Every finding on record at Sylacauga Health and Rehab Services

Based on observations, interviews and review of facility's policies titled, Food Receipts and Storage, Food, Leftover -Storage and Use, Service ware/Silverware, Handling and, Hand Washing (Infection Control), the facility failed to ensure: 1. supplements in the resident's refrigerator were not expired; 2. utensils and plates at the tray line was not wet nesting; 3. dietary staff washed hands when entering the kitchen and; 4. roast beef in the reach in refrigerator was labeled with an open and use by date. This had the potential to affect 138 of 138 residents who received meals from the kitchen. Findings Include: 1) A review of a policy titled, Leftover-Storage and Use with an effective date of ,[DATE], revealed: PURPOSE: To assure that food borne illnesses are avoided. PR[NAME]ESS: . 9.bulked items that requires refrigeration .may be stored .not beyond the best by or expiration date then discarded . On [DATE] at 9:57 am, the survyor observed on the South hall supplement refrigerator one Nepro Therapeutic Nutrition Butter pecan eight fluid ounces supplement drink, with an expiration date of [DATE]. On [DATE] at 10:20 a.m., the surveyor observed in the East dining hall supplement refrigerator door four butter pecan magic cups four fluid ounces, with an expiration date of (MONTH) 14, 2019. On [DATE] at 2:59 pm, the surveyor conducted an interview with (Employee Identifier) EI # 8, Dining Service Manager. EI # 8 was asked what was expired in the resident's supplement refrigerators on the South and East hall. EI #8 replied on the South hall Glucerna with a date of (MONTH) 1, 2019 and on the East hall honey thick mighty shake with a date of (MONTH) 14 2019. EI #8 was asked why were the expired items in the refrigerators. EI #8 replied, the refrigerator on the South hall someone else was responsible for, but dietary over looked items on the East side. EI #8 was asked who was responsible for making sure items were not expired in the resident supplement refrigerators. EI #8 replied, dietary aides. EI #8 was asked what did the facility policy say regarding expired items in the supplement refrigerators. EI #8 replied, they need to be disposed off. EI #8 was asked when was the refrigerator checked last for expired items. EI #8 replied, last night. EI #8 was asked when should expired items be taken out of the resident supplement refrigerators. EI #8 replied, immediately. 2) A review of a facility policy titled, Service ware/Silverware, Handling with an effective date of ,[DATE] revealed: PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses.PR[NAME]ESS: .8. Service ware should be air dried and stored turned upside down, or covered. On [DATE] at 10:51 am, the surveyor observed wet silverware in a tray. The surveyor observed EI #11, Dietary Aide wrapping wet utensils. She was wiping the utensils off with a coffee filter. She dried forks, knives and spoons and wrapped them. She wrapped several sets of spoon, knives and forks in napkins. She changed her coffee filter one time. She reached down in her smock pocket for a marker and continue to dry and wrap utensils. On [DATE] at 11:43 am, the surveyor observed EI #12 Dietary Aide, bringing wet plates from the dish room to the tray line. The surveyor observed wet plates in the plate warmer. The dietician moved plates from one slot to another slot in the plate warmer. EI #7 turned 20 plates over in the plate warmer that were wet. EI #13, Cook, observed wet plates at the tray line and used a coffee filter to dry wet plates that were stacked on top of each other. On [DATE] at 8:15 am, an interview was conducted with EI #11. EI #11 was asked what was she wrapping wet. EI #11 replied, silverware. EI #11 was asked what type of container were the spoons, forks, and knives in. EI #11 replied, silver ware rack. EI #11 was asked why were the utensils wet. EI #11 replied, they were not dry. EI #11 was asked who was responsible for making sure utensils were dry. EI #11 replied, she assumed it was her. EI #11 was asked how should utensils be allowed to dry. EI #11 replied, air dry. EI #11 was asked what was the facility policy on drying utensils. EI #11 replied, air dry. EI #11 was asked why was it important that utensils air dry. EI #11 replied, so the napkin would not be wet when the utensils were served. EI #11 was asked did she use a coffee filter to dry spoons, forks and knives. EI #11 replied, yes ma'am. EI #11 was asked why did she use a coffee filter to dry utensils. EI #11 replied, she was told by EI #7, Dietician, to use a coffee filter. EI #11 was asked should she have used a coffee filter. EI #11 replied, she would have used a napkin. EI #11 was asked what was the potential harm to the residents when utensils were wet in a tray. EI #11 replied, contamination from the water. EI #11 was asked how many times did she change her coffee filter when drying utensils. EI #11 replied, twice. On [DATE] at 8:28 am, an interview was conducted with EI #12, Dietary Aide. EI #12 was asked who was responsible for bringing the plates out of the dish room on [DATE] to the plate warmer. EI #12 replied, she was. EI #12 was asked were the plates dry. EI #12 replied, no ma'am. EI #12 was asked why should plates be dry. EI #12 replied, if you send them out wet, dust was out there and could stick on the plates and they did not want to put food on wet plates. EI #12 was asked what was the facility policy on serving food to resident on wet plates. EI #12 replied, cross contamination. On [DATE] at 8:34 am, an interview was conducted with EI # 13, the Cook. EI #13 was asked what was stacked on top of each other wet in the plate warmer on [DATE]. EI #13 replied, she had a couple of plates that still had water on them. EI #13 was asked how many were wet. EI #13 replied, about ten. EI #13 was asked why were they stacked on top of each other wet. EI #13 replied, they were not letting them dry before they brought them from the dish room. EI #13 was asked how should plates be allowed to dry. EI #13 replied, stack to the side at least face down. EI #13 continued to say if there was not enough room, leave the dishes in the rack. EI #13 was asked did she dry plates with a coffee filter at the tray line. EI #13 replied yes ma'am. EI #13 was asked why did she dry plates with a coffee filter. EI #13 replied, it helped absorb the water quicker. EI #13 was asked what was the facility policy on drying plates. EI #13 replied, they should leave them in the rack in the dish room/stack to the side before bringing to the plate warmer. On [DATE] at 11:05 am, an interview was conducted with EI #7 Dietician. EI #7 was asked how many plates did she move from one plate warmer to the other plate warmer. EI #7 replied, she did not count them, she just turned them upside down. EI #7 was asked why were the plates wet. EI #7 replied, the dishes just came out of the dishwasher and they were stacked incorrectly. EI #7 was asked why did she tell staff to use a coffee filter to dry utensils and plates. EI #7 replied, they were on the line and all of it was wet and there was no bacteria in a coffee filter. EI #7 was asked how should plates and utensils be allowed to dry. EI #7 replied, air dry. EI #7 was asked what was the potential harm to the resident when utensils were wet in a utensil tray and plates were stacked on top of each other, wet. EI #7 replied, potential for bacteria grow. 3) A review of a policy titled, Hand Washing (Infection Control) with an effective date of ,[DATE] revealed: Purpose: To provide guideline to employees for proper and appropriate hand washing techniques that will aide in the prevention of the transmission of infections. On [DATE] at 11:43 am, the surveyor observed EI #11 returning to the kitchen without washing her hands. She came back in the kitchen with the resident meal tickets. She was also observed touching a brown box pulling the tape off the box. On [DATE] at 8:22 am, an interview was conducted with EI #11. EI #11 was asked when entering the kitchen with the resident meal tickets did she wash her hands. EI #11 replied, no ma'am she did not. EI #11 was asked why not. EI #11 replied she was rushed. EI #11 was asked why was it important that she wash her hands in the kitchen. EI #11 replied, because of cross contamination. EI #11 was asked did she touch a box and pull the tape off the box. EI #11 replied, yes. EI #11 was asked when should she wash her hands in the kitchen. EI #11 replied every time she changed what she were doing. EI #11 was asked what was the facility policy on hand washing in the kitchen. EI #11 replied, wash hands every time you do a new task. On [DATE] at 11:35 am, an interview was conducted with EI #2, DON (Director of Nursing). EI #2 was asked should staff wash their hands when entering the kitchen. EI #2 replied, yes. EI #2 was asked why should staff wash their hands when entering the kitchen. EI #1 replied, she did not know what they may have touched out on the hall. EI #2 was asked what was the potential harm to residents when staff did not wash their hands when entering the kitchen. EI #2 replied, cross contamination. 4) A review of a facility policy titled, Food Receipts and Storage with an effective date of ,[DATE] revealed: PURPOSE: Food should be . stored properly to prevent food borne illnesses. PR[NAME]ESS: . 2. Storage: .b. Items should be dated (month, day and year) should not be stored greater than one year or by Best by Date whichever is sooner n. Refrigerated and frozen items removed from original packaging should be labeled , covered and dated. On [DATE] at 6:27 pm, the surveyor and EI #10 observed roast beef in the reach in refrigerator was opened and not in a zip loc bag. The roast beef was opened with no opened or use by date on the meat wrapping. The wrapping was ripped opened. On [DATE] at 8:44 am, an interview was conducted with EI #10, Cook. EI #10 was asked what did she observe in the reach in refrigerator that was not in a plastic bag. EI #10 replied, roast beef. EI #10 was asked to describe the item. EI #10 replied, it was partially opened, it was in a small mixing bowl along with two other packages of meats that were in a plastic container. EI #10 was asked did the roast beef have an open and use by day on it. EI #10 replied, no it did not. EI #10 was asked was it in a zip loc bag. EI #10 replied, no, it was in an opened package of meat. EI #10 was asked why was it not in a zip loc bag. EI #10 replied she did not know. EI #10 was asked what was the facility policy on items once they were opened. EI #10 replied, once opened they put in a zip loc bag, write down the date they were opened and a use by date. EI #10 was asked why was it important that food items have an opened and use by date on them. EI #10 replied, so they will know when to discard them and know when they food would go bad.

Based on record review, interview and review of a facility policy titled Notification of a Change in Medical Condition of Residents, the facility failed to ensure Resident Identifier (RI) #71's family representative was notified promptly of resident's fall on 4/16/19 at 5:00 AM. This affected one of three residents reviewed for falls. Findings Include: A review of a facility policy titled Notification of a Change in Medical Condition of Residents, with a date of 2/1/07 revealed: .STANDARD Notification of the physician, resident's representative, should occur promptly .when there is a change in the resident's condition. This would include but is not limited to: .An accident involving the resident which results in injury and has the potential for requiring physician intervention. RI #71 was admitted to the facility on [DATE] and readmitted on [DATE] with a [DIAGNOSES REDACTED]. A review of a facility report titled Resident Incident Report revealed: date/time 4/16/19 05:00 AM . resident was found sitting in the floor by bed. Resident was hollering out It hurts It hurts Resident guarding right wrist/forearm . Family notified : 4/16/19 08:59 AM . On 4/16/19 at 10:36 AM during an interview with RI #71's representative, it was revealed the representative was notified at 9:00 AM of RI #71 having a fall at 5:30 AM on 4/16/19. The staff reported to her that RI #71 was found on the floor at 5:30 AM, yelling in pain and pointing to right lower arm. The family representative revealed RI #71 had falls before and the staff had notified her timely. The representative was concerned that the fall occurred at 5-5:30 and she was not notified until 9 AM. A review of nurses notes, dated 4/16/2019 at 8:59 AM, revealed resident was found in the floor at 5:00 AM, the nurse assessed, nurse documented resident saying it hurt and she broke her arm, MD notified and Family notified. On 4/16/19 at 11:00 AM, a phone interview was conducted with Employee Identifier (EI) #3 , the Licensed Practical Nurse on duty during the fall. EI #3 was asked when did RI #71 fall. EI #3 replied, RI #3 was heard yelling and staff entered the resident's room around 5:00 AM and found the resident on the floor. EI #3 was asked how the fall occurred. EI #3 replied, she did not know, the resident was found on the floor and was saying it hurts, it hurts, my arm is broke. EI #3 revealed she assessed RI #71 and notified the Doctor. EI #3 was asked why was the Doctor notified. EI #3 replied, it was their policy to notify the Doctor. EI #3 was asked what time was the Doctor notified. EI #3 replied, somewhere between 6 and 7 AM. EI #3 was asked if the Doctor gave new orders. EI #3 replied, yes get an X-ray and she called for the X-ray service. EI #3 was asked when was the family representative notified. EI #3 replied, around 9:00 AM. EI #3 was asked why the family representative was not notified earlier. EI #3 replied, after she assessed the resident and the resident was not complaining of pain, it was early so she did not bother the family. EI #3 was asked if receiving an order for [REDACTED].#3 replied, when she assessed RI #71 and did not see swelling or bruising and RI #71 was not complaining of pain or in any acute distress, she felt it could wait. EI #3 was asked when she found RI #71, what was RI #71 saying. EI #3 replied, it hurts, it hurts, my arm is broke. EI #3 was asked if RI #71 saying it hurt, was an indicator that there could be injury. EI #3 replied, yes, she guessed so. EI #3 was asked when there was a change in resident status how long of time frame before she should notify a family. EI #3 replied, if life or death right away, her assessment did not reveal a life or death matter. On 4/18/19 at 9:01 AM, an interview was conducted with EI #2 Director of Nursing. EI #2 was asked what was the incident on 4/16/19 with RI #71. EI #2 replied the nurse EI #3 heard RI #71 yelling and found the resident on the floor in the resident room. EI #2 was asked what time the resident was found. EI #2 replied 5:00 AM. EI #2 was asked if there was an accident with possible injury. EI #2 replied, yes. EI #2 was asked when should a representative be notified. EI #2 replied, notify the representative as soon as the resident was stabilized. EI #2 was asked what was the policy on notification. EI #2 replied as she read from the policy, should occur promptly. EI #2 was asked if a resident fell at 5:00 AM and the family representative was notified about 9:00 AM, was that a reasonable time frame. EI #2 replied, no, but not speaking for EI #3 it may have been and she stayed late to get all her work done. EI #2 was asked what was a prompt time for notifying a family of a change or incident involving a resident. EI #2 replied, once the resident was stabilized. EI #2 was asked what time was RI #71's family notified. EI #2 replied, 8:59 AM. EI #2 was asked if the incident involving RI #71 required physician intervention. EI #2 replied, yes. EI #2 was asked what was the intervention. EI #2 replied, yes the physician was called and he ordered an x ray of the right wrist and forearm. EI #2 was asked what was the risk of not notifying a family representative of a resident's changes. EI #2 replied, we want to keep the family involved in what was going on with their loved one.

Based on observation, interview, record review and review of facility policies titled, Dressings, Clean (Wound Care) and Hand Washing (Infection Control), the facility failed to ensure: 1. licensed staff changed gloves during wound care for Resident Identifier (RI) #94 and RI #111 after cleaning the wound and before placing the treatment and 2. licensed staff changed gloves during incontinent care after cleaning the resident and before placing the clean brief for RI #94 . This affected two of two residents observed for wound care and one of one resident for incontinent care. Findings Include: 1. A review of a facility policy titled, Dressings, Clean (Wound Care) with an effective date of 3/2018 revealed: .PR[NAME]ESS: 4. Wash hands and put on clean gloves 5. Remove existing dressing 6. Pull your glove off .7. Wash hands and put on clean gloves 8. Cleanse the wound as ordered . 10. Wash hands put on clean gloves 11. Apply treatment as ordered . RI #94 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of RI #94's (MONTH) Physician order [REDACTED]. Right Lower Buttock Pressure Ulcer . Clean with wound cleanser, pat dry, shurprep, periwound, Apply Medi honey . Cover with Bordered Gauze . On 4/16/19 at 11:30 AM, the surveyor observed wound care for RI #94, performed by Employee Identifier (EI) #2, Director of Nursing. EI #2 gathered the needed supplies and entered the resident's room. EI #2 washed her hands put on gloves placed the barrier to the over bed table and prepared the area. EI #2 then removed her gloves, washed her hands and put on clean gloves. EI #2 removed the old dressing and measured the wound. EI #2 then removed her gloves, washed her hands and put on clean gloves. EI #2 opened the packages, sprayed wound cleanser on the 4 x 4's gauze and opened the [MEDICATION NAME] tube and placed some in a small medication cup. EI #2 cleaned the wound with the wound cleanser. EI #2 then, with the same soiled gloves, applied the skin prep, [MEDICATION NAME] and outer covering. She did not remove the soiled gloves and wash her hands prior to applying the treatment to the wound. RI #111 was admitted to the facility 3/20/17. A review of RI #111's (MONTH) 2019 Physician order [REDACTED]. Apply Xeroform gauze cover with border gauze. On 4/16/19 at 3:18 PM, EI #2 was observed performing wound care for RI #111. EI #2 gathered the needed supplies and entered RI #111's room. EI #2 washed her hands, put on gloves, prepared the overbed table with a towel barrier and and placed supplies on the table. EI #2 opened the border gauze taped a dated strip to the outer cover, opened packages of 4 x 4's and sprayed cleanser to them. EI #2 opened the Xeroform and skin preps. EI #2 removed her gloves washed her hands and put on clean gloves. EI #2 removed the old dressing from the right heel, measured the wound then removed her gloves washed hands and put on new gloves. EI #2 cleansed wound with pre-wet 4 x 4's. EI #2, wearing the same soiled gloves, then applied the skin prep. EI #2 picked up the Xeroform folded it in half and applied to RI #111's heel. EI #2 placed the outer dressing. EI #2 then removed her gloves and washed her hands. On 4/16/19 at 3:45 PM, an interview was conducted with EI #2. EI #2 was asked what was the policy for cleaning a wound during wound care. EI #2 replied, clean the wound then change gloves before applying clean treatment. EI #2 was asked when should you wash hands and change gloves during wound care. EI #2 replied, before starting and after finishing. EI #2 was asked when does she wash her hands and change gloves during cleaning of a wound. EI #2 replied, after cleaning it. EI #2 was asked if she washed her hands after cleaning RI #94 and RI #111's wounds, before placing the ordered treatment. EI #2 stated, I guess not. EI #2 was asked what was the procedure after cleaning a wound. EI #2 replied, clean the wound with wound cleanser then place the ordered treatment. EI #2 was asked when was it acceptable to clean a wound then with same gloves apply skin prep and the ordered treatment. EI #2 replied, it was not acceptable. EI #2 was asked what was the harm in not changing gloves and washing hands after cleaning the wound and before placing the ordered treatment and outer dressings. EI #2 replied, cross contamination. 2. A review of a facility policy titled, Hand Washing (Infection Control) revealed, . STANDARD: Hand washing should be performed between procedures with residents. RI #94 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 4/16/19 at 12:10 PM, after providing wound care for RI #94, EI #2 provided incontinent care for RI #94. EI #2 removed the gloves she had on doing the wound care and put on clean gloves, not washing her hands between glove change or between procedures. EI #2 rolled the soiled brief in away from the resident and wiped the front area. EI #2 turned the resident on the left side and placed the clean brief. EI #2 did not wash her hands or change her gloves and placed the clean brief and moisture barrier, then secured the brief. EI #2 pulled RI #94's shirt down and placed the top covers with same soiled gloves. After RI #2 had completed the care she was interviewed. EI #2 was asked when did she change gloves during incontinent care. EI #2 replied, if gloves get soiled and after finishing. EI #2 was asked if she changed her gloves after cleaning RI #94 and before applying moisture barrier and placing the clean brief. EI #2 replied, no. EI #2 was asked when should she touch a clean brief, resident clothing and linens with the same soiled gloves she wore to clean the resident. EI #2 replied, she should not have done that. EI #2 was asked when should she hold the tube of moisture barrier cream and apply moisture barrier cream with same gloves she wore to clean the resident. EI #2 replied, you should not do that. EI #2 was asked what was the harm in wearing the same gloves to clean a resident then place a clean brief and moisture barrier. EI #2 replied, contamination.

Based on record review and interviews, the facility failed to ensure Hospice was coded on the Quarterly Minimal Data Set ((MDS) dated [DATE], for Resident Identifier (RI) #46. This affected one of three residents sampled for Hospice. Findings Include: RI #46 was admitted to the facility on [DATE]. A review of RI #46's Quarterly MDS with an Assessment Reference Date of 1/22/19 did not have Hospice marked in Section O. A review of RI #46's Physician order [REDACTED].#46 was admitted to Hospice services on 08/09/18. On 4/18/19 at 8:39 AM an interview was conducted with Employee Identifier (EI) #5, Stephanie Kelley, LPN, MDS Coordinator and EI #6, Cindy Kromer, RN. EI #5 was asked, what were her responsibilities there. EI #5 replied, MDS assessments and care plans. The surveyor asked for the most recent MDS which was a Quarterly MDS dated [DATE], which did not have Hospice coded. The surveyor informed EI #5 that the MDS had a corrected version with a form titled, Changes in computer system with a date of 4/17/2019, attached to the end of the MDS. EI #5 was asked, what was the correction. EI # 5 replied, Section J for prognosis and Section O for list treatments specifically Hospice. EI #5 was asked, when the MDS was submitted for the most recent Quarterly with Assessment Reference Date of 1/22/2019 was it coded accurately in Section O for Hospice. EI #5 replied, no. E I #5 was asked, who was responsible for coding this section for Hospice on the Quarterly MDS with an assessment reference date of 1/22/2019. EI #5 replied, at that time it was EI #6, RN. EI #6 was asked what was her title. EI #6 replied MDS manager. EI #6 was asked why was this not coded accurately in Section O on the Quarterly with ARD of 1/22/2019. EI #6 replied, punch error, overlooked. E I #6 was asked, what was the potential harm in submitting a MDS that was not coded accurately. EI #6 replied, it would not accurately reflect RI #46's condition.

Based on observation, interview and a review of a facility policy titled Garbage and Refuse, the facility failed to ensure the door on number one dumpster was completely closed. This had the potential to affect all residents residing at the facility. A review of a facility policy titled, Garbage and Refuse with an effective date of 9/2014 revealed: PURPOSE to prevent the spread of bacteria that may cause food borne illnesses. STANDARD: Garbage and refuse containers should be free from cracks or leaks and covered when not in use . PR[NAME]ESS: . 4. dumpster's kept outside the facility should have tightly fitting lids . On 4/15/2019 at 6:27 p.m., the surveyor and (Employee Identifier) EI #9 Dietary Aide, observed three dumpster outside of the facility. Dumpster number one door was opened at the back side of the dumpster, not completely closed. On 4/15/19 at 6:54 pm, an interview was conducted with EI #9. EI #9 was asked which dumpster did she observe opened. EI #9 replied, the first one. EI #9 was asked how far was it opened. EI #9 replied, three inches. EI #9 was asked why was it opened. EI #9 replied, the last person who took out the trash left it opened. EI #9 was asked what was the potential harm to the residents when the dumpster doors was opened. EI #9 replied, animals could get in or something, toxic smells could come out. EI #9 was asked why should the dumpster be closed. EI #9 replied, it was a safety hazard. EI #9 was asked who was responsible for making sure it was closed. EI #9 replied, the whole facility and the kitchen.

Based on observation, interview, record review, and review of Potter and Perry's Fundamentals of Nursing, the facility failed to ensure: 1.) CNAs (Certified Nursing Assistant) provided incontinent care in a manner to prevent infection for RI (Resident Identifier) #72 and #10. The facility further failed to ensure licensed staff: 2.) Did not pull RI #109's privacy curtain wearing gloves, wear those same gloves while administering RI #109's medication and flushes per gastrostomy tube and then straighten RI #109's covers and rinse and dry the syringe used during administration wearing those same gloves. 3.) Washed hands prior to preparing medication for RI #141, did not place gloves on RI #141's overbed table before applying them, did not operate control of RI #141's bed after washing hands and then applied gloves to administer RI #141's inhaler. 4.) Did not place a nebulizer treatment for [REDACTED]. 5.) Did not pull the privacy curtain wearing gloves and then begin wound care for RI #60 wearing those same gloves and did not place a garbage bag containing a soiled dressing and supplies used during wound care on the floor of RI #60's room after wound care was provided. These deficient practices affected RI #72 and RI #10, two of three residents observed for incontinent care; RI #109, RI #141, and RI #96, three of five residents observed during medication administration; and RI #60 one of one resident observed during wound care. Findings include: A review of Potter and Perry's FUNDAMENTALS OF NURSING, Ninth Edition, Chapter 29 Infection Prevention and Control, page 459 revealed the following: . TABLE 29-6 Centers for Disease Control . Standard Precautions . for Use with All Patients . Perform hand hygiene before, after, and between direct contact with patients. Perform hand hygiene after contact with . body fluids, mucous membranes, . excretions, . after contact with inanimate surfaces or articles in a patient room; and immediately after gloves are removed. Wear gloves when touching . body fluids, .excretions, . Remove gloves and perform hand hygiene . when going from a contaminated to a clean body site. 1.) RI #72 was readmitted to the facility on [DATE]. RI #72's quarterly MDS (Minimum Data Set) assessment with an Assessment Reference Date (ARD) of 3/22/18 documented a BIMS (Brief Interview for Mental Status) score of 1, which indicated severe cognitive impairment; and RI #72 was always incontinent of bowel and bladder and was dependent of staff for toileting and personal hygiene. On 05/20/18 at 5:05 a.m., EI #8 CNA, and one assistant provided incontinent care for RI #72, and after cleaning urine and stool from RI #72 removed her gloves. Without performing hand hygiene EI #8 got a clean brief from the closet, and applied the clean brief to RI #72 before washing her hands. When asked if RI #72 was clean, EI #8 replied, no. EI #8 cleaned more stool from RI #72 and again, applied another clean brief without performing hand hygiene and while wearing the soiled gloves. RI #10 was readmitted to the facility on [DATE]. RI #10's annual MDS assessment with an ARD of 1/31/18 documented RI #10 had long and short term memory problems and severly impaired cognitive skills for daily decision making; and RI #10 was always incontinent of bowel and bladder and was dependent of staff for toileting and personal hygiene. On 5/20/18 at 5:19 a.m., EI #8 and one assistant provided incontinent care for RI #10. After cleaning urine and stool from RI #10, EI #8, while wearing the soiled gloves, applied a clean brief to RI #10, changed gloves and repositioned RI #10 in bed without performing hand hygiene. On 5/20/18 at 6:22 a.m., EI #8 was asked if the facility had a policy about when to change gloves and wash hands. EI #8 said, after and before care. When asked when she should change her gloves, EI #8 replied, after each resident or when she touched something contaminated. When asked when she should wash her hands, EI #8 said, after doing any kind of care with a resident or handling anything contaminated. EI #8 was asked what could happen if she did not change gloves when they were soiled and wash her hands after gloves were removed. EI #8 said, cross-contamination and the spread of germs. When asked what could happen when she put a clean brief on a resident while wearing soiled gloves, EI #8 replied, it transfers the germs. EI #8 was asked why she applied the clean brief and touched other items of the resident's during repositioning while wearing soiled gloves. EI #8 said, she was nervous being watched. 2.) RI #109 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 05/20/18 at 12:22 p.m., during medication pass observation for RI #109, EI # 12, Registered Nurse (RN) was observed pulling RI #109's privacy curtain wearing gloves. EI #12 then administered RI #109's flushes and medication, straightened his/her covers and rinsed and dried RI #109's syringe and plunger wearing those same gloves. On 05/22/18 at 9:14 a.m., a telephone interview was conducted with EI #12. EI #12 was asked when should she change her gloves and wash her hands during gastrostomy tube medication administration. EI #12 said every time she touched a potentially contaminated surface she should change her gloves and wash her hands. EI #12 was asked did she pull RI #109's privacy curtain while wearing gloves and then wear those same gloves when administering RI #109's gastrostomy tube flushes and medication. EI #12 replied she did and that she knew better. EI #12 was asked if she changed her gloves after administering RI #109's medication before she straightened his/her covers and rinsed and dried the syringe used during administration. EI #12 said no. EI #12 was asked what was the concern with those things. EI #12 answered infection control issues. 3.) RI #141 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 05/21/18 at 8:26 a.m., EI #13, Licensed Practical Nurse (LPN) was observed during medication pass observation. EI #13 entered RI #141's room and laid gloves on RI #141's overbed table. EI #13 was observed applying and removing those gloves without washing her hands. Then after washing her hands to administer RI #141's inhaler, EI #13 operated the bed control on the bedrail before applying her gloves and administering the inhaler. On 05/21/18 at 10:09 a.m., an interview was conducted with EI #13. EI #13 was asked when should she wash her hands during medication administration. EI #13 said before and after. EI #13 was asked did she wash her hands before she began preparing RI #141's medications. EI #13 replied no she did not. EI #13 was asked should gloves be put on an unclean surface. EI #13 said no. When asked if she put RI #141's gloves on his/her overbed table, EI #13 replied she did. EI #13 was asked if she cleaned the overbed table before placing the gloves on it. EI #13 answered no. EI #13 was asked when should she wash her hands when using gloves. EI #13 said before she put them on and after she takes them off. EI #13 was asked did she wash her hands before putting on gloves when administering RI #141's medications. EI #13 replied no. When asked did she wash her hands after she used the control to adjust RI #141's bed before she put on gloves to administer his/her inhaler, EI #13 said no. EI #13 was asked what was the concern with those things. EI #13 answered infection control. 4.) RI #96 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 05/21/18 at 5:21 p.m., EI #11, LPN was observed during medication pass for RI #96. EI #11 placed RI #96's nebulizer treatment in her pocket before entering his/her room. EI #11 was observed taking the treatment from her pocket to administer it. On 05/21/18 at 5:31 p.m., an interview was conducted with EI #11. EI #11 was asked was her pocket considered clean. EI #11 said no. EI #11 was asked should she place medications for administration in her pocket. EI #11 replied no and she thought about it when she put the nebulizer treatment in her pocket that she should not have put it in there. EI #11 was asked what was the concern with putting medications in her pocket. EI #11 answered infection control. 5.) RI #60 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 05/21/18 at 2:02 p.m., EI #10, LPN/Treatment Nurse was observed during wound care for RI #60. EI #10 was observed pulling RI #60's privacy curtain wearing gloves. EI #10 then removed RI #60's wound dressing wearing those same gloves. When wound care was completed, EI #10 placed the garbage bag containing the soiled dressing and supplies used during wound care on the floor of RI #60's room. On 05/22/18 at 2:54 p.m., an interview was conducted with EI #10. EI #10 was asked did she pull RI #60's privacy curtain after applying her gloves to perform wound care. EI #10 said yes. EI #10 was asked did she change gloves before removing RI #60's wound dressing. EI #10 replied no. When asked should she have changed her gloves, EI #10 said yes. EI #10 was asked did she place the garbage bag containing the soiled dressing and other items she used during RI #60's wound care on the floor. EI #10 replied yes she did. EI #10 was asked should the garbage bag have been placed on the floor. EI #10 said no. EI #10 was asked what was the concern with not changing gloves and placing the garbage bag on the floor. EI #10 answered infection control. On 05/22/18 at 3:07 p.m., an interview was conducted with EI #9, Registered Nurse (RN)/Assistant Director of Nursing/Infection Control Coordinator. EI #9 was asked when should a nurse wash her hands during medication pass. EI #9 said before and after and when coming into contact with a resident and between residents. EI #9 was asked when should a nurse change gloves during medication pass. EI #9 replied any time they move from one resident to another or their gloves become visibly soiled. EI #9 was asked should a nurse change gloves and wash their hands when they touch a potentially contaminated object before administering tube medications and inhalers. EI #9 said they should change them as frequently as they need to be changed. EI #9 was asked should a nurse put a medication in their pocket. EI #9 replied no. EI #9 was asked when should a CNA change their gloves during incontinence care. EI #9 replied in between residents, any time they are visibly soiled and any time they move from a dirty item to a clean item. When EI #9 was asked should a CNA put on a clean brief wearing gloves worn during incontinence care, EI #9 said no. EI #9 was asked should a CNA take off soiled gloves and put on a clean pair of gloves without washing her hands. EI #9 replied no. When asked what was the concern with those issues, EI #9 answered cross contamination and infection control.

Based on interview, medical record review, a facility document titled Incident Report and review of a facility policy titled Medication, Oral/Sublingual Administration, the facility failed to ensure Resident Identifier (RI) # 96 received the correct medication on 5/6/18. This resulted in RI # 96 being sent to the emergency room for an evaluation. This affected 1 of 3 residents sampled for medication concerns. Findings Include: Complaint #AL 689 alleged an unknown resident had received the wrong medication and was sent to the hospital. Additional information received during the survey identified RI #96 as the resident who received the wrong medication. A review of a policy titled Medication, Oral/Sublingual Administration with an effective date of 5/2014 documented: Purpose: To administer oral medications in an organized and safe manner . RI # 96 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI # 96's most recent Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/4/18 documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated RI # 96 was cognitively intact. A review of an Incident Report dated 5/7/18 documented RI # 96 was found in his/her room around 4:45 a.m. He/she reported I was dizzy and stumbled. I haven't felt right since that nurse gave me that cup full of medicine. RI # 96's skin was pale and clammy. No injuries or pain reported upon assessment. Further review of the incident reported determined RI # 96 received RI # 91's medication on 5/6/18 during the 5:00 p.m. medication pass. On 5/21/18 at 10:51 a.m. an interview was conducted with RI # 96 in his/her room. RI # 96 reported he/she received the wrong medication and was sent to the hospital. RI #96 further stated he/she received blue, yellow, pink and white pills on 5/6/18. A review of RI # 96's current physician's orders [REDACTED].# 96 should have received the following medication by mouth at 5:00 p.m. daily: [MEDICATION NAME] 3.125 MG (milligrams), [MEDICATION NAME] 40 MG, [MEDICATION NAME] 100 MG, [MEDICATION NAME] 1,000 MG and [MEDICATION NAME] 10 MG. However, review of the physician's orders [REDACTED].# 96 received the following medications instead: [MEDICATION NAME] DR (delayed-release) 500 mg .pnk (Pink) .tab (tablet) (antiepileptic), [MEDICATION NAME] 300 mg .yel (yellow) (antiepileptic), Glimepiride 4mg .bl (blue) (hypoglycemic), [MEDICATION NAME] 40 mg .yel (statin) and Quetiapine 50 mg .wht (white) (antipsychotic). RI # 96 received 3 times the dose of [MEDICATION NAME] that he/she normally would have received. RI # 91 was RI # 96's roommate. A review of a facility document titled Departmental Notes documented RI # 96 was transported to the emergency roiagnom on [DATE] at 5:25 a.m. A review of medical documents from a local hospital revealed RI # 96 arrived at the hospital emergency room with altered mental status on 5/7/18 at 5: 37 a.m RI # 96 was discharged on [DATE] at 9:00 a.m. Documents revealed there was a suspicion RI #96 had received another residents medication by accident on 5/6/18. RI # 96's condition at discharge was stable and he/she was transported back to the nursing home. An interview was conducted with Employee Identifier (EI) #7, Licensed Practical Nurse (LPN) on 5/21/18 at 7:35 p.m. EI #7 stated she was familiar with RI # 96. She further stated the facility told her she gave him/her the wrong medication. EI #7 stated she did not remember giving RI #96 the wrong medication. EI #7 was asked what are the possible side affects of a resident receiving the wrong medication. EI #7 stated the resident could get sick. An interview was conducted with Employee Identifier (EI) # 4, Registered Nurse (RN), Director of Nursing on 5/22/18 at 9:30 a.m. EI # 4 stated she became aware of the incident involving RI # 96 on 5/7/18 when she arrived at work. EI # 4 stated she made sure an incident report was completed. She further stated it was determined that EI #7 gave RI # 96 the wrong medication during the 5:00 p.m. medication pass on 5/6/18. EI # 4 further stated RI # 96's pill pack from the 5:00 p.m. medication pass on 5/6/18 was still on the medication cart. EI # 4 was asked if RI # 96 had any negative effects from receiving the wrong medication. EI # 4 stated he was sleepy and dizzy. An interview was completed with EI # 1, Administrator on 5/22/18 at 9:45 a.m. EI # 1 stated a nursing supervisor called her in the early morning hours of 5/7/18 and informed her RI # 96 had received the wrong medication during the 5:00 p.m. medication pass on 5/6/18. EI # 1 stated she instructed the nursing supervisor to send RI # 96 out to the emergency room for an evaluation. EI # 1 stated RI # 96 left the facility at 5:25 a.m. and returned a few hours later. EI # 1 was asked if RI # 96 had any negative side effects from taking the wrong medication. EI # 1 stated he/she was sleepy. EI # 1 further stated the emergency room found no negative side effects. EI # 1 was asked about the harm of a resident receiving the wrong medication. EI # 1 stated there could be complications because it would be a new medication. An interview was conducted with EI # 5, Medical Doctor on 5/22/18 at 10:25 a.m. EI # 5 stated he was aware RI # 96 received the wrong medication on 5/6/18 and was sent to the emergency room . EI # 5 stated RI # 96 received fluids at the emergency room and was sent back to the nursing home. EI # 5 stated he felt this was a one time error with RI # 96 and the facility immediately sent him/her for an evaluation when they became aware. EI # 5 stated the side effects of RI # 96 taking the wrong medication would be he/she would be sleepy.

Based on interview, medical record review, and review of a facility document titled Incident Report a facility policy titled Medication, Oral/Sublingual Administration and FUNDAMENTALS OF NURSING, NINTH EDITION, the facility failed to ensure a licensed nurse administered the correct medication to Resident Identifier (RI) # 96 on 5/6/18. This affected 1 of 3 residents sampled for medication concerns. Findings Include: Complaint #AL 689 alleged an unknown resident had received the wrong medication and was sent to the hospital. Additional information received during the survey identified RI #96 as the resident who received the wrong medication. A review of a policy titled Medication, Oral/Sublingual Administration, with an effective date of 5/2014, documented: Purpose: To administer oral medications in an organized and safe manner . A review of FUNDAMENTALS OF NURSING, NINTH EDITION Chapter 32 Medication Administration, page 625, documented: .Box 32-4 Steps to Take to Prevent Medication Errors *Prepare medications for only one patient at a time *follow the six rights of medication administration (Right Patient, Right Drug, Right Dose, Right Route, Right Time, and Right Documentation) *Be sure to read labels at least 3 times (comparing Medication Administration Record [REDACTED]. RI # 96 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI # 96's most recent Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/4/18 documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated RI # 96 was cognitively intact. A review of an incident report dated 5/7/18 documented RI # 96 was found in his/her room around 4:45 a.m. He/she reported, I was dizzy and stumbled. I haven't felt right since that nurse gave me that cup full of medicine. RI # 96's skin was pale and clammy. No injuries or pain reported upon assessment. Further review of the incident reported determined RI # 96 received RI # 91's medication on 5/6/18 during the 5:00 p.m. medication pass. On 5/21/18 at 10:51 a.m., an interview was conducted with RI # 96 in his/her room. RI # 96 reported he/she received the wrong medication and was sent to the hospital. RI #96 reported the hospital told him/her that he/she had received a sedative. RI #96 reported he/she felt sleepy after receiving the wrong medication. RI #96 further stated he/she received blue, yellow, pink and white pills on 5/6/18. A review of RI # 96's current physician's orders [REDACTED].# 96 should have received the following medication by mouth at 5:00 p.m. daily: [MEDICATION NAME] 3.125 MG (milligrams), [MEDICATION NAME] 40 MG, [MEDICATION NAME] 100 MG, [MEDICATION NAME] 1,000 MG and [MEDICATION NAME] 10 MG. However, review of the physician's orders [REDACTED].# 96 received the following medications instead: [MEDICATION NAME] DR (delayed-release) 500 mg .pnk (Pink) .tab (tablet) (antiepileptic), [MEDICATION NAME] 300 mg .yel (yellow) (antiepileptic), Glimepiride 4mg .bl (blue) (hypoglycemic), [MEDICATION NAME] 40 mg .yel (statin) and Quetiapine 50 mg .wht (white) (antipsychotic). RI # 96 received 3 times the dose of [MEDICATION NAME] that he/she normally would have received. RI # 91 was RI # 96's roommate. An interview was conducted with Employee Identifier (EI) #7, Licensed Practical Nurse (LPN) on 5/21/18 at 7:35 p.m. EI #7 stated she was familiar with RI # 96. She further stated the facility told her she gave him/her the wrong medications. EI #7 stated she did not remember giving RI #96 the wrong medication. EI #7 was asked what are the possible side affects of a resident receiving the wrong medications. EI #7 stated the resident could get sick. An interview was conducted with EI #1, Administrator, on 5/22/18 at 11:46 a.m., EI # 1 stated EI # 7 gave RI # 96 the wrong medication. EI # 1 stated EI # 7 should have completed the five rights of administrating medication before giving RI # 96 his/her medication.

Based on observation, interview and review of a facility policy titled Nurse Staffing Information, the facility failed to ensure the Nurse Staffing Information was posted daily. On 5/20/18 the Nurse Staffing was posted for 5/18/18. This was observed on one of three days of the survey and had the potential to effect all residents, staff and visitors in the facility. Findings Include: A review of policy titled Nurse Staffing Information with an effective date of 2/2018 documented: .PURPOSE: To provide public access to nurse staffing information .The facility shall make nurse staffing information available to the public .readily accessible to residents and visitors . On 5/20/18 at 4:52 a.m., the surveyor observed the nurse staffing information posted and dated for 5/18/18. On 5/21/18 at 4:22 p.m., an interview was conducted with Employee Identifier (EI) #14, Staffing Coordinator. EI # 14 stated she was responsible for posting the nurse staffing information each morning. EI # 14 further stated the Activities Department posted the nurse staffing information on the weekends. EI # 14 was asked if the nurse staffing information for 5/20/18 should have been dated 5/18/18, and she responded no. EI # 14 stated the Activities Department forgot to post the staffing for 5/20/18. EI #14 stated the nurse staffing information should be posted daily to let the public know the staffing for the building.

Based on observations, interviews and review of facility policies titled Service ware /Silverware, Handling, Food Storage Temperature Logs, Employee Personal Hygiene, Food Receipt and Storage and Food Preparation Principles, the facility failed to ensure: 1) a dietary staff did not place their bare thumb inside a clean plate, 2) dietary staff took the temperatures of chicken fingers, french fries and shrimp and recorded the temperatures on the log sheet, 3) a dietary staff did not leave the dirty side of the kitchen, then go to the clean side of the kitchen with the same pair of dirty gloves and apron on, 4) dented cans in the dry storage area were not stored with regular cans of food, 5) spices on the spice rack were closed, 6) Tri-color pasta and graham cracker crumbs were sealed inside plastic bags, and 7) expired ready care nectar consistency cranberry juice cocktail was not stored in the dry storage area. These deficient practices had the potential to affect 137 of 146 residents who receive meals from the kitchen. 1) A facility policy titled, Service ware/Silverware, Handling with an effective date of 8/2014, documented: PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses. STANDARD: Service ware and silverware should be . handled according to methods that provide effective sanitization and reduce potential contamination. PROCESS: . 7. Direct contact with inside surfaces of cups, glasses, bowls and plates should be avoided . On 4/11/17 at 8:25 a.m., the surveyor observed Employee Identifier (EI) #1, a dietary aide, place her bare thumb on the inside of a plate. On 4/13/17 at 12:23 p.m., EI #1 was asked by the surveyor who was responsible for placing the clean plates on the rack on 4/12/17. EI #1 stated she was. EI #1 was asked did her thumb touch the inside of the plates. EI #1 stated yes. EI #1 was asked did she have on gloves when putting the plates away. EI # 1 stated, no ma'am. The surveyor asked EI #1 what was the potential harm when her thumb was in the residents' plates with no gloves on. EI #1 replied she could have germs on her hand. 2) A facility policy titled, Food Storage Temperature Logs with an effective date of 8/2014, documented: . STANDARD: . Temperatures should be monitored and recorded on a food temperature log . On 4/12/17 at 4:35 p.m., the surveyor observed temperatures of food items being taken at the dinner meal. There was no observation of the temperatures of the shrimp, chicken strips or french fries being taken. On 4/13/17 at 2:14 p.m., an interview was conducted with EI #2, a cook. EI # 2 was asked who took the temperatures of the chicken fingers, french fries and shrimp on 4/12/17. EI #2 stated the temperatures were not taken. EI #2 said they forgot to take the temperatures. EI #2 was asked who was responsible for taking the temperatures of food items. EI #2 replied she was. EI #2 was asked why were the temperatures of the chicken fingers, french fries and shrimp not taken. EI #2 replied she got busy doing something else and forgot. EI #2 was asked what was the facility's policy on taking food temperatures and writing them down. EI #2 replied, we set up the steam table, put the food out, get the thermometer and take the temperature of the food. 3) A facility policy titled, Employee Personal Hygiene with an effective date of 7/2016, documented: PROCESS: . 12. Change gloves when activities are changed . On 4/11/17 at 8:25 a.m., the surveyor observed EI #3, a dietary aide, leave the clean side of the dish wash room and walk to the dirty side with her dirty apron and gloves on. On 4/12/17 at 1:25 p.m., an interview was conducted with EI #3. EI #3 was asked did she leave the dirty side of the dish wash room and go to the clean side. EI #3 replied yes. EI #3 was asked what was the facility's policy on leaving the dirty side and going to the clean side. EI #3 replied staff was to wash their hands and put clean gloves on. EI #3 was asked what potential harm was there when leaving the dirty side and working on the clean side. EI #3 replied cross-contamination. 4) A facility policy titled Food Receipt and Storage, with an effective date of 7/2016, documented: PURPOSE: Foods should be . stored properly to prevent food borne illnesses . PROCESS: . g. Dented, bulging . cans . should be stored in a separate area to be returned to the vendor . On 4/11/17 at 3:15 p.m., the surveyor observed three dented cans of cream of coconut and two dented cans of crushed pineapples in the dry storage area. On 4/13/17 at 12:13 p.m., EI #4, the dining room supervisor, was asked what cans were observed to be dented in the dry storage area. EI #4 replied, fruit cans and three coconut milk cans. EI #4 was asked where should dented cans be placed. EI #4 replied in the breezeway rack on the top shelf. EI #4 was asked who was responsible for removing dented cans from the regular food can area. EI #4 replied whoever unloads the truck, but usually she was responsible. EI #4 was asked when should dented cans be removed. EI #4 replied immediately. EI #4 was asked what was the potential harm when residents are served food from dented cans. EI #4 said metal contaminants or shavings could fall off into the food. 5) A facility policy titled, Food Preparation Principles with an effective date of 7/2016, documented: . PROCESS: . 7. Food should be protected from contamination, while being stored, . On 4/11/17 at 3:15 p.m., the surveyor observed an open container of granulated garlic along with an open container of white pepper on the spice rack. On 4/13/17 at 10:15 a.m., EI #4 was asked were there opened items on the spice cart on 4/11/17. EI #4 replied yes. EI #4 was asked did she remember what was left opened on the cart. EI #4 replied, ground white pepper and granulated garlic. EI #4 was asked what was the potential harm of leaving spices open. EI #4 replied, obviously dust or other contaminants could enter the container. EI #4 also said spices could spoil as they do not keep well. 6) A facility policy titled, Food Receipt and Storage with an effective date of 7/2016, documented: PURPOSE: Foods should be received and stored properly to prevent food borne illnesses . PROCESS: 1 . b . Cartons, bags and containers are sealed . On 4/11/17 at 3:15 p.m., the surveyor observed graham cracker crumbs in a box in a plastic bag. The crumbs were leaking from the plastic bag. The surveyor also observed a 10 pound box of Tri-color pasta in a plastic bag on the inside of a box. The plastic bag was not sealed. On 4/13/17 at 12:21 p.m., EI #4 was asked by the surveyor, when they went into the dry storage area, did she remember if food items were opened and not sealed correctly. EI #4 replied there were graham cracker crumbs and tri-color pasta that was not sealed correctly. EI #4 was asked who was responsible for maintaining the dry storage items. EI #4 replied that she was, but the cooks mostly, as they used foods from the area in food preparation. EI #4 was asked what was the potential harm in not storing items properly in the dry storage area. EI #4 replied contamination and infestation. 7) A facility policy titled, Food Receipt and Storage with an effective date of 7/2016, documented: PURPOSE: Foods should be received and stored properly to prevent food borne illnesses . PROCESS . 2 . f. The First In First Out (FIFO) system should be used to rotate stock . older items pulled to the front of the shelves . On 4/11/17 at 3:15 p.m., the surveyor observed four cartons of ready-care nectar consistency thickened cranberry juice cocktail labeled with a use by date of 2/10/17. On 4/13/17 at 2:39 p.m., EI #4 was asked what items in the dry storage area had expired. EI #4 replied cranberry juice. EI #4 was asked who was responsible for removing expired items out of the dry storage area. EI #4 replied herself or whichever staff was responsible for preparing beverages. EI #4 replied it could be any dietary staff member. EI #4 was asked when should expired items be removed from the dry storage area. EI #4 replied immediately. EI #4 was asked what was the potential harm when residents were served expired food. EI #4 replied contamination and it was not known what organism could be growing in the substance.

Based on an observations, interviews, and record reviews, the facility failed to ensure the medication nurse did not touch a resident's medication with an ungloved hand and administer the medication to the resident. This affected RI (Resident Identifier) #25, one of five residents observed during medication pass. The facility also failed to ensure a CNA (Certified Nursing Assistant) did not touch a residents sandwich with ungloved hands. This affected RI #20, one of twenty one sampled residents. Findings include: A review of POTTER & PERRY . Fundamentals of Nursing, 7th Edition, page 719 Skill 35-1 Administering Oral Medications Steps . 7. Prepare medications: . h. Do not touch medication with fingers . A review of the medical record revealed RI #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The review of an Annual MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 12/11/15, revealed a BIMS (Brief Interview for Mental Status) score of five out of a possible fifteen points. This indicated RI #25 was severely impaired for daily decision making skills. RI #25 was coded as always being incontinent of bladder and bowel and required moderate to extensive assistance with all ADLs (Activities of Daily Living). An observation of a Medication Pass was made for RI #25 on 03/23/16 at 9:20 AM. While EI (Employee Identifier) #3 was administering medications, a pill fell on RI #25's chest. EI #3 picked up the pill with an ungloved hand and placed the medication in RI #25's mouth. An interview was conducted on 3/24/16 at 4:15 PM with EI #4, an RN (Registered Nurse), DON (Director of Nursing). EI #4 was asked how often were staff educated about Infection Control. EI #4 said quarterly and in between if something came up. The medication pass observation was shared with EI #4. EI #4 was asked what should have been done. EI #4 responded she would rather the nurse destroy the pill and obtain another pill from the cart for the resident. An interview was conducted on 3/24/16 at 5:05 PM with EI #3. EI #3 was asked if she had administered medications to RI #25. EI #3 replied she had. EI #3 was asked how many pills were in the pill cup. EI #3 replied six pills. EI #3 was asked to explain what happened when pouring the pills into the resident's mouth. EI #3 stated the pills were poured into RI #25's mouth and one fell out of the cup. EI #3 stated she made the mistake of picking the pill up and placing it in RI #25's mouth. EI #3 was asked to explain the potential harm of touching a medication with an ungloved hand and then placing it in a resident's mouth. EI #3 stated she could have had germs on her hands. EI #3 was asked what procedure should have been followed. EI #3 responded she should have picked up the pill and flushed it down the toilet. EI #3 stated she should have gone to the medication cart, obtained another pill from the back of the packet, and then notified the pharmacy. A review of Food Code US Public Health 2013, revealed, 3-3 Protection from contamination after receiving 3-301.11 Preventing Contamination From Hands. .(B) .employees may not contact exposed, ready to eat food with their bare hands . RI # 20 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the significant change MDS, with an ARD of 03/15/2016, revealed RI #20 was moderately impaired for decision making with a BIMS (Brief Interview for Mental Status) score of 2. This indicated the resident was severely impaired of cognition for daily decision making. RI #20 was assessed as requiring extensive assistance of one person for eating. During the initial tour of the facility on 03/22/2016 at 5:30 PM, EI #5, a CNA, was observed preparing the supper tray for RI #20. EI #5 was noted to place her ungloved hand on RI #20's cheese sandwich while cutting the sandwich in half. After cutting the sandwich, EI #5 picked the sandwich up with her ungloved hand and gave it to RI #20. RI #20 then started eating the sandwich. EI #5 was interviewed on 03/24/2016 at 1:15 PM. EI #5 was asked what the facility instructed her regarding touching a resident's food. EI #5 stated it was ok if they washed their hands.

Based on an observation, interviews, and record reviews, the facility failed to ensure CNAs (Certified Nursing Assistant) provided perineal care in a manner to prevent the potential for cross contamination. This affected RI (Resident Identifier) #14, one of two residents observed for perineal care. Findings include: A review of the facility's Policy and Procedure titled, Perineal Care (Incontinence Care), with an Effective Date of 6/2014, revealed, PURPOSE: Good perineal care helps prevent infection, irritation, and skin breakdown. A review of the Centers for Disease Control and Prevention recommendations with most recent update of November 9, 2011 revealed: .Protocol for Hand Hygiene and Glove Use Observations . Recommendations Hand hygiene . 3. Examples of situations when hand hygiene is indicated: 1. Before and after direct patient contact 2. After completing tasks at one patient station before moving to another station . 6. After contact with items/surfaces at patient stations . Glove use 1. In general, gloves should be worn prior to contact with patients at the treatment station and potentially contaminated surfaces (e.g., [MEDICAL TREATMENT] machine, environmental surfaces).Gloves should always be changed between patients and between clean and contaminated sites on the same patient . A review of RI #14's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of an Admission MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 04/13/15, revealed RI #14 required extensive to total assistance with ADLs (Activities of Daily Living) and was coded as always incontinent of bladder and bowel function. On 3/23/2016 at 6:53 PM, an observation was made of incontinence care provided for RI #14 by EI (Employee Identifier) #1, a CNA (Certified Nursing Assistant) and EI #2, a CNA. RI #14 was turned to the left side with the lift sling rolled underneath the resident, then RI #14 was turned to the right side and EI #1 folded the lift sling with gloved hands and placed the sling in a plastic bag. EI #1 proceeded to provide perineal care to RI #14 without removing gloves or washing her hands. After RI #14's perineal area was cleaned, he/she was turned to the right side by EI #1. EI #2, with gloves on, picked up the trash can and moved it to the bedside and then proceeded to clean RI #14's buttocks and rectal area with disposal wipes. EI #2 failed to remove her gloves and wash her hands after picking up the trash can prior to providing care to the resident. On 3/24/16 at 4:50 PM, an interview was conducted with EI #1. EI #1 was asked, during incontinence care, when should gloves be worn or changed. EI #1 said gloves should be worn at all times and changed when soiled. EI #1 was asked why was it important to wash her hands and change gloves when providing care. EI #1 said to prevent infections and cross contamination. EI #1 was asked when did she wash her hands and change her gloves while providing care for RI #14. EI #1 stated she had washed her hands before she started care and then donned gloves. EI #1 stated she then washed her hands after care. EI #1 stated she had not changed her gloves because she did not feel they were dirty. EI #1 was asked what the negative outcome could be for not washing her hands or changing her gloves when providing care for a resident. EI #1 stated it would be infection. EI #1 was asked should she use the same gloves to provide perineal care after touching other objects in the room. EI #1 stated no. On 3/24/16 at 5:03 PM, the surveyor attempted to phone EI #2 for an interview, no answer to phone call. On 3/24/16 at 4:15 PM, an interview was conducted with EI #4, the DON (Director of Nursing). EI #4 was asked if a CNA removed a Hoyer lift sling from underneath a resident and placed it in a bag and then proceeded to provide perineal care with the same gloves on, was this the appropriate protocol/procedure. EI #4 stated the CNA should have washed her hands and donned clean gloves due to infection control issues.

Based on an observation, record review, and an interview, the facility failed to ensure RI (Resident Identifier) #14's care plan was followed related to re-positioning and checking/changing every two hours as care planned. This affected RI #14, one of twenty-two residents whose care plans were reviewed. Findings Include: A review of a facility document titled, NOLAND HEALTH SERVICES, Policy: Care Plan, with an Effective Date: 2/2015, revealed, PURPOSE: Plans of care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals for the resident. STANDARD: The facility develops a comprehensive plan of care of each resident that includes measurable objectives and time tables to meet a resident's medical, nursing . needs . A review of RI #14's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of an Admission MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 04/13/15, revealed RI #14 required extensive to total assistance with ADLs (Activities of Daily Living) and was coded as always incontinent of bladder and bowel function. A review of a facility document titled, Care Plan, revealed, Related DX (Diagnosis): 438.9 Late Effect Cv (Cerebral Vascular) Dis (Disease) . Problem Onset: 04/06/2015, Problem/Need: (RI #14) needs extensive to total assistance with all ADLs . Goal Target Date: Will be well dressed . and comfortable thru next review . Approaches: . Assist to turn every 2 hours and prn (As Needed) . An additional review of a second facility document titled, Care Plan, revealed, Problem Onset: 04/06/2015 Review dates 5/15, 7/15, 10/15, and 01/16. Problem/Need: (RI #14) has potential for skin breakdown related to immobility and incontinence of B&B (Bowel and Bladder). Approaches: Assist to turn and reposition every 2 hours and prn. Provide incontinence care every 2 hours and prn. On 03/23/2016 from 3:20 PM until 6:45 PM, the surveyor began a continuous observation of RI #14. RI #14 was up in a Geri Chair in the sun room at 3:20 PM. The surveyor observed RI #14 being moved in a Geri chair from the sun room to the Dining Room by a Nurse at 4:05 PM. He/she was left at the dining room table with two other residents. RI #14 remained in the dining room and was continuously observed. At 5:20 PM, RI #14 received a tray from the kitchen and the tray was set up by a CNA (Certified Nursing Assistant). At 5:50 PM, RI #14 received assistance with feeding by the RD (Registered Dietician). The RD continued to assist RI #14 with the evening meal until 6:20 PM. At 6:20 PM, RI #14 was returned from the dining room to his/her room. RI #14 was placed in the bed at 6:45 PM using a Hoyer Lift. The surveyor observed the resident being placed in bed at 6:45 PM. The surveyor observed incontinence care performed for RI #14 at 6:53 PM on 03/23/2016. The continuous observation of RI #14 was 3 hours and 33 minutes. On 03/24/2016 at 5:19 PM, an interview was conducted with EI #1, a CNA. EI #1 was asked if a care plan was developed for a resident that was immobile, confined to a bed and chair and was to be checked and changed every two hours, what would she do. EI #1 replied, I try to do what the care plan is, get up (in the chair), and change position every two hours. EI #1 was asked what a resident's care plan was used for. EI #1 replied, It tells what to do for the resident and what they need. EI #1 was asked if she provided care for RI #14 on 03/23/2016. EI #1 replied, Yes ma'am, I did. EI #1 was asked what RI #14's care plan indicated about checking, changing, and re-positioning him/her. EI #1 replied, Check and change every two hours and re-position every two hours. EI #1 was asked what was the potential harm for not following the care plan for RI #14 related to checking, changing, and re-positioning. EI #1 replied, Breakdown, pressure sores, and skin irritation. EI #1 was asked why RI #14 was not checked, changed, or re-positioned for over three hours on 03/23/2016, from 3:20 PM to 6:53 PM. EI #1 replied, When I went to get RI #14 for the 4 o'clock rounds, the nurse had taken RI #14 to the dining room. When I went to get RI #14 and he/she was eating, they were feeding him/her and I wanted RI #14 to finish eating. EI #1 was informed that RI #14 did not receive an evening tray until 5:20 PM and RI#14 did not receive assistance with eating until 5:50 P.M. When asked if RI #14 was due to be checked, changed, and re-positioned at 4:00 PM, EI #1 replied, Yes ma'am.

Based on record review, observations and interviews, the facility failed to ensure a Certified Nursing Assistant (CNA) cleaned Resident Identifier (RI) #2's labia thoroughly after the resident had an incontinent bowel movement (bm). The CNA was asked to re-wipe the resident's labia and bm was present on the wipe. This affected 1 of 4 residents observed during incontinent care. Findings Include: A review of Potter and Perry's "FUNDAMENTALS OF NURSING" EIGHTH EDITION, Copyright 2013, CHAPTER 39, "Hygiene" page 801 revealed: "...STEP ... (2) ...(d) ...Clean thoroughly around labia minora, clitoris and vaginal orifice.... RATIONALE ...Cleansing method reduces transfer of microorganisms to urinary meatus..." RI #2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #2's Annual Minimum Data Set (MDS) with an ARD (Assessment Reference Date) of 1/20/2015 revealed RI #2's cognitive skills for daily decision making were severely impaired. The MDS also revealed RI #2 as being totally dependent on staff for all ADL's (Activities of Daily Living) and as always being incontinent of bowel and bladder. On 2/5/15 at 10:45 AM, EI (Employee Identifier) #4, CNA was observed performing incontinent care for RI#2. RI #2 had an incontinent bm and also was incontinent of urine. EI #2 wiped the bm and the urine from the resident and placed the brief on the resident. The surveyor asked EI #4 if incontinent care was finished and she said yes. EI #4 was asked to open the resident's labia and wipe and tell the surveyor what she saw. EI #4 said she saw brown spots. When asked what those brown spots were, EI #4 said, "a little bit of boo boo." On 2/5/15 at 2:54 PM, an interview was conducted with EI #4, a CNA. EI #4 was asked when performing incontinent care for RI #2 if she had completed incontinent care. EI #4 replied yes. EI #4 was asked to undo RI #2's brief and separate the labia and wipe and tell the surveyor what she saw. EI #4 re-wiped the resident's labia and stated she saw bm on the wipe. EI #4 was asked what was the potential harm if she did not clean a resident's labia thoroughly after they had an incontinent bm. EI #4 said urinary tract infection. An interview was conducted with the DON (Director of Nursing), EI #1, on 2/5/15 at 3:08 PM. EI #1 was asked when cleaning a resident's labia after having an incontinent bowel movement, how should the labia be cleaned. EI #1 replied from top to bottom to remove any germs from the opening. EI #1 was asked should the resident be wiped until clean. EI #1 stated yes. EI #1 was asked what was the potential harm if a resident's labia was not cleaned thoroughly and a resident has a history of UTI. EI #1 replied potential for infection. EI #1 was asked if it was an acceptable practice of the facility for a CNA to say that incontinent care was finished and then re-wipe the labia and see bowel movement on the wipe. EI #1 stated no.

Based on observation, interview and record review, the facility failed to ensure RI (Resident Identifier) #2, a resident identified by the facility as being at risk for pressure ulcers, did not sit in a geri-chair on top of a hoyer lift pad from 7:40 AM to 10:40 AM ( 3 hrs) on 2/5/2015 without being checked for incontinence or changed. This affected 1 of 5 sampled residents who were at risk of pressure ulcers Findings Include: The facility did not provide a policy on the prevention of pressure ulcers or for the checking and changing of residents. RI #2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #2's Annual Minimum Data Set (MDS) with an ARD (Assessment Reference Date) of 1/20/2015 revealed RI #2's cognitive skills for daily decision making. The MDS also revealed the resident as being totally dependent on staff for all ADL's (Activities of Daily Living) and as always being incontinent of bowel and bladder. A review of RI #2's careplan with a problem/onset date of 03/03/2014 revealed: "(Resident's Name) continues with a potential for s at risk for skin breakdown related to impaired mobility and incontinence of bowel and bladder... Approaches...Observe q (every) 2 hr (hour) & (and) prn (as needed) for incontinence. Provide perineal care as needed." On 2/5/15 RI #2 was continuously observed by the surveyor sitting in the geri chair on top of the Hoyer lift pad from 7:40 AM to 10:40 AM without being checked for incontinence or changed. During an interview on 2/5/2015 at 2:15 PM with Employee Identifier (EI) #4, the CNA was asked how did she know what type of care a resident was supposed to receive. EI #4 said it was in the ADL chart. EI #4 was asked was she assigned to RI #2 on 2/5/2015. EI #4 said yes. EI #4 was asked how often was RI #2 supposed to be checked for incontinence and changed. EI #4 said every 2 hours. EI #4 was asked if RI #2 was checked and changed for incontinence within a 2 hour period. EI #4 said she didn't get to RI #2 on time. EI #4 was asked why was RI #2 sitting in a geri-chair on top of a Hoyer lift pad from 7:40 am to 10: 40 AM on 2/5/15 without being checked for incontinence within a 2 hour period. EI #4 said she was doing rounds and when she got help then she was able to get to RI #2. EI #4 was asked did she follow RI #2's careplan for incontinence. EI #4 said no. EI #2 was asked what was the potential harm if RI #2, who was incontinent of bowel and bladder and at risk of pressure ulcers, sat in the geri-chair on top of the Hoyer lift pad for 3 hours without being checked for incontinence and changed. EI # 4 said RI #2 could get a breakdown. On 2/5/15 at 3:05 PM,an interview was conducted with EI #1, DON (Director Of Nursing). EI #1 was asked how did CNA's know what type of care residents were supposed to receive. EI #1 said they follow their daily care guide. EI #1 was asked how often were incontinent residents supposed to be checked for incontinence and changed. EI #1 said a minimum of every two hours. EI #1 was asked if she could explain to the surveyor why RI #2 was left sitting in the geri chair on top of the Hoyer lift pad from 7:40 AM to 10:40 AM without being checked for incontinence or changed. EI #1 said she could not. EI #1 was asked of RI #2's careplan was followed for checking for incontinence and changing. EI #1 said, "If they did not do it, it was not followed." EI #1 was asked if it was an acceptable practice for an incontinent resident who had a history of [REDACTED]. EI #1 said no. EI #1 was asked what was the potential harm if RI #2, who was incontinent and at risk of developing pressure ulcers and has a history of UTI, sat in her geri-chair on top of the Hoyer lift pad for 3 hours without being checked for incontinence or changed. EI #1 said skin breakdown.

Based on record review and interview the facility failed to ensure there was documentation or communication between the facility and the [MEDICAL TREATMENT] center concerning the [MEDICAL TREATMENT] care of RI (Resident Identifier) #18. This affected 1 of 1 sampled residents observed who received [MEDICAL TREATMENT]. Findings Include: RI #18 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #18's most recent Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 01/31/2015 revealed a BIMS (Brief Interview for Mental Status) score of 10 which revealed that RI #18 was moderately cognitively impaired. A review of the facility"s policy and procedure titled, " [MEDICAL TREATMENT], [MEDICAL TREATMENT] Care", with an effective date of 8/2014 revealed: "...Process ...5. Obtain dry weights from the [MEDICAL TREATMENT] center ...10. Obtain lab work from the [MEDICAL TREATMENT] center, when performed..." A review of the facility's care plans dated 04/22/13 revealed the following problem : "... (Resident's Name) receives [MEDICAL TREATMENT] d/t (due to) [MEDICAL CONDITION] Approaches for this resident included... Obtain weights from [MEDICAL TREATMENT] center..." On 2/5/15 at 3:30 PM, an interview was conducted with EI (Employee Identifier) #7, an RN (Registered Nurse) Supervisor. EI #7 was asked what was the facility policy and procedure on [MEDICAL TREATMENT] regarding communication between the two facilities. EI #7 replied the facility usually sent a weight sheet and they sent it back. EI #7 was asked was there any documentation in the resident's chart from the [MEDICAL TREATMENT] center. She said no she did not see any. EI #7 said [MEDICAL TREATMENT] does not call her specifically. EI #7 was asked why there was not documentation between the [MEDICAL TREATMENT] center and the facility. She said she did not know. EI #7 was asked who was responsible for assuring there was communication between the two facilities. EI #7 replied all the nurses caring for the resident. EI #7 was asked how did the nurses know how to take care of RI #18 when RI #18 returned from the [MEDICAL TREATMENT] center. She replied as far as she knew they would call and let them know. EI #7 was asked what was the harm in no communication between the two facilities. She replied not proper care.

Based on observation, interview and record review, the facility failed to ensure Resident Identifier ( RI) #2's careplan was followed in order to check the resident for incontinence and change RI #2 every 2 hours. RI #2 was observed from 7:40 AM to 10:40 AM (3 hrs) on 2/5/15 sitting in the geri chair on top of the Hoyer lift pad without being checked for incontinence. This affected 1 of 22 residents whose care plans were reviewed. Findings Include: The facility did not have a policy for Certified Nursing Assistant (CNA) for rounding, checking and changing of residents. RI #2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #2's Annual Minimun Data Set (MDS) with an ARD (Assessment Reference Date) of 1/20/2015 revealed RI #2's cognitive skills for daily decision making were severely impaired. The MDS also revealed RI #2 as being totally dependent on staff for all ADL's (Activities of Daily Living) and as always being incontinent of bowel and bladder. A review of RI #2's careplan with a problem/onset date of 03/03/2014 revealed: "(Resident's Name) continues with a potential for s at risk for skin breakdown related to impaired mobility and incontinence of bowel and bladder... Approaches...Observe q (every) 2 hr (hour) & (and) prn (as needed) for incontinence. Provide perineal care as needed." On 2/5/15 RI #2 was continuously observed by the surveyor sitting in the geri chair on top of the Hoyer lift pad from 7:40 AM to 10:40 AM without being checked for incontinence or changed. During an interview on 2/5/2015 at 2:15 PM with Employee Identifier (EI) #4, the CNA was asked how did she know what type of care a resident was supposed to receive. EI #4 said it was in the ADL chart. EI #4 was asked was she assigned to RI #2 on 2/5/2015. EI #4 said yes. EI #4 was asked how often was RI #2 supposed to be checked for incontinence and changed. EI #4 said every 2 hours. EI #4 was asked if RI #2 was checked and changed for incontinence within a 2 hour period. EI #4 said she didn't get to RI #2 on time. EI #4 was asked why was RI #2 sitting in a geri-chair on top of a hoyer lift pad from 7:40 am to 10: 40 AM on 2/5/15 without being checked for incontinence within a 2 hour period. EI #4 said she was doing rounds and when she got help then she was able to get to RI #2. EI #4 was asked did she follow RI #2's careplan for incontinence. EI #4 said no. EI #2 was asked what was the potential harm if RI #2, who was incontinent of bowel and bladder and at risk of pressure ulcers, sat in the geri-chair on top of the Hoyer lift pad for 3 hours without being checked for incontinence and changed. EI # 4 said RI #2 could get a breakdown. On 2/5/15 at 3:05 PM,an interview was conducted with EI #1, DON (Director Of Nursing). EI #1 was asked how did CNA's know what type of care residents were supposed to receive. EI #1 said they follow their daily care guide. EI #1 was asked how often were incontinent residents supposed to be checked for incontinence and changed. EI #1 said a minimum of every two hours. EI #1 was asked if she could explain to the surveyor why RI #2 was left sitting in the geri chair on top of the Hoyer lift pad from 7:40 AM to 10:40 AM without being checked for incontinence or changed. EI #1 said she could not. EI #1 was asked of RI #2's careplan was followed for checking for incontinence and changing. EI #1 said, "If they did not do it, it was not followed." EI #1 was asked if it was an acceptable practice for an incontinent resident who had a history of [REDACTED]. EI #1 said no. EI #1 was asked what was the potential harm if RI #2, who was incontinent and at risk of developing pressure ulcers and has a history of UTI, sat in her geri-chair on top of the Hoyer lift pad for 3 hours without being checked for incontinence or changed. EI #1 said skin breakdown.

Based on record reviews, observations and interviews, the facility failed to ensure a CNA (Certified Nursing Assistant) was seated when feeding UR (Un-sampled Resident) #1 during the breakfast meal on 2-4-15. This affected 1 of 5 staff members observed feeding residents on 2-4-15. Findings include: A review of a facility document titled, "RESIDENT RIGHTS" with no date revealed: "...QUALITY OF LIFE...a) Dignity. The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity..." UR (Unsampled Resident) #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of UR # 1's most recent Significant Change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 1/30/2015 revealed the resident was severely cognitively impaired for daily decision making. The MDS further revealed the resident is totally dependent on staff for all ADLs (Activities of Daily Living). On 2/4/15 at 8:28 AM, EI(Employee Identifier) #6 was observed standing while feeding UR #1. On 2-4-15 at 8:58 AM, an interview was conducted with EI #6. EI #6 was asked what position should she be in when feeding a resident. EI #6 said standing on the right. EI #6 was asked what position she was in when feeding UR #1. EI #6 said standing. EI #6 was asked should she have been seated when feeding UR #1. EI #6 said yes she was supposed to sit, but UR #1's condition and the chair was low. EI #6 was asked can the bed be lowered. EI #6 said yes. EI #6 was asked why she was not seated when feeding UR#1. EI#6 said the resident was so stiff and when she stood she could reach better. EI #6 also said she stood to give good service to her. EI #6 was asked what was the potential harm if she did not sit when feeding a resident. EI #6 said the resident may think she was in a hurry and just do the job to finish. EI #6 was asked how she thought it made UR #1 feel when she stood to feed the resident. EI #6 said the resident might think she was in a hurry. On 2-5-15 at 9:10 AM, an interview was conducted with EI # 1, DON (Director of Nursing). EI #1 was asked what position should a CNA be in when feeding a resident. EI #1 said they should be sitting. EI #1 was asked if it was an acceptable practice of this facility for a CNA to stand while feeding a resident. EI #1 said she preferred them to sit. EI #1 was asked how she thought it would make the resident feel if a CNA stood while feeding. EI #1 said it was more comforting to have them seated.

Based on record review, observation and interviews, the facility failed to ensure a licensed staff member closed the door or pulled the privacy curtain when administering [MEDICATION NAME] nasal spray to RI (Resident Identifier) #16 with the roommate present in the room during medication administration pass on 2/4/15. This affected 1 of 3 licensed staff members observed during medication pass administration. Findings Include: A review of a facility document titled, "An Explanation of the Rights of Nursing Facility Residents" with no date revealed: "...Some of these resident rights include: the right to be treated with dignity, privacy,... the right to privacy including accommodations, medical treatment,..." RI #16 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Involuntary Movement. A review of RI #16's most recent Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/17/2014 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15 which indicated the resident was cognitively intact. The MDS also revealed the resident was totally dependent on staff for all ADLs (Activities of Daily Living). A review of RI #16's physician's orders [REDACTED]. On 2/4/15 at 8:11 AM, EI (Employee Identifier) #8, LPN (Licensed Practical Nurse) was observed to enter RI #16's room and administer [MEDICATION NAME] nasal spray. RI #16's roommate was present and awake in the next bed. EI #8 did not pull the privacy curtain or close the door during the administration of the [MEDICATION NAME] nasal spray. On 2/4/15 at 12:50 PM, an interview was conducted with EI #8. EI #8 was asked what should be done when giving medications with the roommate present in the room. EI #8 said pull the curtains. EI #8 was asked if she closed the door or pulled the privacy curtain when giving medications to RI #16. EI #8 said no, she never pulls the curtain but she knows that she should. EI #8 also said no, she did not close the door. EI #8 was asked if she should have closed the door and pulled the privacy curtain when giving medications to RI #16. EI #8 said yes. EI #8 was asked why she did not close the door or pull the privacy curtain when giving medications to RI #16. EI #8 said she was nervous. EI #8 was asked what was the potential harm if she did not pull the privacy curtain when roommates were present in the room or close the door when administering medications. EI #8 said everybody else would see what she was doing with the resident and no privacy. On 2/5/15 at 9:16 AM, an interview was conducted with EI #1, DON (Director of Nursing). EI #1 was asked what should be done when giving medications with both roommates present in the room. EI #1 said privacy should be provided. EI #1 was asked if the door should be closed and the privacy curtain pulled when administering medications with both roommates present in the room. EI #1 said yes. EI #1 was asked if it was an acceptable practice of that facility for a nurse to administer medications and leave the door open. EI #1 said she would rather privacy be provided. EI #1 was asked if it was an acceptable practice of that facility for a nurse to administer medications with both roommates present in the room and not pull the privacy curtain. EI #1 said it is not an acceptable practice. EI #1 was asked what was the potential harm if a nurse does not close the door when administering medications or pull the privacy curtain when both roommates are present in the room. EI #1 said violation of resident privacy.

Based on record reviews, observations and interviews, the facility failed to ensure a CNA (Certified Nursing Assistant) changed gloves or washed his hands after cleaning bm (bowel movement) from RI (Resident Identifier) #7 and before he touched a clean brief during incontinent care on 2/4/15. The facility further failed to ensure a CNA changed gloves or washed her hands after cleaning bm from RI #2 and before touching a clean brief during incontinent care on 2/5/15. This affected 2 of 4 sampled residents observed during incontinent care. Findings Include: A review of Potter and Perry 's "FUNDAMENTALS OF NURSING" EIGHTH EDITION, Copyright 2013, CHAPTER 28, " Infection Prevention and Control " page 419 revealed: " ...Change gloves and perform hand hygiene between tasks and procedures on the same patient after contact with materials that contains a high concentration of microorganisms. Remove gloves promptly after use, before touching noncontaminated items ...Perform hand hygiene immediately to avoid transfer of microorganisms ... " 1) RI #7 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #7 's most recent Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 01/19/2015 revealed the resident was severely cognitively impaired for daily decision making. The MDS further revealed the resident was totally dependent on staff for bathing and personal hygiene. The MDS also revealed the resident was frequently incontinent of bowel and bladder. On 02/4/15 at 11:58 AM, EI (Employee Identifier) #3, CNA was observed performing incontinent care for RI #7. RI #7 had a large incontinent bm. EI #3 wiped the bm from the resident, removed his gloves and sanitized his hands. EI #3 donned clean gloves and removed several wipes from the container. EI #3 again wiped RI #7's buttocks and then touched the clean brief and placed it underneath the resident without changing his gloves or washing or sanitizing his hands. On 2/4/15 at 12:20 PM, an interview was conducted with EI #3. EI #3 was asked what should he have done after he cleaned bm from RI #7 and before he touched the clean brief. EI #3 said he should have removed his gloves, sanitized his hands, put more gloves on and then got the brief. EI #3 was asked if he had changed gloves or sanitized or washed his hands after he wiped RI #7 's buttocks and before he touched the clean brief. EI #3 said he guessed he had not. EI #3 was asked why did he not change gloves or wash or sanitize his hands after he wiped RI #7 's buttocks and before he touched the clean brief. EI #3 said he was not thinking. EI #3 was asked what the potential harm was if he did not change gloves or wash or sanitize his hands after he cleaned a resident s buttocks and before he touched a clean brief. EI #3 said cross contamination and infection. On 2/5/15 at 9:24 AM, an interview was conducted with EI #1, DON (Director of Nursing). EI #1 was asked at what point should a CNA change gloves or wash or sanitize their hands during incontinent care. EI #1 said, "Anytime you go from a dirty surface to a clean surface, you need to wash your hands." EI #1 was asked if a CNA should change gloves or wash or sanitize their hands after cleaning a resident 's buttocks and before touching a clean brief. EI #1 said yes. EI #1 was asked if it was an acceptable practice of that facility for a CNA to clean a resident 's buttocks and touch a clean brief without changing gloves or washing or sanitizing their hands. EI #1 said no. EI #1 was asked what the potential harm was if a CNA did not change gloves or wash or sanitize their hands after cleaning a resident 's buttocks and then touching a clean brief. EI #1 said the spread of infection. 2) RI #2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #2 's most recent Annual MDS with an ARD of 01/20/2015 revealed the resident was severely cognitively impaired for daily decision making. The MDS further revealed the resident was totally dependent on staff for all ADLs (Activities of Daily Living). The MDS also revealed the resident was always incontinent of bowel and bladder. On 2/5/15 at 10:45 AM, EI #4, CNA was observed performing incontinent care for RI#2. RI #2 had an incontinent bm. EI #2 cleaned the bm from the resident and touched the clean brief and placed it underneath the resident without changing her gloves or washing or sanitizing her hands. On 2/5/15 at 2:49 PM, an interview was conducted with EI #4. EI #4 was asked what should she have done after cleaning bm from an incontinent resident and before touching the clean brief. EI #4 said change gloves. EI #4 was asked if she washed her hands or changed gloves after she cleaned bm from RI #2 and before she touched the clean brief. EI #4 said no. EI #4 was asked if she should have and she said yes. EI #4 was asked why she did not wash her hands or change gloves after she cleaned bm from RI #2 and before she touched the clean brief. EI #4 said she forgot and she was nervous. EI #4 was asked what was the potential harm if she did not wash her hands or change gloves after she cleaned bm from a resident and then touched a clean brief. EI #4 said infection. On 02/5/15 at 3:10 PM, an interview was conducted with EI #1, DON/Infection Control Nurse. EI #1 was asked how infections were prevented in the facility. EI #1 said basic hand washing and cleaning. EI #1 was asked how infections were controlled in the facility. EI #1 said they make sure the staff did proper hand washing and cleaning of that resident and any other resident. EI #1 was asked how infections were investigated in the facility. EI #1 said by urinalysis, weekly vital signs, a change in the resident's mental condition and lab work. EI #1 was asked if direct care staff were washing their hands and changing gloves according to facility protocol. EI #1 said they should be. EI #1 was asked how direct care staff were monitored to ensure they were washing their hands and changing gloves according to facility protocol. EI #1 said visual observation by the managers.