Every finding on record at Washington County Nursing Home

Based on a facility policy titled ABUSE, NEGLECT AND EXPLOITATION PREVENTION, REPORTING AND INVESTIGATING and a review of a facility document titled,Grievance report record review and interviews, the facility failed to ensure an allegation of abuse was reported to the State Survey Agency. This affected RI (Resident Identifier) #122, one of one sampled residents reviewed for abuse reporting. Findings include: A review of a facility policy titled, ABUSE, NEGLECT AND EXPLOITATION PREVENTION, REPORTING AND INVESTIGATING with a revised date of (MONTH) (YEAR) revealed the following: .V. INVESTIGATION . B. The DON(Director of Nursing)/Designee will report alleged abuse/suspected instances of mistreatment .immediately (as soon as possible but not to exceed 2 hours). RI #122 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a facility document titled, Grievance report with a submitted date of 9/22/2017 revealed EI (Employee Identifier) #2, RN (Registered Nurse) informed the Abuse Coordinator/DON, EI #1 of RI #122's family member commenting on social media regarding his concern of RI #122 being snatched and jerked around and mistreated at the facility. According to the Grievance report EI (Employee Identifier) #1, DON conducted interviews from 09/22/2017 until 09/28/2017 with staff and family members of RI #122 regarding this submitted grievance. On 02/15/2018 at 4:35 p.m., a telephone interview was conducted with EI #2, the nurse who reported the social media comment. EI #2 explained she was informed by a Certified Nursing Assistant, whose name she could not remember, of a allegation made by RI #122's family member. EI #2 further explained she informed EI#1, the DON, once the allegation was reported to her. On 02/15/2018 at 5:11 p.m., an interview was conducted with EI #1. EI #1 was asked how did the facility define abuse. EI #1 explained the definition of abuse was the willful infliction of harm to a resident and the types of abuse were verbal, sexual, mental, neglect, physical, exploitation. EI #1 was asked when should allegations of abuse be reported to the State Survey Agency. EI #1 explained within two hours of suspected abuse. EI #1 said the facility is to report all allegations of abuse. EI #1 was asked why should allegations of abuse be reported the State Agency. EI #1 explained it was part of the regulations. EI #1 was asked who was the Abuse Coordinator at the facility. EI #1 said she was the Abuse Coordinator and so was the Social Service Coordinator. EI #1 was asked to review the Grievance report dated 9/22/2017 regarding RI #122. EI #1 was asked why were interviews conducted regarding the allegations written on social media regarding RI #122. EI #1 said because she was concerned about the statement that was posted on social media by RI #122's family member regarding the resident being snatched around and mistreated and wanted to verify if the allegation had occurred. EI #1 was asked who had conducted the interviews. EI #1 explained she had conducted all the interviews but one and stated Social Services had conducted the last interview. EI #1 was asked why was this incident/allegation not reported to the State Agency. EI #1 explained she did not report it because she felt she had ruled out any allegation of abuse. EI #1 was asked what was the facility's policy for reporting allegations of abuse to the State Survey Agency. EI #1 said to report it within two hours of the receipt of the allegation. EI #1 was asked was the allegation regarding RI #122 reported to the State Survey Agency. EI #1 said no. EI #1 was asked should the allegation regarding RI #122 have been reported to the State Agency. EI #1 said yes.

Based on record review and interview, the facility failed to ensure the Quality Assessment and Assurance (QA&A) Committee developed and implemented an action plan after the unexpected death of Resident Identifier (RI) #1 in the facility on 11/13/2016. During the evening of 11/13/2016, EI #12, a Licensed Practical Nurse (LPN) incorrectly read RI #1's activities of daily living (ADL) sheet. The ADL sheet, also known as the plan of care kardex indicated the resident was prescribed a pureed diet. EI #12 gave RI #1 a roast beef sandwich, that was not of a pureed texture. During the 11:00 PM - 7:00 AM shift, RI #1 was given another sandwich, which was not of a pureed texture, by EI #13, a Certified Nursing Assistant (CNA). Within minutes, the call light to RI #1's room came on, the staff responded and found RI #1 choking; the resident was patting on his/her chest, slumped over to the right side and blue in color. The staff performed the [MEDICATION NAME] maneuver. Other staff members responded to the call for help and tried to perform the [MEDICATION NAME] maneuver as well. The staff did manually remove what appeared to be chewed up bread from the resident's mouth. The emergency room (ER) physician was called and asked the staff to transport the resident to the ER, which was attached to the nursing home. The ER physician stated RI #1 arrived in the ER and was pronounced dead on arrival due to aspiration of a large food bolus lodged in the resident's throat. The ER physician stated she was told the resident had been given a roast beef sandwich; however, he/she was ordered a pureed diet. The ER physician also removed what appeared to be chewed up bread from the resident's mouth. RI #1's death certificate indicated the immediate cause of RI #1's death as Asphyxiation, with an underlying cause of Aspiration. The date/time of death was listed as 11/13/2016 at 11:35 PM. This deficient practice placed RI #1, one of four sampled residents identified by the facility who received a pureed diet, in immediate jeopardy as it was likely to cause serious injury, harm and/or death. On 12/29/2016 at 1:55 PM, EI #9, the Director of Nursing and EI #10, the Administrator were notified of the findings of immediate jeopardy in the area of administration, F 520. Findings include: Refer to F 281, F 282, F 367 and F 490 The facility's policy titled QUALITY ASSESSMENT AND ASSURANCE dated November 2016, documented POLICY The purpose of this policy is to ensure that this facility will operate a Quality Assessment and Assurance Committee to identify quality issues and develop and implement appropriate plans of action to correct identified quality deficiencies within the facility through an interdisciplinary approach. PROCEDURE . 2. a. Meet at least quarterly, and as needed, to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities . b. Develop and implement appropriate plans of action to correct identified quality deficiencies; . During an interview on 12/30/2016 at 10:36 AM, Employee Identifier (EI) #9 acknowledged the facility had not discussed in QA the events/circumstances that took place during the unexpected death of RI #1 in the facility on 11/13/2016. ************************* On 12/30/2016 at 3:30 PM, the facility provided the following Allegation of Compliance (AOC) for F 520, which documented: On 12/29/2016, the Administrator/Designee began in-servicing facility staff regarding how to bring a concern to the QA&A Committee. The Administrator/Designee will provide this education to each oncoming shift prior to oncoming staff being allowed to take the floor until direct care staff members have been in-serviced. By 12/30/2016, the Administrator will hold a meeting of the QA&A Committee for the purposes of: (1) Fully informing the Committee of the results of the complaint and re-certification survey, and the AOC therefore. (2) Obtaining the QA&A Committee input into these corrective actions. (3) Education of QA&A Committee regarding committee role in review of facility monitoring plans (under AOC) and committee responsibility for additional development and implementation of additional of additional corrective action as needed. By 12/30/2016, the Administrator/Designee will in-service the facility QA&A Committee regarding the Committee's responsibility to identify areas of quality concern, including the development of root cause analysis, action plans and the outcome of those action plans with revision as necessary. ************************* After reviewing the facility's information provided in their AOC, inservice records completed as of 12/30/2016, meal observations and interviews with facility staff, it was determined the facility had implemented their AOC, the immediate jeopardy was relieved and the scope and severity was lowered to a D level. This deficiency was cited as a result of the investigation of complaint/report number AL 920.

Based on observations, interviews and record review, Employee Identifier (EI) #9, the Director of Nursing (DON) who served as the Interim Administrator from June to December 2016, who was responsible for the overall management of the nursing facility, failed to ensure specific interventions were put in place after the unexpected death of Resident Identifier (RI) #1 in the facility on 11/13/2016 to prevent recurrence. During the evening of 11/13/2016, EI #12, a Licensed Practical Nurse (LPN) incorrectly read RI #1's activities of daily living (ADL) sheet. The ADL sheet, also known as the plan of care kardex indicated the resident was prescribed a pureed diet. EI #12 gave RI #1 a roast beef sandwich, that was not of a pureed texture. During the 11:00 PM - 7:00 AM shift, RI #1 was given another sandwich, which was not of a pureed texture, by EI #13, a Certified Nursing Assistant (CNA). Within minutes, the call light to RI #1's room came on, the staff responded and found RI #1 choking; the resident was patting on his/her chest, slumped over to the right side and blue in color. The staff performed the [MEDICATION NAME] maneuver. Other staff members responded to the call for help and tried to perform the [MEDICATION NAME] maneuver as well. The staff did manually remove what appeared to be chewed up bread from the resident's mouth. The emergency room (ER) physician was called and asked the staff to transport the resident to the ER, which was attached to the nursing home. The ER physician stated RI #1 arrived in the ER and was pronounced dead on arrival due to aspiration of a large food bolus lodged in the resident's throat. The ER physician stated she was told the resident had been given a roast beef sandwich; however, he/she was ordered a pureed diet. The ER physician also removed what appeared to be chewed up bread from the resident's mouth. RI #1's death certificate indicated the immediate cause of RI #1's death as Asphyxiation, with an underlying cause of Aspiration. The date/time of death was listed as 11/13/2016 at 11:35 PM. According to EI #9, the investigation into the unexpected death of RI #1 in facility focused on snacks of residents who were ordered a pureed diet. The facility did not verify to ensure the resident's diet order, care plan, ADL sheet and tray card indicated the correct physician ordered diet. EI #9 provided no monitoring of the residents' meals or snacks to prevent recurrence. After the facility had knowledge that RI #1's physician's orders [REDACTED].#7 was observed to receive a regular diet. RI #7 was ordered a mechanical soft diet with ground meat. This deficient practice placed RI #1, one of four sampled residents identified by the facility who received a pureed diet, in immediate jeopardy as it was likely to cause serious injury, harm and/or death. This deficient practice also affected RI #7, one of nine sampled residents observed for meals. On 12/30/2016 at 12:00 PM, EI #9, the DON and EI #10, the Administrator were notified of the findings of immediate jeopardy in the area of administration, F 490. Findings include: Refer to F 281, F 282 and F 367 The Washington County Hospital & Nursing Home CEO/Administrator Position Description dated September 2008, documented . Job Summary: Manages and directs the organization toward its primary objectives . takes steps to ensure that appropriate measures are taken to correct unsatisfactory results . DUTIES AND RESPONSIBILITIES: Demonstrates Competency in the Following Areas: Responsible for all aspects of the operation of the facility . During an interview on 12/29/2016 at 6:00 PM, EI #10, the Administrator stated from 6/22/2016 to 12/14/2016, EI #9 served as the facility's interim Administrator. In an interview on 12/29/2016 at 6:43 PM, EI #9, the current Director of Nursing (DON) who served as the Interim Administrator from June to December 2016, stated she completed the investigation into the unexpected death of RI #1 on 11/13/2016. EI #9 stated after the investigation, she instructed the licensed nurses to make sure the appropriate snack was being delivered and given to residents. When asked if she established any follow-up monitoring, EI #9 said no. EI #9 was then asked, how did she identify other residents at risk of the identified deficient practice. EI #9 explained she only reviewed snacks of residents who received a pureed diet. In a follow-up interview on 12/30/2016 at 10:36 AM, EI #9 acknowledged that she was the final decision maker regarding the investigation into the unexpected death of RI #1 that occurred on 11/13/2016. When asked what did she determine to be the root cause, EI #9 stated she could not determine a root cause because she didn't know what caused RI #1's death. RI #1's DEATH RECORD which was certified 11/17/2016 listed the immediate cause of RI #1's death as Asphyxiation, with an underlying cause of Aspiration. The date/time of death was listed as 11/13/2016 at 11:35 PM. ************************* On 12/30/2016 at 3:30 PM, the facility provided the following Allegation of Compliance (AOC) for F 490, which documented: On 12/30/2016, the Administrator and outside regulatory legal counsel conducted 1:1 inservice training with the DON regarding the DON's responsibility for ensuring appropriate care and services for each resident in order to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, including, but not limited to quality assessment, identification of issues, concerns and areas for improvement, and development, implementation and evaluation of issue resolution strategies and/or plans of improvement. ************************* After reviewing the facility's information provided in their AOC, inservice records completed as of 12/30/2016, meal observations and interviews with facility staff, it was determined the facility had implemented their AOC, the immediate jeopardy was relieved and the scope and severity was lowered to a D level. This deficiency was cited as a result of the investigation of complaint/report number AL 920.

Based on observations, interviews and record reviews, during the evening of 11/13/2016, Employee Identifier (EI) #12, a Licensed Practical Nurse (LPN) who was assigned to care for Resident Identifier (RI) #1, incorrectly read RI #1's activities of daily living (ADL) sheet. The ADL sheet, also known as the plan of care kardex indicated the resident was prescribed a pureed diet. EI #12 gave RI #1 a roast beef sandwich, that was not of a pureed texture. During the 11:00 PM - 7:00 AM shift, RI #1 was given another sandwich, which was not of a pureed texture, by EI #13, a Certified Nursing Assistant (CNA). Within minutes, the call light to RI #1's came on, the staff responded and found RI #1 choking; the resident was patting on his/her chest, slumped over to the right side and blue in color. The staff performed the [MEDICATION NAME] maneuver. Other staff members responded to the call for help and tried to perform the [MEDICATION NAME] maneuver as well. The staff manually removed what appeared to be chewed up bread from the resident's mouth. The emergency room (ER) physician was called and asked the staff to transport the resident to the ER, which was attached to the nursing home. The ER physician stated RI #1 arrived in the ER and was pronounced dead on arrival due to aspiration of a large food bolus lodged in the resident's throat. The ER physician stated she was told the resident had been given a roast beef sandwich; however, he/she was ordered a pureed diet. The ER physician also removed what appeared to be chewed up bread from the resident's mouth. RI #1's death certificate indicated the immediate cause of RI #1's death as Asphyxiation, with an underlying cause of Aspiration. The date/time of death was listed as 11/13/2016 at 11:35 PM. This deficient practice placed RI #1, one of four sampled residents identified by the facility who received a pureed diet, in immediate jeopardy as it was likely to cause serious injury, harm and/or death. On 12/29/2016 at 1:55 PM, Employee Identifier (EI) #9, the Director of Nursing (DON) and EI #10, the Administrator were notified of the findings of immediate jeopardy in area of dietary services, F 367. Furthermore, the facility failed to ensure RI #7 received a mechanical soft diet with ground meat as ordered by the physician on 12/29/2016. This deficient practice affected RI #7, one of nine sampled residents observed for meals. Findings include: On 12/27/2016, the State Agency received a complaint which alleged RI #1, who was on a pureed diet, was given two roast beef sandwiches. Once the resident started to eat the second sandwich, he/she started coughing, choking and throwing up. The complainant alleged the resident died as the result of strangulation on the roast beef sandwich that he/she was not supposed to have. The facility's policy titled Serving a Meal dated July 2015, documented . PROCEDURE . 2. Diets should be served in accordance with the physician's orders [REDACTED]. 1) RI #1 was admitted to the facility on [DATE] with an admit [DIAGNOSES REDACTED]. RI #1Comprehensive Swallow-Voice Assessment (CSA) dated 12/29/2015 indicated a chief complaint of Dysphasia. The assessment further indicated . Patient benefits from Pureed consistency food . Pt (patient) at risk for choking (with) solid foods due to poor ability to masticate (chew) and coughing while eating . RI #1's PLAN OF CARE KARDEX dated 7/21/2016, indicated the resident was on a pureed diet with aspiration precautions. RI #1's Quarterly Minimum Data Set (MDS) with an assessment reference date of 10/11/2016, indicated RI #1 required extensive assistance of one person for eating. During this assessment period, RI #1 required a mechanically altered and therapeutic diet. The MDS further indicated RI #1 experienced coughing/choking with meals/medications. RI #1's care plan titled . has a h/o (history of) swallowing difficulty . potential for . aspiration . with a problem onset date of 2/12/2016 and last revised 10/12/2016, had an approach of *Provide (his/her) diet as ordered . RI #1's Physician Orders for November 2016 indicated the resident was ordered a NAS/CCD (no added salt/consistent carbohydrate diet) pureed diet with double portions. RI #1's Departmental Notes dated 11/13/2016 11:07 PM, written by EI #12, a LPN documented . (HE/SHE) ATE A ROAST BEEF AND CHEESE SANDWICH . FOR THIS NURSE TONIGHT . RI #1's Departmental Notes dated 11/14/2016 12:54 AM, written by EI #12, a LPN, documented CALL LIGHT CAME ON IN RESIDENTS ROOM AND CNA (NAME) WENT TO CHECK AND SEE WHAT RESIDENT NEEDED. CNA SAID WHEN SHE WENT IN ROOM RESIDENT WAS SITTING ON THE SIDE OF THE BED WITH THE URINAL IN (HIS/HER) HAND AND SHE ASKED (HIM/HER) IF (HE/SHE) HAD TO VOID AND (HE/SHE) SAID THEN SHE SAW THAT (HE/SHE) APPEARED TO BE CHOKEING (CHOKING) SHE STARTED PATTING (HIM/HER) ON THE BACK TRYING TO GET IT UP AND SHE CAME OUT ANDD (AND) CALLED FOR HELP THIS NURSE AND CNA (EI #13) WENT TO ROOM AND WHEN WE ENTERED ROOM (HE/SHE) WAS LAYING OVER ON THE END OF THE BED AND APPEARED TO BE BLUE CNAS GOT RESIDENT UP TO WHERE I COULD GET BEHIND (HIM/HER) AND DO THE [MEDICATION NAME] MANEUVER TO ATTEMPT TO DISLODGE ANY FOOD THAT MIGHT BE IN AIRWAY NO FOOD WAS DISLODGED. I INSTRUCTED CNA TO CALL UNIT 1 AND 3 FOR HELP. THE NURSES CAME AND WE GOT (HIM/HER) IN THE W/C (WHEELCHAIR) AND TOOK (HIM/HER) TO ER AND WHEN WE GOT THERE THE DR. (DOCTOR) STATED THAT (HE/SHE) WAS DOA (DEAD ON ARRIVAL) SHE STATED TOD (TIME OF DEATH) WAS 2325 (11:25 PM) 11/13/16 . In an interview on 12/29/2016 at 7:59 AM, EI #12, a LPN acknowledged that she was assigned to care for RI #1 during the 7:00 PM - 7:00 AM shift on 11/13/2016. EI #12 was asked to describe what happened on the evening of 11/13/2016. EI #12 stated she had given the resident a roast beef sandwich. Later in the shift, EI #13, a CNA gave the resident another sandwich and shortly there after the call light in RI #1's room lit up. According to EI #12, EI #14, another CNA responded to the call light and went into RI #1's room, found the resident in trouble and called for help. According to EI #12, she and EI #13 (CNA) responded. EI #12 stated when she went in RI #1's room, she found the resident slumped over to the right side blue in color. EI #12 stated she performed the [MEDICATION NAME] maneuver without success. More help was called for along with a call to the emergency room . EI #12 stated prior to RI #1's being transported to the ER, a manual sweep of RI #1's mouth was done. This sweep resulted in a small amount less than nickel-size of chewed bread being removed from the resident's mouth. EI #12 stated once in the ER, another piece of chewed up bread was removed from RI #1's mouth. EI #12 was asked, what was RI #1's diet order. EI #12 replied the resident was to have a pureed diet. When asked if a sandwich was an acceptable food item for a pureed diet, EI #12 said no. EI #12 explained that if a resident was ordered a pureed diet received a sandwich, the resident could choke and/or aspirate. When asked if RI #1's physician's orders [REDACTED].#12 said no because the resident was given a sandwich. EI #12 acknowledged that she read RI #1's ADL (activities of daily living) sheet (PLAN OF CARE KARDEX) incorrectly. EI #12 stated she thought RI #1's sheet indicated pureed diet as needed; however, it stated assist the resident as needed with eating. EI #12 stated she should have checked RI #1's chart (medical record). When asked if RI #1's care plan regarding the resident's diet was followed, EI #12 said no because the resident was given a sandwich. On 12/29/2016 at 7:41 AM, an interview was conducted with EI #13, the CNA assigned to care for RI #1 during the 11:00 PM - 7:00 AM shift on 11/13/2016. EI #13 acknowledged that after she conferred with EI #12, the LPN, she gave RI #1 half of a sandwich. According to EI #13, EI #12 told her that RI #1 had been given a whole sandwich earlier. After the half of sandwich was given to RI #1, RI #1's roommate requested a sandwich, so EI #13 left the room to get a sandwich for RI #1's roommate. EI #13 stated within about five minutes, the call light in RI #1's room came on. EI #13 stated when she entered RI #1's room, the CNA that first responded (EI #14) stated RI #1 was hitting his/her chest, slumped over and gasping for air. In an interview on 12/29/2016 at 9:32 AM, EI #14, a CNA stated she responded after she saw the call light come on in RI #1's room. EI #14 stated when she went into RI #1's room, she found the resident choking because the resident was hitting on his/her chest. EI #14 stated she performed the [MEDICATION NAME] maneuver and then called for help. According to EI #14, a nurse (EI #12) came into RI #1's room and also performed the [MEDICATION NAME] maneuver; however, the resident did not respond. EI #14 stated a quarter size amount of sandwich was removed from the resident's mouth. Afterwards, the resident was transported to the emergency room . In an interview on 12/29/2016 at 9:19 AM, EI #15, a LPN acknowledged that she responded to a call for help in RI #1's room on 11/13/2016. EI #15 stated when she entered the room, she saw RI #1 gasped a few times. EI #15 stated she was asked to contact the emergency room . EI #15 stated she left the resident's room to call the ER. After speaking with the ER physician, EI #15 stated when she returned to RI #1's room, the resident had been placed in a wheelchair by the nursing staff. The resident was then taken to the ER. The WASHINGTON COUNTY HOSPITAL and NURSING HOME PROGRESS NOTES dated 11/13/2016 11:10 PM, documented . Called from NH (nursing home)-pt (patient) in distress per NA (Nurses Assistant)-choking. Pt brought to ER (emergency room ) in wheelchair DOA (dead on arrival) (secondary to) aspiration of large food bolus lodged in throat. Pupils fixed & dilated. No pulse or spontaneous respirations TOD (time of death) 23:35 (11:35 PM) . During an interview on 12/29/2016 at 10:16 AM, the emergency room (ER) physician was asked, what was the cause of death for RI #1. The ER physician stated based on her findings, she was told the resident was motioning for his/her throat as if he/she was choking and the resident was ordered a pureed diet, but given a roast beef sandwich. The ER physician further explained that based on the large bolus of chewed food she removed from RI #1's mouth, she felt Asphyxiation with the underlying cause of Aspiration was the cause of RI #1's death. RI #1's DEATH RECORD which was certified 11/17/2016 listed the immediate cause of RI #1's death as Asphyxiation, with an underlying cause of Aspiration. The date/time of death was listed as 11/13/2016 at 11:35 PM. 2) RI #7 was admitted to the facility on [DATE] with an admit [DIAGNOSES REDACTED]. RI #7's Quarterly Minimum Data Set (MDS) with an assessment reference date of 11/14/2016, indicated RI #7 required limited assistance of one person for eating. During this assessment period, RI #7 required a mechanically altered and therapeutic diet. RI #7's care plan titled . (RI #7) on a mechaical (mechanical) soft diet with ground meat for eas (ease) of chewing . with a problem onset date of 3/24/2016 last reviewed 11/14/2016 had a documented approach of *Provide (his/her) diet as ordered . RI #7's Physician Orders for December 2016 indicated on 3/4/2016, the resident was ordered a mechanical soft with ground meat diet. During the breakfast meal observation on 12/29/2016 at 8:30 AM, RI #7 was a served a sausage patty, that was not ground meat texture. RI #7 bit the sausage patty, chewed it up and spit it out. RI #7's meal ticket indicated the resident was on a regular diet. During the lunch meal observation on 12/29/2016 at 12:15 PM, RI #7 was served a hamburger and french fries. RI #7 only ate the top bun of the hamburger, no meat. In an interview on 12/29/2016 12:40 PM, EI #5, the Dietary Manager was asked, who was responsible for ensuring a resident was provided the correct diet. EI #5 stated dietary was. When asked, how she found out what a resident's diet physician's orders [REDACTED]. EI #5 was asked, what diet was RI #7 ordered. EI #5 stated, the resident was ordered a regular diet. When asked to explain RI #7's physician's orders [REDACTED].#7 was ordered a mechanical soft with ground meat diet, EI #5 stated she didn't have that order. In an interview on 12/29/2016 at 4:00 PM, EI #17, a LPN was asked, what diet was RI #7 ordered. EI #17 replied, on 3/4/2016 RI #7 was ordered a mechanical soft with ground meat diet. When asked what RI #7's meal ticket indicated, EI #17 stated the meal ticket revealed RI #7 was on a regular diet. EI #17 explained that RI #7 was supposed to have a mechanical soft with ground meat diet. In an interview on 12/30/2016 at 9:30 AM, EI #18, a Registered Nurse was asked, why was RI #7 ordered a mechanical soft with ground meat diet. EI #18 stated it was because of the resident's teeth. ************************* On 12/30/2016 at 3:30 PM, the facility provided the following Allegation of Compliance (AOC) for F 367, which documented: RI #1 -no longer at facility RI #7 - On 12/29/2016, at approximately 3:15 PM, the DON and Dietary Manager verified RI #7's physician diet order. Dietary Manager ensured that RI #7's diet order was appropriately documented in the dietary department and will verify that RI #7's tray contains the appropriate diet. On 12/29/2016, at approximately 3:30 PM prior to the service of the evening meal, the DON provided the Dietary Manager with all current resident diet orders. The Dietary Manager will be responsible for ensuring that each resident receives the correct diet per physician order [REDACTED]. On 12/29/2016, the DON/Unit Managers/Designees in-serviced all facility direct care unit staff members on duty, who provided food assistance (passing out trays, assisting residents with meals, or dining room supervision) on the following: Each staff member will be given a printed copy of the physicians' diet order for the residents on their unit. The staff member must verify that the tray tag matches the order before the tray is served. If the order does not match the tray tag, the Dietary Manager or designee is to be contacted immediately for corrective action. Staff were also instructed that they must check the physician's diet order prior to providing any snack, and were given a list of snacks appropriate and available for resident on mechanical soft and pureed diets. DON/Unit Managers/Designees will provide the above education to each oncoming shift prior to oncoming staff being allowed to take the floor until all facility direct care unit staff members who provide food assistance have been in-serviced. On 12/30/2016, the Dietary Manager/Designee will re-inservice all dietary staff on appropriate documentation of and service of each resident's diet as ordered, including appropriate documentation on tray tags. The Dietary Manager/Designee will provide this education to each oncoming shift prior to oncoming staff being allowed to take the floor until all facility dietary staff has been in-serviced. On 12/29/2016, the DON/Unit Manager/Designee began re-inservicing all direct care staff on following physicians' dietary orders, including appropriate and available snack choices for residents on pureed or mechanical soft diets, notification to physician if resident wishes to receive foods which are not part of his/her ordered diet, and verification that tray tags match the diet ordered. The DON/Unit Managers/Designees will provide this education to each oncoming shift prior to oncoming staff being allowed to take the floor until direct care staff members have been in-serviced. On 12/ , the DON/Unit Manager/Designee conducted 100% audit of all dietary orders, care plans and kardexes to ensure resident dietary orders were appropriately transcribed and documented. Beginning on 12/29/2016, the DON/Designee will provide a weekly list of all dietary orders to the Dietary Manager/Designee. ************************* After reviewing the facility's information provided in their AOC, inservice records completed as of 12/30/2016, meal observations and interviews with facility staff, it was determined the facility had implemented their AOC, the immediate jeopardy was relieved and the scope and severity was lowered to a D level. This deficiency was cited as a result of the investigation of complaint/report number AL 920.

Based on observations, interviews and record reviews, the facility's nursing staff failed to ensure Resident Identifier (RI) #1's care plan was followed to receive a pureed diet. On [DATE], Employee Identifier (EI) #12, a Licensed Practical Nurse (LPN) gave RI #1 a roast beef and cheese sandwich, that was not of pureed texture. Afterwards during the 11:00 PM - 7:00 AM shift, EI #13, a Certified Nursing Assistant gave RI #1 a half of roast beef sandwich, that was not of pureed texture. Shortly after EI #13 left RI #1's room another CNA responded to a call light and found RI #1 hitting his/her chest as if he/she was choking. The nursing staff performed the [MEDICATION NAME] maneuver to include a manual sweep of RI #1's mouth. It was reported the nursing staff was able to retrieve a small amount of what appeared to be chewed up bread before RI #1 was taken to the emergency room (ER). The ER physician stated the resident arrived in the ER and was pronounced dead on arrival due to aspiration of a large food bolus lodged in the resident's throat. The ER physician stated she was told the resident had been given a roast beef sandwich; however, the resident was ordered a pureed diet. The ER physician also removed what appeared to be chewed up bread from the resident's mouth. RI #1's death certificate indicated the cause of death as Asphyxiation due to Aspiration. This deficient practice placed RI #1, one of four sampled residents identified by the facility who received a pureed diet, in immediate jeopardy as it was likely to cause serious injury, harm and/or death. On [DATE] at 1:55 PM, Employee Identifier (EI) #9, the Director of Nursing (DON) and EI #10, the Administrator were notified of the findings of immediate jeopardy in area of resident assessment, F 282. Furthermore, the facility failed to ensure RI #7 received a mechanical soft diet with ground meat as care planned on [DATE]. This deficient practice affected RI #7, one of nine sampled residents observed for meals. Findings include: On [DATE], the State Agency received a complaint which alleged RI #1, who was on a pureed diet, was given two roast beef sandwiches. Once the resident started to eat the second sandwich, he/she started coughing, choking and throwing up. The complainant alleged the resident died as the result of strangulation on the roast beef sandwich that he/she was not supposed to have. The facility's undated policy titled DEVELOPMENT OF RESIDENT PLAN OF CARE documented PURPOSE To gather definitive information on a resident's strengths and needs in order to develop an individualized person centered plan of care. POLICY Plans of care are developed by the interdisciplinary team (IDT), to coordinate and communicate care approaches and goals for the resident related to clinical [DIAGNOSES REDACTED]. 1) RI #1 was admitted to the facility on [DATE] with an admit [DIAGNOSES REDACTED]. RI #1's PLAN OF CARE KARDEX dated [DATE], indicated the resident was on a pureed diet with aspiration precautions. RI #1's care plan titled . has a h/o (history of) swallowing difficulty . potential for . aspiration . with a problem onset date of [DATE] and last revised [DATE], had an approach of *Provide (his/her) diet as ordered . RI #1's Physician Orders for [DATE] indicated the resident was ordered a NAS/CCD (no added salt/consistent carbohydrate diet) pureed diet with double portions. RI #1's Departmental Notes dated [DATE] 11:07 PM, written by EI #12, a Licensed Practical Nurse (LPN) documented . (HE/SHE) ATE A ROAST BEEF AND CHEESE SANDWICH . FOR THIS NURSE TONIGHT . RI #1's Departmental Notes dated [DATE] 12:54 AM, written by EI #12, a LPN documented CALL LIGHT CAME ON IN RESIDENTS ROOM AND CNA (NAME) WENT TO CHECK AND SEE WHAT RESIDENT NEEDED. CNA SAID WHEN SHE WENT IN ROOM RESIDENT WAS SITTING ON THE SIDE OF THE BED WITH THE URINAL IN (HIS/HER) HAND AND SHE ASKED (HIM/HER) IF (HE/SHE) HAD TO VOID AND (HE/SHE) SAID THEN SHE SAW THAT (HE/SHE) APPEARED TO BE CHOKEING (CHOKING) SHE STARTED PATTING (HIM/HER) ON THE BACK TRYING TO GET IT UP AND SHE CAME OUT ANDD (AND) CALLED FOR HELP THIS NURSE AND CNA (EI #13) WENT TO ROOM AND WHEN WE ENTERED ROOM (HE/SHE) WAS LAYING OVER ON THE END OF THE BED AND APPEARED TO BE BLUE CNAS GOT RESIDENT UP TO WHERE I COULD GET BEHIND (HIM/HER) AND DO THE [MEDICATION NAME] MANEUVER TO ATTEMPT TO DISLODGE ANY FOOD THAT MIGHT BE IN AIRWAY NO FOOD WAS DISLODGED. I INSTRUCTED CNA TO CALL UNIT 1 AND 3 FOR HELP. THE NURSES CAME AND WE GOT (HIM/HER) IN THE W/C (WHEELCHAIR) AND TOOK (HIM/HER) TO ER AND WHEN WE GOT THERE THE DR. (DOCTOR) STATED THAT (HE/SHE) WAS DOA (DEAD ON ARRIVAL) SHE STATED TOD (TIME OF DEATH) WAS 2325 (11:25 PM) [DATE] . In an interview on [DATE] at 7:59 AM, EI #12, a LPN acknowledged that she was assigned to care for RI #1 during the 7:00 PM - 7:00 AM shift on [DATE]. EI #12 was asked if she had given RI #1 something to eat and she said yes. EI #12 explained that earlier in the shift, she had given RI #1 a sandwich. According to EI #12, during the 11:00 PM - 7:00 AM shift, RI #1 was given another sandwich by a CNA, later identified as EI #13. EI #12 was asked, what was RI #1's diet order. EI #12 replied the resident was to have a pureed diet. When asked if a sandwich was an acceptable food item for a pureed diet, EI #12 said no. EI #12 explained that if a resident was ordered a pureed diet received a sandwich, the resident could choke and/or aspirate. EI #12 acknowledged that she read RI #1's ADL (activities of daily living) sheet (PLAN OF CARE KARDEX) incorrectly. EI #12 stated she should have checked RI #1's chart (medical record). When asked if RI #1's care plan regarding the resident's diet was followed, EI #12 said no because the resident was given a sandwich. During an interview on [DATE] at 7:41 AM, EI #13, a CNA acknowledged that after she conferred with EI #12, the LPN, she gave RI #1 half of a sandwich. When asked if RI #1's care plan was followed, EI #13 said no because the resident was given a sandwich. In an interview on [DATE] at 9:32 AM, EI #14, a CNA stated she responded after she saw the call light come on in RI #1's room. EI #14 stated when she went into RI #1's room, she found the resident choking because the resident was hitting on his/her chest. EI #14 stated she performed the [MEDICATION NAME] maneuver and then called for help. According to EI #14, a nurse (EI #12) came into RI #1's room and also performed the [MEDICATION NAME] maneuver; however, the resident did not respond. EI #14 stated a quarter size amount of sandwich was removed from the resident's mouth. Afterwards, the resident was transported to the emergency room . When asked if RI #1's care plan was followed, EI #14 said no. The WASHINGTON COUNTY HOSPITAL and NURSING HOME PROGRESS NOTES dated [DATE] 11:10 PM, documented . Called from NH (nursing home)-pt (patient) in distress per NA (Nurses Assistant)-choking. Pt brought to ER (emergency room ) in wheelchair DOA (dead on arrival) (secondary to) aspiration of large food bolus lodged in throat. Pupils fixed & dilated. No pulse or spontaneous respirations TOD (time of death) 23:35 (11:35 PM) . During an interview on [DATE] at 10:16 AM, the emergency room (ER) physician was asked, what was the cause of death for RI #1. The ER physician stated based on her findings, she was told the resident was motioning for his/her throat as if he/she was choking and the resident was ordered a pureed diet, but given a roast beef sandwich. The ER physician further explained that based on the large bolus of chewed food she removed from RI #1's mouth, she felt Asphyxiation with the underlying cause of Aspiration was the cause of RI #1's death. RI #1's DEATH RECORD which was certified [DATE] listed the immediate cause of RI #1's death as Asphyxiation, with an underlying cause of Aspiration. The date/time of death was listed as [DATE] at 11:35 PM. 2) RI #7 was admitted to the facility on [DATE] with an admit [DIAGNOSES REDACTED]. RI #7's care plan titled . (RI #7) on a mechaical (mechanical) soft diet with ground meat for eas (ease) of chewing . with a problem onset date of [DATE] last reviewed [DATE] had a documented approach of *Provide (his/her) diet as ordered . RI #7's Physician Orders for [DATE] indicated on [DATE], the resident was ordered a mechanical soft with ground meat diet. During the breakfast meal observation on [DATE] at 8:30 AM, RI #7 was a served a sausage patty, that was not ground meat texture. RI #7 bit the sausage patty, chewed it up and spit it out. RI #7's meal ticket indicated the resident was on a regular diet. During the lunch meal observation on [DATE] at 12:15 PM, RI #7 was served a hamburger and french fries. RI #7 only ate the top bun of the hamburger, no meat. In an interview on [DATE] at 9:30 AM, EI #18, a Registered Nurse was asked, why was RI #7 ordered a mechanical soft with ground meat diet. EI #18 stated it was because of the resident's teeth. When asked was RI #7's care plan followed during the breakfast and lunch meal observation on [DATE], EI #18 said no, not at all. When asked, what harm could have occurred, EI #18 stated RI #7 could have choked or aspirated. ************************* On [DATE] at 3:30 PM, the facility provided the following Allegation of Compliance (AOC) for F 282, which documented: RI #1 - no longer at facility RI #7 - On [DATE], at approximately 3:15 PM, the DON and Dietary Manager verified RI #7's physician diet order. Dietary Manager ensured that RI #7's diet order was appropriately documented in the dietary department and will verify that RI #7's tray contains the appropriate diet. On [DATE], at approximately 3:30 PM prior to the service of the evening meal, the DON provided the Dietary Manager with all current resident diet orders. The Dietary Manager will be responsible for ensuring that each resident receives the correct diet per physician order [REDACTED]. On [DATE], the DON/Unit Manager/Designee began re-inservicing all direct care staff on following physicians' dietary orders, including appropriate and available snack choices for residents on pureed or mechanical soft diets, notification to physician if resident wishes to receive foods which are not part of his/her ordered diet, and verification that tray tags match the diet ordered. The DON/Unit Managers/Designees will provide this education to each oncoming shift prior to oncoming staff being allowed to take the floor until direct care staff members have been in-serviced. On [DATE], the DON/Unit Manager/Designee conducted 100% audit of all dietary orders, care plans and kardexes to ensure resident dietary orders were appropriately transcribed and documented. ************************* After reviewing the facility's information provided in their AOC, inservice records completed as of [DATE], meal observations and interviews with facility staff, it was determined the facility had implemented their AOC, the immediate jeopardy was relieved and the scope and severity was lowered to a D level. This deficiency was cited as a result of the investigation of complaint/report number AL 920.

Based on observations, interviews and record reviews, the facility's nursing staff failed to ensure Resident Identifier (RI) #1 received a pureed diet as ordered by the physician. On [DATE], Employee Identifier (EI) #12, a Licensed Practical Nurse (LPN) gave RI #1 a roast beef and cheese sandwich, that was not of a pureed texture. Afterwards during the 11:00 PM - 7:00 AM shift, EI #13, a Certified Nursing Assistant (CNA) gave RI #1 a half of roast beef sandwich, that was not of a pureed texture. Shortly after EI #13 left RI #1's room another CNA responded to a call light and found RI #1 hitting his/her chest as if he/she was choking. The nursing staff performed the [MEDICATION NAME] maneuver to include a manual sweep of RI #1's mouth. It was reported the nursing staff was able to retrieve a small amount of what appeared to be chewed up bread before RI #1 was taken to the emergency room (ER). The ER physician stated the resident arrived in the ER and was pronounced dead on arrival due to aspiration of a large food bolus lodged in the resident's throat. The ER physician stated she was told the resident had been given a roast beef sandwich; however, the resident was ordered a pureed diet. The ER physician also removed what appeared to be chewed up bread from the resident's mouth. RI #1's death certificate indicated the cause of death as Asphyxiation due to Aspiration. This deficient practice placed RI #1, one of four sampled residents identified by the facility who received a pureed diet, in immediate jeopardy as it was likely to cause serious injury, harm and/or death. On [DATE] at 1:55 PM, Employee Identifier (EI) #9, the Director of Nursing (DON) and EI #10, the Administrator were notified of the findings of immediate jeopardy in area of resident assessment, F 281. Furthermore, the facility failed to ensure RI #7 received a mechanical soft diet with ground meat as ordered by the physician on [DATE]. This deficient practice affected RI #7, one of nine sampled residents observed for meals. Findings include: On [DATE], the State Agency received a complaint which alleged RI #1, who was on a pureed diet, was given two roast beef sandwiches. Once the resident started to eat the second sandwich, he/she started coughing, choking and throwing up. The complainant alleged the resident died as the result of strangulation on the roast beef sandwich that he/she was not supposed to have. The facility's policy titled physician's orders [REDACTED]. following the physician's orders [REDACTED]. 6. All physician orders [REDACTED]. Chapter 23 titled Legal Implications in Nursing Practice page 311 of Fundamentals of Nursing Ninth Edition with a copyright date of 2017, documented . Health Care Providers' Orders. The health care provider (physician or advanced practice nurse) is responsible for directing medical treatment. Nurses follow health care providers' orders unless they believe the orders are in error, violate agency policy, or are harmful to the patient . 1) RI #1 was admitted to the facility on [DATE] with an admit [DIAGNOSES REDACTED]. RI #1Comprehensive Swallow-Voice Assessment (CSA) dated [DATE] indicated a chief complaint of Dysphasia. The assessment further indicated . Patient benefits from Pureed consistency food . Pt (patient) at risk for choking (with) solid foods due to poor ability to masticate (chew) and coughing while eating . RI #1's Quarterly Minimum Data Set (MDS) with an assessment reference date of [DATE], indicated RI #1 required extensive assistance of one person for eating. During this assessment period, RI #1 required a mechanically altered and therapeutic diet. The MDS further indicated RI #1 experienced coughing/choking with meals/medications. RI #1's Physician Orders for [DATE] indicated the resident was ordered a NAS/CCD (no added salt/consistent carbohydrate diet) pureed diet with double portions. RI #1's Departmental Notes dated [DATE] 11:07 PM, written by EI #12, a Licensed Practical Nurse (LPN) documented . (HE/SHE) ATE A ROAST BEEF AND CHEESE SANDWICH . FOR THIS NURSE TONIGHT . RI #1's Departmental Notes dated [DATE] 12:54 AM, written by EI #12, a LPN documented CALL LIGHT CAME ON IN RESIDENTS ROOM AND CNA (NAME) WENT TO CHECK AND SEE WHAT RESIDENT NEEDED. CNA SAID WHEN SHE WENT IN ROOM RESIDENT WAS SITTING ON THE SIDE OF THE BED WITH THE URINAL IN (HIS/HER) HAND AND SHE ASKED (HIM/HER) IF (HE/SHE) HAD TO VOID AND (HE/SHE) SAID THEN SHE SAW THAT (HE/SHE) APPEARED TO BE CHOKEING (CHOKING) SHE STARTED PATTING (HIM/HER) ON THE BACK TRYING TO GET IT UP AND SHE CAME OUT ANDD (AND) CALLED FOR HELP THIS NURSE AND CNA (EI #13) WENT TO ROOM AND WHEN WE ENTERED ROOM (HE/SHE) WAS LAYING OVER ON THE END OF THE BED AND APPEARED TO BE BLUE CNAS GOT RESIDENT UP TO WHERE I COULD GET BEHIND (HIM/HER) AND DO THE [MEDICATION NAME] MANEUVER TO ATTEMPT TO DISLODGE ANY FOOD THAT MIGHT BE IN AIRWAY NO FOOD WAS DISLODGED. I INSTRUCTED CNA TO CALL UNIT 1 AND 3 FOR HELP. THE NURSES CAME AND WE GOT (HIM/HER) IN THE W/C (WHEELCHAIR) AND TOOK (HIM/HER) TO ER AND WHEN WE GOT THERE THE DR. (DOCTOR) STATED THAT (HE/SHE) WAS DOA (DEAD ON ARRIVAL) SHE STATED TOD (TIME OF DEATH) WAS 2325 (11:25 PM) [DATE] . In an interview on [DATE] at 7:59 AM, EI #12, a LPN acknowledged that she was assigned to care for RI #1 during the 7:00 PM - 7:00 AM shift on [DATE]. EI #12 was asked if she had given RI #1 something to eat and she said yes. EI #12 explained that earlier in the shift, she had given RI #1 a sandwich. According to EI #12, during the 11:00 PM - 7:00 AM shift, RI #1 was given another sandwich by a CNA, later identified as EI #13. EI #12 was asked, what was RI #1's diet order. EI #12 replied the resident was to have a pureed diet. When asked if a sandwich was an acceptable food item for a pureed diet, EI #12 said no. EI #12 explained that if a resident was ordered a pureed diet received a sandwich, the resident could choke and/or aspirate. When asked if RI #1's physician's orders [REDACTED].#12 said no because the resident was given a sandwich. During an interview on [DATE] at 7:41 AM, EI #13, a CNA acknowledged that after she conferred with EI #12, the LPN, she gave RI #1 half of a sandwich. In an interview on [DATE] at 9:32 AM, EI #14, a CNA stated she responded after she saw the call light come on in RI #1's room. EI #14 stated when she went into RI #1's room, she found the resident choking because the resident was hitting on his/her chest. EI #14 stated she performed the [MEDICATION NAME] maneuver and then called for help. According to EI #14, a nurse (EI #12) came into RI #1's room and also performed the [MEDICATION NAME] maneuver; however, the resident did not respond. EI #14 stated a quarter size amount of sandwich was removed from the resident's mouth. Afterwards, the resident was transported to the emergency room . The WASHINGTON COUNTY HOSPITAL and NURSING HOME PROGRESS NOTES dated [DATE] 11:10 PM, documented . Called from NH (nursing home)-pt (patient) in distress per NA (Nurses Assistant)-choking. Pt brought to ER (emergency room ) in wheelchair DOA (dead on arrival) (secondary to) aspiration of large food bolus lodged in throat. Pupils fixed & dilated. No pulse or spontaneous respirations TOD (time of death) 23:35 (11:35 PM) . During an interview on [DATE] at 10:16 AM, the emergency room (ER) physician was asked, what was the cause of death for RI #1. The ER physician stated based on her findings, she was told the resident was motioning for his/her throat as if he/she was choking and the resident was ordered a pureed diet, but given a roast beef sandwich. The ER physician further explained that based on the large bolus of chewed food she removed from RI #1's mouth, she felt Asphyxiation with the underlying cause of Aspiration was the cause of RI #1's death. RI #1's DEATH RECORD which was certified [DATE] listed the immediate cause of RI #1's death as Asphyxiation, with an underlying cause of Aspiration. The date/time of death was listed as [DATE] at 11:35 PM. 2) RI #7 was admitted to the facility on [DATE] with an admit [DIAGNOSES REDACTED]. RI #7's Quarterly Minimum Data Set (MDS) with an assessment reference date of [DATE], indicated RI #7 required limited assistance of one person for eating. During this assessment period, RI #7 required a mechanically altered and therapeutic diet. RI #7's Physician Orders for [DATE] indicated on [DATE], the resident was ordered a mechanical soft with ground meat diet. During the breakfast meal observation on [DATE] at 8:30 AM, RI #7 was a served a sausage patty, that was not ground meat texture. RI #7 bit the sausage patty, chewed it up and spit it out. RI #7's meal ticket indicated the resident was on a regular diet. During the lunch meal observation on [DATE] at 12:15 PM, RI #7 was served a hamburger and french fries. RI #7 only ate the top bun of the hamburger, no meat. In an interview on [DATE] at 4:00 PM, EI #17, a LPN was asked, what diet was RI #7 ordered. EI #17 replied, on [DATE] RI #7 was ordered a mechanical soft with ground meat diet. When asked what RI #7's meal ticket indicated, EI #17 stated the meal ticket revealed RI #7 was on a regular diet. EI #17 explained that RI #7 was supposed to have a mechanical soft with ground meat diet. ************************* On [DATE] at 3:30 PM, the facility provided the following Allegation of Compliance (AOC) for F 281, which documented: RI #1 - no longer at facility RI #7 - On [DATE], at approximately 3:15 PM, the DON and Dietary Manager verified RI #7's physician diet order. Dietary Manager ensured that RI #7's diet order was appropriately documented in the dietary department and will verify that RI #7's tray contains the appropriate diet. On [DATE], at approximately 3:30 PM, prior to the service of the evening meal, the DON provided the Dietary Manager with all current resident diet orders. The Dietary Manager will be responsible for ensuring that each resident receives the correct diet per physician order [REDACTED]. On [DATE], the DON/Unit Managers/Designees began re-inservicing all licensed nursing staff on accurate transcription of physicians' diet orders and communication of those orders to dietary. The DON/Unit Managers/Designees will provide this education to each oncoming shift prior to oncoming staff being allowed to take the floor until all facility licensed nursing staff members have been in-serviced. On [DATE], the Dietary Manager/Designee will re-inservice all dietary staff on appropriate documentation of and service of each resident's diet as ordered, including appropriate documentation on tray tags. The Dietary Manager/Designee will provide this education to each oncoming shift prior to oncoming staff being allowed to take the floor until all facility dietary staff has been in-serviced. On [DATE], the DON/Unit Manager/Designee began re-inservicing all direct care staff on following physicians' dietary orders, including appropriate and available snack choices for residents on pureed or mechanical soft diets, notification to physician if resident wishes to receive foods which are not part of his/her ordered diet, and verification that tray tags match the diet ordered. The DON/Unit Managers/Designees will provide this education to each oncoming shift prior to oncoming staff being allowed to take the floor until direct care staff members have been in-serviced. On [DATE], the DON/Unit Manager/Designee conducted 100% audit of all dietary orders, care plans and kardexes to ensure resident dietary orders were appropriately transcribed and documented. Beginning on [DATE], the DON/Designee will provide a weekly list of all dietary orders to the Dietary Manager/Designee. ************************* After reviewing the facility's information provided in their AOC, inservice records completed as of [DATE], meal observations and interviews with facility staff, it was determined the facility had implemented their AOC, the immediate jeopardy was relieved and the scope and severity was lowered to a D level. This deficiency was cited as a result of the investigation of complaint/report number AL 920.

Based on observations, interviews and record review, the facility failed to ensure the Assistance Director of Nursing (ADON), Employee Identifier (EI) #7 did not place the red biohazard bag filled with soiled dressings on the floor after providing wound care to Resident Identifier (RI) #2 on 12/28/2016. This deficient practice affected RI #2 one of two sampled residents observed for wound care. Findings Include: RI #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An Admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 11/28/2016, assessed RI #2 as having a Stage 3 pressure ulcer. On 12/28/2016 at 11:00 a.m., the surveyor observed EI #7 (ADON) and EI #8, Certified Nursing Assistant (CNA) prepare to provide wound care on RI #2. After completion of wound care and disposal of dressings soiled with serosanguineous (serum and blood) drainage from RI #2 into a red biohazard bag, EI #7 closed up the bag and placed the bag on the floor. On 12/29/2016 at 8:40 a.m., the surveyor conducted and interview with EI #7. The surveyor asked EI #7 what did she do with the red biohazard bag filled with soiled dressings after she completed wound care on RI #2. EI #7 replied, I put it on the floor. EI #7 was asked what could be the risk in putting a red biohazard bag of soiled dressings on the floor. EI #7 replied, If it had some drainage outside the bag it would have got on the floor. On 12/29/2016 at 12:52 p.m., the surveyor interviewed EI #3 Registered Nurse (RN) Infection Control. EI #3 was asked if the red biohazard bag with the soiled dressings should be placed on the floor. EI #3 replied, No. The surveyor asked EI #3 what could be the risk of putting a red biohazard bag filled with soiled dressings on the floor. EI #3 stated, Risk of contamination when you put it on the floor.

Based on observation, interview and record review the facility failed to ensure Employee Identifier (EI) #1, a Certified Nursing Assistant (CNA) failed to open RI #4's perineal area and clean the outer and inner area. This affected one of two sampled residents observed for incontinent care. Findings include: A facility's POLICY AND PROCEDURE TITLE: . with a revised date of 02/2015 . documented POLICY Peri-care will be performed on all residents following all incontinent episodes . PROCEDURE . PERI-CARE FOLLOWING URINARY INCONTINENCE . 4. Wash the pubic area first, clean the entire perineal area with disposable wipe, moving from front to back, using a clean area of the disposable cloth for each wipe or a new wipe for each stroke. RI #4 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #4's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/25/16 documented RI #4 was is totally dependant on staff for toilet use with assistance of two persons. The resident was assessed as being incontinent of bowel and bladder. On 12/28/16 at 11:55 a.m. EI #1 and EI #2, both Certified Nursing Assistants (CNAs) were observed performing incontinent care for RI #4. EI #1 failed to open RI #4's perineal area and clean the outer and inner area. An interview was conducted with EI #1 on 12/29/16 at 9:53 a.m. she was asked if she performed incontinent care for RI #4 on 12/28/16 in the surveyors presence. She stated, Yes. EI #1 was asked why she failed to open RI #4's perineal area and clean each side and down the center. EI #1 replied, RI #4's legs being tight it was more difficult to open so she had just wiped down. EI #1 was asked what the facility's policy was related to cleaning the resident's perineal area. EI #1 replied, open the perineal area and clean down one side change position of the cloth, wipe down other side and change position of clothe, wipe down center. EI #1 was asked what the potential for harm was if the perineal area was not opened and cleaned. She replied, infection. An interview was conducted with EI #3 Registered Nurse Infection Control on 12/29/16 at 12:54 p.m. EI #3 was asked what she would expect a CNA to do regarding cleaning a resident's perineal area. She replied, they should open up the perineal area. EI #3 was asked what the potential for harm was if the perineal area was not opened and cleaned. She stated, Harboring infection because you are not, opening and cleaning the inside.

Based on observation, interview and record review the facility failed to ensure the number of hours were documented on the daily staffing posted. This have the potential to affect all residents in the facility. Findings Include: On 12/28/16 the posted staffing for this day documented the date, the number of Registered Nurses (RN), Licensed Practical Nurses (LPN)Certified Nursing Assistants (CNA) and the census. The actual hours of each category of staff was not documented. On 12/29/16 the posted staffing for this day documented the date, the number of Registered Nurses (RN), Licensed Practical Nurses (LPN)Certified Nursing Assistants (CNA) and the census. The actual hours of each category of staff was not documented. On 12/29/16 at 10:35 a.m. Employee Identifier (EI) #9, Director of Nurses was asked to review the posting requirements for staffing. EI #4 stated we did the number of staff but not the hours. EI #4 further commented we just missed that.

Based on interviews and record reviews, the facility failed to ensure the physician-ordered medications included all required components for administration of the medications. This affected RI (Resident Identifier) #'s 3,5,6,7, 8 and 10; six of fourteen sampled residents. Findings include: A review of an undated facility policy titled, POLICY & PROCEDURE TITLE: physician's orders [REDACTED]. [REDACTED]. PROCEDURE: 1. All physician's orders [REDACTED]. if not directly written by the physician) and the signature of the person who accepted the order. All other details pertinent to carrying out the order should be included in this order also. (Example: Medication orders should include a minimum of: the name of the medication, the strength, the route, the frequency and duration). A review of RI #3's medical record revealed RI #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED].#3 revealed, [MEDICATION NAME] 100 MG (Milligrams)/5 ML (Milliliters) SYRUP GIVE 10 CC (Cubic Centimeters) EVERY FOUR HOURS AS NEEDED DX (Diagnosis): COUGH/CONGESTION . A review of the MAR (Medication Administration Record) dated February 2016 for RI #3 revealed, [MEDICATION NAME] 100 MG/5 ML SYRUP GIVE 10 CC EVERY FOUR HOURS AS NEEDED DX: COUGH/CONGESTION . A review of RI #5's medical record revealed RI #5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED].#5 revealed, [MEDICATION NAME] 4 MG TABLET EVERY 4 HOURS AS NEEDED FOR NAUSEA/VOMITING .; [MEDICATION NAME] 2 MG/ML VIAL ADMINISTER 4 MG Q (every) 4 HOURS PRN (as needed) .; [MEDICATION NAME] 100 MG/5 ML SYRUP GIVE 2 TSP (TEASPOON) EVERY 4 HOURS PRN (AS NEEDED). A review of the MAR indicated [REDACTED].; [MEDICATION NAME] 2 MG/ML VIAL ADMINISTER 4 MG Q 4 HOURS PRN .; [MEDICATION NAME] 100 MG/5 ML SYRUP GIVE 2 TSP (TEASPOON) EVERY 4 HOURS PRN (AS NEEDED). A review of the medical record revealed RI #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED].#6 revealed, . CALCIUM ACETATE 667 MG 1 TABLET DAILY WITH BEDTIME SNACK . A review of the medical record revealed, RI #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED].#7 revealed, . [MEDICATION NAME] DM ([MEDICATION NAME]) ER (Extended Release) 600-30 MG 1 TABLET every 12 hours PRN for cough . A review of the MAR indicated [REDACTED]. [MEDICATION NAME] DM ER ,[DATE] MG 1 TABLET every 12 hours PRN for cough . A review of RI #8's medical record revealed the resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED].#8 revealed, . POTASSIUM CL (Chloride) 20 MEQ (Milliequivalents)/10 ML (Milliliters) GIVE 20 mEq BID (twice daily) EVERY DAY . A review of the MAR indicated [REDACTED]. POTASSIUM CML 20 MEQ /10 ML GIVE 20 mEq BID EVERY DAY . A review of the medical record revealed RI #10 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED].#10 revealed, .BIOFREEZE EVERY 6 HRS (HOURS) AS NEEDED FOR PAIN . A review of the physician's orders [REDACTED].#10 revealed, .ASPIRIN 81 MG TABLET GIVE 2 TABLETS QD(EVERY DAY) . On 02/18/16 at 3:45 PM, an interview was conducted with EI (Employee Identifier) #1, an LPN (Licensed Practical Nurse). EI #1 was asked the rights of administering medications. EI #1 stated, Right patient, right route, right medication, right dose, right amount, right time and right order. EI #1 was asked what should be included on medication orders. EI #1 said, Medication dose, route, how often, doctor ordered it, resident name and room. EI #1 was asked the significance of having routes in the physician orders. EI #1 stated, You want to know how to give it right away. On 2/18/16 at 4:06 PM, an interview was conducted with EI #2, an LPN. EI #2 was asked the rights of administering medications. EI #2 stated, Right patient, right medication, time, route, frequency and duration. EI #2 was asked what should be included on medication orders. EI #2 said, Diagnosis. EI #2 was asked the significance of having routes in physician orders. EI #2 stated, That way you know how someone takes medication. EI #2 was shown the physician's orders [REDACTED]. EI #2 was asked if the physician's orders [REDACTED].#3. EI #2 said, No route. EI #2 was asked if the physician's orders [REDACTED].#5. EI #2 said, [MEDICATION NAME] 4 mg, [MEDICATION NAME] 2 mg and [MEDICATION NAME] 100 mg all had no route. EI #2 was asked if the physician orders [REDACTED].#6. EI #2 said, Calcium Acetate 667 mg capsule 1 tab (tablet) bedtime snack, (had) no route. EI #2 was asked if the physician orders [REDACTED].#7. EI #2 said, No route. EI #2 was asked if the physician orders [REDACTED].#8. EI #2 said, No route on Potassium, [MEDICATION NAME] no route and Biofreeze no route. EI #2 was asked if the physician orders [REDACTED].#10. EI #2 stated, Biofreeze, no route and Aspirin, no route. EI #2 was asked who was responsible for ensuring all Physician orders [REDACTED].#2 replied, Whoever is writing should make sure (it) is complete and whoever is noting it off should do this as well. EI #2 was asked who was responsible for monitoring that orders were complete. EI #2 said, whoever was checking the charts. On 2/18/16 at 3:42 PM, an interview was conducted with EI #3, Director of Nursing. EI #3 was asked the rights of administering medications. EI #3 stated, Patient, medication, dose, route and time. EI #3 was asked what should be included on medication orders. EI #3 said, Medication,dose, route, frequency and resident name. EI #3 was asked the significance of having routes in physician orders. EI #3 said, Ensure it's given properly. EI #3 was shown the physician orders [REDACTED]. EI #3 was asked if the physician orders [REDACTED].#3. EI #3 said the [MEDICATION NAME] did not have a route. EI #3 was asked if the physician orders [REDACTED].#5. EI #3 said the [MEDICATION NAME] 4 mg, No route, [MEDICATION NAME] 2 mg, No route, and [MEDICATION NAME], No route. EI #3 was asked if the physician orders [REDACTED].#6. EI #3 said the Calcium Acetate did not have a route. EI #3 was asked if the physician orders [REDACTED].#7. EI #3 said the [MEDICATION NAME] had, No route. EI #3 was asked if the physician orders [REDACTED].#8. EI #3 said the Potassium had, No route, the [MEDICATION NAME], No route, the Biofreeze, No route. EI #3 was asked if the physician orders [REDACTED].#10. EI #3 said Biofreeze had, No route, and Aspirin, No route. EI #3 was asked who was responsible for ensuring that all the physician's orders [REDACTED].#3 said, The physician and nurse. EI #3 was asked who was responsible for monitoring the physician's orders [REDACTED].#3 stated, The nurse.

Based on interviews and record reviews, the facility failed to ensure the resident's physician was notified of a fall on 3 occasions for RI (Resident Identifier) #6. This affected 1 of 2 residents sampled for falls. Findings include: A review of an undated facility policy titled, physician's orders [REDACTED]. POLICY: It is the policy of the Washington County Nursing Home to provide its resident's with quality care by properly taking off and following the physician's orders [REDACTED]. PROCEDURE: .7. A physician will be notified of the following changes: a)an accident involving the resident which results in injury and requires physician intervention outside of facility standing orders. A review of an undated facility document titled, Washington County Nursing Home Standing Orders, revealed, .11. Wounds/Skin Tears: Initiate treatment for [REDACTED]. A review of an undated facility document titled, WOUND CARE PROTOCOL, revealed; TYPE OF WOUND, Skin Tear/Abrasion with redness, slough, or s/s (signs and symptoms) of infection, WOUND CARE PROTOCOL, Notify MD (Medical Doctor), TREATMENT, Notify MD for further orders. A review of RI #6's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Annual MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 2/4/16, revealed RI #6 had moderately impaired cognitive skills. The assessment indicated RI #6 required extensive assistance from staff for transfers. RI #6 was assessed as requiring extensive assistance from staff for all ADLs (Activities of Daily Living). A review of a facility fall report for RI #6 dated 03/10/15 and titled, WASHINGTON COUNTY NURSING HOME QUALITY ASSURANCE FALL REPORT, revealed RI #6 had a fall in which the resident received a small abrasion to the knee. The Physician was not notified. A review of a facility fall report for RI #6 dated 06/16/15 and titled, WASHINGTON COUNTY NURSING HOME QUALITY ASSURANCE FALL REPORT, revealed RI #6 had a fall in which the resident received a red area to the left cheek. The Physician was not notified. A review of a facility fall report for RI #6 dated 11/02/15 and titled, WASHINGTON COUNTY NURSING HOME QUALITY ASSURANCE FALL REPORT, revealed RI #6 had a fall in which the resident received a small skin tear to the left outer upper arm. The Physician was not notified. On 02/18/16 at 3:40 PM, an interview was conducted with EI (Employee Identifier) #1, an LPN (Licensed Practical Nurse). EI #1 was asked who should be notified if there was a resident who had fallen. EI #1 said, Sponsor, if hurt, the doctor is notified too. EI #1 was asked when the doctor should be notified. EI #1 stated, We use our own judgment but if it is a skin tear, we don't do it, we tend to that ourselves but if it's more serious we do notify the doctor. EI #1 was asked what was the facility's policy on notification. EI #1 replied, If a weekday notify the primary doctor, if night notify the emergency room doctor and when day arrives we notify the primary doctor. EI #1 was asked why the physician should be notified in the event of a fall. EI #1 stated, To let them know the status, further treatment or change in medicine. EI #1 was asked the significance of notifying the doctor of a fall. EI #1 said, For the resident's well being to provide the best care we can. On 02/18/2016 at 3:53 PM, an interview was conducted with EI #2, an LPN. EI #2 was asked who should be notified if there was a resident who had fallen. EI #2 responded, First, the charge nurse, that way charge nurse can assess for wounds and injuries, vital signs before resident is moved. EI #2 was asked who the charge nurse was supposed to notify in the event of a fall. EI #2 stated, If they fall, notify sponsor and then the doctor that they have fallen as well. EI #2 was asked when the doctor should be notified. EI#2 said, If there's an injury, but (if) they had any suspected injury in need of x-ray, or trauma, or taken to the emergency room , or if need to suture then we notify him (the doctor) but in general we will send a fax. EI #2 was shown the facility fall reports to review. EI #2 was asked if any communication was provided to the doctor. EI #2 said, No. EI #2 was asked what was the facility's policy on notification. EI #2 stated, If there's an injury to notify the doctor. EI #2 was asked why the physician should be notified in the event of a fall. EI #2 said, If there is some type of change in mental status or injury not caught . (at) the time of the fall it may have shown up another time. EI #2 was asked the significance of notifying the doctor of a fall. EI #2 replied, To where the doctor will be in tuned, with the doctor keep lines of communication open. On 2/18/16 at 3:31 PM, an interview was conducted with EI #3, the Director of Nursing. EI #3 was asked who should be notified if there was a resident who had fallen. EI #3 said, The family and they only notify the physician if the resident requires active immediate treatment. EI #3 was asked when the doctor should be notified. EI #3 said, Only if treatment is needed or orders from him. EI #3 was asked what was the facility's policy on notification. EI #3 said, As I have stated. EI #3 was asked why the physician should be notified in the event of a fall. EI #3 stated, Once the nurse assess(ed) the resident with the fall, if there is any indication the Physician should be notified, it's that nurse's clinical judgement. EI #3 was asked the significance of notifying the doctor of a fall. EI #3 said, The significance of us notifying them is that we feel we need them to assess further or order tests. EI #3 was shown facility the fall reports to review. EI #3 was asked if any communication was provided to the doctor. EI #3 stated, RI #6, 3/10/15, house orders. 6/16/15, red area to cheek, neuro checks and 11/2/15, house orders. EI #3 was asked if the facility notified the Physician of any head injuries. EI #3 responded, If anything was wrong with Neuro checks we would have notified the doctor.

Based on observations, interviews, and record reviews, the facility failed to ensure: 1. A Licensed Nurse cleansed the buttocks and rectal area while providing incontinence care for RI (Resident Identifier) #4. This affected one of three residents observed for incontinence care. 2. RI #1 was not observed with a thick, white dried substance on the tongue. This was observed on three of three survey days. Findings include: 1) A review of the facility's document with a revision date of 07/2010 revealed: "MANUAL TITLE, NURSING HOME INFECTION CONTROL MANUAL POLICY AND PROCEDURE TITLE ADMINISTERING PERINEAL CARE/INCONTINENT POLICY ...Always note and give special attention to cleaning all areas of the perineum after each incontinent episode to prevent urine scalding the resident's skin. ... PERI-CARE FOLLOWING URINARY INCONTINENCE (MALE)... 6. Turn resident to side and continue to cleanse buttocks and anal area (continue to use front to back swipes and folding the wipe after each swipe). ..." A review of the document titled, "CARE PLAN, Problem Onset: 08/05/2014," revealed: "... I am incontinent of bowel and bladder and I wear absorbing pads for extra protection increasing my risk for UTI's (Urinary Tract Infections) and skin break down. ... I will be provided with appropriate skin care and interventions, to hopefully help prevent UTI's, skin break down or skin injuries. ..." A review of the medical records revealed RI #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Quarterly MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 11/11/2014, revealed RI #4 was severely impaired of cognitive skills for daily decision making. This MDS also indicated RI #4 required total assistance with ADLs (Activities of Daily Living). RI #4 was coded as always incontinent of bowel and bladder function. An observation was made on 02/11/2015 at 11:30 AM, of EI (Employee Identifier) #1, the DON (Director of Nursing), performing incontinence care on RI #4. EI #1 and EI #2, an RN (Registered Nurse,) washed their hands following wound care and donned new gloves. EI #2 turned RI #4 over to his right side and then to his back. EI #1 wiped downward on the right side of the groin and then took a new wipe and wiped downward on the left side of the groin. EI #1 then lifted the penis and wiped from the urinary meatus outward in a circular motion with a new wipe. A new wipe was obtained and EI #1 wiped the shaft of the penis in a downwards motion. EI #1 took off her gloves and donned new gloves. EI#1 replaced the brief and placed the wedge behind RI #4's left side. Both EI #1 and #2 took their gloves off and washed their hands with soap and water. The rectal and buttock areas were not cleaned during the incontinence care. On 02/12/2015 at 1:00 PM, an interview was conducted with EI #1. EI #1 was asked if she had performed incontinence care on RI #4. EI #1 stated, "Yes." EI #1 was asked what areas were cleaned during incontinence care on RI #4. EI #1 stated, "Peri (Perineal) area and Penis." EI #1 was asked if the buttocks and rectal areas were cleaned during the incontinence care of RI #4. EI #1 stated, "No." EI #1 was asked what potential harm could occur to a residents skin if urine was not removed. EI #1 stated, "Redness, excoriation." 2) A review of the facility's document dated January 2014, revealed: "MANUAL TITLE NURSING SERVICES POLICY AND PROCEDURE MANUAL POLICY AND PROCEDURE TITLE ACTIVITIES OF DAILY LIVING (ADLS)... PROCEDURE ... 2. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. ..." A review of the facility document titled, "CARE PLAN with a Problem Onset 06/30/2014, revealed, "... I have an implant (post) in my upper right gum area that my upper dentures fastened onto with h/o (history of) becoming inflamed and painful. I no longer wear my dentures. ...Goal and Target date, I will not develop any s/s (signs or symptoms) (of) oral infection from my implant/post. Approaches ... Perform good oral care q (every) 2 hours ..." A review of POTTER - PERRY, FUNDAMENTAL OF NURSING, PAGE 884, BOX 39-11 revealed, "Oral Health, Evidence Summary, Oral care is (an) essential nursing intervention. A client's oral health affects his or her general level health and rate of recovery. ... Poor oral hygiene measures result in decreased saliva volume, increased dental plaque, and altered oral flora. ..." A review of POTTER - PERRY, FUNDAMENTAL OF NURSING, PAGE 887, SKILL 39-4 revealed, "... 17. Rationale: Microorganisms collect and grow on tongue's surface and contribute to bad breath. ..." A review of the medical records revealed RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Quarterly MDS with an ARD of 12/17/2014, revealed RI #1 was severly impaired for cognitive daily decision making skills. This MDS also indicated RI #1 required extensive and total assistance with ADLs. On 02/10/2015 at 10:36 AM, an observation was made on tour of RI #1 lying in bed. A thick white dried substance was noted on her tongue and her lips were dry. On 02/11/2015 at 10:35 AM, an observation was made of RI #1 in bed, with a thick, white dried substance on her tongue. On 02/12/2015 at 9:00 AM, an observation was made of RI #1 in bed, with a thick, white dried substance on her tongue. On 02/12/2015 at 9:02 AM, an interview was conducted with EI #7, a CNA (Certified Nursing Assistant). EI #7 was asked what daily care was provided to residents. EI #7 stated, "I do mouth care, personal care, and brush their hair. If they are bed residents I give perineal care and freshen them up." EI #7 was asked how often should oral care be performed on residents. EI #7 stated, "Every two hours on a total care resident. I offer it to the ones that get up." EI #7 was asked what potential harm could occur to a resident if oral care was not provided. EI #7 stated, "There is a lot of gunk and they can aspirate it. Some have bad teeth. We have a resident that her tongue gets very dry, so we have to do mouth care." EI #7 was asked who was the resident. EI #7 stated, "(RI #1)." EI #7 was asked how is oral care performed on a total care resident. EI #7 stated, "We have swabs with mouthwash and moisturizer on it." On 02/12/2015 at 10:40 AM, an interview was conducted with EI #8, an LPN (Licensed Practical Nurse). EI #8 was asked what was included when performing daily care to residents. EI #8 stated, "If they don't get a bath, they'll go ahead and freshen them up. We do dentures and brush the teeth with mouth swabs. EI #8 was asked if oral care should be performed during daily care and as needed. EI #8 stated, "Yes." EI #8 was asked why should the mouth be cleaned everyday. EI #8 stated, "They can have soreness of the gums, mouth irritation, tooth decay and bad breath." EI #8 was asked what potential harm could occur to a resident if oral care was not provided to a resident everyday and as needed. EI #8 stated, "They can have soreness of the gums, bad breath, mouth irritation and tooth decay." On 02/12/2015 at 1:00 PM, an interview was conducted with EI #1, the DON. EI #1 was asked when should oral care be performed on total care residents. EI #1 stated, "They get it at least in the morning and the evening." EI #1 was asked how was oral care performed on totally dependent residents. EI #1 stated, "We use mouth swabs." EI #1 was asked what potential harm could occur to a resident if oral care is not performed daily and as needed. EI #1 stated, "Dignity and infection control."

Based on observation, interviews, and record review, the facility failed to ensure a Licensed Nurse locked a medication cart prior to leaving the cart unattended. This was observed on 02/10/2015 and affected one of three units, in the facility. Findings include: A review of the Facility's Document titled, "MANUAL TITLE: NURSING SERVICE POLICY & (and) PROCEDURE MANUAL POLICY & PROCEDURE TITLE: STORAGE OF MEDICATIONS PURPOSE: Medications and biologicals are stored safely, securely, and properly following manufacturer recommendations. ... POLICY 1. Only licensed nurses, pharmacy personnel, and those lawfully authorized are allowed access to medication. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. ..." On 02/10/2015 at 4:10 PM, an observation was made during medication pass of EI (Employee Identifier) #9 leaving the medication cart unlocked and unattended. On 02/10/2015 at 4:25 PM, an interview was performed with EI #9, an LPN (Licensed Practical Nurse). EI #9 was asked should the medication cart be locked before leaving it. EI #9 stated, "Yes." EI #9 was asked why the medication cart should be locked. EI #9 stated, "To keep residents from going in and getting medications." EI #9 was asked what potential harm could occur to residents if the medication cart was not locked and left unattended. EI #9 stated, "They could take somebody's medicine that they're not supposed to." EI #9 was asked what adverse reaction could potentially occur if a resident took the wrong medications. EI #9 stated, "They could have an adverse reaction or be allergic to it." On 02/12/2015 at 1:00 PM, an interview was conducted with EI #1, the DON (Director of Nursing). EI #1 was asked when should medication carts be locked. EI #1 stated, "When they're not in the nurses view." EI #1 was asked why should the medication cart be locked. EI #1 stated, "For safety, if they're not locked someone could open the cart and there are medicines in there." EI #1 was asked what potential harm could occur if the medication carts are left unlocked. EI #1 stated, "They could potentially take the medicines out and self administer them."

Based on observations, interviews, and record reviews, the facility failed to ensure CNAs (Certified Nursing Assistants) removed their gloves and did not double glove: 1. After removing stool from RI (Resident Identifier) #7's bottom prior to placing a clean brief and pants. 2. After providing incontinence care for RI #5, prior to applying an adult brief. This had the potential to affect RI #5 and RI #7, two of three residents observed for incontinence care. Findings include: A review of "Potter - Perry Fundamentals of Nursing," 6th Edition, Chapter 33, page 793, revealed, "Skill 33-1 Hand Hygiene ... The CDC (Centers for Disease Control) (2002) recommends the following: 1. Wash hands with plain soap or antimicrobial soap and water when hands are visibly dirty. 2. If hands are not visibly soiled, use an alcohol-based waterless antiseptic agent for routinely decontaminating hands in all other clinical situations: ... b. After contact with body fluids or excretions, mucous membranes, nonintact skin or wound dressings as long as hands are not visibly soiled. c. When moving from a contaminated body site to a clean body site during client care; after contact with inanimate objects (including medical equipment) in the immediate vicinity of the client ... f. After removing gloves. ..." 1. A review of RI #7's medical record revealed RI #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #7's Quarterly MDS (Minimum Data Set), dated 11/18/14, revealed RI #7 had long and short term memory problems and was severely impaired for decision making. RI #7 required extensive to total assistance for all activities of daily living. RI #7 was coded as frequently incontinent of bowel and bladder. During an observation of incontinence care on 2/11/15 at 4:40 PM, two CNAs, EI (Employee Identifier) #3 and EI #4, applied double gloves and completed incontinence care which involved removing stool off of RI #7. EI #3 and EI #4 removed the top pair of contaminated gloves after providing incontinence care. EI #3 applied a clean brief and EI #4 put a clean pair of pants on the resident. Both CNAs assisted RI #7 to a chair. EI #3 and EI #4 washed their hands and changed gloves. EI #3 and EI #4 were asked about the double gloving technique. Both CNAs stated they were taught to double glove during incontinence care. 2. A review of RI #5's medical record revealed RI #5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a Quarterly MDS for RI #5, with an Assessment Reference Date of 12/10/14, revealed RI #5 had short term and long term memory problems and was severely impaired for cognitive skills for daily decision making. RI #5 was coded as requiring total assistance from staff for all ADLs. RI #5 was coded as always incontinent of bladder and bowel functions. On 2/12/15 at 9:35 AM, EI #3, a CNA, was observed to enter RI #5's room, wash her hands, close the door, and EI #5 then applied two pairs of gloves. EI #6, a CNA, entered RI #5's room with the Hoyer lift, washed her hands and applied two pairs of gloves. After the resident was transferred via Hoyer lift and two person assist, EI #3 removed her gloves, washed her hands, and applied two pairs of gloves. EI #3 then provided perineal care to RI #5. EI #3 removed her gloves, washed her hands and applied two pairs of gloves. EI #6 turned RI #5 to the left side. EI #3 cleansed the buttocks and rectal area of RI #5 and discarded the wipe. EI #3 removed the top pair of gloves, placed an adult brief on the resident and placed RI #5's pants on using the first layer of gloves. On 2/12/15 at 10:20 AM, an interview was conducted with EI #3. EI #3 was asked what was the facility's policy regarding applying gloves. EI #3 stated, "Double glove." EI #3 was asked what was the purpose of double gloving while providing care. EI #3 stated, "If you have one glove on and that glove should tear, there is another glove to protect you." EI #3 was asked when should hands be washed and gloves changed during incontinence care. EI #3 stated, "Once I double glove and the top glove gets dirty, I remove that glove and when the second glove becomes dirty, I take it off (and) wash my hands and double glove again. If both gloves become soiled, I remove both gloves, wash hands, and double glove again." EI #3 was asked what the potential negative outcome was of double gloving and not washing your hands. EI #3 stated, "If I am cleaning a resident with BM (bowel movement) and I have on double gloves if I take the top glove off the bottom glove is clean." EI #3 stated, "I go ahead and take both gloves off & wash my hands, and put on double gloves." EI #3 was questioned regarding the care she had provided for RI #7 on 2/11/15. EI #3 stated when she removed the top gloves after cleaning stool she then placed a clean brief on the resident prior to washing her hands. EI #3 was asked what the concern was when she removed stool with the top glove and removed the top glove, then applied a clean brief without washing her hands. EI #3 stated, "It would cause infection." An interview was conducted with the Infection Control Nurse, EI #5, on 2/12/15 at 3:05 PM. EI #5 was asked to explain the rationale behind double gloving during incontinence care. EI #5 said double gloving was done during perineal care, bathing and with isolation. EI #5 explained when staff members were providing care and the top layer became contaminated, they would have to remove it before continuing. She said when staff used double gloves they were suppose to clean from front to back without contaminating. EI #5 was asked what the concern was when double gloves were used during incontinence care when stool was involved. EI #5 stated, "The second layer could possibly get contaminated, and they (the residents) could get an infection. I would have them take them off and wash their hands."

Based on observations, record review and interview: MANUAL DISHWASHING 1) The facility failed to follow correct manual dishwashing procedures for the three-compartment sink chemical concentration as evidenced by: a. The test strips observed to be utilized by staff had an expiration date of 11/15/13. POTENTIAL CROSS CONTAMINATION 2) a. The facility failed to assure light bulbs in two of two refrigerated units were shielded, coated or otherwise shatter-resistant in areas where there was exposed food. 3) The facility failed to assure four of nine sectional plates were clean and in good condition. Two of the nine were chipped and two of the nine contained standing water. The above practices posed the potential for food contamination and compromised food safety. This deficient practice had the potential to affect all 60 residents who received meal trays from dining services. Findings include: MANUAL DISHWASHING 1) The facility failed to follow correct manual dishwashing procedures (i.e. three compartment sink chemical concentration) as evidenced by: a. The test strips observed to be utilized by staff had an expiration date of 11/15/13. On 7/02/2014 at 9:30 AM an observation was made of manual dishwashing. The value obtained on the test strip was 150 ppm (parts per million). The container of test strips was examined and the printed expiration date was 11/l5/13 (7+ months prior). The Dietary Manager, Employee Identifier (EI) #3 went into her office to obtain another container of test strips. The container obtained from her desk drawer had an expiration date of 1/15/14. EI #3 said those had been left by the representative. On 7/02/2014 at 9:45 AM, EI #3 dialed the sanitizer chemical manufacturer's customer service number and the representative stated, "We do not guarantee the accuracy after expiration date." A review of the facility "Manual Warewashing" policy (dated 09/2004) revealed: "5. ...If chemical sanitizing is used, the sanitizer must be mixed to the proper concentration and the water temperature must be correct. ..." On 7/03/2014 at 10:08 AM, EI #3 was asked what was her procedure to assure test strips were current. EI #3 responded that she did not have one, but her plan was to have a policy and train staff members. POTENTIAL CROSS CONTAMINATION 2) On 07/01/2014 at 8:30 AM, during the initial tour, light bulbs in a four-door refrigerated unit were observed. One socket was without a bulb and the other bulb was not protected. At this time, the Dietary Manager (EI #3) was asked if the bulb was coated. EI #3 responded, "No." EI #3 was asked if that was a problem and why. EI #3 stated that it was a problem due to the potential of the bulb breaking and falling into food. On 7/2/2014 at 10:00 AM a four-door refrigerated unit located in the hall contained milk. The light bulbs were not shielded or coated. A review of the Food and Drug Administration's 2013 Food Code revealed: "Functionality 6-202.11 Light Bulbs, Protective Shielding. (A) ...light bulbs shall be shielded, coated, or otherwise shatter-resistant in areas where there is exposed FOOD; clean EQUIPMENT, UTENSILS..." 3) The facility failed to assure four of nine sectional plates were clean and in good condition. Two of the nine were chipped and two of the nine contained standing water. On 7/01/2014 at 11:05 AM just prior to tray line service, sectional plates were observed. Out of the nine plates observed, two were chipped and two contained standing water. On 7/03/2014 at 10:15 AM, EI #3 was asked why the damaged sectional plates had not been removed from the inventory and why some were not free of water. EI #3 responded that the condition of the dinnerware had not been observed by dietary staff.

Based on observation, interview and record review, the facility failed to ensure Resident Identifier (RI) #10 and RI #11's catheter bag was covered and not visible on three of three days of the survey. This affected two of two residents observed with catheters. Findings Include: A review of the "Facility's Handbook" that is provided to all residents and families upon admission with a Revised date on 05/08 documented, "...Resident rights...The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility..." RI #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #10's Initial Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/02/14 reveled RI #10 was severely impaired for decision making. The MDS also documented RI #10 had a catheter. During initial tour on 7/1/14 at 8:20 AM, RI #10 was observed lying in her bed asleep. RI #10's door was propped open and the catheter was visible from the doorway. The catheter was not in a privacy bag. On 7/2/14 at 2:45 PM, RI #10 was observed lying in her bed with the door open. RI #10's catheter bag was observed from the doorway with urine in the bag. There was no privacy bag on the catheter. On 7/3/14 at 9:05 AM, RI #10 was observed lying in her bed. RI #10's catheter bag was observed from the door. The catheter contained urine and it was not in a privacy bag. On 7/3/14 at 9:20 AM, EI (Employee Identifier) #6 (Certified Nursing Assistant) was asked if she normally worked with RI #10. EI #6 said she did. EI #6 was asked if RI #10's catheter bag was ever covered. EI #6 said they do not cover them if the resident does not leave the room. EI #6 was asked if RI #10's door stayed open. EI #6 said RI #10's father wanted the door open at least 6 inches and he does not want it shut. EI #6 was asked if RI #10's catheter bag was normally uncovered and she said it was. EI #6 was asked what was the facility's policy on catheter bags and privacy bags. EI #6 said, "I don't know." EI #6 was asked if she thought the catheter bag being uncovered would be a dignity concern. EI #6 said she did not know. RI# 11 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #11's most recent Significant Change MDS with an ARD date of 6/5/14 documented RI #11 scored an 11 out of possible 15 on the Brief Interview for Mental Status indicating she was moderately cognitively impaired. The MDS also revealed RI #11 had a catheter. On 7/1/14 at 3:30 PM, an observation was made of RI# 11's foley catheter drain bag hanging from the bed frame. The bag contained urine which was visible from the hallway. On 7/2/14 at 3:30 PM an observation was made of RI #11's foley catheter drain bag hanging from the bed frame. It contained urine in the catheter bag that was visible from the hallway. On 7/3/14 at 10:00 AM an observation was made of RI #11's foley catheter drain bag hanging from the bed frame. The bag contained urine that was visible from the hallway. On 7/3/14 at 10:30 AM an interview was conducted with EI# 5 (Certified Nursing Assistant). EI# 5 was asked if she normally took care of RI#11. EI #5 said she did. EI #5 was asked if she provided catheter care for RI # 11 and she said she did. EI #5 was asked should RI #11's catheter bag be visible from the hall. EI #5 stated, "No, but the policy says if they are in the room it does not have to be covered." EI #5 was asked if a resident's door was left open could the drain bag be visible from the hallway. EI #5 replied, "Yes." EI #5 was asked if she felt a resident's catheter bag that is visible to others would be a dignity issue. EI #5 stated, "Yes, if it was me I probably would be embarrassed." On 7/3/14 at 9:30 AM, EI #4 (Licensed Practical Nurse) was asked if RI #10 and RI #11 had catheters. EI #4 said they do. EI #4 was asked if the catheters were ever covered in a privacy bag. EI #4 said they do not cover them while they are in the room. EI #4 was asked if she was aware they were not in a privacy bag. EI #4 said she was. EI #4 was asked what was the facility's policy of catheter bags for residents and how they were supposed to be hung. EI #4 said she was not sure. EI #4 was asked if RI #10 kept her door open. EI #4 said she does. EI #4 was asked when the resident's doors are open, could visitors and other residents see the catheter from the hall. EI #4 said they could. EI #4 was asked if she thought the catheters not being in a privacy bag would be a dignity issue for the residents. EI #4 said "Yes Ma'am." On 7/3/14 at 9:45 AM, EI #2 (Registered Nurse/ Unit 1 Manager), was asked if RI #10 and RI #11 had catheters. EI #2 said they do. EI #2 was asked if their catheters are ever in a privacy bag. EI #2 said RI #11's was when she left her room, but RI #10's was not because she did not leave her room. EI #2 was asked if the catheter bags were visible when walking into the room or down the hallway. EI #2 said they were. EI #2 was asked if RI #10 kept her door open. EI #2 said she does. EI #2 was asked if the residents doors are open, could visitors or other residents see the catheter from the hallway. EI #2 replied, "Yes Ma'am." EI #2 was asked if she thought the catheters not being in a privacy bag would be a dignity issue for the residents. EI #2 said, "Yes, I do." On 7/3/14 at 10:40 AM, EI #1 (Director of Nursing) was asked if RI #10 and RI #11 had catheters. EI #1 said they did. EI #1 was asked if RI #10 and 11's catheters were in a privacy bag. EI #1 said they were when they were up, but they did not cover them when they are in bed. EI #1 was asked if RI #10 kept her door open. EI #1 said she did because her father wanted it left open. EI #1 was asked if the catheters were visible from the door. EI #1 said, "Yes." EI #1 was asked what was the facility's policy on catheters and how they were supposed to be hung. EI #1 said they were supposed to be covered when they are out of their room. EI #1 was asked if the resident's doors were open, could visitors and other residents see them from the hallway. EI #1 said, "If they looked they could." EI #1 was asked if she thought the catheters not being in a privacy bag would be a dignity issue for the residents. EI #1 said, "I guess potentially it could."

Based on observations, record reviews, and interviews, the facility failed to utilize bed and chair alarms per manufacture's instructions by attaching the pull cord of the alarm with a diaper pin instead of the clasp provided. This affected Resident Identifier's (RI) # 6, 7, 8, 9 and 10. The facility further failed to ensure RI #11's bed alarm was attached to her while she was in bed on 06/04/13. This affected 1 of 3 sampled residents for assistive devices. Findings include: The facility policy titled "Safety Alarms," revised date, April 2006, documented the following: "POLICY 1. The facility will utilize safety alarms for residents that are high risk for falls. The staff will monitor these alarms to ensure proper functioning and use, and document accordingly. 2. The use of safety alarms will be communicated to staff through the ADL (Activities of Daily Living) Supplement Care Plans. 3. There are different types of alarms which are used in our facility: wheelchair alarms, chair alarms, bed alarms and door alarms. ... PROCEDURE ... B. The safety alarms are to be checked for proper functioning and use according to the following schedule: 1. The Restorative Care Department checks the alarms three times per week for proper functioning and documents this on their checklist. 2. The LPN (Licensed Practical Nurse) charge nurse is responsible for checking that the alarms are being properly used at every shift... 3. The CNA's (Certified Nursing Assistant) are responsible for activating the bed and wheelchair alarms when a resident is placed in their bed, their wheelchair, or wherever the alarm is indicated. ... D. To properly set and use the alarms, see the instruction manual located in the medicine room at each unit. ..." The instruction manual for the alarm used by RI #11 documented: "... ALWAYS check that magnet cord is not frayed or worn and could break. DO NOT use if cord is damaged. ...2. Attach clip near shoulder: Of clothing patient is not likely to remove; and Out of the patient's reach 3. Check that attachment point is in good condition and is not frayed or torn. 4. Secure clip lock by rotating it clockwise. This will reduce risk that patient can remove clip..." 1). During the initial tour on 06/04/13 at 5:00 PM, RI #11 was observed lying in her bed. There was a bed alarm on the bed and the cord to the alarm was draped over the headboard of the bed. The cord had several knots in it and there was an open diaper pin attached to the end of the cord. The cord was frayed. On 06/04/13 at 5:40 PM, Employee Identifier (EI) #5, (Charge Nurse) was asked to make an observation with the surveyor in RI #11's room. Upon entering the room, EI #5 was asked to show the surveyor where RI #11's bed alarm was attached to her. EI #5 noticed the cord draped over the headboard and took the cord and pinned it to RI #11's shirt on the right shoulder. EI #5 was asked was RI #11 suppose to have an alarm on while in the bed. EI #5 replied yes. EI #5 was asked why RI #11 did not have the alarm on while she was in the bed. EI #5 replied they (CNA) forgot to put it back on after they changed her. RI #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #11's most recent Quarterly Minium Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 4 which indicated a severe impairment in cognitive skills for daily decision making. RI #11 required extensive to total assistance from staff for all her Activities of Daily Living Skills. RI #11's care plan, with a problem onset date of 01/23/13, revealed, "... Problem/Need I have poor safety awareness and I have a history of falls..." The approach listed was, "*...I use a string alarm while in the chair * I use a string alarm while in the bed..." RI #11's "Fall Risk" assessment dated [DATE] documented him with a total score of 14. "The score of 10 or above represents HIGH RISK..." On 06/06/13 at 8:20 AM, RI #11 was observed in bed with the string alarm pinned to the back of her gown at the left shoulder area with a diaper pin. On 06/06/13 at 10:15 AM, RI #11 was observed in the day area in a geri chair and the string alarm was pinned to her blouse at the right shoulder area with a diaper pin. 2). The installation instructions for the alarm used by RI #7, documented: " ... The (name of alarm) is designed to be installed by the end-user who should ensure that the product is properly installed and tested . This product is intended to be used on wheelchairs, standard upright chairs and beds to assist caregivers trained in its use. Inspect the product for damage before each use and do not use if the product appears to be damaged or is not functioning properly. Never alter the product in any way.... " RI #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most current Quarterly MDS assessment, dated 05/20/13, documented RI #7 with short and long term memory loss and severely impaired in daily decision making. RI #7's "Fall Risk" assessment dated [DATE] documented him with a total score of 16. "The score of 10 or above represents HIGH RISK..." RI #7's care plan with a problem onset date of 08/29/12 documented ."... Problem/Need I have poor safety awareness and I have a history of falls..." The approach listed was "...I use a string alarm while in the chair..." On 06/05/13 at 11:45 AM, RI #7 was observed in the day area seated in a geri chair. The cord to the alarm on RI #7 was pinned to his right shoulder area with a diaper pin. On 06/07/13 at 10:45 AM, EI #6 (CNA) was asked how did she put a bed or chair alarm on a resident. EI #6 replied that she would fasten the cord in the mid back. EI #6 was asked what was used to attached the cord to the resident. EI #6 replied, a diaper pin. EI #6 was asked why a diaper pin. EI #6 replied so the resident could not undo it. EI #6 was asked what should be used to attached the cord. EI #6 replied she had only seen the pins because the clamps would not work. EI #6 was asked who instructed the staff to use the diaper pins. EI #6 replied with a name of a nurse who use to be the charge nurse. EI #6 was asked how long had she been using a diaper pin to attach the cord. EI #6 replied at least two years. EI #6 was asked if she knew of any incidents where a resident had been injured by a diaper pin. EI #6 replied she did not know of any. EI #6 was asked what could be the potential harm when a diaper pin was used to secure the alarm. EI #6 replied if it was not attached it could poke the skin. EI #6 was asked when was the last time she was inserviced about the bed and chair alarms. EI #6 replied sometime in February or March of this year and she further explained that they were shown the proper way to use them and what to do if not working. EI #6 stated they did not specify the use of a diaper pin just to make sure they were hooked up. On 06/07/13 at 10:50 am, EI #5 (LPN), was asked who was responsible for attaching the alarms and checking for proper functioning. EI #5 replied the CNA can initiate turning on the bed and chair alarms. EI #5 was asked when were the alarms monitored. EI #5 replied that was her first duty after shift report. EI #5 was asked what was used to attach the alarm cord to the resident. EI #5 replied a diaper pin, the ones with the plastic head. EI #5 was asked what should be used to attached the cord. EI #5 replied she did not know. EI #5 was asked who instructed her to use a diaper pin to attach the cords. EI #5 replied EI #3, (Restorative Nurse). On 06/07/13 at 11:10 AM, EI #3, (Restorative Nurse), was asked what was monitored when the alarms were checked. EI #3 replied to made sure it was functioning, if the string was attached and made sure it sounded. EI #3 was asked what was used to attach the alarm cord. EI #3 replied a diaper pin. EI #3 was asked why was a diaper pin used. EI #3 replied they had problems with the clips that came with the alarm. EI #3 was asked what should be used per the manufacture's guidelines. EI #3 replied he had not read the guidelines on the alarms. EI #3 was asked who instructed the use of the diaper pins. EI #3 replied it was the care plan team decision. EI #3 was asked how long had the diaper pins been used. EI #3 replied for at least the past 2 to 3 years. EI #3 was asked if he knew of any incidents of a resident getting injured by the diaper pins. EI #3 replied not to his knowledge. EI #3 was asked what was the potential harm of using a diaper pin to attach the cord. EI #3 replied if a resident was able to unpin the pin themselves they could stick theirself. On 06/07/13 at 11:45 AM, the company that supplied RI #7's alarm was contacted. In speaking with the Supervisor Account Manager about the alarm, he was asked would they ever recommend the use of a diaper pin to attach the cord. He replied they (the company) would not recommend the use of a diaper pin. When asked if using a diaper pin was improper use of the product. He replied, definitely and they should be using the clip. On 06/07/13 at 12:00 PM, the company that supplied RI #11's alarm was contacted. In speaking with a Customer Service Account Manager about the alarm, he was asked about the use of a diaper pin to attached the cord. He replied it was important to only use the product as intended and any modifications would void the warranty. They can not use the product except the way it was intended to be used. On 06/07/13 at 12:45 PM, EI #4, (Director of Nurses) was asked if she was aware that diaper pins were used attach the cords on the bed and chair alarms. She replied she was aware and they had used the diaper pins for about 5 or 6 years. EI #4 was asked who decided to use the diaper pins and why. EI #4 replied they met as a resident care team and they had incidents of residents that were taking the cords off and they had to come up with a solution. EI #4 was asked who consulted with the manufacturer and asked about using diaper pins. EI #4 replied, they did not. EI #4 was asked if she was aware that using a diaper pin to attach the cord is consider improper use of the alarm. EI #4 replied, no she was not. On 06/07/13 at 2:45 PM, EI #7, (Medical Director) was asked if he was aware that the facility was using diaper pins to attach the alarm cords. EI #7 replied no he was not aware of that. The surveyor expressed the concern of the pin coming open. EI #7 commented, that would not be good. 3). RI #6 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Significant Change in Status MDS with an ARD (Assessment Reference Date) of 5/13/2013, revealed RI #6 had a BIMS score of 4 out of a possible 15. This indicated that RI #6 was cognitively impaired. RI #6 was coded as being totally dependent on 2 or more staff members for transfers, locomotion, and personal care. A review of RI #6's care plans revealed a care plan with a problem onset date of 5/21/2013 for risk for falls due to being transferred via Hoyer lift for all transfers. RI #6 also had a history of [REDACTED]." On 6/7/2013 at 2:35 PM, RI #6 was observed in bed in low position with an alarm cord pinned to the right shoulder of RI #6's gown with a diaper pin. 4). RI #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Significant Change in Status MDS, with an ARD of 4/25/2013, revealed RI #9 had a BIMS score of 8 out of a possible 15. RI #9 had some short term and long term memory loss. RI #9 was coded as requiring limited assistance of one for transfers and locomotion. RI #9 required extensive assistance for personal hygiene and bathing. RI #9 had impairment of range of motion for upper and lower extremities on both sides. A review of the care plans for RI #9 revealed a care plan with a problem onset date of 5/3/2013 for "I have a history of falls and I have problems with my balance during transfers and ambulation which also increases my risk for falls." An intervention included on this care plan was for use of a string alarm while in chair. On 6/7/13 at 8:29 AM, RI #9 was observed in the dining room with the alarm cord attached to the right side of his shirt at the upper shoulder level with a diaper pin. On 6/7/13 at 8:35 AM, RI #9 ambulated to his room with a rolling walker and standby assistance of one staff member. The alarm cord was removed from the back of RI #9's shirt and taken to the room by the staff member. RI #9 was assisted to sit on the side of the bed by the staff member and the alarm cord was pinned to the right sleeve of RI #9's shirt with a diaper pin. During an interview with RI #9 at 8:45 AM, the resident leaned back on his bed and the cord came out of the alarm with the pin intact to the right sleeve of his shirt. The alarm was sounding, a staff member entered the room and reconnected the alarm cord. On 6/7/13 at 9:37 AM, RI #9 ambulated with a rolling walker and standby assistance of one staff member to a recliner in the sitting area. The staff member was observed pinning the alarm string to the shirt of RI #9 with a diaper pin. On 6/7/13 at 10:09 AM, an interview was conducted with EI #1 (CNA). EI #1 was asked how she placed an alarm on a resident (bed and chair alarm). EI #1 stated the sensor alarm was placed under the resident's buttocks and she had to ensure it was working in the bed. The bed alarm, string alarm was placed on the opposite side of the bed with velcro where the resident would exit from and clip the string to the fartherest side of the resident's clothing. EI #1 also stated to clamp the string with a safety pin. EI #1 stated some of the alarms have clips on the end of the cord. EI #1 stated when the facility gets new alarms in, the alarms have clips on them. EI #1 stated the sensor alarms were also used in the wheelchair and placed under the resident's buttocks. EI #1 was asked what was used to attach the string of the alarm to the resident. EI #1 stated a safety pin or some of the new ones had clips. EI #1 was asked why a pin was used. EI #1 stated to secure the string better, residents can remove the clips from clothing. EI #1 was asked who instructed her to use a diaper pin to attach the alarm string to a resident. EI #1 stated they had done this for a long time. EI #1 was asked if she was aware of any incidents where a resident was injured by the diaper pin. EI #1 stated, "No ma'am." 5). RI #10 was admitted to the facility on [DATE]. RI #10 [DIAGNOSES REDACTED]. The most recent (Quarterly) MDS, with an ARD of 2/3/13, identified RI #10 to have a BIMS(Brief Interview for Mental Status) score of 3 out of 15, which indicated RI #10 was severely impaired for cognitive functioning. RI #10 required no assistance for transferring and ambulation, but required total assistance with eating, and extensive assistance for her bath. An observation of RI #10 was made on 6/6/13 at 2:40 PM, while sitting in the day area. The chair alarm cord was secured with a diaper pin. An observation of RI #10 was made on 6/7/13 at 8:50 AM, while sitting in the day area. The chair alarm cord was secured with a diaper pin. 6). RI #8 was readmitted to the facility on [DATE]. RI #8's [DIAGNOSES REDACTED]. The most recent (Significant Change) MDS, with an ARD of 3/22/13, identified RI #8 to have severely impaired cognitive functioning. RI #8 required total assistance of all of her activities of daily living including, transfers, mobility, bath and hygiene. The resident's care plan dated 4/1/13, documented: "...*I use a string alarm while in the chair...*I use string alarm while in bed..." An observation of RI #8 was made on 6/6/13 at 2:50 PM, while laying on her right side in bed. The bed alarm cord was secured with a diaper pin. A CNA, EI #2, was interviewed on 6/7/13 at 10:10 AM. EI #2 was asked how did she secure alarms. EI #2 answered, with a safety pin attached to the upper center portion of the resident's back. The surveyor asked why did she use the safety pin. EI #2 said because it had a safety catch and it could not pop loose and injure the resident. The surveyor asked EI #2 who instructed her to use the diaper pins to secure the cord alarms for the residents. EI #2 said it may have been EI #3, the RN, Restorative Nurse or EI #4, the DON (Director of Nursing). She said they had been using the diaper pins for a long time. When the surveyor asked EI #2, when was the last time she attended an in-service on bed/chair alarms, EI #2 said she could not remember, but it was probably conducted by EI #3.

Based on record review and interviews the facility failed to notify the sponsor of a change in the resident's condition and treatment. Resident Identifier (RI) #1 developed a blanchable abrasion to the right buttock, however the facility failed to notify the sponsor of the area and when the treatment changed. This affected one of four sampled residents. Findings include: RI #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the discharge Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/9/12 , identified the resident's cognitive status for daily decision making as severely impaired. The Minimum Data Set (MDS) further revealed RI #1 as totally dependent on staff for bed mobility, dressing, eating, toilet use and personal hygiene. During the Weekly Skin Audit on 12/1/2011, a blanchable abrasion to RI #1's right buttocks was identified. The following treatment was ordered: physician's orders [REDACTED]. (change) daily (and) PRN ( as needed)..." The treatment was changed on the following dates: physician's orders [REDACTED]. (change) q (every) 3 days & (and) PRN (as needed)..." Physicians order dated 12/20/11 at 9:30 AM documented the following: "Monitor open blanchable area to coccyx (and) buttocks q (every) day (and) apply A (and ) D ointment..." Physicians order dated 12/26/11 at 7:00 AM documented the following: " D/C (discontinue) current order to coccyx (and) BIL (bilateral) buttocks...new orders: cleanse BIL (bilateral) buttock (and) coccyx (with) wd (wound) cleanser, pat dry (and) skin prep (and) apply Derma Gel. Cover (with) clear film (and) (change) qod (every other day) (and) PRN (as needed) ..." Physicians order dated 12/28/11 (no time) documented the following: " D/C (discontinue) tx (treatment) BIL (bilateral) buttocks (and) Coccyx, new orders to cleanse multiple shallow open blanchable areas to coccyx (and) BIL(bilateral) buttocks (with) wd (wound) cleanser, pat dry (and) skin prep peri wd (wound). Apply santyl to open wd (wound) bed, cover (with) 2 x (by) 2, then clean film. Place a small piece of [MEDICATION NAME] strip paste to bottom edge of drsg (dressing) (and) hold for 15 secs (seconds). Monitor BID ( twice a day) (change) qod (every other day) and PRN (as needed)..." Physicians order dated 1/3/12 at 2:52 PM documented the following: "...D/C (discontinue) current tx (treatment) orders to coccyx. New orders are as follows: cleanse areas X (times) 2 to coccyx (with) wound cleanser (and) pat dry, skin prep peri-wound (and) apply restore ... thin [MEDICATION NAME] dressing (change) q (every) 3 days and PRN (as needed)..." Physicians order dated 1/12/12 at 5:05 PM documented the following: "D/C (discontinue) current tx (treatment) orders to coccyx. New orders are as follows: cleanse area x (times) 2 to coccyx (with) wound cleanser (and) pat dry. Skin prep peri-wound, apply small square of biatin nonadhesive,...after applying [MEDICATION NAME]. Cover (with) restore ... thin [MEDICATION NAME]. Place a small piece of [MEDICATION NAME] strip paste to bottom edge of dressing and hold for 15 secs.(seconds) (change) q (every) 3 days (and) PRN (as needed)..." Physicians order dated 1/26/12 at 9:40 AM documented the following: "D/C (discontinue) Current Tx (treatment) orders to coccyx. Cleanse open blanchable area to inner R (right) buttocks and coccyx (with) Wound Cleanser-Pat dry-Skin Prep peri - Wound-Apply small piece of [MEDICATION NAME]-Then apply small square of Biatin nonadhesive over [MEDICATION NAME]-Cut a V shape @ (at) the bottom edge of the Restore ... thin [MEDICATION NAME] then apply over Biatin (change) (every) 3 days (and) PRN (as needed)..." Further review of RI #1's medical record revealed no documentation that her sponsor was notified of the area to her right buttocks or the changes in condition and the above treatment changes. During an interview 10/12/2012 at 10:05 AM, EI #1, the Director of Nursing, was asked if RI #1's sponsor was notified of the area to her right buttocks noted on 12/1/2011. After looking through RI #1's medical record, EI #1 stated, "No". RI #1 was discharged from the facility 2/9/2012. This citation was written as a result of the investigation of Complaint #AL 638.

Based on record review and interviews, the facility failed to investigate an injury of unknown origin. This affected Resident Identifier (RI) #4, one of one resident sampled for an injury of unknown origin. Findings Include: RI #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of RI #4's most current Quarterly Minimum Data Set (MDS), dated [DATE], revealed RI #4's BIMS (Brief Interview for Mental Status) score was 4, indicating severe impairment in cognitive skills for daily decision-making. The MDS also indicated RI #4 required extensive assistance with Activities of Daily Living and was incontinent of bowel and bladder. A review of the facility's Nurses' Notes for RI #4 revealed the following: "... 03/29/12 0820 (8:20 AM) Informed per (Employee Identifier/EI #1) CNA (Certified Nursing Assistant), Resident (with) lg (large) bruise to chest area - upon assessment noted lg purple bruise to (right) (upper) chest above breast - tenderness to touch - unknown occurrence - resident noted (with) falls on 3/23 & (and) 3/26 (See Nurses Notes) No injuries reported ..." On 04/27/12 at 9:20 AM, during an interview with EI #4 (a Registered Nurse/Unit Manager), the surveyor gave her the Nurse Note, dated 03/29/12 at 0820 (8:20 AM), and asked who wrote the note and what was the note about. EI #4 said (name of EI #1) reported to her that RI #4 had a bruise to her chest. Upon assessment, the resident had a bruise to her right chest above the breast and was tender to touch upon palpation. She also stated that they (the facility) did not know how it happened, so it was considered an unknown occurrence. The surveyor asked what did she mean by an unknown occurrence. EI #4 stated no one knew how the bruise happened. The surveyor asked what type of investigation was done when the bruise was found. EI #4 stated she talked with several staff members. The surveyor asked where was the documentation to reflect the staff interviews. EI #4 stated she did not have any documentation because she did not write anything down. The surveyor asked what else did she do. EI #4 said she looked at the falls the resident sustained [REDACTED]. The surveyor asked were there any injuries or bruising with those falls. EI #4 stated no. The surveyor asked when was the last body audit completed on RI #4. EI #4 stated she did weekly skin assessments on her residents and RI #4's last body audit was done on 03/27/12. The surveyor asked were there any bruises noted on the body audit. EI #4 stated no. On 04/27/12 at 10:02 AM, during an interview with EI #3 (the Director of Nursing), the surveyor asked when was she made aware of the large bruise to RI #4's chest area. EI #3 stated the report was placed in her box the same day (3/29/12). The surveyor asked what would be her interpretation, based upon the Nurses' Note dated 03/29/12 at 0820. EI #3 stated the facility had a resident with a bruise and they did not know how it happened. The surveyor asked would this be considered an injury of unknown origin. EI #3 stated yes, the bruise would be considered an injury of unknown origin. The surveyor asked what did the policy and the procedure document to do when there was an injury of unknown origin. EI #3 said the injury will be investigated. The surveyor asked, based on the facility's policy and procedure for investigating an injury of unknown origin, was policy followed. EI #3 stated, "No." A review of the facility's policy titled "ABUSE PREVENTION, REPORTING AND INVESTIGATING," dated May 2011, revealed the following: "... IV. IDENTIFICATION The facility will identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation. ... 1. Injuries of unknown source: An injury should be classified as an 'injury of unknown source' when both of the following conditions are met: a. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and, b. The injury is suspicious because of the extent of the injury or the location of the injury (e.g. (for example), the injury is located in an area not generally vulnerable to trauma) ..."

Based on record review and interviews, the facility failed to report an injury of unknown origin to the State agency within 24 hours. This affected Resident Identifier (RI) #4, one of one resident sampled for injury of unknown origin. Findings Include: RI #4 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of RI #4's most current Quarterly Minimum Data Set (MDS), dated [DATE], revealed RI #4's BIMS (Brief Interview for Mental Status) score was 4, indicating severe impairment in cognitive skills for daily decision-making. The MDS also indicated RI #4 required extensive assistance with Activities of Daily Living and was incontinent of bowel and bladder. A review of the facility's Nurses' Notes for RI #4 revealed the following: "... 03/29/12 0820 (8:20 AM) Informed per (Employee Identifier/EI #1) CNA (Certified Nursing Assistant), Resident (with) lg (large) bruise to chest area - upon assessment noted lg purple bruise to (right) (upper) chest above breast - tenderness to touch - unknown occurrence - resident noted (with) falls on 3/23 & (and) 3/26 (See Nurses Notes) No injuries reported ..." On 04/27/12 at 10:02 AM, during an interview with EI #3, (the Director of Nursing/DON) the surveyor asked when was she made aware of the large bruise to RI #4's chest area. EI #3 stated the report was placed in her box the same day (3/29/12). The surveyor asked what would be her interpretation, based upon the Nurses' Note dated 03/29/12 at 0820. EI #3 stated the facility had a resident with a bruise and they did not know how it happened. The surveyor asked would this be considered an injury of unknown origin. EI #3 stated yes, the bruise would be considered an injury of unknown origin. The surveyor asked what did the policy and the procedure document should done when there was an injury of unknown origin. EI #3 said the injury will be investigated and the State Department of Public Health notified within 24 hours and a full report sent within five working days. The surveyor asked, based on the facility's policy and procedure, was policy followed. EI #3 stated, "No." A review of the facility's policy titled "ABUSE PREVENTION, REPORTING AND INVESTIGATING," dated May 2011, revealed the following: "... IV. IDENTIFICATION The facility will identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation. The DON (Director of Nursing)/Designee will report all alleged/suspected instances of mistreatment, ... to other officials in accordance with State law immediately (as soon as possible but not to exceed 24 hours). 1. Injuries of unknown source: An injury should be classified as an 'injury of unknown source' when both of the following conditions are met: a. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and, b. The injury is suspicious because of the extent of the injury or the location of the injury (e.g. (for example), the injury is located in an area not generally vulnerable to trauma) ..."