Every finding on record at West Gate Village

Based on observation, interview and review of facility policies, Food Storage, Food Temperatures and Hand Washing, the facility failed to ensure: 1. a half bag of frozen breaded squash and 3/4 bag of frozen sweet potato fries in the freezer were labeled with an open and use by date, 2. the temperature of the gravy, super potatoes and soup was taken during the lunch meal on 6/19/19, and temperatures of the foods were placed on the log and 3. the dayshift cook washed her hands before changing tasks and after removing her gloves. This had the potential to affect all 114 residents receiving meals from the kitchen. Findings Include: 1. A review of a facility policy titled, Food Storage dated 2013, revealed: .Procedure .15. Frozen Foods: . c. All foods should be covered, labeled and dated. On 6/17/19 at 3:30 PM, during the initial tour of the kitchen with EI (Employee Identifier) #4, Dietary Manager (DM), the freezer was observed. In the freezer, the surveyor observed an open bag of frozen squash and an open bag of sweet potato fries which was not labeled with an open or use by date. The surveyor asked EI #4 what were the items that were open and not labeled with an open or use by date. EI #4 replied, a half bag of breaded squash and 3/4 bag of frozen sweet potato fries. EI #4 was asked if these items should be labeled. EI #4 replied, yes. EI #4 was asked why was there no label on the squash or fries. EI #4 replied, she did not know. EI #4 was asked what would the harm be in the squash and fries not having a label. EI #4 replied, they would not know when they were opened . On 6/20/19 at 10:08 AM, a follow up interview was conducted with EI #4. EI #4 was asked what was the policy regarding labeling foods in the freezer. EI #4 replied, there must be a label on everything opened and placed in the freezer or refrigerator. EI #4 was asked was the frozen breaded squash and frozen sweet potato fries labeled. EI #4 replied, no. EI #4 was asked when should the squash and fries be labeled. EI #4 replied, when they were placed back in the freezer. EI #4 was asked who was responsible for labeling the squash and sweet potato fries. EI #4 replied, the cook that took it out and put it back. EI #4 was asked what would the harm be in no label. EI #4 replied, if not labeled staff could not tell when it was opened and how long it had been there. 2. A review of a facility policy titled, Food Temperatures dated 2013 revealed: Policy: The temperatures of the food items will be taken and properly recorded for each meal. Procedure: 1. All hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 (degrees) F (Fahrenheit). On 6/19/19 at 10:50 AM, the surveyor entered the kitchen for the trayline observation. EI #4 took the temperatures of the foods on the steam table which included green lima beans, fried breaded squash, mashed potatoes, pureed squash, pureed green lima beans, pureed ham, cabbage, peppered steak chopped ham, cut up ham and sliced ham. The surveyor observed gravy and super potatoes on the stove top that had not been tempted. The surveyor also observed EI #5, the Dayshift Cook place six individual bowls of soup on the tray line once she removed them from the microwave. The bowls of soup had not been tempted. The surveyor observed the gravy, super potatoes and soup being served. EI #5 took the bowls of soup from the microwave and placed them on the trayline. On 6/19/19 at 11:40 AM, EI #5 started plating food. She plated gravy, super potatoes and all of the bowls of soup that was not tempted. On 6/19/19 at 12:15 PM, the surveyor asked EI #4 where was the temperature log. EI #4 reached and got the book from the shelf and said she did not put the temperatures down. She asked for the ones the surveyor had. The surveyor asked for a copy of the log before temperatures were added. EI #4 was then asked what was the temperature for the gravy, super potatoes and soup. EI #4 replied, she did not get them. On 6/20/19 at 9:59 AM, during an interview with EI #5, she was asked when was the temperature of the super potatoes, gravy and soup taken. EI #5 replied, she did not know. EI #5 was asked if the temperature of the gravy, super potatoes and soup was taken before served. EI #5 replied, she thought EI #4, the DM, took them. EI #5 was asked who usually took the temperatures of the foods on the trayline. EI #5 replied, they all worked together; the cook, DM or those helping. EI #5 was asked what would the risks be in serving foods that had not been tempted. EI #5 replied, the food could not be hot enough and cause someone to get sick. On 6/20/19 at 10:02 AM, a follow up interview was conducted with EI #4, DM. She was asked when should the temperature of foods be taken. EI #4 replied, first set up the food on the line then take the temperature of all the foods. EI #4 was asked when should the temperatures be logged. EI #4 replied, as they were taken. EI #4 was asked was the temperature of the gravy, super potatoes and soup taken. EI #4 replied, no. EI #4 was asked why not. EI #4 replied, she thought the other person did it. EI #4 was asked if the super potatoes, gravy and soup was served to residents. EI #4 replied, yes. EI #4 was asked what was the harm in not taking the temperature of those foods. EI #4 replied, they must know the temperature was right to not cause harm and grow bacteria. EI #4 was asked how many residents receive meals from the kitchen. EI #4 replied, 114 were fed from the kitchen. 3. A review of a facility policy titled, Hand Washing dated 2013 revealed: Policy: Staff will wash hands as frequently as needed throughout the day . Procedure: .1. When to Wash Hands: .During food preparation, as often as necessary to remove soil and contaminated and to prevent cross contamination when changing tasks. On 6/19/19 at 11:10 AM, EI #5 was observed to put on gloves and added frozen squash to the deep fryer. EI #5 removed her gloves and went to the pantry and got six individual cans of soup. EI #5 removed a cloth from the sanitizer bucket and wiped the top of each can. EI #5 opened and poured each can into an individual bowl and placed each bowl with a lid into the microwave. EI #5 took the empty cans to the trash can, lifted the lid without using gloves, and did not wash her hands. EI #5 then went to the deep fryer and picked up and shook each basket. EI #5 walked to the steam table and propped up on the steam table using her hands. On 6/19/19 at 11:50 AM, while plating food, EI #5 removed her gloves and picked up an individual serving bowl and several disposable gloves. These items were placed on the steam table counter. EI #5 put on clean gloves and continued plating the food. EI #5 did not wash her hands when she removed the gloves. On 6/20/19 at 9:59 AM, an interview was conducted with EI #5. EI #5 was asked what was the policy regarding when to wash hands while in the kitchen. EI #5 replied, all the time; when changing gloves and when stopping one thing and starting another. EI #5 was asked if she washed her hands when she took off her gloves and got individual bowls of soup ready and lifted the lid to the trash can and discarded the trash. EI #5 replied, no. EI #5 was asked if she washed her hands when she left the tray line for an individual bowl then returned to the tray line and continued plating food. EI #5 replied, no. EI #5 was asked what was the harm in touching the trash can lid and other items in the kitchen without washing her hands. EI #5 replied, she could pass germs to residents from the trash can to the food. EI #5 was asked what was the harm in not washing her hands when she removed her gloves. EI #5 replied, she could pass germs and could make residents sick. On 6/20/19 at 10:05 AM, an interview was conducted with EI #4, DM. EI #4 was asked what was the policy regarding when to wash hands while in the kitchen. EI #4 replied, wash hands when staff come in and when staff touch anything. EI #4 was asked when should staff wash their hands while in the kitchen. EI #4 replied they should wash their hands all the time. EI #4 was asked if it would be acceptable for staff to touch a trash can lid then go touch the deep fryer without their washing hands. EI #4 replied, no. EI #4 was asked if it would be acceptable for trayline staff to leave the trayline to get a bowl and gloves, then return to the trayline without washing their hands. EI #4 replied, no anytime they (staff) change a task, they should wash their hands and anytime they remove their gloves they should wash their hands. EI #4 was asked what would the risks be in the staff not washing their hands when changing tasks and removing gloves while working in the kitchen. EI #4 replied, there could be germs on their hands that could get to the food and contaminate it.

Based on observations, interviews and medical record review, the facility failed to ensure nebulizer treatment masks were placed in Ziploc plastic bags and not left on the resident's bed or on the resident's bedside table. This affected Resident Identifier (RI) #10 and #37, two of six residents observed who received breathing treatments. Findings Include: 1) RI #10 was re-admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A physician order [REDACTED]. On 06/17/19 at 3:38 PM, RI #10 was observed resting in a wheelchair watching television. Also observed was a breathing treatment machine (nebulizer) sitting behind RI #10 on his/her bed with the treatment mask beside it on the bed. The empty Ziploc bag was also on the bed. On 06/17/19 at 4:34 PM, an interview was conducted with Employee Identifier (EI) #6, Registered Nurse (RN)/Unit Manager. EI #6 was asked, what did she see on RI #10's bed. EI #6 replied, nebulizer, treatment mask and a Ziploc bag. EI #6 was asked, where was the mask lying. EI #6 replied, on the bed. EI #6 was asked, where was the Ziploc bag. EI #6 replied, same (on the bed). EI #6 was asked, should the mask be lying on the bed beside the Ziploc bag. EI #6 replied, no. EI #6 was asked, who was responsible for placing the mask in the Ziploc bag. EI #6 replied, the cart nurse. EI #6 was asked, what was the potential harm in not keeping mask in a Ziploc bag. EI #6 replied, bacteria and infection. 2) RI #37 was re-admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A physician order [REDACTED]. On 06/17/19 at 3:45 PM, EI #37 was resting in bed with his/her eyes open. Also observed was a breathing treatment machine on the bedside table with the breathing treatment mask lying beside the machine, not in a Ziploc plastic bag. The plastic Ziploc bag was lying on top of the mask and the nebulizer machine. On 06/17/19 at 4:44 PM, an interview was conducted with EI #6. EI #6 was asked, what did she see on RI #37's bedside table. EI #6 replied, nebulizer treatment machine, treatment mask and Ziploc bag. EI #6 was asked, where should the mask be. EI #6 replied, in the Ziploc bag. EI #6 was asked, where was the Ziploc bag. EI #6 replied, on the bedside table lying on top of the mask and nebulizer. EI #6 was asked, was there anything in the bag. EI #6 replied, no. EI #6 was asked, should the mask be lying on the bedside table not covered. EI #6 replied, no EI # 6 was asked, who was responsible for placing the mask in the Ziploc bag. EI #6 replied, the cart nurse. EI #6 was asked, why was the treatment mask not in the Ziploc bag. EI #6 replied, she did not know. It was an oversight. EI #6 was asked, what was the potential harm of not keeping the mask in the Ziploc bag between treatments. EI #6 replied, contamination and bacteria.

Based on observations, interviews, medical record reviews, and a facility policy titled, Policy: Isolation Policy the facility failed to ensure staff did not enter into Resident Identifier (RI) #108's room before putting on a gown and gloves. RI #108 was a resident on strict contact isolation precautions. This was observed on 6/18/19. This affected RI #108, one of five residents sampled who were on isolation precautions. Findings include: A review of facility policy titled, Policy: Isolation Policy with a revised date of 11/21/13. revealed: . 2. RESPONSIBILITY . Employees at all levels should be knowledgeable in the use of appropriate isolation techniques .9. Contact Precautions .B. Gloves and Handwashing .wear gloves .when .handling items potentially contaminated .C. Gown .Wear a gown .when entering the room of a resident on contact precautions. RI #108 was admitted to the facility on [DATE], with a primary [DIAGNOSES REDACTED]. A review of RI #108's physician orders [REDACTED].ISOLATION-STRICT CONTACT IN A PRIVATE ROOM . On 6/18/19 at 9:51 AM, the surveyor observed signage on RI #108's door indicating Contact Precautions. RI #108 was in a private room. On 6/18/19 at 12:41, PM EI (Employee Identifier) #1, CNA (Certified Nursing Assistant) was observed entering the room of RI #108 without putting on personal protective equipment (PPE) (Gown and gloves). EI #1 walked though RI #108's room, and touched handles on the bathroom sink with her bare hands prior to washing her hands. On 6/19/19 at 10:36 AM, a telephone interview was conducted with EI #1. EI #1 was asked, when should anyone enter a contact isolation room without wearing PPE. EI #1 replied, never. EI #1 was asked, who was responsible for wearing PPE. EI #1 replied, anyone entering the room. EI #1 was asked, where should PPE be put on. EI #1 replied, outside the threshold of the door. EI #1 was asked, when delivering trays on 6/18/19, did you enter RI #108's room and touch the sink handles prior to putting on PPE. EI #1 replied, she thought she remembered doing that. EI #1 was asked, when should staff enter a resident's room on contact precautions and touch handles of the sink without PPE. EI #1 replied, they should not. On 6/19/19 at 9:27 AM, an interview was conducted with EI #2, RN (Registered Nurse), Infection Control Nurse. EI #2 was asked, what was the policy and procedure regarding putting on PPE for contact isolation. EI #2 replied, If shoe covers are needed, they are applied first. EI #2 said next, the gown was donned, and gloves were put on last. EI #2 was asked, who should put on PPE. EI #2 replied, anyone entering a contact isolation room should wear PPE. EI #2 was asked, where should PPE be put on. EI #2 replied, outside threshold of the door. EI #2 was asked, when should staff enter into a contact isolation room without putting on PPE. EI #2 replied, never. EI #2 was asked, what was the harm in entering a contact isolation room without PPE and then touching handles to sink with bare hands. EI #2 replied, there was a risk of contamination.

Based on record reviews, interviews, review of a job description and review of the Care Planning Policy and Procedure, the facility failed to ensure comprehensive care plans were developed for 3 residents within the required time after their admission into the facility. This affected RI (Resident Identifier) #s 74, 75 and 78, three of thirty-one care plans that were review. Findings Include: The facility's policy titled, . Job Description MDS (Minimum Data Set)/CP (Care Plan) Coordinator, form was reviewed. The general purpose of the job indicated, The primary purpose of this job title is to plan, organize, develop, and direct the MDS schedules . in accordance with current/applicable Federal, State . Guidelines, and Regulations . Responsibilities /Duties: 3- Understand and follow the rules, regulations, and guidelines of the RAI (Resident Assessment Instrument) process. The facility's Care Planning Policy and Procedure, revised date 02/20/18, revealed Policy: The care plan is a guide for all staff on a course of action that will attain or maintain a resident's highest practicable level of well being . The procedure included, . 3. The interdisciplinary team will use the RAI process . and complete an interdisciplinary care plan within 7 days of the completion of the Care Area Assessment Protocol (CAAs). RI #74 was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. The facility provided an admission MDS with an assessment reference date (ARD) of 05/24/18. When the surveyor requested the comprehensive care plan, the facility could not provide one. RI #75 was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. The facility provided an admission MDS with an ARD of 05/11/18. When the surveyor requested the comprehensive care plan, the facility could not provide one. RI #78 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The facility provided an admission MDS with an ARD of 03/07/2018 and a quarterly MDS with an ARD of 06/03/18. When the surveyor requested the comprehensive care plan, the facility could not provide one. On 07/12/18 at 03:45 PM, an interview was conducted with Employee Identifier (EI) #2, the Care Plan Coordinator. EI #2 was asked when were comprehensive care plans supposed to be developed. She replied, at least by day 21, their policy was seven days after the CAA was completed. EI #2 was asked who was responsible for ensuring care plans were developed. She said she signed for completion and two other RNs (Registered Nurse) sign also. EI #2 was asked what was the facility's policy regarding the development of comprehensive, person-centered care plans. She reported they were supposed to develop one for everyone. The nursing provided the care plans for diagnoses, medications, ADLs (activity of daily living) and resident preferences and activity choices. EI #2 also reported the care plans had to be person centered. The Care Plan Coordinator was asked when was RI #74 was admitted to the facility. She replied, 5/17/18. When asked when should the comprehensive care plan have been developed, EI #2 replied, on 6/6/18. When asked why it not done, EI #2 reported she would say that they had gotten behind and just did not get EI#74's completed by that time. EI #2 was then asked when was RI #78 admitted to the facility. She replied, 02/26/18. She was asked when should RI #78's comprehensive care plan have been developed. EI #2 answered, 3/16/18. When asked how many assessments had been done for RI #78, EI #2, replied the resident had had two. When asked when the second one was done, what was done during resident's care review. EI #2 reported they updated the 48 hour (of admission to the facility) care plan and added what they needed to. When asked why was the comprehensive care plan not done, EI #2 replied, they got behind. EI #2 was asked when was resident RI #75 admitted to the facility. She replied, 5/4/18. When asked when should RI #75's comprehensive care plan have been developed, she replied, 5/24/18. When asked why it was not done, she replied they got behind and did not get RI #75's completed on time. EI #2 was asked what the concern was for not developing a comprehensive plan of care timely. She reported they do not have all the problems identified they would need to have addressed, including an in depth ADL care plan. On 07/12/18 at 4:04 PM, an interview with the Director of Nursing (DON), EI #1 was conducted. She was asked when were comprehensive care plans supposed to be developed. EI #1 replied, by day 21. When asked who was responsible for ensuring comprehensive care plans were developed, EI #1 replied, the care plan team and coordinators. EI #1 was asked what was the facility's policy regarding the development of comprehensive, person-centered care plans. She reported, developing them within 21 days. When asked what was the concern for not developing a comprehensive plan of care, EI #1 replied, possibly not providing the best care possible. EI #1 was asked what was the concern of a comprehensive plan of care not being developed after 2 resident assessments had been completed. EI #1 replied there was a potential for not providing optimal care or be fully aware of the residents needs.

Based on observation, record review, interviews and a facility policy titled, Inservice material for Handwashing, the facility failed to ensure a Certified Nursing Assistant (CNA) washed his hands or changed his gloves after providing incontinent care and before applying a barrier cream to Resident Identifier (RI) #5. This affected one of one residents observed for incontinent care. Findings Include: A facility policy titled, Inservice material for Handwashing with a revised date of of 2/2010 revealed: . 1. Indications for handwashing and hand antisepsis . C. Change gloves during patient care if moving from a contaminated body site to a clean body site. F. Wash hands after contact with body fluids or excretions, mucous membranes . G. It may be necessary to wash hands between tasks and procedures on the same resident to prevent cross contamination . RI #5 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A 14 day scheduled Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/30/2017, revealed RI #5 required extensive assistance with personal hygiene and was frequently incontinent of bowel and bladder. On 6/8/2017 at 9:30 AM, an observation of incontinent care was observed on RI #5. After completing the incontinent care, Employee Identifier (EI) #2, CNA, failed to change gloves or wash his hands before applying a barrier cream to RI #5's buttock area. On 6/8/2017 at 2:10 PM an interview was conducted with EI #2. EI #2 was asked what did the facility policy indicate about when hands should be washed when performing incontinent care. EI #2 said, when going from dirty to clean. EI #2 was asked when performing care for RI #5 if he changed gloves and washed his hands after performing incontinent care and before applying the barrier cream to the resident's buttocks. EI #2 said, no. EI #2 was asked why did he not change his gloves or wash his hands after performing incontinent care and before applying the barrier cream to the RI #5's buttocks. EI #2 said, a step was forgotten. EI #2 was asked what was the potential harm to a resident when gloves were not changed and hands were not washed prior to applying the barrier cream. EI #2 said spread of bacteria. On 6/8/2017 at 2:40 PM, an interview was conducted with EI #1, Infection Control Nurse. EI #1 was asked at what point should staff wash hands during perineal care. EI #1 responded: I have to think about it . definitely before starting, after removing soiled items, after I get through with the front genitals before I go to the back, and wash hands and change gloves before I put moisture barrier on and when I get done.

Based on observations, record reviews, and interviews, the facility failed to ensure: (1) Two Certified Nursing Assistants (CNAs) washed their hands and changed their gloves after cleaning bowel movement (BM) and urine and before touching clean items during incontinent care of Resident Identifier(RI) #9 and RI #10 on 5/3/16 and 5/4/16. This affected two of three sampled residents who were observed during incontinent care. (2) A licensed staff member washed her hands before preparing and administering medication by [DEVICE] to RI #8 on 5/3/16. This affected one of one sampled resident observed during medication administration who received medication by (peg) percutaneous endoscopic gastrostomy tube. (3) A CNA did not touch RI #14's chicken at the 5/4/16 lunch meal with her bare fingers. This affected one of 14 sampled residents observed for meals. Findings include: (1) A facility policy titled, Incontinent Care .Using Disposable Wipes, with a revision date of 12/2012, revealed: OBJECTIVE: To cleanse the perineum, prevent infection and odors, and prevent skin breakdown . PROCEDURE: . 2. Wash hands. Apply gloves. 5. Male- . Begin by cleaning the urethra and moving outward . while using a clean area of the disposable . wipe or a new wipe for each stroke.clean the penis, scrotum, and inner thighs . 6.Clean the buttocks and anal area, moving upwards toward the back . 8. Removed any wet incontinent pad. 9. Removed and dispose of gloves, wash hands. Apply clean gloves. 10. Apply new dry incontinent pad under resident. A facility policy regarding the use of gloves with a revised date of 11/12 revealed: PROCEDURE: .3. Change gloves during patient care if moving from a contaminated body site to a clean body site. 4. e) during all cleaning . body fluids, . 9. Hand washing is necessary when gloves are removed. A facility policy titled, Handwashing Policy and Procedure, with a revised date of 2/10, indicated: Procedure: . 3. Wash hands before and after performing invasive procedures . assisting a resident with personal care . immediately after gloves are removed .performing personal hygiene, to avoid transfer of microorganisms to other . environments. 5.wash hands between tasks and procedures on the same resident to prevent cross contamination of different body sites. RI #10 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #10's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/2/16, indicated RI #10 was impaired of upper extremities, was frequently incontinent of bladder and required extensive assist toilet use and personal hygiene. A review of RI #10's care plan, with a problem onset date of 10/26/15, indicated the resident was occasionally incontinent of bladder. Approaches included: Perineal care after each incontinent episode . Change incontinent briefs every (q) 2 hours (h) and as needed (prn) . On 5/3/16 at 3:51 PM, incontinent care was observed on RI #10. During the incontinent care, Employee Identifier (EI) #3, CNA, was observed wiping the right side of the resident from the pubis downward to the scrotum twice with the same area of the disposable wipe. The wipe was then folded and the left side of the resident was wiped from the pubis to the scrotum without obtaining a new wipe or folding the wipe. A new wipe was obtained and EI #3, lifted RI #10's penis with the wipe and proceeded to wipe up the shaft of the penis twice. The wipe was not folded nor was a new wipe obtained. EI #3 then wiped the head of the penis in a circular motion, folded the wipe and wiped down the penis to the scrotum. The resident was rolled to the right side. EI #3 wiped the resident's rectal area three times, from top to bottom, bottom to top and bottom to top again without folding or obtaining a new wipe. A clean wipe was obtained and EI #3, again wiped bottom to top, top to bottom, folded the wipe and wiped bottom to top. At this time, BM was observed on the wipe. EI #3 removed the urine soiled brief from RI #10 and placed a clean brief under the resident. EI #3 reached into the resident's bedside drawer and retrieved barrier cream, rubbed the cream onto the resident's buttocks, and placed the cream back into the drawer. The resident was then rolled supine on the back and the clean brief was secured. Throughout the entire incontinent care of RI #10, EI #3 did not wash her hands or change her gloves. On 5/5/16 at 2:10 PM, an interview was conducted with EI #3, CNA. EI #3 was asked what did the facility policy indicate regarding performing incontinent care on a male resident. EI #3 said on a male resident, wipe around the top of the penis then wipe down. EI #3 was asked what did she not do when performing incontinent care on the resident. EI #3 said she failed to get a new wipe. EI #3 was asked if it was an appropriate practice to wipe back over the same area with the same wipe when performing incontinent care. EI #3 said no. EI #3 was asked when should gloves be removed, hands washed and new gloves be applied during incontinent care. EI #3 said after cleaning BM. EI #3 was asked when did she wash her hands. EI #3 said when she got through. EI #3 was asked if she had washed her hands prior to going into the bedside table drawer and touching clean items. EI #3 said no. EI #3 was asked should she have washed her hands and changed her gloves prior to going into the resident's bedside table. EI #3 said yes. EI #3 was asked what did the facility policy indicate about changing gloves and washing hands during incontinent care. EI #3 said when going from dirty to clean. EI #3 was asked what was the potential harm to the resident when hands are not washed and gloves changed during incontinent care. EI #3 said breakdown and cross contamination. RI #9 was readmitted to the facility on [DATE]. A quarterly MDS with an ARD of 3/10/16 indicated RI #9 was always incontinent of bladder and bowel and needed extensive assistance for personal hygiene. A review of RI #9's care plan, with a problem onset date of 10/6/15, indicated RI #9 was, FUNCTIONALLY INCONTINENT OF BOWEL AND BLADDER . Approaches . CHECK Q2H (every two hours) AND CHANGE PER INCONTINENT EPISODES AND PROVIDED PROMPT INCONTINENT CARE . On 5/4/16 at 3:50 PM, incontinent care was observed for RI #9. The incontinent care was performed by EI #4, CNA. Upon entering the room, EI #4 put on gloves and failed to wash her hands prior to performing incontinent care. After EI #4 separated RI #9's labia and was wiped down. A clean underpad and brief was placed under the resident. A barrier ointment was applied to the reddened area on the resident's buttocks. EI #4 failed to remove her gloves and wash her hands after cleaning the resident's labia and before applying barrier ointment and before touching a clean underpad and brief. On 5/5/16 at 2:15 PM, an interview was conducted with EI #4. EI #4 was asked what should be done upon entering a resident's room to perform incontinent care. EI #4 said wash hands. EI #4 was asked if she had washed her hands prior to donning her gloves. EI #4 said no. EI #4 was asked what did she not do prior to applying barrier ointment and placing a clean underpad brief under the resident. EI #4 said she should have taken off her gloves and washed her hands and put on new gloves. EI #3 was asked what was the potential harm to the resident. EI #4 said risk of infection and cross contamination. A review of a facility policy titled, Medication Administration Procedures Enteral Tube Administration, with a date of 01/12, revealed: Procedures . 3. Wash hands and prepare medications . 2) RI #8 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #8's most recent Quarterly MDS with an ARD of 03/02/2016 revealed the resident had severely impaired cognitive skills for daily decision making. The MDS also revealed the resident had a feeding tube. On 5/3/2016 at 4:33 PM, EI #1, LPN (Licensed Practical Nurse), was observed preparing medications for RI #8. EI #1 had just previously administered medications to another resident and did not wash her hands after finishing with that resident or before beginning to prepare medications for RI #8. EI #1 prepared the medications and administered them to RI #8 with gloved hands. EI #1 did not wash her hands before donning the gloves. On 5/4/2016 at 3:19 PM, an interview was conducted with EI #1. EI #1 was asked if she washed her hands in between giving medications to the other resident and RI #8. EI #1 said she did not. EI #1 was asked if she should have washed her hands in between the two residents. EI #1 said absolutely. EI #1 was asked why she did not wash her hands in between the two residents. EI #1 said she forgot. EI #1 was asked if she washed her hands before preparing and administering the medication for RI #8 via (by) PEG tube. EI #1 said no. EI #1 was asked why she did not wash her hands. EI #1 said she forgot. EI #1 was asked what the potential harm was in not washing her hands in between preparing medication to two residents. EI #1 said cross contamination and infection control. EI #1 was asked what the potential harm was in not washing her hands before administering medication via PEG tube. EI #1 said infection control. 3) RI #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 05/04/16 at 12:35 PM, during the lunch meal observation, EI #7, CNA, was observed setting up RI #14's lunch tray. EI #7 picked up the chicken breast with her bare fingers to pull the meat off the bone. On 05/04/16 at 12:37 PM, EI #7 was asked if she pulled RI #14's meat off the chicken breast with ungloved fingers. EI #7 replied, yes. EI #7 was asked what should she do if she had to touch a resident's food. EI #7 replied, put on gloves. EI #7 was asked what could be the potential harm. EI #7 replied, contaminating it. On 5/5/2016 at 1:59 PM, an interview was conducted with EI #2, RN (Registered Nurse)/Infection Control Nurse. EI #2 was asked how infections were prevented in the facility. EI #2 said hand washing. EI #2 was asked how infections were controlled in the facility. EI #2 said they would shut the side of the unit down, in-service the staff, contact the sponsors and they would keep the staff on the same assignment until the unit was cleared. EI #2 was asked if direct care staff were washing their hands and changing gloves according to facility protocol. EI #2 said they did have episodes when staff did not and she stopped them and went over the policy. EI #2 was asked how she monitored direct care staff to ensure they were washing their hands and changing gloves according to facility protocol. EI #2 said she was on the hall a lot and she did random hand washing and perineal care checks. EI #2 was asked how CNAs should handle a resident's food. EI #2 said they should never handle the food and if they needed to cut the food, there was a butter knife and fork to use. EI #2 was asked what the potential harm was if a CNA touched food with their bare hands and the resident ate it. EI #2 said they just contaminated it. EI #2 was asked what the potential harm was if a CNA cleaned urine and bowel movement from a resident and did not change gloves or wash hands and touched the clean brief, cream and bedside drawers. EI #2 said they just contaminated everything. EI #2 was asked when should hands be washed during medication pass. EI #2 said anytime gloves were needed to administer medications, hands should be washed. EI #2 said she tried to wash her hands after each resident because when entering a room, staff did not know what they were touching. EI #2 was asked what the potential harm was in not washing hands after giving medication to one resident, then prepare and administer medication to another resident via PEG tube without washing their hands. EI#2 said cross contamination.

Based on observation, record review, and interview, the facility failed to ensure a licensed staff member did not leave the MAR (Medication Administration Record) uncovered in plain view of the public on top of the medication cart during medication administration on 5/3/2016. This affected one of six nurses observed during medication administration. Findings Include: A review of the facility's Resident Handbook with a date of October 2015 revealed: .II. YOUR RIGHTS AS A RESIDENT . 14. Medical Records. Information contained in your medical records is confidential and will not be disclosed to unauthorized persons . 19. Personal Privacy. You have the right to personal privacy, including privacy in .medical treatment . On 5/3/2016 at 4:30 PM, EI (Employee Identifier) #1 was observed during medication administration. EI #1 prepared medication and entered a resident's room leaving the MAR uncovered on top of the medication cart in plain view of the public. On 5/4/2016 at 3:15 PM, an interview was conducted with EI #1. EI #1 was asked how she found the MAR on top of the medication cart when she came out of the resident's room. EI #1 said she did not close it. EI #1 was asked if she covered or closed the MAR to protect privacy when she went into the resident's room. EI #1 said not that particular time, she did not. EI #1 was asked if she should have covered the MAR and protected privacy when she went into the resident's room. EI #1 said absolutely. EI#1 was asked why she did not provide privacy for the MAR when she went into the resident's room. EI #1 said she must have forgotten. EI #1 was asked what the potential harm was in not covering the MAR when going into the resident's room and leaving the MAR open on top of the medication cart. EI #1 said it was a HIPAA (Health Insurance Portability and Accountability Act) violation because people could read the resident information and know what medications the resident was on and the diagnoses.

Based on observations, interview and record review the facility failed to ensure the commode seat was not loose in Room Locators's (RL) #2 and #4, and the anchor bolts securing the commode were not rusted in RL #1, 5, #6 and #7. This affected 6 rooms on Unit A. Findings Include: The facility job description titled, Director of Maintenance Job Description, not dated, revealed: .General Purpose: To plan, organize and direct the overall operation of the department in accordance with current federal, state and local standards, ensuring that the facility is maintained in a safe, comfortable condition . Essential Job Functions: A. Maintenance Functions Duties: Plan, develop and direct the Maintenance Department, .assist in establishing and maintaining a preventive maintenance program; . A facility form titled, Preventative Maintenance Inspection Checklist, with a section for the checking of commodes was left blank. During the initial tour on 05/03/16 beginning at 10:35 AM, the following were observed: RL #1 - the anchor bolts on both sides of the commode were rusted. RL #2 - the commode lid was loose on the right side. RL #4 - the commode lid was loose. RL #5 - the anchor bolts on both sides of the commode were rusted and the seat was rusted at the lid joints. RL #6 - the anchor bolts on both sides of the commode were rusted. RL #7 - the anchor bolts on both sides of the commode were rusted. On 05/05/16 at 2:30 PM, EI (Employee Identifier) #6, Maintenance Director, was asked who was responsible for the anchor bolts on the commodes. EI #6 replied, maintenance. EI #6 was asked how often were the anchor bolts checked or cleaned. EI #6 replied once a month.

Based on record review, observation, and interview, the facility failed to ensure a licensed staff member locked the treatment cart before entering a resident's room and closing the door on 5/4/2016. This affected one of seven nurses observed who administered treatments and medications during the survey. Findings Include: A review of a facility policy titled, Medication Administration Medication Administration-General Guidelines with a date of 01/2012 revealed: .Procedures . 11. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. On 5/4/2016 at 3:44 PM, EI (Employee Identifier) #5, RN (Registered Nurse) Supervisor, was observed assisting with wound care. EI #5 was standing at the treatment cart and entered the resident's room leaving the treatment cart unlocked and unattended. On 5/5/2016 at 1:20 PM, an interview was conducted with EI #5. EI #5 was asked how she found the treatment cart when she exited the resident's room to retrieve supplies from the treatment cart. EI #5 said she found it unlocked. EI #5 was asked how she should have found the treatment cart. EI #5 said it should have been locked. EI #5 was asked why the treatment cart was not locked before she entered the resident's room. EI #5 said it should have been locked as soon as she stepped away from it. EI #5 was asked what the potential harm was in leaving the treatment cart unlocked when she entered a resident's room and closed the door. EI #5 said a resident could have gone in the cart and pulled things out and ingested them.

Based on observations, record reviews, and interviews, the facility failed to ensure call lights were within residents' reach. This affected RI (Resident Identifier) #3 and RI #6, two of five residents sampled for call lights. Findings include: A review of the facility's undated policy titled, Call Light revealed, . 6. Place call light within reach. A review of a document titled, INSTRUCTORS GUIDE ORIENTATION FOR C.N.A.S (Certified Nursing Assistants) DAY ONE, revealed: . J. CALL LIGHT SYSTEM/BEDS . Call lights are to be within reach. A review of the medical record revealed RI #3 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #3's Annual MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 3/5/15, revealed a BIMS (Brief Interview for Mental Status) score of 11 out of 15 possible points. This score indicated RI #3 was moderately impaired for daily decision making skills. A review of RI #3's care plan, with a problem onset date of 04/07/2014, revealed, Extensive assist-self-care deficit related to physical limitations . Resident with a hx (history) [MEDICAL CONDITION] with left sided [MEDICAL CONDITION] . Approaches, Keep call light within easy reach and remind resident to use it . A review of RI #3's care plan, with a problem onset of 04/07/14, revealed, At risk for falls due to decreased mobility, R/T (related to) disease process. (L) (left) [MEDICAL CONDITION]. Approaches, Keep call lights within easy reach and remind to call for assistance. A review of RI #6's medical record revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #6's Admission MDS, with an ARD of 5/8/15, revealed a BIMS score of 6 out of 15 possible points. This score indicated RI #6 was severely impaired for daily decision making skills. A review of the care plan for RI #6, with a problem onset date of 08/11/2014, revealed, EXTENSIVE ASSIST WITH DAILY CARE RELATED TO DX (DIAGNOSIS) OF [MEDICAL CONDITION]. Approaches, Demonstrate the use of the call light and remind resident to call for assist. During initial tour of the facility on 06/09/2015 at 4:25 PM, an observation was made of RI #3's call light. The call light was on the seat of a chair which was located on the right side of the bed, with a pillow over it. There was also a sign on the wall above the resident's head which read, Please place my call light on my bedside table with my water on my right side within reach Thank You. The resident stated the resident was able to use the call light when it was within reach. The call light must be on the right side due to left [MEDICAL CONDITION]. An observation was made on 06/09/15 at 5:34 PM. RI #6 was in bed with eyes open and then closed them back. The call light was on the floor near the head of the bed. An observation was made on 06/10/15 at 4:32 AM. RI #6 was asleep in bed with the call light on the floor out of reach. An interview was conducted on 06/11/2015 at 10:30 AM with EI (Employee Identifier) #1, a CNA (Certified Nursing Assistant.) EI #1 was asked what was the purpose of call lights. EI #1 stated the call lights were used in case the residents needed something. EI #1 was asked whose responsibility it was to answer the call light. EI #1 replied, anybody. When asked where the call light should be located, EI #1 stated within the resident's reach. EI #1 was asked if she had been scheduled to care for RI #3 on Tuesday, 06/09/2015 and she said yes. EI #1 was asked if RI #3 was able to use the call light. EI #1 stated RI #3 was able to use the call light as long as it was on the bedside table within reach. An interview was conducted on 06/11/2015 at 11:10 AM with EI #2, an RN (Registered Nurse.) EI #2 was asked what was the purpose of call lights. EI #2 stated it was for the residents to let the staff know when they needed something. EI #2 was asked whose responsibility it was to answer the call light. EI #2 replied that everyone could answer call lights. When asked where the call light should be located, EI #2 stated within easy reach of the resident. EI #2 was asked if she had been scheduled to care for RI #3 on 06/09/2015, and she said yes. EI #2 was asked if RI #3 was able to use the call light and she stated yes. An interview was conducted on 06/11/15 at 11:30 AM with EI #7, a CNA. EI #7 was asked if she had been assigned to care for RI #6 on 06/09/15. EI #7 stated yes. EI #7 was asked what shift and she responded 10:00 AM to 6:00 PM. EI #7 was asked if RI #6 could use the call light. EI #7 stated, Yes ma'am. EI #7 was asked how often a call light should be checked to verify it is within the resident's reach. EI #7 stated, Every two hours when doing rounds. EI #7 was asked where the call light should be located. EI #7 stated, At reach all times, we have a pin thing to use. An interview was conducted on 06/11/15 at 11:44 AM with EI #8, a CNA. EI #8 was asked if she had been assigned to care for RI #6 on 06/09/15. EI #8 stated, I came in at 4:00 AM on 06/10/15. When asked what shift, EI #8 stated 4:00 AM. EI #8 was asked if RI #6 could use the call light. EI #8 stated, Yes ma'am. EI #8 was asked how often a call light should be checked to verify it is within the resident's reach. EI #8 stated, When we make rounds every two hours. That morning it would have been around 5:00 AM. EI #8 was asked where the call light should be located. EI #8 stated, In reach. EI #8 was asked what the potential concern would be of RI #6's call light being located on the floor under the head of the bed on 06/09/15 at 5:34 PM and on 06/10/15 at 4:32 AM. EI #8 stated that it would not be within reach for RI #6 to use. An interview was conducted on 06/11/2015 at 3:20 PM with EI #3, a CNA. EI #3 was asked what was the purpose of call lights. EI #3 stated, so the resident can notify staff if they need assistance. EI #3 was asked who was responsible for answering call lights. EI #3 replied all staff. When asked where the call light should be located, EI #3 stated within reach of the resident. EI #3 was asked if she had been scheduled to care for RI #3 on Tuesday, 06/09/2015, and she said yes. EI #3 was asked if RI #3 was able to use the call light and she said yes. An interview was conducted on 06/11/2015 at 5:18 PM with EI #4, RN (Registered Nurse)/DON (Director of Nursing.) EI #4 was asked what was the purpose of call lights. EI #4 stated so the residents can notify staff if they need assistance. EI #4 was asked who was responsible for answering call lights. EI #4 replied all staff in the facility. When asked where the call light should be located, EI #4 stated within reach of the resident. EI #4 was asked the potential negative effect on the resident if the call light was not within reach. EI #4 replied their need might not be met.

Based on observations, record reviews, and interviews, the facility failed to ensure two resident's care plans were followed regarding call lights being within reach. This affected RI (Resident Identifier) #3 and RI #6, two of five residents sampled for care plans. Findings include: An untitled facility document titled, INSTRUCTOR'S GUIDE ORIENTATION FOR C.N.A.S DAY ONE . G.Explain that all care given to each resident should be given per their care plan.T. Discuss and give examples of following the plan of care. Discuss and show the location of the residents' care plans and the facility poliicy of review staff members' adherence to following each residen't plan of care. Discuss F246 and F312, accomodation of needs and assistance with ADLs (Activities of Daily Living), based on each residents individualized needs. A review of the medical record revealed RI #3 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #3's Annual MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 03/05/2015, revealed a BIMS (Brief Interview for Mental Status) score of 11 out of 15 possible points. This score indicated RI #3 was moderately impaired for daily decision making skills. A review of the care plan for RI #3, with a problem onset date of 04/07/2014, revealed, Extensive assist-self-care deficit related to physical limitations.Resident with a hx (history) [MEDICAL CONDITION] with left sided [MEDICAL CONDITION] . Approaches, Keep call light within easy reach and remind resident to use it . A review of the care plan for RI #3, with a problem onset of 04/07/14, revealed, At risk for falls due to decreased mobility, R/T (related to) disease process. (L) (left) [MEDICAL CONDITION]. Approaches, Keep call lights within easy reach and remind to call for assistance. A review of the medical record revealed RI #6 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #6's Admission MDS, with an ARD of 05/08/2015, revealed a BIMS score of 6 out of a possible 15. This score indicated RI #6 was severely impaired for daily decision making skills. A review of the care plan for RI #6, with a problem onset date of 08/11/2014, revealed, EXTENSIVE ASSIST WITH DAILY CARE RELATED TO DX (DIAGNOSIS) OF [MEDICAL CONDITION]. Approaches, Demonstrate the use of the call light and remind resident to call for assist. An observation was made during the initial tour of the facility on 06/09/15 at 4:25 PM. RI #3's call light was on the seat of a chair which was located on the right side of the resident's bed. There was a pillow on top of the call light. There was also a sign on the wall above the resident's head which read, Please place my call light on my bedside table with my water on my right side within reach Thank You. RI #3 stated the resident was able to use the call light when it is within reach. The resident's daughters made the sign. The call light must be on the right side due to left [MEDICAL CONDITION]. An observation was made on 06/09/15 at 5:34 PM. EI #6 was in bed with eyes open and then closed them back. The call light was on the floor near the head of the bed. An observation was made on 06/10/15 at 4:32 AM. RI #6 was asleep in bed with the call light on the floor out of reach. An interview was conducted on 06/10/15 at 2:14 PM with EI (Employee Identifier) #6, a CNA (Certified Nursing Assistant). EI #6 was asked where care plans were kept. EI #6 stated, In the break room cart. EI #6 was asked why it was important to follow them. EI #6 stated, So you can learn and find out more about them (patient). EI #6 was asked what could be the potential harm of not keeping the call light within the resident's reach reach as care planned. EI #6 stated, Resident would not be able to get in touch with you if they needed anything. An interview was conducted on 06/11/15 at 9:46 AM with EI #1, a CNA. EI #1 was asked where the care plans were kept and she stated the care plans were kept in the break room. EI #1 was asked why it was important to follow the care plans. EI #1 stated the care plans were to make sure staff knew everything about the residents. EI #1 was asked what could be the potential harm of not keeping the call light within reach as care planned. EI #1 stated something might happen and the residents might have an accident. An interview was conducted on 06/11/15 at 1:17 PM with EI #2, an RN (Registered Nurse). EI #2 was asked where the care plans were kept. EI #2 stated, In binder in the break room on each hall. EI #2 was asked why it was important to follow the care plan. EI#2 stated, Tool to take care of your patient, to be personal for each patient.

Based on observation, record reviews, and interviews, the facility failed to ensure that privacy and dignity were maintained during personal care by ensuring the door, blinds, and privacy curtain did not remain open for RI (Resident Identifier) #13 while receiving personal care. This affected RI #13, one of six sampled residents for care. Findings include: A review of the facility's, "Resident Handbook," dated November 2013, revealed, "... #19 Personal Privacy. You have the right to personal privacy, including privacy in accommodations, medical treatment, written and telephone communications, personal care, ..." A review of the facility document titled, "A Matter of RIGHTS, A Guide to Your Rights and Responsibilities as a Resident," undated, revealed a section sub-titled, "Privacy, Confidentiality and HIPAA (Health Insurance Portability and Accountability Act). Your Right to privacy and confidentially is as important to you as it is to any other person. You have the right to: ...have other people respect your personal privacy during telephone calls and personal visits, as you receive care and in connection with written communications; ..." A review of the medical record revealed RI #13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #13's MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 03/05/2014, revealed the following: A BIMS (Brief Interview for Mental Status) score of three (3), indicating severe cognitive impairment. RI #13 was assessed as needing extensive assistance with all ADL's (Activities of Daily Living). Also, RI #13 was incontinent of bowel and bladder. On 06/11/2014 at 9:10 AM, the surveyor observed two CNA's (Certified Nursing Assistants) enter RI #13's room to perform an incontinence check. The door was observed not shut all the way. The privacy curtain was only closed half way and the other resident in the room was able to watch in the mirror, the care being provided for RI #13. Also, the blinds at RI #13's bedside were left open while care was provided. An interview was conducted with EI (Employee Identifier) #1, a CNA, on 6/12/2014 at 8:50 AM. EI #1 was asked, what was the policy regarding maintaining resident privacy and dignity. EI #1 replied knock on the door, tell the resident what they were going to do, and give them choices. EI #1 was asked what she was supposed to do upon entering a resident's room. EI #1 replied knock on the door. EI #1 was asked what measures were taken to provide a resident with privacy during incontinence care. EI #1 replied pull the curtains. EI #1 was asked if there were windows and doors near a resident where she will be providing care, what should be done. EI #1 replied close the blinds and curtain. EI #1 was asked if there was an obstacle preventing her from shutting the resident's door, what should she do. EI #1 replied she would see what was in the way of the door and call maintenance if it would not shut. An interview was conducted with EI #2, a CNA, on 6/12/2014 at 9:00 AM. EI #2 was asked about the policy concerning resident privacy and dignity. She answered she would knock on the door before entering, pull the curtain all the way around so they can't see through. EI #2 was asked what measures were taken to preserve resident's privacy during incontinence care. She answered curtains. EI #2 was asked if windows/doors were near a resident where care would be provided, what should she do before beginning. She answered close the blinds and the curtains. EI #2 was asked if there were obstacles preventing the door from being shut, what should she do. She answered move the object in the door. An interview was conducted with EI #3, a CNA, on 6/12/2014 at 9:16 AM. EI #3 was asked, what was the policy regarding maintaining resident privacy and dignity. EI #3 replied knock on the door, ask to come in, pull the curtain and give the resident privacy. EI #3 was asked what was she supposed to do upon entering a resident's room. EI #3 replied knock on the door. EI #3 was asked what measures were taken to provide a resident with privacy during incontinence care. EI #3 replied pull the curtains. EI #3 was asked if there were windows and doors near a resident where she would be providing care, what should be done. EI #3 replied make sure the blinds and the curtains were closed. EI #3 was asked if there was an obstacle preventing her from shutting the resident's door what should she do. EI #3 replied turn the chair. An interview was conducted with EI #5, an RN (Registered Nurse), on 6/12/2014 at 9:20 AM. EI #5 was asked what education was provided regarding privacy and dignity of residents. She answered that staff should knock before going into a room and wait until someone says come in. EI #5 was asked when staff was giving care what do they need to do to preserve the privacy of the resident. She answered pull curtains and close the blinds, make sure the door was closed, and let the room-mate know they were about to provide care. EI #5 was asked what should be done before entering a resident's room. She answered knock on the door and request to come in.

Based on an observation, interviews, and record reviews, the facility failed to ensure that: 1) During incontinence check for RI (Resident Identifier) #13, the CNA's (Certified Nursing Assistants) washed their hands prior to gloving and after removing gloves. This affected RI #13, one of six sampled residents observed for various care. 2) A staff member did not work and care for residents while exhibiting a frequent cough. This was observed on 1 of 3 CNA's while performing an incontinence check for RI #13. Findings include: 1) A review of the facility's policy and procedure titled, "Handwashing Policy and Procedure," with a revised date of 2/10, revealed, "Purpose: The use of appropriate handwashing and hand antisepsis practices are recommended to promote improved hand-hygiene practices and reduce the transmission of microorganisms to patient and personnel in the health-care setting. Procedure: 1. Wash hands after touching blood, body fluids, secretions, excretions, mucous membranes, non-intact skin and contaminated items, regardless of whether gloves are worn. ... 3. Wash hands before and after performing invasive procedures, entering and exiting isolation precaution settings, when feeding residents, when assisting a resident with personal care, when handling invasive devices, when changing a dressing, when handling soiled linens and equipment, immediately after gloves are removed, between resident contacts, and when otherwise indicated, such as performing personal hygiene, to avoid transfer of microorganisms to other residents or environments. ..." A review of RI #13's current medical record revealed, RI #13 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a quarterly Minimum Data Set, with an Assessment Reference Date of 03/05/2014, indicated RI #13 was coded as always incontinent of bowel and bladder function. An observation was made on 06/11/2014 at 9:10 A.M. EI (Employee Identifier) #1, CNA, and EI #2, a CNA, entered the room of RI #13 to check the resident for incontinence. EI #1 and EI #2 did not wash their hands before they donned their gloves. RI #13 was dry and was assisted with the urinal. EI #1 and EI #2 left the room without washing their hands. On 6/12/2014 at 9:00 A.M., an interview was conducted with EI #2. EI #2 was asked when were hands supposed to be washed when taking care of a resident. EI #2 stated that hands should be washed before and after taking care of a resident. EI #2 was asked what was the outcome of not washing hands between patients and after incontinence care. EI #2 stated that the outcome was passing germs. On 06/12/2014 at 9:36 A.M., an interview was conducted with EI #4, RN (Registered Nurse)/Infection Control Nurse. EI #4 was asked to explain when employees were supposed to wash their hands. EI #4 stated that hands need to be washed anytime personal care was performed, before they go in the room and if they glove it, wash it. EI #4 was asked what was the risk to residents if the employees did not wash their hands. EI #4 stated spreading infection. 2) A review of the facility's undated policy and procedure titled, "Policy for Employee Illness," revealed, "Policy: Any staff member who displays signs/symptoms of communicable or contagious illness will not be permitted to work until symptoms subside. Purpose: To protect the safety and health of our residents and employees. Procedure: Any employee who has contracted a communicable or Contagious illness shall report this fact to the Administrator immediately, as stated in the Employee Handbook. The administrator will confidentially evaluate the situation to determine whether the employee will be allowed to remain on duty in accordance with applicable federal and state laws and regulations. Addendum: Any employee who is in the work place exhibiting signs Or symptoms of illness, including but not limited to: persistent coughing, vomiting, diarrhea, and/or temp> 100.5, will need to leave the premises until the symptoms subside." An observation was made on 6/11/2014 at 9:10 A.M., EI #1 and EI #2 entered RI #13's room, but did not wash their hands, prior to donning their gloves. RI #13 was assisted with the urinal. EI #1 was observed coughing and stated, "I went to the Dr (doctor) yesterday and they gave me an antibiotic. I started it today." EI #1 and EI #2 left the room without washing their hands. On 6/12/2014 at 9:00 A.M., an interview was conducted with EI #2. EI #2 was asked, what the policy stated about employees coming to work sick. EI #2 stated, that policy stated a worker's temperature should be below 100.5 to be allowed to remain at work. EI #2 was asked how a staff member not washing their hands while they were sick or coughing could impair the health of the residents in the facility. EI #2 stated that they could pass it to the residents. On 6/12/2014 at 9:36 A.M., an interview was conducted with EI #4. EI #4 was asked what the facility's policy regarding employees coming to work sick, symptomatic, and coughing. EI #4 stated that if employees were symptomatic with productive cough, nausea, vomiting, diarrhea, have a fever of 100.5, they should call 2 hours before their shift. EI #4 was asked what impact could an ill employee have on residents in the facility. EI #4 stated they could pass it on to the residents.

Based on observation, interviews and record review, the facility failed to ensure incontinence care was provided in a manner to prevent cross contamination. Facility staff did not open RI (Resident Identifier) #1's labia and did not change the wipe when using more than one front to back motion while cleaning the vaginal area. This affected 1 of 2 residents observed for incontinence care. Findings include: A review of the facility's policy and procedure titled, "Incontinent Care using Disposable Wipes," with no reference date, revealed, "PROCEDURE: ...5. Wash entire perineal area (outer and inner labia) with disposable wipe, moving from front to back, while using a clean area of the disposable for each wipe or a new wipe for each stroke..." RI #1 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #1's most recent Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/24/12, revealed that RI #1 had short and long term memory problems and was severely impaired for decision making. Her Bowel and Bladder assessment indicated she was incontinent and required extensive care for hygiene/bathing. On 05/01/13 at 2:40 PM, Employee Identifier (EI) #1, a Certified Nursing Assistant (CNA), was observed providing incontinent care for RI #1. EI #1 did not open RI #1's labia and only cleaned with one wipe from front to back while cleaning the vaginal area. EI #1 further failed to change the position of the wipe and used the same wipe to make three front to back motions on the vaginal area. On 05/02/13 at 11:50 AM, during a phone interview, EI #1 was asked what care she had provided for RI #1 on 05/01/13, at 2:40 PM, with EI #2, another CNA. She replied perineal care. EI #1 was asked if RI #1 was wet when she provided the incontinent care. EI #1 stated yes she was wet. EI #1 was asked why she did not open RI #1's labia when she cleaned her. EI #1 stated that she opened it but not with her hand like she should have. She was asked how many times she should have used the same wipe and how many times she should have cleaned from front to back with the same wipe. She stated "One time per wipe." EI #1 was asked why did she use more than one front to back motion with the same wipe. She stated, "Well, actually I thought I was just assisting EI #2 and then she handed me the wipe so that is why I was looking crazy at her." She was asked what the potential for harm was if the labia was not opened and cleaned. EI #1 said, "Set up an infection." She was then asked what was the potential for harm if she used the same wipe and did not change the position of the wipe and repeated cleaning with an up and down motion inside the vaginal area. EI #1 stated, "That can also cause infection." On 05/02/13 at 9:50 AM, during a phone interview, EI #2, a (CNA), was asked what care she had provided with EI #1 on 05/01/13, at 2:40 PM for RI #1. She replied perineal care, dry and turn. EI #2 was asked if EI #1 provided the perineal care the correct way, step-by-step as she advised. EI #2 said, "To me she messed up in the middle, she wiped up and down more than one time and did not open the labia." She was asked what the potential for harm would be if a female resident's labia is not opened to clean it, the same wipe is used without changing the position, and an up and downward motion is used more than once. EI #2 said, "Have an infection."

Based on observations and interviews, the facility failed to ensure floors in bathrooms and residents rooms were clean and sanitary. This affected RI (Resident Identifier) #'s 1, 2, 3, 5, 6, 8, 9 and 15. Eight of 21 sampled residents were affected on 3 of 4 halls observed during the survey. Findings include: During the initial tour on 04/30/13 at 11:20 AM, the surveyor observed RI #1's room and bathroom. Brown stains were observed in the resident's room. Brown stains were also observed on the bathroom floor and the base boards. During the initial tour on 04/30/13 at 11:14 AM, RI #2's bathroom was observed to have brownish stains on the floor and under the sink. During the initial tour on 04/30/13, at 11:16 AM, RI #3's bathroom was observed to have a black substance on the floor entering the bathroom from the room. There were also brown stains observed on the bathroom ceiling tiles. During the initial tour on 4/30/13 at 11:50 AM, the surveyor observed RI # 8's bathroom. Brown stains were noted around the bathroom baseboards and the base of the toilet. A family interview was conducted with RI #8's family on 5/2/13 at 1:50 PM. During the interview RI #8's family member reported that she and her sister find RI #8's room dirty when they are in the facility. During the initial tour on 4/30/13 at 11:55 AM, the surveyor observed RI #9's bathroom. Dirt was observed on the baseboard and bathroom floor. On 05/01/13, at 5:05 PM an observation was made of RI #15's room. The floors had a black substance on all of the tiles and under the sink in the room. The ceiling tiles had a brownish circle observed on two of the tiles. During the initial tour on 04/30/13 at 10:10 AM, the surveyor observed RI #5's room and bathroom. The bathroom floor tiles and grout were noted to be stained with a reddish/orange colored substance. This same substance was noted in the tiles and grout around the toilet. RI #5 was interviewed on 4/30/13 at 5:05 PM. RI #5 was asked about the floors he stated they were "atrocious" and slick. On 05/01/13 at 10:50 AM, the surveyor observed RI #5's room and bathroom. The bathroom floor and tiles were observed to have the same reddish/orange substance on the tiles and grout as previously observed on 4/30/13. The tiles and grout around the toilet area had the same reddish/orange substance as well. The stain noted previously under the sink was still present. During the initial tour on 04/30/13 at 10:10 AM, the surveyor observed RI #6's bathroom floors. The floors were observed to have a reddish/orange like stain to the floor tiles and grout. RI #6's floor in his room was observed to have the same reddish/orange substance on the tiles. On 05/01/13 at 11:42 AM, the surveyor observed RI #6's room and noted the reddish/orange stains on the floor in RI #6's room. These circle areas were noted to be in between RI #6's bed and the roommate as well as around the edge of the floor at RI #6's head of bed area. The floor tiles and grout in RI #6's bathroom were observed and noted to have the same reddish/orange stains as previously observed. On 05/02/13 at 2:00 PM, a walk-around tour was conducted to include the rooms of RI #'s 1, 2, 3, 5, 6, 8, 9 and 15. The surveyor was accompanied by EI #3, the Maintenance Supervisor. During this tour, an interview was conducted with EI #3. He was asked to describe the brownish stains on the rooms and bathroom floors. He stated they were all just dirty, needed cleaning, and some of the tiles needed to be replaced. He was asked to explain what the red circled area on the ceiling tiles in RI #3's and #15's rooms was. EI #3 stated it was condensation from the air conditioner. EI #3 was asked who was responsible for repairing the ceilings when they were stained. He stated Maintenance. He was asked how often the floors were cleaned and waxed. He stated the contracted cleaning service could answer that question better. He was asked who was responsible for cleaning the floors in the rooms in question. EI #3 stated the contracted cleaning service. An interview was conducted on 05/02/13 at 2:20 PM with EI #4, the contracted cleaning Housekeeping Supervisor. EI #4 was asked what she could tell the surveyor about the black/brown stains on the floors in RI#'s 1, 2, 3, 5, 6, 8, 9 and 15's rooms. She stated they were just dirty and needed cleaning. She was asked how often the floors were cleaned and waxed. She stated that the rooms were cleaned and waxed when the room was empty.