Every finding on record at The Healthcare Center of Eastview

Based on resident record review, interview, review of a facility reported incident, and review of a facility policy titled Abuse, Neglect and Exploitation the facility failed to report an allegation of abuse within two hours to the State Agency when Resident Identifier (RI) #7 alleged abuse on 10/20/2023. This deficient practice affected one of five residents reviewed for abuse concerns. Findings include: On 10/23/2023 the facility reported to the Alabama Department of Public Health Online Incident Report System alleged physical abuse that someone pushed RI #7 down on 10/12/2023. The report documented the Administrator was made aware of the allegation on 10/20/2023. A facility policy titled Abuse, Neglect and Exploitation with a revised date of 11/2017 documented the following: . PROCEDURE: In response to alleged . incidents involving abuse, . the Facility will take the following steps: If determined to be reportable, the event will be reported to the Alabama Department of Public Health . within two (2) hours of the incident if the event involves abuse . or not later than twenty-four (24) hours if the event does not involve abuse . RI #7 was readmitted to the facility on [DATE] and discharged on [DATE] with diagnoses to include Dementia. An interview was conducted with the Administrator on 05/16/2024 at 10:20 AM. The Administrator said, the local ombudsman reported to the facility on [DATE] that RI #7 had reported being pushed while in the facility. The Administrator said, it was reported to the State Agency on 10/23/2023 and should have been reported on 10/20/2023 after the report was received. The Administrator said, it was important to report allegations of abuse within two hours to ensure the safety of residents and start an investigation. ********************************** This deficiency was cited as a result of the investigation of complaint/report number AL00045965.

Based on observation, interview, review of a facility policy titled Daily Dumpster Monitoring, and the United States (U.S.) Food and Drug Administration (FDA) 2022 Food Code, the facility failed to ensure the top lid and side door on one of two dumpsters was not open during an observation on 09/10/2023. The facility further failed to ensure the grease vat top was not broken and did not have excessive grease build up on the outside of the grease bin. This was observed on 09/10/2023, 09/12/2023, and 09/13/2023. This had the potential to effect 102 of 102 residents in the facility. Findings include: A facility policy titled Daily Dumpster Monitoring dated 10/2006 documented: . Maintenance and Housekeeping staff will inspect all dumpsters each day to ensure that the surrounding areas are free of debris and that the dumpster lids are closed. The U.S. FDA 2022 Food Code included the following: . 5-5 Refuse, Recyclables, and Returnables . 5-501.13 Receptacles. (A) . receptacles and waste handling units for REFUSE, recyclables, and returnables and for use with materials containing FOOD residue shall be durable, cleanable, insect- and rodent-resistant, leakproof, and nonabsorbent. 5-501.15 Outside Receptacles. (A) Receptacles and waste handling units for REFUSE, recyclables, and returnables used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers. (B) Receptacles and waste handling units for REFUSE and recyclables . shall be installed so that accumulation of debris and insect and rodent attraction and harborage are minimized . 5-501.110 Storing Refuse, Recyclables, and Returnables. REFUSE, recyclables, and returnables shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. 5-501.111 Areas, Enclosures, and Receptacles, Good Repair. Storage areas, enclosures, and receptacles for REFUSE, recyclables, and returnables shall be maintained in good repair. 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: . (B) With tight-fitting lids or doors if kept outside the FOOD ESTABLISHMENT. On 09/10/2023 at 11:38 AM, an observation was made with Employee Identifier (EI) #4, Dietary Cook, of a grease vat outside the facility with a broken lid preventing it from being closed and grease on the outside of the container. EI #4 agreed the lid was broken, and grease was on the outside. On 09/10/2023 at 11:40 AM, an observation was made with EI #4 of two dumpsters outside the facility, with one of them having an open top and side door. EI #4 agreed that doors were open and should be closed to keep animals out. On 09/12/2023 at 12:00 PM, the surveyor observed a broken lid on the grease vat located outside the facility, with grease present on the exterior of the bin. On 09/13/2023 at 9:46 AM, an observation was made with EI #5, the Dietary Manager, of the presence of grease on the exterior of the grease vat located outside the facility. EI #5 was interviewed on 09/13/2023 at 9:00 AM. EI #5 stated, the doors on the outside garbage dumpster should always be closed to prevent rodents from entering it and thrash from blowing out. EI #5 further said, the grease vat top should be completely sealed where nothing could drain out and the outside of the bin should be clean. EI #5 said, if rodents got inside the building it could make the residents sick.

Based on resident record review, interviews, and review of Centers for Medicare & Medicaid Services Long Term Care Facilities Resident Assessments Instrument 3.0 User Manual Version 1.17.1, the facility failed to ensure timely completion, submission, and acceptance of Minimum Data Set (MDS) Assessments for Resident Identifier (RI) #1, RI #6, RI #11, RI #15, RI #17, RI #19, and RI #26. This had the potential to affect seven of 29 residents for whom MDS assessments were reviewed. Findings include: Review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2019, revealed the following: CHAPTER 5: SUBMISSION .OF THE MDS ASSESSMENTS Nursing homes are required to submit Omnibus Budget Reconciliation Act (OBRA) required Minimum Data Set (MDS) records for all residents in Medicare- or Medicaid-certified beds regardless of the pay source . All Medicare and/or Medicaid-certified nursing homes . must transmit required MDS data records to CMS' Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system . 5.2 Timeliness Criteria . - For all non-Admission OBRA and PPS assessments, the MDS Completion Date (Z0500B) must be no later than 14 days after the Assessment Reference Date (ARD) (A2300). Assessment Transmission: . (non-comprehensive) MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days) . RI #1 was admitted to the facility on [DATE]. RI #1's quarterly MDS assessment with an Assessment Reference Date (ARD) of 07/05/2023 documented Open status and had not been completed, submitted, and accepted. Section Z0500B of the assessment was blank and had not been signed and dated by the Registered Nurse (RN) as complete. RI #6 was admitted to the facility on [DATE] and discharged on [DATE]. RI #6's quarterly MDS assessment with an ARD of 05/26/2023 documented Closed status and had not been submitted and accepted. Section Z0500B was not signed and dated by the RN as completed until 09/12/2023. RI #11 was admitted to the facility on [DATE]. RI #11's quarterly MDS assessment with an ARD of 07/31/2023 documented Open status and had not been completed, submitted, and accepted. Section Z0500B was blank and had not been signed and dated by the RN as complete. RI #15 was admitted to the facility on [DATE]. A review of RI #15's quarterly MDS assessment with an ARD 06/27/2023 documented Open status and had not been completed, submitted, and accepted. Section Z0500B was blank and had not been signed and dated by the RN as complete. RI #17 was readmitted to the facility on [DATE]. RI #17's quarterly MDS assessment with an ARD of 06/27/2023 documented Open status and had not been completed, submitted, and accepted. Section Z0500B was blank and had not been signed and dated by the RN as complete. RI #19 was admitted to the facility on [DATE]. RI #19's quarterly MDS assessment with an ARD of 06/28/2023 documented Open status and had not been completed, submitted, and accepted. Section Z0500B was blank and had not been signed and dated by the RN as complete. RI #26 was admitted to the facility 03/13/2023. RI #26's quarterly MDS assessment with an ARD of 06/15/2023 documented Open status and had not been completed, submitted, and accepted. Section Z0500B was blank and had not been signed and dated by the RN as complete. On 09/12/2023 at 4:00 PM EI #2 MDS Coordinator was asked about RI #6's quarterly MDS dated [DATE]. EI #2 said it had not been submitted. When asked what the time frame for submission of the quarterly MDS dated [DATE] was, EI #2 said, it would be 06/23/2023 and she had not submitted it yet. When EI #2 was asked why it was not yet submitted, she repeated, she had not submitted it yet. EI #2 said, the MDS should be submitted to be in compliance with CMS guidelines. On 9/12/23 at 6:24 PM EI #2 was questioned further about MDS assessments not being submitted. EI #2 said, her duties as the MDS Coordinator were to coordinate the MDS process including all assessments and ensuring they were completed and submitted. EI #2 was asked when should an MDS be submitted. EI #2 said, per the guidelines. When EI #2 was asked what were the guidelines EI #2 said she went by the time line the computer gave her. EI #2 was asked to review with the surveyor the list of residents with concerns of the MDS submissions. EI #2 said, RI #1's quarterly MDS dated [DATE] had not been transmitted and should have been done by 08/02/2023. EI #2 said, RI #11's quarterly MDS dated [DATE] had not been transmitted and the date should have been 08/28/2023. EI #2 said, RI #15's quarterly MDS dated [DATE] had not been transmitted and should have been by 07/25/2023. EI #2 said, RI #17's quarterly MDS dated [DATE] had not been transmitted and should have been by 07/25/2023. EI #2 said, RI #19's quarterly MDS indicated open, it should have been submitted 07/26/2023. When EI #2 was asked if this MDS was submitted timely, she said, no. EI #2 said, she had not had the opportunity to complete and transmit it. EI #2 was asked when should RI #26's quarterly MDS dated [DATE] have been transmitted. EI #2 said, by 07/13/2023 and it had not yet been transmitted. When EI #2 was asked how she knew when to transmit, she said, per the manual. On 09/13/2023 at 8:38 AM EI #2 was further interviewed, she was asked how many days after the ARD date should the MDS be completed. EI #2 said, it depended on the assessment. EI #2 was asked what would the completion date be for a quarterly MDS with the ARD 06/15/2023. EI #2 said, within 14 days of that type of assessment being completed. EI #2 was asked, how many days after the completion of the quarterly MDS assessment should it be submitted. EI #2 said, within 14 days of that quarterly type assessment. On 09/13/2023 at 8:59 AM an interview with EI #1 the Director of Nursing was done. EI #1 was asked how many days after the ARD date of a quarterly MDS should the MDS be completed. EI #1 said, 14 days. EI #1 said, a discharge MDS should be completed in seven or 14 days. EI #1 was asked how many days after the completion of the quarterly MDS assessment should it be submitted. EI #1 said, it should be at the time of completion, when a MDS was completely closed you had 14 days to submit it. EI #1 said, the concern with MDS assessments not submitted/transmitted timely was a compliance issue.

Based on interview, review of the Notice of Medicare Non-Coverage (NOMNC) CMS Form 10123, review of a facility policy titled Notice of Medicare Non-Coverage, and review of beneficiary notification for Resident Identifier (RI) #29 and RI #140, two of two residents sampled for beneficiary liability, the facility failed to ensure RI #29 and RI #140 were issued a beneficiary liability notice at least two days prior to the end of Medicare Part A covered days. Findings include: A facility policy titled Notice of Medicare Non-Coverage, revised 07/2014, documented: . Skilled Nursing Facilities are required to issue a notice of non-coverage to a resident at least two (2) days before the resident's coverage of services should end. The purpose of the notice is to ensure that residents are notified of their appeal rights when services are terminating. RI #29 was admitted to the facility on [DATE]. RI #29's SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review form completed by the facility, documented RI #29's Medicare Part A Skilled Services Episode started on 04/24/2023 and the last covered day of Part A services was on 05/12/2023. RI #140 was admitted to the facility on [DATE]. RI #140's SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review form completed by the facility, documented RI #140's Medicare Part A Skilled Services Episode started on 01/19/2023 and the last covered date of Part A services was on 03/09/2023. An interview was conducted on 09/12/2023 at 4:07 PM with Employee Identifier (EI) #6, Bookkeeper/Business Manager. EI #6 stated she was responsible for providing the SNF notices to residents and the SNF notices should be issued 48 hours before the last covered date. EI #6 stated RI #29's last covered date was 05/12/2023 and the notice was signed /issued on 05/12/2023 and RI #140's last covered date was 03/09/2023 and the notice was signed/issued on 03/10/2023. EI #6 stated RI #29 and RI #140 should have been given their SNF Beneficiary notices 48 hours (2 days) before their last covered date, so that they were aware of their last covered date and they could have appealed it if they had wanted to.

Based on observations, interview, resident record review, and review of the Long-Term Care Facility Resident Assessment Instrument 3.0, the facility failed to ensure a care plan for oxygen use was in place for Resident Identifier (RI) #11. This had the potential to affect RI #11, one of 19 residents for whom care plans were reviewed during the survey. Findings include: A review of Long-Term Care Facility Resident Assessment Instrument 3.0, documented: .4.2 .The RAI-related processes help staff identify key information about residents as a basis for identifying resident-specific issues and objectives. In accordance with 42 CFR 483.21(b) the facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident ' s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment .4.7 . the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident ' s highest practicable physical, mental, and psychosocial well-being . RI #11 was readmitted to the facility on [DATE] and had diagnoses to include Pneumonia and Chronic Ischemic Heart Disease. RI #11's annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 05/01/2023 documented in Section O, RI #11 received oxygen therapy while a resident at the facility. RI #11's September 2023 physician orders documented an order dated 11/19/2021 for RI #11 to receive Oxygen at two liters per minute via nasal cannula continuously. On 09/11/2023 at 5:51 PM RI #11 was observed receiving oxygen at a rate of two liters per minute. On 09/12/2023 at 9:38 AM the surveyor reviewed the care plans for RI # 11 and was unable to locate a care plan pertaining to the use of oxygen. On 09/13/2023 at 11:01 AM RI #11 was observed receiving oxygen at a rate of two liters per minute. On 09/12/2023 at 4:19 PM an interview was conducted with Employee Identifier (EI) #2, a Registered Nurse (RN), and MDS Coordinator. EI #2 stated that RI #11's most recent annual MDS assessment was completed on 05/01/2023, and identified RI #11 as utilizing oxygen. When asked about a care plan for RI #11's oxygen usage, EI #2 said, she was unable to locate an oxygen care plan. Additionally, EI #2 said, if oxygen was in use a care plan was needed. EI #2 explained, care plans were developed based on observations and the MDS process, and it was the responsibility of the entire team to create the care plans.

Based on observation, interviews, record review, and review of a facility policy titled Standard Precautions, the facility failed to ensure a Licensed Nurse washed her hands after she administered an eye drop medication to Resident Identifier (RI) #24, removed her gloves, and prior to administering RI #24's oral medications. This affected one of three nurses and one of three residents observed during medication pass. Findings Include: A review of a facility policy titled Standard Precautions, with a revised date of 9/2010, revealed . Standard Precautions will be used in the care of all residents . POLICY INTERPRETATION AND IMPLEMENTATION: 1. Hand Hygiene. b. Wash hands immediately after gloves are removed. and when otherwise indicated to avoid transfer of microorganisms to other residents or environments. On 2/20/20 at 8:30 a.m., the surveyor observed Employee Identifier (EI) #1, a Registered Nurse (RN), during medication administration pass. EI #1 gave an eye drop medication to RI #24's right and left eyes, removed her gloves, and did not wash her hands or use hand sanitizer prior to administering RI #24's oral medications. On 2/20/20 at 10:30 a.m., the surveyor conducted an interview with EI #1. EI #1 was asked, what she should have done after administering an eye drop medication to RI #24, removing her gloves, and prior to administering RI #24's oral medications. EI #1 stated she should have removed her gloves and washed her hands. EI #1 was asked why she had not wash her hands or used hand sanitizer. EI #1 stated, she forgot. EI #1 was asked, what does the facility Hand Washing Policy state should be done after giving a resident an eye drop medication and removing gloves. EI #1 stated, go directly and wash hands. EI #1 stated, hands should be washed before patient care, after patient care, after removing gloves, before applying gloves and in between residents. EI #1 was asked, what would be the concern if a Licensed Nurse did not wash or sanitize her hands after she gave an eye drop medication, removed her gloves, and prior to administering oral medications. EI #1 stated, it could transfer germs to the resident, herself, or other people. On 2/20/20 at 10:45 a.m., the surveyor conducted an interview with EI #2, an Infection Control Preventionist/Registered Nurse. EI #2 was asked, what should a Licensed Nurse do after she gave an eye drop medication, removed her gloves, and prior to administering oral medications. EI #2 stated, she should wash her hands or use a hand sanitizer. EI #2 was asked, what does the facility Hand Washing Policy state should be done after administering an eye drop medication to a resident, removing gloves and prior to administering an oral medication to a resident. EI #2 stated, she should wash her hands after she removed her gloves. EI #2 was asked, what would be the concern if a Licensed Nurse did not wash her hands or use hand sanitizer after she gave an eye drop medication, removed her gloves, and prior to administering oral medications. EI #2 stated, it could cause an infection to the resident, the nurse, and other people.

Based on observations, interviews, and review of facility policies titled, SANITARY CONDITIONS OF THE FOOD SERVICE DEPARTMENT, and, FOOD FROM OUTSIDE SOURCES, the facility failed to ensure: 1. vents located above the tray line were clean and not full of dust particles; and 2. foods being brought in from outside the facility were properly labeled and were discarded after expiration. These failures had the potential to effect 62 of 74 residents in the facility, who received meals from the kitchen. Findings include: 1. A facility policy titled, SANITARY CONDITIONS OF THE FOOD SERVICE DEPARTMENT revised 2/15, revealed, POLICY: Facilities and equipment used in the preparation and serving of food provided to residents are safe and sanitary. PR[NAME]EDURE: 1. The facility is arranged so contact with contaminated sources . is unlikely to occur. On 01/23/19 at 11:33 a.m. , while watching the tray line, a large vent above where the tray line was being conducted, was observed to be full of gray dust-like particles. On 01/24/19 at 09:52 a.m. an interview was conducted with Employee identifier (EI) #3, Dietary Manager. EI #3 was asked, who is responsible for cleaning the vents in the kitchen. EI #3 replied, maintenance does it. EI #3 was asked, how often are they cleaned. EI #3 replied, he cleans them, usually once a month. EI #3 was asked if she noticed a lot of dust in the vent located above the tray line yesterday. EI #3 replied, yes. EI #3 was asked, what is the potential concern for a vent, located above where the tray line is, being full of dust. EI #3 replied, particles could get in the food. 2. A facility policy titled, FOOD FROM OUTSIDE SOURCES, revised 10/17, revealed, POLICY: The facility procures food based on the current menu from sources approved or considered satisfactory by federal, state or local authorities. Food that is brought to residents from family, visitors or volunteers is handled in a safe and sanitary manner. PR[NAME]EDURE: . 4. a. ii. Refrigerated foods are labeled with the date and time of storage. iii. Commercially prepared foods are discarded no later that the Use By Date. b. iii. The label includes the resident's name and room number, the date it is received and stored, and the date it should be discarded. A tour of the refrigerator on unit two with EI #5, Certified Nursing Assistant, on 01/23/19 at 4:48 p.m. revealed, a brown plastic bag with a resident's name on the outside and nothing else, contained an open container of potato salad with an expiration date of 1/14/19. An interview was conducted with EI #4, Licensed Practical Nurse, on 01/24/19 at 10:19 a.m EI #4 was asked, who is responsible for checking the dates of food items in the unit refrigerators. EI #4 replied, house keeping normally does that. EI #4 was asked, how should food items brought in from outside the facility be stored. EI #4 replied, it is supposed to have the name and date, and be separately bagged. EI #4 was asked, when should food items be is discarded. EI #4 replied, definitely after food expires or spoils. EI #4 was asked, what is the potential concern of an out-dated item being in the unit refrigerator. EI #4 replied, a resident could get sick.

Based on observation, interviews, and review of a facility policy titled, Standard Precautions, the facility failed to ensure a Laundry Aide did not allow clean towels, sheets, and wash cloths touch her dress on her upper body when removing these items from the second dryer and during folding. Further, the Laundry Aide did not wash her hands after putting soiled laundry in the small washing machine, prior to putting on another pair of gloves. This had the potential to affect 23 of 74 residents in the facility. Findings Include: A review of a facility policy titled, Standard Precautions, with a revised date of 12/2009, revealed: .1. Hand Hygiene a. Wash hands after touching .contaminated items, whether or not gloves or worn . On 01/24/19 at 08:43 a.m., the surveyor observed the laundry room in the facility. The surveyor observed Employee Identifier (EI) #1, a Laundry Aide, remove the following clean items (for station 1 residents) from the second dryer: 4 sheets and 4 pads. The items touched her personal dress on the upper body area. The surveyor observed EI #1 fold the 4 sheets and 4 pads and touched her personal dress on her upper body area. On 01/24/19 at 08:53 a.m., the surveyor observed EI #1 put on a disposable apron and gloves. EI #1 removed the soiled towels, wash cloths, and sheets from the gray linen container for station 1 residents. EI#1 placed the soiled items in the small washing machine, started the washing machine to wash the clothes, removed her gloves (EI #1 did not wash hands), put on gloves, and rolled the gray linen container to the outside of the soiled utility room. An interview was conducted on 01/24/19 at 11:23 a.m. with EI #1, a Laundry Aide. EI #1 was asked when you took the 4 sheets and 4 pads from the second dryer for station 1 residents and started folding these items, did the clean laundry items touch your dress on your upper body. EI#1 stated she did not intend for the clothes to touch her dress, but should have put on an apron. EI #1 was asked if clean clothes being removed from a dryer and folding clean laundry should touch an employee's dress. EI #1 stated no, because it could contaminate the clean clothing and a resident has a potential to get an infection. EI #1 was asked what did you do after you removed the soiled towels, wash cloths and sheets from the gray linen container for station 1 residents, and placed these items in the small washer. EI #1 stated she removed her gloves, and did not wash her hands, put on another pair of gloves, and then rolled the gray linen cart to outside of soiled utility room. EI#1 was asked why did you not wash your hands after putting the soiled linen for station 1 residents in the small washer. EI #1 stated that she should have, but didn't. EI #1 was asked what was the concern with not washing your hands after placing soiled laundry in the washer. EI #1 stated you can spread germs to other people. EI #1 was asked what the facility policy was on hand hygiene. EI #1 stated you should pull your gloves off after touching a contaminated item and wash your hands. EI #1 was asked if the facility policy was followed. EI #1 stated no. On 01/24/19 at 11:45 a.m. an interview was conducted with EI #2, Housekeeping/Laundry Supervisor. EI #2 was asked what was the concern with a laundry aide taking 4 sheets and 4 pads from the second dryer, touching her personal dress with these items, and then touching her personal dress when folding these items. EI #2 stated it could cause contamination and infection to anyone. EI #2 was asked what was the concern when a laundry aide removed soiled towels, wash cloths and sheets from a gray linen container, placed these soiled items in the small washing machine, and not wash her hands prior to putting on another pair of gloves, and then roll the gray linen container to outside of the soiled utility room. EI #2 stated it could cause contamination and infection to other residents. EI #2 was asked what was the facility policy on handling of soiled laundry with hand hygiene. EI #2 stated you should wash your hands after touching anything that is contaminated and this prevents the spread of infection.

Based on medical record review, interview with staff and review of a facility policy titled ADMINISTRATIVE POLICY, the facility failed to ensure Resident Identifier (RI) #285's fall risk assessment was completed upon admission. This deficient practice affected one of one residents investigated for falls. Findings Include: A review of a facility policy titled, ADMINISTRATIVE POLICY with a revised date of 10/2013 documented the following: . PURPOSE: Residents are assessed, . to identify care needs and to develop a plan of care. STANDARD: According to federal regulations, the facility conducts initially . a comprehensive, accurate . assessment of each resident's functional capacity . RI #285 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #285's 14 day assessment Minimum Data Set (MDS) with an Assessment Reference Date of 12/28/2017 revealed RI #285's Brief Interview for Mental Status score of 7, indicating cognition was severely impaired. Section G of the MDS, documented RI #285 required two plus person physical assist with transfers. On 01/24/18 at 6:00 PM, RI #285 told the surveyor he/she had a fall on 01/19/2018 when going to the bathroom with one staff member assisting him/her. RI #285 said he/she hurt his right side and hit his/her upper right forehead. He/she said he/she had pain to the right side of his/her abdominal area. RI #285 said an X-ray was done. RI #285 said he/she had tennis shoes on and the nurse took him/her by wheelchair into the bathroom and when he/she was trying to get back into the wheelchair from the toilet he/she fell . RI #285 said he/she was told there were no fractures. RI #285 said usually with his/her transfers that there is always two staff members, but this time there was only one staff member. On 01/25/2018 at 08:30 AM, RI #285's fall risk assessment dated [DATE] was reviewed on the computer and observed to be blank. The surveyor asked for a copy of the fall risk assessment. Employee Identifier (EI) #1, Registered Nurse (RN) Director of Nursing (DON) and EI #2, RN, MDS Coordinator provided a filled out/completed fall risk assessment hand signed and dated 01/25/2018 (no time was documented). On 01/25/2018 at 9:15 AM, EI #2 was asked when was the fall risk assessment filled out. EI #2 said she had filled it out on 01/25/2018 at 9:00 AM. EI #2 was asked if the fall risk assessment had been completed on admission. EI #2 said, no and this was the first fall risk assessment done on RI #285. EI #2 was asked if the fall assessment was completed in the computer, why was it not signed in the computer. EI #2 said because she wanted to talk to the person who initially did the assessment. EI #2 was asked why was the fall assessment hand signed by herself and EI #1. EI #2 said, because it was never done initially. EI #2 was asked who was responsible to complete the . Fall Risk Assessment. EI #2 said, the admitting nurse.

Based on medical record review, staff interview and a review of a facility policy titled Care Plans the facility failed to ensure a care plan was developed for fall prevention on resident identifier (RI) #285. This deficient practice affected one of 18 sampled residents whose Care Plans (CP) were reviewed. Findings Include: A review of a facility policy titled Care Plans with a revised date of 09/2009 documented the following: . PURPOSE: Plans of Care are developed by the interdisciplinary team, to coordinate and communicate the plan of care for the resident. STANDARD: According to federal regulations, the facility develops a comprehensive plan of care for each resident . to meet a resident's medical, nursing and mental/psychosocial needs . PR(NAME)ESS: I. Entry Record a) . assessment must be completed on every admission . no later that the entry date Plus 14 calendar days . II. a) The comprehensive assessment is completed no later that 14 days of admission . RI #285 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #285's 14 day assessment Minimum Data Set (MDS) with an Assessment Reference Date of 12/28/2017 revealed RI #285's Brief Interview for Mental Status score of 7, indicating cognition was severely impaired. Section G of the MDS, documented RI #285 required two plus person physical assist with transfers. On 01/24/18 at 06:00 PM, RI #285 told the surveyor he/she had a fall on 01/19/18 when going to the bathroom with one staff member assisting him/her. RI #285 said he/she hurt his right side and hit his/her upper right forehead. He/she said he/she had pain to the right side of his/her abdominal area. RI #285 said an X-ray was done. RI #285 said he/she had tennis shoes on and the nurse took him/her by wheelchair into the bathroom and when trying to get back into the wheelchair from the toilet he/she fell . RI #285 said he/she was told there were no fractures. RI #285 said usually with his/her transfers there was always two staff members, but this time there was only one staff member. On 01/25/2018 at 8:30 AM, RI #285's Fall Risk assessment dated [DATE] was reviewed on the computer and it was observed to be blank. The surveyor asked for a copy of the Fall Risk Assessment. Employee Identifier (EI) #1, Registered Nurse (RN) Director of Nursing (DON) and EI #2, RN, MDS Coordinator provided a filled out/completed Fall Risk Assessment which was hand signed and dated 01/25/2018 (no time was documented). RI #285's care plan (CP) was reviewed and no fall CP was found. On 01/25/2018 at 9:15 AM, EI #2 was asked when was the Fall Risk Assessment filled out. EI #2 said at 9:00 a.m., on 01/25/2018 and she had filled it out. EI #2 was asked if the Fall Risk Assessment had been completed on admission. EI #2 said, no and this was the first Fall Risk Assessment done on RI #285. EI #2 was asked if completed in the computer why was it not signed in the computer. EI #2 said because she wanted to talk to the person who initially did the assessment. EI #2 was asked why was it hand signed by herself and EI #1. EI #2 said because it was never done initially. EI #2 was asked who was responsible to fill the Fall Risk Assessment out. EI #2 said, the admitting nurse. EI #2 was asked if RI #285 had ever had any falls at the facility. EI #2 said, yes sometime last week with no injury. EI #2 was asked how did RI #285 fall. EI #2 said she did not know. EI #2 was asked what interventions were in place for falls upon admission. EI #2 said, she did not know. EI #2 was asked if there was a fall CP for RI #285. EI #2 said, no. RI #285's 12/28/17 MDS documented RI #285 required two person assist with transfers. EI #2 was asked did the MDS address if RI #285 was at risk for falls. EI#2 said, no it did not. EI #2 was asked was fall CP put in place after RI #285 fell on [DATE]. EI #2 said, no. EI #2 was asked should RI #285 been CP for falls. EI #2 said, yes.

Based on interviews, observations, medical record review, and a review of Fundamentals of Nursing Chapter 28 the facility failed to ensure palm guards were applied to Resident Identifier (RI) #32's hands as directed by physician's orders [REDACTED].#32 with a call bell he/she could activate if assistance is needed. These deficient practices affected one of one residents sampled for rehabilitation and restorative. Findings Include: A review of Potter and Perry Fundamentals of Nursing with a copyright of 2017 Chapter 28 Immobility, page 408 and 414 documented: . Nurses intervene to maintain maximum Range of Motion (ROM) in unaffected joints and . collaborate with physical therapists to design interventions to strengthen affected muscles, and joints . Fingers and Thumb. The ROM in the fingers and thumb enables a patient to perform Activities of Daily Living (ADLs) and activities requiring fine-motor skills . Resident Identifier (RI) #32 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #32's annual Minimum Data Set (MDS) with an Assessment Reference Date of 01/01/2018 revealed RI #32's Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Section G of the MDS, for Functional Status documented RI #32 was totally dependent on staff for all activities of daily living (ADL) and Range of Motion (ROM) upper extremity impairment on both sides. A review of RI #32's January 2018 Physician order [REDACTED]. On 01/24/18 at 10:05 AM, RI #32's call button was secured to the gown. RI #32 was asked if he/she could push the call button. RI #32 attempted to push the call button but could not due to bilateral contractures to hands. RI #32 was observed not having palm guards in his/her hands. On 01/24/18 at 12:30 PM, RI #32 was observed not having palm guards in his/her hands. On 01/25/18 03:30 PM, the surveyor and Employee Identifier (EI) #3 Registered Nurse (RN) Unit Manager to RI #32's room assess hands. EI #3 attempted to open the fingers on bilateral hands with no success. EI #3 was asked if there were palm guards in RI #32's hands bilaterally. EI #3 said no. On 01/25/18 at 02:56 PM, an interview was conducted with EI #3, Registered Nurse/Unit Manager. EI #3 was asked what did the January Physician order [REDACTED]. EI #3 said to have the palm guards to bilateral hands. EI #3 was asked why should RI #32 have the palm guards. EI #3 said for contracture management. EI #3 was asked who was responsible to ensure RI #32 had the palm guards per Physician order. EI #3 said the nurse. EI #3 was asked if the Physician order [REDACTED].#3 said no. On 01/25/18 at 03:00 PM, EI #3 to RI #32's room with the surveyor. EI #3 asked RI #32 to push the call button. RI #32 was unable to push the call button due to hands being contracted. EI #3 was asked how did RI #32 make the staff aware when he/she needed something. EI #3 said RI #32 would call out or the roommate would let someone know. EI #3 said she should have gotten RI #32 another type of call button that he/ she could use. EI #3 was asked why could RI #32 not push the call button. EI #3 said because of the hand contractures. EI #3 asked what was the potential harm in RI #32 not being able to push the call button. EI #3 said it puts RI #32 at risk for aspiration and danger.

Based on observation, interview, resident record review, review of a facility policy titled Monthly Physician's Orders and review of a facility policy titled Pressure Ulcers the facility failed to ensure licensed staff provided as needed (PRN) Medication as ordered for constipation for Resident Identifier (RI) #77 and further failed to ensure RI #32 was turned and repositioned every two hours as care planned. These deficient practices affected two of 18 residents sampled. Findings include: 1. Review of the facility policy titled Monthly Physician's Orders with an effective date of 2/1/2004 revealed the following: . PURPOSE: To provide a documented review of the medical plan of care for each resident on a monthly basis by the physician. Resident #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of RI #77's Admission MDS (Minimum Data Set) assessment with an Assessment Reference Date of 12/26/17 revealed a BIMS (Brief Interview for Mental Status) score of 13 which indicated intact cognition. On 01/24/18 at 04:13 PM RI #77 told the surveyor about having to take stool softeners at times because of constipation. RI #77 said, I ask for them about every three days. On 01/25/18 at 05:26 PM RI #77 told the surveyor about having gone three, maybe four consecutive days without having a bowel movement (BM). RI #77 said, About one time a week they have to pull it (BM) out. RI #77's January 2018 Physicians orders documented: . Order Date . 12/19/17 . [MEDICATION NAME] SODIUM 100 MG (milligram) SOFTGEL- GIVE ONE SOFTGEL BY MOUTH DAILY AS NEEDED FOR CONSTIPATION . 12/19/17 POLYETHYLENE [MEDICATION NAME] 3350 POWD- (powder) GIVE 17GM (gram) BY MOUTH DAILY AS NEEDED FOR CONSTIPATION . Review of RI #77's January 2018 Bowel Report and DAILY BM (Bowel Movement) MONITORING SHEET revealed four consecutive days Resident #77 did not have a Bowel Movement, 1/12/18, 1/13/18, 1/14/18, and 1/15/18. Review of RI #77's January 2018 Medication Administration Record [REDACTED]. On 01/25/18 at 5:55 PM, Employee identifier (EI) #4, Certified Nursing Assistant (CNA) said she took care of the resident about three days a week on first shift. When asked about RI #77's bowel patterns, EI #4 said, RI #77 did not really have BMs on the first shift. EI #4 was asked how often RI #77 was constipated. EI #4 was not sure but said, RI #77 might have BMs on another shift. On 01/25/18 at 6:25 PM, EI #5, CNA said, she always took care of RI #77 when she worked on the second shift. When asked what RI #77's bowel patterns were, EI #5 said, RI #77 did not really have a BM and sometimes nurses had to give a stool softener. EI #5 said, RI #77 would sometimes ask the staff to dig the BM out because it was stuck in RI #77's bottom. On 01/26/18 at 9:45 AM, EI #3, Registered Nurse (RN) was asked how many days had RI #77 gone without having a BM. EI #3 said, she was not sure, but the resident would be treated with standing orders or with a laxative already in place, if they did not have a BM in three days. When asked how often RI #77 had to be cleaned out (have BM manually removed), EI #3 said, maybe once or twice. On 01/26/18 at 11:30 AM, EI #1, Director of Nursing (DON) was asked how she would know when residents were not having regular BMs. EI #1 said, the facility had a system in their computerized charting called the BM report and it reported residents who had not had a BM for three days. EI #1 was asked to review both the Bowel Report and the BM Monitoring Sheets and was asked how many days Resident #77 had gone without a BM. After reviewing the reports EI #1 said, four days (1/12, 1/13, 1/14, and 1/15). When asked what she would expect staff to do if RI #77 was requesting BM to be pulled out and had BM stuck inside the rectum, EI #1 said, call the Doctor, treat, and assess. 2. A review of a facility policy titled Pressure Ulcers with a revised date of 11/2011 documented: . STANDARD: Pressure Ulcers are defined as ulcerations and/or necrosis of tissues overlying a bony prominence that has been subjected to pressure . PRESSURE ULCER PREVENTION . Assist the resident to change position . every two hours . Resident Identifier (RI) #32 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #32's annual Minimum Data Set (MDS) with an Assessment Reference Date of 01/01/2018 revealed RI #32's Brief Interview for Mental Status (BIMS) score of 15, indicating cognition intact. Section G of the MDS, for Functional Status documented RI #32 was totally dependent on staff for all activities of daily living (ADL). Section M documented RI #32 was at risk of developing pressure ulcers. On 01/24/2018 at 10:01 AM, RI #32 was observed lying in supine position. On 01/24/18 at 12:30 PM, RI #32 was observed lying in supine position. On 01/24/2018 at 03:00 PM, RI #32 was observed lying in supine position. On 01/25/18 at 03:00 PM, an interview with Employee Identifier (EI) #3, Registered Nurse (RN) Unit Manager. EI #3 was asked did RI #32 have any pressure ulcers. EI #32 said, no. EI #3 was asked if RI #32 was at risk for developing pressure ulcers. EI #32 said, yes. EI #3 was asked how often was RI #32 to be turned. EI #3 said, every two hours because RI #32 is at risk for developing pressure ulcers. EI #3 was asked who was responsible to ensure RI #32 was turned. EI #3 said, the Certified Nursing Assistants (CNA) and the nurses. EI #3 was asked if RI #32 could turn or reposition his/her self. EI #3 said, no. EI #3 was asked what was the potential harm in not turning RI #32 every two hours. EI #3 said, potential for developing pressure ulcers.

Based on observation, review of Physician order's, review of Fundamentals of Nursing and staff interview the facility failed to ensure Resident Identifier (RI) #32's hand splints were in place to prevent decreased ROM. This deficient practice was observed on three of four days of the survey for one of one residents sampled for rehabilitation and restorative. Findings Include: A review of Potter and Perry Fundamentals of Nursing with a copyright of 2017 Chapter 28 Immobility page 408 and 414 documented: . Nurses intervene to maintain maximum Range of Motion (ROM) in unaffected joints and . collaborate with physical therapists to design interventions to strengthen affected muscles and joints . Fingers and Thumb. The ROM in the fingers and thumb enables a patient to perform Activities of Daily Living (ADLs) and activities requiring fine-motor skills . Resident Identifier (RI) #32 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #32's annual Minimum Data Set (MDS) with an Assessment Reference Date of 01/01/2018 revealed RI #32's Brief Interview for Mental Status (BIMS) score of 15, indicating intact. cognition. Section G of the MDS, for Functional Status documented RI #32 was totally dependent on staff for all activities of daily living (ADL) and Range of Motion (ROM) upper extremity impairment on both sides. A review of RI #32's January 2018 Physician order [REDACTED]. On 01/24/2018 at 10:05 AM, RI #32's call button was observed secured to his/her gown. RI #32 was asked if he/she could push the call button. RI #32 responded he/she could not push the call button and he/she did not know he/she had one. RI #32 attempted to push the call button but could not due to bilateral contractures to hands. Bilateral hands observed with no palm guards. On 01/24/2018 at 12:30 PM, RI #32 was observed without palm guards in bilateral hands. On 01/25/2018 03:30 PM, the surveyor and Employee Identifier (EI) #3 Registered Nurse (RN)/Unit Manager went to RI #32's room assess hands. EI #3 attempted to open the fingers on bilateral hands with no success. EI #3 was asked if there were palm guards in RI #32's hands bilaterally. EI #32 said, no. On 01/25/2018 at 02:56 PM, an interview was conducted with EI #32. EI #32 was asked what did the January Physician order [REDACTED]. EI #3 said, to have the palm guards to bilateral hands. EI #3 was asked why should RI #32 have the palm guards. EI #3 said, for contracture management. EI #3 was asked who was responsible to ensure RI #32 had the palm guards per Physician order. EI #3 said, the nurse. EI #3 was asked if the Physician order [REDACTED].#3 said, no. On 01/25/2018 at 03:00 PM, EI #3 went to RI #32's room with the surveyor. EI #3 asked RI #32 to push the call button. RI #32 was unable to push the call button due to hands being contracted. EI #3 was asked how did RI #32 make the staff aware when he/she needed something. EI #3 said, RI #32 would call out or the roommate would let someone know. EI #3 said, I should have gotten RI #32 another type of call button that he/she could use. EI #3 was asked why could RI #32 not push the call button. EI #3 said, because of the hand contractures. EI #3 asked what was the potential harm in RI #32 not being able to push the call button. EI #3 said, puts RI #32 at risk for aspiration and danger. Position, Mobility 01/24/2018 10:01 AM, RI #32' bilateral hands observed with fingers clinched and closed. RI #32 was asked to open his/her hands and said, I can not open them. A review of RI #32's January 2018 Physician orders [REDACTED]. RI #32 was observed lying supine with no palm guards on to bilateral hands. 01/24/2018 12:30 PM, resident observed in supine position. 01/24/2018 03:00 PM, resident observed in same supine position. 01/25/18 14 03:00 PM, an interview was conducted with EI #3, RN/Unit Manager. EI #3 was asked did RI #32 have any pressure ulcers. EI #3 said, No. EI #3 was asked if RI #32 was at risk for developing pressure ulcers. EI #3 said, yes. EI #3 was asked how often was RI #32 to be turned. EI #3 said, every two hours because RI #32 was at risk for pressure ulcers. EI #3 was asked who was responsible to ensure RI #32 was turned. EI #3 said, the CNA and nurses. EI #3 was asked could RI #32 turn or reposition his/herself. EI #3 said, no. EI #3 was asked what is the potential harm in not turning and repositioning RI #32. EI #3 said, the potential for developing a pressure ulcer.

Based on medical record review, a review of a facility policy titled Resident Assessment Instrument the facility failed to ensure a resident admitted to the facility was assessed for falls and a fall prevention care plan was in place prior to the resident sustaining a fall on 12/20/17. This deficient practice affected Resident Identifier (RI) #285, one of one sampled resident investigated for falls. Findings Include: A review of a facility policy titled Resident Assessment Instrument with a revised date of 10/2013 documented . PURPOSE: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop a plan of care. STANDARD: According to federal regulations, the facility conducts initially . a comprehensive, accurate . assessment of each resident's functional capacity . RI #285 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #285's 14 day assessment Minimum Data Set (MDS) with an Assessment Reference Date of 12/28/2017 revealed RI #285's Brief Interview for Mental Status score of 7, indicating severely impaired cognition. Section G of the MDS, documented RI #285 required two plus person physical assist with transfers. On 01/24/2018 at 06:00 PM, RI #285 told the surveyor he/she had a fall on 01/19/18 when going to the bathroom with one staff member assisting him/her. RI #285 said he/she hurt his right side and hit his/her upper right forehead. He/she said he/she had pain to the right side of his/her abdominal area. RI #285 said an X-ray was done. RI #285 said he/she had tennis shoes on and the nurse took him/her by wheelchair into the bathroom and when trying to get back into the wheelchair from the toilet he/she fell . RI #285 said he/she was told there were no fractures. RI #285 said usually with his/her transfers there was always two staff members, but this time there was only one staff member. On 01/25/2018 at 08:30 AM, RI #285's Fall Risk assessment dated [DATE] was reviewed on the computer and it was observed to be blank. The surveyor asked for a copy of the Fall Risk Assessment. Employee Identifier (EI) #1, Registered Nurse (RN) Director of Nursing (DON) and EI #2, RN, MDS Coordinator provided a filled out/completed Fall Risk Assessment which was hand signed and dated 01/25/2018 (no time was documented). On 01/25/2018 at 9:15 AM, EI #2 was asked when was the Fall Risk Assessment filled out. EI #2 said at 9:00 a.m., on 01/25/2018 and she had filled it out. EI #2 was asked if the Fall Risk Assessment had been completed on admission. EI #2 said, no and this was the first Fall Risk Assessment done on RI #285. EI #2 was asked if completed in the computer why was it not signed in the computer. EI #2 said because she wanted to talk to the person who initially did the assessment. EI #2 was asked why was it hand signed by herself and EI #1. EI #2 said because it was never done initially. EI #2 was asked who was responsible to fill the Fall Risk Assessment out. EI #2 said, the admitting nurse. EI #2 was asked if RI #285 had ever had any falls at the facility. EI #2 said, yes sometime last week with no injury. EI #2 was asked how did RI #285 fall. EI #2 said she did not know. EI #2 was asked what interventions were in place for falls upon admission. EI #2 said, she did not know. EI #2 was asked if there was a risk for falls care plan (CP) for RI #285. EI #2 said, no. EI #2 was asked what would have indicated to her that RI #285 needed a fall CP. EI #2 said, the fall risk assessment. EI #2 was asked how would she have known if RI #285 needed a fall CP if the fall assessment was not done. EI #2 said, we missed out on this one. The 12/28/2017 MDS RI #285 was a two person assist with transfers does the MDS address if RI #285 was at risk or not for falls. EI#2 said no it does not. EI #2 was asked was a fall CP put in place after the fall on 01/20/2018. EI #2 said no. EI #2 was asked should have RI #285 been CP for falls. EI #2 said, yes.

Based on observations and interviews, the facility failed to ensure hand rails were firmly secured to the walls. The facility further failed to ensure the hand rails were free of splinters. This affected 2 of 2 units in the facility. Findings Include: A review of the BALL HEALTHCARE SERVICES, INC. (Incorporation) DIRECTOR OF MAINTENANCE JOB DESCRIPTION with a date of 05/99 Modi (modified) 05/03 revealed the following: . GENERAL PURPOSE: To plan, organize and direct the overall operation of the department in accordance with current federal, state and local standards, ensuring that the facility is maintained in a safe, comfortable condition . Essential Job Functions: A. Maintenance Functions Duties: . ensure proper maintenance of the facility including carpentry work, groundskeeping, painting, equipment and HVAC (Heating Ventilation and Air Conditioning) systems . On 10/17/16 at 5:20 p.m., during the initial tour of the facility the hand rail outside of Room Locater (RL) #5 was observed to be loose and not firmly secured to the wall. On 10/19/16 at 5:55 p.m., the surveyor made several observations throughout the facility of the following: 1. The hand rail located outside of RL #5 remained loose and not firmly secured. 2. The hand rail located outside of RL #6 was pulled away from the wall, was loose and was not firmly secured. 3. The hand rail located out side RL #7, which was just past RL #8, was loose and not firmly secured. 4. The hand rail located outside of RL #9 and RL #2, had a gap where the hand rails met, and splinters were felt on top of the hand rail. 5. The hand rail located between RL #10 and the nurses station was loose and not firmly secured. 6. The hand rail located on the left side of the hall heading out to the exit door located across from RL #11 had sharp edges on the top of the hand rail where the two hand rail pieces joined together. 7. The hand rail located between RL #12 and RL #13 had a sharp edge. 8. The hand rail located to the right side of RL #14 was loose and not firmly secured. 9. The hand rail located between RL #15 and #16 (across from RL #14) was loose and not firmly secured. On 10/20/16 at 8:55 a.m., during a tour of the outside and inside of the facility with Employee Identifier (EI) #7, the surveyor addressed the identified areas of concern with the hand rails with EI #7. The surveyor also identified several additional areas of concern with hand rails. The following additional concerns were identified: 1. The hand rails between RL #17 and RL #18 were loose. 2. The hand rails between RL #19 and RL #20 were loose. 3. The hand rails to the right side of RL #14 had a corner piece of the wooden hand rail which had a gap and sharp edges. 4. The hand rails between RL #21 and RL #12 had a sharp edge. 5. The hand rail outside the side door from RL #22, across from RI #11, had sharp edges. 6. The hand rail across the hall from RL #5, located on the wall going to the exit door was loose, and not firmly secured. The hand rail could be lifted up several inches. 7. The hand rail (under the bulletin board) by RL #23 was loose and not firmly secured. 8. The corner of the hand rail outside of RL #24 was sharp. 9. The hand rail underneath the Kiosk, between RL #25 and RL #26, was loose. 10. The hand rail between RL #26 and RL #27 was loose. On 10/20/16 at 9:40 a.m., an interview was conducted with EI #7. When asked who was resposible for the maintenance in the facility, EI #7 replied, I am. EI #7 was asked how were needed repairs reported to him. EI #7 replied, there is a maintenance log at each nurses station (Station I and Station 2) and its logged in the book. EI #7 said he looked at the maintenance log every morning. When asked if anyone reported the hand rails. EI #7 replied, No. EI #7 was asked what potentially could happen to a resident if the hand rails have sharp edges or are loose and not secured. EI #7 replied, the resident could get a skin tear from the splinters, the resident could jerk the hand rail off the wall and it could fall on them. EI #7 said the resident could also fall if the hand rail is loose.

Based on observations and interviews, the facility failed to ensure staff knocked on the doors of Room Locator's (RL) #1, #2, #3 and #4 before entering the residents' rooms. This affected 3 of 4 halls of the facility. Findings Include: A review of Potter and Perry Fundamentals of Nursing, Ninth Edition, page 324, ELEMENTS OF PROFESSIONAL COMMUNICATION revealed the following under the heading Courtesy: Common courtesy is part of professional communication. To practice courtesy, say hello and goodbye to patients and knock on doors before entering . 1. On 10/17/2016 at 4:45 p.m., during the initial tour the surveyor observed Employee Identifier (EI) #5 enter RL #1 without knocking. EI #5 then walked out of RI #1 and walked across the hall into RL #2 without knocking. EI #5 then walked out of RL #2 and walked back into RL #1 again without knocking. On 10/20/16 at 11:20 a.m., a telephone interview was conducted with EI #5. The surveyor asked EI #5 how was she trained as a Certified Nursing Assistant (CNA) to enter a residents room. EI #5 stated, To knock before entering. The surveyor informed EI #5 that she was observed entering RL #1 then went into RL #2 and back into RL #1 without knocking. EI #5 stated, I don't remember, if the resident was screaming, I probably got upset and just entered without thinking. EI #5 was asked what kind of issue is it to enter into a residents room without knocking. EI #5 stated, It's a privacy issue. The surveyor asked EI #5, how should you enter a residents room. EI #5 said, Knock and wait for them to respond to you. 2. On 10/18/16 at 12:29 p.m., while observing the staff pass lunch trays, the surveyor observed EI #10 enter RL #3 without knocking on the door or calling the resident's name to request entrance. On 10/20/16 at 3:23 p.m., an interview was conducted with EI #10. The surveyor asked EI #10 how she was trained as a Licensed Practical Nurse (LPN) to enter a resident's room. EI #10 said, knock on the door and call the resident by name. The surveyor informed EI #10 that she was observed entering RL #3 without knocking or calling the resident's name. EI #10 said, she did not knock because the door was open. EI #10 was asked how you should enter a resident's room even if the door is open. EI #10 said, knock. EI #10 was asked if she knock on the door. EI #10 replied, No Ma'am. 3. On 10/18/16 at 12:37 p.m., while observing the staff pass lunch trays, the surveyor observed EI #9 enter into RL #4 with a meal tray. EI #9 did not knock on the door or call the resident's name to request entrance. On 10/20/16 at 1:37 p.m., an interview was conducted with EI #9. The surveyor asked EI #9 how she was trained as a CNA to enter a resident's room. EI #9 stated, knock and wait for someone to tell you to come in. The surveyor informed EI #9 that she was observed entering RL #4 without knocking on the door or calling the resident's name to request entrance. EI #9 said, she could not recall if she did or did not knock. EI #9 was asked what kind of issue it was when you do not knock on a resident's door. EI #9 replied, a dignity or privacy issue.

Based on observations, interviews and record review, the facility failed to ensure staff followed Resident Identifier (RI) #10's care plan to be checked and changed every 2 hours. This affected RI #10, one of 14 residents whose plan of care was reviewed. Findings Include: A facility policy titled Care Plans with an effective date of February 1, 2004 revealed the following: . PURPOSE: Plans of Care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals for the resident. STANDARD: According to federal regulations, the facility develops a comprehensive plan of care for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing and mental/psychosocial needs, . RI #10 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A most recent Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/11/2016, revealed RI #10 with a Brief Interview for Mental Status (BIMS) score of 0 indicating RI #10 was severly impaired in cognition. Section G: Functional Status for toilet use revealed RI #10 was coded as total dependence. Under Section H: Bowel and Bladder, RI #10 was coded as always incontinent. A review of RI #10's Care Plan, with a problem onset date of 03/10/2015, revealed under Problem/Need, RI #10 is totally incontinent of Bowel and Bladder due cognitive deficit . Approaches: Check at least every 2 hours and change as needed . Provide incontinent care q (every) 1-2 hours and prn (as needed) . On 10/18/16, the surveyor tracked the resident from 9:20 a.m. to 1:30 p.m. At 1:30 p.m. the surveyor observed staff remove the resident from the hallway and take RI #10 into the bedroom. On 10/20/16 at 2:55 p.m., an interview was conducted with Employee Identifier (EI) #6, a Certified Nursing Assistant (CNA). The surveyor asked EI #6 if she was assigned to care for RI #10 on 10/18/16. EI #6 replied, yes. The surveyor asked EI #6 if RI #10 was total care. EI #6 replied, He/she is. EI #6 was then asked if she was responsible for checking and changing RI #10. EI #6 replied, Yes, it takes two of us to do it. When asked how often RI #10's care plan indicated the resident was to be checked and changed, EI #6 replied, Every 2 hours. EI #6 was asked what kind of harm could come to a resident who was not checked and changed every 2 hours as care planned. EI #6 replied, He/she could have skin breakdown. On 10/20/16 at 3:30 p.m., an interview was conducted with EI #1, the Director of Nursing (DON). EI #1 was asked how do the CNAs know what type care to provide to a resident. EI #1 replied, Initially when we establish the plan of care. The surveyor handed EI #1 RI #10's Totally incontinent of Bowel and Bladder care plan. The surveyor asked EI #1 to tell the surveyor how often RI #10's care plan indicate RI #10 was to be checked and changed. EI #1 replied, Every 2 hours and as needed. EI #1 was asked what type of harm could occur to the resident if not checked and changed according to the care plan. EI #1 replied, Skin break down, infections, UTI (Urinary Tract Infection). EI #1 was asked what type of care does RI #10 require. EI #1 replied, total care.

Based on observations, interviews and record reviews, the facility failed to ensure incontinent care was provided to Resident Identifier (RI) #10, a totally dependant resident who required incontinent checks every two (2) hours. This affected RI #10, one of two residents observed for incontinent care. Findings Include: A facility policy titled Perineal Care with a effective date of February 1, 2004, documented: PURPOSE: Good perineal care helps prevent infection, irritation and skin breakdown. STANDARD: Residents who are incontinent of urine or feces should receive perineal care as needed. RI #10 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A most recent Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/11/2016, revealed RI #10 with a Brief Interview for Mental Status (BIMS) score of 0 indicating RI #10 was severly impaired in cognition. Section G: Functional Status for toilet use revealed RI #10 was coded as total dependence. Under Section H: Bowel and Bladder, RI #10 was coded as always incontinent. A review of RI #10's Care Plan, with a problem onset date of 03/10/2015, revealed under Problem/Need, RI #10 is totally incontinent of Bowel and Bladder due cognitive deficit . Approaches: Check at least every 2 hours and change as needed . Provide incontinent care q (every) 1-2 hours and prn (as needed) . On 10/18/16, the surveyor tracked the resident from 9:20 a.m. to 1:30 p.m. At 1:30 p.m., the surveyor observed staff remove the resident from the hallway and take RI #10 into the bedroom. On 10/18/16 at 1:35 p.m., the surveyor observed Employee Identifier (EI) #4 and EI #6, Certified Nursing Assistants (CNAs) assist RI #10 to bed and remove the resident's pants. RI #10 was observed to have on an adult brief. When asked by the surveyor was RI #10 soiled, EI #4 said there was a small amount of bowel movement and urine on RI #10's brief. On 10/20/16 at 2:55 p.m., an interview was conducted with EI #6. The surveyor asked EI #6 if she was assigned to care for RI #10 on 10/18/16. EI #6 replied, yes. The surveyor asked EI #6 if RI #10 was total care. EI #6 replied, He/she is. EI #6 was then asked if she was responsible for checking and changing RI #10. EI #6 replied, Yes, it takes two of us to do it. On 10/20/16 at 3:30 p.m., an interview was conducted with EI #1, the Director of Nursing (DON). EI #1 was asked what type of care does RI #10 require. EI #1 replied, total care.

Based on observations, interviews and record review, the facility failed to ensure a minimum air gap of one inch existed between the food service drain and the floor sink drain to prevent potential sewage back flow into the dishwashing equipment. This affected two of six food service drain pipes and two of four floor sink drains observed in the kitchen. Findings Include: The 2013 Food Code by the United States (U. S.) Public Health Service and the Food and Drug Administration (FDA) included: . 5-202.13 Back Flow Prevention, Air Gap. An air gap between the water supply inlet and the floor level rim of the PLUMBING FIXTURE, EQUIPMENT, . may not be less than 25 mm (millimeters) (1 inch ). On 10/18/16 at 12:20 p.m., two food service drain pipes were observed coming from the dish machine and one pipe coming from the dishwashing area scrap sink. All three pipes drained into one floor sink drain. The pipe coming from the scrap sink extended down into the floor sink drain. There was no air gap between the floor level of the floor sink drain and the end of the food service drain pipe coming from the scrap sink. On 10/18/16 at 12:22 p.m., one food service drain pipe was observed coming from the garbage disposal in the dishwashing area. There was no air gap of at least one inch between the floor level of the floor sink drain and the end of the garbage disposal drain pipe. On 10/18/16 at 4:05 p.m., Employee Identifier (EI) #8, the Dietary Manager was interviewed while making an observation of the drain coming from the scrap sink. EI #8 was asked, if the drain pipe backs up, where would the water go. EI #8 observed the floor sink drain and said that water could back up and overflow into the dish machine. EI #8 was shown the drain pipe from the garbage disposal and asked if there was a one inch air gap from the drain pipe to the top of the floor sink drain. EI # 8 said no. On 10/18/16 at 4:13 p.m., (EI) #7, the Director of Maintenance was interviewed while making an observation of the floor sink drains. EI #7 measured the drain pipe coming from the scrap sink which extended into the floor sink drain. The pipe extended four inches from the floor level into the floor sink drain. EI #7 was asked if there was a problem with the scrap sink drain pipe. EI #7 said there was a problem with potential back flow. EI #7 measured the air gap for the drain pipe coming from the garbage disposal to the floor sink drain. There was less than a one-fourth inch clearance from the floor level to the end of the drain pipe. EI #7 was asked if there was a problem with the garbage disposal drain pipe. EI #7 said there was a problem with potential back flow.

Based on observations, interviews and record review, the facility failed to ensure: 1) a Certified Nursing Assistant (CNA), Employee Indentifer (EI) #4, did not place the plastic trash bag on the floor when providing incontinent care to Resident Identifier (RI) #10 on 10/18/16; and 2) the Treatment Nurse, EI #3, changed her contaminated gloves before applying a clean dressing to RI #5's left heel on 10/20/16. These deficient practices affected RI #10, one of two residents observed for incontinent care and RI #5, one of two residents observed during wound care. Findings Include: 1. RI #10 was originally admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 08/11/16, assessed RI #10 as having short and long term memory problems with severely impaired cognitive skills for daily decision making. RI #10 was also assessed as being totally dependant on staff for all Activities of Daily Livings and was always incontinent of bowel and bladder. On 10/18/16 at 1:35 p.m., the surveyor observed EI #4 and EI #6 prepare to provide incontinent care to RI #10. EI #4 placed disposable wipes in a pink basin, opened a plastic bag and placed the bag on the floor. After using a disposable wipe to wipe above RI #10's vaginal area, EI #4 threw the wipe in the plastic bag on the floor. On 10/19/16 at 2:35 p.m., the surveyor conducted an interview with EI #4. The surveyor asked EI #4, when providing incontinent care, where is the plastic bag that is used to put used disposable wipes in placed. EI #4 replied, We are trained to place them inside the garbage can. The surveyor asked EI #4 should the bag be placed on the floor. EI #4 said no. The surveyor asked EI #4 what is it considered when a plastic bag is placed on the floor. EI #4 replied, Infection and cross contamination. On 10/20/16 at 11:15 a.m., the surveyor conducted an interview with EI #2, the Assistant Director of Nursing/Infection Control nurse. The surveyor asked EI #2 where are the CNAs taught to place the plastic bag which will be used for placing used supplies in when providing incontinent care. EI #2 said the plastic bags are tied to the bed rail or placed in the garbage can. The surveyor asked EI #2 should the plastic bag be placed on the floor. EI #2 replied, Never. The surveyor asked EI #2 what is it considered when the plastic bag is placed on the floor. EI #2 replied, Cross contamination. That's an infection control issue. 2. RI #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An Annual MDS assessment, with an ARD of 07/25/16, assessed RI #5 as having a Stage I or higher pressure ulcer. On 10/20/16, between 11:29 and 11:55 a.m., the surveyor observed EI #3, the Treatment Nurse perform wound care to RI #5's left heel. EI #3 removed the old dressing which contained a minimal amount of serous drainage. EI #3 removed her gloves, washed her hands and put on a clean pair of gloves. EI #3 cleaned the left heel with Normal Saline gauzes then patted the area dry with 4x4 gauzes. EI #3 then picked up the clean dressing, with contaminated gloves still on, applied the dressing to RI #5's left heel and wrapped the dressing with a Kling wrap. On 10/20/16 at 11:50 a.m., the surveyor conducted an interview with EI #3. The surveyor asked EI #3, after cleaning RI #5's wound to the left heel with soaked Normal Saline gauzes, what should she have done before applying the clean dressing. EI #3 replied, Washed my hands. The surveyor asked EI #3, if this is not done, what could that be considered. EI #3 replied, Contamination, possible contamination and introducing bacteria to the area. On 10/20/16 at 3:46 p.m., the surveyor conducted an interview with EI #1, the Director of Nursing. The surveyor asked EI #1 what should a nurse performing wound care do after the wound had been cleaned and before applying a clean dressing on the wound. EI #1 replied, Remove her gloves and wash her hands. The surveyor asked EI #1, when this is not done, what type concern or issue would that be considered. EI #1 replied, Infection control.