Based on interviews, record review, facility policy review, and document reviews, the facility failed to ensure Certified Nursing Assistant (CNA) #4 did not raise her voice at one (Resident #1) of seven sampled residents. Findings included: Review of a facility policy titled, Federal Rights of Resident/Guest(s), dated 11/28/2016, indicated, Respect and dignity. The resident/guest has a right to be treated with respect and dignity. A review of Resident #1's Face Sheet revealed the facility admitted the resident on 10/27/2022 with diagnoses that included Unspecified Dementia, Adjustment Disorder with Depressed Mood, and Adjustment Disorder with Anxiety. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/01/2023, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 9 (nine), indicating the resident had moderate cognitive impairment. The MDS indicated Resident #1 required extensive assistance with personal hygiene and was always incontinent of bladder and bowel. A review of Resident #1's care plan with a start date of 10/31/2022, revealed the resident was totally incontinent of bowel and bladder. The care plan directed staff to provide perineal care after each incontinent episode and indicated the resident was on a disposable brief program. Another care plan with a start date of 11/03/2022, indicated Resident #1 had impaired communication related to Dementia. This care plan directed staff to USE SHORT SIMPLE SENTENCES, REPEAT, REPHRASE, AND ADJUST TONES AS NEEDED. A review of the facility Verification of Investigation report indicated on 02/22/2023, Certified Nursing Assistant (CNA) #2 and CNA #3, witnessed CNA #4 scream at Resident #1 because Resident #1 had removed their incontinence brief. Per the report, CNA #4 told Resident #1, I told you to keep your brief on. According to the report, Resident #1 reported they were upset CNA #4 yelled at them. A review of an undated handwritten statement signed by Registered Nurse (RN) #5, the nurse at the time of the incident, indicated CNA #4 was generally loud and boisterous (noisy, energetic, and cheerful), and the CNA had been told to tone it down previously. A review of an undated, typed statement with CNA #4, conducted by the facility as part of their investigation, revealed CNA #4 reported Resident #1 kept removing their incontinence brief during the shift. CNA #4 acknowledged she asked the resident to keep their brief on. In an interview on 07/06/2023 at 2:48 PM, CNA #2 stated she was uncomfortable with the way CNA #4 had yelled at Resident #1. In an interview on 07/06/2023 at 3:10 PM, CNA #3 stated she and CNA #2 witnessed CNA #4 in the entrance of Resident #1's room and they overheard the CNA yell, I told you to keep your brief on at the resident CNA #3 stated she did not think it was right the way CNA #4 spoke to Resident #1, because the resident was dependent on staff and should not be treated that way. In an interview on 07/06/2023 at 3:40 PM, the Administrator stated it was reported that CNA #4 raised her voice at Resident #1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and review of the Centers for Medicare & (and) Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure Resident Identifier (RI) #74's Quarterly Minimum Data Set (MDS) assessment dated [DATE], and RI #120's Quarterly MDS assessment dated [DATE], was accurately coded to reflect the residents received Dialysis treatments during these assessment periods. This affected RI #74 and RI #120, two of 33 sampled residents for whom MDS assessments were reviewed. Findings Include: A review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, dated 10/2019 revealed the following: . SECTION O: SPECIAL TREATMENTS, PROCEDURES, AND PROGRAMS Intent: The intent of the items in this section is to identify any special treatments, procedures, and programs that the resident received during the specified time periods . Planning for Care Reevaluation of special treatments and procedures the resident received or performed, or programs that the resident was involved in during the 14-day look-back period is important to ensure the continued appropriateness of the treatments, procedures, or programs . O0100J, Dialysis Code peritoneal or renal dialysis which occurs at the nursing home or at another facility . 1) RI #74 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of End Stage Renal Disease and Dependence on Renal Dialysis. A review of RI #74's May 2021 Physicians Orders revealed: . 1/04/21 .TRANSFER TO . Dialysis (Facility) . ON MON (Monday), WED (Wednesday), FRI (Friday) . CHAIR TIME 5:20 AM . RI #74's Quarterly MDS assessment, with an Assessment Reference Date (ARD) of 06/07/2021, did not reflect RI #74 received dialysis services during this assessment period. On 11/03/2021 at 3:53 PM, an interview was conducted with Employee Identifier (EI) #8, Registered Nurse (RN)/MDS Coordinator. EI #8 was asked, when did RI #74 receive dialysis. EI #8 replied, three times a week on Monday, Wednesday, and Friday. EI #8 was asked how long had RI #74 been receiving dialysis. EI #8 replied, since 2014. EI #8 was asked, when did RI #74 go to dialysis during May of 2021. EI #8 replied, on his/her scheduled days, Monday, Wednesday, and Fridays. EI #8 was asked, when should the MDS assessment be coded for dialysis. EI #8 replied, if the resident had received it for the look back time it should be marked on the MDS assessment. EI #8 was asked to review RI #74's Quarterly MDS assessment dated [DATE], then the surveyor asked EI #8 how dialysis was coded. EI #8 replied, it was not coded for dialysis. EI #8 was asked how should the Quarterly MDS assessment dated [DATE] have been coded for dialysis. EI #8 replied, it should have been coded for dialysis. EI #8 was asked, what was the problem with RI #74's Quarterly MDS assessment dated [DATE] not being coded for dialysis. EI #8 replied, it would not have indicated RI #74 was receiving dialysis and would not be accurate. 2) RI #120 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include End Stage Renal Disease and Dependence on Renal Dialysis. A review of RI #120's September 2021 Physicians Orders revealed RI #120 had an order dated 08/10/2021 to transfer to dialysis on Monday, Wednesday and Fridays. RI #120's Quarterly MDS assessment, with an ARD of 09/20/2021, did not reflect RI #120 received dialysis services during this assessment period. On 11/01/2021 at 8:35 AM, the surveyor observed that RI #120 had an AV (Arterio/Venous) graft in his/her left upper arm. RI #120 said he/she had been on Dialysis for years and went to Dialysis on Mondays, Wednesdays, and Fridays. On 11/04/2021 at 9:37 AM, the surveyor conducted an interview with EI #8. When asked if RI #120 received dialysis services, EI #8 said yes. EI #8 said RI #120 had received dialysis since he/she had been at the facility. The surveyor asked EI #8, should RI #120's MDS assessments have coded him/her as receiving dialysis services. EI #8 said yes. The surveyor asked EI #8, when reviewing RI #120's Quarterly MDS assessment dated [DATE], was RI #120 coded as receiving dialysis services during this assessment period. EI #8 said no. When asked was this MDS assessment an accurate MDS assessment, RI #8 said no. The surveyor asked EI #8 why should the residents' MDS assessment be coded accurately. EI #8 said the MDS assessment painted a picture of the care the resident was receiving.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to ensure licensed staff did not place the end of the tubing from the tube feeding bottle on the bed covers of Resident Identifier (RI) #113 after disconnecting the tubing from the resident, prior to administering medications by gastrostomy tube. This affected RI #113, one of two residents observed receiving medications by gastrostomy tube. Findings Include: RI #113 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of Dysphagia and Gastrostomy Status. A review of RI #113's November 2021 Physician Orders revealed RI #113 was to receive Keppra and Topamax per gastrostomy tube. On 11/02/2021 at 4:11 PM, Employer Identifier (EI) #5, a Licensed Practical Nurse (LPN) was observed giving medications to RI #113. EI #5 prepared the Topamax and Keppra for administration by Gastrostomy tube. EI #5 was observed to disconnect the connecting tubing from RI #113 and lay the end of the tubing on the bed covers beside RI #113. EI #5 administered the medication and water flush, and reconnected the tubing to the gastrostomy tube. On 11/02/2021 at 4:33 PM, EI #5 was interviewed. EI #5 was asked, what was the process for handling the connecting tubing once it was disconnected from the resident when administering medications by way of the tube. EI #5 replied, disconnect it, and hang over the feeding pole so it does not touch anything. EI #5 was asked where did she place RI #113's tubing when she disconnected it. EI #5 replied, she laid it on the bed covers beside the resident. EI #5 was asked, what was the harm in placing the connecting tubing on the resident's bed covers. EI #5 replied, the risk of spreading infection through the tube when she reconnected it. On 11/03/2021 at 4:01 PM, an interview was conducted with EI #7, the Infection Control Nurse. EI #7 was asked, what was the policy on handling the connecting tubing while giving medications per tube. EI #7 replied, it should not be in contact with anything. EI #7 was asked, what was the harm in the nurse placing the connecting tubing on the covers with the resident. EI #7 replied, infection control.

Based on observation, interview and review of a facility policy tilted Hand Hygiene, the facility failed to ensure Employee Identifier (EI) # 1, Certified Nursing Assistant (CNA), washed and sanitized her hands while feeding multiple residents lunch on 11/14/19 in the dining room. This affected four residents, during one of three dining observations in the dining room. Findings Include: A review of a facility policy titled Hand Hygiene, dated November 14, 2016, revealed the following: Hand washing should be performed between procedures with resident/guest(s) based upon the principle that all blood, bodily fluids, secretions, excretions (except sweat), no-intact skin, and mucus membranes may contain transmissible infectious agents . On 11/14/19 at 11:58 a.m., the surveyor observed EI #1 sitting in front of four residents at a table in the dining room. EI #1 proceeded to feed all four residents during the observation. EI #1 was observed touching the residents' clothes, hands and tops of cups with her bare hand while feeding all four residents. EI #1 did not sanitize her hands between residents. EI #1 was also observed coughing into her left hand and then continuing to feed the residents without sanitizing her hands. EI #1 was further observed to remove a soiled clothing protector from the table with her bare hands and place it in a plastic bag. EI # 1 then proceeded to feed the three remaining residents without sanitizing her hands. On 11/14/19 at 12:30 p.m. an interview was completed with EI #1. EI #1 stated staff should use sani-wipes to clean their hands when feeding multiple residents; however, she stated there were times she had not done that when feeding the residents on 11/14/19. EI #1 was asked if she should have washed or sanitized her hands when she coughed, before feeding another resident. EI #1 stated yes, she should have sanitized her hands. EI #1 was asked why you should sanitize your hands while feeding multiple residents. EI #1 stated so there would not be cross contamination. EI #1 was asked what was the possible negative outcome of not sanitizing your hands while feeding multiple residents or after coughing, prior to feeding another resident. EI #1 stated the residents could get sick. An interview was completed with EI #2, Registered Nurse (RN)/Infection Control, on 11/14/19 at 1:00 p.m. EI #2 was asked when staff should sanitize their hands when feeding multiple residents at the same time. EI #2 responded prior to feeding the resident and after feeding the resident. EI #2 was asked if staff should sanitize their hands if they cough while feeding a resident, before continuing to feed. EI #2 stated yes, they should. EI #2 was asked why staff should sanitize their hands between residents when feeding multiple residents. EI #2 stated to prevent cross contamination. EI #2 was asked what was the potential harm of not sanitizing hands when feeding multiple residents or not sanitizing hands when coughing, prior to feeding a resident. EI # 2 stated cross contamination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and a review of the facility's policy titled, Privacy Upon Entering Resident's Room, the facility failed to ensure staff knocked and requested permission prior to entering Resident Identifier ( RI) #31's room. This affected one of 37 sampled resident's room observed for resident's privacy. Findings Include: A review of the facility's policy titled, Privacy Upon Entering Resident's Room with an effective date of 11/06/14, revealed the following: PURPOSE: The resident has the right to privacy .PROCESS: 1. Prior to entering Resident's room, knock on door and ask permission to enter. RI #31 was re-admitted to the facility on [DATE] with diagnoses including Muscle Weakness and Chest Pain. A review of RI #31's Quarterly Minimum Data Set (MDS) dated [DATE] revealed RI #31 had a Brief Interview for Mental Status score of 7, indicating cognition was severely impaired. On 09/25/18 beginning at 9:28 AM, the following was observed for RI #31: 1. Employee Identifier (EI) #12, Certified Nursing Assistant/CNA entered RI #31's room after knocking, but did not ask permission to enter nor did she announce who she was. 2. 9:37 AM, EI #12, observed to re-entered the resident's room after knocking, but did not ask permission to enter, nor did she announce who she was. 3. 9:50 AM, EI #12 entered resident's room without knocking or asking permission to enter. 4. 9:51 AM, EI #14, Licensed Practical Nurse/LPN entered resident's room without knocking and asking permission to enter. On 9/25/18 at 9:59 AM, during an interview with EI #12, CNA, and EI #14, LPN, the surveyor asked what should be done prior to entering a resident's room. EI #12 and EI #14 stated, Knock on the door and asked if there was something that the resident needs. The surveyor asked was that the facility's policy and procedure. EI #12 and EI #14 stated, Yes. The surveyor asked what else should be done prior to entering a resident's room. EI #14 stated, Tell them who you are. EI #12 stated, I can't think of anything. The surveyor asked EI #12 the last time she entered RI #31's room with the bag, did she knock before entering. EI #12 stated,No, I didn't. The surveyor asked EI #14, when she entered RI #31's room did she knock before entering the resident's room. EI #14 stated, No. The surveyor asked why not. EI #14 stated, I forgot I know better. EI #12 stated, I didn't think about it. The surveyor asked when did they ask permission to enter the resident's room. EI #12 and EI #14 stated, I did not. The surveyor asked what type of issue was it when staff do not knock or staff do not ask permission to enter a resident's room. EI #12 stated, Taking away their right to privacy. EI #14 stated, Taking away their right to privacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure a smoking assessment was completed for Resident Identifier (RI) #106 when the resident was identified as being a smoker. This deficient practice affected RI #106, one of six residents sampled for smoking. Findings Include: RI #106 was admitted to the facility on [DATE], with a diagnosis of Nicotine Dependence. RI #106's admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date of 08/26/18, assessed RI #106 as scoring a 13 on the Brief Interview for Mental Status indicating RI #106 was cognitively intact. On 09/25/18 at 2:21 p.m., RI #106 shared with the surveyor that he/she smoked and smoked before being admitted to facility. On 09/25/18 at 2:32 p.m., the surveyor observed RI #106 smoking in the smoking area with other residents. On 09/27/18 at 7:44 a.m., RI #106 was again observed in the smoking area. This time smoking with a family member. On 09/27/18 at 08:52 a.m., record review revealed there was no smoking assessment found in RI #106's records. On 09/27/18 at 8:54 a.m., the surveyor conducted an interview with Employee Identifier (EI) #10, the Registered Nurse (RN) Unit Manager for the unit where RI #106 resided. The surveyor asked EI #10 how long had RI #106 been a resident at the facility. EI #10 said RI #106 was admitted to the facility on [DATE]. The surveyor asked EI #10 was RI #106 a smoker. EI #10 said yes. The surveyor asked EI #10 how did the facility determine a residents smoking status. EI #10 said the resident would tell the facility on admission and a User Defined Assessment (Safe Smoking Review) would be completed. When asked to show the surveyor RI #106's smoking assessment EI #10 looked in the computer, under assessments, and stated she did not see one. EI #10 said when the facility finds out that the resident is a smoker a smoking assessment should be done. On 09/27/18 at 11:23 a.m., the surveyor conducted an interview with EI #11, a RN/MDS Coordinator. The surveyor asked EI #11 how long had RI #106 been a resident at the facility. EI #11 said since 08/18/18. EI #11 said RI #106 was not a smoker when he/she was admitted . EI #11 said the day after RI #106's admission MDS assessment was completed, RI #106 was observed smoking. The surveyor asked EI #11 what type assessment was completed for residents who smoke. EI #11 said a User Defined Assessment. When asked when should the assessment be completed, EI #11 said when the resident is identified as being a smoker.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, medical record review and a review of the facility's policy titled, Person Centered Care Plans the facility filed to ensure Resident Identifier (RI) #98's care plan was followed for staff to provide weight bearing assist during transfer. This affected one of 37 resident's whose care plans were reviewed. Findings Include: A review of the facility's policy titled, Person Centered Care Plans with an effective date of 8/15/18, revealed the following: . STANDARD: . the facility develops and implements a baseline plan of care . that includes the . healthcare information necessary to properly care for the immediate needs of the resident . PROCESS: I . f) the MDSC (Minimum Data Set Coordinator) will ensure care plan intervention(s) are entered into Care Guide ADLs (Activities of Daily Living)/Intervention . This will provide the CNA (Certified Nursing Assistant) with individualized information needed to meet the resident's care needs. 1. RI #98 was re-admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Syncope and Collapse and Postural Kyphosis. A review of RI #98's Annual MDS dated [DATE] revealed RI #98's Brief Interview for Mental Status score of 13, indicating cognition intact. The MDS also documented RI #98 required extensive assist of one person for transfer, and limited assist of one person for walk in room. A review of RI #98's care plan titled, I WILL MAINTAIN SELF CARE X (TIMES) 90 DAYS . with a start date of 3/14/2017 revealed the following: Intervention . ONE PERSON ASSIST WITH . POSITIONING . Status Active . Role (s) Nursing Assistant . Start Date 3/14/2017 . A review of RI #98's care plan titled, POTENTIAL FOR FALLS . R/T (RELATED TO) IMPAIRED MOBILITY . with a start date of 3/14/2017 revealed the following: Intervention . ASSIST WITH AMBULATION . Status Active . Role (s) . Nursing Assistant . Start Date 3/14/2017 . STAFF TO ENSURE RESIDENT IS STABLE AND SITTING BEFORE LETTING GO OR LEAVING RESIDENT DURING TRANSFER AS RESIDENT WILL ALLOW. 09/19/18 . Start Date 9/19/2018 . A review of the facility's INCIDENT WITNESS STATEMENT for witness,[Employee Identifier (EI) #1/Certified Nursing Assistant], revealed the following: .Date/Time: 9/19/2018 05:45 AM . Witness: (EI #1) . Statement: I was assisting resident to (his/her) recliner, I let go of (him/her) and he/she lost (his/her) balance and sat in the floor. (EI #1's printed name) Date 9-22-18 . On 9/25/18 at 9:25 AM, the following was observed during initial tour of RI #98: large bruised areas to bilateral lower extremities and arms , awake, alert and oriented, up to recliner, The surveyor asked RI #98 what happened to her legs, large bruised areas. RI #98 said he/she fell last Wednesday, the CNA had gotten him/her out of bed, him/her back was facing the dresser, the CNA put him/her (sleepwear) on. RI #98 said he/she was standing in front of him/her chair (pointed to recliner) and the CNA let him/her go and he/she fell backward. On 9/26/18 at 11:51 AM, during an interview with EI #1, CNA, regarding RI #98's, incident dated 9/19/18 at 5:45 AM, the surveyor provided a copy of EI #1's witness statement documented on 9/22/18. The surveyor asked what happed on 9/19/18 at 5:45 AM. EI #1 stated, I was by myself, transferring the resident from the bed to the chair. The surveyor asked how did she transfer the resident. EI #1 stated, I had my left hand was around the back and my right arm was on the resident's right forearm. I assisted (him/her) to the bedside commode and then to the recliner. The resident was facing the recliner and I helped the resident put (his/her) (sleepwear) on and then the resident was turning and (he/she) fell. The surveyor asked in her statement she said she let the resident go, was that correct. EI #1 stated, Yes, I let go for the resident to turn around. The surveyor asked why. EI #1 stated, For (him/her) to turn around, like I always do. The surveyor asked what type of assist and with how many people did the resident require for transferring. EI #1 stated, (He/she) is a one assist. The surveyor asked was that provided during the entire process of transfer. EI #1 stated, Yes. The surveyor asked how, you said you let (him/her) go. EI #1 stated, No, I guess not. The surveyor asked who took her statement. EI #1 stated, No one, I saw a note on the bulletin board telling me where I needed to go to sign a 9A (Incident Report) and what nurses station to go to. I went to the left wing, on the 200 hall, and told the nurse what I needed and she went into a drawer, gave me the paper (pointed to statement) and I signed it and gave the paper back to the nurse. On 9/27/18 at 8:38 AM, an interview was conducted with EI #3, Registered Nurse/RN/MDS and EI #11, RN/MDS. The surveyor and staff reviewed the care plan titled Potential for Falls, the Annual MDS dated [DATE] and the Incident/Accident (I/A) information dated 9/19/18. The surveyor asked what type of assistance did the resident require according to the MDS (8/16/18). EI #3 stated, Extensive one person assist weight bearing. The surveyor asked what did that mean. EI #3 stated, Provide weight bearing assistance during transfers. The surveyor asked according to the care plan interventions dated 3/14/17 related to ambulation/toileting and mobility what was documented. EI #3 stated, Assist with ambulation, toileting and mobility as needed. There is an ADL (Activities of Daily Living) care plan that tells the number of people requiring to assist. EI #11 exited the room and returned with the ADL care plan. The staff and the surveyor reviewed the ADL care plan and the surveyor asked how many staff were required and what intervention was put in place. EI #3 stated, One person was implemented on 3/14/17. The surveyor asked were both interventions on the fall and the ADL care plan current and were they implemented prior to the fall on 9/19/18. EI #3 stated, Yes. EI #11 stated, It hasn't changed. The surveyor asked based on the care plans for ADL and potential for falls and the I/A investigation, was the care plan followed. EI #3 stated, In essence not completely, she (CNA) should have followed through completely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record reviews and a review of the facility's policy titled, Prescriber Medication Orders, the facility failed to ensure a verbal order for Resident Identifier (RI) #95 had all the verbal components upon receipt from the physician. The verbal ordered lacked the time the order was given. This affected one of 39 sampled residents whose physician's orders were reviewed. Findings Include: A review of the facility's policy titled, Prescriber Medication Orders dated 03/11, revealed the following: . Policy Medications are administered only upon the clear, complete, and . order . RI #95 was readmitted to the facility on [DATE] with diagnoses including: Unspecified Dementia, Adjustment Disorder with Depressed Mood and Adjustment Disorder with Anxiety. A review of RI #95's current Quarterly Minimum Data Set (MDS) dated [DATE] revealed RI #95 Brief Interview for Mental Status score of 4, indicating cognition was severely impaired. On 9/26/18 at 10:18 AM, the following observation was made: Employee Identifier (EI) # 16, Licensed Practical Nurse/LPN, prepared and administered the following medications for RI #95:: 1. Cozaar 25 mg (milligram) one po (by mouth) QD (every day) at 9A (AM). 2. Sinemet 25-100 mg one po QD at 9A 3. Buspar HCL (Hydrocholoride) 15 mg one po QID (four times a day) 4. Flavoxate HCL 100 mg one po TID (three times a day) 5. Norco 5/325 mg one po BID (twice a day) 6. Azo Cranberry tab 2 po QID 7. Dilantin 100 mg 2 po BID 8. Linzess 145 mcg (microgram) one po QD 9. Keppra 750 mg one po BID 10. Lexapro 20 mg one po QD 11. Centrum Silver one po QD 12. Seroquel 200 mg one po BID 13. Vitamin D3 2000 Units one po QD 14. Sodium Bicarb 10 grain tablet one po BID 15. Abilify 20 mg one po QD at 9AM 16. Macrodantin 50 mg one po QD On 9/26/18 at 10:30 AM during an interview with EI #16, the surveyor asked what was the time frame for medication administration. EI #16 stated, An hour before and one hour after. EI #16 further stated the ADON (Assist Director of Nurses) had received a verbal order for the medications to be administered late. EI #16 and the surveyor reviewed the resident's chart for the physician's order. The surveyor asked where was the order to administer the medications late from the physician. After review of the physician's orders, EI #16 stated, I'll have to go back in and put a note in since it was a verbal order. The surveyor asked when should a verbal order from a physician be written. EI #16 stated, Within an hour. A review of the facility's handwritten Physician Orders revealed the following: . Order Date . 9/26/18 . Time Code (no time documented) Verbal order given per (Name of Physician) to give resident 9AM medication between 10AM-11:00AM . (signature of EI #2) On 9/26/18 at 10:53 AM, during an interview with EI #16 and EI #8, Director of Nursing/DON and the surveyor, a review was conducted of the physicians's orders for RI #95. The surveyor asked was there a time for the order written to give the 9 AM medications late. EI #16 stated, Not a time. The surveyor asked should there be a time documented when the order was written. EI #16 stated, Yes ma'am. The surveyor asked what was the the facility's policy and procedure. EI #8 stated, I will find out for you. The surveyor asked EI #16 when they reviewed the orders earlier, after she administered the 9 AM medications at 10:20 AM, was the order for late medication administration written. EI #16 stated, It was not written. The surveyor asked EI #8 when should verbal orders be written. EI #8 stated, When it was given to the nurse by the MD. The surveyor asked EI #16 was that what happened. EI #16 stated, No ma'am, not written at the time. On 9/26/18 at 2:52 PM, during an interview with EI #2, Assistant Director of Nurses/ADON, the surveyor and EI #2 reviewed RI #95's physicians orders. The surveyor asked when she wrote the order, did she document the time she received the order. EI #2 stated, No ma'am, I did not . The surveyor asked should she have. EI #2 stated, Yes, because on the order sheet you are supposed to document a time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of the WHO (World Health Organization) recommendations for hand hygiene, and facility policy titled, Dressing - Clean, the facility failed to ensure residents with facility acquired pressure ulcers received wound care in a manner to prevent the potential for cross contamination. This affected RI (Resident Identifier) #22 and RI #60, two of two residents with facility acquired pressure ulcers whose wound care treatments were observed. Findings Include: 1. A review of the medical record revealed RI #22 was admitted to the facility on on 6/15/18 and readmitted on [DATE] with diagnoses to include fracture of femur, with current diagnoses of Pressure ulcer of left buttock and Escherichia coli infection. A review of the medical record revealed laboratory results dated [DATE] for RI #22's wound culture indicating presence of Pseudomonas aeruginosa and Escherichia coli. A review of the admission MDS (Minimum Data Set) assessment dated [DATE] revealed RI #22 had a BIMS (Brief Interview for Mental Status) score of 3 out of a possible 15. This score indicated RI #22 had severe cognitive impairment for daily decision making skills. The MDS indicated RI #22 was totally dependant on two staff for bed mobility and transfers. This assessment indicated no pressure ulcer present on admission. Also, no skin issues were identified at the time of the assessment. A review of the IC. VI -4 a WHO recommendations, provided by the facility revealed, WHO recommendations - 5 moments for hand hygiene. 3. After any procedures or body fluid exposure. A review of the policy titled, Dressings - Clean with an effective date of December 20, 2016 revealed: . PURPOSE: To provide guidelines for the care of wounds and soiled dressings, to decrease the potential for nosocomial infection. PROCESS: . 11. Cleanse the wound as ordered; pick up moistened sponges and wipe the area, cleaning one wound at a time do not contaminate other skin surfaces, . An observation was made on 9/25/18 at 3:43 PM, of pressure ulcer care provided to RI #22 by EI (Employee Identifier) #9, an LPN (Licensed Practical Nurse). There was no indication of contact precautions or any PPE (Personal Protective Equipment) outside of RI #22's room. The wound had previously been identified in a lab result having Pseudomonas and E. Coli (Escherichia Coli) bacteria. EI #9 and EI #7, a CNA (Certified Nursing Assistant) had only gloves for PPE. During the treatment, the LPN had used her gloved hand to remove gauze packing from RI #22's wound. She did not change gloves or wash her hands but proceeded to her clean supplies, poured normal saline onto gauze pads and used those soaked pads to clean RI #22's wound. After the resident complained of pain, EI #9 stopped the treatment, threw all of the supplies away and left the room to retrieve pain medication for the resident. After receiving the pain medication RI #22 later said he was okay for the treatment to continue. EI #9 gathered new supplies and donned gloves. EI #9 poured normal saline to gauze pads from the clean tray. EI #9 then used the soaked pads to clean the wound, disposed of the used gauze pads, then reached in the clean supply tray to get more soaked gauze pads, with the same contaminated glove. EI #9 used the gauze with the contaminated glove to clean inside RI #22's wound. EI #9 then threw the gauze in the biohazard bag. EI #9 reached back into the tray for a third time to get soaked gauze to clean the bed of RI #22's wound with the same contaminated glove. An interview was conducted with EI #9, an LPN (Licensed Practical Nurse) on 09/26/18 at 4:24 PM. EI #9 was asked when was RI #22 identified with Pseudomonas in the pressure ulcer wound. She answered on 9/12/18 when Vancomycin was started. EI #9 was asked what precautions should be taken by staff assisting during wound care for a person with an open wound identified with Pseudomonas. EI #9 answered, to wash and glove like they normally did and stand away, not in contact with the patient. EI #9 added that should be standard. EI #9 was asked when gauze packing is removed from a wound with Pseudomonas and E. Coli and the nurse does not change gloves or wash her hands, what was the concern. EI #9 answered, the risk for infection. EI #9 was asked when a nurse used contaminated gloves to reach in a tray with clean supplies to pour normal saline on gauze pads what was the concern. EI #9 answered, the risk for infection. EI #9 was asked when a nurse used contaminated gloves to clean the bed of a wound, what was the concern. EI #9 answered, the risk for infection. EI #9 was asked what was the concern of a nurse cleaning a wound infected with Pseudomonas and E. Coli with gauze soaked with NS, disposing of that piece of gauze and using the same gloves to reach back in the tray of clean supplies to get gauze and clean the wound again. EI #9 answered, cross contamination. EI #9 was asked what was the concern of a nurse reaching back in the tray of clean supplies for the third time to get gauze to clean the wound with contaminated gloves. She answered cross contamination. 2. A review of the Quarterly MDS assessment dated [DATE] revealed RI #60 was admitted to the facility on [DATE]. RI #60 was assessed as having short and long-term memory deficit. RI #60 was also assessed as severe impaired cognitive skills for daily decision making. Current diagnoses included Idiopathic Progressive Neuropathy, Osteo Arthritis, and Intervertebral Disc Degeneration - Lumbosacral Region. RI #60 was coded as total dependant on staff for bed mobility and transfers. The MDS also reflected RI #60 had a Stage II pressure ulcer. An observation was conducted on 9/26/18 at 2:15 PM of wound care treatment for RI #60 by EI #9. EI #9 was observed to wash her hands, donn gloves and clean RI #60's wound with wet gauze. After disposing of the gauze, EI #9 put the same gloved hand back in the barrier tray to remove more gauze, then wiped in a circular motion with that contaminated glove. EI #9 did not change gloves and washed her hands. EI #9 then applied the gel sheet over the wound site and placed the border dressing over the wound site with the same contaminated glove. An interview was conducted with EI #9, an LPN (Licensed Practical Nurse) on 09/26/18 at 4:24 PM. EI #9 was asked during wound care for RI #60, what was the concern of reaching back into the clean barrier with contaminated gloves to retrieve gauze and clean the wound again. EI #9 answered she believed she had stopped in between and got new gloves. EI #9 was asked after cleaning the wound for RI #60 with the second gauze and the contaminated glove, what was the concern of not changing gloves before covering the wound. EI #9 answered the possibility of drainage on her glove.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews and a review of the facility's policy titled, Incidents and Accidents, the facility failed to ensure: 1. staff did not let go of Resident Identifier (RI) #98 during positioning from standing to sitting in a chair. RI #98 sustained a fall and as a result of this fall, sustained a left calf hematoma and bruising to his/her wrist. RI #98 required x-rays as a result of staff not following RI #98's potential for falls and ADL's care plans, to assist the resident with positioning; 2. RI #44's bedside table did not have gouged areas exposing the particle board and rough edges and 3. RI #87's wheel chair did not have exposed screws protruding from the left front rail of the wheelchair and a tattered torn and rough padding was not exposing foam to the right arm rest. This affected one of 7 residents identified with a history of falls, one of 27 sampled residents with bedside tables and one of 21 residents' wheelchairs observed with torn and tattered areas. Findings Include: A review of the facility's policy titled, Incidents and Accidents, with an effective date of November 10 th, 2014, revealed the following: . PURPOSE: The resident . environment remains as free of accident hazards as is possible . STANDARD: An incident is an occurrence . Examples include but are not limited to: fall/observed on floor . skin tears/bruises . equipment malfunction causing injury to resident . 1. RI #98 was re-admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Syncope and Collapse and Postural Kyphosis. A review of RI #98's Annual MDS dated [DATE] revealed RI #98's Brief Interview for Mental Status score of 13, indicating cognition intact. The MDS also documented RI #98 required extensive assist of one person for transfer, and limited assist of one person for walk in room. A review of RI #98's incident and accident report, dated 09/19/18 at 5:45 AM, revealed RI #98 sustained a fall with a skin tear and a hematoma to the left lower leg. The resident sustained no head injury. A review of RI #98's care plan titled, I WILL MAINTAIN SELF CARE X (TIMES) 90 DAYS . with a start date of 3/14/2017 revealed the following: Intervention . ONE PERSON ASSIST WITH . POSITIONING . Status Active . Role (s) Nursing Assistant . Start Date 3/14/2017 . A review of RI #98's care plan titled, POTENTIAL FOR FALLS . R/T (RELATED TO) IMPAIRED MOBILITY . with a start date of 3/14/2017 revealed the following: Intervention . ASSIST WITH AMBULATION . Status Active . Role (s) . Nursing Assistant . Start Date 3/14/2017 . A review of the facility's INCIDENT WITNESS STATEMENT for witness,[Employee Identifier (EI) #1/Certified Nursing Assistant], revealed the following: .Date/Time: 9/19/2018 05:45 AM . Witness: (Employee Identifier/EI #1) . Statement: I was assisting resident to (his/her) recliner, I let go of (him/her) and (he/she) lost (his/her) balance and sat in the floor. (EI #1's printed name) Date 9-22-18 . A review of the facility's interview with EI #1, conducted by facility staff dated 9/27/18 at 9:41 PM, revealed the following: . 3. Have you assisted this resident prior to the morning of 09/19/2018? Yes several times . (EI #1 printed name and signature) 9-27-2018 On 9/25/18 at 9:25 AM, large bruised areas to RI #98's bilateral lower extremities and arms was observed during the initial tour. The surveyor asked RI #98 what happened to his /her legs, referring to the large bruised areas. RI #98 said he/she fell last Wednesday. He/she said the CNA had gotten him/her out of bed to put his/her (sleepwear) on. RI #98 said he/she was standing in front of his/her chair (pointed to recliner) and the CNA let him/her go and he/she fell backward. On 9/26/18 at 11:51 AM, an interview was conducted with EI #1 CNA, regarding RI #98's incident dated 9/19/18 at 5:45 AM. The surveyor provided EI #1 with a copy of her witness statement documented on 9/22/18. The surveyor asked what happed on 9/19/18 at 5:45 AM. EI #1 stated, I was by myself, transferring the resident from the bed to the chair. The surveyor asked how did she transfer the resident. EI #1 stated, I had my left hand was around (his/her) back and my right arm was on the resident's right forearm. I assisted (him/her) to the bedside commode and then to the recliner. The resident was facing the recliner and I helped the resident put (his/her) (sleepwear) on and then the resident was turning and (he/she) fell. The surveyor asked in her statement she said she let the resident go, was that correct. EI #1 stated, Yes, I let go for the resident to turn around. The surveyor asked why. EI #1 stated, For (him/her) to turn around, like I always do. The surveyor asked what type of assist and with how many people did the resident require for transferring. EI #1 stated, (He/she) is a one assist. The surveyor asked was that provided during the entire process of transfer. EI #1 stated, No, I guess not. The surveyor asked who took her statement. EI #1 stated, No one, I saw a note on the bulletin board telling me where I needed to go to sign a 9A (Incident Report) and what nurses station to go to. I went to the left wing, on the 200 hall, and told the nurse what I needed and she went into a drawer, gave me the paper (pointed to statement) and I signed it and gave the paper back to the nurse. On 9/26/18 at 12:12 PM, during a phone interview with EI #15, Licensed Practical Nurse/LPN, the surveyor asked if she remembered the fall regarding RI #98's fall on 9/19/18. EI #15 stated, Yes. The surveyor asked when did she investigate that fall. EI #15 stated, The same morning of the fall around 5:45 AM. The surveyor asked based on the fall investigation, what did she determine was the cause of the fall. EI #15 stated,, According to the resident and EI #1, EI #1 stated she let go of the resident during transfer from the bed to the recliner. The surveyor asked what did EI #1 tell her when she asked why did she let go of the resident. EI #15 stated, She only said she just let the resident go as the resident was turning. The surveyor asked according to the care plan that documented assist with ambulation, mobility, and transfers, did EI #1 provide assistance during the resident's transfer on 9/19/18. EI #15 stated, No, she let go of the resident. The surveyor asked did she review the resident's care plan. EI #15 stated, Yes, she was a transfer assist x 1. The surveyor asked based on her assessment, her investigation and review of the resident's care plans, was the care plan followed. EI #15 stated, No. The surveyor asked based on the her assessment, her investigation and review of the resident's care plans, was the fall avoidable. EI #15 stated, Yes. On 9/27/18 at 8:38 AM, during an interview EI #3, Registered Nurse/RN/MDS and EI #11, RN/MDS, the surveyor and staff reviewed the care plan titled Potential for Falls, Annual MDS dated [DATE] and Incident/Accident (I/A) information dated 9/19/18. The surveyor asked what type of assistance did the resident require according to the MDS (8/16/18). EI #3 stated, Extensive one person assist weight bearing. The surveyor asked what did that mean. EI #3 stated, Provide weight bearing assistance during transfers. The surveyor asked according to the care plan interventions dated 3/14/17 related to ambulation/toileting and mobility what was documented. EI #3 stated, Assist with ambulation, toileting and mobility as needed. There is an ADL (Activities of Daily Living) care plan that tells the number of people requiring to assist. EI #11 exited the room and returned with the ADL care plan. The staff and the surveyor reviewed the ADL care plan and the surveyor asked how many staff were required and what intervention was put in place. EI #3 stated, One person and was implemented on 3/14/17. The surveyor asked were both interventions on the fall and the ADL care plan current and were they implemented prior to the fall on 9/19/18. EI #3 stated, Yes. and EI #11 stated, It hasn't changed. The surveyor asked based on the care plans for ADL and potential for falls, the I/A investigation, was the care plan followed. EI #3 stated, In essence not completely, she (CNA) should have followed through completely. The surveyor asked EI #3 you stated that staff did not follow through completely, was this fall preventable. EI #3 stated, Possible preventable. The surveyor asked how could this fall have possibly been prevented. EI #3 stated, If she (CNA) could have continued to assist the resident to the chair. On 09/27/18 at 10:07 AM, an interview was conducted with EI #2/Assistant Director of Nurses/ADON. The surveyor and EI #2 reviewed RI #98's I/A investigation, care plans for potential for falls and ADLs and the MDS dated [DATE]. The surveyor asked what did the facility determine was the cause of the fall. EI #2 stated, The CNA let go of the resident at that time and the resident tried to grab the foot of the bed and the padding came loose and the resident fell. The surveyor asked based on all of the information reviewed, was this fall preventable. EI # stated, Yes Ma'am. 2. RI #44 was admitted to the facility on [DATE] with diagnosis including Hypertension and Atherosclerotic Heart Disease. A review of RI #44's September 2018 Physician Orders revealed the following: .Order Date . 4/28/17 . Orders . PLAVIX 75 MG (MILLIGRAM) TABLET GIVE ONE TABLET BY MOUTH EVERYDAY . Order Date 5/03/17 . Orders . ASPIRIN 81 MG CHEW TABLET GIVE ONE TABLET BY MOUTH EVERYDAY . A review of RI #44's current Quarterly MDS dated [DATE] revealed RI #44's BIMS score of 3, indicating cognition severely impaired. A review of RI #44's care plan titled, POTENTIAL FOR SKIN TEARS with a start date of 4/28/17 revealed the following: .Intervention . OBSERVE FOR ENVIRONMENTAL CONCERNS . Status Active . Role (s) All . Start Date 4/28/2017 . On 9/25/18 at 9:16 AM, RI #44 was observed during the initial tour of the facility sitting in his/her wheelchair (w/c). The resident's bedside table with observed with gouged out areas exposing wood like areas, jagged, and rough to the touch. The surveyor asked RI #44 who had he/she told about the table. RI #44 said about a week ago, he/she told a nurse, but did not know who the nurse was. The surveyor asked what was the nurse's response. RI #44 said the nurse told him/her that the facility was supposed to get some new things,which would be nice. On 9/26/18 at 8:00 AM, RI #44 was observed in his/her w/c with the breakfast tray on the bedside table. The bedside table was observed with gouged out areas, exposed openings with wood like areas, edges rough. On 9/26/18 at 8:05 AM, EI #17, LPN/Staff Development, was observed standing in the day room with the residents eating breakfast. The surveyor asked whose bedside table was RI # 44's breakfast tray sitting on. EI #17 stated, Its (his/her) table, (RI #44). The surveyor asked EI #17 to describe the areas on the bedside table. EI #17 stated top of the table is peeling off, (touched the areas of the bedside table) and stated, Its' rough. The surveyor asked what was the potential for harm. EI #17 stated, Skin Tears. 3. RI #87 was re-admitted to the facility on [DATE] with diagnoses including: Type II Diabetes Mellitus and Atherosclerotic Heart Disease of Native Coronary Artery and Hypertension. A review of RI #87's current Quarterly MDS dated [DATE] revealed RI #87's Brief Interview for Mental Status score of 3, indicating severely impaired in cognition. A review of RI #87's care plan titled, POTENTIAL FOR SKIN TEARS with a start date of 3/2/17 revealed the following: . Intervention . OBSERVE FOR ENVIRONMENTAL CONCERNS . Status Active . Role (s) All . Start Date 3/2/2017 . On 9/26/18 at 8:00 AM, RI #87 was observed with discolorations to the Bilateral Upper Extremities. RI #87's w/c left arm rest was observed with round padding, front aspect torn, tattered with foam exposed, left round padding loose, not secured and the front aspect of the w/c rail-2 screws noted protruding outward, not screwed in and secured. 09/26/18 08:12 AM, during an interview with EI # 16, Licensed Practical Nurse/LPN, the surveyor asked what type of coverings did the resident have on his/her w/c armrest. EI #16 stated, Both have padded armrest. The surveyor asked EI #16 to describe the padded armrest. EI #16 stated, Both padded armrests are dirty, the right armrest is torn and left armrest is dirty and both need to be replaced. The surveyor asked what was the potential for harm. EI #16 stated, If the left armrest moves the resident could get pinched and the front area on the left side of the chair, screws are sticking out and the right padding, I don't know. The surveyor asked what could happen to the resident's skin. EI #16 touched both padding's on the wheelchair. EI #16 then stated, The right armrest is torn and could cause skin breakdown, because the resident has areas of redness.

Based on observation, interviews and a review of the facility policy's titled, Storage of Medications and Biologicals, the facility failed to ensure: 1. a bottle of expired Bismatrol 8 ounce (236ml/milliliter) was not left on a medication cart and 2. an expired box of Ear Drops (Carbamide Peroxide 6.5% (percent)-0.5ounce,15ml) was not left on a medication cart. The deficient practices affected two of five medication carts viewed for expired medications. Findings Include: A review of the facility policy's titled, Storage of Medications and Biologicals dated 03/11, revealed the following: . Procedures . 11. Outdated, . medications . are removed from stock . disposed of according to procedures for medication disposal . On 9/27/2018 at10:00 AM, the surveyor conducted a medication cart reviews on the Right Wing. Employee Identifier (EI) #4, LPN/Licensed Practical Nurse was also present. There on one of two med carts was a stock bottle of Bismatrol 8 ounce (236ml), with an expired date of July 2018. The surveyor asked EI # 4 who was responsible for checking the medication carts for expired medications. EI #4 stated, All nurses that worked the medication cart. The surveyor asked EI #4 did she agree the Bismatrol was expired on July 2018. EI #4 stated, Yes. The surveyor asked EI #4 what was the potential harm for using expired medications. EI #4 stated, The medications change the formulary and it does not work good. On 9/27/2018 at 10:45 AM, the surveyor conducted medication cart reviews on the Left Wing. EI #5, LPN was also present. There on one of three med carts was an unopened box of Ear drops (Carbamide Peroxide 6.5%-0.5ounce-15ml-), with an expiration date of 8/18. The surveyor asked who was responsible for checking medication carts for expired medication. EI #5 stated, All nurse's, but this was not the cart she usually worked. The surveyor asked if she agreed the ear drop medication had an expiration date of 8/18. EI #5 stated, Yes. The surveyor asked what was the potential harm of using medications that were expired. EI #5 stated, She did not think there was any harm. EI #5 further stated, The person should have checked the expiration date before the medication was put on the medication cart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, review of a policy titled, Multidrug Resistant Organism and review of a policy titled, Contact Precautions, the facility failed to ensure the licensed nurse: 1. changed gloves and washed her hands during wound care treatment, after removing contaminated materials from the pressure ulcer cite during care for RI (Resident Identifier) #22 2. utilized appropriate Personal Protective Equipment during care for RI #22 3. disposed of potentially contaminated linens appropriately after wound care for RI #22 and 4. did not use contaminated gloves during wound care for RI #60. This affected RI #22 and RI #60, two of two resident identified with facility acquired pressure ulcers and two of five residents with pressure ulcers. Findings Include: A review of the medical record revealed RI #22 was admitted to the facility on [DATE] with diagnoses to include fracture of femur, with current diagnoses of Pressure ulcer of left buttock and Escherichia coli infection. A review of the medical record revealed laboratory results dated [DATE] for RI #22's wound culture indicating presence of Pseudomonas aeruginosa and Escherichia coli. A review of the admission MDS (Minimum Data Set) assessment dated [DATE] revealed RI #22 had a BIMS (Brief Interview for Mental Status) score of 3 out of a possible 15. This score indicated RI #22 was cognitively impaired for daily decision making skills. The MDS also indicated RI #22 was extensive to total dependant on two staff for bed mobility and transfers. This assessment indicated no pressure ulcer present on admission. Also, no skin issues were identified at the time of the assessment. A review of a policy titled, Multidrug Resistant Organism (MDROs) with an effective date of 9/1/17, revealed, .Purpose: To prevent transmission of multi-drug resistant organisms (MDROs). When implementation of routine control measures is not effective, control measures should be intensified. Policy: Prevention, containment and eradication measures including use of contact precautions are indicated to prevent the spread of resistant microorganisms that have been identified within a facility. I. General Measures: A. Prevention and control of MDROs within this facility is considered a resident/guest safety measure.I. Standard precautions shall be used at all times for resident/guest care as identification of resident/guest(s) colonized or infected with MDROs is not always possible. A review of a policy titled, Contact Precautions with and effective date of 12/1/2009, revealed, . PURPOSE: It is the intent of this facility to use contact precautions in addition to Standard Precautions for resident/guest's . environment. Indirect Contact Transmission - transfer of the infectious agent through a contaminated intermediate object or person.II. GLOVES AND HAND HYGIENE . B. Gloves should be changed after having contact with infective material . An observation was made on 9/25/18 at 3:43 PM, of pressure ulcer care provided to RI #22 by EI (Employee Identifier) #9, an LPN (Licensed Practical Nurse). There is no indication of contact precautions or any PPE (Personal Protective Equipment) outside of RI #22's room. The wound had previously been identified in a lab report results as having Pseudomonas and E. Coli (Escherichia Coli) bacteria. EI #9 and EI #7, a CNA (Certified Nursing Assistant) used only gloves for PPE during the entire observation. EI #9 placed towels above and below the wound site. During the treatment, the LPN had used her gloved hand to remove gauze packing from RI #22's wound. She did not change gloves or wash her hands but proceeded to her clean supplies, poured normal saline onto gauze pads, and used those soaked pads to clean RI #22's wound. After the resident complained of pain, EI #9 stopped the treatment and threw all of the supplies away. When she re-entered the room, EI #9 gathered new supplies and donned gloves. EI #9 poured normal saline to the gauze pads, used the soaked pads to clean the wound, disposed of the used gauze pads and then reached in the clean supply tray to get another soaked gauze, with the same contaminated glove. She then cleaned the wound in to outer circle, threw the gauze in a bio bag and then EI #9 reached into the tray for second time to get another wet gauze, without changing gloves. EI #9 used the gauze with the contaminated glove to clean inside RI #22's wound. EI #9 disposed of the gauze and reached back into the tray for a third time to get soaked gauze to clean the bed of RI #22's wound, with the same contaminated glove on. During the observation EI #9 was asked what type of infection was in the wound. EI #9 answered Pseudomonas. During the observation, EI #7, CNA, was asked how far he was standing from the open uncovered wound. He answered approximately twelve inches. At 4:26 PM, after care was completed, EI #7 retrieved a bag for the towels that had been lying next to RI #22's infectious wound. EI #9 threw away the wound vacuum equipment that had been on the bedside table saying, You can't take it back out of the room because of contamination. EI #9 and EI #7 took the bio (biological) hazard bag and the bag of towels to the soiled utility room. The bag of towels was put with other soiled linens. When asked why, EI #9 answered, If it had had wound drainage on it we would have put it in a melt away bag. Potentially contaminated linen items are put in melt away bags and separated from other linens. An interview was conducted with EI #7 on 9/26/18 at 4:12 PM. EI #7 was asked what he had been trained related to PPE to be used when assisting with wound care involving Pseudomonas or E. Coli. EI #7 answered to double glove, wash your hands, make sure everything was sterile and clean. Make sure things are red bagged, if need to be. If linens have to be washed, they have to be put in their melt-away bags. Make sure your clothing was not touching them and gown up if you are supposed to. If they need to be isolated, they will have it posted. EI #7 was asked if anything had been posted outside of RI #22's room regarding isolation, he answered no ma'am. EI #7 was asked if the towels were put in a melt away bag and he answered no ma'am. EI #7 was asked if he and EI #9 had double gloved and he answered that he was not, but was not certain if the nurse had. EI #7 was asked if he or the nurse had worn an isolation gown, he answered no ma'am. EI #7 was asked when had he received training regarding PPE and he answered it had been a few months prior to the survey. EI #7 was asked if he was aware RI #22 had Pseudomonas and E. Coli in his/her wound and he answered he was not. EI #7 was asked if he should have been made aware, he answered he believed so. EI #7 was asked what he would have done if he had been aware that he was going to be 10-12 inches from an open wound that was infected with Pseudomonas and E. Coli. EI #7 answered he would have definitely had on an isolation gown and double gloved. EI #7 was asked what was the facility policy regarding following appropriate PPE guidelines. EI #7 answered if residents needed to be on isolation, they are educated and made aware. He said isolation supplies should be outside the room. An interview was conducted with EI #9, an LPN (Licensed Practical Nurse) on 09/26/18 at 4:24 PM. EI #9 was asked what was the facility policy or actions that should be taken when a resident was found to have Pseudomonas in their pressure ulcer wound. EI #9 answered to notify the physician and describe the wound and the concern to them. EI #9 added that was all she had been told to do. EI #9 was asked when was RI #22 identified with Pseudomonas in the pressure ulcer wound. She answered on 9/12/18 when Vancomycin was started. EI #9 was asked what was done or what measures where put in place at that time. EI #9 answered the antibiotic had been started. EI #9 was asked what should have been done when the Pseudomonas was identified in RI # 22's wound. EI #9 answered, to call the physician, notify him of laboratory results, review current treatment and ask if there were any new orders. EI #9 was asked what PPE should be donned during wound care for a resident with an open wound identified with Pseudomonas and she answered gloves. EI #9 was asked if that was all and she answered as far as she was aware of, they always just use gloves. EI #9 was asked what precautions should be taken by staff assisting during wound care for a person with an open wound identified with Pseudomonas. EI #9 answered to wash and glove like they normally do and stand away, not in contact with the patient. EI #9 added that should be standard. EI #9 was asked when gauze packing is removed from a wound with Pseudomonas and E. Coli and the nurse does not change gloves or wash her hands, what was the concern. EI #9 answered, the risk for infection. EI #9 was asked when a nurse used contaminated gloves to reach in a tray with clean supplies to pour normal saline on gauze pads, what was the concern. EI #9 answered, the risk for infection. EI #9 was asked when a nurse used contaminated gloves to clean the bed of a wound, what was the concern. EI #9 answered, the risk for infection. EI #9 was asked what was the concern of staff assisting with wound care standing 10-12 inches from a wound infected with Pseudomonas and E. Coli with only gloves for PPE. EI #9 answered, they would be at risk for cross contamination. EI #9 was asked what was the concern of a nurse cleaning a wound infected with Pseudomonas and E. Coli with gauze soaked with NS, disposing of that piece of gauze and using the same gloves to reach back in the tray of clean supplies to get gauze and clean the wound again. EI #9 answered, cross contamination. EI #9 was asked what was the concern of a nurse reaching back in the tray of clean supplies for the third time to get gauze to clean the wound with contaminated gloves. She answered, cross contamination. EI #9 was asked what should be done with towels used during wound care for a wound infected with Pseudomonas and E. Coli. EI #9 answered, they should be placed in a red melt-away bag. EI #9 was asked if that was done after care for RI #22. She answered, not at that time. EI #9 was asked if it was true that towels used during wound care for a resident with Pseudomonas and E. Coli were not contaminated unless wound drainage was visible, she answered no, it is contaminated. EI #9 was asked what was the concern of a nurse performing care to an open wound infected with Pseudomonas and E. Coli with no PPE except for gloves. EI #9 answered the facility does not put residents on isolation for Pseudomonas. EI #9 was asked if RI #22 should have been on isolation. EI #9 answered, possibly but when the wound and drainage are covered with a bandage, they are not put on isolation if contained in the bandage. EI #9 was asked would she expect, while doing wound care, to wear a gown since the wound and drainage was not covered at that time and she answered yes. EI #9 was asked should gowns be outside the room if needed for resident/wound care and she answered yes. EI #9 was asked what she had been trained related to PPE to be used when performing wound care for a resident who has Pseudomonas and E. Coli. EI #7 answered just the same as any other wound care. EI #9 was asked how would that prevent the potential for cross contamination and she answered as long as she did not come in contact with anything else with the resident it was okay. EI #9 was asked if anything was posted outside RI #22's room indicating an infection and she answered, no ma'am. EI #9 was asked how would CNAs or other staff know about the potential exposure to Pseudomonas and E. Coli, she answered they would not know. EI #9 was asked during wound care for RI #60, what was the concern of reaching back into the clean barrier with contaminated gloves to retrieve gauze and clean the wound again. EI #9 answered, she believed she had stopped in between and got new gloves. EI #9 was asked after cleaning the wound for RI #60 with a second gauze and the contaminated glove, what was the concern of not changing gloves before covering the wound. EI #9 was answered, the possibility of drainage on her glove. An interview was conducted with EI #18, LPN/Infection Control Nurse, on 9/27/18 at 9:33 AM. EI #18 was asked what was the facility policy or actions taken when a resident is found with Pseudomonas in their pressure ulcer wound. EI #18 answered based on case by case, the decision would be made whether or not to place the resident on contact precautions. EI #18 was asked when was RI #22 identified with Pseudomonas in their pressure ulcer wound. She answered 9/16/18. EI #18 was asked what was done or what measures were put in place at that point. EI #18 answered the MD (Medical Doctor) was notified, new orders were received to discontinue Vancomycin and begin Levaquin. EI #18 added RI #22 already had orders for wound care and they stayed the same. EI #18 was asked when was it done and she answered on 9/16/18. EI #18 was asked if the MD addressed contact precautions and she answered the nurses notes did not specify. EI #18 was asked if the MD should address contact precautions and she answered, yes. EI #18 was asked what PPE should be donned during wound care for a resident with a wound identified with Pseudomonas and she answered gloves and gown. EI #18 was asked what precautions should be taken by staff during wound care for a person with a wound identified with Pseudomonas. EI #18 answered, on a case by case basis. EI #18 was asked when gauze packing was removed from a wound with Pseudomonas and the nurse did not change gloves or wash her hands, what was the concern. EI #18 answered, contamination. EI #18 was asked when a nurse used contaminated gloves to reach in a tray with clean supplies to pour normal saline on gauze, what was the concern and she answered, contamination. EI #18 was asked when a nurse used contaminated gloves to clean the bed of a wound, what was the concern. EI #18 answered, reinfecting the area. EI #18 was asked what was the concern of staff assisting with wound care, standing 10-12 inches from a wound infected with Pseudomonas with only gloves for PPE. EI #18 answered, she would not be concerned if staff were not having any contact. EI #18 was asked what was the concern of a nurse cleaning a wound infected with Pseudomonas with gauze soaked with NS, disposing of that piece of gauze and using the same gloves to reach back in the tray of clean supplies to get gauze and clean the wound again. EI #18 answered, contamination. EI #18 was asked what was the concern of a nurse reaching back in the tray of clean supplies for the third time to get gauze to clean the wound with contaminated gloves. EI #18 answered, contamination. EI #18 was asked what should be done with towels used during wound care for a wound with Pseudomonas. EI #18 answered, to put them in a melt away bag, put in a red bag and take it to laundry. EI #18 was asked if it was true that towels used during wound care for a resident with Pseudomonas were not contaminated unless wound drainage was visible and she answered, no. EI #18 was asked how did she know they were not contaminated. EI #18 answered, if they were in that residents room they were contaminated. EI #18 was asked how could she ensure that drainage from a wound with Pseudomonas was contained within a bandage. EI #18 answered, if the outside of the bandage was clean with no drainage noted. An interview was conducted with EI #8, the Director of Nursing on 9/27/18 at 12:06 PM. EI #8 was asked when was EI #22 identified with Pseudomonas and E. Coli in their pressure ulcer wound. She answered, 9/19/18. EI #8 was asked what was done or what measures were put in place after the infection had been identified. EI #8 answered, the antibiotic was changed to Levaquin and RI #22 was sent out that same day. EI #8 was asked when RI #22 returned on 9/24/18, whether she knew if the Pseudomonas and E. Coli were clear and isolation precautions had been set up, she answered, no. EI #8 was asked if isolation should have been started and she answered, yes. EI #8 was asked what was done or what measures were put in place. EI #8 answered, nothing that referred to isolation. EI #8 was asked what should have been done. EI #8 answered, if RI #22 left the facility showing Pseudomonas and E. Coli positive per laboratory results and came back without documentation that it was cleared, they should have had isolation precautions in place. EI #8 was asked why should it have been done and she answered, to keep it from spreading. EI #8 was asked what PPE should be donned during wound care for a resident with a suspicion of a wound identified with E. Coli and Pseudomonas. EI #8 answered, use a mask with the goggles, gown, gloves, and entire PPE packet. 2. A review of the Quarterly MDS assessment dated [DATE] revealed RI #60 was admitted to the facility on [DATE]. RI #60 was assessed as having short and long-term memory deficit. RI #60 was assessed as severly impaired cognitive skills for daily decision making. Current diagnoses included Idiopathic Progressive Neuropathy, Osteo Arthritis, and Intervertebral Disc Degeneration - Lumbosacral Region. RI #60 was coded as total dependant of staff for bed mobility and transfers. The MDS also reflected RI #60 had a Stage II pressure ulcer. An observation was conducted on 9/26/18 at 2:15 PM, of wound care treatment for RI #60 by EI #9. EI #9 was observed to wash her hands, donn gloves and clean RI #60's wound with wet gauze. After disposing of the gauze, EI #9 put the same gloved hand back in a barrier tray to remove more gauze, then wiped in a circular motion with that contaminated glove. EI #9 did not change gloves and washed her hands. EI #9 then applied the gel sheet over the wound site and placed the border dressing over the wound site, with the same contaminated glove. An interview was conducted with EI #9, an LPN (Licensed Practical Nurse) on 09/26/18 at 4:24 PM. EI #9 was asked during wound care for RI #60, what was the concern of reaching back into the clean barrier with contaminated gloves to retrieve gauze and clean the wound again. EI #9 answered, she believed she had stopped in between and got new gloves. EI #9 was asked after cleaning the wound for RI #60 with the second gauze and the contaminated glove, what was the concern of not changing gloves before covering the wound. EI #9 answered, the possibility of drainage on her glove. An interview was conducted with EI #18 on 9/27/18 at 11:56 AM. EI #18 was asked when should gloves be changed. EI #18 answered, when they were visibly soiled, after resident care and after exposure to blood or drainage. EI #18 was asked should a nurse change their gloves after cleaning a wound before placing a new dressing and she answered, yes. EI #18 was asked should a nurse place a contaminated gloved hand in clean supplies and she answered, no. EI #18 was asked what was the potential harm for not changing gloves after cleaning a wound before placing a new dressing. EI #18 answered, contamination. EI #18 was asked what was the potential harm for placing a contaminated gloved hand in clean supplies. EI #18 answered, contamination

Based on observations, interview, review of a facility policy titled Cleaning of Miscellaneous Equipment and Utensils and review of the 2017 U.S. (United States) Public Health Service Food Code, the facility failed to ensure: 1) a container of mustard in the walk-in-cooler did not have mustard on the outside of the container on two of four days of the survey; 2) a scoop was not stored in the flour bin on the initial tour of the kitchen and 3) dust particles were not observed on the back of the oven, and on pipes above the area where desserts and breads were prepared. This was observed on one of four days of the survey. These deficient practices had the potential to affect all 135 residents receiving meals from the dietary department. Findings Include: (1) On 09/24/18 at 5:03 p.m., the surveyor observed in the walk-in cooler a gallon container of mustard with mustard on the outside of the container. On 09/26/18 at 10:52 a.m., the surveyor observed mustard to remain on the outside of the container. On 09/26/18 at 1:40 p.m., the surveyor conducted an interview with Employee Indentifer (EI) #6, the Dietary Manager (DM). The surveyor asked EI #6 what was on the outside of the mustard container. EI #6 said dried mustard. The surveyor asked EI #6, how should containers be when placed back into the walk-in refrigerator. EI #6 said they should be wiped off and cleaned. The surveyor asked EI #6 when containers are stored with food on the outside of the container what is there a potential for. EI #6 said the mustard could get on other items. (2) Review of a facility policy titled Cleaning of Miscellaneous Equipment and Utensils, with an effective date of 08/23/17, documented: . 23. Ingredient Bins: . Place scoops in covered containers or plastic zip lock bags . On 09/24/18 at 5:03 p.m., the surveyor observed a scoop inside the flour bin. On 09/26/18 at 1:40 p.m., the surveyor conducted an interview with EI #6. The surveyor asked EI #6 where should the container (scoop) to remove flour from the flour bin be stored. EI #6 said some where other than the flour bin. The surveyor asked EI #6 what was there a potential for when it is stored in the flour bin. EI #6 said germs. (3) A review of the 2017 U.S. Public Health Service Food Code documented: . 4-6 CLEANING OF EQUIPMENT AND UTENSILS . 4-601.11 . Nonfood-Contact Surfaces . (C) NonFOOD-CONTACT SURFACES . shall be kept free of an accumulation of dust . On 09/26/18 at 10:41 a.m., the surveyor observed dust like particles on the pipes above a food preparation table and on the back of the oven. On 09/26/18 at 11:09 a.m., the surveyor conducted an interview with EI #6. The surveyor asked EI #6 what was the table beneath the pipes used for. EI #6 said the table was used to prepare dessert and mix breads. The surveyor asked EI #6 what did it look like was on the pipes and on the area behind the stove. EI #6 said it looked like dust. EI #6 proceeded to rub the pipes above the preparation table and dust fell onto the table. The surveyor asked EI #6 what was there a potential for if the dust came loose from the areas. EI #6 said it could fall into the food.