Every finding on record at Westside Terrace Health & Rehabilitation Center

Based on observations, record review, and interviews the facility failed to ensure staff checked and changed Resident Identifier (RI) #41 before ambulating the resident in the hallway. This deficient practice affected one of two sampled residents who were reviewed for personal hygiene/incontinence care. Findings included: RI #41 was admitted to the facility on [DATE]. RI #41 has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a significant change Minimum Data Set (MDS), with an assessment reference date (ARD) of 05/15/2022, revealed RI #41 scored 4 on a Brief Interview for Mental Status, which indicated severe cognitive impairment. Per the MDS, the resident required extensive assistance of one person for transfers and toilet use. A review of a Care Plan, dated 05/13/2022 revealed RI #41 was incontinent of urine and bowel. The goal was for the resident to be clean, dry and odor free. Interventions included: - Incontinence checks every two hours and as needed. - Provide prompt incontinent care. - Ask resident if s(he) needs to have a bowel movement when capable of responding. - Ensure the resident is clean, dry and odor free. - Assist as needed for toileting and/or incontinence care. - Resident wears incontinence pads/briefs. - Cleanse perineal-area and apply barrier cream after incontinent episodes and as needed. - Maintain resident dignity. Observations on 07/28/2022 at 1:36 PM revealed an unidentified staff member brought RI #41 out of the dining room to a group exercise. At 1:56 PM, Employee Identifier (EI) #11, a Restorative Aide (RA), put a gait belt on RI #41 and assisted him/her to stand with a walker and ambulate down the hallway. EI #4 followed the resident down the hallway with the resident's wheelchair, which had a towel in the seat that was urine-stained and wet and had a strong urine odor. The resident's pants were wet on the back. EI #11 and EI #4 ambulated RI #41 down to the end of the hallway and back. EI #4 took RI #41 to his/her room and stated she was going to take the resident to the bathroom. EI #4 started to gather items she would need in the bathroom and excused herself from the room. On 07/28/2022 at 1:58 PM, EI #10, a Certified Nurse Aide (CNA), entered the room and offered to take RI #41 to the bathroom. The resident declined but the resident stated his/her pants did feel wet and agreed to go in the bathroom. EI #10 took RI #41 into the bathroom, where the resident stood up, using the handrail for support. EI #10 pulled down the resident's pants and removed the adult brief, which was saturated with urine and soiled with feces. EI #10 started providing incontinent care with toilet paper, then EI #9, a CNA, entered the room with wipes and assisted EI #10 to finish providing incontinent care. During an interview on 07/28/22 at 2:08 PM, EI #9 stated residents should be toileted or checked every two hours and as needed. She stated she did not know when RI #41 had last been toileted, but it looked like it had been a while. During an interview on 07/28/2022 at 2:22 PM, EI #12, a Licensed Practical Nurse (LPN), stated RI #41 would need to be offered to toilet every two hours and checked for incontinence. EI #12 stated RI #41 would tell staff at times when he/she needed to use the restroom but was mostly incontinent. EI #12 stated she was not sure when the resident had last been toileted. During an interview on 07/29/2022 at 3:36 PM, EI #2, the Director of Nursing (DON), stated dependent residents should be checked for incontinence every two hours and changed if needed. EI #2 stated the staff should have taken RI #41 to his/her room and changed the resident prior to having the resident ambulate down the hall. During an interview on 07/29/2022 at 4:01 PM, EI #1, the Administrator, stated residents should be checked and changed every two hours and should not be left sitting wet and soiled. EI #1 stated the staff should have changed RI #41 prior to ambulating him/her.

Based on observations, interviews and reviews of policies titled Dietary Meal Service, Dietary Sanitation Flatware Washing and Sanitation, Dietary Sanitation Food Storage and a facility document titled Lunch Meal, dated 8-14-19 week 2, the facility failed to ensure: 1. two packs containing 36 hot dogs in the freezer, with ice crystal on them, were labeled with an opened and use by date; 2. the temperatures of six milks and sweet peas were taken at the lunch tray line on 8/14/19 and; 3. six spoons and one fork were not wet in silverware bags. This had the potential to affect the residents who would receive the hotdogs from the kitchen, the six residents who received the milk during the lunch meal from the kitchen and six residents who would have received wet utensils during the lunch meal on 8/14/19. The facility served 155 residents from dietary. Findings Include: 1) A review of a facility policy titled, DIETARY Sanitation Food Storage, with an effective date of 7/10/03 revealed: .Procedure: .4) . vi) Opened foods will be dated and labeled upon storage. On 8/12/19 at 1:56 p.m., the surveyor toured the kitchen with (Employee Identifier) EI #1, Dietician and EI #2 Dietary Manager. The surveyor observed in the freezer two packages of hotdogs wrapped in saran wrap with no opened or use by date label on the package. There were 25 hotdogs in the first package and 11 hotdogs in the second package of hotdogs. Ice crystals were observed on the saran wrap covering the hotdogs. On 8/14/2019 at 4:00 p.m., an interview was conducted with EI #2. EI #2 was asked what was the opened and use by date on the hot dogs in the freezer. EI #2 replied, they did not have anything on them. EI #2 was asked what label was on the hot dogs. EI #2 replied, no label. EI #2 was asked what was the facility policy on labeling food items once out of the original container. EI #2 replyed, properly wrap, label, date, initial and put in the proper place. EI #2 was asked when should food items be labeled. EI #2 replied, all the times when going in and out of the cooler or freezer. EI #2 was asked who was responsible for labeling food items. EI #2 replied, all kitchen staff. EI #2 was asked why was it important that food items were labeled. EI #2 replied, because, if it is not done right, possibly someone could get sick. EI #2 was asked what was on the hot dog wrapping. EI #2 replied, ice crystals. 2) A review of a facility policy titled, DIETARY Meal Service with a effective date of 7/10/03 revealed: .Procedure .13. The Tray line Log and Temperature Record will be completed when food is prepared and prior to meal service . A review of the Lunch Meal form, dated 8/14/19, revealed no temperatures for the sweet peas and milk were documented. On 8/14/19 at 10:19 a.m., during the lunch tray line the surveyor observed EI #1 taking temperatures of all foods on the tray line. EI #1 took the temperature of all the foods on the tray line except the sweet peas. The surveyor observed no one taking the temperature of the milk. The surveyor observed six milk carton leaving the kitchen without any temperature being taken. On 08/14/2019 at 3:46 p.m., an interview was conducted with EI # 1. EI #1 was asked who took the temperatures of the Milk and English peas. EI #1 replied, no one. EI #1 was asked what foods temperature should be taken at the tray line. EI #1 replied, all foods that are served to residents. EI #1 was asked what was the facility policy on taking food temperature at the tray line. EI #1 replied, all food temperatures be taken prior to distribution to residents. EI #1 was asked why should food temperature be taken at the tray line. EI #1 replied, in order to prevent food borne illness and bacteria growth. EI #1 was asked where was the recording temperatures for the English peas and milk. EI #1 replied, it was not recorded. EI #1 was asked what was the temperature for the English peas. EI #1 replied, they did not know. EI #1 was asked what was the temperature for the milk. EI #1 replied, unknown. 3) A review of a facility policy titled, DIETARY Sanitation Flatware Washing and Sanitation revealed: Policy: Follow the steps below when washing flatware. Procedures: 9. Allow to air dry. On 8/14/19 at 10:19 a.m., the surveyor observed in the food preparation area staff putting utensils in bags. EI #3 was asked if the utensil was ready to go out to the residents. EI #3 replied, yes. The surveyor put on a pair of gloves and pulled silverware out of the utensil bag. The surveyor pulled 10 bags. In six of the bags there were six spoons and one fork wet in utensils bags and ready to go out to the residents. There were five forks in the utensil holder wet. On 8/14/19 at 4:24 p.m., an interview was conducted with EI #3. dietary aide. EI #3 was asked what did she see on spoons in the utensil bags. EI #3 replied, speck of water. EI #3 was asked why were they wet. EI #3 replied, they suppose to be dry. EI #3 was asked how should utensil be allowed to dry. EI #3 replied, air dry. EI #3 was asked how many spoons were wet. EI #3 replied, three. EI #3 was asked how many forks were wet. EI #3 replied, one. EI #3 was asked why should utensil be dry before giving them to the residents. EI #3 replied, make sure they are clean and dry before giving them to the residents. EI #3 was asked what was wet in the blue utensil crate. EI #3 replied, silverware. EI #3 was asked why were they wet in the blue silverware crate. EI #3 replied so they could air dry. EI #3 was asked did they air dry. EI #3 replied some did and some were still wet. EI #3 was asked did she see the wet spoons prior to putting them in the bag. EI #3 replied, no she did not. EI #3 was asked why did she bag them. EI #3 replied, she did not see them wet. EI #3 was asked did she normally bag silverware. EI #3 replied, no.

Based on observations, interviews and a review of a facility policy titled Dietary/Food Handling and the Food and Drug Administration, (YEAR) Food Code, the facility failed to ensure: 1. a package of hamburger buns was not left opened and labeled with a use by date; 2. a 46 fluid ounce supplement in the supplement refrigerator was not expired and; 3. a cook changed her gloves after wiping gravy off the floor and wiping gravy off another worker's pant leg. This was observed on one of three days of the survey and had the potential to affect 157 of 157 residents who received meals from the kitchen. Finding Include: 1) A review of a facility policy titled, Dietary/Food Handling with a revision date of [DATE], addressed .POLICIES AND PR[NAME]EDURES . 11) Food handlers must wash their hands.g) After engaging in other activities that contaminate the hands. On [DATE] at 8:36 a.m., the surveyor observed buns in a package opened and not sealed. There were four hamburger buns in the package. The Surveryor was unable to see the open and use by date on the package. The surveyor also observed a roach crawling on top of the warmer located near the buns. On [DATE] at 9:09 a.m., an interview was conducted with EI #3, Director of Dietary Services. EI #3 was asked what food item was opened and not sealed properly. EI #3 replied, four hamburger buns. EI #3 was asked why were the buns opened. EI #3 replied, they had used some out of them. EI #3 was asked what did the facility policy say regarding opened food items. EI #3 replied, when opening bread they should tie it back up. EI #3 was asked who was responsible for making sure food items were sealed. EI #3 replied, the supervisor or the certified dietary manager. EI #3 was asked what type of bug was in the kitchen crawling on top of the warmer. EI #3 replied, a roach. EI #3 was asked what was the potential harm to the residents when a food item was opened and a bug potentially got in the hamburger buns. EI #3 replied, they could get sick. EI #3 was asked when should food items be sealed. EI #3 replied, at all times. 2) A record review of the (YEAR) Food Codeby United State Public Health Service (USPHS), and the Food and Drug Administration (FDA) included the following: [DATE] Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (B) .(G) of this section, refrigerated, READY-TO-EAT-TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and packaged by a FOOD PR[NAME]ESSING PLANT shall be clearly marked (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use by-by date on FOOD SAFETY. On [DATE] at 9:03 a.m., the surveyor and dietary manager toured the nurses unit supplement refrigerators. In one of the refrigerator there was a thickened nectar consistency 46 fluid ounces supplement. The use by date on the container was [DATE]. On [DATE] at 9:31 a.m., an interview was conducted with EI #3. EI #3 was asked what food item on the hall was in the supplement refrigerator and expired. EI #3 replied, thickened tea dated [DATE]. EI #3 was asked why was it expired in the refrigerator. EI #3 replied, because it was not checked on grand rounds (checking refrigerator thoroughly weekly of resident's personal items and expired items). EI #3 was asked who was responsible for making sure food items were not expired in the hall supplement refrigerator. EI #3 replied, the floor administrator/nurse. EI #3 was asked why was it important that food items were not expired in the supplement refrigerator on the hall. EI #3 replied, because they did not want to make anyone sick. EI #3 was asked when should food items in the hall unit supplement refrigerator be discarded. EI #3 replied, when they were out of date. EI #3 was asked what was the potential harm to the residents when a food item was expired in the supplement refrigerator. EI #3 replied, potential harm to get sick. On [DATE] at 1:41 p.m., an interview was conducted with EI #6, Clinical Nurse Manager. EI #6 was asked who was responsible for checking the unit supplement refrigerator. EI #6 replied, dietary in the morning, they replenish the refrigerator and Tuesday they (nurses) do make rounds of the refrigerator, and the floor administrator. EI #6 was asked why was it important that expired food items were not in the refrigerator. EI #6 replied, to prevent residents from getting sick. EI #6 was asked how often did she check the supplement refrigerator. EI #6 replied, it was supposed to be checked daily and weekly. EI #6 was asked what was the potential harm to the residents if they were given an expired food item. EI #6 replied, gastric upset. 3) A review of a document titled, Food Code (YEAR) [DATE] Package Integrity. Food package shall be in good condition and protect the integrity of the content so that the food is not exposed to ADULTERATION or potential contaminants. On ,[DATE]/ (YEAR) at 10:37 a.m., the surveyor observed the cook, EI #4, drop gravy on the floor. She wiped the floor with a cloth that she retrieved from under the steam table . The cook also wiped EI #5's pants with the cloth. She then put the cloth on the floor and used her foot to continue wiping the floor. She picked up the cloth and put it on a cart. She did not change her gloves. She continue serving food. On [DATE] at 9:47 a.m., the surveyor conducted an interview with EI #4, Cook II. EI #4 was asked what food item fell to the floor from the warmer. EI #4 replied, gravy. EI #4 was asked what did she do when the gravy fell to the floor. EI #4 replied, she got a towel and she did not remember what she did. EI #4 was asked where did she get the cloth/towel to wipe the worker's pant legs and floor. EI #4 replied she thought it was on the cart. EI #4 was asked did she change her gloves. EI #4 replied, no ma'am. EI #4 was asked why she did not change her gloves. EI #4 replied, she was not thinking at the time. EI #4 was asked what did she do after wiping EI #5 clothes and floor. EI #4 replied, she continued serving the line/serving food. EI #4 was asked should she have changed her gloves. EI #4 replied, yes. EI #4 was asked why should she have changed gloves. EI #4 replied, because the gloves were not clean. EI #4 was asked what did the facility policy say regarding changing gloves. EI #4 replied, change gloves at all times when you touch something. EI #4 replied, they were suppose to change gloves, wash hand and put on more clean gloves when going back to serving or touching food. EI #4 was asked why was it important to change gloves when working on the tray line. EI #4 replied, for food safety, everything was supposed to be clean. On [DATE] at 2:19 p.m., the surveyor conducted an interview with EI #7, Infection Control, RN (Register Nurse) Risk Manager. EI #7 was asked when should staff wash their hands in the kitchen. EI #7 replied, when they were soiled. EI #7 was asked should staff change their gloves and wash their hands after dropping a pan of gravy on the floor and wiping another staff's pant leg and wiping the floor. EI #7 replied, yes. EI #7 was asked should EI #4 have changed her gloves. EI #7 replied, yes it would have been a good idea to change her gloves. EI #7 was asked why should she have changed gloves. EI #7 replied, to prevent contamination of the food that she was serving.

Based on observation, interview and review of facility policies Hand Hygiene and Med Pass Tips, the facility failed to ensure: 1. licensed staff did not pull gloves from her uniform pocket then change a dressing covering Resident Identifier (RI) #10'[MEDICAL CONDITION] and touch the clean packaging of 4 x 4 gauze and packed abd (abdominal) pads with the same gloves 2. the same licensed staff washed her hands when she changed gloves; 3. licensed staff did not pick up a tablet she dropped on the top of the medication cart and place it in the medication cup with the other medications and then give to RI #142 and; 4. the same licensed staff did not use the same gloves she had on to administer RI #142's by mouth medication to administer the prescribed eye drops. This was observed on 8/7/18 and affected one of four licensed staff and two of six residents observed for medication pass. Findings Include: (1 & 2) A review of facility policy titled, Hand Washing with a revised date of 5/20/14 revealed, Policy: Hand washing shall be regarded by this facility as the single most important means of preventing the spread of infections. 2) Employees must perform . d) Before handling clean or soiled dressings, gauze pads, etc., e) After handling used dressings, .f) after contact with blood, body fluids, excretions, secretions .i) After removing gloves: . RI # 10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/07/18 at 10:00 AM Employee Identifier (EI) #2, Licensed Practical Nurse was observed giving RI #10 the AM medication. EI #2 got [MEDICATION NAME] 1 milligram tablet from the medication cart, crushed the medication and placed it in a medication cup. EI #2 took gloves from a glove box on the medication cart and placed them in her right uniform pocket. EI #2 entered RI #10's room washed her hands removed gloves from her uniform pocket and put them on. EI #2 moved the trash can next to RI #10's wheelchair then with the same gloves removed a dressing covering the resident'[MEDICAL CONDITION] and chest area. EI #2 took a package of 4 x 4 gauze and abd pads from the shelf and placed them on the resident's over bed table. EI #2 removed a roll of tape from RI #10's bedside cabinet drawer with the same gloves on. EI #2 removed 4x4's from the multi pack and sprayed wound cleaner to a small stack and cleaned the mucus from RI #10's chest [MEDICAL CONDITION]. EI #2 removed her gloves and got more from a box in the room and put them on. EI #2 did not wash her hands between glove changing EI #2 returned the supplies to the shelf and drawer with the same gloves on. EI #2 then removed her gloves and washed her hands. On 8/07/18 at 11:15 AM, an interview was conducted with EI #2. EI #2 was asked what was the policy on where she should put gloves when she removed them from a glove box. EI #2 replied she put them on the tray. EI #2 was asked if she should place gloves she removed from a glove box in her uniform pocket. EI #2 replied, no. EI #2 was asked if she used gloves she pulled from her uniform pocket to provide care for RI #10. EI #2 replied yes. EI #2 was asked what was the harm in using gloves from her uniform pocket. EI #2 replied, risk of spreading germs from her to a resident. EI #2 was asked if she should have the same gloves on to clean up the area and return the supplies to the shelf. EI #2 replied, no. EI #2 was asked what would the risk be. EI #2 replied, she could spread germs to the clean items and back to the resident. EI #2 was asked what should she have done. EI #2 replied, she should have removed the soiled gloves washed her hands and put on clean gloves then put the package of 4 x 4's and abd pads back on the shelf. EI #2 was asked what was the policy on when to wash hands after removing gloves. EI #2 replied, they should wash after each time they take gloves off. EI #2 was asked if she washed her hands when she changed her gloves. EI #2 replied, no. (3&4) A review of a facility policy Med Pass Tips with a revised date of 7/5/7 revealed: Procedure: .5. Apply gloves .11. Wash hands RI #142 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #142's (MONTH) (YEAR) Physicians Orders revealed .[MEDICATION NAME] 20 Mg (milligram) tablet .Tamsulosin 0.4 mg .[MEDICATION NAME] 100 mg .[MEDICATION NAME] 75 mg .[MEDICATION NAME] 0.5 mg . Miralaz 17 grams .[MEDICATION NAME] 1 drop left eye twice a day . On 8/07/18 at 10:50 AM EI #2, was observed giving RI #142's morning medication. EI #2 prepared the medications. As she was removing the tablets from the packaging she dropped the [MEDICATION NAME] on top of the medication cart. EI #2 put on a glove and picked up the [MEDICATION NAME] tablet and placed it in the medication cup. EI #2 entered RI #142's room with the prepared medication. EI #2 put on gloves and gave RI #142's by mouth medications and cup of water. EI #2 then with same gloves administered the [MEDICATION NAME] eye drop to the left eye. On 8/7/18 at 11:15 AM an interview was conducted with EI #2. EI #2 was asked, if she recalled dropping the [MEDICATION NAME] tablet on top of the medication cart. EI #2 replied, yes. EI #2 was asked what was the policy on dropping a medication. EI #2 replied she should have discarded it and got another. EI #2 was asked if she discard it. EI #2 replied no, she was not thinking. EI #2 was asked what was the risks of giving a medication that had dropped on top of the medication cart. EI #2 replied, risk of transferring germs. EI #2 was asked what was the policy on giving eye drops. EI #2 replied, the nurse should wash their hands put on gloves and administer the eye drops, then take the gloves off and wash their hands. EI #2 was asked how she administered the eye drops. EI #2 replied, she had on the gloves she gave the by mouth medications with then put the eye drop in. EI #2 was asked what was the risk of using same gloves for by mouth meds then giving an eye drop. EI #2 replied, could spread germs or cause an eye infection. On 8/09/18 at 9:02 AM an interview was conducted with EI #1, Director of Nursing. EI #1 was asked what was the policy on where staff should get gloves from to use while on medication pass. EI #1 replied, from a glove box. EI #1 was asked when should staff use gloves for care that they have removed from their uniform pocket. EI #1 replied, never. EI #1 was asked what was the harm in using gloves pulled from a uniform pocket. EI #1 replied, they are not clean, the inside of a pocket was not clean. EI #1 was asked what was the policy on washing hands when changing gloves. EI #1 replied, wash hands immediately when removing gloves. EI #1 was asked what was the harm when staff did not wash hands between glove changes. EI #1 replied, there was a risk for transmitting germs. EI #1 was asked what was the policy on hand hygiene during a dressing change. EI #1 replied, change the dressing then remove the gloves, wash the hands and put up the supplies. EI #1 was asked when should staff change a dressing then with same gloves put up supplies. EI #1 replied, never. EI #1 was asked what would the risk be of doing a dressing change, then with same gloves touch the packages of supplies and placing them back on shelf. EI #1 replied, transmitting germs. EI #1 was asked what was the policy if a nurse dropped a medication while preparing it. EI #1 replied, it should be discarded and get another. EI #1 was asked what was the risks of using a tablet that was dropped on the medication cart. EI#1 replied, it could be contaminated. EI #1 was asked what was the policy on administering eye drops. EI #1 replied, wash hands put on gloves give the eye drop then remove the gloves and wash their hands. EI #1 was asked when should a nurse use the same gloves she had on to administer by mouth medications then administer an eye drop. EI #1 replied never, the nurse should give the by mouth medication then remove the gloves and wash their hands and put on clean gloves and administer the eye drops. EI #1 was asked what would the harm be in a nurse using the same gloves she had on to administer the by mouth medications then instill an eye drop. EI #1 replied, the risk of transmitting germs from the mouth to the eyes.

Based on observation, interview, and a review of the facility's policy titled Resident Rights, the facility failed to ensure photographs were not taken of RI (Resident Identifier) #1 on an employee's personal cell phone that captured RI #1's room, personal items, and unclothed, uncovered body. This deficient practice affected one of three residents sampled for personal privacy. Findings Include: A review of an undated facility policy titled Resident Rights documented the following: . YOUR RIGHTS AS A RESIDENT . Privacy You have the right to personal privacy, including privacy in accommodations, . and records, . electronic and telephone communications, . RI #1 was admitted to the facility on [DATE]. On 9/5/2017 the State Agency received a complaint regarding an incident that occurred on 9/2/2017. The complainant indicated RI #1's body was covered with red bumps, and Licensed Practical Nurses (LPN) and Certified Nursing Assistants (CNA) took pictures of RI #1 on their cell phones. On 9/7/2017 at 10:40 a.m. in a telephone interview, EI (Employee Identifier) #3 LPN, was asked if she could show the surveyor pictures of RI #1. EI #3 said, she took pictures following the incident on 09/02/2017 and sent them to EI #1, the DON (Director of Nursing). When asked of what body parts pictures were taken, EI #3 replied, RI #1's buttocks, arms, shoulders, and thighs. EI #3 was asked who told her to take the pictures. EI #3 stated, EI #2, the RN (Registered Nurse) Supervisor had asked EI #1, the DON, if pictures were needed, and the DON said yes. On 9/7/2017 at 11:05 a.m., EI #2, RN (Registered Nurse) Supervisor, was asked, who took the pictures of RI #1 following the incident on 09/02/2017. EI #2 said, EI #3 took pictures of RI #1 and sent the pictures to the DON. On 9/7/2017 at 11:35 a.m., in a telephone interview, EI #4, LPN, was asked who took pictures of RI #1. EI #4 said, she took pictures of RI #1 on her personal phone, then asked EI #3 to take pictures since her phone took better pictures. EI #4 was asked who initially told her to take pictures. EI #4 replied, she did not know who suggested the pictures but, they were taken and sent to the DON, EI #1. On 9/7/2017 at 1:30 p.m., EI #1, DON, was asked if she had pictures of RI #1 on her phone. EI #1 said, she deleted the pictures. When asked on whose phone the pictures were taken, EI #1 replied, EI #4, LPN. EI #1 was not aware EI #3 had taken pictures and sent them to her. When asked why the pictures were made, EI #1 said, so she could see what was going on with RI #1. When asked who gave the nurses permission to take pictures, EI #1 stated, I assumed (EI #2) did. She just said I'm gonna send you pictures. EI #1 said, she did not ask who took the pictures. When asked what the risk would be of taking pictures of a resident on an employee's personal phone, EI #1 said, they could share them with someone else. When asked if she knew if the employees had deleted their pictures, EI #1 said, she did not know. On 9/7/2017 at 2:25 p.m. EI #3 LPN, arrived at the facility to show the surveyor pictures of RI #1 that were still on her personal phone. EI #3's phone contained 14 pictures of RI #1's bed, room, personal belongings, neck, shoulders, arms, back, chest, thighs, pubic area, and buttocks. EI #3 said the cell phone was her personal phone. When asked if there was a risk to RI #1 for those pictures to be on her personal phone, EI #3 said, confidentiality. On 9/7/2017 at 4:25 p.m. EI #5 the Administrator, was asked how she could guarantee someone else would not have access to the employee's phone and view the pictures of RI #1 or share them with others. EI #5 said, she could not guarantee that someone would not do those things. When asked how it would make RI #1 feel to know nude pictures were being viewed by others, EI #5 replied, embarrassed.

Based on observations, interviews and record reviews the facility failed to ensure: 1) Cool items on tray line remained below 41 degrees Fahrenheit (F) 2) Cooks took temperatures of second trays of cooked foods to ensure they reached temperatures of 135 degrees F before serving 3) Turnovers and rolls were dated and labeled and rolls were securely resealed. 4) A male employee had a hair restraint over mustache. These deficiencies had the potential to affect all 154 residents receiving meals from the dietary department. Findings Include: The facility policy titled, Dietary/Food Handling dated 7/10/03 stipulated: POLICIES AND PROCEDURES . 2. Temperatures must be maintained in accordance to Food Code recommendations. a) Cold food -- (may not exceed 55 degrees without being discarded); . c) Cooking of hazardous food (e.g.,(for example) ground beef) -- 155 degrees or above. 10) Hairnets or caps must be worn to effectively keep hair from contacting exposed food, clean equipment, utensils and linens. 14) . c) Opened containers must be dated and sealed or covered during storage. 2013 U. S. Public Health Service Food Code, Section 3-501.17 (p. page 92), documents: . commercially processed food open and hold cold . (B) refrigerated, READY-TO- EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in . (1) The day the original container of opened in the FOOD ESTABLISHMENT shall be counted as Day 1; . (C) A refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD ingredient or a portion of a refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is subsequently combined with additional ingredients or portions of FOOD shall retain the date marking of the earliest-prepared of first-prepared ingredient. 1. On 8/31/2016 at 11:40 a.m., during a steam table tray line observation, a tray of egg salad sandwiches and pimento cheese sandwiches, cantaloupe, and lemon ice box pie, were noted to be sitting in a regular metal pan on a tray cart. They were not being stored in a way to keep them cool. The sandwiches were egg salad, which was 55 to 62 degrees F and Pimento cheese sandwich was 55 degrees F. The icebox pie was 65 degrees F. 2. The cook acquired a second pan of Macaroni and Cheese. The cook removed the pan from the warmer and began serving plates from the pan. The cook did not check the temperature on the second pan of the Macaroni and Cheese. Another cook checked the temperature and discovered it to be 125 degrees F. The second temperature taken was 132 degrees F. The cook went back to serving from the pan. 3. 08/30/2016 at 10:15 a.m, an initial tour of the freezer revealed a bag of soft rolls opened and not securely closed and there was no date or label as to when it was opened. There was also a freezer bag of several turnovers that was not dated and labeled. 4. On 8/31/2016 at 11:15 a.m., a male dietary aide came into the kitchen with a mustache that was not covered. An interview on 8/31/2016 at 9:10 a.m, with the Dietary Director, Employee Identifier (EI) #1 and the Registered Dietitian, EI #2 revealed they were not aware that the second serving of the Macaroni and cheese did not reach 135 degrees F. When the surveyor asked what temperature should the food temperature be, EI #1 said 150 degrees F. When they were told the second serving of Macaroni and Cheese only reached 125 - 132 degrees F, they were surprised. When asked what temperature should a sandwich with egg salad and pimento cheese and cool food items be, EI #1 said 41 degrees or lower. When asked what was the possible danger of temperatures being too warm, especially with mayonnaise in the sandwich, EI #2 said growth of bacteria could cause a food borne illness. EI #1 said they (staff) know they should date and label items as soon as they go into the cooler and freezer. EI #1 and EI #2 were asked what was the danger of not dating and labeling opened food items. EI #2 said they would not know how long it had been opened. EI #1 and #2 were asked what was the problem with hair not being in hair restraints. EI #1 said their policy is All hair in. When asked the danger, EI #2 said, hair could fall into food or on tables.

Based on interviews and record review, the facility failed to ensure a physical abuse allegation for RI (Resident Identifier) #1 was reported to the State Agency. This affected one of three abuse investigation files reviewed. Findings Include: A review of a facility policy titled, RISK MANAGEMENT RESIDENT ABUSE INVESTIGATION AND REPORTING OF ALLEGED VIOLATIONS OF RESIDENT ABUSE . with an effective date of 07/10/03 revealed the following: Policy: It is the policy of this facility to take appropriate steps to prevent the occurrence of abuse .to ensure that all alleged violations of Federal or State laws which involve .abuse .are reported immediately .Such violations will also be reported to state agencies .The facility will investigate each such alleged violation thoroughly and report the results of all investigations to .state agencies as required by state and federal law. RI (Resident Identifier) #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 08/30/2016 at 4:20 p.m., a telephone interview was conducted with an ombudsman. The ombudsman was asked if she had a current issue or case with the facility. The ombudsman explained RI #1 reported staff had beaten him/her all the time. The ombudsman stated the facility mailed her the investigation regarding the alleged abuse. On 08/31/2016 at 4:40 p.m., an interview was conducted with EI (Employee Identifier) # 4, DON (Director of Nursing) RN (Registered Nurse). EI #4 was asked to tell the surveyor about the incident involving RI #1. EI #4 explained the ombudsman visited the facility on 04/18/2016. EI #4 stated RI #1 asked the ombudsman how she would feel if she had been thrown around. EI #4 further explained that the facility conducted an investigation of the allegations. EI #4 was asked when was it reported to the State Agency. EI #4 explained it was not reported to the state. On 09/01/2016 at 9:00 a.m., an interview was conducted with EI #5, Abuse Coordinator/RN. EI #5 was asked what types of incidents did the facility report to the State. EI #5 stated any alleged abuse. On 09/01/2016 at 3:45 p.m., an interview was conducted with EI #6, Administrator. EI #6 was asked if the incident involving RI #1 was reported to the State. EI #6 said no. EI #6 was asked why not. EI #6 said because of his/her behavior when people gave basic care. EI #6 was asked who was responsible for reporting alleged incidents of abuse to the State. EI #6 stated the Administrator. EI #6 was asked what the facility's policy said about reporting. EI #6 explained to report all suspected abuse. This deficiency was cited as a result of the investigation of the complaint/report #AL 378.

Based on interviews and record review, the facility failed to ensure the reporting component of the facility's abuse policy was followed. This affected Resident Identifier (RI) #1, one of three abuse investigation files reviewed. Findings Include: A review of a facility policy titled, RISK MANAGEMENT RESIDENT ABUSE INVESTIGATION AND REPORTING OF ALLEGED VIOLATIONS OF RESIDENT ABUSE . with an effective date of 07/10/03 revealed the following: Policy: It is the policy of this facility to take appropriate steps to prevent the occurrence of abuse .to ensure that all alleged violations of Federal or State laws which involve .abuse .are reported immediately .Such violations will also be reported to state agencies .The facility will investigate each such alleged violation thoroughly and report the results of all investigations to .state agencies as required by state and federal law. Procedure: The facility shall take the following steps to prevent, detect and report abuse .REPORTING .The Administrator shall also notify .state agency in accordance with state law . RI #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 08/31/2016 at 4:40 p.m, an interview was conducted with EI (Employee Identifier) # 4, DON (Director of Nursing) RN (Registered Nurse). EI #4 was asked when was the incident involving an allegation of abuse concerning RI #1 reported to the State. EI #4 explained it was not reported. On 09/01/2016 at 9:00 a.m, an interview was conducted with EI #5, Abuse Coordinator/RN. EI #5 was asked what types of incidents did the facility report to the State. EI #5 stated any alleged abuse. On 09/01/2016 at 3:45 p.m., an interview was conducted with EI #6, Administrator. EI #6 was asked if the incident involving RI #1 was reported to the State. EI #6 said no. EI #6 was asked why not. EI #6 said because of his/her behavior when people gave basic care. EI #6 was asked who was responsible for reporting alleged incidents of abuse to the State. EI #6 stated the Administrator. EI #6 was asked what the facility's policy said about reporting. EI #6 explained to report all suspected abuse. This deficiency was cited as a result of the investigation of the complaint/report #AL 378.

Based on observation, record review and interviews the facility failed to ensure a CNA (Certified Nursing Assistant) wiped front to back during RI (Resident Identifier)#1's incontinent care on 08/31/2016. RI #1 is a resident who is dependent on staff for all ADL'S (Activities of Daily Living). This affected one of two sampled residents observed during incontinent care. Findings Include: A review of Potter and Perry's Fundamentals of Nursing Eighth Edition, Chapter 39, Hygiene, page 802 revealed: .q. Wash back. (This follows both female and male perineal care.) .(5) Clean buttocks and anus, washing front to back . RI #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's quarterly MDS (Minimum Data Set) with an Assessment Reference Date (ARD) of 06/04/2016 revealed RI #1 was dependent for all ADL's, and was always incontinent of bladder and bowel. On 08/31/2016 at 10:05 a.m., an observation of incontinent care was done. EI #7, CNA wiped the buttock area of RI #1 back to front and stool was on the buttock. On 08/31/2016 at 11:10 a.m., an interview was conducted with EI #7. EI #7 was asked what was the facility's policy on incontinent care. EI #7 said wipe front to back. EI #7 was asked what direction she wiped RI #1's buttock with stool present. EI #7 said back to front. EI #7 was asked which way was she supposed to wipe. EI #7 said front to back. EI #7 was asked what was the potential harm in wiping back to front. EI #7 said it could cause a UTI (Urinary Tract Infection).

Based on observation, record review and interview the facility failed to ensure a licensed staff member did not turn the faucet off with bare hands after washing her hands during medication administration on 08/30/2016. This affected one of one residents observed during medication administration. The facility further failed to ensure on 08/30/2016, during medication administration, a licensed staff member did not place the glucometer and the insulin syringe on an unclean surface. This affected Resident Identifier RI) #25 and 26, two of two residents observed during medication administration. Findings Include: A review of Potter and Perry's Fundamentals of Nursing Eighth Edition, Chapter 28, Infection Prevention and Control, HAND HYGIENE, page 427 revealed: .To turn off hand faucet, using clean, dry paper towel; avoid touching handles with hands . 1) RI (Resident Identifier)#25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #25's 14 day MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 08/31/2016 revealed a BIMS (Brief Interview for Mental Status) score of 10, which indicated the resident was moderately impaired for daily decision making. On 08/30/2016 at 4:35 p.m., EI (Employee Identifier) # 3, LPN (Licensed Practical Nurse) was observed during medication administration with RI #25. EI #3 entered RI #25's room, administered the medication and washed her hands, then turned the faucet off with bare hands. EI #3 exited the room. On 08/31/2016 at 3:50 p.m., an interview was conducted with EI #3. EI #3 was asked when she washed her hands during medication administration with RI #25, what did she do. EI #3 said she turned the faucet off with her bare hands. EI #3 was asked how should she wash her hands. EI #3 said turn the faucet off with a paper towel. EI #3 was asked why should she turn the faucet off with a clean paper towel. EI #3 said so she would not recontaminate her hands. EI #3 was asked what was the potential harm in turning the faucet off with bare hands. EI #3 said recontamination. On 09/01/2016 at 3:15 p.m., an interview was conducted with EI #4, RN (Registered Nurse) Infection Control. EI #4 was asked how should staff be washing their hands. EI #4 said turn the faucet off with a paper towel. EI #4 was asked why should the faucet be turned off with a paper towel. EI #4 said to protect clean hands and not recontaminate. EI #4 was asked what was the potential harm in turning the faucet off with bare hands. EI #4 said recontamination. 2)RI #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #26's most recent MDS with an ARD of 02/16/2016 revealed the resident had a BIMS of 15, which indicted the resident was cognitively intact. On 08/30/2016 at 4:15 p.m., EI #3 was observed during medication administration with RI #26. EI #3 entered the room with the glucometer. EI #3 laid the glucometer on the bedside table with no barrier and did not clean the table. EI #3 obtained RI #26's blood glucose and then exited the room. EI #3 entered RI #26's room and laid the insulin syringe on the counter with no barrier. On 08/31/2016 at 3:50 p.m., an interview was conducted with EI #3. EI #3 was asked where should the glucometer be placed when she went into a residents room. EI #3 said a barrier should be put down. EI #3 was asked where should the insulin syringe be placed when she entered a resident's room. EI #3 said a barrier should be put down. EI #3 was asked why should a barrier be down or the area be cleaned. EI #3 said a barrier should be down because of contamination. On 09/01/2016 at 3:15 p.m., an interview was conducted with EI #4, RN, Infection Control. EI #4 was asked when a staff member entered a resident's room with a glucometer and an insulin syringe, where should it be placed. EI #4 said on a barrier. EI #4 was asked why should there be a barrier. EI #4 said infection control purposes. EI #4 was asked what was the potential harm in not placing them on a barrier. EI #4 said infection or contamination.

Based on observations, interview and review of a facility policy titled DIETARY Sanitation Personal Cleanliness and Standards for Sanitation, the facility failed to ensure food was prepared and served in a manner to prevent cross-contamination by the following: 1) dietary staff were wearing dangling earrings; 2) a dietary staff aide's hair was not completely covered with a hair restraint; 3) the Robut Coupe blender was not air dried before being stored; 4) the meat slicer was not free of a grease like substance and food particles before being stored; 5) silver wear was not completely air dried prior to being inserted into paper utensil sleeves; and 6) an accumulation of dust-like particles were on fans in the kitchen. This had the potential to affect all 155 residents receiving meals from dietary. Findings Include: 1) A facility policy titled DIETARY Sanitation Personal Cleanliness and Standards for Sanitation, with an effective date of 07/10/03, documented: Policy: Seven out of ten poisonings caused by pathogens are due to poor hygiene of food handlers. Dietary personnel shall follow sanitary standards. Procedures: . 5) . (Note: Employees with pierced ears may wear only small earrings.) . On 08/12/15 at 10:34 a.m., the surveyor observed Employee Identifier (EI) #7, the Certified Dietary Manager (CDM), with dangling earrings in her ears. On 08/12/15 at 11:03 a.m., the surveyor observed a dietary aide, EI #11, with dangling earrings in her ears. On 08/12/15 at 5:37 p.m., the surveyor conducted an interview with EI #11. The surveyor asked EI #11 what did the faility's policy say about wearing earrings in the kitchen. EI #11 replied, No dangling earrings. The surveyor asked EI #11 were the earrings she was wearing dangling. EI #11 said they were dangling just a little. On 08/13/15 at 2:08 p.m., the surveyor conducted an interview with EI #7, the CDM. The surveyor asked EI #7 what was the facility's policy on wearing jewelry in the kitchen. EI #11 said, small earrings and you could wear a watch and wedding band. 2) A review of the 2013 Food and Drug Administration Food Code revealed: . 2-4 HYGIENIC PRACTICES . Hair Restraints 2-402.11 Effectiveness. (A) Except as provided in . (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair covers or nets, beard restraints, and clothing that cover body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD . On 08/12/15 at 11:03 a.m., the surveyor observed EI #11, a dietary aide with two long pieces of hair extending from beneath her hair restraint. On 08/12/15 at 11:35 a.m., the surveyor observed EI #11 preparing sandwiches with the hair on the back of her head still not covered by the hair restraint. On 08/12/15 at 5:37 p.m., the surveyor conducted an interview with EI #11. The surveyor asked EI #11 what did the faility's policy say about wearing hair restraints. EI #11 replied, All your hair must be on the inside of the net, no hair hanging out. The surveyor asked EI #11 was all of her hair beneath her hair restraint that morning. EI #11 replied, No Ma'am it was not. The surveyor asked EI #11 why was all of her hair not under the hair restraint. EI #11 said she did not check her hair and fold it underneath the hair restraint real good. On 08/13/15 at 2:08 p.m., the surveyor conducted an interview with EI #7, the CDM. The surveyor asked EI #7 what did the facility's policy say about using hair restraints while in the kitchen. EI #7 said the front and forehead should be covered and there should be no hair dangling while working with food. The surveyor asked EI #7 what was there a potential for if hair is not completely restrained. EI #7 replied,Hair can go in food and it can fly anywhere. 3) A review of the 2013 Food and Drug Administration Food Code revealed: . PROTECTION OF CLEAN ITEMS . Drying 4-901.11 Equipment and Utensils, Air Drying Required. After cleaning and SANITIZING, EQUIPMENT . (A) Shall be air dried . On 08/12/15 at 11:58 a.m., the surveyor observed the Robut Coupe blender stored with water on the inside of the blender. EI #12, a cook/dietary aide was present at this time. On 08/12/15 at 5:25 p.m., the surveyor conducted an interview with EI #12. The surveyor asked EI #12, when she and the surveyor observed the Robut Coupe blender that morning, what was on the inside of the blender. EI #12 replied, Water. The surveyor asked EI #12 how should the Robut Coupe blender be stored. EI #12 replied, When you wash it, it should be air dried. On 08/13/15 at 2:08 p.m., the surveyor conducted an interview with EI #7, the CDM. The surveyor asked EI #7 should the Robut Coupe blender be stored with water on the inside. EI #7 replied, No, Ma'am. 4) A review of the 2013 Food and Drug Administration Food Code revealed: 4-6 CLEANING OF EQUIPMENT AND UTENSILS . Objective 4-601.11 Equipment, Food -Contact Surfaces . (A) EQUIPMENT FOOD-CONTACT SURFACES . shall be clean to sight and touch . On 08/12/15 at 11:18 a.m., the surveyor observed the meat slicer covered with a plastic covering. The surveyor asked EI #12 to remove the covering from the meat slicer. After EI #12 removed the plastic covering, the surveyor observed a grease like substance on the back of the meat slicer. The surveyor also observed a small orange colored looking substance on the back as well as on the knob of the meat slicer. On 08/12/15 at 5:25 p.m., the surveyor conducted an interview with EI #12. The surveyor asked EI #12, what did it appear to be on the knob and on the back of the meat slicer. EI #12 replied, Some dry ham, and on the back, grease and ham. The surveyor asked EI #12 how should the meat slicer be stored. EI #12 replied, It should be properly cleaned and sanitized. On 08/13/15 at 2:08 p.m., the surveyor conducted an interview with EI #7, the CDM. The surveyor asked EI #7 who was responsible for ensuring the meat slicer was cleaned before it was stored. EI #7 said the user was responsible. EI #7 also said the facility's policy states it should be cleaned before and after use. 2. On 08/11/15 at 3:00 p.m., EI #13, a Dietary Supervisor was observed wearing dangling earrings and post earrings outside of the hair restraint. On 08/11/15 at 3:00 p.m., the Dietary Manager, EI #7 was observed wearing dangling earrings outside of the hair restraint. On 8/12/15 at 9:30 a.m., an interview was conducted with EI #13. EI#13 was asked what was the policy for wearing earrings while working in the kitchen while plating food. EI #13 stated that earrings can be worn but they must be dime sized, not dangling. EI#13 was also asked what type of contaminant earrings were. EI #13 replied it was a physical contaminant, if it falls off. When asked what was the potential harm to the residents while wearing jewelry while plating food. EI#13 replied, they could get it into their mouth and swallow it. On 8/12/15 at 10:40 a.m., EI #13 was observed wearing 2 sets of gold loop earrings and studs while plating food. EI #13's hair restraint was observed to be behind her ears with the earrings exposed. 5) On 08/12/15 at 11:10 a.m., EI #11, a dietary aide was observed inserting utensils that were still wet and contained water droplets on them into the white paper sleeves to be used for the lunch meal. On 08/12/15 at 11:15 a.m., an interview was conducted with EI #11. The surveyor asked EI #11 should the utensils be free of water droplets and completely dry before being packed. EI #11 stated yes they should. The surveyor asked EI #11 if the utensils were free from water droplets and completely dry. EI #11 replied, no they are not. When asked what was the potential for harm to the residents if the utensils were not completely dry before packing, EI#11 stated, it can cause bacterial growth and affect the resident if they are not completely dry. 6) On 8/12/15 at 12:10 p.m., the fans hanging above the ice machine and the eye wash station in the kitchen were observed to have a build up of dust on the fans and the fans pull rope. On 08/13/15 at 2:25 p.m., an interview with EI #9, the Plant Operations Manager was conducted. EI # was also asked who was responsible for cleaning the lint on the fans that hang from the ceiling in the kitchen and how often were they cleaned. EI# said there were two individuals responsible for cleaning the fans and the last time the fans were cleaned was on July 30th.

Based on observation, interviews and review of the U. S. Public Health Service Food Code, the facility failed to ensure trash and debris on the grounds beneath the loading dock were properly contained in the dumpster. This has the potential to affect all 160 residents residing in the facility. Findings Include: 1. A review of the 2013 Food and Drug Administration Food Code revealed: . 5-5 REFUSE . 5-501.15 Outside Receptacles . (B) Receptacles and waste handling units for REFUSE . are minimized and effective cleaning is facilitated around . the unit . On 08/11/15 at 3:30 p.m., the surveyor observed the area beneath the loading deck near the dumpster. There was an empty juice carton, pieces of white paper, a piece of a withered looking lettuce leaf and wood and twigs observed on the ground. Employee Identifier (EI) #7, the CDM (Certified Dietary Manager)/Food Service Director, accompanied the surveyor to the area beneath the loading deck. The surveyor asked EI #7 what would she say was on the ground. EI #7 replied trash. The surveyor asked EI #7 who was responsible for keeping the area clean. EI #7 said maintenance. The surveyor asked EI #7 would she say the area needed to be cleaned. EI #7 replied, Yes I would. 2. On 08/11/15 at 3:30 p.m., the area beside the dumpster was observed. The surveyor observed garbage and debris such as paper, a sponge, pieces of cardboard and a juice carton in the area. On 08/13/15 at 2:25 p.m., an interview with EI #9, the Plant Operations Manager was conducted. The surveyor asked EI #9 how often the area beside the dumpster was cleaned. EI #9 said the area was pressure cleaned once a week and the debris was picked up daily. EI #9 was asked when did the individual responsible for cleaning that area clean it. EI #9 replied that another individual, a maintenance tech, came to clean the area of the debris as soon as the surveyors addressed the issue. The surveyor asked EI #9 what hours did the person responsible for keeping the area clean work. EI #9 replied the person responsible for keeping the grounds near the dumpster clean worked from 6 a.m. - 2 p.m.

Based on observation, interview and review of a facility policy titled Administration of Dermal Patches, the facility failed to ensure a Licensed Nurse, Employee Identifier (EI) #4 provided privacy for Resident Identifier (RI) #16 while applying a [MEDICATION NAME] Patch on 8/12/15. RI #16, was one of three residents who was affected by this deficient practice during the morning Medication Administration observation. Findings Include: The facility's policy included the following: Administration of Dermal Patches with an Effective date of 04/10 and Reviewed/Updated 01/13, which documented: Policy: Medications are administered as prescribed, in accordance with good nursing principles and practices . RI #16 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #16's medical record revealed PHYSICIAN ORDERS [REDACTED]. On 08/12/15 at 8:44 a.m., the surveyor observed EI #4, a Licensed Practical Nurse administer morning medications to RI #16. RI #16 was observed sitting in a wheelchair in a private room, the door was closed and the blinds at the window were open. The surveyor asked EI #4 could the outside be seen. EI #4 said yes. EI #4 commented that the weather outside was beautiful. The surveyor observed a resident sitting outside in an electric wheelchair near the front entrance of the facility from RI #16's room. Also, an adjacent walkway was observed outside of RI #16's window. EI #4 next removed an old [MEDICATION NAME] Patch from RI #16's left upper back. EI #4 partially removed RI #16's top off the right shoulder exposing skin and a bra strap. EI #4 washed RI #16's skin on the right shoulder and patted the area dry. EI #4 then applied a new [MEDICATION NAME] Patch to RI #16's right upper back. The blinds to the window remained open during this entire procedure. Two passerby's, using the adjacent walkway outside of RI #16's window, were also observed by the surveyor. On 08/12/15 at 12:50 p.m., the surveyor conducted an interview with EI #4. The surveyor asked EI #4, when administering medications such as a [MEDICATION NAME] Patch, what was she suppose to do. EI #4 stated, Apply the patch and provide privacy. The surveyor asked EI #4 when she applied RI #4's [MEDICATION NAME] Patch to the right upper back, what she failed to do. EI #4 stated, Provide privacy, by not closing the shade (blinds) on the window. The surveyor asked EI #4 what was the purpose of closing the shade (blinds) to the window. EI #4 stated, To provide privacy, because I was doing something to (RI #16's) back exposing (RI #16's) skin. The surveyor asked EI #4 what was she (EI #4) able to see out of the window from RI #16's room. EI #4 stated, Another resident sitting out there and two people who had walked by. On 08/13/15 at 8:00 a.m., the surveyor conducted an interview with EI #1, the Director Of Nursing (DON). The surveyor asked EI #1, when a medication nurse does an invasive procedure such as an injection, eye drops, or apply a patch exposing a resident's skin, when is privacy expected to be implemented by the nurse. EI #1 stated, When they administered the patch, or any medication other than the [MEDICATION NAME]. The surveyor asked EI #1 how often are the Licensed Nurses inserviced on privacy when giving medications. EI #1 sated, We do an annual inservice on Med Pass and orientation. The surveyor asked EI #1 if a resident's door and shade/blinds are not closed while the nurse is providing an invasive procedure, would privacy consider to be maintained. EI #1 stated, The door should be closed in a private room, curtain pulled in a semi-private. At night the blinds needed to closed. But during the day they don't, the window have tint to them.

Based on observation, interview, and review of a facility policy titled Storage of Medications, the facility failed to store a controlled medication, Ativan, in a permanently affixed compartment inside the refrigerator. This deficient practice affected one (1) of two (2) medication rooms in the facility. Findings Included: A facility policy titled: Storage of Medication with an Effective date of 07/10/03, documented: Purpose The purpose of this procedure is to ensure that medications are stored in a safe, secure, and orderly manner. General Guidelines . 7) Medications requiring refrigeration must be stored in the refrigerator located in the drug room at the nurses' station. Medication must be separately from food and must be labeled. 8) All controlled drugs are stored under double-lock and key. The facility policy failed to include compliance with the regulations to secure the control drugs in a permanently affixed compartment inside the refrigerator. An Internet article titled Controlled Substance Schedule from the United States Department of Justice Drug Enforcement Administration (DEA) . dated May 4, 2015, documented: . Definition of Controlled Substance Schedules Drugs and other substances that are considered controlled substances under the Controlled Substances Act (CSA) are divided into five schedules. An updated and complete list of the schedules is published annually in Title 21 Code of Federal Regulations (C.F.R.) 1308.11 through 1308.15. Substances are placed in their respective schedules based on whether they have a currently accepted medical use in treatment in the United States, their relative abuse potential, and likelihood of causing dependence when abused. Some examples of the drugs in each schedule are listed below. . Schedule IV Controlled Substances Substances in this schedule have a low potential for abuse relative to substances in Schedule III. Examples of Schedule IV substances include: alprazolam (Xanax®), carisoprodol (Soma®), clonazepam (Klonopin®), clorazepate (Tranxene®), diazepam (Valium®), lorazepam (Ativan®), midazolam (Versed®), temazepam (Restoril®), and triazolam (Halcion®). On 08/12/15 at 12:23 p.m., the surveyor conducted an observation of the medication room with the Director Of Nursing (DON), Employee Identifier (EI) #1 and a LPN (Licensed Practical Nurse), EI #8. While conducting the observation of the medication room, the surveyor asked EI #1 if there were any controlled medications in the refrigerator. EI #1 said yes, Ativan. EI #1 identified injectable, Ativan 2 mg (milligrams) vials, a total of two, as stock supply. Also, a bottle of Ativan concentrate 30 ML (milliliters) bottle stock supply for hospice residents usage, no resident (s) named or prescribed for at this time. Then EI #8, removed the locked box attached to the rack. The locked box was not permanently affixed to the inside of the refrigerator. The box contained Ativan 2 mg, two vials of stocked (Injectable), and Ativan concentrate 30 ML. The rack was easily removed out of the refrigerator by EI #8. On 08/12/15 at 12:40 p.m., the surveyor conducted an interview with EI #1. The surveyor asked EI #1 when storing narcotics in the refrigerator, how should they be stored. EI #1 stated, Securely under two locks. The lock to the med (medication) room door and the lock in the frig (refrigerator). The surveyor asked EI #1 should the narcotics be stored in a locked box permanently affixed inside the refrigerator. EI #1 stated, That would be ideal. The surveyor asked EI #1 how does the process say narcotics should be stored inside the refrigerator. EI #2 stated, We need to secure the shelf inside the refrigerator.

Based on observations, interviews, and review of facility policy and procedures, the facility failed to ensure: 1) a Licensed Nurse did not touch medication with her bare hand when preparing and administering medication to Resident Identifier (RI) #15 on 08/12/15. This affected one of three nurses observed for med pass. 2) the facility further failed to ensure a CNA ( Certified Nursing Assistant) changed her contaminated gloves before touching a clean brief during incontinence care on 08/12/15. This affected RI #4, one of two residents observed during incontinence care. Findings include: 1. A review of a facility policy and procedure titled, NURSING Medication Oral Medications, with a revision date of 05/23/11 revealed: Purpose The purpose of this procedure is to provide guidelines for the administration of oral medications. . Procedure: Steps in the Procedure 1. Wash your hand thoroughly before beginning the procedure. . 3. Arrange the medication tray and cups in the medicine room or move the medication cart to a position outside the resident's room. 4. Select the correct drug from the stock supply or unit dose drawer. Compare the medication label with the medication administration record. . 7. For unit dose tablets/capsules put packaged tablet/capsule directly into medicine cup. RI #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An Admission MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 08/3/2015 identified RI #15 with a Urinary Tract Infection within the last 30 days. On 08/12/15 at 8:02 a.m., the surveyor observed a LPN (License Practical Nurse), EI (Employee Identifier) #8, punch a pill out of a med blister pack into an ungloved hand, place it in a medicine cup with the same ungloved hand and proceeded to RI #15's room down the hall and administer the medicine to RI #15. On 08/12/15 at 8:06 a.m. the surveyor conducted an interview with EI #8. The surveyor asked EI #8 who did she just administer meds to. EI #8 stated, (the resident's name), RI #15. EI #8 was asked how she punched the pill out of the blister pack into the cup. EI #8 stated, I didn't use a cup, I touched the pill. EI #8 was asked how she touched it. EI #8 stated, I punched it out into my hand and put it into the cup. I know better. EI #8 was asked how it should have been done. EI#8 stated, I should have punched it out into the cup. EI #8 was asked what the potential harm was in touching a resident's pill with an ungloved hand. EI #8 stated, Contamination. On 08/13/15 at 2:19 p.m. the surveyor conducted an interview with EI #1, the RN (Registered Nurse), DON (Director of Nursing)/ Infection Control Coordinator. The surveyor asked EI #1 how infections were prevented in the facility. EI #1 stated they educate on good hand washing. EI #1 was asked how they ensured the staff understood what was taught to them. EI #1 stated, By testing on the Care to Learn and they have to past a percentage of the test. EI #1 was asked how pills should be placed from the med card into a med cup. EI #1 stated, Without touching it with your hand. EI #1 was asked should the LPN punch a pill into his or her hand and place it in the med cup and then administer it to a resident. EI #1 stated no. EI #1 was asked what was the facility's policy on punching meds out of a pill blister pack into a med cup. EI #1 stated to punch it into the cup. EI #1 was asked what the potential harm to a resident was if a LPN punched a pill into his or her hand and put it in a medicine cup and then administer it to a resident. EI #1 stated, Potential for infection. 2. A facility policy titled Standard Precautions, with an effective date of 07/10/03, documented: Policy: Standard precautions will be used in the care of all residents regardless of their [DIAGNOSES REDACTED]. Standard precautions apply to blood, body fluids, secretions, excretions regardless of whether or not they contain visible blood, nonintact skin, and mucous membrane. Procedures: . 2) Gloves: . c) Change gloves between tasks and procedures on the same resident after contact with material that may contain a high concentration of microorganisms . RI #4 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Quarterly MDS Assessment with an ARD of 07/29/15, identified RI #4 as scoring a 3 on the BIMS (Brief Interview for Mental Status) indicating severely impaired cognition. RI #4 was also assesses as needing extensive assistance with personal hygiene and being incontinent of bowel and bladder. On 08/12/15 between 4:06 p.m. - 4:32 p.m., the surveyor observed incontinent care being provided to RI #4 by EI #5 and EI #6. RI #4 was transported to bed with a Hoyer lift and the resident's pants was pulled down. After RI #4's pants was pulled down and the adult brief was removed, RI #4 urinated. EI #5 provided incontinent care to RI #4, removed her gloves, washed her hands then put on a clean pair of gloves. EI #5 then picked up a clean adult brief (laid it down) and removed the soiled adult brief from beneath RI #4. EI #5 next picked up the clean adult brief and placed it on RI #4. EI #5 did not change her contaminated gloves after handling the soiled brief and before touching the clean adult brief of RI #4. On 08/12/15 at 4:35 p.m., the surveyor conducted an interview with EI #5, one of the CNA's providing incontinent care for RI #4 on 08/12/15. The surveyor read back the observation of the incontinent care to EI #5 and asked the CNA was that what happened. EI #5 replied, Yes Ma'am. The surveyor asked EI #5 what should she have done after she removed RI #4's soiled brief and before picking up the clean brief. EI #5 replied, Changed my gloves. The surveyor asked EI #5 why should she have changed her gloves. EI #5 said because she had touched the old brief. The surveyor asked EI #5 what could it be considered when touching the soiled brief and then picking up the clean brief. EI #5 replied, Contamination. On 08/13/15 at 1:55 p.m., the surveyor conducted an interview with EI #3, one of the RN (Registered Nurse) Clinical Nurse Managers. The surveyor asked EI #3 should gloves be changed when handling a soiled/dirty brief and before picking up a clean brief. EI #3 replied, Yes. The surveyor asked EI #3 what would it be considered if this was not done. EI #3 replied, Contamination. On 8/13/15 at 2:19 p.m. the surveyor conducted an interview with EI #1. EI #1 was asked, when touching a dirty brief and before touching a clean brief what should the CNA's do. EI #1 stated the CNA's should wash their hands. EI #1 was asked what the facility's policy on handwashing was. EI #1 stated, Wash hands going from clean to dirty, when providing care and making direct contact. EI #1 was asked what the potential harm to the resident was with not washing hands and not changing gloves when going from dirty to clean. EI #1 stated, Infection potential.

Based on observations and interview, the facility failed to ensure the State Survey Results were easily accessible to all residents on three (3) of 3 days of the survey. This had the potential of affect all residents residing in the facility. Findings Include: On 08/11/15 at 4:38 p.m., during the initial tour of the facility, the surveyor observed the State Survey Results posted at the top of a bulletin board on the main hallway. The Survey results were not in easily accessible reach of all residents. On 08/12/15 at 10:02 a.m., the surveyor observed the State Survey Results to remain posted at the top of the bulletin board. On 08/13/15 at 9:17 a.m., the State Survey Results remained at the top of the bulletin board not in easily accessible reach of all residents. On 08/13/15 at 9:57 a.m., the surveyor accompanied the DON (Director of Nursing), Employee Identifier (EI) #1, to where the State Survey Results were posted. The surveyor asked EI #1 were the State Survey Results easily accessible to all residents. EI #1 replied, No.

Based on observations, interview, and record review, the facility failed to ensure the nurse staffing information sheets were posted at the beginning of each shift and contained the actual hours worked for all nursing staff listed on the sheets. The actual hours worked by nursing staff was not listed on the 18 months of staffing information sheets that were reviewed during the survey. This had the potential to affect all 160 residents residing in the facility. Findings Include: The facility policy titled Nursing Staff Data Posting with an effective date of 2/01/11 documented: Policy It is the policy of this facility to complete Nursing Staff Data Posting each shift with actual hours worked from the previous shift. Procedure: 1. Data requirements. the facility must post the following information on a daily basis * Facility Name. * The current date. * The total number and the actual hours worked per shift by licensed and unlicensed nursing staff directly responsible for resident care. * Resident census. 3. The facility will maintain the posted daily nurse staffing data for a minimum of 18 months. On 08/11/2015 at 2:15 p.m., the surveyor observed the nurse staffing information sheet, titled NURSING STAFF DIRECTLY RESPONSIBLE FOR RESIDENT CARE, posted in the front lobby at the receptionist's window. This staffing sheet was dated 08/11/2015 and had been filled out for the entire day, instead of by each shift. This staffing information sheet did not include the actual hours worked by the direct care staff. This staffing form also included a statement at the bottom of the form which documented: .The facility must post nursing staff daily at the beginning of each shift. On 08/13/2015 at 7:35 a.m., the surveyor reviewed the NURSING STAFF DIRECTLY RESPONSIBLE FOR RESIDENT CARE sheets for the past 18 months, from 02/01/2014 to 07/31/2015. These staffing sheets did not document the mandated actual hours worked by nursing staff. On 08/13/15 at 1:55 p.m., the surveyor interviewed EI (Employee Identifier) #2, Staff Development. EI #2 stated she was responsible for the staff posting information. EI #2 explained that she filled out the nursing staff information and placed the form in the Night Supervisors packet. The Night Supervisor then posts the staffing sheet every night after midnight, for the next day. When EI #2 was asked if the actual hours worked were supposed to be on the staffing sheets, she stated that per the facility policy the actual hours worked should be listed. EI #2 further stated that the actual hours worked by nursing staff were not listed on any of the staffing sheets.

Based on record review, observations and interviews, the facility failed to ensure that a CNA (Certified Nursing Assistant) did not touch a clean brief with contaminated gloved hands during the incontinent care of RI (Resident Identifier) #9 on 9/17/14. The facility further failed to ensure that a CNA washed her hands and changed her gloves during the incontinent care of RI #13 on 9/17/14. This affected 2 of 2 residents observed during incontinent care. Findings Include: A review of a facility policy titled, "NURSING Elimination Perineal Care" with an effective date of 12/19/07 revealed: "...12) Remove gloves and discard into designated container. Wash and dry your hands thoroughly...." A review of a facility policy titled, "INFECTION CONTROL Blood Borne Pathogens Hand washing" with an effective date of 7/10/03 revealed: "...2) Employees must perform hand washing procedures under the following conditions: ...f) After contact with blood, body fluids, excretions, secretions, mucous membranes, or non-intact skin; g) After handling items potentially contaminated with blood, body fluids, excretions, or secretions; ..." A review of Potter and Perry's "FUNDAMENTALS OF NURSING" Eighth Edition, Chapter 28 page 419 revealed, "...Change gloves and perform hand hygiene between tasks and procedures on the same patient after contact with material that contains a high concentration of microorganisms. Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces, and before going to another patient. Perform hand hygiene immediately to avoid transfer of microorganisms to other patients or environments. ..." A review of a facility document titled, "Course Completion Report" revealed that EI (Employee Identifier) #2 completed an infection control course on 9/25/2013 and again on 1/28/2014. The document also revealed that EI #2 completed a course on perineal care on 9/16/2014. A review of a facility document titled, "Peri-care Check off list 2014" revealed that EI #3 attended a peri-care inservice. 1) RI #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI 9's most recent Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 7/18/2014, revealed that RI #9 had a BIMS (Brief Interview for Mental Status) score of 3 which indicated RI #9 was severely cognitively impaired for daily decision making. RI #9 was identified as being totally dependent on staff for toileting needs. The MDS also revealed that RI #9 was always incontinent of bowel and had an indwelling catheter. On 9/17/14 at 10:39 AM, EI #2 (a CNA) was observed performing incontinent care for RI #9. EI #2 wiped down the left and right sides of the resident's labia with a different wipe each time, and then discarded them. EI #2 wiped down the middle of the resident's labia with a wipe and discarded it. EI #2 then wiped down the catheter tubing three times; each time with a different wipe and discarded them. EI #2 then touched the resident's clean brief to pull it up between the resident's legs and taped it without changing gloves or washing her hands. On 9/17/14 at 10:59 AM, an interview was conducted with EI #2, CNA. EI #2 was asked after she had cleaned RI #2's peri area and catheter, what should she have done before touching RI #9's clean brief. EI #2 said she should have taken her gloves off. EI #2 was asked at what point during incontinent care should hands be washed or sanitized. EI #2 said that she never heard of that before because she had on two pair of gloves. EI #2 was asked what was the potential harm if she cleaned the resident's peri area and performed catheter care and then touched the resident's clean brief. EI #2 said infection. On 09/18/14 at 8:48 AM, an interview was conducted with EI #1, Infection Control Nurse/DON (Director of Nursing). EI #1 was asked how were infections prevented in that facility. EI #1 said through education along with monthly infection control follow-ups and QA (Quality Assurance) follow-ups. EI #1 was asked how were infections controlled in that facility. EI #1 said if an infection was identified that needed isolation, it would be set up. EI #1 also said it depended on what organism was identified. EI #1 was asked if direct care staff were washing their hands and changing their gloves according to facility protocol. EI #1 said yes. EI #1 was asked how she monitored direct care staff to ensure they were washing their hand and changing their gloves according to facility protocol. EI #1 said random audits and check-offs were done. On 9/18/14 at 8:57 AM, an interview was conducted with EI #1, DON. EI #1 was asked at what point during incontinent care would she expect CNAs to wash their hands or change their gloves. EI #1 said before they started and after they finished incontinent care. EI #1 said that wearing double gloves was allowed, but if they wore one pair of gloves they should have washed their hands and changed their gloves before they started, after they finished with the dirty area and after they finished completely. EI #1 was asked if it was acceptable care in that facility for a CNA to clean a resident's peri area and catheter, and then touch a clean brief with the same contaminated gloves. EI #1 said no. EI #1 was asked why was it not acceptable and she said it was not a good practice. EI #1 was asked what was the potential harm if a CNA cleaned a resident's peri area and catheter, and then touched a clean brief with the same contaminated gloves. EI #1 said the resident would be at risk for infection. 2) RI #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #13's most recent MDS with a ARD of 08/03/2014 revealed a BIMS score of 2 out of 15 (cognitively impaired). RI #13 was identified as having short and long term memory problems and as being severely impaired in cognition for daily decision making. RI #13 was also identified as being totally independent on staff for all ADL's (Activities of Daily Living) and as always being incontinent of bowel and bladder. On 09/17/2014 at 3:50 PM, the surveyor observed EI #3 (a CNA) performing incontinent care on RI #13. When placing the clean brief on RI #13, EI #3 did not wash her hands or change her gloves. EI #3 also pulled up the covers over RI #13, with the same contaminated gloves. On 09/17/2014 at 5:20 PM, an interview was conducted by the surveyor with EI #3. EI #3 was asked at what point during incontinent care was she supposed to change gloves and wash her hands. EI #3 said when she was finished wiping and before she put a clean brief underneath the resident. EI #3 was asked when she cleaned urine from RI #13 and before she touched a clean brief what she should have done. EI #3 explained she should have removed her gloves, washed her hands and applied new gloves. EI #3 was asked if she washed her hands and changed her gloves after cleaning urine from RI #13, and before touching clean brief and linens. EI #3 said she did not. EI #3 was asked should she have. She said yes. EI #3 was asked why she did not wash her hands or change her gloves after cleaning RI #13's perineal area of urine, and before touching the clean brief and linens. EI #3 said it slipped her mind because she was a little nervous. EI #3 was asked what was the potential harm if she did not wash her hands and change her gloves after cleaning urine and before touching a clean brief. She stated the resident could become infected with a urinary tract infection.

Based on interview and record review, the facility failed to report to the State Agency an injury of unknown origin. On 04/02/13, the facility was made aware Resident Identifier (RI) #1 had suspicious bruising to her arms and bilateral breasts. The facility began an investigation on 04/02/13 to determine the cause of RI #1's injury of unknown origin, which was completed 10 days later on 04/12/13. As of 05/22/13, the facility had not reported this injury of unknown origin to the State Agency. This deficient practice affected RI #1, one of three sampled residents. Findings include: The facility's policy titled "RESIDENT ABUSE INVESTIGATION AND REPORTING OF ALLEGED VIOLATIONS OF RESIDENT ABUSE (170-10-02) dated 07/10/03 documented "Policy: It is the policy of this facility to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown source and misappropriation of resident property and to ensure that all alleged violations of Federal or State laws which involve mistreatment, neglect, abuse, injuries of unknown source and misappropriation of resident property are reported immediately to the Administrator of the facility. Such violations will also reported to state agencies in accordance with existing state law ... REPORTING A) Any employee who suspects an alleged violation shall immediately notify the Administrator or his/her designee. The Administrator shall also notify the appropriate state agency in accordance with state law. B) The results of all investigations must be reported to the Administrator or his/her designee and to the appropriate state agency, as required by state law, within five (5) working days of the alleged violation ... ." On 05/07/13 the State Agency received a complaint. According to the complainant, it was determined RI #1 had large bruised areas under her arms, inner arms and to her nipples on both breast. The complainant stated there was no indication the nursing home investigated the cause of RI #1's bruising. RI #1's nursing notes dated 04/02/13 7:04 PM, documented " ... INCIDENT TYPE: other: Huge area of discoloration to bil (bilateral) breast and under right arm pit. DATE OF INCIDENT: 04/02/2013 TIME OF INCIDENT: 06:00PM ... INJURY: bruising to bil breast/right arm pit ... ." In an interview on 05/22/13 at 2:25 PM, EI #4, the Abuse Coordinator, stated she began an investigation of 04/02/13 regarding the bruising to RI #1. EI #1 stated the investigation was complete on 04/03/13. According to EI #4 at the onset of RI #1's bruising she didn't know what happened. When asked if she reported the incident to the State Agency, EI #4 stated she had 24 hours and she didn't feel like it was abuse. When asked if she knew the cause of RI #1's bruising on 04/02/13, EI #4 said no. EI #1 stated once she became aware of the bruising she began an investigation and contacted RI #1's physician who ordered lab work. When asked how could she complete her investigation, when the results of RI #1's lab work was not back and several staff interviews were completed after 04/03/13. EI #1 stated she spoke with the staff via phone. According to EI #1 her investigation was not documented as complete until 04/12/13. EI #1 explained that she didn't feel like this incident was an allegation of abuse. This deficiency was cited as a result of the investigation of complaint/report number AL 961.

Based on observation, interview and record review, the facility failed to ensure Employee Identifier (EI) #1, a Certified Nursing Assistant (CNA) wiped Resident Identifier (RI) #1's buttock from front to back during the provision of incontinent care on 05/22/13. This deficient practice affected RI #1, one of three sampled residents. Findings include: The facility's policy and procedure titled "Perineal Care (40-100-03)" dated 12/19/07, documented " ... Steps in the Procedure ... 9) For a female resident: ... b) Wash perineal area, wiping from front to back ... ." RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an assessment reference date of 02/08/13 identified RI #1 as being moderately impaired in cognitive skills for daily decision making, with long and short term memory problems. RI #1 was assessed as being always incontinent of bowel and bladder functions and being totally dependent on staff for toilet use. During the provision of incontinent care on 05/22/13 beginning at 11:36 AM, EI #1, a CNA, wiped RI #1's buttock area from back to front. In an interview on 05/22/13 at 11:42 AM, EI #1 was asked what direction should she wipe a resident. EI #1 stated from front to back. When asked if that is what she had done, EI #1 replied, "I didn't, I did it backwards." The surveyor EI #1 what was the potential harm in wiping RI #1's buttocks from back to front. EI #1 stated Urinary Tract Infection. This deficiency was cited as a result of the investigation of compliant/report number AL 961.