Every finding on record at Allen Morgan Health and Rehabilitation Center

Based on policy review, medical record review, observation, and interview, the facility failed to ensure residents were free from accident hazards for 2 of 2 (Resident #5 and #19) sampled residents reviewed. The findings include: 1. Review of the facility policy titled, [Named Facility] Chemical Storage Policy, dated 6/2025, revealed .All chemicals used within the facility will be stored labeled, handled, and disposed of in a safe manner .Keep in locked cabinets or rooms when not in direct use .must never be .stored in resident rooms . Review of the facility policy titled, [Named Facility] Accident and Hazard Prevention Policy, dated 6/2025, revealed .The facility is committed to providing an environment that is free from avoidable accident hazards.Sharps or personal care items.razors.accessible to residents who cannot safely use them.Residents accessed as unable to safely manage personal care items will have such items secured by staff. Review of the undated facility policy titled, [Named Facility] Sharps Safety Policy, revealed .The facility maintains procedures for the safe use, storage, and disposal of sharps to prevent injury.to residents.to establish safe practices related to sharps and personal care items capable of causing injury.Sharps include, but are not limited to.Disposable razors.sharps must not be left unattended in resident rooms or common areas.Any sharps injury or exposure will be reported immediately.Education includes proper handing.non-compliance will be addressed per facility policy. 2. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction, Atrial Fibrillation, and Dementia. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed a score of 7 on the Brief Interview for Mental Status (BIMS) assessment, which indicated Resident #5 was severely cognitively impaired. Resident #5 had no limitations in Range of Motion (ROM) to the upper extremities, used a wheelchair for mobility and required supervision with bed mobility. Observation in Resident #5's room on 2/9/2026 at 10:25 AM, 12:04 PM, and 2:36 PM, revealed a bottle of bleach wipes left on Resident #5's dresser. During an observation and interview on 2/9/2026 at 3:32 PM, Licensed Practical Nurse (LPN) B confirmed that bleach wipes should never be left in a resident's room and removed the bleach wipes from Resident #5's dresser. During an interview on 2/11/2025 at 11:15 AM, the Director of Nursing (DON) was asked should bleach wipes be left in a resident's room. The DON stated, Bleach wipes should never be left in a resident's room. 3. Review of medical record revealed Resident #19 was admitted to the facility on [DATE], with diagnoses including Cerebral Ischemia and Post Traumatic Stress Disorder. Review of admission MDS dated [DATE], revealed it had not been transmitted at the time of the survey. Observation in Resident #19's room on 2/9/2026 at 10:12 AM, 12:00 PM, and 3:24 PM, revealed 1 black razor in a wash basin in the shower. During an observation and interview on 2/9/2026 at 3:30 PM, Registered Nurse (RN) A was asked if a razor should be left in Resident #19's room unsecured and unattended. RN A stated, No they should be kept in the Resident's drawer out of sight. During an interview on 2/10/2026 at 8:10 AM, the DON was asked if a razor should be left unsecured and unattended in a resident's room. The DON stated No .

Based on policy review, temperature log review, observation, and interview the facility failed to ensure the low temperature (chemical sanitization) dish machine reached the required wash temperature of 120 degrees. The facility had a census of 14 residents and 14 of those residents received a tray from the kitchen. The findings include: The facility did not provide the owner's manual for use of the dish machine. Review of the facility's undated policy titled, DISHMACHINE TEMPERATURE RECORD (LOW TEMPERATURE MACHINE), revealed .CORRECTIVE ACTION: Stop using the machine and notify your supervisor if .the wash temperature is less than 120 [symbol for degrees Fahrenheit] .Do not use the dishmachine until your supervisor tells you that is can be used again . Review of the July 2021 dish machine temperature logs revealed, the breakfast wash temperature was less than 120 degrees Fahrenheit on 7/5/2021, 7/6/2021, 7/7/2021, 7/8/2021, 7/10/2021, 7/12/2021, 7/13/2021 and 7/14/2021. The lunch wash temperature was less than 120 degrees Fahrenheit on 7/13/2021 and 7/14/2021. The dish machine temperature log revealed no corrective action was documented. Observation of the dish machine in use on 7/14/2021 at 6:15 PM, revealed the temperature during the wash cycle was 98 degrees Fahrenheit on the dish machine thermometer. The Dietary Manager confirmed the dish machine wash cycle did not meet proper temperature. During an interview on 7/14/2021 at 6:34 PM, the Dietary Director stated that education needs to be done.

Based on Centers for Disease Control and Prevention (CDC) guidance, policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 1 of 2 nurses (Licensed Practical Nurse (LPN) #1) failed to perform hand hygiene for 1 of 3 sampled residents (Resident #28) observed during medication administration. The findings include: Review of the CDC guidance titled, Infection Prevention during Blood Glucose Monitoring and Insulin Administration, dated 2/2/2011, revealed .wear gloves .during any .procedure that involves potential exposure to blood or body fluids . Review of the facility's policy titled, Handwashing/Hand Hygiene, with a revision date of 8/2019, revealed hand hygiene should be performed after handling contaminated objects and when anticipating contact with blood or body fluids. The facility's policy also revealed .Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare associated infections . Observation in the resident's room on 7/12/2021 at 8:20 AM, revealed LPN #1 touched Resident #28's over bed table, moved the bed covers, handed him a glass of water, removed a breakfast tray from the over bed table, took an alcohol prep pad out of his uniform pocket, and cleaned the resident's left lower abdomen. LPN #1 then administered the scheduled dose of insulin to Resident #28 without gloves or performing hand hygiene. Observation in the resident's room on 7/12/2021 at 8:30 AM, revealed LPN #1 entered Resident #28's room, moved a wheelchair, touched the over bed table, moved the resident's gown, took an alcohol prep out of his uniform pocket, and cleaned the back of the resident's left arm. LPN #1 then administered the sliding scale dose of insulin to Resident #28 without gloves or performing hand hygiene. During an interview on 7/14/2021 at 4:20 PM, the Director of Nursing (DON) confirmed that hand hygiene and donning gloves should be performed prior to administering insulin medication.

Based on policy review, observation, and interview, the facility failed to ensure food was served under sanitary conditions when 1 of 5 (Certified Nursing Assistant (CNA) #1) staff members placed a dirty meal tray on a cart with a clean undelivered meal tray and failed to perform hand hygiene during dining observations. The findings included: The facility's Handwashing/Hand Hygiene policy with a revision date of (MONTH) (YEAR) documented, Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections .Policy Interpretation and Implementation .2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .7. Use an alcohol-based hand rub containing at least 62% (percent) alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations .b. Before and after direct contact with residents .l. After contact with objects (e.g. (example), medical equipment) in the immediate vicinity of the resident .o. Before and after eating or handling food . Observations in the Skilled hall on 10/1/18 beginning at 12:43 PM, revealed CNA #1 entered Resident #84's room, delivered a meal tray to this resident, and picked up a dirty tray (Resident #84's tray from breakfast) and placed this tray in the cart with 1 clean tray still left to deliver. CNA #1 then entered Resident #83's room, delivered a meal tray to this resident, and did not perform hand hygiene. CNA #1 removed a pillow and adjusted this resident's bed, and continued to set up the tray without performing hand hygiene. Observations in the Skilled hall on 10/02/18 beginning at at 8:17 AM, revealed CNA #1 delivered a meal tray to Resident #20, adjusted Resident #20's bed, touching the bed, and continued to set up the meal tray without performing hand hygiene. CNA #1 then used hand gel prior to leaving the room. CNA #1 entered Resident #231's room, delivered a meal tray to this resident, adjusted the bed touching the bed, and continued setting up the meal tray without performing hand hygiene. CNA #1 then used hand gel prior to leaving the room. CNA #1 entered Resident #83's room, delivered a meal tray to this resident, adjusted the bed, touching the bed, and moved a pillow from under Resident #83's arm, then continued to set up the tray without performing hand hygiene. Interview with the Director of Nursing (DON) on 10/2/18 at 4:47 PM, in room [ROOM NUMBER], the DON was asked if a tray that had been in a room, had been uncovered, and that a resident had already eaten from the tray, should the tray be placed back on the cart with trays that had not been delivered. The DON stated, No. The DON was asked what should be done after assisting residents, touching objects, and before setting up a meal tray. The DON stated, .hand wash .

Based on policy review, personnel record review, and interview, the facility failed to follow the facility policy for prescreening of 5 of 5 (Licensed Practical Nurse (LPN) #1 and 2, Registered Nurse (RN) #1, Certified Nursing Assistant (CNA) #1, and Housekeeping staff #1) employees. The findings included: 1. The facility's Background Screening Investigations policy documented .Our facility conducts employment background screening checks, reference checks and criminal conviction investigation checks on individuals making applications for employment .The Personnel/Human Resources Director, or other designee, will conduct employment background checks, reference checks and criminal conviction checks .on persons making application for employment with this facility . 2. Review of personnel records revealed the facility did not complete a reference check on the following: a. Review of the personnel record for LPN #1 revealed a hire date of 10/3/17. There was no documentation a reference check was completed. b. Review of the personnel record for LPN #2 revealed a hire date of 9/25/17. There was no documentation a reference check was completed. c. Review of the personnel record for RN #1 revealed a hire date of 9/25/17. There was no documentation a reference check was completed. d. Review of the personnel record for CNA #1 revealed a hire date of 8/22/17. There was no documentation a reference check was completed. e. Review of the personnel record for Housekeeping Staff #1 revealed a hire date of 10/11/17. There was no documentation a reference check was completed. Interview with the Human Resources Director on 11/1/17 at 12:57 PM, in the conference room, the Human Resources Director was asked if she completed reference checks on new employees. The Human Resources Director stated, No . Interview with the Director of Nursing (DON) on 11/1/17 at 1:03 PM, in the conference room, the DON was asked if she completed reference checks on new employees. The DON stated, .I don't write it anywhere .

Based on policy review, review of the Safety Data Sheets (SDS), review of the Material Safety Data Sheets (MSDS), observation, and interview, the facility failed to ensure the environment was free from the accident hazards of chemicals, aerosol sprays, and sharps, in 6 of 21 (Room #136, 135, 120, 122, 126, and 136) resident rooms. The findings included: 1. The facility's Shaving the Resident policy documented, .Dispose of the razor in a designated sharps container .the razor must be transported .in a puncture-resistant, closed container . 2. The SDS for (brand name) Chlorhexidine Gluconate 4% (percent) Solution documented, .Hazard Statements Causes skin irritation Causes serious eye damage Suspected of causing cancer .Store locked up .May cause irritation of respiratory tract .May cause severe damage to eyes .Prolonged contact may cause redness and irritation .Ingestion may cause irritation to mucous membranes .gastrointestinal irritation, nausea, vomiting and diarrhea . 3. The SDS for (brand name) Mouthwash documented, .Direct Contact with eyes may cause temporary irritation . 4. The SDS sheet for PDI Sani-Cloth Bleach Germicidal Disposable Wipes documented, .Caution: Causes moderate eye irritation. Avoid contact with eyes . 5. The MSDS sheet for (brand name) VapoRub Ointment documented, .Eye contact with the product may produce mild transient, superficial irritation .Possible mild gastrointestinal irritation with nausea and vomiting and diarrhea, if large quantities are ingested . 6. Observations in Room #136 on 10/30/17 at 11:08 AM, 12:25 PM, and 2:27 PM, revealed the following unsecured and unattended hazards: a. a bottle of chlorhexidine gluconate 4% solution skin antiseptic wash on top of the chest of drawers b. a large pair of scissors on top of the over-bed table 7. Observations in Room #135 on 10/30/17 at 11:10 AM, and 2:45 PM revealed the following unsecured and unattended hazards: a. 1 large bottle of aerosol hair spray on the over-bed table b. 1 large bottle of dry mouth rinse on the counter in the bathroom 8. Observations in Room 120 on 10/30/17 at 11:19 AM, 2:27 PM, and 4:43 PM revealed the following unsecured and unattended hazards: a. a jar of vaporub ointment on top of the night stand b. a disposable razor in the bathroom b. 1 can of aerosol deodorant in the bathroom 9. Observations in Room 122 on 10/30/17 at 11:24 AM and 2:49, and 4:48 PM, revealed the following unsecured and unattended hazards: a. 3 disposable razor in the bathroom b. 1 can of aerosol deodorant in the bathroom c. 1 jar of vaporub on the night stand 10. Observations in Room 126 on 10/30/17 at 12:21 PM, revealed the following unsecured and unattended hazards: a. 1 container of sani-cloth germicidal bleach wipes on the bathroom counter b. 1 disposable razor on the bathroom counter 11. Observations in Room #128 on 10/30/17 at 2:52 PM, revealed the following unsecured and unattended hazards: a. 1 container of sani-cloth bleach wipes on top of the chest of drawers Interview with the Director of Nursing (DON) on 10/30/17 at 5:24 PM, in unit 1, the DON was asked if it was acceptable to store chemicals, aerosols, and sharps in the resident rooms. The DON stated, No.

Based on policy review, observation and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions when 1 of 1 (Dietary Staff #1) staff failed to perform hand hygiene during dish washing, 1 of 7 (Certified Nursing Assistant (CNA) #2) staff members observed during dining placed a dirty meal tray from breakfast on the cart with the noon meal trays, a black oven with carbon build up that stored food and kitchen supplies, a dirty oven with black grease build up with clean plates being kept warmed inside, and carbon buildup on skillets and pans. The facility had a census of 21 residents all receiving a meal tray from the kitchen. The findings included: 1. The facility's DISHMACHINE TEMPERATURES policy documented, .Dish area must have a dirty area and a clean area. One associate loads the machine from the dirty area and another associate unloads the machine from the clean area . 2. Observations in the dishwashing area, on 10/30/17 at 9:19 AM, revealed Dietary Staff #1 placed dirty dishes in the dishware, then walked over and removed clean dishes. Dietary Staff #1 failed to perform hand hygiene before removing clean dishes. Interview with Dietary Staff #1 on 10/30/17 at 9:25 AM, in the dishwashing area, Dietary Staff #1 was asked if he washed his hands after putting in the dirty dishes and going to the clean side and removing the clean dishes. Dietary Staff #1 stated, No. 3. Observations during dining in the unit 1 hallway on 10/30/17 at 12:46 PM, revealed CNA #2 removed a dirty breakfast tray from a resident's room and placed it on the top rack of the meal cart that contained a total of 4 other meal trays that hadn't been served. CNA #2 then proceeded to serve the remaining trays from the cart. Interview with the Director of Nursing (DON) on 10/31/17 at 7:38 AM, in the conference room, the DON was asked if it was acceptable for staff to remove a dirty tray from a resident's room and place it in the cart with meal trays that haven't been served. The DON stated, No. 4. The facility's .STORAGE OF POTS, DISHES, FLATWARE, UTENSIL policy documented, .Pots, dishes, and flatware are stored in such a way as to prevent contamination by splash, dust, pest, or other means .Remove carbon build-up from pots . 5. The facility's .CLEANING OF FOOD AND NONFOOD CONTACT SURFACES policy documented, .The food-contact surfaces of all cooking equipment shall be kept free of encrusted grease deposit and other accumulated soil . 6. Observations in the kitchen on 10/31/17 at 3:45 PM, revealed a dirty oven with black buildup and the following items stored inside: 1 small skillet with black carbon buildup 1 open bag of taco season 1 open bag on mashed potatoes 1 unopened bag of mashed potatoes 10 scoops 1 towel 1 box of gloves Interview with the Executive Chief on 11/01/17 at 12:15 PM, in the Executive Chief's office, the Executive Chief was asked should staff store food, utensils, towels, gloves, and skillets in an oven. The Executive Chief stated, No .she was hoarding them . 7. Observations in the kitchen on 10/31/17 at 4:00 PM, revealed a dirty oven with black greased build up and inside was stored 30 clean white plates being kept warmed. Interview with the Executive Chief on 10/31/17 at 4:03 PM, in the kitchen, the Executive Chief was asked why there were clean dishes in a dirty oven. The Executive Chief stated, .to warm the plates .the plate warmer had torn up . The Executive Chief was asked should clean dishes be stored in a dirty oven. The Executive Chief stated, No. 8. Observations in the kitchen on 10/31/17 at 8:30AM, revealed 8 muffin pans with buildup of a black substance on them. Observations in the kitchen on 11/01/17 at 12:00 PM, revealed 6 skillets with buildup of a black substance on them. Interview with the Executive Chief on 11/01/17 at 12:15 PM, in the Executive Chief's office, the Executive Chief was asked what were the black substance on the muffin pans and skillets. The Executive Chief stated, .carbon .

Based on policy review, medical record review, observation, and interview, the facility failed to provide care in a manner that enhanced the dignity of 1 of 2 (Resident #90) residents observed with a indwelling urinary catheter. The findings included: 1. The facility's Quality of Life-Dignity policy documented, .Demeaning practice and standards of care that compromise dignity are prohibited .Staff shall promote dignity and assist residents as needed by .Helping the resident to keep urinary catheter bags covered . Medical record review revealed Resident #90 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #90's room on 10/30/17 at 12:58 PM, 5:00 PM, and 5:24 PM, revealed Resident #90 had an indwelling urinary catheter with the drainage bag uncovered and in full view. Interview with the Director of Nursing (DON) on 10/30/17 at 5:24 PM, in Resident #90's room the DON was asked if it was acceptable to have the resident's indwelling urinary catheter bag uncovered. The DON stated, No.

Based on review of the Prevention and treatment of [REDACTED].#93) sampled residents reviewed with a pressure ulcer. The findings included: The Prevention and treatment of [REDACTED].Suspected Deep Tissue Injury: Depth Unknown .Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear . area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue . Evolution may be rapid exposing additional layers of tissue even with optimal treatment . Medical record review revealed Resident #93 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The ADMISSION EVALUATION AND INTERIM CARE PLAN dated 10/6/17 documented, .break down to heels bilateral .surgical incision .lumber spine . The NURSE'S NOTES documented, .10/9/17 Skin Note: L Heel .3 .cm (centimeters) blisters noted dried up. Floating Heels @ (at) night . The physician order [REDACTED].Apply skin prep to L (left) Heel Daily .Float heels as tolerated while in bed . There were no documentation the physician was notified of the skin breakdown until 10/9/17. The were no documentation of physician's orders [REDACTED]. The care plan dated 10/15/17 documented, .Problem .has impaired skin integrity related to blisters to left heel .Approach .apply skin prep to left heel daily until healed .Start Date 10/15/2017 . The WEEKLY PRESSURE ULCER PROGRESS REPORT documented, .L Heel DTI (deep tissue injury) . Date Identified .10/9/17 .Date Dr. (doctor) Notified 10/9/17 .Date 10/9/17 Length 3x (by) 3 .Black .Stage DTI .Float Heels .Weight 145 .10/11/17 .3x3 .BLK (black) .DTI .Float Heels .10/17/17 .3x3 .BLK .DTI .10/24/17 .3x3 .Weight 153 . Review of the TREATMENT RECORD for the month of October revealed Resident #93 received application of skin prep to the left heel daily from October 11th through 30th. Observations during wound care in Resident #93's room on 10/31/17 at 2:35 PM, revealed Resident #93 had 3 small unopened black areas on the left heel. Interview with the Treatment Nurse on 10/31/17 at 2:56 PM, in the conference room, the Treatment Nurse was informed that Resident #93 had been assessed on 10/6 with breakdown on her heel and was asked what treatment had been done for her on the 6th. The Treatment Nurse stated, .that would have been (Named Registered Nurse (RN) #2) .I didn't see her till 10/9 . The Treatment Nurse was asked when you saw Resident #93 on 10/9 what was put in place for the left heel DTI. The Treatment Nurse stated, .to float heels and (apply) skin prep .didn't write it (referring to order) till 10/11 . The Treatment Nurse was asked when you saw her on 10/9 why wasn't the order written till 10/11. The Treatment Nurse stated, .I forgot to get the order . Interview with the Director of Nursing (DON) on 10/31/17 at 3:15 PM, at the nurse's station, the DON was asked what she would expect her staff to do for a resident that had been assessed with [REDACTED]. The DON stated, .to put something in place .to notify the physician or nurse practitioner. The DON was asked if it was acceptable to wait 5 days to put a treatment in place for skin breakdown of a heel or DTI. The DON stated, No . Interview with RN #1 on 10/31/17 at 3:36 PM, in the conference room, RN #1 was asked if she completed Resident #93's admission assessment. RN #1 stated, Yes, ma'am. RN #1 was asked did she have breakdown to her heels. RN #1 stated, .yes . RN #1 was asked did you notify the physician. RN #1 stated, .I don't think so .

Based on medical record review, observation and interview, the facility failed to obtain a physicians order and medical justification for indwelling urinary catheter use for 1 of 2 (Resident #90) sampled residents reviewed with an indwelling urinary catheter. The findings included: 1. Medical record review revealed Resident #90 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #90 was coded for an indwelling urinary catheter. Review of the care plan dated 10/23/17 revealed, Resident #90 had an indwelling urinary catheter. Medical record review revealed no physician's orders or medical justification for the use of the indwelling urinary catheter. Observations in Resident #90's room on 10/30/17 at 12:58 PM, 5:00 PM, and 5:24 PM, revealed Resident #90 had an indwelling urinary catheter. Interview with License Practical Nurse (LPN) #3 on 10/31/17 at 2:15 PM, at the unit 1 medication cart, LPN #3 was asked if there was an order and [DIAGNOSES REDACTED]. LPN #3 stated, No it's not there. Interview with the Director of Nursing (DON) on 10/31/17 at 2:31 PM, at the unit 1 nurse's station, the DON was asked if it was acceptable to not have an order or [DIAGNOSES REDACTED]. The DON stated, .No .we did not get the order .

Based on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained as evidence by a mop stored in a bucket of water in 1 of 1 biohazard rooms and by a nebulizer mask and a bi-pap mask not properly stored. The findings included: 1. The facility's General Infection Control Practices policy documented, .Infection Control Considerations Related to Medication Nebulizers / Continuous Aerosol .7. Store the circuit in plastic bag, marked with date and resident's name, between uses . 2. Observations in Resident #90's room on 10/30/17 at 2:27 PM, 4:43 PM, and 5:33 PM, revealed an uncovered nebulizer mask resting on the night stand. 3. Observations in Resident #91's room on 10/30/17 at 2:50 PM, 4:52 PM, and 5:34 PM, revealed a bi-pap machine at the bedside with the mask uncovered. Interview with the Director of Nursing (DON) on 10/30/17 at 5:33 PM, in Resident #90's room, the DON was asked if it was acceptable to have a nebulizer mask uncovered on the resident's nightstand. The DON stated, No. Interview with the DON on 10/30/17 at 5:34 PM, in Resident #91's room, the DON was asked if it was acceptable to have a bi-pap mask on the resident's night stand uncovered. The DON stated, No. 4. Observations in unit 1 Biohazard Room on 10/31/2017 at 8:30 AM and 8:52 AM, revealed a mop stored in a bucket of dirty water. Interview with the Laundry/Housekeeping Supervisor on 10/31/17 at 8:50 AM, in unit 1 Biohazard Room, the Laundry/Housekeeping Supervisor was asked if a mop should be stored in a bucket of water. The Laundry/Housekeeping Supervisor stated, No it should not.

Based on policy review, observation and interview, the facility failed to ensure food was served under sanitary conditions as evidenced by 4 of 7 (Certified Dietary Manager (CDM), Dining Director (DD), Server #1, Dietary Staff #1) staff members observed during dining entering the Unit 2 food serving area with hair not completely covered. The census that day was 9 residents from Unit 2 and 4 residents from Unit 1 eating in that dining room, with the potential for 13 trays to be contaminated. The findings included: The facility's Personal Hygiene and Uniforms .Hair Restraints policy documented, .must wear hair restraints such as hats, hair coverings or nets .Hair restraints must be worn so that hair effectively keep from contacting exposed food, clean equipment, utensils, linens, and single -serve articles . Observations in the Unit 2 dining and food serving area revealed the following: a. On 8/15/16 at 11:50 AM, Dietary Staff #1 was in the Unit 2 serving area with hair not completely covered by with a hair restraint/net. b. On 8/15/16 at 11:54 AM, the DD walked into the Unit 2 serving area with hair not completely covered by the hair net. c. On 8/15/16 at 11:55 AM, Server #1 walked into the Unit 2 serving area with hair not completely covered by the hairnet. d. On 8/15/16 at 11:57 AM, the CDM walked into the Unit 2 serving area with hair not completely covered by the hair net. Interview with the CDM, on 8/16/16 at 6:45 PM, in the Day Room, was asked if it is acceptable for dietary staff to have hair not completely covered while in the food serving area for the residents. The CDM stated, No, it is not acceptable.

Based on policy review, medical record, observation and interview, the facility failed to ensure 2 of 3 (Licensed Practical Nurse (LPN #1) and Registered Nurse (RN #1) medication nurses did not leave medication unattended and out of their sight. The Findings included: Review of the facility's Storage of Medications policy documented, .The facility shall store all drugs and biological in a safe, secure, and orderly manner .Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others . Observations in the Unit 2 Day Room on 8/16/16 at 9:25 AM, revealed the door to the Medication Room was left unsecured. Observations in Resident #30's room on 8/16/16 at 8:39 AM, revealed LPN #1 entered Resident #30's room, laid the nebulizer medication on the over bed table. LPN #1 went into the bathroom and left the medication unattended and out of her sight. Interview with LPN #1 on 8/16/17 at 7:12 PM, at the medication cart on Unit 2, LPN #1 was asked should the medication room be locked at all times. LPN #1 stated, Yes. Interview with the DON on 8/16/16 at 5:36 PM, in the DON's office, the DON was asked should a nurse leave the medication unattended. The DON stated, No .

Based on policy review, observation and interview, the facility failed to ensure practices to prevent the spread of infection were maintained when 1 of 3 (Registered Nurse #1) medication nurses failed to clean the reuseable resident equipment after use. The findings included: Review of the facility's Administering Medications through a Small Volume (Handheld) Nebulizer policy documented, .27. Rinse and disinfect the nebulizer equipment according to facility protocol, or: a. Wash pieces with warm, soapy water. b. Rinse with hot water; c. Place all pieces in a bowl and cover with [MEDICATION NAME] (rubbing) alcohol. Soak for five minutes; d. Rinse all pieces with sterile water (NOT tap, bottled, or distilled); and e. Allow to air dry on a paper towel . Observations in Resident #69's room on 8/16/16 at 4:03 PM, revealed (Registered Nurse, (RN #1) laid the vial of [MEDICATION NAME] medication on the over bed table, administered the PO (by mouth) medications. RN #1 went into the bathroom and left the vial of medication unattended and out of her sight. Interview with the Director of Nursing (DON) on 8/16/16 at 5:35 PM, in the DON's office, the DON was asked, after being used what are your expectations for cleaning the nebulizer equipment. The DON stated, The nebulizer equipment should be cleaned with soap and water after use.

Based on medical record review and interview, the facility failed to accurately assess residents for medications for 1 of 7 (Resident #9) sampled residents of the 14 residents included in the stage 2 review. The findings included: Medical record review revealed Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The admission Minimum Data Set (MDS) with an assessment reference date of 6/30/15 did not reflect that Resident #9 received an antianxiety medication ([MEDICATION NAME]). Interview with Licensed Practical Nurse (LPN) #1 on 8/18/15 at 4:58 PM, in the conference room, LPN #1 was asked if [MEDICATION NAME] should have been on Resident #9's admission MDS. LPN #1 stated, Yes.

Based on policy review, observation, and interview, the facility failed to ensure 1 of 3 (Registered Nurse (RN) #1) nurses followed practices to prevent the spread of infection and cross contamination during medication administration. The findings included: The facility's Handwashing/Hand Hygiene policy documented, .Policy Statement. hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation. 6. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60- (to) 95% (percent) [MEDICATION NAME] or [MEDICATION NAME] for all the following situations. 6. a. Before and after direct contact with residents. j. After removing gloves. Observations in Resident #42's room on 8/18/15 at 5:10 PM, revealed RN #1 washed her hands and applied gloves, administered 1 eyedrop into Resident #42's right eye, removed her gloves, and failed to perform hand hygiene, applied new gloves, and administered 1 eyedrop into Resident #42's left eye. Interview with the Director of Nursing (DON) on 8/19/15 at 9:40 AM, in the conference room, the DON was asked what should staff do between changing gloves. The DON stated, Should wash hands.

Based on policy review, observation and interview, it was determined the facility failed to ensure food was stored, prepared and distributed under sanitary conditions as evidenced by the chef not wearing a hair and beard cover; food left opened in the freezer and cooler; enchilada sauce sitting on the floor; opened and undated sauces, syrups and vinegars; food service equipment with a grease build up and unknown particles; carbon build up on pots and pans and the kitchen floor was dirty on 2 of 2 (8/11/14 and 8/12/14) days of kitchen observations. The findings included: 1. Review of the facility's "Preventing Foodborne Illness - Food Handling" policy documented, "...All food service equipment and utensils will be sanitized according to current guidelines and manufacturers' recommendations..." Review of facility's "Food Storage" policy documented, "...Food items will be stored on shelves... All containers must be accurately labeled... Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before refrigerated... All foods should be covered, labeled and dated... Foods should be covered, labeled, and dated..." Review of the facility's "General Preparation and Handling" policy documented,"The kitchen and equipment are clean... All food service equipment should be cleaned, sanitized, dried, and reassembled after each use..." 2. Observations in the kitchen on 8/11/14 at 6:30 PM, revealed the following: a. A block of cheese, individual slices opened, undated and uncovered in the walk in cooler. b. A styrofoam cup of vanilla ice cream and cookies were covered with saran wrap but undated in the freezer. c. The preparation (prep) sink had water draining into a pipe in the floor and copious amounts of bubbles were spilling out of the drain. d. Food particles and grease build up on the 4 eyed stove and dark brown grease build were on the stainless steel back splash. e. The dishwasher rack had clean silverware, a dirty napkin and a box of latex gloves were sitting on top of the silverware. f. Two dish carts next to the dishwasher contained 11 bowls stored right side up and there was water in a bowl. The base of the carts was dirty with spills and stains. Observations in the kitchen on 8/11/14 at 6:30 PM and 8/12/14 at 10:00 AM, revealed the following: a. A box of beef steaks (5 steaks), in a plastic bag, that was opened to air in the freezer. b. A box of cat fish fillets, in a plastic bag, that was opened to air in the freezer. c. A box of wheat dinner rolls, in a plastic bag, that was opened to air in the freezer. d. A box with a 20 pound bag of black eyed peas opened to air in the freezer. e. A gallon container of lime juice, in the dry storage room, was opened and undated. There was an unknown black substance on the top of the juice and the handle of the container. f. A 5 quart 9 ounce container of balsamic vinegar, in the dry storage room, was opened and undated and had an unknown brown substance around the cap and sides of the container. g. An opened gallon container of rice vinegar, in the dry storage room, had an unknown black substance on the side of the container. h. A gallon container of apple cider, in the dry storage room, was opened and not dated. i. A gallon container of cooking sherry wine, in the dry storage room, was opened and undated. j. An 8 pound 2 ounce container of enchilada sauce, in the dry storage room, was sitting on the floor. k. There were 2 opened containers of soy sauce, in the dry storage room, that were opened and undated. l. A container of pancake syrup, in the dry storage room, was opened and undated. m. The 4 eyed stove had a dark brown grease build up on the stainless steel back splash. n. Two ovens had grease build up on the glass fronts and food particles, spills and carbon build up on the bottoms and sides of the ovens. o. Carbon and grease build up on the grill and grease and food particles in the grease pan. p. Dark brown oil and food particles were floating in both sides of the deep fryer. There was a grease build up and food particles in the bottom of the fryer next to the electrical socket. q. The glass on the front of the steam table was smeared with grease and an unknown food particles. r. The skillets, pots and pans had a carbon build up on the bottom. s. Two dish carts bases had spills and stains. t. The industrial can opener had an unknown black substance on the opening prong. u. The kitchen floor was dirty with spills of unknown substances. During an interview in the kitchen on 8/12/14 at 10:15 AM, the Kitchen Manager (KM) was asked what was the proper procedure for food storage after it is opened. The KM stated, "The bags should at least be resealed and dated." The KM was asked if she was aware that bubbles come from the drain for the prep sink. The KM stated, "I don't know why. There is no soap used in that sink." The KM was then asked if the containers of vinegar, soy sauce and syrup were stored appropriately. The KM stated, "The jugs should be dated when opened. When there is a spill, the jug should be wiped down." The KM was asked if it was appropriate to store food on the floor. The KM stated, "Never." The KM was asked if she felt the two ovens were clean. The KM stated, "No. There is grease build up inside the ovens and the front glass looks like they have been sprayed and they (staff) didn't wipe the glass down." The KM was asked how often the fryer grease was changed. The KM stated, "It gets changed as it's needed." The chef stated, "It's (grease in the fryer) clearly done for and needs changing now." The KM was what was on the front glass of the steam table. The KM stated, "It's old splatter." The KM was asked if she was aware there were multiple skillets, pots and pans with carbon build up on them. The KM stated, "Yes, I am aware." The KM was asked how often the base of the dish carts were cleaned and if they appeared clean to her. The KM stated, "They (dish carts) are cleaned regularly but they need more cleaning." The KM was asked if the industrial can opener was clean. The chef slid the can opener out of it's table clamp and placed on the table. The chef stated, "Rusty and lovely and dirty." The KM was then asked if she felt her kitchen was clean. The KM stated, "No." 3. Review of facility's "Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices" policy documented, "...Food Services employees shall follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness... Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens..." Observations in the kitchen on 8/12/14 at 10:00 AM, revealed the chef not wearing a hair or beard restraint." During an interview in the kitchen on 8/12/14 at 10:00 AM, the Chef was asked if it was his normal routine to not wear a beard/mustache cover. He stated, "Yes."

Based on policy review, review of personnel files and interview, it was determined the facility failed to ensure pre-employment abuse and background checks were conducted, failed to provide abuse prohibition training and failed to develop policies to include prevention, reporting, training and screening of staff prior to having direct contact with the residents for 9 of 20 (Sitters #1, 2, 3, 4, 5, 6, 7, 8 and 9) personnel files reviewed. The findings included: Review of the facility's "Abuse and Neglect" policy did not document the elements for prevention, reporting, training or screening of individuals for abuse prohibition. Review of personnel files for Sitters #1, 2, 3, 4, 5, 6, 7, 8 and 9 revealed the facility failed to ensure pre-employment abuse and background checks were conducted, failed to provide abuse prohibition training and failed to develop policies to include prevention, reporting, training and screening prior to having direct contact with the residents. During an interview in the Assistant Director of Nursing's (ADON) office on 8/13/14 at 2:30 PM, the ADON was asked at what point does the facility become involved when family members hire sitters. The ADON stated, "If sitters are paid by the family we still have requirements. They have to have the same thing drug screen, abuse training, policy and background checks. I think, I don't want to tell you wrong. They have to have those things before they come on campus."

Based on policy review, observation and interview, it was determined the facility failed to ensure medications were stored properly as evidenced by unsecured medication, medications and food stored in the same refrigerator, supplies stored past their expiration date and medication stored with other supplies in 3 of 6 (medication storage room in the first floor family room, first floor chart room beside the main dining room and central supply storage room) medication storage areas. The findings included: 1. Review of the facility's "Storage of Medication" policy documented, "...2. The nursing staff shall be responsible for maintaining medication storage... 4. The facility shall not use discontinued, outdated... drugs... All such drugs should be returned to the dispensing pharmacy or destroyed... 7...Compartments... containing drugs and biologicals shall be locked when not in use... shall not be left unattended... 8...Drugs shall be stored in an orderly manner in cabinets, drawers, carts... 9...Medication must be stored separately from food..." 2. Observations in the first floor family room revealed the following: a. On 8 /11/14 at 8:00 PM - the medication storage room door was open. b. On 8/13/14 at 7:45 AM - seven Phenadoz 12.5 milligram (mg) suppositories, a vial of Aplisol vial and seven 650 mg Acetaminophen 650 suppositories were stored in the refrigerator with food items. c. On 8/13/4 at 7:50 AM - four mineral oil enemas 4.5 fluid (fl) ounces (oz) in the cabinet were stored past the expiration date of 12/13. During an interview in the Assistant Director of Nursing's (ADON) office on 8/13/14 at 2:50 PM, the Director of Nursing (DON) was asked if medications and food should be stored in the same refrigerator. The DON stated, "No." The DON was asked if outdated enemas should be stored in the medication storage room. The DON stated, "No." 3. Observations in the first floor chart room beside the main dining room on 8/12/14 at 9:40 and 9:50 AM, revealed a 16 oz bottle of Milk of Magnesia, a pint bottle of Robafen and a 12 oz bottle of Antacid were left on the counter unattended and our of the nurse's sight. During an interview in the chart room on 8/12/14 at 9:50 AM, Nurse #2 was asked if the medications should be in the chart room unattended. Nurse #2 stated, "No, I was down the hall and she just brought this (Milk of Magnesia, Robafen and Antacid) from central supply and left it. I don't know why she did that." During an interview in the ADON's office on 8/13/14 at 2:50 PM, the DON was asked if medications should be left unattended. The DON stated, "No." 4. Observations in the central supply storage room on 8/13/14 at 2:20 PM, revealed a bottle of Robasem DM stored in the third drawer of a plastic storage container with items such as an edema glove, a plastic bedrail, a desk wheel and other non-medication items. During an interview in the central supply storage room on 8/13/14 at 2:30 PM, the ADON was asked if medication should be stored in the drawer with an edema glove, a plastic bedrail, a desk wheel and other non-medication items. The ADON stated, "No."

Based on policy review, review of personnel files and interview, it was determined the facility failed to provide documentation that sitters were free from communicable diseases prior to having contact with residents living in the facility for 8 of 20 (Sitters #2, 3, 4, 5, 6, 7, 8 and 9) personnel files reviewed. The findings included: Review of the facility's "Rules for Non-Registry Private Duty Personnel" policy documented, "...Only private duty personnel who are approved by the Private Duty Registry Coordinator will be allowed to report for duty... Approval will not be given until a TB ([DIAGNOSES REDACTED]) screening has been completed... All private duty personnel are to have an annual health examination verifying the absence of communicable disease... This consists of a test for [DIAGNOSES REDACTED]...TB skin skin tests and the chest x-ray are required on an annual basis. The chest x-ray is done if someone is unable to take the TB skin test..." During review of the personnel files for Sitters #2, 3, 4, 5, 6, 7, 8 and 9 the facility was unable to provide documentation these sitters were free from communicable diseases prior to having contact with residents living in the facility. During an interview in the Assistant Director of Nursing's (ADON) office on 8/13/14 at 2:30 PM, the ADON was asked at what point does the facility become involved when family members hire sitters. The ADON stated, "If sitters are paid by the family we still have requirements. They have to have the same thing... I think, I don't want to tell you wrong. They have to have those things before they come on campus."