Based on interview, record review, and a review of facility policies titled, ABUSE AND NEGLECT: RECOGNIZING AND REPORTING and NEW HIRE POLICY, the facility failed to ensure their policies contained information or direction to staff on how they would implement each of the Seven (7) Components of Abuse per State and Federal Regulations as well as ensure that systems for timely registry, licensure and background checks were completed. This deficient practice was evident through one of nine personnel files reviewed. Findings include: A review of a policy titled ABUSE AND NEGLECT: RECOGNIZING AND REPORTING, with a revised date of 11/28/17 revealed: .POLICY . Seven(7) Components of Abuse per State and Federal Regulations 1. Screening of potential hires 2. Training of employees a. New employees at time of hire b. Ongoing for current employees 3. Prevention of abuse 4. Identification of incidents which need to be investigated 5. The investigative process 6. Protection of the resident during an investigation 7. Reporting to the appropriate authorities A review of the above policy did not contain a description of what was expected by the staff for each of the seven components. A review of a policy titled, NEW HIRE POLICY with an effective date of 01/09/15 revealed, .POLICY . Professional licensure and certifications shall be verified prior to employment with the appropriate licensing board: . A review of a form utilized by the titled, PRE-EMPLOYMENT SCREENING AN AGENT OF EMPLOYERS SCREENING SERVICES, INC (Incorporation) revealed, EI (Employee Identifier) #8, LPN (License Practical Nurse) signed and gave permission for a background check to be performed on 2/07/18. A review of EI #8's personnel record revealed a hire date of 2/6/18. The background check was performed 2/7/18. EI #8's licensure and certification was verifed on 2/7/18 and the abuse registry was checked or verified on 2/8/18. The dates revealed the information was not obtained until after the date of hire. On 06/07/18 at 09:42 AM, an interview was conducted with EI #4, the Director of Nursing (DON), Registered Nurse (RN). EI #4 was asked, what the seven components of abuse were in the facility's abuse policy. EI #4 said, screening of new hires, education, prevention, keeping the residents safe, identifying things that needed to be investigated, investigative, protection from abuse and reportable. EI #4 was asked to show the surveyor what the facility did as it related to the policy for screening new hires for abuse. EI #4 said it was not in the policy. On 06/07/18 at 10:18 AM, an interview was conducted with EI #4. EI #4 returned with a new hire policy. EI# 4 stated that staff referred to the new hire policy for screening of potential hires under the abuse policy. EI #4 was asked what did she direct staff to do regarding screening of potential hires. EI #4 said, we would refer back to the new hire policy. EI #4 was asked based on what policy. EI #4 replied, the abuse and neglect policy. EI #4 was asked, where in the abuse policy did it direct staff to refer to the new hire policy regarding screening of potential new hires. EI #4 stated that the people responsible for new hires were aware of the new hire policy and screening process. EI #4 was asked who was responsible for new hires. EI #4 said, the ladies in the office. EI #4 was asked, what if they were on extended leave how would another staff know how to refer to the new policy. EI #4 said, we would educate anyone who would have to fill in that job roll. EI #4 was asked what was the purpose of policy and procedures. EI #4 stated for reference of what our policy and procedures are and directs the staff. EI #4 was asked, where was it documented in the abuse policy for staff to refer to the new hire policy for the screening of new hires. EI #4 stated it was not specifically spelled out. EI #4 was asked regarding the new hire policy, what should be checked prior to employment. EI #4 said the licensure and certification status. EI #4 reviewed personnel file of EI #8 and was asked what was EI #8's hire date. EI #4 stated EI #8's hire date was 2/6/18. EI #4 was asked, according to the new hire form, what was EI #8's hire date. EI #4 said, EI #8's hire date was 2/6/18. EI #4 was asked, what was on the enrollment change form for EI #8. EI #4 stated 2/7/18. EI #4 was provided with the criminal background form and asked, when was the background checked. EI #4 stated 2/7/18. EI #4 was asked, when was the Licensure and Certification check done. EI #4 stated 2/7/18. EI #4 was asked when was the nurse aide registry check performed. EI #4 said 2/8/18. EI #4 was asked, if the new hire date documented 2/6/18, and policy documented licensure and certification should be verified prior to employment, based upon screening potential hires from the abuse policy, was the policy for new hire and abuse followed. EI #4 stated she felt like it was a clerical error. On 06/07/18 at 11:24 AM, an interview was conducted with EI #9, Business Office Manager/BMO. EI #9 was asked, when did she complete the licensure and certification checks on EI #8. EI #9 stated, they are usually checked the day before or morning the new hire comes in to work. EI #9 was asked when was licensure verifications and certifications done for screening of potential hires. EI #9 stated the day before or the morning before they come in to fill out paperwork. The new hire generally fills out paperwork before they can work. EI #9 was asked who was responsible to ensure licensure and certification information was done prior to hire. EI #9 stated, I do that on everybody. EI #9 was asked if that was policy and procedure. EI #9 stated that was just how it was always done and how she continued when corporate took over. EI #9 was asked when EI # 8 was hired, was policy and procedure followed for screening prior to hire. EI #9 stated she forgot to do the CNA registry check until the following day. EI #9 was asked, when was the abuse registry checked. EI #9 stated on 2/7/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review and a review of the facility's monitoring document titled, Incontinent Care Monitoring,, the facility failed to ensure a Certified Nursing Assistant/CNA separated Resident Identifier (RI) #48's perineal area to visualize the perineal opening, wiped from front to back, changed gloves after cleaning the resident and before applying a clean brief This deficient practice affected one of two residents observed during incontinent care. Findings Include: A review of the facility monitoring document titled, Incontinent Care Monitoring without a date, revealed the following: . 12. Removed and clean BM (Bowel Movement) if present . 13. Removed gloves 14. Washed hands . 15. Clean gloves applied . 18. Area wiped only once using the same wipe . 19. Cleaned from front to back 20. Remove gloves and dispose properly 21. Wash hands 22. Apply clean gloves . RI #48 was admitted to the facility on [DATE] with diagnoses including Sepsis due to Urinary Tract Infection (UTI). A review of RI #48's Quarterly Minimum Data Set MDS) dated [DATE] revealed RI #48 had a Brief Interview for Mental Status score of 15, indicating cognition intact. The MDS also documented RI #48 as requiring extensive assistance with toileting and personal hygiene.; and frequently incontinent of urine. On 06/06/18 at 6:50 AM, the following was observed during incontinent care:-EI #2, CNA, washed her hands and applied gloves, EI # removed the resident's brief observed with a moderate amount of yellow urine. EI #2 obtained a separate periwipe and wiped the right and the left groin. EI #2 obtained a periwipe and down the perineal opening once. EI #2 did not wipe the right and left area of the perineal area and did not visualize the perineal opening. EI #2 removed her soiled gloves and applied gloves. EI #2 did not wash her hands after removing her soiled gloves and before applying clean gloves. RI #48 was positioned on the right side. EI #2 obtained separate periwipes and wiped the left buttock from back to front twice. EI #2 repositioned the resident on the left side, EI #2 obtained a clean brief and placed underneath RI #48 and removed old brief. EI #2 did not remove her soiled gloves after cleaning and before applying a clean brief. EI #2 obtained a periwipe and wiped the right buttock from front to back three times without changing the position of the periwipe. EI #2 pulled the clean brief out from underneath the resident. EI #2 removed her soiled gloves and applied clean gloves. EI #2 did not wash her hands after removing her soiled gloves and before applying clean gloves. EI #2 applied a barrier ointment cream to RI #48. EI #2 removed her soiled gloves and applied clean gloves. EI #2 did not wash her hands after removing soiled gloves and before applying clean gloves. EI #2 secured RI #48's brief, gathered the soiled linen bags and disposed of the linen bags. EI #2 removed her soiled gloves and applied clean gloves EI #2 did not wash her hands after removing her soiled gloves and before applying clean gloves. EI #2 assisted the resident to the right side by placing a pillow under the resident's back and shoulder and floated the resident's right lower extremity. On 06/06/18 at 7:00 AM, during an interview with EI #2, the surveyor asked when did she visualize the perineal opening and wipe the right and the left sides of the perineal area. EI #2 stated, I didn't. The surveyor asked what direction should a resident be wipe. Front to back. The surveyor asked when she wiped the buttock, what direction did she wipe. EI #2 stated, From the top of the buttocks to the bottom. The surveyor asked when should hands be washed. EI #2 stated, Before you start the care, anytime come into contact with bowel movement, should change gloves and wash hands. The surveyor asked did she wash her hands between changing gloves every time. EI #2 stated, No, ma'am, not every time. The surveyor asked did she change gloves after cleaning the resident and before applying a clean brief. EI #2 stated, No, I did not. The surveyor asked did EI #2 remember using the same area of the periwipe three times without changing the position of the periwipe. EI #2 said she did not remember. The surveyor asked what was the potential harm to the resident knowing all that she had done. EI #2 stated, Urinary Tract Infection and skin breakdown.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and medical record review, the facility failed to ensure Resident Identifier (RI) #45's Oxygen (02) concentrator humidifier water bottle was not empty during the administration of oxygen and that the filter did not have an accumulation of dust. This affected one of four residents observed with oxygen. Findings Include: RI #45 was admitted to the facility on [DATE] with diagnoses including: Chronic Obstructive Pulmonary Disease Exacerbations and Cardiovascular Disease with Diastolic Heart Failure. A review of RI #45's current Significant Change Minimum Data Set (MDS) dated [DATE] revealed RI #45's Brief Interview for Mental Status score of 6, indicating cognition severely impaired. The MDS also documented RI #45 was short of breath/trouble breathing with exertion, sitting at rest and lying flat. A review of RI #45's June 2018 Physician's Orders revealed the following: . 02 (oxygen) @ (at) 2L (liter)// MIN (minute) VIA NC (nasal cannula) . On 6/06/18 at 6:15 AM, during initial tour, no water was observed in RI #45's humidifier bottle and oxygen was infusing at 2l/nc; an accumulation of dust and debris was observed in the oxygen filter. On 6/06/18 at 7:20 AM , during an interview with Employee Identifier (EI) #5, LPN, the surveyor and EI #5 observed RI #45's oxygen concentrator with the humidifier and asked what was in the humidifier's bottle. EI #5 observed the humidifier and stated, Approximately 30 cc (cubic centimeter) of water. The surveyor asked how much water should be in the humidifier bottle at all times. EI #5 stated, At least 200 cc (cubic centimeter). The surveyor asked what was on the oxygen filter. EI #5 stated, looks probably dust. The surveyor asked when was the last time EI #5 had checked the resident. EI #5 stated, About 15 to 5 this morning (6/6/18). On 6/07/18 at 3:46 PM, during an interview with EI #6, LPN/Restorative Nurse, the surveyor asked who was responsible for cleaning the oxygen filters, when and replacing the water in the humidifier bottles. EI #6 stated, The nurse is responsible to change the bottles out, when the bottle is low or empty, we have a contract that cleans the machine, I don;t know how often, but I don't know. The surveyor asked what about the Certified Nursing Assistants/CNAs. EI #6 stated, Nursing staff and CNAs can clean them as needed, but Southeastern comes once a month to service. On 6/07/18 at 4:10 PM, during an interview with EI # 4, Chief Nursing Officer, EI #4 informed the surveyor that maintenance was responsible for cleaning the oxygen filters as needed. The surveyor asked how is maintenance made aware when a resident's oxygen filter needs cleaning. EI #4 stated, Either verbally by staff or they write it in the maintenance book. On 6/08/18 at 8:41 AM, during an interview with EI #7, Maintenance Director, the surveyor asked who was responsible to ensure oxygen filters are clean in between Southeastern's servicing. EI #7 stated, I'm not sure, the whole facility. The surveyor informed EI #7 that EI #4 said that maintenance, EI #7 was responsible. The surveyor asked EI #7 to explain. EI #7 stated, No ma'am I can't explain that, the specific task has not been assigned to me.; to my assumption, I was not aware that they needed to be cleaned more than once a month, not as far as the oxygen filters on the concentrators.

**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 title, OXYGEN ADMINISTRATION PER SIMPLE MASK, as well as procedure for incontinence care, this facility failed to ensure staff implemented infection control measures during incontinence care and the placement of oxygen on a resident (RI #48) after the oxygen tubing was on the floor. This affected one of four residents observed during incontinence care and oxygen administration. Findings Include: A review of the facility's monitoring document titled, Incontinent Care Monitoring without a date, revealed the following: . 20. Remove gloves and dispose properly 21. Wash hands 22. Apply clean gloves . A review of the facility's policy titled, OXYGEN ADMINISTRATION PER SIMPLE MASK with a revised date of 03/24/16, revealed the following: POLICY . Oxygen tubing must be kept off of the floor . RI #48 was admitted to the facility on [DATE] with diagnoses including: Sepsis Due To Urinary Tract Infection (UTI) and Chronic Obstructive Pulmonary Disease. A review of RI #48's Quarterly Minimum Data Set MDS) dated [DATE] revealed RI #48 had a Brief Interview for Mental Status score of 15, indicating intact cognition. A review of RI #48's June 2018 Physician's Orders revealed the following: . MEDICATIONS . 02 (oxygen) @ (at) 3L (Liter)/ (per) MIN (minute) NC (Nasal Cannula) . On 06/06/18 at 6:50 AM, the following was observed during incontinence care: Employee Identifier (EI) #2, CNA, washed her hands and applied gloves, EI #2 was observed to remove her gloves and apply clean gloves after wiping the perineal area, after wiping the left and right buttock. EI #2 did not wash her hands after removing her soiled gloves and before applying clean gloves. EI #2 removed RI #48's soiled brief and applied a clean brief, removed her soiled gloves and applied clean gloves. EI #2 did not wash her hands after removing her soiled gloves and before applying clean gloves. EI #2 applied a barrier cream to RI #48, removed her soiled gloves and applied clean gloves. EI #2 did not wash her hands after removing her soiled gloves and before applying clean gloves. On 06/06/18 at 7:00 AM, during an interview with EI #2, the surveyor asked when should hands be washed. EI #2 stated, Before you start the care, anytime come into contact with bowel movement, should change gloves and wash hands. The surveyor asked did she wash her hands between changing gloves every time. EI #2 stated, No, ma'am, not every time. The surveyor asked did she change gloves after cleaning the resident and before applying a clean brief. EI #2 stated, No, I did not. The surveyor asked what was the potential harm to the resident knowing all that she had done. EI #2 stated, Urinary Tract Infection and skin breakdown. On 6/06/18 06:45 AM, RI #48 was resting in bed and awake, oxygen nasal cannula on the floor. RI #48 stated, I must have lost it during the night. On 6/06/18 at 6:50 AM, RI #48 was observed with nasal cannula on. Several staff were observed in the resident's room. The surveyor asked staff who put the nasal cannula on the resident. EI #3, CNA, stated, I did. The surveyor asked where did she get the nasal cannula from. EI #3 stated, It was in the floor, but I wiped it off. The surveyor asked what did she wipe the nasal cannula off with. EI #3 stated, A sani-wipe from off the medication cart. The surveyor asked was that policy and procedure to clean a nasal cannula with a sani wipe. EI #3 stated, No. The surveyor asked what should she have done. EI #stated, Got another one (nasal cannula). The surveyor asked why didn't she. EI #3 stated, I don't know. On 06/07/18 11:44 AM, during an interview with EI #4, Chief Nursing Officer/CNO, the surveyor asked when a resident's oxygen tubing (NC) is on the floor what should staff do. EI #4 stated, To change the tubing out.