that Resident Identifier (RI) #4's tube feeding bottles/containers of formula were free of a cream colored solid residue build-up on the bottom of the containers. This affected one of two residents sampled for tube-feeding. Findings Include: A review of the facility's policy titled, Gastric [MEDICATION NAME] (Tube Feeding) Updated: 6/10, revealed the following: Policy: . Page 4 . Note: Formula . No particles should be in the formula. If clabbering of milk is noted, remove from shelf/room immediately and report findings to DON (Director of Nursing) and central supply Supervisor . If tube feeder is in the B-Bed, place feeding pump between A & B bed . Page 5 . Remember to shake formula vigorously due to residue that may have settled in the bottom of the bottle . A review of the facility's insert for formula titled, ROSS READY TO HANG SUGGESTED SETUP PROCEDURE without a date, revealed the following: . 4. Turn container upside down and shake vigorously, . for at least 10 seconds. Proper shaking ensures uniform consistency and proper product flow . RI #4 was re-admitted on [DATE] with [DIAGNOSES REDACTED]. RI #4's most recent Quarterly Minimum Data Set (MDS) with an ARD (Assessment Reference Date) of 05/20/16 documented RI #4's Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated severe impairment in cognition. On 06/08/16 at 9:00 AM, the surveyor entered RI #4's room accompanied by a second surveyor to observe RI #4's tube feeding container. The tube-feeding was in progress with a cream colored solid residue observed in the base of the container, and on the sides of the container The container was up side down during feeding. Employee Identifier (EI) #4, Licensed Practical Nurse/LPN, came in the room with the next 24 hour feeding container. EI #4 was asked if she had noticed the residue in the bottom of the container. EI #4 stated she had. On 06/09/16 at 9:00 AM, during an interview with EI #4, the surveyor asked when she (EI #4) made rounds on 06/08/16 did she observe residue in the tube feeding bottle. EI #4 stated yes she did. The surveyor asked what should she have done with the bottle. EI #4 stated she should have changed the bottle then. EI #4 also stated she did not know if that was policy but basic nursing, she should have changed the bottle. The surveyor asked what was the potential harm. EI #4 replied the resident would not get the nutrients needed. On 06/09/16 at 2:55 PM, an interview was held with EI# 5, DON. EI# 5 was asked what the nurse should do prior to hanging tube feeding formula. EI# 5 stated verification with the MAR (Medication Administration Record), shake it well (the formula in the bottle) and prepare the tubing by priming. EI# 5 was asked what should be done if residue is noted in the bottle. EI# 5 explained that if residue is noted in the bottle then the nurse should shake the container again to remix the product. EI # 5 was asked what if settlement is still observed, what should the nurse do then. EI# 5 stated that the bottle of formula should be discarded and replaced with a new bottle. When asked what is the potential harm if the process is followed and residue is still observed after repeated shaking. EI# 5 stated that the nurse should remove the bottle immediately report it to the DON and to Central Supply. EI#5 also stated so that the resident will receive their adequate nutrition.

Based on observation, interview and record review, the facility failed to ensure a Certified Nursing Assistant changed her soiled gloves after providing incontinent care to Resident Identifier (RI) #7, and before applying a clean brief and ointment to the resident. This affected RI #7, one of one resident observed during incontinent care. Findings Include: A review of the facility's policy titled, Infection Control Policy & (and)Procedures, updated 02/13/2002, documented the following: .GENERAL INFECTION CONTROL: Within the health-care setting, GENERAL INFECTION CONTROL PROCEDURES have been developed to minimize the risk of residents acquiring infection from contact with contaminated devices, objects, or surfaces . INFECTION CONTROL PROCEDURES are designed to prevent transmission of a wide range of microbiological agents and to provide a wide margin of safety in the varied situations encountered in the health-care environment. General infection control procedures apply to: Feces . Urine . A review of the facility's .INCONTINENT CARE POLICY & (AND)PROCEDURE, updated 11/09 revealed the following: Provide peri-Care . After Either Procedure: -Remove Gloves and Discard - Wash Hands -Change Gloves Apply clean pad or brief as needed - Apply incontinent product,- cream or ointment or gel. On 06/09/16 at 10:25 AM, the following was observed during incontinent care observation: Employee Identifier (EI) #9, EI #11 (CNA) and EI #12 (CNA) Certified Nursing Assistant, washed their hands and applied gloves. After EI #9 clean RI #7, who had stooled and urinated, EI #9 applied a place a clean brief underneath RI#7. EI #9 then applied ointment and secured the brief. EI #9 did not change her gloves after cleaning RI #7 and before applying a clean brief and ointment to RI #7. On 06/09/16 at 10:40 AM, EI #9 was asked what should be done after a resident is cleaned and before applying a clean brief. EI #9 replied remove gloves and wash hands, but that was not what she had done. EI #9 was asked what was the potential for harm. EI #9 replied infection, UTIs and skin breakdown.