Every finding on record at Terrace Manor Nursing & Rehabilitation Center, Inc

Based on interview, record review, and a review of facility policies titled, ABUSE AND NEGLECT: RECOGNIZING AND REPORTING and NEW HIRE POLICY, the facility failed to ensure their policies contained information or direction to staff on how they would implement each of the Seven (7) Components of Abuse per State and Federal Regulations as well as ensure that systems for timely registry, licensure and background checks were completed. This deficient practice was evident through one of nine personnel files reviewed. Findings include: A review of a policy titled ABUSE AND NEGLECT: RECOGNIZING AND REPORTING, with a revised date of 11/28/17 revealed: .POLICY . Seven(7) Components of Abuse per State and Federal Regulations 1. Screening of potential hires 2. Training of employees a. New employees at time of hire b. Ongoing for current employees 3. Prevention of abuse 4. Identification of incidents which need to be investigated 5. The investigative process 6. Protection of the resident during an investigation 7. Reporting to the appropriate authorities A review of the above policy did not contain a description of what was expected by the staff for each of the seven components. A review of a policy titled, NEW HIRE POLICY with an effective date of 01/09/15 revealed, .POLICY . Professional licensure and certifications shall be verified prior to employment with the appropriate licensing board: . A review of a form utilized by the titled, PRE-EMPLOYMENT SCREENING AN AGENT OF EMPLOYERS SCREENING SERVICES, INC (Incorporation) revealed, EI (Employee Identifier) #8, LPN (License Practical Nurse) signed and gave permission for a background check to be performed on 2/07/18. A review of EI #8's personnel record revealed a hire date of 2/6/18. The background check was performed 2/7/18. EI #8's licensure and certification was verifed on 2/7/18 and the abuse registry was checked or verified on 2/8/18. The dates revealed the information was not obtained until after the date of hire. On 06/07/18 at 09:42 AM, an interview was conducted with EI #4, the Director of Nursing (DON), Registered Nurse (RN). EI #4 was asked, what the seven components of abuse were in the facility's abuse policy. EI #4 said, screening of new hires, education, prevention, keeping the residents safe, identifying things that needed to be investigated, investigative, protection from abuse and reportable. EI #4 was asked to show the surveyor what the facility did as it related to the policy for screening new hires for abuse. EI #4 said it was not in the policy. On 06/07/18 at 10:18 AM, an interview was conducted with EI #4. EI #4 returned with a new hire policy. EI# 4 stated that staff referred to the new hire policy for screening of potential hires under the abuse policy. EI #4 was asked what did she direct staff to do regarding screening of potential hires. EI #4 said, we would refer back to the new hire policy. EI #4 was asked based on what policy. EI #4 replied, the abuse and neglect policy. EI #4 was asked, where in the abuse policy did it direct staff to refer to the new hire policy regarding screening of potential new hires. EI #4 stated that the people responsible for new hires were aware of the new hire policy and screening process. EI #4 was asked who was responsible for new hires. EI #4 said, the ladies in the office. EI #4 was asked, what if they were on extended leave how would another staff know how to refer to the new policy. EI #4 said, we would educate anyone who would have to fill in that job roll. EI #4 was asked what was the purpose of policy and procedures. EI #4 stated for reference of what our policy and procedures are and directs the staff. EI #4 was asked, where was it documented in the abuse policy for staff to refer to the new hire policy for the screening of new hires. EI #4 stated it was not specifically spelled out. EI #4 was asked regarding the new hire policy, what should be checked prior to employment. EI #4 said the licensure and certification status. EI #4 reviewed personnel file of EI #8 and was asked what was EI #8's hire date. EI #4 stated EI #8's hire date was 2/6/18. EI #4 was asked, according to the new hire form, what was EI #8's hire date. EI #4 said, EI #8's hire date was 2/6/18. EI #4 was asked, what was on the enrollment change form for EI #8. EI #4 stated 2/7/18. EI #4 was provided with the criminal background form and asked, when was the background checked. EI #4 stated 2/7/18. EI #4 was asked, when was the Licensure and Certification check done. EI #4 stated 2/7/18. EI #4 was asked when was the nurse aide registry check performed. EI #4 said 2/8/18. EI #4 was asked, if the new hire date documented 2/6/18, and policy documented licensure and certification should be verified prior to employment, based upon screening potential hires from the abuse policy, was the policy for new hire and abuse followed. EI #4 stated she felt like it was a clerical error. On 06/07/18 at 11:24 AM, an interview was conducted with EI #9, Business Office Manager/BMO. EI #9 was asked, when did she complete the licensure and certification checks on EI #8. EI #9 stated, they are usually checked the day before or morning the new hire comes in to work. EI #9 was asked when was licensure verifications and certifications done for screening of potential hires. EI #9 stated the day before or the morning before they come in to fill out paperwork. The new hire generally fills out paperwork before they can work. EI #9 was asked who was responsible to ensure licensure and certification information was done prior to hire. EI #9 stated, I do that on everybody. EI #9 was asked if that was policy and procedure. EI #9 stated that was just how it was always done and how she continued when corporate took over. EI #9 was asked when EI # 8 was hired, was policy and procedure followed for screening prior to hire. EI #9 stated she forgot to do the CNA registry check until the following day. EI #9 was asked, when was the abuse registry checked. EI #9 stated on 2/7/18.

Based on observation, interview, medical record review and a review of the facility's monitoring document titled, Incontinent Care Monitoring,, the facility failed to ensure a Certified Nursing Assistant/CNA separated Resident Identifier (RI) #48's perineal area to visualize the perineal opening, wiped from front to back, changed gloves after cleaning the resident and before applying a clean brief This deficient practice affected one of two residents observed during incontinent care. Findings Include: A review of the facility monitoring document titled, Incontinent Care Monitoring without a date, revealed the following: . 12. Removed and clean BM (Bowel Movement) if present . 13. Removed gloves 14. Washed hands . 15. Clean gloves applied . 18. Area wiped only once using the same wipe . 19. Cleaned from front to back 20. Remove gloves and dispose properly 21. Wash hands 22. Apply clean gloves . RI #48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #48's Quarterly Minimum Data Set (MDS) dated [DATE] revealed RI #48 had a Brief Interview for Mental Status score of 15, indicating cognition intact. The MDS also documented RI #48 as requiring extensive assistance with toileting and personal hygiene.; and frequently incontinent of urine. On 06/06/18 at 6:50 AM, the following was observed during incontinent care:-EI #2, CNA, washed her hands and applied gloves, EI # removed the resident's brief observed with a moderate amount of yellow urine. EI #2 obtained a separate periwipe and wiped the right and the left groin. EI #2 obtained a periwipe and down the perineal opening once. EI #2 did not wipe the right and left area of the perineal area and did not visualize the perineal opening. EI #2 removed her soiled gloves and applied gloves. EI #2 did not wash her hands after removing her soiled gloves and before applying clean gloves. RI #48 was positioned on the right side. EI #2 obtained separate periwipes and wiped the left buttock from back to front twice. EI #2 repositioned the resident on the left side, EI #2 obtained a clean brief and placed underneath RI #48 and removed old brief. EI #2 did not remove her soiled gloves after cleaning and before applying a clean brief. EI #2 obtained a periwipe and wiped the right buttock from front to back three times without changing the position of the periwipe. EI #2 pulled the clean brief out from underneath the resident. EI #2 removed her soiled gloves and applied clean gloves. EI #2 did not wash her hands after removing her soiled gloves and before applying clean gloves. EI #2 applied a barrier ointment cream to RI #48. EI #2 removed her soiled gloves and applied clean gloves. EI #2 did not wash her hands after removing soiled gloves and before applying clean gloves. EI #2 secured RI #48's brief, gathered the soiled linen bags and disposed of the linen bags. EI #2 removed her soiled gloves and applied clean gloves EI #2 did not wash her hands after removing her soiled gloves and before applying clean gloves. EI #2 assisted the resident to the right side by placing a pillow under the resident's back and shoulder and floated the resident's right lower extremity. On 06/06/18 at 7:00 AM, during an interview with EI #2, the surveyor asked when did she visualize the perineal opening and wipe the right and the left sides of the perineal area. EI #2 stated, I didn't. The surveyor asked what direction should a resident be wipe. Front to back. The surveyor asked when she wiped the buttock, what direction did she wipe. EI #2 stated, From the top of the buttocks to the bottom. The surveyor asked when should hands be washed. EI #2 stated, Before you start the care, anytime come into contact with bowel movement, should change gloves and wash hands. The surveyor asked did she wash her hands between changing gloves every time. EI #2 stated, No, ma'am, not every time. The surveyor asked did she change gloves after cleaning the resident and before applying a clean brief. EI #2 stated, No, I did not. The surveyor asked did EI #2 remember using the same area of the periwipe three times without changing the position of the periwipe. EI #2 said she did not remember. The surveyor asked what was the potential harm to the resident knowing all that she had done. EI #2 stated, Urinary Tract Infection and skin breakdown.

Based on observation, interview and medical record review, the facility failed to ensure Resident Identifier (RI) #45's Oxygen (02) concentrator humidifier water bottle was not empty during the administration of oxygen and that the filter did not have an accumulation of dust. This affected one of four residents observed with oxygen. Findings Include: RI #45 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #45's current Significant Change Minimum Data Set ((MDS) dated [DATE] revealed RI #45's Brief Interview for Mental Status score of 6, indicating cognition severely impaired. The MDS also documented RI #45 was short of breath/trouble breathing with exertion, sitting at rest and lying flat. A review of RI #45's (MONTH) (YEAR) physician's orders [REDACTED]. 02 (oxygen) @ (at) 2L (liter)// MIN (minute) VIA NC (nasal cannula) . On 6/06/18 at 6:15 AM, during initial tour, no water was observed in RI #45's humidifier bottle and oxygen was infusing at 2l/nc; an accumulation of dust and debris was observed in the oxygen filter. On 6/06/18 at 7:20 AM , during an interview with Employee Identifier (EI) #5, LPN, the surveyor and EI #5 observed RI #45's oxygen concentrator with the humidifier and asked what was in the humidifier's bottle. EI #5 observed the humidifier and stated, Approximately 30 cc (cubic centimeter) of water. The surveyor asked how much water should be in the humidifier bottle at all times. EI #5 stated, At least 200 cc (cubic centimeter). The surveyor asked what was on the oxygen filter. EI #5 stated, looks probably dust. The surveyor asked when was the last time EI #5 had checked the resident. EI #5 stated, About 15 to 5 this morning (6/6/18). On 6/07/18 at 3:46 PM, during an interview with EI #6, LPN/Restorative Nurse, the surveyor asked who was responsible for cleaning the oxygen filters, when and replacing the water in the humidifier bottles. EI #6 stated, The nurse is responsible to change the bottles out, when the bottle is low or empty, we have a contract that cleans the machine, I don;t know how often, but I don't know. The surveyor asked what about the Certified Nursing Assistants/CNAs. EI #6 stated, Nursing staff and CNAs can clean them as needed, but Southeastern comes once a month to service. On 6/07/18 at 4:10 PM, during an interview with EI # 4, Chief Nursing Officer, EI #4 informed the surveyor that maintenance was responsible for cleaning the oxygen filters as needed. The surveyor asked how is maintenance made aware when a resident's oxygen filter needs cleaning. EI #4 stated, Either verbally by staff or they write it in the maintenance book. On 6/08/18 at 8:41 AM, during an interview with EI #7, Maintenance Director, the surveyor asked who was responsible to ensure oxygen filters are clean in between Southeastern's servicing. EI #7 stated, I'm not sure, the whole facility. The surveyor informed EI #7 that EI #4 said that maintenance, EI #7 was responsible. The surveyor asked EI #7 to explain. EI #7 stated, No ma'am I can't explain that, the specific task has not been assigned to me.; to my assumption, I was not aware that they needed to be cleaned more than once a month, not as far as the oxygen filters on the concentrators.

Based on observation, interviews, medical record review and a review of the facility's policy title, OXYGEN ADMINISTRATION PER SIMPLE MASK, as well as procedure for incontinence care, this facility failed to ensure staff implemented infection control measures during incontinence care and the placement of oxygen on a resident (RI #48) after the oxygen tubing was on the floor. This affected one of four residents observed during incontinence care and oxygen administration. Findings Include: A review of the facility's monitoring document titled, Incontinent Care Monitoring without a date, revealed the following: . 20. Remove gloves and dispose properly 21. Wash hands 22. Apply clean gloves . A review of the facility's policy titled, OXYGEN ADMINISTRATION PER SIMPLE MASK with a revised date of 03/24/16, revealed the following: POLICY . Oxygen tubing must be kept off of the floor . RI #48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #48's Quarterly Minimum Data Set (MDS) dated [DATE] revealed RI #48 had a Brief Interview for Mental Status score of 15, indicating intact cognition. A review of RI #48's (MONTH) (YEAR) physician's orders [REDACTED]. MEDICATIONS . 02 (oxygen) @ (at) 3L (Liter)/ (per) MIN (minute) NC (Nasal Cannula) . On 06/06/18 at 6:50 AM, the following was observed during incontinence care: Employee Identifier (EI) #2, CNA, washed her hands and applied gloves, EI #2 was observed to remove her gloves and apply clean gloves after wiping the perineal area, after wiping the left and right buttock. EI #2 did not wash her hands after removing her soiled gloves and before applying clean gloves. EI #2 removed RI #48's soiled brief and applied a clean brief, removed her soiled gloves and applied clean gloves. EI #2 did not wash her hands after removing her soiled gloves and before applying clean gloves. EI #2 applied a barrier cream to RI #48, removed her soiled gloves and applied clean gloves. EI #2 did not wash her hands after removing her soiled gloves and before applying clean gloves. On 06/06/18 at 7:00 AM, during an interview with EI #2, the surveyor asked when should hands be washed. EI #2 stated, Before you start the care, anytime come into contact with bowel movement, should change gloves and wash hands. The surveyor asked did she wash her hands between changing gloves every time. EI #2 stated, No, ma'am, not every time. The surveyor asked did she change gloves after cleaning the resident and before applying a clean brief. EI #2 stated, No, I did not. The surveyor asked what was the potential harm to the resident knowing all that she had done. EI #2 stated, Urinary Tract Infection and skin breakdown. On 6/06/18 06:45 AM, RI #48 was resting in bed and awake, oxygen nasal cannula on the floor. RI #48 stated, I must have lost it during the night. On 6/06/18 at 6:50 AM, RI #48 was observed with nasal cannula on. Several staff were observed in the resident's room. The surveyor asked staff who put the nasal cannula on the resident. EI #3, CNA, stated, I did. The surveyor asked where did she get the nasal cannula from. EI #3 stated, It was in the floor, but I wiped it off. The surveyor asked what did she wipe the nasal cannula off with. EI #3 stated, A sani-wipe from off the medication cart. The surveyor asked was that policy and procedure to clean a nasal cannula with a sani wipe. EI #3 stated, No. The surveyor asked what should she have done. EI #stated, Got another one (nasal cannula). The surveyor asked why didn't she. EI #3 stated, I don't know. On 06/07/18 11:44 AM, during an interview with EI #4, Chief Nursing Officer/CNO, the surveyor asked when a resident's oxygen tubing (NC) is on the floor what should staff do. EI #4 stated, To change the tubing out.

Based on observation and interviews, the facility failed to ensure the lights in residents' rooms were covered and drawers (dressers and bedside tables) had securely attached, or existing pull knobs/handles. Additionally, the drawer in one resident's dresser/vanity was off track impeding the function. This affected Room Locator (RL) #s: 1, 4, 6, 7, 9, 10, 11, 12, 13, 14, 23, 24 and 25; or 13 of 35 resident rooms. Findings included: During the initial tour on 05/25/17 and throughout the survey (through 05/25/17) the following concerns were noted: 1) Fluorescent light fixtures over the residents' dressers/vanity area were uncovered in RL #s: 7, 9, 10, 11 14, and 23. On 05/23/17 at 5:30 p.m., RI #4 (in RL #9) complained the fluorescent light hurt his/her eyes, so he/she kept the privacy curtain partially closed. On 05/25/17 at 11:30 a.m., RI #9 stated the uncovered light was too bright (glared in his/her face) in RL #10. On 05/25/17 at 11:00 a.m., the surveyor asked the Maintenance Director (Employee Identifier/EI) #3 if the facility had covers for the fluorescent lights. EI #3 stated they did not. 2) Bedside tables lacked handles or the handles were partially detached in RL #s: 1, 4, 6, 11, 12, 13, 14, 25. EI #3 acknowledged these concerns on 05/25/17 during a tour of the rooms, at 11:00 a.m. At 11:45 a.m., the cabinet door in RL #24, was observed to have only two extended screws with which to open two of the two cabinet doors. 3) The top dresser drawer (one of four) in RL #12 was off track, making it difficult to open and close. EI #3 attempted to fix the drawer on 05/25/17 at 11:05 a.m., but was unsuccessful.

Based on medical record review, interview and observation, the facility failed to ensure a care plan for pain was written for Resident Identifier (RI) #8 as well as a plan for RI #1's incontinence. This affected 2 of 12 sampled residents. Findings include: 1) RI #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. physician's orders [REDACTED].>Tylenol 325 milligrams (mg) at 7 a.m., written 3/10/17. Tylenol 500 mg at 8 p.m., written 3/10/2017. [MEDICATION NAME] 50 mg (1/2 tab) at 11:30 a.m., written 5/3/2017. [MEDICATION NAME] 100 mg (2 capsules by mouth at bedtime), written 3/10/2017. Review of RI #8's comprehensive care plans revealed there was no care plan developed for pain. On May 23, 2017 at 2:16 p.m., RI #8 was observed grimacing in pain and stated that his/her back was hurting. An interview was conducted with Employee Identifier (EI) #4, a Licensed Practical Nurse, and EI #5, a Registered Nurse, on May 25, 2017 at 11:39 a.m. Both nurses answered no when asked if there was a care plan for pain included on RI #8's chart. 2) RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent (quarterly review) Minimum Data Set (MDS) assessment with an assessment reference date of 04/05/17 identified RI #1 as in need of extensive assistance with all activities of daily living, including toileting. RI #9 was assessed as always incontinent of both bowel and bladder. Despite this assessment, the care plans did not address the resident's incontinence status, nor his/her need of toileting assistance/monitoring. On 05/25/17 at 12:45 p.m., the surveyor interviewed the MDS Coordinator/Registered Nurse, EI #5. EI #5 was unable to locate an incontinence care plan, explaining the care plan coordinator (who was away from the facility) usually wrote a separate care plan for incontinence. EI #5 stated she helped with the oversight of care planning, but had not reviewed RI #1's chart and care plans previously. When asked what could potentially happen without a plan to direct the resident's incontinence care, EI #5 responded they were supposed to have one to follow and they did try to address all needs. EI #5 acknowledged RI #1 as totally dependent upon staff.

Based on observation and interviews, the facility failed to ensure sliding closet doors were securely affixed to the top and/or bottom tracks for Resident Locator (RL) #s: 1, 4, 8, 9, 11, 13, 19 and 22. This posed a potential hazard for the residents in 8 of 35 rooms. Findings included: On 05/23/17 at 5:30 p.m., the residents in RL #4 commented their closet doors were aggravating. On closer inspection, the surveyor observed the sliding wood doors were totally detached from the tracks on either side of the vanity. This was observed also on 05/24/17 at 8:30 a.m. Both of the residents' two doors were merely propped on the floor, over the closet areas, posing a potential accident hazard. During a confidential interview, one resident stated the closet doors were not good; every time they pushed the closet doors they'd about fall down. On 05/25/17 at 11:00 a.m., the closet doors in RL #s: 1, 8, 9, 11 and 13 were also not securely attached. The closet doors in RL #19 and 22 were attached only to the top rollers and track, with nothing to secure the bottom. On 05/25/17 at 11:00 a.m., Employee Identifier (EI) #3 toured the rooms with the surveyor. When questioned about the closet doors, EI #3 explained the facility's option was to replace the closet doors with curtains, stating he had to constantly re-hang doors because it was not a good system. On 05/25/17 at 11:20 a.m., the surveyor questioned the facility Administrator (EI #2) about the closet doors. EI #2 explained their plan was to replace the doors with curtains.

Based on observations and interviews, the facility failed to ensure semi-private rooms were of a sufficient size to provide 80 square feet of living space for each occupant. This affected Room Locators (RL) #1 through 6, and RL #15 through 22, or 14 of 35 total rooms. Findings included: On 05/25/17 at 11:30 a.m., during a confidential interview, a resident in a semi-private room stated there was not enough room to move his/her wheelchair without moving other furniture in the room. He/she expressed a desire to bring a recliner from home, but the room would not accommodate it. On 05/25/17 at 10:50 a.m., the surveyor asked the Assistant Administrator (Employee Identifier/EI #1) whether or not the facility had a waiver in place for room size. EI #1 stated they had no room measurements available. On 05/25/17, the Maintenance Director measured each room (35) in the facility and provided a copy of these measurements to the surveyors. Of the 35 rooms, the following 14 two-bed rooms were less than 160 square feet in size: Rl # SIZE 1 - 6 11' 8 x 13' 4 (11.6' x 13.3') = 154 sq ft 15 - 22 11' 7 x 13' 4 (11.6' x 13.3') = 154 sq ft.

Based on observation, interview and record review Employee Identifier (EI) #1 Certified Nursing Assistant (CNA) failed to provide catheter care for Resident Identifier (RI) #2, a resident with a history of a Urinary Tract Infection [MEDICAL CONDITION], in a manner to prevent cross contamination. This affected one of two residents observed for incontinent care. Findings Include: An undated facility policy titled: FOLEY CATHETER CARE POLICY BASIC RESPONSIBILITY: C.N.A. GENERAL INFECTION CONTROL GUIDELINES: OBSERVE UNIVERSAL PRECAUTIONS .PROCEDURE: CLEANSE PERINEUM FROM FRONT TO BACK . A facility document titled: RESIDENT CARE PLAN .revealed on 3/14/16, UTI .Proteus mirabilis. [MEDICATION NAME] as ordered . RI #2's lab results with a date of 3/12/16, documented .Criteria met for urine culture. Culture ordered . Culture dated 03/14/16 documented Identity Proteus mirabilis. A facility document titled: RESIDENT CARE PLAN .revealed on 5/11/16, Actual [MEDICAL CONDITION] requiring ABT (Antibiotics). RI #2 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 5-25-16 at 9:36 AM, the surveyor observed catheter care along with EI #2 Infection Control Nurse for the facility. RI #2 requested the bedpan for a bowel movement before beginning the catheter care. EI #1/CNA assisted RI #2 on the bedpan. EI #1 cleaned the bowel movement from RI #2, removed her gloves, washed her hands and began to perform catheter care for RI #2. EI #1 failed to open RI #2's labium and clean inside of the area. On 5/25/16, at 12:25 PM, the surveyor conducted and interview with EI #1 CNA. EI #1 was was asked what she failed to do when providing catheter care for RI #2. EI #1 replied,open the labia and clean. EI #1 was asked what the potential for harm would be if a resident's labium were not opened and cleaned. EI #1 stated this could, cause infection. On 5/26/16 at 12:45 PM, an interview was conducted with EI #2/Infection Control Nurse. She was asked if EI #1 opened RI #2's labium when she provided catheter care on 5/25/16. EI #2 stated, No not like I would have. EI #2 was asked what the potential for harm was if the labium were not opened and cleaned. EI #2 stated, Infection. Anybody with a catheter would be at risk.

Based on observation, interview and record review Employee Identifier's (EI)'s #3 and 4 Licensed Practical Nurses failed to prepare Resident Identifier's (RI)'s #9 and 10's medication in a manner to prevent cross contamination. EI #3 and #4 touched the top and the inside of RI #9 and 10's medication cup with their bare fingers. This affected two of four observations of medication administration. Findings Include: A facility document titled: Medication Administration. A. General Guidelines. Policy: Medications are to be administered as prescribed, in accordance with nursing practices and only by persons legally authorized to do so. RI #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 5/25/16, at 7:45 AM EI #3 was observed preparing RI #9's medication. She touched the top and the inside of the medication cup with her bare fingers. On 5/25/16, and interview was conducted with EI #3. The surveyor asked EI #3 if she remembered touching the top and the inside of RI #9's medication cup. EI #3 replied, no that she did not remember. EI #3 was asked what the potential for harm would be for touching the top and the inside of the medication cup with a bare finger. EI #3 replied, Infection Control, a person could get something in the medication cup from their hands. On 5/25/16, at 8:15 AM EI #4 was observed preparing RI #10's medications. She touched the top and the inside of the medication cup with her bare fingers. RI #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An interview was conducted with EI #4 on 5/25/16, at 2:25 PM. The surveyor asked EI #4 if she remembered touching the top and the inside of RI #10's medication cup with her bare fingers. EI #4 closed her eyes and stated, Yes I can see what I done, when I moved it over. EI #4 was asked what the potential for harm was for touching the top and the inside of a medication cup with her bare fingers. She stated, A big Infection Control issue. An interview was conducted with EI #2 Infection Control Registered Nurse on 5/26/16, at 11:10 AM. The surveyor asked EI#2 if a nurse should touch the top or inside of a residents medication cup. EI #2 replied, no. She was then asked what the potential for harm would be if a nurse touched the top and inside of a residents medication cup. EI #3 stated, Resident could get a Staph infection or E-Coli or other infections.

Based on observation, record review, and interview, the facility failed to provide privacy to RI (Resident Identifier) #1 during the administration of evening medication on 4/8/15. This affected 1 of 8 sampled residents. Findings Include: A review of an undated policy titled, "Medication Administration" documented the following: "...Privacy must be provided if a resident so desires..." RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's most recent Quarterly Minimum Data Set with an Assessment Reference Date of 1-19-15 documented a Brief Interview of Mental Status score of 4, which indicated severe impairment of mental status. A review of RI #1's most recent physician's orders [REDACTED]...8 AM 4 PM...)" On 4/8/15 at 3:30 PM, the Surveyor observed EI (Employee Indentifer) #1 administering medication to RI #1 in the hallway. Prior to giving RI #1 the medication, EI #1 said to the resident, "This is your [MEDICATION NAME]." An interview was conducted with EI #1, Licensed Practical Nurse (LPN), on 4/18/15 at 6:30 PM. EI #1 explained that giving oral medication in the hallway was okay. EI #1 was asked if she gave RI #1 medication in the hallway and she stated yes. EI #1 was asked if this provided RI #1 with privacy. EI #1 stated nobody knew what was in the pill cup so it was private. EI #1 was asked if she received permission by RI #1 to give the medication in the hallway. EI #1 stated she did not today, but had in the past. EI #1 stated RI #1 had been okay in the past, receiving medication in the hallway. EI #1 was asked if she told RI #1 what medication the resident would be taking. EI #1 stated she told RI #1 each time, prior to giving the medication so RI #1 would be okay with taking the medication.

Based on observations, interviews, and record review, the facility failed to remove a lap buddy during a scheduled activity for Resident Identifier (RI) #2, as care planned. This affected one of three sampled residents with a restraint. Findings include: RI #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The RESIDENT CARE PLAN, updated 2/13/15 for, "Potential for falls d/t (due to) Hx (History) of falls, Diabetic with potential for falls..." revealed: "Tabs monitor in w/c (wheelchair) Lap buddy when in w/c - Release and reposition Q (every) 2 (symbol for hours) and PRN (as needed) During supervised activities and meals." A review of RI #2's Annuam MDS (Minimum Data Set), with the Assessment Reference Date of 2/02/2015, revealed RI #2 had short and long term problems and was severely impaired in decision-making skills. This assessment also documented RI #2 as able to 'sometimes understands and sometimes understood.' The assessment identified RI #2 as totally dependent on two plus persons with physical assistance for bed mobility, transfers, dressing, toilet use, and bathing. RI #2 was documented as having no upper body impairment, and an impairment of one side with lower extremities. A review of RI #2's narrative note of the Care Area Assessment Detail Documentation for the trigger of Falls, dated 2/05/15, revealed: "Resident is a unilateral A/K (above knee) [MEDICAL CONDITION] He/She currently utilizes these fall risk devices: ...(2) Seat belt with alarm, (3) Lap buddy... Proceed to CP (Care Plan)..." The physician's orders [REDACTED]. "...LAP BUDDY WHEN UP IN W/C D/T (DUE TO) HX OF FALLS R/T BALANCE AND L AKA..." Observations of RI #2 were made on 4/8/15 at 10:30 AM, 1:15 PM, and at 2:40 PM, seated in the wheelchair with a lap buddy in place. At 2:40 PM, RI #2 was taken from the beauty shop, to a structured activity in the dining room. RI #2 had the lap buddy attached to the wheel chair. The activity group was seated at the tables, coloring pictures. The activity director stood next to and assisted RI #2. The lap buddy was not removed throughout the duration of the activity. There were seven residents present, with three staff. In an interview with the Activity Director, Employee Identifier (EI) #3, on 4/9/15 at 8:30 AM, the surveyor inquired if RI #2 had the lap buddy on while in the activity group. RI #3 said, "Yes, that was on me. I just forgot to take it off." An interview on 4/09/15 at 1:28 PM with the Director of Nursing, EI #2, revealed she already knew the Activity group had forgotten to remove the lap buddy. EI #2 said the Activities staff usually took it off.

Based on observations, interview and review of the 2013 Food Code, the facility failed to ensure: 1) light bulbs were shielded, coated or otherwise shatter resistant in areas exposed to food; 2) a scoop was not stored inside protein powder; 3) the dish racks were not placed on the floor; and 4) routine cleaning of the tea urn spigot. These deficient practices had the potential to all residents receiving food from the kitchen. Findings include: 1) According to "Food Code U.S. Public Health Health Service FDA 2013 ... Functionality 6-202.11 Light Bulbs, Protective Shielding. (A) Except as specified in ? (B) of this section, light bulbs shall be shielded, coated, or otherwise shatter-resistant in areas where there is exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; or unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES ... ." On 5/6/2014 at 3:37 PM, a three door stand was observed with two bulbs that were not shielded. On 5/6/2014 at 3:40 PM, the lightening on a stand up in the freezer in the outside storage was observed with not enough protection. On 5/8/2014 at 10:22 AM, Employee Identifier (EI) #3, the Dietary Manager was asked if three bulbs observed in two units in two different areas were shielded, coated or otherwise shatter-resistant? EI #3 said no, one had partial shielding. 2) On 5/6/2014 at 4:48 PM, a can of protein powder had a scoop stored inside. At 4:50 PM, EI #3, was asked what was the problem? EI #3 responded, cross-contamination, let us just throw that away. 3) During observation of machine dishwashing on 5/7/2014 at 10:15 AM, the dish racks were observed on the floor. On 5/8/2014 at 10:22 AM, EI #3 was asked, had she observed staff to place the dish racks on the floor. EI #3 said yes. When asked if this was an acceptable practice, EI #3 said no. 4) According to "Food Code U.S. Public Health Health Service FDA 2013 ... Frequency 4-602.11 Equipment Food-Contact Surfaces and Utensils. ... (E) Except when dry cleaning methods ... UTENSILS and EQUIPMENT contacting FOOD that is not TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cleaned: (1) At any time when contamination may have occurred; (2) At least every 24 hours for iced tea dispensers and ... ." On 5/7/2014 at 10:30 AM, EI #3 disassemble the tea urn spigot and a brown solid residue built up was observed adhering to the plunger. On 5/8/2014 at 10:22 AM, EI #3 was asked if she had a cleaning schedule. EI #3 stated she did not know of a protocol for that.

Based on observation and interview, the facility failed to prepare and serve sausage in a manner that was palatable. On 3/14/13, the sausage was over-cooked so that it was hard, crusty and difficult to cut. This had the potential to affect all residents who had planned meals served from the kitchen. Findings include: On 3/14/13 at 8:45 AM, the breakfast sausage was observed to be dark with blackened areas and to have crusty edges. A piece of the sausage was removed from the pan to test. Employee Identifier (EI) #11 (the Dietary Manager) stated, "This is too hard to serve." The sausage could not be cut with the side of a fork. The patty could only be cut with a knife with effort. EI #11 further stated she realized the sausage was too done, over-cooked and would see that it was corrected.

Based on observations and interview, the facility failed to maintain sanitary conditions by: 1. Storing personal food items in the kitchen refrigerator used for preparation of residents' food. 2. Ice cream was not maintained frozen hard. 3. An activity staff member was allowed to enter the kitchen food preparation area, walk through the dishwashing area, stand adjacent to the clean pot rack and then go into the dry storage area without washing her hands or to have hair restraint in place. This had the potential to affect 42 of 42 residents who were fed from the kitchen. Findings include: 1) During the initial tour of the kitchen on 3/12/13 at 4:10 PM, the refrigerator was noted to contain plastic dishes and plates with small to medium amounts of left-over food. Foods included nuts, chips and dip, sausage balls, chocolate/oatmeal cookies and fudge. When Employee Identifier (EI) #12 (the Cook) was asked who brought the food. EI #12 replied, "The nurses and the Dietary Manager. They are giving one of the RNs (Registered Nurses) a shower. She's getting married." On 3/13/13 at 10:10 AM, EI #11 (the Dietary Manager) was asked where the employees store their personal foods. EI #11 stated it was stored in the clock room, since there was no room in here (the kitchen) to store their stuff. When asked if the staff was allowed to hold things in the kitchen refrigerator, she again stated no, they are not supposed to do that since they don't have room. She was then asked if there another reason not to put employee food in the kitchen refrigerator and she replied, "Infection, cross contamination." 2) The International Dairy Foods Association website (http://www.idfa.org/news--views/media-kits/ice-cream/storing-and-handling-tips/), undated, included the following information: "... Ice cream is a perishable product and should be treated carefully. When frozen desserts are exposed to temperatures above 10 degrees Fahrenheit (F), they become subject to adverse changes in body, texture, and flavor characteristics. ... freezer case should not be above -20 degrees F. If kept at a proper temperature, ice cream will be thoroughly frozen and will feel hard to the touch. ..." The Food and Drug Administration (FDA) and the Centers for Disease Control and Prevention (CDC) of the United States (U.S.) Department of Health and Human Services (HHS) and the Food Safety and Inspection Service of the U.S. Department of Agriculture (USDA), 2009 Food Code, 3-501.11 Frozen Food, revealed: "Stored frozen Foods shall be maintained frozen." The ice cream in the freezer compartment was tested for firmness and found to be soft to the touch. EI #13 (a Dietary Aide) was asked to check the ice cream temperature. When the temperature was checked by puncturing the Styrofoam container with the thermometer, the internal temperature registered 5.1 degrees F. 3) The FDA and the CDC of the U.S. Department of HHS and the Food Safety and Inspection Service of the USDA, 2009 Food Code, 2-402.11, Hair Restraints, revealed: "... shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed Food; clean Equipment, Utensils and Linens and unwrapped Single-Service and Single-Use Articles." On 3/13/13 at 10:00 AM, during a kitchen observation, an activity department employee was noted to enter the kitchen through the door from the dining room. She passed through the beverage area, through the dishwashing (clean and dirty areas) and stood adjacent to the clean pot rack that contained utensils. The employee spoke to EI #11. EI #11 was gathering "snacks" for the employee. When EI #11 entered the dry storage area, she was followed by the activity employee. The activity staff person had not washed her hands, nor did she have any type hair restraint for her long, shoulder-length hair. On 3/13/13 at 10:10 AM, EI #11 was asked if other people (other than Dietary employees) were allowed to come into the kitchen. EI #11 replied, "Only on that side, coming to my office."

Based on observation, record review and interviews, the facility failed to store biohazard materials in a secured, locked area. The biohazard containment area had containers overflowing, bags unsecured and biohazard debris on the ground. This had the potential to attract pests and rodents and affect 46 of 46 residents in the facility. The facility further failed to ensure Licensed staff did not administer medications to Resident Identifier (RI) #15 after the medication was dropped onto the top of the medication cart. This affected 1 of 4 nurses observed during medication pass. Findings include: 1) The facility policy titled, "Infectious Waste, Handling of," no date, documented the following information: "... Purpose: The purpose of this procedure is to provide a definition of and guidelines for the safe and appropriate handling of infectious waste... General Guidelines 1. For the purpose of this policy, infectious waste includes human blood and blood-soiled articles, contaminated items (i.e. (such as), soiled dressings), items contaminated with feces from a person diagnosed as having a disease that is transmitted through feces, and disposable sharps (i.e., needles/scalpels) ... 6. Outside of compactor/dumpster must be locked when not in use and at night ... Infection Control Protocol and Safety ... 4. After completion of the procedure, clean, store and/or dispose of equipment and supplies in red barrels in the biohazard containment area. Insure the enclosure is locked." On 03/12/13 at 4:35 PM, during the initial tour, it was noted the facility had several residents on contact isolation. On 3/12/13 at 4:55PM, the following observation was made of the containment area for the biohazard waste, which was located outside the side entrance: 1) the door to the enclosement was unlocked and the lock was hanging unlocked on the latch and the key was in the keyhole. 2) there were five storage containers of which: - the first red container was overflowing of red biohazard bags and the lid was not secured. - the second red container was full and the lid was not secured. - the third container was a regular gray-colored garbage can with a lid that was not secured, the bags were also not secured and contaminated items were hanging out of the bag. - the fourth container was a yellow colored barrel that was overflowing with red bags that were not secured and contaminated items were hanging out of the bag. There was contaminated debris, such as gloves on the ground by the storage door. On 03/12/13 at 5:40 PM, Employee Identifier (EI) #2 (the Director of Nurses) was asked how did the facility contain the biohazard waste. EI #2 replied the employees bring it out and put it inside the gate. EI #2 was asked was the area suppose to be kept locked. EI #2 replied she knew there was a lock and a key. At this time EI #2 observed the unlocked gate door and the lock hanging on the latch with the key in the keyhole. EI #2 was asked to describe what she saw to the surveyor. EI #2 replied there are 4 containers that are overflowing, the bags were not secured and gloves were on the ground. EI #2 further commented the facility had an increase in contact isolation residents and they needed an increase in the pick-up of waste from one time a week to at least two times a week. EI #2 was asked if the biohazard waste was properly contained. EI #2 replied no. In an interview on 3/16/13 at 1:20 PM, EI #14 (the Infection Control Nurse) was asked about the handling of the biohazardous waste. EI #14 stated the CNAs (Certified Nursing Assistants) and Aides take the bags to storage. When asked how they are secured, she replied they tie them in a knot, a double knot, and do not overfill. When asked if the area is locked, EI #14 replied it was supposed to be locked, but said the key was hanging off the canopy at the fence. But, it is now on the nurses medicine cart. When asked why it should be locked, EI #14 replied, "If someone comes up in there, it has all kinds of things in there --- bacteria, blood, glass, needles, etc." 2) A review of the facility's policy and procedure titled, "Medication Administration using 'Pouch System'," without a date, revealed the following: "... If a pill is dropped, a replacement pill should be obtained from the last pouch available in the cycle. Pharmacy should be notified of the pouch that needs to be replaced. If a pill is dropped and it is the last available pouch, the pill(s) may be replaced from the stat cabinet or back-up. Pharmacy must be notified promptly." RI #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 03/12/13 at 5:15 PM, the surveyor observed EI #7 (a Licensed Practical Nurse/LPN) during medication pass observation. The following was observed: EI #7 proceeded to dispense RI #14's medication. During the dispensing of RI #14's medications into the medication cup, a Simvastin 10 mg (milligram) tablet fell on to the medication cart's countertop. EI #7 proceeded to pick the pill up from off the countertop with a spoon and placed the tablet back into the medication cup with the other medications. EI #7 mixed the medications with applesauce and administered the medications to RI #14. On 03/12/13 at 5:21 PM, during an interview with EI #7, the surveyor asked when was the last time the medication countertop was cleaned. EI #7 stated, "When I started." The surveyor asked what time was that. EI #7 stated, "Between 3:30 and 4:00 (PM)." The surveyor asked was the top of the medication cart clean. EI #7 stated, "Yes." The surveyor asked what medication fell on to top of the medication cart. EI #7 stated, "Simvastin." The surveyor asked when the medication came into contact with the top of the medication cart, what should she (EI #7) have done. EI #7 stated, "Threw it (Simvastin) away." The surveyor asked was that policy and procedure. EI #7 responded, "Yes." The surveyor asked why was the pill not thrown away. EI #7 stated, "I don't have another one to give him." The surveyor asked why not. EI #7 stated, "Pharmacy bring medications in packet, if we drop one, have to bring one from pharmacy."

Based on observation, record reviews and interviews, the facility failed to ensure mattresses were correctly sized to fit residents' bed frames. This affected Room Locator (RL) #1 and RL# 3 through # 32, thirty-two of 63 beds in the facility on 2 of 2 halls. This also affected Resident Identifier (RI) #9, who was observed during a medication pass, with his feet noticeably positioned off the end of his mattress and touching the footboard. Findings include: An invoice from a medical equipment supplier documented the following purchase of beds for the facility: "... Date 4/12/2012 Quantity 30 Med-Mizer Retracta Bed Package with Headboard and footboard ***Note: Beds are sold as Used/As Is Condition** ** No manufacture Warranty..." An invoice from a medical equipment supplier documented the following purchase of 25 mattresses for the facility: "... 2/27/2013 ... 25 Each ... Multilayer multizoned foam with 4 way stretch cover with fire barrier ..." On 03/14/13 at 7:55 AM, during medication pass, the following was observed in RL #2; Resident Identifier (RI) #9's mattress was observed with a large space between the end of the mattress and the footboard. RI #9's lower legs and feet were positioned off the end of the mattress with soles of his feet against the footboard. The surveyor measured the space, which was approximately eight and a half inches. The surveyor asked RI #9 how tall he was and RI #9 responded six feet. On 03/14/13 at 8:55 AM the following observations were made of the gap between the foot of the mattress and the footboard in Room Locator (RL) #1, and RL #3 through RL #33 was measured by Employee Identifier (EI) #2 (the Director of Nursing/DON) and EI #5 (the Director of Maintenance): RL #1 - 3 1/2 inches RL #3 - 4 inches RL #4 - 3 inches RL #5 - 3 1/2 inches RL #6 - 3 inches RL #7 - 4 1/2 inches RL #8 - 3 inches RL #9 - 3 3/4 inches RL #10 - 4 inches RL #11 - 4 inches RL #12 - 5 inches RL #13 - 5 1/2 inches RL #14 - 4 1/2 inches RL #15 - 3 1/2 inches RL #16 - 2 1/2 inches RL #17 - 3 inches RL #18 - 3 inches RL #19 - 7 inches RL #20 - 9 inches RL #21 - 4 1/2 inches RL #22 - 3 inches RL #23 - 4 inches RL #24 - 3 1/2 inches RL #25 - 3 inches RL #26 - 2 inches RL #27 - 3 inches RL #28 - 5 inches RL #29 - 2 1/2 inches RL #30 - 2 1/2 inches RL #31 - 2 1/2 inches RL #32 - 3 1/2 inches RL #33 - 4 inches On 03/14/13 at 10:20 AM, EI #5 was asked who was responsible to put mattresses on residents' beds. EI #5 replied he only put mattresses on the bed when he was asked. EI #5 was asked when he put a mattress on a bed did he ever notice the mattress was too short. EI #5 replied no, he did not pay that much attention. EI #5 was asked who was responsible for ordering mattresses. EI #5 replied Housekeeping. On 03/14/13 at 10:30 AM, EI #8 (the Staffing Coordinator) was asked who was responsible for ordering mattresses. EI #8 replied that would be EI #9 (the Administrator). EI #8 was asked who would be responsible to measure the beds to get the right size mattress. EI #8 replied that would be Housekeeping. EI #8 further commented they had ordered mattresses a long time ago. On 03/14/13 at 4:45 PM, during an interview with EI #9 (the Administrator), the surveyor asked why did he order the mattresses on 2/27/13. EI #9 replied, "We needed them, because I noticed the mattresses were too short for the bed frames. We purchased new beds and beds were four inches longer than old ones." EI #9 further stated, "Mattresses were too short for new beds, 80 inches and old beds, 76 inches." The surveyor asked when was he made aware that the mattresses were too short. EI #9 stated, "About a month ago." The surveyor asked what was done regarding the mattresses. EI #9 stated he ordered 25 new mattresses on the the 27th of February, 2013. EI #9 further stated that he thought 25 would be enough mattresses until today (03/14/13), after the surveyors observed the short mattresses. EI #9 stated after the walk-through with the surveyors, he realized the facility needed 33 new mattresses. EI #9 also stated he purchased eight mattresses from a local medical supply company and replaced eight of the old mattresses today (03/14/13). The surveyor asked what was put in place immediately after becoming aware a month ago of the short mattresses. EI #9 stated they used blankets and foam wedges to put in the spaces where the mattresses were too short for the bed frames. The surveyor asked what happened with the blankets and the foam wedges, because there were no observations of those items in the spaces. EI #9 stated, "I don't know, staff may have taken out." The surveyor asked what documentation was there to reflect the staff was inserviced on using the blankets and the foam wedges to fill in the spaces. EI #9 stated, "Probably none, just word of mouth." The surveyor asked by whom. EI #9 stated, "By me, talking to employees." On 3/15/13 at 10:00 AM observations of the residents, rooms and beds for the identified potential for increased risk: a.) The resident in RL #7 stated they had put a new mattress on his bed yesterday (on 3/14/13), but it was hard although it fits the bed better. He also stated he did not have a new bed. His bed had been there since he had been there for the past 4 or 5 years. b.) RL #28 had booties and blanket at the foot of the bed in the gap between the mattress and footboard. The resident in RL #28 stated she keeps the blanket to put across her feet at night because her feet get cold. c.) RL #30 had a large gap at the foot of the bed. The resident in RL #30 was asked if she ever had a problem getting her feet or arms caught in the gap at the foot of the bed area. She stated, "No, just my clothes sometimes, my housecoat." On 03/15/13 at 10:05 AM, the surveyor asked EI #9 who was responsible for ensuring the mattress size was the correct size for the bed frame. EI #9 stated, "Basically me and maintenance man." The surveyor asked how did he know the mattresses were too short for the bed frames he had ordered. EI #9 stated, "I make daily rounds every morning, I just hadn't picked up that mattresses were shorter." The surveyor asked why were new beds purchased and when were they purchased. EI #9 replied, "Actually, probably summer." The surveyor asked how many. EI #9 responded 33. The surveyor asked why were the new beds ordered. EI #9 stated, "Better for skin, traditional beds when raised can cause shearing, with new beds when raised mattresses never change position." The surveyor asked who ordered the mattresses. EI #9 stated, "I did." The surveyor asked what was done to ensure mattresses and bed frames were correct in size. EI #9 stated, "Housekeeping put them on and I assumed we were using 80 inch mattresses." The surveyor asked what size beds were ordered. EI #9 stated 80 inches. The surveyor asked what size were the old beds. EI #9 stated 76 inches. The surveyor asked when did you check the new bed frames to ensure the mattresses would fit. EI #9 stated, "Well, I didn't, because I assumed that mattress we were using fit." The surveyor asked regarding the new mattress that were ordered on [DATE], when will they be in. EI #9 stated, "Next week." So we can fill in those voids (spaces). The surveyor asked why was staff instructed to fill the spaces. EI #9 responded, "Couple of them (spaces between mattress and the foot board) was apparent, five to six inch gap." The surveyor asked what was the potential for a space that large. EI #9 stated, "Entrapment with siderail, but five to six inch space between mattress and footboard/headboard, I can't see entrapment there with that small of space." The surveyor asked why fill it (space/gap), if not a concern. EI #9 stated, "Entrapment not an issue." The surveyor asked why fill it, if not a concern. EI #9 replied, "Keep mattress from moving." The surveyor informed EI #9 of the statement he made earlier that with the new beds he ordered, the mattresses did not move and never changed position. The surveyor then asked why fill the gap with blankets or wedges. EI #9 stated, "Getting larger men and mattress wasn't long enough for them." The surveyor asked why not purchase a mattress and bed that would fit larger individuals. EI #9 stated, "I thought using 80 inch mattress." The surveyor asked what was put in place for larger individuals with short mattresses. EI #9 stated, "Using foam wedges and quilts." The surveyor asked what happened with the foam wedges and quilts, because on tour and during the observation of beds, no wedges, blankets or quilts were being used. EI #9 stated, "I don't know what happen." The surveyor asked as administrator, should he know what happened. EI #9 stated, "Well, been being in place, I make morning rounds." The surveyor asked with rounds on yesterday (03/14/13), what did he observe regarding the beds. EI #9 replied, "I didn't observe the beds yesterday, concern on halls and storage." The surveyor asked who was ultimately responsible for the safety and welfare of the residents, building and the staff. EI #9 stated, "Me primarily, but all staff." On 3/16/13 at 9:00 AM, EI #15 (a Licensed Practical Nurse) was asked if she had noticed a space/gap between the mattress at the footboard of the bed. EI #15 stated she had on some of the beds, she just thought that was the way were were made. EI #15 was asked what would happen if a resident got caught in the gap between the mattress and footboard. EI #15 replied, "If you really thought. If they scooted down there they could get a foot caught, but that has never happened as far as I know."

Based on observation, interview and record review the facility failed to ensure Resident Identifier (RI) #5's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. This affected 1 of 4 medication carts. Findings include: A review of the facility's policy and procedure titled, "HIPAA (Health Insurance Portability & Accountability Act)," undated, revealed the following: "... Policy Interpretation and Implementation ... 5. For HIPAA reasons, all medical records must be maintained in a matter (manner) to not be readily accessible. ..." A review of the facility's employee handbook revealed the following: "... Privacy and Confidentiality of Medical Information All information of a medical ... nature regarding any Resident in the Nursing Home is strictly confidential ..." 1) RI #5 was admitted to the facility on [DATE]. A review of RI #5's March 2013 MAR indicated [REDACTED]. During the initial tour on 03/12/13 at 4:35 PM, the following observation was made: A medication cart was positioned on the West Hall, with drawers facing the hallway. A book containing residents' MARs was opened and RI #5's March 2013 MAR indicated [REDACTED]'s name, RI #5's allergies and RI #5's [DIAGNOSES REDACTED]. On 03/12/13 at 4:36 PM, during an interview with Employee Identifier (EI) #3 (the Registered Nurse/RN), the surveyor asked who was responsible for the medication cart. EI #3 stated, "Mine." The surveyor asked which resident's MAR indicated (Name of RI #5)." The surveyor asked what was the policy and procedure for privacy regarding a resident's MAR indicated Supposed to been covered." The surveyor asked was policy and procedure followed for maintaining resident's privacy. EI #3 stated, "No." 2) On 03/14/13 at 5:05 PM, the medication cart on the West Hall was observed with RI #5's MAR indicated [REDACTED]. The Licensed staff (EI #1) was in RI #5's room giving her medication. The MAR indicated [REDACTED] Resident's name Diagnosis Medications Date of Birth Medicaid Number EI #1 (Licensed Practical Nurse, LPN) was asked what did she see wrong with the MAR indicated [REDACTED]. EI #1 was asked what was the facility's Policy and Procedure for resident information. EI #1 replied to make sure all resident information is kept confidential. She said the MAR indicated [REDACTED]. EI #1 was asked why she did not protect the resident's information. EI #1 replied she just was not paying attention.

Based on observations, interviews and record reviews, the facility failed to determined if two residents, Resident Identifier (RI) #6 and RI #13 could safely self-administer medications. RI #6 was observed during administration of a [MEDICATION NAME] treatment in the absence of the nurse. RI #13 was observed to self administer [MEDICATION NAME] Inhalation. This affected two of four nurses observed during medication pass. Findings Include: A review of the facility's policy and procedure titled, "Self-Administration of Medication," without a date, revealed the following: "...General Guidelines 1. A resident may not be permitted to administer or retain any medication ... unless so ordered, in writing, by the attending physician. 2. ... A. The physician's orders [REDACTED]. A review of the facility's policy and procedure titled, "E. Small Volume Nebulizer," without a date, revealed the following: "... Nurses must remain with resident during administration unless a self-administration order and complete assessment is in place. ..." 1) RI #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #6's current Quarterly Minimum Data Set (MDS), dated [DATE], revealed RI #6's BIMS (Brief Interview for Mental Status) score was 5, indicating severe impairment in cognitive skills. On 03/13/13 at 11:06 AM, during medication pass observation, the following was observed: Employee Identifier (EI) #4 (the Licensed Practical Nurse/LPN) administered RI #6's oral medications. EI #4 then administered the [MEDICATION NAME] nebulizer treatment. At 11:20 AM, after beginning the nebulizer treatment, EI #4 exited RI #6's room and walked across the hall to another resident's room, out of view of RI #6's room. At 11:25 AM, EI #4 entered RI #6's room and encouraged the resident to take deep breaths. At 11:30 AM, the nebulizer treatment was completed. On 03/13/13 at 11:32 AM, during an interview with EI #4, the surveyor asked what was the policy and procedure for staying with a resident during the administration of a nebulizer treatment. EI #4 stated, "Supposed to keep eye contact on them." The surveyor asked how often. EI #4 stated, "I would have to look because I was across the hall." The surveyor asked did she maintain eye contact with the resident at all times during the administration of the nebulizer treatment. EI #4 stated, "No, I don't suppose I did." 2) RI #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the most current MDS, dated [DATE], revealed RI #13's BIMS score was 15, indicating RI #13 was cognitively intact. On 03/13/13 at 11:41 AM, during medication pass observation, the following was observed: EI #6 (LPN) dispensed and administered oral medications and eye drops to RI #13. EI #6 handed RI #13 the [MEDICATION NAME] inhaler and the resident gave herself (RI #13) two puffs from the inhaler. RI #13 returned the [MEDICATION NAME] inhaler to EI #6. On 03/13/13 at 11:55 AM, during an interview with EI #6, the surveyor asked what type of an assessment did RI #13 have to self-administer the [MEDICATION NAME] inhaler. EI #6 stated, "I don't know, I'll check." RI #13's self-administration assessment for medication was not completed by the facility until 3/15/13.

Based on observations, interviews and review of the facility's policy, the facility failed to: 1) date and label a milk shake stored in the reach in freezer with the date prepared or the use by date; 2) ensure a dishwasher did not pick up rubber gloves off the floor and clip to a clean drying rack that contained pots and pans air drying; and 3) ensure trays were delivered to residents in a manner to prevent cross contamination. This affected 53 of 56 residents receiving meals from the dining room. Findings include: 1) A review of the facility's undated policy titled "Food Receiving and Storage" documented, "...7. All foods stored in the refrigerator or freezer will be covered, labeled and dated ("use by" date) ... ." During the initial tour of the kitchen with Employee Identifier (EI) #6, the Dietary Manager (DM), on 03/13/2012 at 10:30 AM, a home made milk shake was observed in the reach in freezer with no prepared or use by date. On 03/15/2012 at 2:45 PM, EI #6, the DM was asked what did she instruct staff to write on food container labels when storing. EI #6 replied to date with prepared and use by dates. EI #6 was asked if there was an undated milk shake stored in the reach in freezer on 03/13/2012 at 10:30 AM and she replied yes. 2) A review of the facility's undated policy titled "Sanitization" documented, "...2. All utensils, counters, shelves and equipment shall be kept clean ... ." On 03/13/2012 at 12:25 EI #16, the dishwasher, was observed to pick up rubber gloves off the floor and attach them to clothes pins hooked on a drying rack containing pots and pans. EI #6 stated the pots, pans and items on the rack were clean and placed on the rack to air dry. EI #6 was asked what picking items off the floor and placing them on the clean cart would cause and she replied contamination of the clean items. 3) A review of the facility's undated policy titled "Sanitization" documented, "...14. Dumbwaiters (carts) may be used to transport food to dining areas and soiled dishes back to the dietary department provided that the compartment is sanitized between the transportation of soiled dishes and food ... ." During the lunch meal service on 03/13/2012 at 11:43 AM, the staff were observed using a three tier utility cart to deliver six resident meal trays to the Rehabilitation Hall. The three tier utility cart was brought back to the kitchen and reloaded with more trays. The utility cart was not sanitized before six more trays were placed on the cart and taken to residents' rooms on the South Hall. During the set up of the residents' meal trays, the staff placed the dome lids of the trays on the residents' over bed tables and beds. The tray dome lids were returned to the utility cart and taken back to the dining room where they were placed on a dining table. The cart was not cleaned before placing other residents' lunch trays on for delivery. On 03/15/2012 at 2:45 PM, EI #6 was asked what happens when a Certified Nurse Assistant takes a tray into a resident's room, removes the dome lid, places it on the resident's bed or overbed table and then returns the lid to the utility cart; EI #6 replied that the utility cart was contaminated. EI #6 was asked what could serving resident trays from the contaminated utility cart cause. EI #6 replied the resident could get sick and infection could spread throughout the building.