Every finding on record at Timberland Health and Wellness Center

Based on observations, interviews, and review of facility polices titled Meal Temperature Log, Meal Temperature Record, Sanitation and Leftovers, the facility failed to ensure: 1) the temperature of carrots were taken and recorded after being placed back on the steam table; 2) food debris was not in a sectional plate; and 3) orange juice and cranberry juice in the refrigerator was labeled with an open and use by date. This had the potential to affect 85 of 89 residents who received meals from the kitchen. Findings Include: 1) A review of a facility policy titled Meal Temperature Log with no revised date revealed: Policy Temperature of all potentially hazardous foods being served to the residents and staff will be recorded on a meal by meal basis to ensure food are served in a safe and sanitary manner . 1. A log will be maintained on a daily basis for all foods served from the dietary department. Temperatures will be recorded for all potentially hazardous foods. A review of a document titled Meal Temperature Record with the month of Feb (February)/March listed at the top of the form. The lunch meal temperatures was recorded in the middle of the form and on a blank sheet of typing paper attached to the form. On 02/28/18 at 11:05 a.m., Employee Indentifer (EI) #8, the morning Cook, took the carrots off the steam table and placed them back on the stove. At 11:32 a.m. the carrots were brought back to the steam table. No one took the temperature of the carrots. On 03/01/18 at 11:46 a.m., the surveyor conducted an interview with EI #8. EI #8 was asked what was the temperature of the carrots when they were placed back on the trayline. EI #8 replied, she did not take the temperature of the carrots when they were placed back on the steam table. EI #8 was asked who recorded the temperatures of the carrots. EI #8 replied, nobody. EI #8 was asked why the temperature of the carrots was not taken when brought back to tray line. EI #8 replied, they got caught up in their work. EI #8 was asked what was the facility's policy regarding taking food temperatures on the tray line and writing them down. EI #8 replied, they should take temperatures of all foods on the line and record temperatures as they take them. EI #8 was asked what was the potential harm when food temperatures were not taken or written down. EI #8 replied, if food temperatures were not taken or written down, there was a chance of food poisoning and food borne illness. On 03/01/18 at 04:14 p.m., an interview was conducted with EI #10, the Dietary Manager. EI #10 was asked what was the temperature of the carrots when they were placed back on the tray line. EI #10 replied, she had no idea. EI #10 was asked what was the potential harm when food temperatures were not taken or written down. EI #10 replied, a food borne illness can break out and bacteria can grow if it was not at the correct temperature. 2) A review of a facility policy titled Sanitation with a date of Nov (November) 2017, revealed: . Policy Interpretation and Implementation . 3. china . that cannot be sanitized . shall be discarded . On 02/28/18 at 11:43 a.m., eight sectional plates were observed stacked on top of each other. The top sectional plate had food debris in it. The surveyor observed EI #8 putting food in the plate. On 03/01/18 at 12:15 p.m., the surveyor conducted an interview with EI #8. EI #8 was asked what was in the sectional plate that she placed food in. EI #8 replied, food particles. EI #8 was asked why was food particles in the plate. EI #8 replied, the dishwasher washed it but she did not scrub it out. EI #8 was asked what was the facility's policy on putting food in dirty plates. EI #8 replied, they were not suppose to put food in dirty plates. EI #8 was asked who was responsible for making sure plates that residents were to be served from were clean. EI #8 replied, the dishwasher, the tray aide and the cook. EI #8 was asked why did she place food in a sectional plate that was dirty. EI #8 said she did not see the food in the plate. EI #8 was asked what was the potential harm to the resident when food was placed in a dirty plate. EI #8 replied, it was not clean and could cause illness. On 03/01/18 at 04:19 p.m., the surveyor conducted an interview with EI #10. EI #10 was asked what food debris was in the sectional plate. EI #10 replied, grits. EI #10 was asked what was the potential harm to the residents when food was placed in a dirty plate. EI #10 replied, contamination. 3) A review of a facility policy titled Leftover with a date of [DATE] revealed: . Policy Interpretation and Implementation . 5. Cover, label and date all containers with the date that the food was first prepared . On 02/27/18 at 3:29 p.m., the surveyor observed three pitchers of orange juice and one pitcher of cranberry juice in the refrigerator with no open or use by date on the containers. On 03/01/18 at 4:25 p.m., the surveyor conducted an interview with EI #9, the evening cook. EI #9 was asked what was in the pitchers in the refrigerator with no use by dates on them. EI #9 replied, orange juice and cranberry juice. EI #9 was asked why was there no use by date on the containers. EI #9 replied, they forgot to put a date on the containers. EI #9 was asked who was responsible for putting use by dates on food items. EI #9 replied, the morning dishwashers. EI #9 was not sure who was responsible for labeling. EI #9 was asked why should food items be labeled. EI #9 replied, so they would know when they went in and when they should come out. EI #9 was asked how should food items be labeled. EI #9 replied, put the open date and use by date on the container. EI #9 was asked what was the potential harm when food items were not labeled. EI #9 replied, they would not know how long it had been there and there was a possibility for bacteria build up. On 03/01/18 at 4:33 p.m., an interview was conducted with EI #10. EI #10 was asked who was responsible for putting use by dates on food items. EI #10 replied, everybody who puts food items in the cooler. EI #10 stated anything that was open should have a use by date on it. EI #10 was asked why should food items be labeled. EI #10 replied, so the next person will know what it was, how long it has been there and when to discard it. EI #10 was asked what was the potential harm when food items were not labeled. EI #10 replied, the next person who comes in would not know how long it had been there and bacteria can grow.

Based on interview, record review, review of a facility policy titled ABUSE/REPORTING and review of the Alabama Department of Public Health Online Incident Reporting System, the facility failed to ensure an allegation of physical abuse was reported to the State Survey Agency within a two hour time frame when RI #76 hit RI #41 on 12/27/17. This deficient practice affected Resident Identifier (RI) #41 and RI #76, two of two residents reviewed for Facility Reported Incidents. Finding Include: A facility policy titled ABUSE/REPORTING, dated December 2017, documented . Reporting/Documentation Requirements Ensure that all alleged violations involving abuse . are reported to the administrator of the center and to other officials (including to the State Survey Agency .) in accordance with State law through established procedures in these timeframes: · If the event that cause the allegation involve abuse . the event must be reported immediately, but no later than 2 hours after the allegation is made . RI #41 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 01/17/18, assessed RI #41 to score a 6 on the Brief Interview for Mental Status (BIMS) indicating RI #41 had severely impaired cognition. RI #76 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A Significant Change MDS assessment, with an ARD of 01/21/18, assessed RI #76 to score a 3 on the BIMS indicating RI #76 also had severely impaired cognition. A review of the Alabama Department of Public Health Online Incident Reporting System documented: . Date/Time Submitted: Wednesday, December 27, 2017 5:42 . PM . Incident Type . Physical Abuse . Date and time of incident or alleged incident: 12/27/2017 Time: 02:17 PM Narrative summary of incident: (RI #76) hit (RI #41) due to becoming agitated when (RI #41) did not move his/her w/c (wheelchair) fast enough . On 03/01/18 at 2:56 p.m., the surveyor conducted an interview with Employee Identifier (EI) #2, the RN (Registered Nurse)/Risk Manager. The surveyor asked EI #2 when was she made aware RI #41 and RI #76 were involved in an altercation. EI #2 said it was within five to ten minutes of the altercation. The surveyor asked EI #2 did she remember the date of the altercation. EI #2 said, December 27, 2017 at approximately 2:17 p.m. The surveyor asked EI #2 when was this incident reported to the State Survey Agency. EI #2 replied, December 27, 2017 at 5:42 p.m. The surveyor asked EI #2 what was the time frame for reporting abuse to the State Survey Agency. EI #2 said within two hours. When asked if the incident was reported in that time frame, EI #2 said no.

Based on observation and interview, the facility failed to ensure a Certified Nursing Assistant (CNA) did not stand while feeding Resident Identifier (RI) #33 the lunch meal on 02/28/18. This affected RI #33, one of one residents observed being fed during the survey. Findings Include: RI #33 was admitted to the facility on [DATE], and readmitted on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #33's Quarterly Minimum Data Set with an Assessment Reference Date of 01/10/18, revealed RI #33 had a Brief Interview for Mental Status (BIMS) score of 6 indicating severely impaired cognitive status and was totally dependant on staff for eating. On 02/28/18 at 12:20 p.m., Employee Identifier (EI) #4, a CNA was observed feeding RI #33 the lunch meal. EI #4 was standing on the left side of the bed. EI #4 stood the entire time while feeding the resident. At 12:40 p.m., the CNA completed the task of feeding RI #33. On 02/28/18 at 12:45 p.m., an interview was conducted with EI #4. EI #4 was asked what was the facility's policy on how staff should be positioned when feeding a resident. EI #4 replied, she should be sitting. EI #4 was asked if she stood the entire time while she fed RI #33. EI #4 replied, yes. EI #4 was asked what was the harm in standing while feeding a resident. EI #4 replied, there really was no harm but if could be a dignity issue. On 03/01/18 at 2:45 p.m., an interview was conducted with EI #1, the Director of Nursing. EI #1 was asked what was the facility's policy for staff when they fed a resident. EI #1 replied, they should be at eye level and sitting. EI #1 was asked what was the harm in staff not sitting while feeding a resident. EI #1 replied, it would be dignity.

Based on observation, interview and review of a facility policy titled Linen and Laundry Orientation Checklist, the facility failed to ensure: 1) clean laundry was covered as it was delivered to the unit; and 2) Employee Identifier (EI) #6 and EI #7 did not have clean linen and resident clothes touching their uniforms. This was observed on 02/27/18 at 3:30 p.m., during the initial tour of the facility, and affected one of six units in the facility. Findings Include: A review of a facility policy titled Linen with a effective date of Nov (November) 2017 revealed: . Purpose The purpose of this procedure is to provide guidelines for the proper handling, washing, transporting, . Procedure Guidelines In resident rooms 1. Do not allow . to touch uniform. An undated facility document titled Laundry Orientation Checklist revealed: . FOLDING AND TRANSPORTING OF CLEAN LINEN .Transport clean linens: Covered clean carts, bags, . On 02/27/18 at 3:30 p.m., upon arriving to the 800 hall, the surveyor observed two laundry aides delivering clothes and blankets to the unit. EI #6 was holding three blankets in her left arm and up against her upper body touching her uniform. EI #7 was leaning over a rolling basket of uncovered clothing reaching for clothing on the top of the pile. Her uniform was observed to be touching the clothes piled in the basket as she leaned. On 02/27/18 at 3:45 p.m., an interview was conducted with both employees. EI #6 was asked if the blankets should be touching her uniform EI #6 replied, no. EI #6 was asked when did she come to work today. EI #6 replied, at 8:00 a.m. this morning. EI #6 was asked if her uniform was considered clean or dirty. EI #6 replied, dirty I guess. On 02/27/18 at 3:50 p.m., an interview was conducted with EI #7. EI #7 was asked if the laundry cart should be covered. EI #7 did not reply. EI #7 was asked if her uniform should be touching the clean clothes. EI # 7 replied, there was nothing wrong with it. EI #7 was asked what time did she report to work that day. EI #7 replied, 8:00 a.m. EI #7 was asked if there was a risk that her uniform could have become contaminated when she loaded the washers with soiled clothing and linens. EI #7 replied no. EI #7 was asked what was the potential harm in her uniform touching the clean clothing. EI #7 replied, nothing her clothes were clean. On 02/28/18 at 12:35 p.m., an interview was conducted with EI #5, the Housekeeping Supervisor. EI #5 was asked what was the facility's policy on transporting clothes. EI #5 replied they should be covered with a sheet. EI #5 replied, yes, and her staff told her they did not have it covered. EI #5 was asked if the staffs clothes should touch clean clothes and linens. EI #5 replied, no, not at any time. EI #5 was asked why staff clothes should not come into contact with clean linens and resident clean clothes. EI #5 replied, there was germs and bacteria on staffs clothes that could get on the clean clothes and linens. On 03/01/18 at 2:45 p.m., EI #11, the RN (Registered Nurse)/Infection Control Nurse was interviewed. EI #11 was asked how should clothes or linens be transported on the units. EI #11 replied, covered. EI #11 was asked what was the potential for harm if clean clothes and linens were not covered while transporting to the units. EI #11 replied, possible contamination. EI #11 was asked if clean resident clothes or linen should touch employees clothes or uniform. EI #11 replied, no. EI #11 was asked if employee uniforms were considered clean or dirty. EI #11 replied dirty. EI #11 was asked what was the harm in employees uniforms coming into contact with clean resident clothes and linens. EI #11 replied, contamination from what may be on their uniform to the clean clothes.

Based on observation and interview, the facility failed to ensure the controlled box containing the refrigerated [MEDICATION NAME] ([MEDICATION NAME]) in the Station 2 Medication Room was permanently affixed to the refrigerator. This was observed on 03/01/18, during the medication room observation and affected one of two medication rooms observed. Findings Include: On 03/01/18 at 11:30 a.m., the surveyor and Employee Identifier (EI) #3, a Licensed Practical Nurse, did an observation of the Medication Room on station 2. The medications in the room were checked for availability and expiration dates. EI #3 was asked to open the refrigerator for observation of the medications inside the refrigerator. After unlocking the refrigerator and verifying the temperature the surveyor asked if there was a secured box for controlled refrigerated medications. EI #3 replied, yes and removed the complete box which was locked but not permanently affixed to the refrigerator. There was a locked box with the label Controlled Substance E-Kit Refrigerated Items . [MEDICATION NAME] Injection . 3 [MEDICATION NAME] (ORAL) . 30 ml (milliliters) . Inside the box was three injections of [MEDICATION NAME] and a 30 ml bottle of oral [MEDICATION NAME]. On 03/01/18 at 11:30 a.m., EI #3 was asked if the locked box was permanently affixed to the refrigerator. EI #3 replied, no it was not. EI #3 was asked if the locked box should be permanently affixed. EI #3 replied, she thought so. On 03/01/18 at 11:42 a.m., an interview was conducted with EI #1, the Director of Nursing (DON). EI #1 was asked if the locked box for controlled medications inside the refrigerator was permanently affixed. EI #1 replied no. EI #1 was asked if the locked box should be permanently affixed inside of the refrigerator. EI #1 replied, yes. EI #1 was asked why was the locked box not permanently secured to the inside of the refrigerator. EI #1 replied, she was not sure. EI #1 was asked what was in the box. EI #1 replied, 3 [MEDICATION NAME] injectable's and a 30 ml bottle of oral [MEDICATION NAME]. EI #1 was asked what was the risk of the box not being permanently affixed inside the refrigerator. EI #1 replied, anyone could take the box out of the refrigerator.

Based on observations, record review, and interview, the facility failed to ensure: 1) staff washed and dried hands in accordance with facility policy to prevent potential cross contamination; 2) bulk cornmeal was not stored without a lid and with a scoop inside the bin; 3) Food items in the cooler were labeled with item name, open date, and use by dates. Further, open foods were not stored securely to prevent contamination; and 4) commercial health shakes were labeled in a manner such that the use by date was evident. These failures had the potential to affect all 85 residents receiving meals from the dietary department. Findings include: 1) Review of the facility's policy titled Personnel Standards, dated 11/2001, revealed the following: Policy Dietary personnel shall follow sanitary standards. Policy Interpretation and Implementation . 2 . b. Hands must be washed after each trip to the restroom, after leaving storage rooms, washrooms . and at any other time it is necessary . During the initial tour of the kitchen on 01/03/2017 beginning at 4:50 p.m., it was noted there was no foot-pedal trash can by the handwashing sink. Instead, staff utilized a large garbage bin with a lid. One staff member was observed washing and drying hands, then touching the lid of the garbage bin to dispose of her towel. She then proceeded to the meal service line. On 01/04/2017 at 11:20 a.m., there was again no foot-pedal trash can by the handwashing sink. A large garbage bin was noted and the lid was on the floor beside it. A dietary aide was observed picking up trash from the floor with gloved hands, and placing it in the garbage bin. Without washing hands or changing gloves, she then went and handled clean serving utensils. Another dietary staff member, the Cook, picked up the garbage bin lid and placed it back over the bin. Employee Identifier (EI) #1, the Dietary Manager, was then observed washing hands and disposed of her towel by sliding it under the garbage bin lid. She then continued on with meal prep. During an interview with EI #1, the Dietary Manager, on 01/05/2017 at 8:51 a.m., EI #1 said, staff should wash their hands anytime they change tasks. When asked how staff should dispose of towels after washing and drying hands, she said, they should have had a trash can by the sink. She said, if staff were using the garbage bin with lid to dispose of their towels, they should not have been touching it after washing their hands. After discussing observations of staff touching the garbage bin lid, EI #1 said, it could result in contaminated hands. She said, if staff were not washing their hands after touching garbage, it could also result in cross contamination. 2) Review of the facility's policy titled Food Storage, dated 11/2001, revealed the following: Policy Food storage areas shall be maintained in a clean, safe, and sanitary manner. Policy Interpretation and Implementation . 2. All foods or food items not requiring refrigeration . shall be kept clean and dry at all times . During the initial tour of the kitchen on 01/03/2017 at 4:50 p.m., a plastic container of cornmeal was observed without a lid. The lid was lying on top of another container. The cornmeal was uncovered and a scoop was stored in the bin, in direct contact with the cornmeal. During an interview with EI #1, the Dietary Manager, on 01/05/2017 at 8:51 a.m., EI #1 said, bulk items, such as cornmeal, should be covered once the amount needed was obtained to prevent possible contamination. She also stated the scoop should then be washed and air dried, then placed in a bag for storage. 3) During the initial tour of the kitchen on 01/03/2017 at 4:50 p.m. the following items were observed in the walk-in cooler: - An open plastic sleeve of American cheese. Plastic wrap was wrapped loosely around the cheese and did not cover all of the open areas. The cheese was observed exposed and sitting directly on the shelf of the cooler. The packaging was not labeled with an open date or a use by date. - Open package of round slices of luncheon meat. The item was not labeled with an item name, open date, or use by date. - Open bag of grated cheddar cheese wrapped in plastic wrap. This item was not labeled with an open date or a use by date. - Hamburger patties dated 1/5/17 - Macaroni and Cheese dated 1/2 - Meat dated 1/2 - Pineapple rings dated 12/30 - Jello dated 12/27/16 - Chicken Salad dated 12/31/16 - Lettuce dated 12/23/16. The lettuce was wilting and turning a brownish-red color. - A brown bag wrapped in plastic wrap with no item name, open date, or use by date. On 01/05/2017 at 8:51 a.m., EI #1, the Dietary Manager, stated staff were not consistently labeling the items. She said some of the staff were labeling with use by dates and others were labeling with the prepared or open dates. When asked what the policy said regarding labeling of open food items, EI #1 said, items should be labeled with the date they were received, an open date, and a use by date so staff knew they were not serving something that could have bacteria growing in it. 4) Review of the manufacturer's information for the facility's commercial shakes revealed the shakes had a shelf life of 14 days once thawed. During the initial tour of the kitchen on 01/03/2017 at 4:50 p.m., a case of thawed commercial shakes, dated 1-2-17 was observed in the walk-in cooler. On 01/04/2017 at 11:20 a.m., two open cases of thawed commercial shakes were noted in the cooler. They were labeled with dates of 1-2-17 and 1-4-17. Neither case was labeled with use by dates. During an interview with EI #1, the Dietary Manager, on 01/05/2017 at 8:51 a.m., EI #1 said the shakes had a 14 day use by date once thawed. She said the cases should have been labeled with open/thaw dates and use by dates. The dietary manager stated, the dates present were dates the items were received. The case was not labeled with a thaw date or use by date.

Based on observation, interview, and record review the facility failed to ensure a CNA (Certified Nursing Assistant) who provided incontinent care to RI (Resident Identifier) #1 on 1/4/2017, washed her hands and changed gloves before going from dirty to clean. This affected one of three incontinent care observations. Findings included: Review of the facility policy titled Handwashing dated 7/2015 revealed the following: . 1. All personnel shall follow our established handwashing procedures to prevent the spread of infection and disease . 2. Employees must perform appropriate handwashing procedures under the following conditions: . g. After contact with . body fluids, excretions, secretions, . h. After handling items potentially contaminated with . body fluids, excretions, or secretions; . j. After removing gloves; . m. Upon completion of duty . RI #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1's Significant Change MDS (Minimum Data Set) with an Assessment Reference Date of 12/1/2016 revealed RI #1 was always incontinent of bowel and bladder and was totally dependent on staff for personal hygiene. On 1/4/2017 at 5:45 p.m. EI (Employee Identifier) #4 CNA, did not change her gloves or wash her hands during incontinent care provided to RI #1. EI #4 removed RI #1's brief soiled with urine, cleaned RI #1's perineum and buttocks, then, while wearing the same soiled gloves, applied a clean brief to RI #1, dressed and repositioned RI #1 in bed. EI #4 then cleaned RI #1's water basin, removed her gloves, and without washing her hands placed the water basin in RI #1's closet. EI #4 then put on new gloves to pick up the soiled trash and linen bags. EI #4 removed the gloves and took the bags to barrels in the soiled utility room. EI #4 then washed her hands. On 1/4/2017 at 6:10 p.m. EI #4 was asked what the facility policy was for infection prevention during incontinent care. EI #4 said, to wash hands, sanitize and change gloves. When asked when she should have changed gloves, EI #4 said, between each thing she did and between cleaning the resident and applying the clean brief. When asked why she touched the clean brief while wearing the same gloves used to clean RI #1's perineum, EI #4 said, she was nervous and she should have changed gloves. When asked what the potential harm was in not changing gloves and washing her hands per the policy, EI #4 said, infection and bacteria. On 1/5/2017 at 12:15 p.m. EI #2 DON (Director of Nursing), was asked, when should hands be washed during incontinent care. EI #2 said, before and after care, and any time gloves were changed. When asked if gloves should be changed without washing hands, EI #2 said, no. When asked if gloves should be changed before applying a clean brief, EI #2 said, yes. When asked what the potential negative outcome would be, of not changing gloves and not washing hands between glove changes during incontinent care, EI #2 said, there was a risk for infection.

Based on observation, interview, and record reviews, the facility failed to ensure a Certified Nursing Assistant (CNA) washed her hands when changing gloves during incontinent care for Resident Identifier (RI) #6, a resident currently being treated for [REDACTED]. This affected one of three residents observed for incontinent care and one of two residents for UTI's. Findings included: A facility policy titled: Handwashing with a date of July 2015 indicated: Policy Handwashing shall be regarded by this Center as the single most important means of preventing the spread of infections. Policy Interpretation and Implementation 1. All personnel shall follow our established handwashing procedures to prevent the spread of infection . 2. Employees must perform appropriate handwashing procedures under the following conditions: . g. After contact with . excretions . mucous membranes . h. After handling items potentially contaminated with . body fluids, excretions . j. After removing gloves . 3. The use of gloves does not replace handwashing. A facility policy titled: PREVENTING THE SPREAD OF INFECTIONS dated July 2015 indicated: . HANDWASHING . Hand Washing also prevents the spread of microorganisms from one part of the body, such as bowel, to other parts where they could cause infection of the . urinary bladder . Resident Identifier (RI) #6 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Significant Change Minimum Data Set with an Assessment Reference Date of 12/15/2016 revealed RI #6 was totally dependent on staff with one person assist for hygiene and was always incontinent of bowel and bladder. A physician's orders [REDACTED].#6 was receiving [MEDICATION NAME] 500-125 milligrams by mouth two times a day for a Urinary Tract Infection. On 1/4/2017 at 9:50 a.m. incontinent care with bowel movement was observed on RI #6. Throughout the incontinent care, removal of soiled brief, the application of barrier cream and placing of a clean underpad and brief, Employee Identifier (EI) #3 CNA, did not wash or sanitize her hands after changing gloves or before donning clean gloves. On 1/5/2017 at 11:28 a.m. an interview was conducted with EI #3. EI #3 was asked what did the facility's policy indicate when hands should be washed during incontinent care. EI #3 said, hands should be washed before and after care. When asked when she had washed her hands during incontinent care, EI #3 said, she had washed them before and after the care. EI #3 was asked what was the importance of handwashing and the potential harm to a resident when hands are not washed during incontinent care. EI #3 said, infection. On 1/5/2017 at 12:15 p.m., an interview was conducted with EI #2, DON (Director of Nursing). EI #2 was asked according to the facility's policy, when should hands be washed. EI #2 said, hands should be washed before care, when changing gloves and after care was completed to prevent infection. EI #2 was asked what was the potential harm for a resident when hands were not washed during incontinent care and when gloves were changed. EI #2 said, a risk for infection.

Based on observations, record review, and interview, the facility failed to ensure: 1) items in the walk-in cooler were labeled with a use by date; 2) all foods were checked prior to service on 12/02/2015 for the breakfast meal to ensure they were at a temperature of 135 degrees Fahrenheit (F) or greater; 3) eggs were not served at a temperature of 120 degrees F; and 4) foods were not kept at room temperature for greater than an hour and a half prior to cooking for the 12/02/2015 lunch meal. These failures had the potential to affect all 88 residents for whom meals were prepared and served during the survey. Findings include: 1) Review of the Food and Drug Administration Food Code 2013, Chapter 3 Food, page 92, revealed the following: .3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) .refrigerated, READY-TO -EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded . (B) .refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD . shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded . During the initial tour of the kitchen on 11/30/2015 at 5:04 PM, the following items were observed in the walk-in cooler with no use by dates: plastic container of applesauce a pitcher of Sugar Free Shakes cantaloupe Three partial cartons of thickened beverages Jello During an interview with Employee Identifier (EI) #1, the Dietary Manager, on 12/02/2015 at 2:05 PM, EI #1 stated anything that was open should be labeled with a use by date Review of the Food and Drug Administration Food Code 2013, Chapter 3 Food, page 91, revealed the following: . 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling . TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57oC (135oF) or above .or (2) At 5ºC (41ºF) or less . 2) On 12/2/2015 at 6:47 AM, staff began checking temperatures of items on the steam table. A pan containing bacon, pork sausage patties, pork sausage links, and turkey sausage links was noted on the line. Staff checked the temperature by placing the thermometer into the pork sausage patties and stated the meat was 142 degrees F. Staff did not check the temperature of the pork or turkey sausage links prior to serving. Also, during the service, staff was observed plating gravy over biscuits. The temperature of the gravy was not checked prior to serving. Review of the facility's Meal Temperature Record for the 12/02/2015 breakfast meal, revealed there was no space to document the temperature of the gravy. Also, there was only a space for regular meat, chopped meat, and pureed meat. There were no spaces to record the temperatures of different meats. Staff documented one temperature, 142 degrees F. During an interview with EI #1, the Dietary Manager, on 12/02/2015 at 2:05 PM, EI #1 stated every item on the steam table should be checked before serving to ensure they are at the proper temperature. EI #1 stated staff probably should have checked the temperature of all the sausages and also the gravy. EI #1 explained if the temperature was not right, there was a risk of bacterial growth in the food. 3) On 12/2/2015 at 6:47 AM, staff began checking temperatures of items on the steam table. Fried eggs (hard fried, over easy, and sunny side up) were noted on plates inside a pan on the steam table. The sunny side up eggs had visibly runny yolks. Staff obtained a temperature of 120 degrees F and did not pull the eggs from the line. Staff then began serving the eggs. The first cart was complete at 7:28 AM. At 7:30 AM, EI #1, the Dietary Manager was asked what temperature the eggs should be. EI #1 said they should be at least 155 degrees F. The Dietary Manager then rechecked the temperature of the eggs and obtained a temperature of 100 degrees F. During an interview on 12/2/2015 at 2:05 PM, EI #1, the Dietary Manager, stated the eggs should have been at a temperature of 135 degrees F on the steam table. EI #1 went on to explain eggs should never have been on the steam table at a temperature of 120 degrees because eggs that are not cooked properly could potentially result in salmonella or bacterial growth. 4) On 12/02/2015 at 6:47 AM, items in pans and covered with foil were noted on the counter at room temperature. These items were labeled for the 12/02/2015 lunch meal and were labeled as the following: okra and tomatoes, plain okra, pureed meat, pureed rice, tomato, and meat. At 8:20 AM, these items remained on the counter at room temperature. The Dietary Manager stated the items would be cooked after breakfast. During an interview on 12/02/2015 at 2:05 PM, EI #1, the Dietary Manager, stated staff normally pull the foods out of the cooler when they get ready to cook it. EI #1 said the items should not have been left out that long.

Based on observations, record review, and interviews the facility failed to ensure (Resident Identifier) RI #4's siderails were padded as care planned. This affected RI #4, one of thirteen residents for which care plans were reviewed. Findings included: The facility's policy and procedure titled Care Plan--Comprehensive dated November 2001, documented . The Comprehensive Care Plan has been designed to: a. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems; e. Identify the professional services that are responsible for each element of care; . RI #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #4 had a Quarterly (Minimum Data Set) MDS with an (Assessment Reference Date) ARD of 11/10/2015. This MDS identified RI #4 as a 3 out of 15 for cognitive patterns for daily decision making skills, which indicated severe impairment. The MDS further revealed RI #4 required supervision with most (Activities of Daily Living) ADLs and set help with bed mobility and transfers. RI #4's (Range of Motion) ROM identified No impairment of both sides of upper and lower extremities. The Potential for ADL Deficit care plan dated 11/17/2015 stipulated: Potential For ADL Deficit R/T (related to) Dementia; Weakness: Res. (Resident) requires supervision w/ (with) setup help for bed mobility . Interventions . Padded 1/2 sr's (side rails) to bed as enabler . The surveyor observed RI #4 lying in bed and side rails were not padded on 12/2/2015 at 7:00 AM and 8:00 AM. On RI#4's Order Summary Report dated December 2, 2015 has the following Order Status: Active . Padded 1/2 side rails to bed as enabler.Order Date 06/01/2015 . On 12/2/2015 at 1:45 PM an interview was conducted with (Employee Identifier) EI #6, a (Certified Nursing Assistant) CNA. EI #6 was asked if RI #4's bed had padded 1/2 side rails. EI #6 stated, No, they are not padded. EI #6 was asked if RI #4's bed is supposed to have padded 1/2 side rails. EI #6 stated, I am not sure, but I will look in the kardex. The kardex showed Positioning Devices 1/2 padded siderails as enabler. EI #6 was asked whose responsibility was it to pad the side rails. EI #6 said the Restorative Aides will usually pad the side rails. EI #6 was asked why RI #4's side rails were not padded. EI #6 replied that she did not know. On 12/2/2015 at 1:50 PM an interview was conducted with EI #5, a Restorative (Licensed Practical Nurse) LPN. EI #5 was asked if RI #4's bed had padded 1/2 side rails. EI #5 stated, No. EI #5 was asked if RI#4 was supposed to have padded sided rails. EI #5 said yes, this resident does have a physician order [REDACTED].#5 said when RI #4 was transferred on September 1, 2015 from room [ROOM NUMBER] B to the Dementia Secure Unit; the bed in room [ROOM NUMBER] B which had 1/2 padded side rails did not transfer with RI #4 and the bed in room [ROOM NUMBER] B should have been transferred with RI #4. EI #5 was asked whose responsibility was it to transfer a resident's bed from one room to another. EI #5 stated, Housekeeping does the transfers. On 12/2/2015 at 2:05 PM an interview was conducted with EI #4, an LPN. EI #4 was asked if RI #4's bed had padded 1/2 side rails. EI #4 stated, No. EI #4 was asked if RI #4 was supposed to have padded 1/2 side rails. EI #4 said yes, and RI #4 is care planned for 1/2 padded side rails. EI #4 was asked what was the potential harm if this resident does not have 1/2 padded side rails to use as an enabler. EI #4 said the resident could bump up against the side rail and cause a bruise. On 12/2/2015 at 5:00 PM an interview was conducted with EI #3, the Care Plan Coordinator, (Registered Nurse) RN. EI #3 was asked why RI #4 was care planned for padded side rails. EI #3 said for skin prevention issues. EI #3 was asked what was the potential harm if RI#4 does not have padded side rails. EI #3 answered bruises, bumps, and skin tears.

Based on observations, interviews and review of documents, the facility failed to ensure: 1) A CNA (Certified Nursing Assistant) washed her hands prior to, during, and after performing incontinence care. This had the potential to affect RI (Resident Identifier) #6, one of two residents observed for incontinence care. 2) Licensed nurses washed their hands in a manner to prevent the potential of cross contamination, by turning the water faucets off with wet, bare hands. This affected RI #'s 12 and 13, two of seven residents observed during medication administration. Findings include: 1) A review of the facility's policy, dated August 2014, entitled, "HANDWASHING ... Policy Interpretation and Implementation," revealed, "All personnel shall follow our established handwashing procedures to prevent the spread of infection and disease to other personnel, patients, and visitors. ... e. Before handling clean or soiled dressings, gauze pads, etc.(etcetera); ... h. After handling items potentially contaminated with blood, body fluids, excretions, or secretions; ... j. After removing gloves; ... m. Upon completion of duty. ..." A review of the medical records revealed RI #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Significant Change of Status MDS (Minimum Data Set) with an assessment reference date of 09/08/2014, revealed that resident was incontinent of bladder and bowel. This MDS also revealed RI #6 was cognitively impaired for daily decision making skills and required extensive assistance with ADLs (Activities of Daily Living). The resident was identified as nonverbal and incontinent. On 10/28/2014 at 4:10 PM, an observation was made of incontinence care being performed on RI #6. EI #10, a CNA, entered the room and donned clean gloves without washing her hands. EI #10 pulled out the foot of RI #6's bed from the wall and went to stand at RI #6's left side. EI #10 assisted EI #6, another CNA, with turning the resident from side to side during incontinence care. RI #6 was turned to the right side and EI #10 wiped RI #6's buttock in a circular motion with a wet soapy washcloth without changing the gloves or washing hands. EI #10 folded the cloth and wiped RI #6's rectal area. A smear of brown stool was observed on the washcloth. EI #10 obtained a new wet soapy cloth from EI #6 and wiped RI #6's rectal area twice. EI #6 obtained clean water in the basin. EI #10 obtained a clean wet cloth from EI #6 and wiped the resident's buttock in a circular motion. EI #10 folded the cloth and wiped the resident's rectal area. EI #10 then discarded the cloth in the plastic bag at the end of the bed. EI #10 continued to assist EI #6 with turning RI #6. The CNAs placed a clean pad and brief under RI #6 and then repositioned the resident in the bed. EI #10 did not wash her hands or change her gloves during RI #6's care. On 10/30/2014 at 3:03 PM, an interview was conducted with EI #10. EI #10 was asked what she did when she went into RI #6's room to assist with incontinence care. EI #10 stated, "Put on my gloves." EI #10 was asked how had she provided assistance with the incontinence care for RI #6. EI #10 replied, "I helped her (EI#6) turn the resident (RI#6) with the pad and I helped (EI#6) hold the resident's (RI #6) leg over so she could clean. EI #10 was then asked what motion was used when she cleaned RI #6's buttock. EI#10 stated, "Circular." EI #10 was asked when did she wash her hands. EI #10 stated, "I knew I was supposed to wash them when I went in there." EI #10 was then asked at what point did she wash her hands and EI #10 stated, "After we finished." EI #10 was asked if gloves should have been changed after handling the resident prior to incontinence care and she stated, "Yes." EI#10 was asked why. EI #10 stated, "Cause I had touched the cloth pad and that's contamination." EI #10 was asked what the facility's policy was on handwashing. EI #10 stated, "Before contact with each resident; before and after each resident." EI #10 was asked what the facility's policy was on incontinence care regarding what motion was to be used to clean. EI #10 stated, "Front to back." EI #10 was asked what could be the potential negative outcome of hands not being washed prior to incontinence care. EI #10 stated, "They get infection." 2) A review of the facility's Policy and Procedure dated August 2014, and entitled, "PREVENTING THE SPREAD OF INFECTIONS," revealed, "The single most important measure in the Prevention and control of infection is HANDWASHING! HANDWASHING ... HANDWASHING: SOME POINTS TO REMEMBER ... Turn off the water with a dry paper towel and discard it in an appropriate receptacle. Never touch the faucet with your hands after washing. The faucet is considered to be dirty! ... " A medication pass was observed for RI #13 on 10/29/2014 at 8:28 AM, with EI #3, a Licensed Practical Nurse. After hand washing, EI #3 donned gloves and instilled an eye solution into the right eye of RI #13. EI #3 then gave RI #13 a tissue and removed her gloves. EI #3 replaced the medication into the medication cart. EI #3 then went into the kitchenette at the Nurses Station, washed her hands, rinsed them, and turned the water off with wet, bare hands. On 10/29/2014 at 4:07 PM, an interview was conducted with EI #3, a Licensed Practical Nurse. EI #3 was asked how hand washing should be done. EI #3 stated, "Get clean paper towel and turn water on. Let water get hot. Get soap. Lather and scrub hands and nails and wrists. Rinse your hands. Get clean paper towel and turn faucet off. Get another paper towel and dry your hands." EI #3 was asked if it was appropriate to turn water off with wet, bare hands. EI #3 responded, "No." EI #3 was asked why not, and she replied, "Infection Control issue." The surveyor shared the one observation of her turning the water off with wet, bare hands, and asked EI #3 why she had not used a paper towel to turn the water off. EI #3 stated, "I thought I had gotten a paper towel." EI #3 was asked what the potential harm was of turning water off with wet, bare hands, and she replied, "Spreading infection." On 10/29/2014 at 9:35 AM, EI #4, a Licensed Practical Nurse, was observed for medication administration pass. After administering oral medications and insulin to RI #12, EI #4 removed her gloves. EI #4 washed her hands, rinsed them, turned the water off with wet, bare hands, and then dried her hands. EI #4 then donned gloves and obtained toilet paper for RI #12. EI #4 administered 1 drop of Artificial Tears into RI #12's right eye. EI #4 removed her gloves, washed her hands, rinsed them, and then again turned the water off with wet, bare hands. EI #4 dried her hands and donned gloves. EI #4 placed 1 drop of Artificial Tears into RI #12's left eye. EI #4 removed her gloves and washed her hands, rinsed them and turned the water off with wet, bare hands. EI #4 dried her hands and exited the room. EI #4 called the surveyor back to RI #12's room at 9:51 AM and stated, "Supposed to be 2 drops." EI #4 donned gloves and administered 1 drop of Artificial Tears into RI #12's right eye. EI #4 removed her gloves, washed her hands, rinsed them and left the water running at this time. EI #4 dried her hands and donned gloves. EI #4 administered 1 drop of Artificial Tears into RI #12's left eye. EI #4 removed her gloves, washed her hands, rinsed them, turned the water off with wet, bare hands, then dried her hands. An interview was conducted with EI #4, a Licensed Practical Nurse, on 10/29/2014 at 5:27 PM. EI #4 was asked how hand washing should be done. EI #4 stated, "Wash a good 3 minutes, or long enough to sing the birthday song. Hands down. Wash between fingers and around nails. Rinse soap off. Dry hands with paper towels. Discard those paper towels. Get clean paper towels and turn water off." EI #4 was asked if it was appropriate to turn water off with wet, bare hands and she replied, "No." EI #4 was asked why not, and she replied, "Infection Control." The surveyor shared the hand washing observations and asked EI #4 why she had not turned the water off using paper towels during the medication pass observation on 10/29/14. EI #4 stated, "I didn't realize I did that." EI #4 was asked what the potential harm was of turning the water off with wet, bare hands, and she replied, "Spreading germs." On 10/30/2014 at 3:47 PM, an interview was conducted with EI #9, the Infection Control Nurse. EI #9 was asked how hand washing should be done. EI #9 stated, "Turn the faucet on, hands under warm water. Put soap on (hands), agitate between fingers and under nails for a good 20 seconds. Rinse with fingers down ... get a paper towel without touching anything. Pat dry holding hands down, up to wrists. Get clean paper towel and turn water off." EI #9 was asked if it was appropriate to turn water off with wet, bare hands, and she replied, "No." EI #9 was asked why not, and she stated, "Because you are contaminated again." EI #9 was asked what the potential harm was of turning water off with wet, bare hands. EI #9 responded, "You are going to be contaminated. Anything you touch afterwards could be contaminated."

Based on observations, interviews and record reviews, the facility failed to ensure a CNA (Certified Nursing Assistant), performed incontinence care in a manner to prevent the risk of infection. This had the potential to affect RI (Resident Identifier) #7, one of two residents observed for incontinence care. Findings include: A review of the facility's policy dated [DATE] revealed, "Perineal Care ... 18. For a male resident: a. Wet washcloth and apply soap or skin cleansing agent or pick up pre-moistened wipe. b. Wash perineal area starting with urethra and working outward. Fold washcloth or use new washcloth or pre-moistened wipe. (1) Retract foreskin of the uncircumcised male. (2) Wash and rinse urethral area using a circular motion or use pre-moistened wipe and do not rinse. (3) Continue to wipe the perineal area including the penis, scrotum and inner thighs. ... e. Reposition foreskin of the uncircumcised male. ..." A review of the medical record revealed RI #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Annual MDS (Minimum Data Set) assessment with a reference date of 8/5/2014, revealed RI #7 had a BIMS (Brief Interview for Mental Status) score of 4 of a possible 15. This score indicated RI #7 was severely cognitively impaired for skills of daily decision making. RI #7 was assessed as dependant on staff for all ADLs (Activities of Daily Living). RI #7 was incontinent of bowel and bladder. An observation was made on 10/29/2014 at 4:08 PM of EI (Employee Identifier) #8, a CNA, performing incontinence care for RI #7. During the care, EI #8 was observed to hold the foreskin to lift the penis in an upright position to clean, the shaft of the penis. EI #8 did not retract RI #7's foreskin to clean the urethral area. An interview was conducted on 10/30/2014 at 2:31 PM with EI #8. EI #8 was asked how did she clean the penis of RI #7. EI #8 answered, "I hold it by the skin at end of it and wiped down each side with new cloth." EI #8 was asked how should she clean an uncircumcised male resident's urethral area. EI #8 replied, "Supposed to pull back that foreskin." EI #8 was asked why RI #7 was not cleaned according to policy. She answered, "I was nervous." EI #8 was asked what could be the potential negative outcome if a resident with a history of UTIs (Urinary Tract Infections) was not given proper incontinence care. EI #8 answered, "Can get another UTI infection." An interview was conducted with EI #9, the ADON (Assistant Director of Nursing)/Infection Control Nurse on 10/30/2014 at 3:39 PM. EI #9 was asked what were the steps in perineal care for the male resident. She answered, "They should pull the foreskin back, go in circular motion around from the top to prevent germs from going into the opening." EI #9 was asked what could be the potential negative outcome of a male resident with a history of UTI, not having the foreskin retracted and the urethral area. EI #9 answered, "They could get UTIs."

Based on interviews and document reviews, the facility failed to ensure a licensed Nurse did not photograph a resident without permission. This affected RI (Resident Identifier) #11, one of three sampled residents. Findings include: A review of the facility's undated policy titled, "Resident Rights Under Federal Law," revealed, "1. The Resident has a right to a dignified existence...36. Privacy of the resident's body shall be maintained during, but not limited to, toileting, bathing, and other activities of personal hygiene ..." A review of a facility's document titled, "(Corporation's name) "MEMORANDUM," dated 7/22/2014, revealed, "Associate Name: (EI {Employee Identifier} #5) Job Title LPN (Licensed Practical Nurse) Facility Name: (Named facility) ... Violation Stated: Discourteous to Resident and not following Dept (Department) procedure ... Supervisor comments ... LPN took picture of resident without asking permission. Discourteous to resident. Disrespectful to resident." A review of the a facility document titled, "(Corporation's name) "MEMORANDUM," dated 7/23/2014, revealed, "Associate Name: (EI #6) Job Title: CNA (Certified Nursing Assistant) Facility Name: (Named facility) ... Violation Stated: Disrespect to resident and not following Dept procedure ... Supervisor comments ... CNA took sweatshirt off resident and did not put another shirt back on. Resident was covered up with bib/blanket and fed lunch. Dignity of resident was compromised." A review of a facility untitled report dated July 18, 2014, revealed, "(EI #7), Risk Manager and myself (previous administrator), the Administrator spoke with the resident, (RI #11) regarding an accusation that a picture was taken of the resident (RI #11) in bed clothes. Resident was taken to a sitting room for privacy on station 2. I first apologized for the incident that occurred over the weekend. I then asked the resident (RI #11 if a picture was taken of the resident (RI #11) by a staff member on a cell phone. (RI #11) stated, "Yes." I then asked, "Who took the resident (RI #11's) picture." I asked if it was (EI #5) and (RI #11) stated, "Yes." I asked if permission was obtained to take the residents (RI #11's) picture and RI #11 stated, "No." A review of medical records revealed RI #11 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Significant Change MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 9/25/2014, revealed a BIMS (Brief Interview for Mental Status) score of 15 out of a possible 15 points. This indicated RI #11 was cognitively intact for daily decision making skills.This MDS also indicated RI #11 required moderate to extensive assistance with ADLs (Activities of Daily Living). An interview was conducted with RI #11, on 10/30/2014 at 12:20 PM. RI #11 was asked had anyone ever taken pictures of RI #11, without a gown on. RI #11 stated, "Yes, (EI #5)." RI #11 was asked if permission was given to take the picture. RI #11 stated, "No." RI #11 was asked was there an explanation given for taking the picture. RI #11 stated, ("EI #5) didn't tell me why. (RI #11) didn't tell (EI #5) it was okay." RI #11 was asked what affect the picture had on RI #11's family. RI #11 stated, "It made (RI #11) feel bad." RI #11 was asked how did it make RI #11 feel. RI #11 stated, "It made (RI #11) feel bad." RI #11 was asked how did (RI #11's) family find out about this incident. RI #11 stated, "(RI #11) told them." RI #11 was asked how did it affect the family. RI #11 stated, "(RI #11's) family was upset.( RI #11's) family wanted to know why (staff) took pictures of (RI #11)." RI #11 was asked why a gown was not on when the pictures were taken. RI #11 stated, "(EI #6) had bathed and covered (RI #11) with a towel.( EI #6) left the room for a minute and (EI #5) came in and took the picture." RI #11 was asked what EI #5 took the picture with. RI #11 stated, "(EI #5) had a cell phone and snapped the picture." RI #11 was asked if (EI #5) said anything prior to taking the picture to explain why the picture was being taken. RI #11 stated, "No ma'am, just took the picture." RI #11 was asked if EI #5 still worked there and provided care to RI #11. RI #11 stated, "Yes ma'am." An interview was conducted with EI #6, a CNA on 10/30/2014 at 1:25 PM. EI #6 was asked if (EI #6) had taken care of RI #11. EI #6 stated, "Everyday." EI #6 was asked was there an incident where a picture was taken of RI #11 without a gown on. EI #6 stated, "Yes." EI #6 was asked who took the picture. EI #6 stated, "(RI #11) said (EI #5), LPN Charge Nurse." EI #6 was asked what the resident had said about the incident. EI #6 stated, "(RI #11) told me (EI #5) took (RI #11's) blanket off and took (RI #11's) picture. Administration had called (EI #6) in the office and was wrote up because (EI #5) said (EI #6) had left (RI #11) exposed. But (EI #6) didn't, (EI #6) covered (RI #11) up." EI #6 was asked how did RI #11 say it made (RI #11) feel. EI #6 stated, "It made (RI #11) feel real bad." An interview was conducted with EI #5, a LPN on 10/30/2014 at 1:35 PM. EI #5 was asked if (EI #5) had taken care of RI #11. EI #5 stated, "Yes." EI #5 was asked if there was an incident concerning a picture being taken of RI #11, without the residents permission and without a gown on. EI #5 stated, "Yes." EI #5 was asked who took the picture of RI #11. EI #5 stated, "I did." EI #5 was asked if permission had been obtained from RI #11 before taking the picture. EI #5 stated, "No." EI #5 was asked what EI #2, the Director of Nursing did concerning the picture being taken of RI #11, without permission. EI #5 stated, "I received a write up for taking the picture." EI #5 was asked if pictures of RI #11 should have been taken without permission. EI #5 stated, "No." An interview was conducted with EI #2, on 10/30/2014, at 2:30 PM. EI #2 was asked what affect it could have when a resident's privacy and dignity was violated. EI #2 stated, "It could have an emotional affect." An interview was conducted with EI #7 on 10/30/2014 at 4:15 PM. EI #7 was asked how were staff trained to respect resident's privacy and dignity. EI #7 stated, "New hire inservices and yearly, and in any allegation." EI #7 was asked who trained employees about privacy and dignity. EI #7 stated, "I do." EI #7 was asked if taking pictures of RI #11 was a violation of Privacy and Dignity. EI #7 stated, "I would call it bad judgement, but I know the intent was not to hurt the resident. But I would say more of a dignity issue and poor judgement."

Based on interviews and document reviews, the facility failed to ensure a resident's grievance for missing clothes was resolved in a timely manner. This affected RI (Resident Identifier) #18, one of three sampled residents. Findings include: A review of the facility's policy titled, "Protection of Resident's Personal Property, Policy," dated August 2014, revealed, "... 6. The Administrator or his/her designee will log the missing items, complete an investigation on all missing items and document results of findings. The missing item log will be reviewed periodically for trending analysis. 7. The Administrator will ensure that the resident/representative party is informed of the results of the investigation. ... 8. ... The Administrator or Designee will respond to the requestor within a reasonable length of time and will explain the rationale that resulted in the decision." A review of the facility's document titled, "Lost Item Log," dated 9/29/2014, revealed, "Resident's Name: (RI #18) ... Report Date: 9/29/2014 Date Missing: unknown Item Labeled: yes Description: 4 Jogging Suits, 2 Blue, 1 Gray, 1 Red Recovery Date: ... Law Enforcement Involved: no Final Disposition: ongoing." A review of the facility's document titled, "Missing or Lost Article Report" dated 9/29/2014, revealed, "Today's Date: 9/29/2014 Resident's Name: (RI #18) Date item last seen: unknown had packed them up for the summer Date item first discovered missing: (blank) Describe item in detail: 2 blue jogging suits, 1 gray jogging suit, 1 red jogging suit Was item labeled with the resident's name? Yes Approximate Value: $7.50 for each piece ..." A review of a facility's undated policy titled, "Resident Rights Under Federal Law," revealed, "... 15. The Resident has the right to prompt efforts by the Center to resolve grievances. ..." A review of the medical records revealed RI #18 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Significant Change of Status MDS (Minimum Data Set) for RI #18, with an ARD (Assessment Reference Date) of 9/17/2014, revealed a BIMS (Brief Interview for Mental Status) score of 15 out of a possible 15 points.This indicated RI #18 was cognitively intact for daily decision making skills.This MDS also indicated RI #18 required moderate assistance with ADLs (Activities of Daily Living). An interview was conducted with EI (Employer Identifier) #1, a Social Worker, on 10/30/2014 at 2:30 PM. EI #1 was asked who was responsible for following through on grievances and missing articles. EI #1 stated, "(EI #1) usually do." EI #1 was asked what was done when a residents' missing articles were not located. EI #1 stated, "We talk to the resident to see if the facility can replace it or pay for it." EI #1 was asked in what time period were grievances expected to be resolved. EI #1 stated, "It depends on when the resident reports it, sometimes a week or two, or sometimes a little longer. "EI #1 was asked why was RI #18's grievance not resolved sooner. EI #1 stated, "(EI #1) was waiting for family to see if the missing items had been found the missing items in the boxes (RI #18's) family had." An interview was conducted with EI #2, the DON (Director of Nursing), on 10/30/2014 at 2:40 PM. EI #2 was asked who was responsible for following through with residents grievances. EI #2 stated, "Social Services usually follows through. If Social Services is not here, someone in management follows through." EI #2 was asked what time period were resident's grievances expected to be resolved. EI #2 stated, "A couple of weeks would be reasonable, considering what it is." EI #2 was asked if clothes were not found after a grievance was filled out how did the facility resolve it. EI #2 stated, "Normally the facility would replace it. If it's on an inventory sheet and the facility is responsible, the facility would replace it."

Based on interviews and document reviews, the facility failed to ensure a licensed Nurse did not photograph a resident without permission. This affected RI (Resident Identifier) #11, one of three sampled residents. Findings include: A review of the facility's undated policy titled, "Resident Rights Under Federal Law," revealed, "1. The Resident has a right to a dignified existence...36. Privacy of the resident's body shall be maintained during, but not limited to, toileting, bathing, and other activities of personal hygiene ..." A review of the facility's policy titled, "Changing the Resident's Gown or Pajamas," dated November 2001, revealed, "1. Allow the resident as much privacy as possible. Avoid unnecessary exposure of the resident's body. ..." A review of the facility's policy titled, "Dressing and Undressing the Resident," dated November 2001, revealed, "1. Allow the resident as much privacy as possible while he or she is dressing or undressing. ..." A review of a facility's document titled, "(Corporation's name) "MEMORANDUM," dated 7/22/2014, revealed, "Associate Name: (EI {Employee Identifier} #5) Job Title LPN (Licensed Practical Nurse) Facility Name: (Named facility) ... Violation Stated: Discourteous to Resident and not following Dept (Department) procedure ... Supervisor comments ... LPN took picture of resident without asking permission. Discourteous to resident. Disrespectful to resident." A review of the second facility document titled, "(Corporation's name) "MEMORANDUM," dated 7/23/2014, revealed, "Associate Name: (EI #6) Job Title: CNA (Certified Nursing Assistant) Facility Name: (Named facility) ... Violation Stated: Disrespect to resident and not following Dept procedure ... Supervisor comments ... CNA took sweatshirt off resident and did not put another shirt back on. Resident was covered up with bib/blanket and fed lunch. Dignity of resident was compromised." A review of a facility untitled report dated July 18, 2014, revealed, "(EI #7), Risk Manager and myself (previous administrator), the Administrator spoke with the resident, (RI #11) regarding an accusation that a picture was taken of RI #11 in bed clothes. Resident was taken to a sitting room for privacy on station 2. I first apologized for the incident that occurred over the weekend. I then asked RI #11 if a picture was taken by a staff member with an employee (EI #5's) cell phone. (RI #11) stated, "Yes." I then asked, "Who took RI #11's picture." I asked if it was (EI #5) and (RI #11) stated, "Yes." I asked if the resident (RI #11) was asked for permission to take the picture and RI #11 stated, "No." A review of medical records revealed RI #11 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Significant Change MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 9/25/2014, revealed a BIMS (Brief Interview for Mental Status) score of 15 out of a possible 15 points. This indicated RI #11 was cognitively intact for daily decision making skills. This MDS also indicated RI #11 required moderate to extensive assistance with ADLs (Activities of Daily Living). An interview was conducted with RI #11, on 10/30/2014 at 12:20 PM. RI #11 was asked had anyone ever taken pictures of RI #11, without a gown on. RI #11 stated, "Yes, (EI #5)." RI #11 was asked if permission was given to take the picture. RI #11 stated, "No." RI #11 was asked was there an explanation given for staff taking the picture. RI #11 stated, "(EI #5) didn't tell (RI #11) why. (RI #11) didn't tell (EI #5) it was okay." RI #11 was asked what affect the picture had. RI #11 stated, "It made (RI #11) feel bad." RI #11 was asked how did it make (RI #11) feel. RI #11 stated, "It made (RI #11) feel bad." RI #11 was asked how did RI #11's family find out about this incident. RI #11 stated, "(RI #11) told (RI #11's) family." RI #11 was asked how did it affect (RI #11's) family. RI #11 stated, "The family was upset. The family wanted to know why (EI #5) took pictures of (RI #11)." RI #11 was asked why a gown was not on when the pictures were taken. RI #11 stated, "(EI #6) had bathed (RI #11) and covered (RI #11) with a towel. (EI #6) left the room for a minute and (EI #5) came in and took the picture." RI #11 was asked what EI #5 took the picture with. RI #11 stated, "EI #5 had a cell phone and snapped the picture." RI #11 was asked if (EI #5) said anything prior to taking the picture. RI #11 stated, "No ma'am, just took the picture." RI #11 was asked if EI #5 still worked there and provided care to RI #11. RI #11 stated, "Yes ma'am." An interview was conducted with EI #6, a CNA, on 10/30/2014 at 1:25 PM. EI #6 was asked if (EI #6) took care of RI #11. EI #6 stated, "Everyday." EI #6 was asked was there an incident where a picture was taken of RI #11 without a gown on. EI #6 stated, "Yes." EI #6 was asked who took the picture. EI #6 stated, "(RI #11) said (EI #5), LPN Charge Nurse." EI #6 was asked what the resident had said about the incident. EI #6 stated, "(RI #11) told me (EI #5) took (RI #11's) blanket off and took (RI #11's) picture. Administration called (EI #6) in the office and (EI #6) was wrote up because (EI #5) said ( EI #6) had left (RI #11) exposed. But (EI #6) didn't, (EI #6) covered (RI #11) up." EI #6 was asked how did RI #11 say it made (RI #11) feel. EI #6 stated, "It made (RI #11) feel real bad." An interview was conducted with EI #5, an LPN, on 10/30/2014 at 1:35 PM. EI #5 was asked if (EI #5) took care of RI #11. EI #5 stated, "Yes." EI #5 was asked if there was an incident concerning a picture being taken of RI #11, without the residents permission and without a gown on. EI #5 stated, "Yes." EI #5 was asked who took the picture of RI #11. EI #5 stated, "I did." EI #5 was asked if (EI #5) had obtained permission from RI #11 before taking the picture. EI #5 stated, "No." EI #5 was asked what EI #2, the Director of Nursing did concerning the picture being taken of RI #11, without permission. EI #5 stated, "(EI #5 )received a write up for taking the picture." EI #5 was asked if pictures of RI #11 should have been taken without permission. EI #5 stated, "No." An interview was conducted with EI #2 on 10/30/2014 at 2:30 PM. EI #2 was asked what affect it could have when a resident's privacy and dignity was violated. EI #2 stated, "It could have an emotional affect." An interview was conducted with EI #7, an RN/Infection Control Nurse on 10/30/2014 at 4:15 PM. EI #7 was asked how were staff trained to respect resident's privacy and dignity. EI #7 stated, "New hire inservices and yearly, and in any allegation." EI #7 was asked who trained employees about privacy and dignity. EI #7 stated, "I do." EI #7 was asked if taking pictures of RI #11 was a violation of Privacy and Dignity. EI #7 stated, "I would call it bad judgement, but I know the intent was not to hurt the resident. But I would say more of a dignity issue and poor judgement."

Based on observations, interviews, and record reviews, the facility failed to ensure: 1) Licensed Nurse did not place ungloved fingers in the plastic crush bag while preparing medications for administration via [DEVICE] (Gastrostomy tube). This affected RI (Resident Identifier) #9, one of one residents observed during medication pass for [DEVICE] administration of medications. 2) Licensed Nurse cleaned a Glucometer with an EPA (Environmental Protection Agency) approved solution after use prior to placing back into the storage case and returning the case to the medication cart. This was observed on 1 of 2 residents observed for blood glucose check during medication pass. 3) Three staff members wore appropriate personal protective equipment while providing care to RI #4, who had Contact Isolation precautions for[DIAGNOSES REDACTED] (Clostridium Difficile). This was observed on 1 of 5 units in the facility Findings include: 1) A review of RI #9's medical record indicated RI #9 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a Significant Change in Status MDS (Minimum Data Set) for RI #9 with an ARD (Assessment Reference Date) of 10/24/13, indicated RI #9 had a BIMS (Brief Interview for Mental Status) score of 9. This indicated RI #9 out of possible 15 was moderately impaired for cognitive skills. RI #9 was coded as being totally dependent on staff for bed mobility, transfers, locomotion, eating, toilet use, and bathing. A review of the physician's orders [REDACTED].@ 1200 & 1800 (at 12:00 Noon and 6:00 PM)." Also, there was an order for [REDACTED]." On 1/7/14 at 11:53 AM, EI (Employee Identifier) #6 (an LPN - Licensed Practical Nurse) was observed preparing medications for RI #9. EI #6 obtained medications from the medication cart, placed an ungloved finger into the plastic crush bag to open the bag, and placed one of the medications into the bag. EI #6 then crushed the pill using the pill crusher, and placed her ungloved finger inside the crush bag to open the bag and poured the crushed medication into a medication cup. EI #6 then obtained another plastic bag, placed an ungloved finger into the bag to open the bag, placed the medication into the bag, and crushed the pill using the pill crusher. EI #6 then placed an ungloved finger into the bag, and poured the crushed medication into a medication cup. On 1/8/14 at 9:40 AM, an interview was conducted with EI #6. EI #6 was asked what the facility's policy was regarding crushing medications. EI #6 stated, if the medication was [MEDICATION NAME] coated or long acting the medication could not be crushed unless there was an order from the Physician that stated it was OK to crush the medication. EI #6 was asked how the plastic crush bag was opened to place the medication in the bag for crushing or removing the crushed medication. EI #6 stated, "I usually try to squeeze it to get it open." EI #6 was asked should the bag be opened by placing an ungloved finger into the bag. EI #6 stated, "No ma'am." EI #6 was asked why the ungloved finger should not be placed into the bag to open it. EI #6 stated, "Infection Control." EI #6 was asked what the potential negative outcome was for residents if a nurse placed an ungloved finger into the plastic crush bag. EI #6 stated, "If she has any type of infection she is passing it on to the resident. If she has come in contact with any type of bacteria, she could subsequently pass it on to the resident." 2) Based on the facility's Policy entitled, "Obtaining a Fingerstick Glucose Level" and dated "January 2010 ... 19. Clean glucose monitor with approved disinfectant before and after each resident use." On 01/06/2014 at 4:03 PM, EI #1, an L.P.N. performed a fingerstick for an accucheck for RI #18, using a Glucometer from the med (medication) cart. EI #1 did not clean the Glucometer prior to entering the room for RI #18. After performing the fingerstick, EI #1 replaced the Glucometer in it's case and returned it to the med cart. EI #1 told the surveyor, she would "clean my machine when I get done with you." RI #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of physician's orders [REDACTED]. On 01/09/2014 at 10:05 AM, a telephone interview was conducted with EI #1. EI #1 was asked what was the facility's policy on cleaning Glucometers after use. EI #1 stated, "You use the Gluco cleaner after and before, and wait five minutes." EI #1 was asked what was the potential negative outcome of placing an unclean Glucometer back in the pouch or case, and returning it to the med cart. EI #1 stated, "Could possibly get blood on the pouch and a resident could get infection." On 01/09/2014, an interview was conducted with EI #4, the Infection Control Nurse. EI #4 was asked what was the facility's policy on cleaning Glucometers after use. EI #4 stated, Glucometers were to be cleaned before and after each use with "Glucose-Wipes" and wait for 5 minutes. 3) Based on the facility's Policy entitled, "Isolation Precautions, Categories of" and dated "[DATE]," "Policy ... 3. In addition to Standard Precautions, Contact Precautions must be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or patient-care items in the resident's environment ... b. Gloves and Handwashing 1) In addition to wearing gloves as outlined under Standard Precautions, wear gloves ... c. Gown 1) In addition to wearing a gown ..." On 01/07/2014 at 8:17 AM, EI #2, an LPN and EI #3, a CNA (Certified Nursing Assistant) were observed in the room for RI #4, a resident in contact isolation for [DIAGNOSES REDACTED], and not wearing PPE (Personal Protective Equipment). A review of RI #4's records indicated that RI #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of lab results for RI #4 indicated that on 11/25/2013, RI #4 was diagnosed with [REDACTED]. A review of the Quarterly MDS with an Assessment Reference Date of 11/25/2013, indicated RI #4 was coded as having a BIMS of 10 out of 15. This indicated RI #4 was moderately impaired. RI #4 was also coded as requiring extensive assistance with bed mobility and toilet use, and limited assistance with dressing and personal hygiene. On 01/07/2014 at 11:19 AM, EI #1 was observed to provide wound care to the excoriated area of RI #4's buttocks, assisted by EI #2. After having been in the room and properly dressed with gown and gloves, EI #1 removed her gloves and gown, washed her hands and left the room to retrieve a tape measurer. When EI #1 returned to RI #4's room, EI #1 was not wearing a gown, only gloves. EI #1 proceeded to measure the area on RI #4's buttocks. In getting into a good position to measure the area, EI #1's right arm was noted to be on the pink incontinent pad underneath RI #4. After measuring the area, EI #1 proceeded to provide wound care to RI #4's buttocks, still only wearing gloves. On 01/08/2014 at 8:25 AM, EI #3 was observed to enter RI #4's room with his breakfast. EI #3 placed RI #4's tray on the overbed table, donned gloves, and emptied RI #4's urinal. EI #3 removed her gloves and donned clean gloves, then assisted RI #4 with sitting up for his meal. EI #3 was not wearing a gown during this time. On 01/08/2014 at 2:17 PM, an interview was conducted with EI #3. EI #3 was asked what was the facility's procedure on contact isolation. EI #3 stated, "We have to wear gown and gloves. If airborne, you must wear masks. If infection is bad, you put gown, gloves and masks on." EI #3 was asked what PPE should be worn when entering a room if a resident is in contact isolation. EI #3 stated, "Your gloves, and if its bad, put the mask and gown on." EI #3 was asked if a resident was in contact isolation, should staff always wear PPE, and why or why not. EI #3 stated, "They should. It depends on what kind of infection." On 01/09/2014 at 10:05 AM, a telephone interview was conducted with EI #1. EI #1 was asked what was the facility's policy on contact isolation. EI #1 stated, "Always glove and gown up, and mask if you want to, for contact isolation." EI #1 was asked what PPE should be used when entering a room if a resident is on contact isolation for[DIAGNOSES REDACTED]. EI #1 stated, "Gloves and gown, and wash your hands." EI #1 was asked about the potential negative outcomes of not wearing PPE when entering the room of a resident in contact isolation for[DIAGNOSES REDACTED]. EI #1 stated, "You could also get infection, or what they have. You could also carry it back out to someone else. Handwashing is most important, along with gloves and gowns." EI #1 was asked if she recalled re-entering the room for RI #4 on 01/07/2014 and providing care for his buttocks, and not wearing her gown. EI #1 stated, "I do, and I was hoping you wouldn't notice it." On 01/09/2014 at 10:40 AM, a telephone interview was conducted with EI #2. EI #2 was asked what was the facility's policy or procedure for contact isolation. EI #2 stated, "It depends on what they are in isolation for. If it's contact, you gown or suit up." EI #2 was asked what PPE should be used when entering a room of a resident in contact isolation for[DIAGNOSES REDACTED]. EI #2 stated, "Gown and gloves." EI #2 was asked about the possible negative outcomes of not wearing PPE when entering the room of a resident in isolation for[DIAGNOSES REDACTED]. EI #2 stated, "You could transfer the bacteria or infection to another room or hallway if you don't wear all your equipment." On 01/09/2014 at 11:07 AM, an interview was conducted with EI #4. EI #4 was asked what was the potential negative outcome of not wearing PPE when entering a room of a resident in contact isolation for[DIAGNOSES REDACTED]. EI #4 stated, "Spreading it to yourself or someone else when you come out." On 01/09/2014 at 11:35 AM EI #5, the DON (Director of Nursing), was interviewed and asked what was the facility's Policy on cleaning Glucometers after use. She stated, "They should use Gluco wipe before and after each use." EI #5 was then asked when this should be done, she stated "Before and after each use." EI #5 was then asked what was the potential negative outcome of not cleaning the glucometer, and putting it back in the case and then putting it in the drawer on the medication cart. EI #5 stated "Transmission of possible infectious material." EI #5 was asked what was the facility's Policy on contact isolation. EI #5 stated, " The resident identified would have a note put on the door, wear PPE related to the type of infection." EI #5 was asked what PPE should be used if caring for/entering room of a resident with[DIAGNOSES REDACTED]. She stated, "That would depend on what they were going to do for the resident, if they were going to come in contact or had a great potential of contact with stool wear gloves and gown." Next EI #5 was asked what would be the potential negative outcome of not using PPE when entering the resident's room. She stated, "Transmission of[DIAGNOSES REDACTED] to other residents or yourself." EI #5 was asked if during wound care a nurse left the room and came back in and didn't re-gown, what were the potential negative outcomes. She stated, "Transmission of[DIAGNOSES REDACTED] to others if there was contact with stool." EI #5 was then asked what the procedure for crushing medications was. She stated, "We use plastic sleeves, put medicine in and crush with pill crusher." Then she was asked how should the crush bag be opened and she stated, "Should not touch the inside." EI #5 was asked if the nurse should place her ungloved finger in the bag and she stated, "No." EI #5 was asked why or why not and she stated, "Potential for contamination."

Based on observation, interview and record review the facility failed to ensure resident's rooms were free of scuffed sheet rock, scuffed entrance doors and cracked missing floor tile. The facility further failed to ensure resident's wheelchairs (w/c)'s were free of a built up of dust, dirt and debris on the wheelchair frames and a white colored substance splattered on the w/c spokes. This affected Room Locators (RL) 1-20, on four of seven halls. Findings include: The facility "Preventive Maintenance Manual," page 8.10, (no date), documented the following: "Inspecting Resident/Patient Rooms Introduction To ensure that the resident/patient rooms are as safe and comfortable as possible, routine inspections of the rooms should be done. General Inspection The following steps should be taken when performing a general inspection on all resident/patient rooms ... STEP 7 ...Visually check paint, door jams, and door closures, and check wallpaper for damage and tears..." The facility "Preventive Maintenance -Resident's Rooms" checklist, listed the following areas that were to be checked by the Maintenance Department, " ...Paint/ ...Floor .../Doors ... " The facility policy titled "Cleaning Schedules" dated November 2001, documented the following: "Policy Cleaning schedules shall be developed and implemented to ensure that the Facility is maintained in a clean and comfortable manner. Policy Interpretation and Implementation 1. Cleaning schedules are developed and implemented to assure that each area of the Facility is maintained in a safe, clean, and comfortable manner. 2. Cleaning schedules are posted in Nsg (nursing) stations and a copy is available in the department director's office." The facility "Wheelchair Washing" schedule listed a time of 2 pm- 3 pm when wheelchairs were to be cleaned. The days the wheelchairs were to be cleaned were Mondays-Thursdays. On 02/21/2013 at 3:30 PM, the following observations were made: Room Locator (RL) RL#1- the sheetrock on the wall behind the head of the bed was noticeably scuffed. RL#2- the door to the room was scuffed with several black marks RL #3-a picture frame on the TV stand was broken and needed repair RL#4- the tile between the chest of drawers was cracked and missing RL#5-the tile between the chest of drawers was cracked and missing RL#6- the sheetrock on the wall behind the head of the bed was noticeably RL#7- the door to the room and the bathroom door were scuffed with black marks RL#8- the handrail across the hall from this room was not connected at the corner. There was about a 1 inch gap in the handrail where it joined together RL #9-RL #20 the wheelchair's frame was observed with dirt and dust built up During the Resident Council Meeting on 02/22/13, at 9:00 AM, 10 of the 13 residents in attendance were in a wheelchair. The residents were then asked to look at their wheelchairs and tell the surveyor if it was clean or dirty. All residents in wheelchairs stated their chairs were dirty and would like the wheelchair to be cleaned. RI #20 commented during the discussion of the wheelchairs, "It bothers me that my wheelchair is so dirty." On 02/22/13, at 11:45 AM, Employee Identifier (EI) #4, (Housekeeping Supervisor) was asked who was responsible for cleaning wheelchairs. EI #4 replied housekeeping was responsible for cleaning the wheelchairs. EI #4 was asked when the last time the wheelchairs were cleaned was and did he have any documentation. EI #4 replied he did not have any documentation of when the wheelchairs were last cleaned. EI #4 commented the wheelchairs had not been cleaned this week. EI #4 was asked why there were so many dirty wheelchairs. EI #4 replied sometimes the residents would not let them have their wheelchairs between 2 and 3 o'clock during the day. EI #4 was asked if he had thought of cleaning the wheelchairs at another time of the day. EI #4 replied he had not thought of that. On 02/22/13, at 12:00 PM, EI #6 (Maintenance Director) was asked who was responsible for maintaining resident's rooms. EI #6 replied maintenance. EI #6 was asked how often maintenance rounds were done in the resident's rooms. EI #6 replied monthly. EI #6 was asked how he was notified if something needed to be repaired in a resident's room. EI #6 replied there was a repair request book at each nursing station and he would look through it to see what needed to be repaired. EI #6 was asked was he previously aware of the concerns shown to him by the surveyor. EI #6 replied no ma'am.

Based on record review and interviews, the facility failed to ensure the abuse registry checks were completed for newly hired employees prior to them being employed. This affected three of five employees, Employee Identifier (EI) #1, #2, and #3, after reviewing their personal files. Findings Include: A review of the facility's policy and procedure titled "Prevention of Resident Abuse, Neglect, Mistreatment or Misappropriation of Property," dated July 2011 revealed the following: "...SCREENING ... All associates will be screened prior to hire by having a criminal background check performed. The DON (Director of Nursing) or designee will contact the State Board of Nurse's Aide Abuse Registry to determine if a nurse aide has been placed on the abuse registry ... It is the responsibility of the Director of Nursing to ensure these checks are performed..." 1. On 02/21/13 at 3:00 PM, a review of the facility's sheet titled, "NEW HIRE CELEBRATION" Requirements in all Personnel Files revealed EI #1 was hired as a Laundry Aide on 01/25/13. "...NA (not applicable)" was documented in the section, " COPY OF CERTIFICATION/ LICENSE (INCLUDE VERIFICATION SHEET) ..." In EI #1's employee personnel file was a form documenting, "Office of Inspector General U.S. Department of Health & (and) Human Services...(identified EI #1's social security number with a nursing profession background) Search conducted 1/31/13 ..." This search was completed six days after EI #1's date of hire (01/25/13). On 02/21/13, at 4:10 PM, during an interview with EI #5 (Assistant Director of Nursing), the surveyor asked who was responsible for employee registry checks. EI #5 stated, "I do registry and drug." The surveyor asked where was the abuse registry printout for EI #1. EI #5 stated, "It doesn't print out." The surveyor requested the printout of the registry check for EI #1. EI #5 assisted with the computerized registry check printout and the printout was given to the surveyor for review. The surveyor asked if she obtained a printout for all non-nursing. EI #5 stated, "No." The surveyor asked was there a registry check for all non-nursing employees. EI #5 responded, "Yes." The surveyor asked where was the documentation to reflect the abuse registry was checked for EI #1 prior to hire. EI #5 stated there was no documentation. The surveyor asked why not. EI #5 stated, "I just didn't." 2. On 02/21/13 at 3:00 PM, a review of the facility's sheet titled, "NEW HIRE CELEBRATION" Requirements in all Personnel Files revealed EI #2 was hired as Certified Nursing Assistant Student on 01/15/13. The section, "COPY OF CERTIFICATION/LICENSE (INCLUDE VERIFICATION SHEET)" on this form, was left blank by the facility. On 02/22/13 at 12:00 PM, during an interview with EI #5, the surveyor asked when were the abuse registry checks completed for EI #2. EI #5 stated the checks were done last night (02/21/13) around 5 PM. The surveyor asked where were the abuse registry printouts prior to EI # 2's hire date of 01/25/13. EI #5 stated, "We did get it." The surveyor asked where was the documentation to reflect the abuse registry was checked for EI #2. EI #5 responded, "I don't have it, but from now on we will print it. " 3. On 02/21/13 at 3:00 PM, a review of the facility's sheet titled, "NEW HIRE CELEBRATION" Requirements in all Personnel Files revealed EI #3 was hired as a Certified Nursing Assistant Student on 10/30/12. The "COPY OF CERTIFICATION/ LICENSE (INCLUDE VERIFICATION SHEET)" section on this form contained a " X " mark in this section, however EI #3 did not have a verification sheet in the Personnel file. On 02/22/13 at 12:00 PM, during an interview with EI #5, the surveyor asked when were the abuse registry checks completed for EI #3. EI #5 stated the checks were done last night (02/21/13) around 5 PM. The surveyor asked were the abuse registry printouts prior to hire EI #3 ' s 10/30/12 hire date. EI #5 stated, "We did get it." The surveyor asked where was the documentation to reflect the abuse registry was checked for EI #3. EI #5 responded, "I don't have it, but from now on we will print it. "

Based on observations, interviews, and record review, the facility failed to ensure RI (Resident Identifier) #10's tube feeding infused as ordered on [DATE]. The facility also failed to document the start time of this feeding on 02/14/12. This affected one of two residents sampled with tube feedings. Findings include: The facility policy and procedure titled, "Feeding Systems," dated August 2011, revealed: "...2. Continuous Feeding: ...Miscellaneous ...11. All feeding bags and feeding tubing must be dated and timed." RI #10 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #10's Hospital "History and physical," dated 01/15/12, revealed a PEG (Percutaneous Endoscopic Gastrostomy) tube was inserted on 01/12/12. RI #10's Significant Change MDS (Minimum Data Set) Assessment, dated 01/24/12, revealed she had short and long-term memory problems and had severe cognitive impairment. The MDS also showed she was totally dependent on staff members for all her ADLs (Activities of Daily Living). RI #10's February 2012 physician orders [REDACTED].@ (at) 70 cc (cubic centimeters) hr (per hour) x 20 hours, down from 10AM-2PM daily..." The orders also revealed she could not consume anything by mouth. RI #10's Care Plan for "Altered Nutrition and Hydration r/t (related to) DM weakness: ...new peg tube placement," dated 02/01/12, revealed: "...2. Record % of hydration and nutritional intake ...Wts. (weights) q (every) 2 weeks." The Registered Dietitian, EI (Employee Identifier) #6's "Nutritional Progress Notes," dated 02/01/12, revealed her calculated daily nutritional needs to be: 1890 calories, 1890 ccs of fluid, and 81 grams of protein. The progress note revealed the recommended order for tube feeding actually would provide: 2100 calories, 2142 ccs of fluid, and 114 grams of protein. (This is more than her estimated needs). On 02/13/12 at 5:45 PM, during the initial tour of the facility, RI #10 was in bed with her tube feeding (Glucerna 1.5 cal) hanging and attached. The tube feeding was not running; the pump was off. The 1000 ml (milliliter) bottle was dated 02/13/12 and had a start time of "2P" (2:00 PM) handwritten. The rate handwritten was 70 ccs per hour. The feeding was still at the 1000ml line, which was 262 ccs behind what it should have been. On 02/14/12 at 8:47 AM, the same tube feeding bottle for RI #10 that was hanging from the previous evening was still hanging. The feeding was infusing at 70 ccs, and there were 250 ccs left in the bottle. The resident should have received 1312 ccs of Glucerna in the 18.75 hours from 2:00 PM on 02/13/12 to 8:45 AM on 02/14/12, but she actually received only 750 ccs. This means RI #10 did not receive 562 ccs of feeding. This resulted in a deficit of 843 calories and a deficit of 46 grams of protein. On 02/14/12 at 3:27 PM, RI #10 was in her bed with Glucerna tube feeding infusing at 70 ccs per hour. It was dated 02/14/12, but there was no start time documented on the bottle. There was 1000 ml left in the bottle. On 02/14/12 at 3:35 PM, EI #4, RI #10's regular day shift LPN (Licensed Practical Nurse), was asked what the Glucerna order meant by "down from 10A to 2P." She said it meant the tube feeding was turned off during that time frame every day. EI #4 was asked what she is supposed to document on the tube feeding bottle. She said the date and time it is started, the formula, and the resident's name. EI #4 was asked if she was aware there was no start time documented on RI #10's bottle. She said she must have forgotten to document it. EI #4 explained that she hung it at about five minutes until 10:00 AM, so she did not start it then, but came back and started it about 2:15 PM when she came back from lunch. EI #4 was asked how she monitors to make sure RI #10 receives her calculated tube feeding needs. She said the display screen on the pump shows how much has infused. EI #4 explained that the nurses document on the MAR under "intake" the total amount of what the pump shows plus the flushes throughout the shift. She said she documents what the resident receives on her 12 hour (7A to 7 P) shift. EI #4 was asked how she makes sure the resident actually receives what she is ordered. She said the RD determines the needs, the RN (Registered Nurse) orders it, and the nurses follow the orders. EI #4 said the RD follows up and monitors. EI #4 was asked if she started RI #10's tube feeding on 02/13/12. She said she did at 2:00 PM. EI #4 was asked why there was still 1000ml in the bottle at 5:45 PM. She said someone may have turned it off and may have forgotten to turn it back on or let her know. EI #4 was asked if she was aware that it was the same bottle that was hung on 02/13/12. She said she noticed it was her handwriting on the bottle, but it did not strike her as odd because that happens sometimes. EI #4 stated it should have been changed on the night shift. EI #4 was asked if anyone reported turning it off. She said a CNA (Certified Nursing Assistant) reported twice that day it was beeping, so she flushed it and turned it back on. EI #4 was asked if she reported that the same bottle was hanging the next day. She said she did not because she felt like she got it under control after flushing it and turning it back on. EI #4 stated that the pump makes a beeping noise if the tube gets kinked, but it is not loud enough to hear down the hall or at the nurse's station. On 02/15/12 at 11:30 AM, EI #6, the RD, was asked to explain how he calculated RI #10's nutritional needs. He said he considered her height, weight, and her pressure ulcers. He said the tube feeding order provided more than her calculated needs just to make sure she gets what she needs. EI #6 was asked who was responsible for monitoring to make sure RI #10 actually receives her calculated needs. EI #6 said he makes the recommendation and the nurses on the hall make sure it is running at the right rate. EI #6 was asked if he monitors the nurses' documentation. He said he does not. He said he looks at the weights and adjusts the feeding as necessary. On 02/15/12 at 10:03 AM, the Director of Nursing, EI #3, was asked what the purpose was for dating and timing the the tube feeding bottle. She said it was so they would know what time it was hung because they can only hang for a certain time. EI #3 was asked if the documented time was the time it was hung or the time the tube feeding was started. She said it was when they hang it, but she would hang it and start it at the same time. EI #3 was asked if it was ok for nurses to hang it, but not start it until later. She said the policy did not address that, but she would train them to spike it, hang it, and start it at the same time. EI #3 was informed of the observation of RI #10's bottle not having a start time on 02/14/12. She said it should be documented when the feeding is started. EI #3 was asked who was responsible for monitoring to make sure RI #10 received the amount of tube feeding she needed. EI #3 responded, "The nurse on the floor." EI #3 was asked how the nurses monitor. She said as they give medications, when doing flushes, and during rounds, they make sure it is infusing at the correct rate. EI #3 was asked how they would be able to tell if it was behind. She said they know it is turned off from 10 AM to 2 PM, so they would have to pay attention to the date and time it was started. EI #3 was informed that RI #10's tube feeding was off and behind on 02/13/12 during the initial tour. EI #3 said she saw the nurse hang the feeding that day at 2 PM and it should have run out by 4 AM the next day. EI #3 was asked if she was aware of RI #10's tube feeding deficit. She said she was not until the surveyor started asking questions. EI #3 was asked what the potential harm would be of not getting the correct amount of feeding. She said weight loss and nutritional needs not being met. EI #3 explained that it was not a continual problem because RI #10's weight was steady and her wounds were healed. EI #3 was asked if they had a policy about who monitors tube feedings and how they monitor them. She said they do not. EI #3 was asked how they know what has infused since the nurses do not document the Glucerna separate from the water. She said they only document those separately if they are having tube feeding problems. EI #3 was asked how they can know what actually infused if they do not document what is actually infusing. She said she understood.

Based on observations, record review and interviews, the facility failed to ensure Certified Nursing Assistants (CNAs) reported Resident Identifier (RI) #8's complaint of a headache to a licensed nurse. This affected one of 16 sampled residents. Findings include: RI #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), with an assessment reference date of 12/05/11, revealed RI #8 had memory problems with a Brief Interview for Mental Status (BIMS) of 9 (indicating moderately impaired cognition). RI #8 was also identified as occasionally incontinent of bowel and bladder. The pain management section of the MDS revealed RI #8 received pain medication as needed (PRN) for occasional pain. The MDS also identified RI #8's pain as "4" on a scale of zero to ten, with zero being no pain and ten being the worst pain she could imagine. Physicians' orders dated 01/31/12, revealed the inclusion of Tylenol 650 mg (milligrams) po (by mouth) every four to six hours PRN, not to exceed 4000 mg in 24 hours for generalized pain. On 02/14/12 at 10:10 AM, two CNAs provided incontinence care to RI #8. During this care, RI #8 complained of having a headache. The CNAs asked RI #8 if she wanted to stay in the bed until lunch. The CNAs removed the resident's shoes and positioned her in bed, under covers. On 02/14/12 at 11:44 AM, the Licensed Practical Nurse (LPN) Employee identifier (EI) #7 was asked if the CNAs had reported RI #8's complaint of a headache. EI #7 replied "No." EI #7 was asked what RI #8 was ordered for pain. EI #7 replied she had Tylenol. When asked if she had given RI #8 any Tylenol this morning, EI #7 replied she had not. EI #7 stated she had been made aware of the resident's complaint, but she would ask the resident about it now. On 02/14/12 at 1:10 PM, the surveyor asked EI #9 (a CNA) if she had reported RI #8's headache complaint to the nurse. EI #9 replied, "No." EI #9 stated it had slipped her mind. On 02/14/12 at 1:12 PM, the surveyor asked EI #10 (the other CNA) if she had reported to the nurse about RI #8's complaint of a headache. EI #10 replied, "No." When asked why she had not reported the resident's headache, EI #10 explained that when she had come out of the room, the nurse told her that one of the call lights was on and she went to answer the light. On 02/15/12 at 2:10 PM, the surveyor interviewed RI #8's Physician, EI #1. The surveyor asked the Physician if he would expect the CNAs to report RI #8's complaint of a headache to the nurse. EI #1 replied, "Sure."