Every finding on record at Altoona Health & Rehab

Based on interviews, resident record review, review of an online report submitted to the State Survey Agency, review of the facility's abuse investigation, and review of a facility policy titled, ADMINISTRATIVE ABUSE, the facility failed to protect Resident Identifier (RI) #1's right to be free from physical abuse on 01/31/2023 when Employee Identifier (EI) #5 Licensed Practical Nurse (LPN), was witnessed pinching and slapping RI #1. Physical abuse was witnessed by EI #3 Registered Nurse (RN) and EI #4 RN. This deficient practice affected RI #1, one of three residents reviewed for abuse concerns. Findings include: On 02/01/2023 at 6:27 AM, the State Survey Agency received an initial report from the facility regarding an allegation that EI #5, LPN, physically abused RI #1. This report indicated EI #4, witnessed EI #5 pinch and then slap RI #1's arm/hand. A facility policy titled ADMINISTRATIVE ABUSE, with a revised date of 10/2017, documented: Policy Residents have the right to be free from abuse . Residents must not be subject to abuse by anyone, including, but not limited to; facility staff . IDENTIFICATION OF ABUSE . 1. The facility defines types of abuse as follows: . PHYSICAL ABUSE includes, but is not limited to, hitting, slapping, pinching and kicking. RI #1 was readmitted to the facility on [DATE] with diagnoses to include Dementia. RI #1's significant change Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 12/26/2022 documented RI #1 had a Brief Interview for Mental Status (BIMS) score of six, which indicated RI #1 had severe cognitive impairment. A facility document titled VERIFICATION OF INVESTIGATION with an incident date of 01/31/2023 documented the following: . DETAILED DESCRIPTION OF INCIDENT . On Wednesday, February 1, 2023, at approximately 4:34 am, SSD (Social Service Director EI #2) was called by employee (EI #4) RN to report an allegation of physical abuse. The abuse happened on January 31, 2023 at approximately 10:00 pm. Resident (RI #1) was . in the front of the nurses station and had pulled his/her pants down. Employee (EI #4), RN, and employee (EI #3), RN, went to (RI #1) and took him/her to his/her room in an attempt to take him/her to the bathroom. Resident did not want to go to the bathroom or have his/her pants pulled up. (EI #4) . stepped to the doorway and asked for help. (EI #5), LPN, came to the room and stood at the door to observe the situation. Nurse, (EI #4) then stated that (RI #1) became combative and pinched and slapped at Nurse, (EI #5). Nurse, (EI #4) then stated that Nurse, (EI #5) pinched (RI #1) back and slapped his/her hand/arm and causing it to hit the wall. SUMMARY AND OUTCOME OF INVESTIGATION: . Tuesday, February 7, 2023 . After reviewing all pertinent information, the facility will conclude this investigation as substantiated. The eye-witnessed account from (EI #4), RN, is reliable evidence to support physical abuse occurred. The facility will terminate the employer-employee relationship with (EI #5) effective 02/07/23. The facility will communicate findings to the Alabama Board of Nursing . A handwritten statement from the facility's investigative file, signed by EI #4 RN documented the following: At approximately 10pm on 01/31/2023 resident (RI #1) attempted to get up from (his/her) gerichair while resident was in hallway by the nurse's station. This nurse, (EI #4), and Nurse (EI #3) attempted to redirect resident. Resident at this point pulled (his/her) pant/brief down. we went with resident to (his/her) resident bathroom to let resident have bathroom privileges. this nurse stepped to hallway and asked (EI #5) Nurse to help . thinking a familiar face would make resident feel more comfortable. (EI #5) stepped up and this nurse stepped back and (EI #5) forcefully and loudly called resident's name. (EI #5) attempted to redirect resident long enough to allow staff to pull up residents brief/pants. Once resident sat down (he/she) pinched (EI #5) so (EI #5) pinched (RI #1) back. Resident then slapped (EI #5) so (EI #5) slapped resident's hand/arm back and when this happened resident's hand hit the wall and it made a loud noise. A handwritten statement from the facility's investigative file, signed by EI #3 RN and dated 02/01/2023 documented the following: . This nurse was assisting resident to the restroom with (EI #4). Rsd (Resident) was agitated . refused to let us take (him/her) to restroom. (EI #5) walked in and helped us pull (his/her) pants back up. Rsd sat back down, this nurse walked thru bathroom to go around and finish helping rsd. Rsd was hitting . (EI #5) and (EI #5) tapped him/her on his/her right hand . An interview was conducted with EI #3 RN on 06/07/2023 at 9:05 AM. EI #3 was asked to recall the incident involving RI #1. EI #3 explained, RI #1 was at the nursing desk around 10:00 PM and pulled his/her pants down. EI #3 and EI #4 took RI #1 to his/her room and attempted to assist RI #1 to the bathroom. Once in the room RI #1 became agitated and refused to go in the bathroom. While attempting to care for RI #1, EI #5, LPN came in the room to assist. EI #3 stated she left the room for a moment and when she re-entered the room, she saw RI #1 slapping at EI #5. EI #3 saw EI #5 tap RI #1's hand. EI #3 said, RI #1 did not cry out or have any marks or bruises. EI #3 stated after the incident RI #1 consented to leave the room and was calm the rest of the night. EI #3 said, if abuse was observed it was supposed to be reported immediately to protect the resident. An interview was conducted with EI #4 on 06/07/2023 at 10:50 AM. EI #4 was asked to recall the incident involving RI #1 on 01/31/2023. EI #4 said, around 10:00 PM, RI #1 attempted to get up from his/her chair while in the hallway near the nurses desk. EI #4 said, she and EI #3 attempted to redirect RI #1, RI #1 pulled his/her pants down, then they took RI #1 to his/her room to use the bathroom. Once in the room RI #1 refused to allow EI #4 and EI #3 to assist him/her. EI #5 then came to the room to assist with redirecting RI #1. EI #4 said, she observed RI #1 pinch EI #5 and EI #5 then pinched RI #1. RI #1 then slapped EI #5 and EI #5 slapped RI #1's arm causing it to hit the wall. EI #4 stated she did not see any injury. EI #4 said, she did not say anything to EI #5 because she was in shock and felt intimidated by EI #5. EI #4 said, at that point she left the room to go take care of another resident. EI #4 said, shortly after the incident her shift ended and she left the facility a little after 10:30 PM without reporting the incident. EI #4 was asked why she did not report the incident. EI #4 replied, she was in shock. EI #4 said, the incident should have been reported to the abuse coordinator immediately to prevent it from happening again and to protect the resident. After leaving the building that night, EI #4 said, she called EI #6, RN, and left a message about the incident. EI #4 said, EI #6 did not immediately get the message but called her back around 4:00 AM on 02/01/2023. After talking to EI #6, EI #4 called the abuse coordinator EI #2 and reported the incident. An interview was completed with EI #5 on 06/07/2023 at 10:00 AM. EI #5 was asked about the incident involving RI #1. EI #5 said, she was asked to help EI #3 and EI #4 with RI #1 because RI #1 was confused and would not stand up or allow them to assist him/her to the bathroom. EI #5 said, after she, EI #3 and EI #4 pulled up RI #1's pants, RI #1 started hitting and pinching. EI #5 said, she grabbed RI #1's right wrist/arm to keep RI #1 from getting hurt. EI #5 said, she was trying to protect RI #1 when she grabbed RI #1's arm. EI #5 was asked why she was terminated from the facility. EI #5 replied, because of the abuse accusation involving RI #1. An interview was conducted with EI #1, Regional Administrator on 06/07/2023 at 1:00 PM. EI #1 was asked the outcome of the investigation related to physical abuse involving RI #1. EI # 1 said, the investigation was substantiated due to a believable eyewitness account of the incident. This deficient practice was cited as a result of the investigation of complaint/report number AL00043217. ********************************************************* The facility took immediate action to correct the noncompliance by: 1. Reported the incident to the Alabama Department of Public Health (ADPH) on 2/1/2023 and conducted an investigation. 2. Reported an incident of possible physical abuse to local police department on 2/1/2023. 3. Completed an in-service with all staff on the abuse policy from 2/1/2023 - 2/3/2023. 4. Completed one on one education with Registered Nurse (EI #3) on 2/1/2023. 5. Completed one on one education with Registered Nurse (EI #4) on 2/3/2023. 6. Quality Assurance (QA) meeting held on 2/1/2023 to create plan of correction (POC). 7. Weekly abuse monitoring form initiated by Social Services/Abuse Coordinator. The weekly monitoring begin on 02/01/23 for a period of 6 weeks, or longer if deemed necessary by the QA committee. Start date 2/1/2023 - Ongoing. After review of documentation supporting the corrective actions, including in-service records, employee files, education records, and interviews with staff, the survey team verified the facility had implemented corrective actions from 02/01/2023 through 02/03/2023 and had an ongoing monitoring system in place; thus, past non-compliance was cited.

Based on resident record review, interviews, review of an online report submitted to the State Survey Agency, review of the facility's investigation file, and review of a facility policy titled ADMINISTRATIVE ABUSE, the facility failed to ensure staff implemented one of the seven components of the abuse policy. Employee Identifier (EI) #3 Registered Nurse (RN) and EI #4 RN failed to immediately report physical abuse to the abuse coordinator after they witnessed EI #5 Licensed Practical Nurse (LPN) physically abuse Resident Identifier (RI) #1 on 01/31/2023, in accordance with the facility policy. This affected RI #1 one of three residents sampled for abuse. Cross reference F600. Findings include: On 02/01/2023 at 6:27 AM, the State Survey Agency received an initial report from the facility regarding an allegation that EI #5, LPN, physically abused RI #1. This report indicated EI #4, witnessed EI #5 pinch and then slap RI #1's arm/hand. A facility policy titled, ADMINISTRATIVE ABUSE with a revised date of 10/2017 documented Policy: Residents have the right to be free from abuse . Residents must not be subject to abuse by anyone, including, but not limited to; facility staff . The facility defines types of abuse as follows: .PHYSICAL ABUSE includes, but is not limited to, hitting, slapping, pinching and kicking. REPORTING/RESPONSE OF ABUSE . Facility personnel are to report allegations or suspected abuse . immediately to the Administrator, or facility appointed designee. RI #1 was readmitted to the facility on [DATE] with diagnoses to include: Dementia. RI #1's significant change Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 12/26/2022 documented the resident had a Brief Interview for Mental Status (BIMS) score of six which indicated RI #1 had severe cognitive impairment. A facility document titled VERIFICATION OF INVESTIGATION with an incident date of 01/31/2023 documented the following: . DETAILED DESCRIPTION OF INCIDENT . On Wednesday, February 1, 2023, at approximately 4:34 am, SSD (Social Service Director EI #2) was called by employee (EI #4) RN to report an allegation of physical abuse. The abuse happened on January 31, 2023 at approximately 10:00 pm. Employee (EI #4), RN, and employee (EI #3), RN, went to (RI #1) and took (him/her) to (his/her) room in an attempt to take (him/her) to the bathroom. (EI #4) . stepped to the doorway and asked for help. (EI #5), LPN, came to the room and stood at the door to observe the situation. Nurse, (EI #4) then stated that (RI #1) became combative and pinched and slapped at Nurse, (EI #5). Nurse, (EI #4) then stated that Nurse, (EI #5) pinched (RI #1) back and slapped (his/her) hand/arm and causing it to hit the wall. SUMMARY AND OUTCOME OF INVESTIGATION: . Tuesday, February 7, 2023 . After reviewing all pertinent information, the facility will conclude this investigation as substantiated. The eye-witnessed account from (EI #4), RN, is reliable evidence to support physical abuse occurred. Review of the facility's timeline of events revealed the following: On 01/31/2023 at 10:00 PM EI #4 witnessed EI #5 physically abuse RI #1. On 01/31/2023 at 11:13 PM EI #4 placed a call to EI #6 RN, Assistant Director of Nursing (ADON). On 02/1/2023 at 4:11 AM EI #6 became aware of numerous missed calls from EI #4, returned her call, and she informed him of the allegation of physical abuse. On 02/01/2023 at 4:34 AM EI #4 contacted EI #2 Social Services Director/Abuse Coordinator, to report the allegation of abuse, as instructed by EI #6. On 02/01/2023 at 5:45 AM EI #6 arrived at the facility and notified EI #5 of the allegation of abuse, placed her on administrative leave and escorted her from the facility. An interview was conducted with Employee Identifier (EI) #3, Registered Nurse (RN) on 06/07/2023 at 9:05 AM. EI #3 explained, while attempting to care for RI #1, EI #5, LPN came in the room to assist. EI #3 stated she left the room for a moment and when she came back in the room she saw RI #1 slapping at EI #5. EI #3 then saw EI #5 tap RI #1's hand. EI #3 said if abuse was observed it was supposed to be reported immediately to protect the resident. EI #3 said she did not realize what she witnessed was abuse. An interview was conducted with EI #4 on 06/07/2023 at 10:50 AM. EI #4 was asked to recall the incident involving RI #1 on 01/31/2023. EI #4 said around 10:00 PM EI #4 and EI #3 took RI #1 to his/her room to use the bathroom. Once in the room RI #1 refused. EI #5 then came in the room to assist. EI #4 said she observed RI #1 pinch EI #5 and EI #5 then pinched RI #1. RI #1 then slapped EI #5 and EI #5 slapped RI #1's arm causing it to hit the wall. EI #4 said, she did not report this incident prior to leaving the building around 10:30 PM. EI #4 was asked why she did not report the incident, to which she replied, she was in shock. EI #4 said the incident should have been reported to the abuse coordinator immediately to protect the resident. After leaving the building EI #4 said she called EI #6, RN, and left a message about the incident. EI #4 said EI #6 did not immediately get the message but called her back around 4:00 AM on 02/01/2023. After talking to EI #6, EI #4 called the Abuse Coordinator EI #2 and reported the incident. An interview was conducted with EI #2, Abuse Coordinator on 06/07/2023 at 11:34 AM. EI #2 said she was the person staff should report abuse to. She stated staff were told who to call during training and her name and number was posted in the facility. EI #2 said, if staff witnessed abuse they should make sure the resident was safe and report the abuse immediately. When asked why EI #4 did not report the abuse she witnessed involving RI #1, EI #2 said she was not sure, but EI #4 was trained to report abuse immediately. EI #2 said EI #4 reported the abuse after she left the building and when she was notified she began the investigation. A follow up interview was conducted with EI #2 on 06/08/2023 at 11:53 AM. EI #2 said the abuse policy instructed staff to report abuse immediately to the administrator or designee. EI #2 stated she was the designee in the facility. EI #2 was asked if EI #4 followed the abuse policy when she witnessed abuse involving RI #1. EI #2 said no, she did not follow the policy. EI #2 further stated the problem with not reporting immediately was the resident was not protected from further possible abuse. This deficient practice was cited as a result of the investigation of complaint/report number AL00043217. ********************************************************* The facility took immediate action to correct the noncompliance by: 1. Reported the incident to the Alabama Department of Public Health (ADPH) on 2/1/2023 and conducted an investigation. 2. Reported an incident of possible physical abuse to local police department on 2/1/2023. 3. Completed an in-service with all staff on the abuse policy from 2/1/2023 - 2/3/2023. 4. Completed one on one education with Registered Nurse (EI #3) on 2/1/2023. 5. Completed one on one education with Registered Nurse (EI #4) on 2/3/2023. 6. Quality Assurance (QA) meeting held on 2/1/2023 to create plan of correction (POC). 7. Weekly abuse monitoring form initiated by Social Services/Abuse Coordinator. The weekly monitoring begin on 02/01/23 for a period of 6 weeks, or longer if deemed necessary by the QA committee. Start date 2/1/2023 - Ongoing. After review of documentation supporting the corrective actions, including in-service records, employee files, education records, and interviews with staff, the survey team verified the facility had implemented corrective actions from 02/01/2023 through 02/03/2023 and had an ongoing monitoring system in place; thus, past non-compliance was cited.

Based on interviews, record review, review of a facility policy titled, NURSING COMPREHENSIVE CARE PLAN (DEVELOPING), and review of the facility's investigation regarding Resident Identifier (RI) #1's fall, facility staff failed to implement the fall care plan for transfers on 9/29/22, when RI #1 had a fall while being transferred from his/her bed. This affected one of three residents reviewed for care plan concerns. Findings Include: A review of a policy titled NURSING COMPREHENSIVE CARE PLAN (DEVELOPING), Revised 7/14, documented: . Plans of care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals for the resident related to clinical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] RI #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #1's most recent Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/21/22, documented a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated RI #1 was cognitively intact. A review of a document titled Resident Incident Report documented: . 9/29/22 09:27AM . Resident was sitting in floor of room facing his/her bed . Legs were in front of resident . Certified Nursing Assistant (CNA) notified . nurse. Upon entering room assessment was completed . Vital signs taken, resident assessed for pain and injury. Body audit completed. Resident assisted in wheelchair after assessment . A review of RI #1's care plan documented: . I require modified stand and pivot extensive x 2 with my transfers when getting out of bed . start date 2/14/22 . An interview was completed with RI #1 on 11/15/22 at 11:40 AM. RI #1 was asked about the fall that he/she sustained on 9/29/22. RI #1 stated he/she rang the call bell, and a CNA came in the room, and he/she told the CNA he/she wanted to get out of bed. RI #1 stated the CNA never left the room to find assistance with his/her transfer. RI #1 then explained the CNA attempted to transfer him/her to the chair and during this process he/she became top heavy and fell to the floor. RI #1 explained he/she normally received assistance from two CNAs when transferring from the bed to the chair. An interview was completed with Employee Identifier (EI) #3 on 11/15/22 at 9:21 AM. EI #3 explained that on 9/29/22 she answered RI #1's call light. She stated when she entered the room RI #1 requested to be gotten out of bed. EI #3 stated she left the room to find another staff member to assist with the transfer but could not find anyone on the hall. EI #3 stated RI #1 told her they could do the transfer if she would help him/her stand. EI #3 stated she moved the wheelchair by the bed and attempted to transfer him/her by holding onto his/her pants. EI #3 stated when she was holding RI #1's pants he/she went to the floor. EI #3 was asked if RI #1 was a two-person assist. EI #3 stated yes when getting out of bed. EI #3 was asked if she should have waited until another staff member came in the room to assist before attempting to transfer RI #1. EI #3 responded she should have waited but RI #1 was demanding and said he/she would get up without any assistance. EI #3 was asked if she followed RI #1's care plan for a two-person assist when getting him/her out of bed on 9/29/22. EI #3 stated no, she did not follow the care plan. EI #3 was asked why RI #1 was a two-person assist. EI #3 stated to prevent him/her from falling. An interview was completed with EI #1, Registered Nurse (RN) on 11/15/22 at 12:30 PM. EI #1 was asked about RI #1's fall status. EI #1 stated RI #1 was a fall risk prior to 9/29/22 and was still currently a fall risk. EI #1 was asked about the fall sustained by RI #1 on 9/29/22. EI #1 stated the CNA (EI # 3) was attempting to transfer RI #1 when his/her knee gave out and he/she fell to the floor. EI #1 stated RI #1's care plan on 9/29/22 was for a two-person assist when getting out of bed. EI #1 was asked if the care plan was followed on 9/29/22 when the CNA transferred RI #1 without another staff member present. EI #1 stated the CNA did not follow the care plan and the outcome was RI #1 had a fall. An interview was completed with EI #2, Care Plan Coordinator, on 11/16/22 at 11:43 AM. EI #2 was asked about the fall care plan for RI #1. EI #2 stated on 9/29/22 a CNA attempted to transfer RI #1 from the bed to the chair without assistance. She further stated the CNA did not follow the care plan requiring two people to assist with RI #1's transfers. EI #2 stated the CNA should have followed the care plan. EI # 2 was asked how a CNA would know what kind of care to provide a resident. EI #2 stated the care guides were posted inside the closet door in the resident's room. This deficient practice was cited as a result of the investigation of complaint/report number AL 223. ********************************************************* The facility took immediate action to correct the noncompliance by: 1. Reported the incident to Alabama Department of Public Health (ADPH) 9/30/22 and conducted an investigation. 2. Reported an incident of possible neglect to local police department on 9/30/22. 3. Completed in-service with staff on following care guides with transfer on 9/30/22. 4. Completed one on one education with Certified Nursing Assistant (EI #3) on 10/5/22. 5. Issued final warning to EI #3 concerning not following care guides on 10/5/22. 6. Quality Assurance (QA) meeting held on 10/5/22 to create plan of correction (POC). 7. Monitoring for two-person assist compliance . The RN Supervisor or designated quality assurance representative will observe CNA's/Staff three (3) times a week for a period of eight (8) weeks, to ensure compliance with resident care guides. Start date 10/3/22 - Ongoing. After review of documentation supporting the corrective actions, including in-service records, employee files, education records, and interviews with staff, the survey team verified the facility had implemented corrective actions from 9/29/2022 through 10/5/2022 and had an ongoing monitoring system in place; thus, past non-compliance was cited.

Based on interviews, record review, review of a facility policy titled, RESIDENTS THESE ARE YOUR RIGHTS, and review of the facility's investigation regarding Resident Identifier (RI) #1's fall, the facility failed to ensure two staff were present during a transfer on 9/29/22 that resulted in RI #1 sustaining a fall. This affected one of three residents reviewed for fall concerns. Findings Include: A review of a policy titled RESIDENTS THESE ARE YOUR RIGHTS, 10/17, documented: . Federal law requires us to . provide . a safe . environment . RI #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include [CONDITION(S)] Disease. A review of RI #1's most recent Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/21/22, documented a Brief Interview Mental Status (BIMS) score of 15/15 which indicated RI #1 was cognitively intact. A review of a document titled Resident Incident Report documented: . 9/29/22 09:27AM . Resident was sitting in floor of room facing his/her bed . Legs were in front of resident . Certified Nursing Assistant (CNA) notified . nurse. Upon entering room assessment was completed .Vital signs taken, resident assessed for pain and injury. Body audit completed. Resident assisted in wheelchair after assessment . A review of RI #1's care plan documented: . I require modified stand and pivot extensive x 2 with my transfers when getting out of bed . start date 2/14/22 . An interview was completed with RI #1 on 11/15/22 at 11:40 AM. RI #1 was asked about the fall he/she sustained on 9/29/22. RI #1 stated he/she rang the call bell, and a CNA came in the room. He/she told the CNA he/she wanted to get out of bed. RI #1 stated the CNA never left the room to get assistance with his/her transfer. RI #1 then explained the CNA attempted to transfer him/her to the chair and during this process he/she became top heavy and fell to the floor. RI #1 explained he/she normally received assistance from two CNAs when transferring from the bed to the chair. An interview was completed with Employee Identifier (EI) #3 on 11/15/22 at 9:21 AM. EI #3 explained that on 9/29/22 she answered RI #1's call light. She stated when she entered the room RI #1 requested to be gotten out of bed. EI #3 stated she left the room to find another staff member to assist with the transfer but could not find anyone on the hall. EI #3 stated RI #1 told her they could do the transfer if she would help him/her stand. EI #3 stated she moved the wheelchair to the bed and attempted to transfer him/her by holding on to his/her pants. EI #3 stated when she was holding RI #1's pants he/she went to the floor. EI #3 was asked if RI #1 was a two-person assist. EI #3 stated yes when getting out of bed. EI #3 was asked if she should have waited until another staff member came in the room to assist before attempting to transfer RI #1. EI #3 responded she should have waited. EI #3 was asked why RI #1 was a two-person assist. EI #3 stated to prevent him/her from falling. EI #3 further stated the fall could have probably been prevented if two people had been present during the transfer. An interview was completed with EI #1, Registered Nurse (RN) on 11/15/22 at 12:30 PM. EI #1 was asked about RI #1's fall status. EI #1 stated RI #1 was a fall risk prior to 9/29/22 and was still currently a fall risk. EI #1 stated RI #1's fall care plan on 9/29/22 stated RI #1 was a two-person assist when getting out of bed. EI #1 was asked about the fall sustained by RI #1 on 9/29/22. EI #1 stated the CNA was attempting to transfer RI #1 when his/her knee gave out and he/she fell to the floor. EI #1 was asked what could have prevented RI #1 from falling on 9/29/22. EI #1 stated she did not feel the fall could have been prevented with two people because RI #1's knee gave out. She further stated it would have been safer with two people trying to stop the fall rather than one person. This deficient practice was cited as a result of the investigation of complaint/report number AL 223. ********************************************************* The facility took immediate action to correct the noncompliance by: 1. Reported the incident to the Alabama Department of Public Health (ADPH) on 9/30/2022 and conducted an investigation. 2. Reported an incident of possible neglect to local police department on 9/30/22. 3. Completed an in-service with staff on following care guides with transfers on 9/30/22. 4. Completed one on one education with Certified Nursing Assistant (EI #3) on 10/5/22. 5. Issued final warning to EI #3 concerning not following care guides on 10/5/22. 6. Quality Assurance (QA) meeting held on 10/5/22 to create plan of correction (POC). 7. Monitoring for two-person assist compliance . The RN Supervisor or designated quality assurance representative will observe CNA's/Staff three (3) times a week for a period of eight (8) weeks, to ensure compliance with resident care guides. Start date 10/3/22 - Ongoing. After review of documentation supporting the corrective actions, including in-service records, employee files, education records, and interviews with staff, the survey team verified the facility had implemented corrective actions from 9/29/2022 through 10/5/2022 and had an ongoing monitoring system in place; thus, past non-compliance was cited.

Based on record review, interviews, and review of the facility's policy titled Coronavirus Testing the facility failed to perform routine COVID-19 testing for all staff per the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare and Medicaid Services (CMS) guidance. This had the potential to affect 43 of 43. Findings included: A review of the facility's policy titled, Coronavirus Testing, revised 03/14/2022, indicated . Expanded screening testing of asymptomatic healthcare personnel (HCP) should be as follows: HCP who are up to date with all recommended COVID-19 vaccine doses may be exempt from expanded screening testing. HCP who are not up to date with all recommended COVID-19 vaccine doses should continue expanded screening testing. Continued review of the policy revealed a table for, Routine Testing Intervals by County COVID-19 Level of Community Transmission which indicated the minimum testing frequency of staff who were not up to date. The minimum testing frequency in counties with a high (red) transmission rate was twice a week. CMS memorandum, QSO-20-38-NH, revised 03/10/2022, revealed, Up-to-date indicated a person who had received all recommended COVID-19 vaccines, including any booster dose(s) when eligible. Per the memorandum, routine testing should be completed two times a week for any staff not up to date with all recommended COVID-19 vaccination doses when the community transmission level was substantial (orange) or high (red). A review of the COVID-19 Community Transmission Level for the county where the facility was located revealed the transmission level was high. A review of the COVID-19 Staff Vaccination Status for Providers revealed the facility had 79 staff members, 63 of whom were vaccinated, but only 12 of whom had received the booster doses for which they were eligible. This left 51 staff members who were not up-to-date with all COVID-19 vaccination doses. Sixteen staff members had exemptions. A review of the Record of COVID-19 Testing of unvaccinated staff revealed six of the 16 unvaccinated staff members were not being tested as per the guidelines. Records revealed Employee Identifier (EI) #12 was last tested on [DATE]. EI #23 was last tested on [DATE]. EI #22 was last tested on [DATE]. EI #25 had not been tested . EI #9 had not been tested . EI #24 was last tested on [DATE]. A review of the June 2022 working schedule from 06/01/2022 through 06/12/2022 for the above staff members revealed the following: - EI #12 was on the schedule and worked four days (06/01/2022, 06/02/2022, 06/03/2022 and 06/06/2022). - EI #23 was on the schedule and worked seven days (06/01/2022, 06/04/2022, 06/05/2022, 06/06/2022, 06/08/2022, 06/09/2022 and 06/10/2022). - EI #22 was on the schedule and worked seven days (06/02/2022, 06/03/2022, 06/04/2022, 06/07/2022, 06/08/2022 and 06/09/2022). - EI #25 was on the schedule and worked seven days (06/01/2022, 06/02/2022, 06/04/2022, 06/05/2022, 06/06/2022, 06/08/2022 and 06/09/2022). - EI #9 was on the schedule and worked nine days (06/01/2022, 06/02/2022, 06/04/2022, 06/05/2022, 06/06/2022, 06/07/2022, 06/08/2022, 06/11/2022 and 06/12/2022). - EI #24 was on the schedule and worked eight days (06/01/2022, 06/03/2022, 06/04/2022, 06/05/2022, 06/08/2022, 06/10/2022, 06/11/2022 and 06/12/2022). During an interview with EI #2 on 06/13/2022 at 11:26 AM, she stated the facility was not up to date with their policy and their testing. EI #2 stated she did not realize the facility needed to test based on staff being up to date with all COVID-19 vaccine doses. EI #2 stated she had not been keeping up with all the changes with COVID-19 restrictions. EI #2 stated the facility was re-evaluating the infection control program.

Based on observations and interviews the facility failed to ensure temperatures were taken of all six bowls of soup heated in the microwave prior to serving to residents. This had the potential to affect 6 of 6 residents receiving soup from the kitchen. Findings included: 1. On 06/10/2022 at 4:23 PM, during observations of the tray line, Employee Identifier (EI) #6, a Cook, was observed making four cups of chicken broth using chicken base that was put in an insulated cup and hot water. The cups were stirred, lids placed on them, and set aside. At 5:05 PM, EI #6 placed two of the four cups of chicken broth in the microwave oven. Once heated, the cups were removed and placed on a resident's dinner tray and served. The staff member did not take a temperature of the chicken broth prior to serving it to a resident. Further observation at 5:07 PM revealed EI #6 placed the other two cups of chicken broth in the microwave oven. Once heated, the cups were removed, and placed on a resident's dinner tray and served. Again, EI #6 did not take a temperature of the chicken broth prior to serving to a resident. During an observation on 06/10/2022 at 5:20 PM, EI #6 was observed pouring thick, condensed tomato soup into two bowls and adding tap water to each bowl. EI #6 placed a lid on the bowls, placed them in the microwave oven, and then placed a bowl on two different residents' trays at 5:31 PM, without taking a temperature of the soup prior to serving. An interview on 06/10/2022 at 5:47 PM with EI #6 revealed temperatures should be taken of every food served prior to leaving the kitchen. EI #6 acknowledged a temperature was not obtained on the four cups of chicken broth nor the two cups of tomato soup before they were served to residents. On 06/10/2022 at 5:48 PM, an interview with EI #5, EI #6's supervisor, revealed a temperature should be taken of everything before it left the kitchen. On 06/10/2022 at 6:01 PM, an interview with EI #1 revealed he/she expected staff to obtain a temperature of all food items before leaving the kitchen.

Based on record review, interview, and review of the policy titled NURSING COMPREHENSIVE CARE PLAN (DEVELOPING), the facility failed to develop a care plan for Resident Identifier (RI) #29's use of an anticoagulant medication. This had the potential to affect 1 of 23 residents reviewed for care plans. Findings included: A review of the facility's policy titled, NURSING COMPREHENSIVE CARE PLAN (DEVELOPING), revised October 2017, revealed . Plans of Care are developed and implemented by the interdisciplinary team, to coordinate and communicate care approaches and goals for the resident related to clinical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #29's Face Sheet revealed the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed RI #29 had a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. RI #29 required two staff for bed mobility, was totally dependent on staff for transfers and locomotion, and was not ambulatory. The MDS revealed the resident was taking an anticoagulant. A review of RI #29's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #29's care plans revealed no documented evidence the facility developed a care plan to address the resident's use of [MEDICATION(S)] and monitoring for complications related to the use of the medication and the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 06/12/2022 at 6:08 PM, an interview with Employee Identifier (EI) #21, the MDS nurse, revealed the facility would complete a care plan for any resident that was on an anticoagulant medication. While reviewing the care plan for RI #29, EI #21 confirmed the resident was receiving [MEDICATION(S)] and that a care plan had not been developed. EI #21 stated, I must have overlooked it. On 06/13/2022 at 4:53 PM, EI #2, the Director of Nursing (DON), stated in an interview that it was her expectation that if a resident was receiving an anticoagulant medication, it should be addressed on the care plan. EI #2 indicated EI #21 was responsible for developing care plans and care plans were reviewed during weekly meetings when a resident's care plan came due. EI #2 stated during the meetings, care plans were compared to residents' medications to determine what medications needed to be on the care plan. EI #2 stated she would have expected to have caught that the medication was not on RI #29's care plan. EI #2 stated, it would be surprising if we missed something like an anticoagulant. Honestly, I do not know how that got missed.

Based on record review, interviews, observations, review of facility policies titled NURSING MEDICATION ADMINISTRATION, and NURSING GASTROSTOMY TUBE/ADMINISTERING MEDICATIONS, and manufacturer's instructions for [MEDICATION(S)] and [MEDICATION(S)] insulin, the facility failed to have a medication administration error rate less than 5%. Specifically, the facility had four errors out of 27 opportunities for error resulting in a medication error rate of 14.81%. Errors were observed during medication administration for four [Resident Identifier (RI) #18, RI #3, RI #4, and RI #31] of eight residents and the medications were administered by two different nurses. Findings included: A review of the facility's policy titled NURSING MEDICATION ADMINISTRATION last revised 11/2017 indicated .Medication will be given as ordered by a physician . THE SEVEN 'RIGHTS' OF DRUG ADMINISTRATION 1. The right drug: Is the ordered drug the same? 2. The right resident: Is the resident's name the same? 3. The right time: Is the time and frequency of administration the same? 4. The right dose: Is the ordered dose the same? 5. The right route: Is the ordered route the same? 6. The residents right to know: Does the resident know the reason for receiving the medication and what side effects to expect. 7. The resident's right to refuse medication. On 06/11/2022 at 7:57 AM, Employee Identifier (EI) #10, Registered Nurse (RN), was observed preparing and administering medications for RI #18. These medications included [MEDICATION(S)] 0.5 milligrams, one-half tablet, which would make the dose 0.25 milligrams. The label on the card of the [MEDICATION(S)] indicated the tablets were 0.5 milligrams and the tablets were half tablets. EI #10 administered the medication along with other morning medications to RI #18. A review of the June 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 06/11/2022 at 8:25 AM, EI #10 stated she read the order wrong and thought she was only supposed to give a half of a 0.5 milligram tablet of [MEDICATION(S)] to RI #18. During an interview on 06/11/2022 at 8:25 AM, EI #2, Director of Nursing (DON), stated after reading the label on the medication, if the nurse followed the direction on the label, he/she would only be giving 0.25 milligrams. She stated she would obtain clarification from the physician. During an interview on 06/11/2022 at 9:45 AM, EI #2 stated staff were giving the wrong dose of [MEDICATION(S)] to RI #18. EI #2 stated the facility had done a dose reduction of RI #18's [MEDICATION(S)] to 0.25 milligrams prior to the resident being sent to a psychiatric hospital and, while at the hospital, the [MEDICATION(S)] was increased back to 0.5 milligrams but the facility staff did not catch the order change when the resident was readmitted to the facility and resumed the previous order of only giving 0.25 milligrams. A review of the manufacturer's recommendations for the [MEDICATION(S)] [MEDICATION(S)], last revised 03/2021, indicated . Before each injection small amounts of air may collect in the cartridge during normal use. To avoid injecting air and to ensure proper dosing: E. Turn the dose selector to select two units. F. Hold the [MEDICATION(S)] [MEDICATION(S)] with the needle pointing up. Tap the cartridge gently with you finger a few times to make any air bubbles collect at the top of the cartridge. G. Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to 0. A drop of insulin should appear at the needle tip. On 06/11/2022 at 10:46 AM, Employee Identifier (EI) #10, Registered Nurse (RN), was observed preparing and administering medications for RI #3. The medications included [MEDICATION(S)] 12 units via a [MEDICATION(S)]. EI #10 administered the insulin subcutaneously (SQ) in the right upper arm. EI #10 did not prime the needle prior to dialing up the dose of 12 units. A review of the June 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 06/11/2022 at 10:50 AM, EI #10 stated she was not aware the insulin pen needed to be primed first. During an interview on 06/11/2022 at 6:11 PM, EI #18, Licensed Practical Nurse (LPN), stated he learned that day that the needle on insulin pens needed to be primed before each dose. EI #18 stated he originally thought it needed to be primed only when the pen was first opened. During an interview on 06/13/2022 at 9:03 PM, EI #14, Pharmacy Consultant, stated that insulin pens should definitely be primed on the first dose. EI #14 stated staff should be following manufacturer's recommendations. A review of the manufacturer's instructions for [MEDICATION(S)] KwikPen, revised 04/2020, revealed Priming your Pen Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensure that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. Step 6: To prime your Pen, turn the Dose Knob to select 2 units. Step 7: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Step 8: Continue holding your Pen with the Needle pointing up. Push the Dose Knob in until it stops and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. Step 11: Inject the needle into your skin. Push the Dose Knob all the way in. Continue to hold the dose knob in and slowly count to 5 before removing the Needle. On 06/11/2022 at 10:57 AM, Employee Identifier (EI) #16, Licensed Practical Nurse (LPN), was observed preparing and administering medications to RI #4. EI #16 checked RI #4's blood sugar (231) and administered [MEDICATION(S)] insulin 12 units via a [MEDICATION(S)] injection pen. EI #16 administered the insulin subcutaneously in the left upper quadrant of the abdomen. EI #16 did not prime the needle prior to dialing up the dose of 12 units and only held the needle in place for less than three seconds. A review of the June 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 06/11/2022 at 11:05 AM, EI #16 stated she was not aware an insulin pen needed to be primed first. During an interview on 06/13/2022 at 9:03 PM, EI #14, Pharmacy Consultant, stated that insulin pens should definitely be primed on the first dose. EI #14 stated staff should be following manufacturer's recommendations. On 06/11/2022 at 11:18 AM, Employee Identifier (EI) #16, Licensed Practical Nurse (LPN), was observed preparing and administering medications for RI #31. The medications included [MEDICATION(S)] 125 milligrams two capsules. EI #16 opened the capsules and emptied the contents into a plastic medication cup. EI #16 checked placement of RI #31's percutaneous endoscopic gastrostomy (PEG) tube (feeding tube) with the use of a stethoscope pushing 30 milliliters of air into the tube with a syringe and then pulled back on the syringe to check for residual (contents left in the resident's stomach). EI #16 added 30 milliliters of water to the medication cup and poured it into the tube. EI #16 did not flush the tube prior to putting the medication in the tube but did flush it with 30 milliliters of water after. A review of the June 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Check tube placement before medications. Flush tube with 30 milliliters of water before and after medications. Flush tube with five to ten milliliters of water between each medication. During an interview on 06/11/2022 at 11:18 AM, EI #16 she stated she forgot to flush the tube first before administering the medications. She stated she should have flushed it with 30 milliliters of water first. During an interview on 06/13/2022 at 7:34 PM, EI #2, Director of Nursing (DON), stated when administering medication through a tube, a nurse should flush the tube with 30 milliliters of water, mix each medication individually with five to ten milliliters of water before putting them in the tube, and then flush the tube with 30 milliliters of water after.

Based on observations, interviews and a review of a facility policy titled, FOOD AND NUTRITION SERVICES DISHWASHING MACHINE, the facility failed to ensure trays were allowed to air dry before use during meal service on 2/26/2020. This had the potential to affect up to 12 of 46 residents who received meals from the kitchen. Findings Include: A review of a policy titled, FOOD AND NUTRITION SERVICES DISHWASHING MACHINE, with a revised date of 10/17, revealed: Policy The following procedure will be used when using the dishwashing machine. Procedure .9. Air-dry dishes. On 2/26/2020 at 4:39 p.m., the surveyor observed staff using wet trays during meal service. 12 trays were utilized for meal service with water inside of them and/or on the sides of the trays. On 2/26/20 at 5:40 p.m., an interview was conducted with EI #4, Dietary Aide. EI #4 was asked what she saw on the residents' trays. EI #4 replied water drips. EI #4 was asked why there was water in the residents' trays. EI #4 said they did not have time to dry. EI #4 was asked why wet trays should not be used during meal service. EI #4 said it was unsanitary. On 2/26/20 at 5:48 p.m., an interview was conducted with EI #3, a Cook. EI #3 was asked what she observed on trays during meal service/tray line. EI #3 replied, there were water drops. EI #3 was asked why trays should be dry during meal service. EI #3 replied, so other things did not get stuck to them.

Based on observation, interview and review of facility policies titled ICE MACHINE CLEANING PR(NAME)EDURE and ICE, the facility failed to ensure: 1) the ice scoop was not stored in the ice machine and there was not a dark substance on the plastic where the ice dispenses from; and 2) tray cards were not laying on top of two stacks of clean plates; and 3) a dietary aide maintained her hair in the hair net. These concerns were observed during the kitchen observations on 02/06/18 and 02/07/18, and had the potential to affect all 42 resident receiving meals from the kitchen. Findings Include: 1) A review of an undated facility policy titled ICE revealed: . Procedure . 3. and scoops shall be kept clean and shall be stored and handled in a sanitary manner. A review of another policy titled ICE MACHINE CLEANING PR(NAME)EDURE revealed . Procedure . Inspect monthly and clean as needed. At least quarterly. On 02/06/18 at 3:45 p.m., during the initial tour with Employee Identifier (EI) #5, Cook Supervisor, the scoop was observed in the ice inside the ice machine. There was also an observation of a dark substance on the plastic area inside the ice machine where the ice was dispensed from. On 02/06/18 at 4:10 p.m., an interview was conducted with EI #5, the Cook Supervisor. EI #5 was asked what was the dark substance. EI #5 replied, she was not sure. EI #5 was asked where should the ice scoop be stored. EI #5 replied, in the bin on the wall. EI #5 was asked what was the harm in storing the ice scoop inside the ice machine. EI #5 replied, it could contaminate the ice. 2) On 02/07/18 at 10:40 a.m., the surveyor observed three stacks of plates beside the steam table; tray cards were laying on top of the two stacks. Once the surveyor asked EI #3, the Dietary Manager (DM) about this, she removed the top plate from the two stacks that the tray cards were on. On 02/07/18 at 10:45 a.m., an interview was conducted with EI #3, the Dietary Manager. EI #3 was asked where should tray cards be stored. EI #3 stated, Not on top of the plates. EI #3 was asked what was the harm in the tray cards being on top of the plates. EI #3 replied, cross contamination. On 02/08/18 at 9:10 a.m., an interview was conducted with EI #3. EI #3 was asked if she observed the dark substance inside the ice machine. EI #3 replied, yes. EI #3 was asked who was responsible for cleaning the ice machine. EI #3 replied, maintenance. EI #3 was asked how often the machine was cleaned. EI #3 replied she was not sure, then followed up with it was cleaned in November 2017. EI #3 was asked who was responsible for assuring the ice scoop was stored properly. EI #3 replied, the kitchen staff. EI #3 was asked what the harm was in storing the scoop in the ice. EI #3 replied, cross contamination. 3) On 02/07/18 at 11:10 a.m., EI #6, a Dietary Aide entered the food preparation area. EI #6's hair was not completely maintained in the hair net. On 02/07/18 at 11:15 a.m., an interview was conducted with EI #3, the DM. EI #3 was asked to observe the dietary aide. EI #3 was then asked if the hair should be completely under the net. EI #3 replied, yes. EI #3 was asked what was the harm in the hair not being completely under the net. EI #3 replied, hair could get in the food.

Based on interviews and record review, the facility failed to ensure: 1) Resident Identifier (RI) #38's Annual Minimum Data Set assessment, dated 01/15/18, accurately assessed RI #38 was receiving antidepressant medications; and 2) RI #50's Significant Change MDS, dated [DATE], was coded for Hospice. These deficient practices affected RI #38 and RI #50, two of 19 sampled residents whose MDS's were reviewed. Findings Include: 1) RI #38 was admitted to the facility on [DATE], and readmitted on [DATE], with a [DIAGNOSES REDACTED]. RI #38's January 2018 Physician order [REDACTED].> . Other recurrent [MEDICAL CONDITION] ([MEDICATION NAME]) HCL ([MEDICATION NAME]) 10 MG (milligram) CAPSULE GIVE 2 CAPSULES (20 MG) BY MOUTH ONCE DAILY . [MEDICATION NAME] 50 MG TABLET GIVE ONE TAB (tablet) PO (by mouth) QHS (every bedtime) . [MEDICATION NAME] 15 MG TABLET GIVE 1 TAB PO Q HS . RI #38's January 2018 Medication Administration Record [REDACTED]. An Annual MDS assessment with an Assessment Reference Date of 01/15/18, revealed under Section N - Medications, that RI #38 had not received any antidepressant medications during this assessment period. On 02/08/18 at 4:16 p.m., the surveyor conducted an interview with Employee Identifier (EI) #2, the MDS Coordinator. The surveyor asked EI #2 was RI #38 receiving anti-depressant medications. EI #2 said yes. EI #2 said RI #38 was receiving [MEDICATION NAME], Trazadone, and [MEDICATION NAME]. The surveyor asked EI #2 should the antidepressants be coded on RI #38's 01/15/18, MDS. EI #2 said it should. The surveyor asked EI #2 did she see where the antidepressants were coded on the MDS. EI #2 said they were not. The surveyor asked EI #2 was the 01/15/18 Annual MDS assessment an accurate assessment. EI #2 replied, no it would not be. 2) RI #50 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of RI #50's Physicians Orders for the month of October 2017, revealed: . order date 09/15/17 ADMIT TO ALACARE HOSPICE SERVICES . A review of a Significant Change MDS with an Assessment Reference Date of 09/25/17 Section O did not indicate RI #50 was receiving Hospice Services. On 02/08/18 at 3:34 p.m., an interview was conducted with EI #1, the Director of Nursing. EI #1 was asked when did RI #50 receive an order for [REDACTED].#1 was asked, when should a Significant Change MDS have been done. EI #1 replied, on 09/25/17. EI #1 was asked if Hospice was captured on the MDS dated [DATE]. EI #1 replied, no. EI #1 was asked if Hospice should have been checked. EI #1 replied, yes. EI #1 was asked why it was not done. EI #1 replied it was a data entry error. EI #1 was asked what the harm was in Hospice not being coded on the MDS dated [DATE]. EI #1 replied, a coding error.

Based on observations, interviews and record review, the facility failed to ensure Resident Identifier (RI) #27's plan of care to have a bed alarm on the bed was followed. This deficient practice affected RI #27, one of 19 sampled residents whose plans of care were reviewed. Finding Include: RI #27 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #27's I am at risk for falls r/t (related to) my [DIAGNOSES REDACTED]. . *03/14/2017 I am on a bed/chair alarm to alert staff . A Quarterly Minimum Data Set assessment, with an Assessment Reference Date of 12/10/17, identified RI #27 to have short and long term memory problems with moderately impaired cognition. On 02/08/18 at 10:13 a.m., the survyor observed that RI #27 did not have a bed alarm on the bed. On 02/08/18 at 3:29 p.m., the surveyor escorted Employee Identifier (EI) #4, a Certified Nursing Assistant (CNA) to RI #27's room. EI #4 said she did not see a bed alarm on RI #27's bed. When interviewed by the surveyor, EI #4 said RI #27 used to have a bed alarm. When asked by the surveyor why RI #27 had the bed alarm, EI #4 said EI #27 would try to get out of bed and could not stand On 02/08/18 at 5:08 p.m., the surveyor conducted an interview with EI #1, the Director of Nursing. The surveyor asked EI #1, according to RI #27's plan of care, should the resident have a bed alarm. EI #1 replied, yes. The surveyor asked EI #1, if the bed alarm was not on RI #27's bed, was the care plan being followed. EI #1 replied, no.

Based on observation, record review and interview, the facility failed to ensure RI #27, a resident at risk for falls, had a bed alarm on the resident's bed, as ordered by the Physican and care planned by the facility. This deficient practice affected RI #27, one of 19 sampled residents. Finding Include: RI #27 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #27's February 2018 Physician order [REDACTED].> . BED AND CHAIR ALARM TO ALERT STAFF . RI #27's I am at risk for falls r/t (related to) my [DIAGNOSES REDACTED]. . *03/14/2017 I am on a bed/chair alarm to alert staff . A Quarterly Minimum Data Set assessment, with an Assessment Reference Date of 12/10/17, identified RI #27 to have short and long term memory problems with moderately impaired cognition. On 02/08/18 at 10:13 a.m., the survyor observed that RI #27 did not have a bed alarm on the bed. On 02/08/18 at 3:29 p.m., the surveyor escorted Employee Identifier (EI) #4, a Certified Nursing Assistant (CNA) to RI #27's room. EI #4 said she did not see a bed alarm on RI #27's bed. On 02/08/18 at 5:08 p.m., the surveyor conducted an interview with EI #1, the Director of Nursing. The surveyor asked EI #1 was RI #27 at risk for falls. EI #1 said yes. EI #1 said RI #27 was at risk of falls because of RI #27's Dementia. The surveyor asked EI #1 was the bed alarm considered a safety measure. EI #1 said yes.

Based on observation and interview, the facility failed to ensure a Certified Nursing Assistant (CNA) did not place a plastic trash bag on the floor during the provision of incontinent care. This was observed on 02/07/18, and affected Resident Identifier (RI ) #18 one of one resident observed for incontinent care. Findings Include: RI #18 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 02/07/18 at 3:59 p.m., Employee Identifier (EI) #7 was observed providing pericare for RI #18. EI #7 removed RI #18's adult brief and placed the brief in a bag that was on the bed. EI #7 then took the bag and placed it on the floor and continued with incontinent care. On 02/07/18 at 4:10 p.m., an interview was conducted with EI #7. EI #7 was asked where should the trash bag be placed while doing incontinent care . EI #7 replied on the end of the bed. EI #7 was asked where did he place the bag. EI #7 replied on the floor. EI #7 was asked what was the harm in placing the trash bag on the floor. EI #7 replied contamination. On 0 2/08/18 at 3:34 p.m., an interview was conducted with EI # 1,the Director of Nursing. EI #1 was asked where should the trash bag be placed during incontinent care. EI #1 replied on the end of the bed. EI #1 was asked what was the potential for harm in placing the trash bag on the floor. EI #1 replied, contamination and the spread of germs.

Based on observation, interview and record review, the facility failed to ensure the rinse sanitizer solution reached 50 PPMs (parts per million) during dishwashing on 10-7-2015. The sanitizer solution was checked multiple times and found to be at 10 PPMs each time. This had the potential to affect 44 residents receiving meals from the kitchen. Findings Include: A review of the facility's policy titled Dietary- Dishwashing Machine with a date of 1/10 revealed : .9. PPM (parts per million) should read 50 ppm . 12. Check machine to see if it is working properly. On 10/7/2015 at 8:40 AM, the surveyor observed the low temperature dishwashing machine while (Employee Identifier) EI #4, kitchen aid, was washing dishes. The surveyor observed two chemical containers under the dishwasher, one was almost empty, the other full. The surveyor asked EI #4 to check the PPM of the final rinse. EI #4 checked the PPM with a chlorine strip and it registered 10 PPM. EI #4 took another clean strip, tested the PPM again and it still registered 10 PPM. EI #4 said she needed to go get the DM (Dietary Manager), EI #6. The DM tested the PPM which still registered 10 PPM. EI #6 told EI #4 to get a strip from another batch. The PPM still registered 10 PPM. EI #6 said she would call Auto Chlor to check the machine to see if it was working properly. On 10/7/2015 at 3:17 P.M. an interview was conducted with EI #4. EI #4 was asked who is responsible for making sure the PPM is correct on the dishwasher. EI #4 replied we all are. EI #4 was asked when was the last time it was checked. EI #4 said when EI #5, another kitchen aid, checked it this morning. EI #4 was asked how many loads of dishes did you wash this morning. EI #4 said one or two. EI #4 was asked how do you know when the PPM was checked. EI #4 said she checked the log and also made sure herself. EI #4 was asked what the PPM be on the machine should be. EI #4 said 100. EI #4 stated she had not checked the PPM before she used the dishmachine. EI #4 was asked how the dishwasher should be be addressed when the PPM was incorrect. EI #4 said first we check the chlorine container to make sure it was full. EI #4 was asked what was the harm in having a PPM that is not correct. EI #4 said it could leave germs, cause contamination, bacteria and could be fatal. On 10/8/2015 at 8:50 AM an interview was conducted with EI #6, DM. EI #6 was asked who was responsible for making sure the PPM on the dishwasher was correct. EI #6 said whoever is washing the dishes. EI #6 was asked how often was it checked. EI #6 said when they first get here at 5:00 AM when they start the machine and wash the staff breakfast dishes and when they start again to wash the resident's breakfast dishes. EI #6 was asked what were possible causes for the PPM to be incorrect. EI #6 said if the dishwasher was not working correctly and if the chlorine was getting too low and not distributing properly. EI #6 was asked what is the potential for harm in not having the correct PPM. EI # 6 replied cross contamination, bacteria, germs and E. coli (Escherichia coli). An interview was conducted on 10/8/2015 at 9:55 AM with EI #5, kitchen aid. EI #5 was asked what was the facility's policy regarding an incorrect PPM and what should you do. EI #5 said run the cycle again to make sure the chemicals are dropping down, and if it remains incorrect go get the DM. EI #5 was asked what was the potential for harm in not having the correct PPM. EI #5 said people could get sick, bleach is what kills bacteria. A review of the Auto-Chlor Warewashing Service Report dated 10/7/2015 at 11:50 AM revealed services performed/recommendations: primed old product out of line. Now at 100 PPM in sanitizer.

Based on observation, record review and interview the facility failed to ensure a Certified Nursing Assistant (CNA) did not obtain vital signs to include a temperature under the arm in the hallway on Resident Identifier (RI) #8 on 10/6/15; and another CNA did not obtain vital signs in the hall on RI #9 on 10/7/15. This affected two of ten current residents sampled during the survey. Findings include: A review of the facility Resident Handbook page 7 Your Rights as a Resident .The Facility strives to promote care for residents in a manner .that maintains or enhances each resident's dignity . RI #8 was readmitted to the facility 1/26/15. On 10/6/15 at 4:55 PM Employee Identifier (EI) #1, CNA was observed in the hallway taking the vital signs to include a temperature under RI #8's arm. The machine screen was visible to visitors and other residents. An interview was conducted with EI #1 on 10/6/15 at 5:00 PM. EI #1 was asked should you check residents vital signs in the hall to include the temperature under the arm. EI #1 replied I don't know, I guess it is ok. EI #1 was asked If it could be considered a dignity concern to check the residents vital signs in the hall. EI #1 replied I don't know, I guess so. RI #9 was readmitted to the facility 9/12/11. On 10/7/15 at 8:10 AM, EI #2, CNA was observed taking RI #9's vital signs in the hallway. The screen of the machine was visible to visitors and other residents. On 10/7/15 at 12:10 PM an interview was conducted with EI #2. EI #2 was asked where should residents vital signs be taken. EI #2 replied in the resident's room. EI #2 was asked what was the harm in taking a resident's vital signs in the hall. EI #2 replied dignity and privacy. On 10/7/15 at 3:00 PM an interview was conducted with EI #3, Director of Nursing. She was asked how were staff trained as to where to get resident vital signs. EI #3 replied to get them in the resident rooms. EI #3 was asked should staff check vital signs in the hall, corridor or sitting room. EI #3 replied no. EI #3 was asked what was the potential for harm in the staff checking vital signs for the residents in the halls or commons areas. EI #3 replied dignity.

Based on observations, record review and interview: 1) The facility failed to assure food preparation equipment, dishes and utensils were effectively cleaned and sanitized to prevent potential cross contamination and potential food borne illness. (4 of 12 sectional plates were observed to be wet or with food debris). 2) The facility failed to designate a person in charge who was present at the food establishment during all hours of operation and could demonstrate knowledge of foodborne disease prevention, application of the Hazard Analysis and Critical Control Point principles and the requirements of the food code. (One of three cook/supervisors was serve-safe certified). 3) The facility failed to adhere to the 2013 Food Code, 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking and the facility Policy number NTR-150 dated 01/10, titled "Dietary Nourishments and Supplements" as related to Frozen/Thawed Mighty Shakes. (Bulk thawed Mighty Shakes in the kitchen refrigeration not individually dated, 4 of 4 found in nursing station refrigerator with no use by date). 4) The facility failed to prevent potential cross- contamination by: a. A failure to transport glasses on a tray versus stacking and bracing against body. b. A failure to change potentially contaminated gloves during plating of food on the trayline during 2 meal observations on two days and two different staff observed. c. A failure to store equipment, clean dishes and utensils on non-porous surfaces which were maintained clean and sanitized. d. A failure to effectively clean food preparation counter space between use for resident returned soiled food trays and food preparation or delivery of resident meal trays. e. The facility failed to use the employee hand sink only for handwashing (ServSafe Manager Book). The above practices posed the potential for food contamination and compromised food safety. This had the potential to affect all 43 residents receiving meal trays from dining services. Findings include: 1) The facility failed to assure food preparation equipment, dishes and utensils were effectively cleaned and sanitized to prevent potential cross contamination and potential food borne illness. (4 of 12 sectional plates observed to be wet or with food debris). The 2013 Food Code by the United States Public Health Service (USPHS) and the Food and Drug Administration (FDA) included the following: "Objective 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch..." "Drying 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried ..." On 1/05/2015 at 3:40 PM, recently cleaned/stored sectional plates were observed in the presence of the CDM (Certified Dietary Manager) Employee Identifier (EI) #5. Four of 12 plates were observed wet or contained food debris. On 1/07/2015 at 1:20 PM during an interview with the CDM, EI #5 was asked, what condition we saw clean stored sectional plates on 1/05/15. EI #5 answered that there were plates with food debris and with water. EI #5 was asked, what was the risk/potential. EI #5 stated there was a potential to harbor or for the growth of bacteria. 2) The facility failed to designate a person in charge who was present at the food establishment during all hours of operation and could demonstrate knowledge of foodborne disease prevention, application of the Hazard Analysis and Critical Control Point principles and the requirements of the food code (one of three cook/supervisors Serve-Safe certified). The 2013 Food Code by the United States Public Health Service (USPHS) and the Food and Drug Administration (FDA) included the following: "Responsibility 2-101.11 Assignment. (A) ... or shall designate a PERSON IN CHARGE and shall ensure that a PERSON IN CHARGE is present at the FOOD ESTABLISHMENT during all hours of operation..." "Knowledge 2-102.11(A) Demonstration. Based on the RISKS inherent to the FOOD operation, during inspections and upon request the PERSON IN CHARGE shall demonstrate to the REGULATORY AUTHORITY knowledge of foodborne disease prevention, application of the HAZARD Analysis and CRITICAL CONTROL POINT principles, and the requirements of this Code. The PERSON IN CHARGE shall demonstrate this knowledge by: (A) Complying with this Code by having no violations of PRIORITY ITEMS during the current inspection," The January 2015 Dietary Schedule Sheet was observed. Scheduled per shift was a cook and a dietary aide, four employees per day plus the CDM who worked 8-4, Monday through Friday. On 1/07/2015 at 1:42 PM, the CDM EI #5 was asked, how many staff are Serv-Safe qualified. EI #5 responded, me and one other (EI #2). The facility received violations of the regulatory code during this inspection therefore not in compliance with parts of Food Code Chapter 2. 3) The facility failed to adhere to the 2013 Food Code, "3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking" and the facility Policy number NTR-150 dated 01/10, titled "Dietary Nourishments and Supplements" as related to Frozen/Thawed Mighty Shakes (all high protein and high calorie supplements). (Bulk thawed Mighty Shakes were observed in the kitchen refrigerator, not individually dated and 4 of 4 were found in the nursing station refrigerator with no use by date). On 1/06/2015 at 11:27 AM, the nursing station refrigerator was scanned with the CDM for individual cartons of Mighty Shakes with a use by date. Four individual cartons were observed but no use by date was documented. On 01/06/2015 at 11:30 AM, the kitchen refrigerator storage of thawed Mighty Shakes was observed. The cardboard box had a date but individual cartons had no use by date. The above observation was validated by the signature of the CDM. On 1/07/2015 at 1:35 PM, EI #5 was asked, are your staff labeling Mighty Shakes with a use by date per manufacturer's instruction and facility policy NTR-150 dated 01/10. EI #5 responded, No, they did not. 4) The facility failed to prevent potential cross- contamination by: a. A failure to transport glasses on a tray versus stacking and bracing against body. On 1/05/2015 at 5:11 PM, EI #3 was observed to obtain glasses from a rack, stack them, brace them against the body and transport to individual trays. The CDM was called over, EI #5 stated that she had seen it and said that she was going to get rid of those glasses and obtain clean ones. b. A failure to change potentially contaminated gloves during plating of food on the trayline during 2 meal observations on two days and two different staff observed. On 1/05/2015 at 5:05 PM, the cook EI #2 was observed with both hands gloved. EI #2 used gloved hands to sort paper tray cards and place on individual trays. EI #2 went to cabinet doors to obtain alcohol wipes for cleaning thermometers, opened a drawer to obtain serving utensils and failed to wash hands or change gloves prior to monitoring trayline temperatures and plating food. On 1/06/2015 at 11:20 AM, the early cook, EI #4 was observed to open a cabinet door with gloved hand, obtained deli paper and grabbed a serving of cornbread for plating with the potentially contaminated glove. No hand washing nor glove change was noted. This observation was validated by the CDM. c. A failure to store equipment, clean dishes and utensils on non-porous surfaces which were not maintained clean and sanitized. The storage of clean equipment inside cabinet doors and on a bare (porous) wooden surface was observed on 1/05/2015 at 5:13 PM. The shelving was stained, greasy and dirty. The shelves were observed to store sheet pans and steamtable pans. A facility document dated 12/17/2014, indicated a plan to discuss the shelving problem. d. A failure to effectively clean food preparation counter space between use for resident returned soiled food trays and food preparation or delivery of resident meal trays. On 1/06/2015 at 5:30 PM staff was observed to sort scrapped food trays, domes, plates and flatware and store on the counter. Liquids were observed to be poured in the hand sink. The cleaning of this dual use counter was observed. Staff used a cloth with liquids wrung out to wipe the counter (did not rinse nor allow contact for 2 minutes). The Clorox label on the container directed staff to wipe the surface area with the chemical for at least 2 minutes. A review of facility policy/procedure for "Dietary Sanitizing Solution" NTR-165 dated 1/10 failed to address amount of chemical contact time. Facility policy "Dietary Cleaning Counter Space" NTR-104 dated 01/10 failed to address contact time. A review of documentation by the CDM revealed: "Serving counter/dumping counter can lead to cross-contamination if not cleaned properly in between each use." e. The facility failed to use the employee hand sink only for handwashing (ServSafe Manager Book). The 6th Edition of ServSafe Manager at Chapter 9.4 revealed: "Handwashing Stations ... handwashing sinks must be used only for handwashing and not for any other purpose". During the 5:30 PM observation on 1/06/2015, of the breakdown on returned, soiled resident trays revealed liquids were poured down the handsink. The CDM's documentation related to this practice indicated: "Hand washing sink/liquid dump sink can lead to cross-contamination ..."

Based on observation, record review and interviews the facility failed to ensure two rolls of frozen hamburger meat were used by the expiration date. The facility further failed to ensure packages of frozen hashbrown patties, tater tots, a box of chicken patties and two container of frozen B-B-Q meat were discarded by their use by dates. This was observed during the initial kitchen tour on 12/16/2013. This had the potential to affect 47 residents receiving their meals from the kitchen. A review of the facility's policy titled "DIETARY FOOD STORAGE" dated 01/10 revealed "... Procedure ... 5. Stock is rotated with each new order received. Rotating stock is essential to ensure the freshness and highest quality of foods. a. Old stock is used first ... C. Date marking to indicate the date or day by which a ready-to-eat, potentially hazardous food should be consumed, sold, or discarded will be visible on all high risk food. ... 9. Frozen Foods: ... d. All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. ..." On 12/16/2013 at 6:15 PM during the Initial Tour of the kitchen the following observations were made in the freezer. 1. Two rolls of frozen hamburger meat with a manufacture's expiration date of 12/06/13. No facility labeling was observed. 2. One bag of hashbrown patties with a facility label dated 10/21 and the manufacture used by date of 9/26. 3. One brown bag with a date of 9/13 inside a ziplock bag with a open date of 11/14/13 and a used by date of 11/21/13. 4. One box of frozen chicken patties with one facility label dated 10/10. 5. Two 5 pounds containers of frozen B-B-Q meat with a facility label dated 10/31/2013. On 12/18/2013 at 10:35 AM the surveyor interviewed EI (Employee Identifier) #1, Dietary Manager regarding food storage. The surveyor asked EI #1 how should items be labeled in the freezer. EI #1 explained if the items have not been opened the manufacture's expiration date is used. EI #1 further explained when an item is opened two labels should be used; a date when opened and a used by date. When the surveyor asked EI #1 why should items in the freezer have a used by date; EI #1 explained the food items could go bad. When the surveyor asked EI #1 about the labels for the 2 rolls of frozen hamburger meat; EI #1 stated, "They had a date of 12/6/2013- Meaning they were expired." The surveyor asked EI #1 what was the potential for harm with the hamburger meat not discarded. EI #1 stated, "It could make some one sick if it was used." The surveyor asked EI #1 what was the date of 8/21/2013 used for on the box of chicken patties. EI #1 stated that was the date it was received. When the surveyor asked EI #1 if there was a use by date on the box of chicken, EI #1 stated, "No." The surveyor asked EI #1 what was the potential for harm and EI #1 stated, "they could make somebody sick". When the surveyor asked EI #1 what were the three dates for the tater-tots, EI #1 explained the 9/13 was the date the bag come in, 11/14/2013 was the open date and 11/21/2013 was the expiration date. When the surveyor asked what was the potential for harm with these items in the freezer, EI #1 stated, "They could grow bacteria and make someone sick". The surveyor asked EI #1 why there was only one label on each of the 2 containers of B-B-Q meat. EI #1 stated, "It did not have a use by date".

Based on observation, record review and interviews. The facility failed to ensure RI (Resident Identifier) # 6's complaint made during a Care Plan Meeting on 9/25/2013 regarding the consistency of his chopped meat diet order was resolved to his satisfaction. This affected 1 of 8 sampled residents. Finding include: A review of the facility's policy titled "SOCIAL SERVICES GRIEVANCE/COMPLAINTS" dated 04/09 revealed "Policy The facility assist residents... in filing grievances or complaints when such requests are made. All grievances are investigated. Investigation results are reported to the Administrator and the grieving individual. Procedure ...2. Grievances and/or complaints may be submitted orally or in writing. ... 8. The resident, ...will be informed of the findings of the investigation and the plan to correct any identified problems. ..." RI #6 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #6's most recent MDS (Minimum Data Set) with an Assessment Reference Date of 12/15/2013 revealed RI #6's BIMS (Brief Interview for Mental Status) score was 12, indicating moderate impairment in cognitive skills for daily decision-making. A review of RI # 6's Physician order [REDACTED]. A review of RI # 6's tray card documented "...Diet REG (regular) CCD CHOPPED MEATS. A review of RI # 6's current care plan dated 11/6/13 did not reveal an intervention for Chopped meat by hand. An observation of RI # 6's lunch was completed on 12/17/13 at 12:30PM. The surveyor observed that RI # 6 received finely chopped ham on his divided plate. RI # 6 sent a request to the kitchen for hand chopped ham. RI # 6 received the hand chopped ham and ate 100%. On 12/18/2013 at 10:35 AM, the surveyor interviewed EI (Employee Identifier) # 1, Dietary Manager, regarding RI #6's complaint regarding his chopped meat diet. The surveyor asked EI #1 when did RI #6 make a complaint about the chopped meat being chopped too fine. EI #1 explained that it was during his Care Plan Meeting on 9/26/2013. EI #1 further explained she had told him the kitchen staff would hand chop the meat served to him during that meeting. The surveyor asked EI #1 where was the documentation that the chopped meat should be hand chopped. EI #1 looked through RI #6's Care Plans and stated "There is nothing documented on it". When the surveyor asked EI #1 if it was written on RI #6's tray card; EI #1 stated,"Just that he gets chopped meat". The surveyor asked EI #1 how does the staff know to hand chop the meat. EI #1 explained the staff will send him the chopped meat made in the blender; after he tells them he does not like the meat that fine staff will send hand chopped meat to him. The surveyor asked EI #1 if RI #6's complaint had been resolved. EI #1 stated, "If we are sending him the chopped meat prepared (in the blender) we are not sending him what he wants".

Based on observation, interview, and record review, the facility failed to follow the plan of care for RI (Resident Identifier) #6, a resident who is incontinent of bowel. Soap and water was not used following a bowel movement as care planned. The facility further failed to provide food preferences as care planned for RI #6. These observations were made on one of three days of the survey. This affected 1 of 8 sampled residents. Findings Include: 1. RI #6 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #6's most recent MDS (Minimum Data Set) with an Assessment Reference Date of 12/15/2013 revealed RI #6's BIMS (Brief Interview for Mental Status) score was 12, indicating moderate impairment in cognitive skills for daily decision-making. The MDS also documented RI #6 was always incontinent of bowel. A review of RI #6's current Care Plan in the Medical record revealed "...Problem Onset: 02/07/2013 actual pressure ulcers on admission. Resident with actual stage 4 to sacral area... .The interventions included "Cleanse perineal area with soap and water following each bowel movement..." On 12/17/2013 at 3:53 PM, RI #6 was observed during incontinent care. EI (Employee Identifier) #2, CNA (Certified Nursing Assistant) used wipes to clean RI #6's perineal area following a bowel movement. A telephone interview was conducted with EI #2 on 12/18/2013 at 11:45 AM. EI #2 was asked, when incontinent care was provided for RI #6 on 12/17/2013 was the care plan intervention followed for using soap and water to clean the perineal area following a bowel movement. EI #2 stated, "No." EI #2 was asked what was the potential for harm if the care plan intervention was not followed. EI #2 stated, "He could have breakdown of his skin, he already does." An interview was conducted with EI #4 LPN (Licensed Practical Nurse), Restorative/Treatment Nurse on 12/18/2013 at 2:05 PM. EI #4 was asked why was the intervention written for RI #6 for cleaning with soap and water following a bowel movement. EI #4 stated that was his initial care plan. 2. RI #6 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #6's most recent MDS (Minimum Data Set) with an Assessment Reference Date of 12/15/2013 revealed RI #6's BIMS (Brief Interview for Mental Status) score was 12, indicating moderate impairment in cognitive skills for daily decision-making. A review of RI # 6's Physician order [REDACTED]. A review of RI # 6's current care plan dated 11/6/13 did not reveal an intervention for chopped meat by hand. On 12/18/2013 at 10:35 AM, the surveyor interview EI (Employee Identifier) #1 regarding RI #6's Care Plan. When the surveyor asked EI #1 what were RI #6's preference regarding chopped meat, EI #1 explained RI #6 preferred hand chopped meat instead of the blended chopped meat the facility prepared. EI #1 stated she had told RI #6 the facility would provide hand chopped meat for his meals instead of using the blended chopped meat. EI #1 further explained the blended chopped meat was sent to the resident and if he does not want it, they would then send hand chopped meat to him. The surveyor asked EI #1 where was RI #6's preference documented. After EI #1 looked through RI #6's Medical Record, EI #1 explained there was nothing documenting his preference. The surveyor asked EI #1 should RI #6's Care Plan reflect his preferences, EI #1 stated, "Yes".