Every finding on record at Anniston Health and Rehab Services

Based on observation, interview and review of a facility policy titled Cleaning of Miscellaneous Equipment and Utensils and review of the Food Code 2017, the facility failed to ensure pans were allowed to air dry. This was observed during the initial tour of the kitchen on 11/30/21 when wet pans were observed stacked together. The facility further failed to ensure a bucket of water with detergent was not placed next to an open container of sweet tea during lunch preparation on 12/1/21. This had the potential to effect all residents receiving meals from the kitchen. Findings include: A facility policy tilted Cleaning of Miscellaneous Equipment and Utensils with an effective date of 11/2019 documented the following: . Pots and Pans: . Place pots and pans on drain sink to air dry . The Food Code 2017 documented: .Storage 7-201.11 Separation. POISONOUS OR TOXIC MATERIALS shall be stored so they can not contaminate FOOD, . (A) Separating the POISONOUS OR TOXIC MATERIALS by spacing or partitioning . (B) Locating the POISONOUS OR TOXIC MATERIALS in an area that is not above FOOD . On 11/30/21 at 9:45 AM during the initial tour of the kitchen the surveyor observed approximately 11-15 different size pans stacked together on a wire rack with water present between the stacked pans. On 11/30/21 at 9:48 AM an interview was conducted with Employee Identifier (EI) #3, Dietary Manager. EI #3 was asked what the rack was used for. EI #3 stated for drying pans after washing. EI #3 was asked if the pans should be stacked together. EI #3 stated it would be okay if they were dried. EI # was asked if the pans were completely dry. EI #3 stated some of the pans were not completely dry. On 12/01/21 at 11:32 AM the surveyor observed a green bucket labeled detergent with a white rag in water inside the bucket. The detergent bucket was placed within reach of an open tea pitcher. On 12/02/21 at 9:15 AM a follow up interview was completed with EI #3. EI #3 was asked if the pans observed on 11/30/21 stacked together was the proper way to dry pans. EI #3 stated they should be placed separately to dry and should not be stacked together. EI #3 was asked what was the importance of not stacking the pans together to dry. EI #3 stated to make sure they are completely dry and no bacteria was present. EI #3 further stated the potential harm of drying pans stacked together would be the presence of bacteria and not being completely dry. EI #3 was then asked about the observation of an uncovered tea pitcher placed next to a green bucket labeled detergent. EI #3 was asked what was the green bucket. EI #3 stated detergent is put in the green bucket and it was used to clean counters and other surfaces. EI #3 stated the detergent/water was mixed daily and used throughout the day. EI #3 was asked if the green bucket should be placed near items such as an uncovered tea pitcher that could be consumed by residents. EI #3 replied no, you would not want detergent to splash in the tea.

Based on observation, interview, record review, and review of a facility policy titled Medication Administration of Nose Drop; Ear Drop, Oral and Nasal Inhalation; Nebulizer (Respiratory Treatment) the facility failed to ensure Resident Identifier (RI) #26's nebulizer administration sets were stored in a safe and appropriate manner, covered and labeled, in RI #26's room on 12/1/21 on the evening shift and on 12/2/21 during the day shift, two of three days of the survey. This deficient practice affected one of one sampled for respiratory care. Findings include: Review of a facility policy titled, Medication Administration of Nose Drop; Ear Drop, Oral and Nasal Inhalation; Nebulizer (Respiratory Treatment) with an effective date of 9/2014 revealed: . Oral and Nasal Inhalation PURPOSE: To administer oral and nasal medication in a safe and accurate manner. Nebulizer . PROCESS: . 3. After completion of therapy, stored equipment appropriately . RI #26 was readmitted to the facility on [DATE]. RI #26's December 2021 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/01/21 at 5:17 PM, the surveyor observed RI #26 lying in bed. The nebulizer was on the window sill with the nebulizer mask uncovered and not labeled, initialed, or dated. On 12/02/21 at 10:40 AM #26's nebulizer mask was observed on the nebulizer, not in use, not covered and not labeled, dated, or initialed . An interview was conducted on 12/02/21 at 10:50 AM with Employee Identifier (EI) #2 Licensed Practical Nurse (LPN). EI #2 was asked, where was RI #26's nebulizer mask. EI #2 replied, it was not in a bag. EI #2 was asked if it was labeled. EI #2 replied, no ma'am. EI #2 was asked, what was the risk of the nebulizer not being in a bag. EI #2 replied, infection control. EI #2 was asked, should the nebulizer mask and tubing be in a bag. EI #2 replied, yes it should. EI #2 was asked, what was the policy on oxygen tubing and nebulizer. EI #2 replied, oxygen and nebulizer should be labeled with a date and initialed and the nebulizer mask should be in a bag. An interview was conducted on 12/02/21 at 2:32 PM with EI #1 Infection Control Preventionist, Director of Nursing. EI #1 was asked, what was the policy on nebulizer mask and tubing. EI #1 replied, storing the equipment properly putting the mask or nebulizer in a zip lock bag. EI #1 was asked, who was responsible for making sure the nebulizer mask and tubing was in a bag when not in use. EI #1 replied, nurses. EI #1 was asked, what was the risk of the nebulizer mask and tubing not being initialed and dated and not in a bag when not in use. EI #1 replied, not knowing when it was changed last, exposed to potential allergens and bacteria. EI #1 was asked, should the nebulizer tubing and mask been in a bag when not in use. EI #1 replied, yes.

Based on interviews, record review and review of a facility policy titled Notification of a Change in Medical Condition of Residents, the facility failed to ensure Resident Identifier (RI) #1's family/legal representative was notified when RI #1 received a new order to change the treatment to his/her coccyx wound to [MEDICATION NAME] on 03/8/2021. This deficient practice affected RI #1, one of four sampled residents reviewed for notifications. Findings Include: Review of a facility policy titled Notification of a Change in Medical Condition of Residents, with an effective date of 03/2018, documented: PURPOSE: To keep the . family members/legal representatives, responsible for health care decisions, informed of the resident's medical condition so they may direct the plan of care as needed. STANDARD Notification of the . resident's representative, should occur promptly, according to federal regulations, when there is a change in the resident's condition. This would include but is not limited to: . · A need to alter treatment (i.e. (for example), a need to discontinue an existing form of treatment due to adverse consequences or ineffectiveness, or to commence a new form of treatment) . Documenting the Change of Condition a) Nurses should include . The date and time of contact with the . resident's representative . RI #1 was admitted to the facility on [DATE] and readmitted on [DATE]. A review of RI #1's Physician order [REDACTED].#1's coccyx with normal saline, pat dry, and apply [MEDICATION NAME] every five days for shearing. Further review of RI #1's Physician order [REDACTED].#1's coccyx: Wound dressing (1) Topical application of [MEDICATION NAME] to sacral/coccyx area and cover c (with) [MEDICATION NAME] change daily . This order was noted (signed off) by Employee Identifier (EI) #2, a RN (Registered Nurse) Unit Manager. Review of RI #1's Departmental Notes (nurses notes) dated 03/08/2021, revealed there was no documentation the family/legal representative had been notified about the new order for treatment change on 03/08/2021. On 03/16/2021 at 3:07 p.m., the surveyor conducted a telephone interview with RI #1's sponsor/legal representative. When asked if she was notified of any changes to RI #1's wound treatment to his/her coccyx, RI #1's sponsor/legal representative said no. RI #1's sponsor/legal representative said she jut remembered being told the area was red. On 03/18/2021 at 10:34 a.m., an interview was conducted with EI #2, the RN Unit Manager that signed off on the new treatment order on 03/08/2021. EI #2 said on 03/08/2021, the treatment order to RI #1's buttocks was changed to [MEDICATION NAME] and was to be covered with a [MEDICATION NAME] dressing. The surveyor asked EI #2 if RI #1's family was notified of the new treatment order. EI #2 reviewed the nurses notes and said she did not see where she had notified the family. The surveyor asked EI #2 what should be in the nurses notes regarding notification of the family/sponsor. EI #2 said the notes should indicate that the family was notified. On 03/18/2021 at 3:28 p.m., EI #1, the Director of Nursing, said the nurses should notify the resident's sponsor/representative whenever a new order is received. On 03/18/2021 at 3:40 p.m., a follow-up telephone interview was conducted with RI #1's sponsor/representative. The survey asked R #1's sponsor/representative if she recalled the facility notifying her when RI #1 had the new treatment order for [MEDICATION NAME] to be used to his/her coccyx wound. RI #1's sponsor/legal representative said no. This deficiency was cited as a result of the investigation of complaint/report number #AL 295.

Based on observations, interviews, review of facility policies: Dish Machine Sanitization, and Food Preparation Principles, as well as an Ecolab service report, the facility failed to ensure: 1) the dish machine dispensed a sufficient concentration of chlorine for effective sanitization; 2) pureed food was served at a recommended safe temperature on the 06/26/19 lunch tray line; 3) food was reheated to recommended sanitary temperatures prior to service; and 4) milk poured into glasses was stored and served at 41 degrees or less during the 06/26/19 lunch tray line. This affected all 42 residents for whom meals were prepared and served at the time of this survey. Findings Include: 1) DISH MACHINE SANITIZATION The facility policy, Dish Machine Sanitization with an effective date of 07/2014, specifies a process as follows: .4. Dish machine chemical concentration on low temperature machines should be monitored and generally require a minimum of 50 ppm (parts per million) of a hypochlorite solution on dish surface in final rinse. On 06/26/19 at 8:15 AM, the surveyor requested a check of the chlorine concentration as staff processed dishes through the low temperature dish machine. Using a chlorine test strip, the Cook, Employee Identifier (EI) #4, first checked the concentration of rinse water in a glass just processed through the machine. The strip registered less than 50 parts per million (ppm). EI #4 then checked the water in the dish machine reservoir. It too registered less than 50 ppm. Staff did not re-wash the glasses and plates processed. but continued to process breakfast dishes through the machine. At 8:30 AM, the surveyor asked the Dietary Manager, EI #2, to check the chlorine concentration. EI #2 placed a chlorine test strip on the surface of a plate. The strip registered less than 50 ppm. Another test strip was dipped in the reservoir water of the machine after the dish rack had been pulled out. The second strip likewise registered less than 50 ppm. The processed dishes were not re-washed. At this point, the surveyor asked EI #2 and EI #4 how the chlorine concentration was regulated in the dish machine. EI #4 explained the machine dispensed the chlorine solution. When questioned where the chlorine was dispensed, EI #2 showed the surveyor the 10 gallon bucket of Ultra San solution and checked the siphon hose to ensure it was in contact with the solution. At 8:40 AM, EI #2 checked the chlorine concentration of the reservoir immediately after a rack of plates and bases had been washed. Again the test strip registered less than 50 ppm. No dishes were re-washed prior to staff putting them away. The surveyor asked EI #2 what she thought of the chlorine concentration level. EI #2 stated, it looked a little too light. At 11:00 AM, EI #2 informed the surveyor that the Ecolab Representative had been called and determined the dispensing hose might be clogged. A copy of Ecolab's service report was provided, documenting the nozzles were blocked/clogged and had been replaced to improve cleaning. At 11:45 AM, the Ecolab Representative (EI #3) explained to the surveyor, the problem with the chlorine in the dish machine was the system was not siphoning from the 10 gallon bucket. 2) PUREED FOOD TEMPERATURES The facility policy, Food Preparation Principles dated 9/2017, outlines the following: PR[NAME]ESS: .7. Food should be protected from contamination, while being stored, prepared, served or transported to residents. To prevent growth of pathogenic organisms, i.e. food should be maintained at the following temperatures, at all times: a) Refrigerated: 41 degrees F (Fahrenheit), or below b) Prepared food: 135 degrees F, or above .11. Meats and Eggs .l.Re-heat leftovers (only once) thoroughly to 165 degrees Fahrenheit for fifteen (15) seconds. Prior to the start of the 06/26/19 lunch tray line at 12:04 PM, staff did not check the temperature of the pureed chicken or pureed black-eyed peas. A divided Melmac plate of pureed food was observed on the preparation counter (unheated/unrefrigerated) across from the gas stove. At 12:14 PM, EI #4 prepared a plate of pureed chicken, pureed black-eyed peas and mashed potatoes. The plate of pureed food was covered with a lid and placed on the resident's tray. The surveyor asked the staff to remove the plate of pureed food from the cart and check the temperature. EI #2 determined the pureed chicken was 127 degrees F and the pureed black-eyed peas were 99 degrees F. EI #2 commented, The food is not hot enough. 3) REHEATING OF PUREED FOOD At 12:20 PM, EI #2 placed the plate of pureed food into the microwave oven for one minute, 25 seconds. The chicken was reheated to 152.5 degrees F. The black-eyed peas were reheated to 136.5 degrees F. Neither food item attained the recommended temperature of 165 degrees F before staff replaced the food on the tray and sent it out of the kitchen. At 12:55 PM, the surveyor asked the Cook (EI #4) and Dietary Manager (EI #2) at what temperatures should the food be served. EI #4 responded 165 to 200 degrees F. EI #2 stated the lowest temperature should be 135 degrees F. EI #2 then confirmed the re-heated foods had not been heated to an adequate temperature of 165 degrees or greater. 4) MILK STORAGE Throughout the 06/26/19 tray line, several (8 ounce) glasses of milk were stored on the counter at the end of steam table with no means of refrigerant. At 12:47 PM, staff placed a glass of milk (identified by EI #2 as buttermilk) on a resident's tray. The surveyor requested a check of the temperature. EI #2 determined the temperature to be 66 degrees F (15 degrees above recommendations). At 12:52 PM, the surveyor asked EI #2 why the pre-poured glasses of milk were not refrigerated on the tray line. EI #2 explained the milk was usually kept in the reach-in refrigerator. EI #2 affirmed the milk should have been served at a temperature of 41 degrees F or less.

Based on record review and an interview with facility staff, the facility failed to ensure licensed staff clarified medication orders before hand-writing orders for Resident Identifier (RI) #31's medication for Diabetes Mellitus and Anxiety. This affected one of five residents for whom the medication regimen was reviewed. Findings Include: RI #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #31's (MONTH) (YEAR) physician's orders [REDACTED]. 6/2/19 (1) discontinue [MEDICATION NAME] 45 units subcutaneous at bedtime (2) [MEDICATION NAME] 45 units subcutaneous at bedtime (10pm) [DIAGNOSES REDACTED].>6/18/19 (1) discontinue [MEDICATION NAME] 45 units sq at bedtime (2) [MEDICATION NAME] 43 units sq at bedtime [DIAGNOSES REDACTED].> (5) discontinue [MEDICATION NAME] 10 milligrams daily at 4pm RI #31's (MONTH) (YEAR) Medication Administration Record [REDACTED] [MEDICATION NAME] 43 units sq qhs 10pm- date started 6/18/19 [MEDICATION NAME] 15 milligrams twice a daily for anxiety- date started 6/18/19 The Pharmacy consultant's report for RI #31, dated 6/15/19, was reviewed for [MEDICATION NAME] and [MEDICATION NAME] recommendations. The Pharmacist had made a recommendation for a decrease in [MEDICATION NAME] from 45 units to 43 units. The Pharmacy report also indicated that the [MEDICATION NAME] 15 mg 3 times a day had increased in (MONTH) from 10 mg 3 times a day and made the recommendation to decrease the 15 mg to twice a day (10a and 10p) and 10 mg daily at 4pm. The physician wrote on the report [MEDICATION NAME] 15 mg twice a day and [MEDICATION NAME] 43 units at bedtime. It was noted in the 6/18/19 orders that Employee Identifier (EI) #1, Registered Nurse Supervisor had wrote the order to discontinue [MEDICATION NAME] 10 mg at the 4:00 PM dose, instead of 15 mg which was ordered by the Physician for the 4:00 PM dose. The Order for the [MEDICATION NAME] change was accurate on the order, however, was not accurate on the MAR. On 06/26/19 at 11:25 AM, EI #1 was asked what was the reason for which the [MEDICATION NAME] and/or [MEDICATION NAME] were ordered. EI #1 explained the medication was for Diabetes. When asked what could happen if [MEDICATION NAME] and [MEDICATION NAME] were not administered as ordered, due to a transcription error, EI #1 stated the resident could have [MEDICAL CONDITION], or diabetic Ketoacidosis. The surveyor then asked EI #1 to clarify the resident's current medication order for Diabetes. EI #1 stated the ordered medication was [MEDICATION NAME], 43 units at the hour of sleep (HS). When asked the original order date, EI #1 stated the [MEDICATION NAME] had been ordered on [DATE]. The surveyor then questioned EI #1 about the hand-written verbal order, dated 06/02/19 to discontinue the [MEDICATION NAME] 45 units at HS, and start [MEDICATION NAME] 45 units at HS. The surveyor asked why the [MEDICATION NAME] had been changed to [MEDICATION NAME]. EI #1 responded, it was because the insurance would not pay for [MEDICATION NAME], but it would pay for [MEDICATION NAME]. The surveyor asked if the 06/02/19 order was correct, to which EI #1 replied, yes. The surveyor asked why the hand-written (telephone) order of 06/18/19 documented the discontinuation of [MEDICATION NAME] 45 units at HS and the start of [MEDICATION NAME] 43 units at HS when the [MEDICATION NAME] had been discontinued on 06/02/19. EI #1 explained the pharmacy sheet recommended a reduction in the [MEDICATION NAME]. The surveyor asked how a telephone order and a verbal order differed. EI #1 stated for a verbal order the Dr. was standing right in front of you giving you the order, and for a telephone order, the Dr. was on the telephone giving the order. The surveyor then asked if the 06/18/19 order to discontinue the [MEDICATION NAME] 45 and start 43 units was correct. EI #1 responded no, it should have been [MEDICATION NAME]. EI #1 stated she wrote the order wrong; she should have clarified the order. When asked if the physician had told her to order the [MEDICATION NAME] at 43 units, EI #1 explained she thought she just told the Dr. the pharmacy had recommended a reduction of the resident's insulin. EI #1 then said the Dr. told her they could do what the pharmacy recommended. On 06/26/19 at 12:09 PM, EI#1 reveiwed the (MONTH) 15, 19 pharmacy report with the surveyor. The report contained no recommendation to decrease the dosage of [MEDICATION NAME] from 45 to 43 units at HS. The surveyor then asked what had been done with the [MEDICATION NAME] recommendation from the pharmacist. EI #1 stated they had decreased the dosage to [MEDICATION NAME] 15mg BID (twice a day), from the physician's previous order of [MEDICATION NAME] 15mg TID (three times a day). The surveyor asked why had she transcribed/ written the telephone order for the discontinuation of [MEDICATION NAME] 10mg daily at 4 pm. EI #1 responded she may have gotten confused when reading the paper. The surveyor asked what should have been the order for the change in the [MEDICATION NAME]. EI #1 stated she should have discontinued the [MEDICATION NAME] 15mg TID, and started [MEDICATION NAME] 15mg BID. When asked why the [MEDICATION NAME] was administered, EI #1 responded, it was for anxiety. The surveyor asked what could be done differently to avoid the confusion and to transcribe/ write orders correctly. EI #1 stated she could look at the list of recommendations, along with the current orders. The surveyor asked what was the importance of correctly writing physician orders [REDACTED]. EI #1 stated it was to avoid medication errors and possibly harming the resident.

Based on observation, interviews with Employee Identifier (EI) #3 Dietary Manager (DM), and review of the facility policies titled, Dish Machine Sanitation and FOOD CODE, U. S. Public Health Services, 2013, the facility failed to ensure: The dish machine wash cycle reached the required temperature of 120 degrees. The facility further failed to ensure dishwashing cycle temperatures were recorded on 04/26/2017 and 04/27/2017. This was observed on 04/27/2017 and had the potential to effect all 34 residents receiving meals from the kitchen. Finding include: A facility policy titled: Dish Machine Sanitation with an Effective Date 7/2014, documented: PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses .PROCESS . 1. Dish machines using chemicals for sanitation ( also called low temperature machines), may be used if the temperature of the wash/rinse water meets the manufacture's recommendations . the wash and the rinse tank temperature to be a minimum of 120 degrees F . 3. Dish machine wash and rinse temperatures should be recorded before beginning of each dishwashing cycle . FOOD CODE, U. S. Public Health Service 2013, page 134, 4-501.110 Mechanical Warewashing Equipment, Wash Solution Temperature. (B) The temperature of the wash . may not be less than 49 degrees C (120 degrees F). During the tour of the kitchen on 04/27/2017 at 8:35 a. m. with EI #3 , the surveyor observed the dish machine for four different wash cycles with temperatures from 110-112 degrees. The surveyor also observed missing temperature documentation dated 04/25/2017 and 04/26/2017 on the Dietary Daily Shift Report. On 04/27/2017 at 12:10 p.m. an interview was conducted with EI # 3. The surveyor asked EI #3 what should the temperature of the wash cycle be. EI #3 responded 120 degrees for wash. The surveyor asked is 110-112 degrees the correct temperature. EI #3 stated no. The surveyor asked what is the potential problem with the wash cycle not getting up to the correct temperature of 120 degrees. EI #3 replied infection control, the dishes may not be getting clean. EI #3 was asked what is the procedure regarding documentation. EI #3 said to document temperature each time you run a wash/rinse cycle. EI #3 was asked what is the potential problem for not documenting. EI #3 stated you will not know if everything is being ran at the right temperature, so it will kill any bacteria at the right control temperature.

Based on observations, interview, review of Potter Perry, Fundamentals of Nursing, Health Insurance Portability and Accountability Act, and review of a facility policy titled PRIVACY NOTICE, the facility failed to ensure a Licensed Practical Nurse (LPN), Employee Identifier (EI) #2, protected the privacy of Resident Identifiers (RI) #5, RI #7 and RI #8 during the Medication Administration Observation conducted on 04/26/17. This deficient practice affected RI #5, RI #7 and RI #8, three of seven residents observed during the Medication Administration Observation. Findings Include: A facility policy titled PRIVACY NOTICE (not dated) documented: . We are required under the federal health care privacy rules (the Privacy Rules), to protect the privacy of your health information, which includes information about your . treatment, . Potter Perry, Fundamentals of Nursing, Ninth Edition, Unit IV, Professional Standards in Nursing Practice, Health Insurance Portability and Accountability Act, Chapter 23, page 306, revealed: Privacy is the right of the patients to keep personal information from being disclosed. The following privacy concerns were observed during the evening Medication Administration Observation on 04/26/17: 1. At 3:32 p.m., the surveyor observed EI #2, LPN Charge Nurse entered RI #7's room and closed the door leaving RI #7's Medication Administration Record [REDACTED]. 2. At 4:09 p.m., the surveyor observed EI #2 enter RI #5's room and close the door leaving RI #5's MAR indicated [REDACTED]. 3. At 4:27 p.m., the surveyor observed EI #2 enter RI #8's room and close the door leaving RI #8's MAR indicated [REDACTED]. On 04/26/17 at 5:50 p.m., the surveyor conducted an interview with EI #2. The surveyor asked why should your MAR book be covered or closed during your medication pass when you're not at your cart. EI #2 replied, for privacy. The surveyor asked EI #2, did she recall leaving the MAR book uncovered multiple times during the med pass observation. EI #2, said, Yes, I do.

Based on observations, interviews, and review of Potter Perry, Fundamentals of Nursing, Medication Administration, Administering Injections, Centers for Disease Control and Prevention Isolation Guidelines the facility failed to ensure that Employee Identifier (EI) #2, Licensed Practical Nurse, Charge Nurse: 1. Did not turn off the faucet with bare hands during handwashing after administering medications to Resident Identifier #5, RI #7 and RI #8. 2. Changed contaminated gloves prior to giving insulin injections to Resident Identifier (RI) #8. This affected RI #5, RI #7 and RI #8. Three of seven residents observed during evening Medication Pass Observation on 4/26/1. Findings include: Review of Potter Perry, Fundamentals of Nursing, Ninth Edition, Chapter 29, Infection Prevention and Control, Table 29-6, pages 458-459, and Chapter 32, Medication Administration, Skill 32-5. Administering Injections, pages 670-671, documented: .Table 29-6 Centers for Disease Control and Prevention Isolation Guidelines Standard Precautions (Tier One) for Use with All Patients .Perform hand hygiene before, after, and between contact with patients. (Examples of between-contact activities are cleaning hands after a patient care activity, moving to a non-patient care activity, and cleaning hands again before returning to perform patient contact.) . STEP .Apply Clean gloves .RATIONALE Reduces transfer of microorganisms The Surveyor observed the following infection control concerns during evening Medication Pass Observation on 04/26/17: 1. At 3:32 p.m., EI #2 turned off faucet with her bare hands after handwashing in RI #7's room. 2. At 4:09 p.m., EI #2 turned off faucet with her bare hands after handwashing in RI #5's room. 3. At 4:27 p.m., EI #2 donned gloves to draw up insulin for RI #8. EI #2 drew up two separate insulin dosages and discarded syringe wrappers into trash can on cart and pushed down on the trash in the cart while still wearing the same gloves. EI #2 then entered RI #8's room, pulled the privacy curtain, adjusted resident's pillow, pushed paper towel lever and tore off towels to put on overbed table, handed RI #8 the medications from the medication cup, and then administered both insulin injections in RI #8's left upper arm without changing the contaminated gloves. EI #2 then removed the gloves, washed hands in resident's room and turned off the faucet using her bare hands. On 04/26/17 at 5:50 p.m. in an interview with the surveyor, EI #2 was asked, what should you do when you turn off the faucet after handwashing. EI #2 answered, Use a clean paper towel to turn them off. The surveyor asked, did you use a paper towel to turn off the faucets during med pass. EI #2 said, No, I didn't. When EI #2 was asked, did you change gloves after drawing up RI #8's insulin, pushing down the trash, adjusting her/his pillow, getting paper towels from the dispenser - before you gave the two insulin injections. EI #2 replied, No, I put my gloves on too early and touched other stuff. I should have changed them before I gave the insulin. On 04/27/17 at 11:23 a.m. in an interview with the surveyor, EI #1, Registered Nurse, Director of Nursing, Infection Control was asked, should an employee turn off the faucet with bare hands after handwashing. EI #1 said, No. The surveyor asked, is that was an infection control issue. EI #1 replied, Yes. When asked, should a nurse wearing gloves to draw up insulin using those same gloves to administer injections after touching the privacy curtain, paper towel dispenser, pushing down trash, and repositioning the resident. EI #1 answered, No Ma'am. They should wash their hands and change gloves if they touch anything. EI #1 was asked, would it be considered an infection control issue. EI #1 said, Yes Ma'am.

Based on observations, interview, review of Potter Perry, Fundamentals of Nursing, and review of a facility policy titled, Disposal of Medications, Syringes and Needles the facility failed to ensure the following: 1. Employee Identifier EI #2 did not leave the medication cart unlocked prior to entering RI #5 and RI #8's rooms. 2. EI #2 did not sign off Resident Identifier (RI) #7's non-narcotic medications prior to administration of the medication. 3. EI #2 did not dispose of RI #8's discontinued medication by placing it in the trash can on the medication cart. This affected RI #5, RI #7 and RI #8; three of seven residents observed during the evening Medication Pass Observation on 04/26/17. Findings include: The surveyor made the following observations on 04/26/17 during the evening Medication Pass Observation: 1. At 3:32 p.m., EI #2, LPN Charge Nurse prepared medications for RI #7, signed off the medications on the Medication Administration Record [REDACTED]. Review of Potter Perry, Fundamentals of Nursing, Ninth Edition, Unit V, Chapter 32, page 628-629, Right Documentation, revealed: . Never document that you have given a medication until you have actually given it. 2. At 4:09 p.m., EI #2 prepared medications for RI #5 and entered RI #5's room and closed the door after leaving the medication cart unlocked and unattended by facility staff. Review of Potter Perry, Fundamentals of Nursing, Ninth Edition, Unit V, Chapter 32, page 624, Distribution Systems, documented: . Examples of storage areas include .portable locked carts, . Medication storage areas need to be locked when unattended. 3. At 4:27 p.m., EI #2 identified a discontinued [MEDICATION NAME] 20 MG (milligram) tablet from RI #8's medication pouch and disposed of the tablet in the trash can on the medication cart. EI #2 then entered RI #8's room and closed the door after leaving the medication cart unlocked and unattended by facility staff. A facility policy titled, Disposal of Medications, Syringes and Needles with a date of 12/12 revealed the following: 4.a. For the State of Alabama, the appropriate method non-controlled medication destruction is as follows: .Transfer medication to trash receptacle following destruction to unusable consistency . On 04/26/17 at 5:50 p.m. in an interview with EI #2, the surveyor asked, when should you sign out your medications. EI #2 replied, after you give them unless it's a narcotic. The surveyor asked, did you sign out RI #7's medications before he/she took them. EI #2, said, I should not have, but yes, I did. EI #2 was asked, what is the potential harm in leaving your med cart unlocked during your med pass when you're in a resident's room with the door closed. EI #2 answered, The biggest harm is that a resident could get into it and get medicine out of it and it could hurt them. The surveyor asked, what did you do with RI #8's [MEDICATION NAME] that was discontinued. EI #2 said, in the trash. When asked, is that where you typically discard medicine. EI #2 responded, no.

1) Based on interviews, record reviews the facility failed to follow their policy and procedure on Abuse and Neglect by failing to implement the Protection and Reporting elements of the policy when RI (Resident Identifier) #1 made an allegation of sexual abuse against EI (Employee Identifier) #3. On 3/6/2016, RI #1 called the Administrator at home and made an allegation of sexual abuse against EI #3. According to RI #1, EI #3 entered the resident's room on 3/3/2016 and began massaging the resident's chest. Then EI #1 placed his hand in RI #1's pants touching the genital area. The Administrator called the facility and informed EI #3 of RI #1's allegation. After being informed of the allegation by the Administrator, EI #3 went RI #1's room. According to RI #1, EI #3 cursed at the resident. EI #3 worked his shift and reported to work the next day on his scheduled shift (7 AM to 3 PM) during the investigation of the incident. This deficient practice placed RI #1, one of three sampled residents reviewed for abuse, in immediate jeopardy, as it was likely to cause serious injury, harm, or death and had the potential to affect all 39 resident's in the facility. On 4/1/2016 at 7:50 PM, the facility's Administrator, EI #1, Director of Nursing, EI #2, Social Service Director, EI #8, Assistant Administrator, EI #10 and the LPN (Licensed Practical Nurse) Supervisor, EI #4 were notified of the findings of substandard quality of care at the immediate jeopardy level of L in the area of Resident Behavior & Facility Practices, F 226. 2) The facility further failed to ensure the Abuse Registry was checked prior to employment for three of six employee records reviewed. Findings include: The state agency received a complaint on 3/24/2016. The complainant alleged RI #1 called the facility's Administrator on 3/6/2016 and reported that on 3/3/2016, the ADON (Assistant Director of Nursing), EI #3, went into RI #1's room about 10:00 AM and sat on the bed next to the resident rubbing RI #1 on the chest, then EI #3 moved his hands inside the resident's pants touching the genital area. The resident had no reaction so EI #3 removed his hands. The facility's report contained a statement from EI #3 indicating he went to the resident's room to talk to RI #1 after the Administrator informed him (EI #3) about the allegation of sexual abuse. The facility policy titled, ABUSE AND NEGLECT with no implementation date, documented the following: Policy: Facility Approaches to Prevent Abuse and Neglect Abuse Prevention: the facility will develop and implement policies and procedures, which will include . prevention, identification, investigation, protection, and reporting . .5. The facility will implement protection of all residents from possible or potential harm while an investigation is in progress. All reasonable measures will be made to protect during the investigation of alleged abuse, . The facility will recognize the resident's right to make complaints against the facility and will not tolerate any retaliatory behavior against a resident who has reported an incident of alleged abuse, . The facility will also not tolerate the threatening of residents or their visitors in an attempt to discourage them from exercising their rights under this policy. Any and all staff members that are involved with alleged abuse or neglect, will be suspended pending the results of an investigation . .6. The facility will investigate allegations made by residents, .which involve . sexual abuse . .7. The reporting and responding will include all alleged and suspected abuse. VII. Protection of Residents During the Investigation The facility will take all reasonable measures to protect a resident during an investigation of alleged abuse, . VIII. Reporting of Incidents, Investigations and Facility Response to the Results of the Investigation. If the facility employee is suspected of the alleged incident, the employee will be suspended from working in the facility and the initial report to DHCF (Department of Healthcare Facilities) will include the employee(s) being investigated in the 24 hour report. A facility inservice provided to nursing staff with a roster dated 2/29/2016 with the topic Resident Abuse/Neglect revealed the following: .Define Abuse: . sexual abuse . .The DON will make the decision to notify any regulatory agencies that need to be involved . .Any employee suspected or accused of abuse will be immediately suspended and remove from the facilities premise until a comprehensive investigation is complete and the allegation is substantiated or unsubstantiated. According to the facility inservice rooster/signature sheet, EI #3 attended this inservice. A review of the facility report submitted to the State Agency on 3/7/2016 by the facility revealed RI #1 made an allegation of sexual abuse against an employee, EI #3. Included in the facility's investigation was the Summary of Findings, with an occurrence date of 3/3/2016, which documented RI #1 called the Administrator at home on 3/6/2016 and made an allegation of sexual abuse against RI #3 who had been RI #1's nurse that day. The Summary of Findings further revealed EI #3 gave report to the on-coming shift and had no further contact with RI #1. Included in the documentation was a hand written statement from EI #3 indicating EI #3 received a phone call from the Administrator who informed him of the allegation of sexual abuse made by RI #1. EI #3 included in his statement that he then talked with RI #1 after the facility Administrator had informed him of the allegation. The Summary of Findings was co-signed and dated 3/11/2016, by EI #3 as having reviewed the findings along with EI #4, LPN (Licensed Practical Nurse) Abuse Coordinator. RI #1 was admitted to the facility on [DATE]. RI #1's significant change MDS (Minimum Data Set), with an Assessment Reference Date of 3/23/2016, revealed a BIMS (Brief Interview for Mental Status) score of 15, which indicated intact cognition. During an interview on 3/29/2016 at 10:25 AM, RI #1 explained, I just filed a law suit. I was sexually molested here. RI #1 explained how EI #3 came into the room, shut the door, sat down on the bed and rubbed the resident on the chest. RI #1 said, he/she thought it was a massage. RI #1 further explained EI #3 said to let him do what he wanted to do, pinched RI #1's nipples and placed his hand into RI #1's pants. RI #1 stated a few days after the alleged incident he/she called, EI #1, Administrator at home and told her what happened. According to RI #1 as soon as EI #1, Administrator, informed EI #3 about the allegation, EI #3 came to RI #1's room and cursed at the resident. On 3/31/2016 at 9:15 AM, a phone interview was conducted with EI #3, ADON. When asked how he found out about the allegation of sexual abuse RI #1 made against him, EI #3 said while he was working on 3/6/2016 at about 2:30 PM, he received a phone call from the Administrator (EI #1) and was informed of the allegation. When asked what he did after he found out, EI #3 said he went to the door of RI #1's room and asked RI #1, what was going on and was there something wrong. EI #3 was asked who was with him when he went to RI #1's door. EI #3 said there was not anybody with him and he could not remember who might have been in the hall. When asked why he went to RI #1's door to talk to RI #1 after the Administrator had informed him of the allegation, EI #3 said he was just shocked. EI #3 was asked what the Administrator told him when she called him on 3/6/2016 to inform him of the allegation. EI #3 stated the Administrator told him not to go into RI #1's room and not to be around RI #1 without someone else present. When asked about the reason an employee should not go near the resident who made an allegation of abuse against them, EI #3 said it was to protect the employee and the resident. On 3/31/2016 at 12:10 PM, EI #4, LPN (Licensed Practical Nurse) Abuse Coordinator, was asked when and how she became aware of the allegation of sexual abuse made against EI #3 by RI #1. EI #4 said EI #3 called her at home on 3/6/2016, a few minutes after 4:00 PM to inform her of the allegation of sexual abuse made against EI #3 by RI #1. EI #4 was asked who RI #1 first reported the allegation of abuse to. EI #4 said EI #1 had been contacted at home by RI #1. EI #4 was asked what the facility policy was for protection of residents during abuse investigations. EI #4 said the employee would be suspended pending the outcome of the investigation. EI #4 was asked why EI #3 was allowed to go and speak to RI #1 after the abuse allegation was made against him. EI #4 said she had not been made aware of the allegation until EI #3 had already talked to RI #1. When asked why the facility's policy on abuse was not followed including suspension of the employee pending investigation of the allegation, EI #4 said she reviewed the film by 8:30 AM. EI #4 said she also verified the time of the allegation with RI #1 (around 10:00 AM) and the film did not verify anything similar to that time frame. When asked what the potential for harm was if measures are not taken to protect the residents during an investigation of alleged abuse, EI #4 said, there could be retaliation which could create more trauma. When asked what allegations of abuse were to be reported to Law Enforcement agencies, EI #4 said any sexual abuse or physical abuse with injury. EI #4 was asked why the allegation of sexual abuse made against EI #3 by RI #1 was not reported to Law Enforcement, EI #4 said the resident refused. When asked what the potential for harm would be if allegations of sexual abuse were not reported to Police or Law Enforcement, EI #4 said, potential for that type of abuse to happen again. EI #4 was asked what her responsibility was for protection of residents in the facility and ensuring the facility abuse policy was followed. EI #4 said if an allegation was made, it was her responsibility to ensure the employee was kept away from the resident until a determination could be made. A review of EI #3's time card revealed the employee completed his shift on 3/6/2016 and reported back to work on 3/7/2016 at 6:46 AM and resumed his duties. On 4/1/2016 at 11:25 AM, EI #1, Administrator, was asked when and how she was made aware of the allegation of sexual abuse RI #1 made against EI #3. EI #1 explained RI #1 called her from a personal cell phone on Sunday, 3/6/2016 before or after lunch. When asked about the details, EI #1 said RI #1 alleged abuse by EI #3. EI #1 then called EI #3 at the facility and informed him of the allegation. When asked if she advised EI #3 what to do or what not to do, EI #1 said, No. He knew what to do. When asked what she meant by that, EI #1 said, she told him not to go back into the RI #1's room. When asked if she knew EI #3 documented in his statement that he went to RI #1's room and spoke to the resident after she called and informed EI #3 of the allegation, EI #1 said, no. EI #1 also stated she did not know why EI #3 went to talk to RI #1. EI #1 was asked what the facility does to protect residents after an allegation of abuse is made against an employee. EI #1 answered, Separate them, send the employee home. EI #1 was asked about the potential for harm when a resident makes an allegation of abuse and the employee approaches the resident to talk after the allegation was made against them. EI #1 said there was a potential for harm, but she did not know what the extent of the harm would be. When asked about her responsibility was as Administrator to protect residents after an allegation of abuse is made against an employee, EI #1 said, to keep the resident safe. The Administrator admitted she should have sent EI #3 home. During an interview on 4/1/2016 at 2:45 PM, EI #1, the Administrator, was asked who was responsible for notifying Law Enforcement of the sexual abuse allegation. EI #1 said the nurse on the floor. EI #1 was asked why Law Enforcement was not notified of the sexual abuse allegation. EI #1 explained that the allegation was not reported because RI #1 did not want the Police called. When asked if the sexual abuse allegation made by RI #1 should have been reported to Law Enforcement, EI #1 responded, I don't think so. I don't know. When asked if the facility's abuse policy was followed, EI #1 said, No, we didn't. EI #1 was asked if she did not follow the abuse policy, how had she protected the resident during the investigation. EI #1 said she moved EI #3 to another hall and told him not to go over there (to RI #1's hall). When asked why EI #3 had not been suspended per the facility abuse policy for immediate protection of the residents, EI #1 explained, EI #3 was moved from RI #1's unit. On 4/1/2016 at 2:50 PM, EI #2 RN/DON (Registered Nurse/Director of Nursing) was asked why EI #3 was allowed to sign the Summary of Findings dated 3/11/2016 for the allegation made against him. EI #2 stated, because he was gone and EI #3 was acting as the DON. EI #2 was asked who should have signed/reviewed the summary. EI #2 said normally he as the DON would have signed it, but he was out of town. EI #2 admitted that the Assistant Administrator (EI #10) was available to sign and review the summary. When asked what allegations of abuse the facility should report to Law Enforcement, EI #2 said physical harm or sexual abuse. EI #2 was asked why the sexual abuse allegation was not reported to Law Enforcement. EI #2 said he did not know. EI #2 admitted there was a potential for harm if Law Enforcement was not notified and as DON he should have ensured facility policy was followed. When asked what he would do differently with the investigation of alleged sexual abuse made by RI #1, EI #2 said the police should have been notified regardless of what the resident said and EI #3 should not have had contact with RI #1. When asked why EI #3 was allowed to go and talk to RI #1 after the allegation of abuse was reported to the Administrator, EI #2 said EI #3 was the only nurse in the building. When asked how RI #1 was immediately protected from EI #3, EI #2 said EI #3 was leaving his shift that day. EI #2 also stated he was not aware that EI #3 had returned to RI #1's room. 2) The facility policy titled ABUSE AND NEGLECT with no implementation date, documented the following: Policy: Facility Approaches to Prevent Abuse and Neglect Abuse Prevention: .2. The facility will screen all individuals employed in the nursing home, prior to assigning a work duty, which will include.d. CNA/Nurse Registry for past employment/certification verification. On 03/31/16, the personnel files of six staff members, hired within the previous four months were reviewed. Three of six files, a paid feeding assistant (hired 3/7/16), a dietary staff member (hired 3/21/16) and a housekeeper (hired 12/19/15), lacked documentation that the Abuse Registry had been checked prior to their hire dates to ensure they were not on the Nurse Aide Abuse Registry as outlined in the facility's policy. On 03/31/16 at 11:58 AM, the Assistant Administrator, EI #10, confirmed that the Nurse Aide Registry should have been completed prior to hiring each of the individuals. When asked why would it be important to check this registry prior to hire, EI #10 explained the facility could see whether the person had been listed on the Abuse Registry.

Based on record review and interview the facility's Administrator (EI #1) and Director of Nursing (EI #2) failed to provide management and oversight to ensure RI #1, a resident, who reported an allegation of sexual abuse against Employee Identifier (EI) #3 to the Administrator, was protected. After the Administrator was informed of an abuse allegation by RI #1, EI #3 was not suspended, completed his shift and allowed to report to work during the investigation of the incident. During interviews with EI #1, the Administrator and EI #2, the Director of Nursing, confirmed that the Administration failed to protect RI #1 during the investigation of the allegation of sexual abuse. EI #2 admitted the facility should have reported the incident to law enforcement. This deficient practice placed RI #1, one of three sampled residents reviewed for abuse in immediate jeopardy, and threatened the health and safety of all 39 current residents as it was likely to cause serious injury, harm, or death. On 4/1/2016 at 7:50 PM, the facility's Administrator, EI #1, Director of Nursing, EI #2, Social Service Director, EI #8, Assistant Administrator, EI #10 and the LPN (Licensed Practical Nurse) Supervisor, EI #4 were notified of the findings of substandard quality of care at the immediate jeopardy level of L in area of Administration at F 490. Findings include: Cross reference F 226. The facility Job Description Titled ADMINISTRATOR, signed and dated 2/14/1985 by EI #1 revealed the following: .PURPOSE OF YOUR JOB POSITION: The primary purpose of your job position is to direct the overall operation of the facility's activities in accordance with current applicable Federal, State, and local standards, guidelines and regulations, and as directed by the governing board, to assure that the highest degree of quality patient care is maintained at all times. MAJOR DUTIES & (and) RESPONSIBILITIES: .1. Establish and direct the implementation of written policies and procedures that reflect the goals and objectives of the facility. The facility's Job Description titled Director of Nursing Services signed and dated 7/1/1999 by EI #1 and EI #2 revealed the following: .Duties and Responsibilities . Resident Rights . . Report and investigate all allegations of resident abuse . The state agency received a complaint on 3/24/2016. The complainant alleged RI #1 called the facility's Administrator on 3/6/2016 and reported that on 3/3/2016, the ADON (Assistant Director of Nursing), EI #3, went into RI #1's room about 10:00 AM and sat on the bed next to the resident rubbing RI #1 on the chest, then EI #3 moved his hands inside the resident's pants touching the genital area. The resident had no reaction so EI #3 removed his hands. The facility's report contained a statement from EI #3 indicating he went to the resident's room to talk to RI #1 after the Administrator informed him (EI #3) about the allegation of sexual abuse. During a phone interview on 3/31/2016 at 9:15 AM, EI # 3, ADON was asked how he found out about the allegation of sexual abuse made against him by RI #1. EI #3 said while he was working on 3/6/2016 at about 2:30 PM, he received a phone call from EI #1, the Administrator, and was informed of the allegation. When asked what he did after he found out, EI #3 said he went to the door of RI #1's room and asked RI #1, what was going on and was there something wrong. On 4/1/2016 at 11:25 AM, EI #1, Administrator, was asked when and how she was made aware of the allegation of sexual abuse RI #1 made against EI #3. EI #1 explained RI #1 called her from a personal cell phone on Sunday, 3/6/2016 before or after lunch. When asked about the details, EI #1 said RI #1 alleged abuse by EI #3. EI #1 then called EI #3 at the facility and informed him of the allegation. When asked if she advised EI #3 what to do or what not to do, EI #1 said, No. He knew what to do. When asked what she meant by that, EI #1 said, she told him not to go back into the RI #1's room. When asked if she knew EI #3 documented in his statement that he went to RI #1's room and spoke to the resident after she called and informed EI #3 of the allegation, EI #1 said, no. EI #1 also stated she did not know why EI #3 went to talk to RI #1. EI #1 was asked what the facility does to protect residents after an allegation of abuse is made against an employee. EI #1 answered, Separate them, send the employee home. EI #1 was asked about the potential for harm when a resident makes an allegation of abuse and the employee approaches the resident to talk after the allegation was made against them. EI #1 said there was a potential for harm, but she did not know what the extent of the harm would be. When asked about her responsibility was as Administrator to protect residents after an allegation of abuse is made against an employee, EI #1 said, to keep the residents safe. The Administrator admitted she should have sent EI #3 home. During an interview on 4/1/2016 at 2:45 PM, EI #1, the Administrator, was asked who was responsible for notifying Law Enforcement of the sexual abuse allegation. EI #1 said the nurse on the floor. EI #1 was asked why Law Enforcement was not notified of the sexual abuse allegation. EI #1 explained that the allegation was not reported because RI #1 did not want the Police called. When asked if the sexual abuse allegation made by RI #1 should have been reported to Law Enforcement, EI #1 responded, I don't think so. I don't know. When asked if the facility's abuse policy was followed, EI #1 said, No, we didn't. EI #1 was asked if she did not follow the abuse policy, how had she protected the resident during the investigation. EI #1 said she moved EI #3 to another hall and told him not to go over there (to RI #1's hall). When asked why EI #3 had not been suspended per the facility abuse policy for immediate protection of the residents, EI #1 explained, EI #3 was moved from RI #1's unit On 4/1/2016 at 2:50 PM, EI #2 RN/DON (Registered Nurse/Director of Nursing) was asked what allegations of abuse should the facility report to Law Enforcement. EI #2 said physical harm or sexual abuse. EI #2 was asked why the sexual abuse allegation was not reported to Law Enforcement. EI #2 said he did not know. EI #2 admitted there was a potential for harm if Law Enforcement was not notified and as DON he should have ensured facility policy was followed. When asked what he would do differently with the investigation of alleged sexual abuse made by RI #1, EI #2 said the police should have been notified regardless of what the resident said and EI #3 should not have had contact with RI #1. When asked why EI #3 was allowed to go and talk to RI #1 after the allegation of abuse was reported to the Administrator, EI #2 said EI #3 was the only nurse in the building. When asked how RI #1 was immediately protected from EI #3, EI #2 explained that EI #3 left at the end of his shift. EI #2 also stated he was not aware that EI #3 had returned to RI #1's room after being informed of the abuse allegation.

Based on record review and interview the facility failed to notify the physician of a 16.3 percent (23.4 pound) significant weight loss during a one month period between November and December of 2015 for Resident Identifier (RI)#6. This affected one of ten sampled residents. Findings included: The facility policy titled CHANGE IN STATUS NOTIFICATION dated 7/31/2005 revealed the following: .Anytime a change in status occurs, the following must be notified: 1. sponsor 2. physician 3. Administrator and/or assistant administrator 4. DON (Director of Nursing) and/or ADON (Assistant Director of Nursing). The notifications must be recorded in the medical record. Change of status includes, but is not limited to: .5. change in vital signs 8. any change in the resident's normal condition. RI #6 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. RI #6's medical record revealed there was a 23.4 pound weight loss between November and December of 2015. Although RI #6 was re-weighed the day after the first December weight, there was no documentation of any follow-up by the facility. There was no documentation the physician was notified of the weight loss. On 3/29/16 at 4:00 PM, when Employee Identifier ( EI) #4, Nursing Supervisor, was asked if the family was notified, EI #4 stated there was no working number and all the mail was returned. EI #4 was then asked if the physician was notified. EI #4 stated this was a new physician in November. EI #4 then stated No, he was not notified in December. On 3/30/16 at 8:00 AM the physician was asked if he was aware of RI #6's weight loss and he stated he was now aware. When asked if he had been notified during December when the weight loss was identified, he replied, I was not.

Based on record review and interview the facility failed to complete the Quarterly Minimum Data Set (MDS) with an assessment reference date that was due in December 2015. As a result a 23.4 pound significant weight loss (16.3 per cent) was not identified or addressed for Resident Identifier (RI) #6. This affected one of 10 sampled residents whose MDS was reviewed. Findings include: Facility policy for the MDS (Minimum Data Set) with a copyright date of 2015 revealed the following: .Policy Explanation and Compliance Guidelines: The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity. MDS Completion Process: .6.b. Quarterly- Assessment reference date (ARD) plus 14 calendar days and the ARD must be no more than 92 days from the ARD of the prior assessment. RI #6 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The list of completed MDS's included a 3/24/15 Significant Change in Status, 6/23/15 and 9/22/15 quarterly assessments. There was no evidence in the medical record the 12/15 quarterly MDS had been completed and available for review. RI #6's current annual MDS with an ARD of 3/21/16 was being completed. On 3/29/16 at 11:00 AM Employee Identifier (EI) #4 was asked if RI #6 had a quarterly MDS for December. EI #4 stated it was not in the computer, but it should be available in the computer. When asked why the MDS was not available, EI #4 stated it was missed. When EI #4 was then asked what was the harm for such an omission, she stated, something like RI #6's weight loss would go undetected. On 3/30/2016 the facility signed RI #6's December assessment with an Assessment Reference Date (ARD) of 12/23/15 as complete.

Based on record review and interview the facility failed identify and assess RI #6's significant weight loss of 23.4 pounds during a one month period of time from November 2015 to December 2015. This represented 16.3% loss of body weight. This affected one of 10 sampled residents. Findings include: The undated facility policy titled Weight Assessment and Intervention revealed: .Policy Statement The nursing staff and the dietitian/dietary manager will cooperate to prevent, monitor and intervene for undesirable weight loss for our residents. 3. Any weight change of greater than or less than 5 pounds within 30 days will be retaken for confirmation. If the weight is verified, nursing will immediately notify the dietitian and/or dietary manager. 4. The dietitian will review the weights for all residents at least quarterly to follow individual weight trends over time. Negative trends will be assessed and addressed by the dietitian . RI #6 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A 9/21/15 progress note by EI # 8, the Certified Dietary Manager, documented the resident was on a regular no concentrated sweet diet .having some teeth pain, some teeth loose . recommend staff encourage po (by mouth) intake when less than 50%. The review of the facility weight records revealed RI #6 had a recorded weights of 144.9 pounds in October and 143.4 pounds in November. The 10/5/15 RD (Registered Dietitian) progress note identified a diet change to a pureed diet and a recommendation that If not on shakes BID (two times per day) add shake BID. RI #6's December 1, 2015 weight was recorded as 121 pounds with a re-weigh on 12/2/2015 of 120 pounds. Further review of the medical record revealed neither the physician nor the dietitian were notified of the resident's 23.4 pound weight loss from November to December. A CDM (Certified Dietary Manager) progress note, dated 12/21/15 revealed the resident was on a pureed NCS (No Concentrated Sweet) diet, encouragement given to consume at least 50 % of all meals and continues the diabetic HS (hour of sleep) snack. No additional assessments, interventions or additional shakes as recommended by the dietitian were initiated by the facility. The 12/23/15 Minimum Data Set (MDS) with an Assessment reference Date of 12/23/15 identified the resident's weight at 120 pounds with weight loss. However, this assessment was not signed off as complete until March 30, 2016. On 3/29/16 the dietitian recommended RI #6 receive fortified foods at meals and to continue to give shakes BID. After a review of the medical record on 3/29/16 at 11:45 AM the nursing supervisor, Employee Identifier (EI) #4 stated the 12/1/2015 weight was validated the next day and the weight was one pound less, but there was no follow-up by the facility. During this same interview, the Certified Dietary Manager (CDM), EI #8 stated she had questioned the CNA (Certified Nursing Assistants), because RI #6 had decreased soda intake and had been put on a pureed diet on 10/4/15 because of teeth problems. When asked what was put in place at that time EI #8 stated nothing was put in place at that time. When asked what was being done now, EI #8 stated, Really nothing different- try to get (RI #6) to eat more. EI # 8 stated there was always harm with rapid weight loss. When asked if she considered the 23 pound weight loss in one month to be excessive, she stated, yes. The Medical Director was interviewed on 3/30/16 at 8:00 AM. At that time he stated the weight loss should have been investigated for the causative factors. He stated he was not notified of the weight loss in December. He further stated RI #6 had a good BMI (Basal Metabolic Index) but if weight loss was occurring it should have been addressed, it would have been a problem. When asked what should be done now, he replied, assess RI #6's nutritional intake and see a psychiatrist concerning possible adjustments in her medications.

Based on observation, interviews and record review, the facility failed to: 1) consistently label and date leftover food with a use-by date; 2) ensure food on the 03/29/16 lunch tray line was served at recommended safe temperatures; and 3) effectively sanitize utensils processed in the 3-compartment sink. This had the potential to affect all 39 residents for whom food was prepared and served at the time of this survey. Findings included: 1) FOOD STORAGE The facility policy, Storage of Frozen and Refrigerated Foods (undated) includes the following refrigerator/freezer guidelines to maintain the proper temperature in refrigerators and freezers. .Label and date all leftovers with product name, date it was refrigerated and date it expires (3 days from in date) and refrigerate immediately. .Do not keep potentially hazardous food in refrigerator over 48 hours. On 03/28/16 at 7:00 PM, during the initial tour of the Dietary Department, the surveyor observed a container of leftover Macaroni Salad stored in the reach-in refrigerator with no label to indicate a date by which it needed to be discarded. 2) FOOD SERVICE The 2013 Food and Drug Administration Food Code specifies under 3-202.11(D) TIME/TEMPERATURE CONTROL FOR SAFETY FOOD . shall be at a temperature of 135 degrees F or above. On 03/29/16 at 11:58 AM (just prior to the start of the tray line), the Cook measured (via a stem-type food thermometer) the internal temperature of the cooked pork chops on the lunch tray line as 121 degrees Fahrenheit (F). Although the cook stated the meat was not hot enough, and documented this finding on the Dietary Daily Shift Report the staff went ahead with the plating of the residents' meals. After the second of four food carts had been served (at 12:15 PM), the Cook stopped the meal service to again check the food temperatures on the tray line. By this time, the internal temperature of the Pork Chops had dropped to 98 degrees F. The staff removed the meat (Pork Chops and the alternate of Ham) from the steam table and reheated both. 3) DISHWASHING The facility policy Testing of Concentration of Sanitizer Solution in 3-Compartment Sink (revised 06/03/13) documents the following: Purpose: .To ensure adequate sanitzation of dietary pots & pans at all times . The policy specifies: Dietary staff will test concentration of sanitation solution (Chlorine based) during set up of 3-compartment sink for use. This is to be tested before beginning washing any pots or pans . Procedure: 1. Fill sanitizer sink with water that is below 160 Degrees F and Sanitizer. 2. To take ppm (parts per million) reading, dip test strip paper in sanitizer/water solution, don't shake. Compare colors at once. 3. PPM reading should be between 50 and 20ppm. If found to be below 50, add more sanitizer and recheck with new paper strip . On 03/30/16 at 8:00 AM, the final rinse compartment of the 3-compartment sink contained water in which assorted utentsils were submerged: a 4-quart metal measuring container, three serving spoodles, a Dinex mug, and a 1/3-size metal steam table pan. The surveyor tested the content of chemical sanitizer in the sink with a test strip (as staff processed the residents' breakfast dishes through the dishmachine nearby). The concentration of chlorine in the final rinse sink registered less than 10 ppm. At 8:08 AM, one staff member left the dishmachine, and removed the soaking utensils from the final rinse sink. This staff member immediately placed the items on drying racks. At 8:11 AM, the surveyor asked the staff member responsible for dishwashing (Employee Identifier/EI #5), how often she checked the chemical concentration of the final rinse sink. EI #5 explained the water was checked every time the water was run, which had been after breakfast that morning. When asked what the chlorine concentration was supposed to be, EI #5 stated, 50 to 200 ppm. EI #5 checked the concentration and determined it was 10 ppm. Additional water and sanitizer were dispensed by EI #5's activation of the control box above the final rinse sink. Four subsequent pumps of the chlorine dispenser were made by EI #5 and EI #6, and with each activation of the dispenser, another check of the chlorine concentration was made. The test strip continued to measure less than 50 ppm. Multiple additional pumps of the chemical dispenser were made by the staff (both EI #5 and #6). When checked a fifth time with a test strip, the reading was above 50 ppm (as recommended). On 03/30/16 at 3:15 PM, the Maintenance Director (EI #7) explained the Ecolab Technician (responsible for the maintenance of the chemical sanitizing dispenser) had repaired the dispenser by replacing the battery pack inside. On 03/30/16 at 4:15 PM, the surveyor asked the Certified Dietary Manager (EI #8) what problem could result from the lack of labeling stored left-over foods. EI #8 explained they would not know the date of expiration or when to use the food; it was typically kept for three days. In response to the question of why pork chops had been served at a temperature less than recommended, EI #8 did not know; but assumed the staff member was nervous. In regard to the low chlorine concentration in the 3 compartment sink, EI #8 stated the staff should not have processed the utensils because the items would not be properly sanitized.

Based on observation, interview and record review the facility failed to ensure nursing staff consistently knocked or otherwise sought permission prior to entering a resident's room on 03/28/16 and 03/29/16. This affected Resident Identifier (RI) #3, one of 10 sampled residents. Findings include: RI #3 has resided in the facility since 11/01/12, with a re-admission on 02/29/16 with a [DIAGNOSES REDACTED]. A significant change Minimum Data Set assessment (with an assessment reference date of 03/10/16) identified RI #3 as having moderate difficulty with hearing, but with an ability to usually understand others and be understood. On 03/28/16 at 7:45 PM, a staff member (Employee Identifier/EI) #9, entered RI #3's room (through the open door) without knocking. On 03/29/16 at 5:00 PM, EI #9 entered the resident's room without knocking or first addressing the residents inside. EI #9 again walked into the resident's room at 5:05 PM, 5:38 PM and 5:39 PM, each time without receiving permission. During a confidential interview on 03/29/16 at 4:30 PM, and again on 04/01/16 at 8:10 AM, one resident was asked if staff knocked on his/her door prior to entering. The resident stated the staff never knock, they just come on inside. When asked if that bothered him/her, the resident's comment was, I'm used to it. The facility's policy related to Dignity (undated) specifies the following: The facility must promote Care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his/her individuality. .Always knock before entering a resident's room. This is their home, allow time for the resident to respond before proceeding. No response is construed as consent.

Based on interviews and record reviews the facility failed to ensure: 1) RI (Resident Identifier) #2's and #13's weekly wound documentation included the characteristics/descriptions of the wound bed including appearance of the wound bed, tissue types within the wound and a description of the surrounding skin; 2) staff documented witness statements and documented names of witnesses on the incident report for RI #14 on 2/6/2015. This affected 3 of 5 sampled residents whose records were reviewed. Findings include: 1) A review of the facility's undated Wound and Skin Care Protocols documented: . Assessment and Documentation.1. A complete wound assessment and documentation will (be) done weekly on all pressure ulcers. The criteria to be included.Appearance of the wound bed.when there is a combination of tissue types they should be identified by the percentage present. Undermining/tunneling. Surrounding skin.Drainage/exudate describe the amount, color, consistency and odor. 1a) RI #2 was readmitted to the facility on [DATE]. RI #2's annual MDS (Minimum Data Set), with an assessment reference date of 5/18/2015, revealed the resident presented with one stage three wound and one unstageable wound on admission. The facility Skin Observation Tool forms dated 5/23/2015 through 7/18/2015 revealed the assessments of RI #2's pressure ulcers on the right trochanter and the left heel contained measurements and stage, but no additional documentation of the appearance of the surrounding skin or of the wound bed to include viable and/or non-viable tissue, and the presence or absence of undermining, tunneling, or drainage. 1b) RI #13 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #13's most recent quarterly MDS, with an assessment reference date of 7/1/2015, revealed one stage three, one stage four, and one unstageable wound. Facility Skin Observation Tool forms dated 2/13/2015 through 7/17/2015 revealed weekly measurements and stage of RI #2's pressure ulcers on the left trochanter, sacrum, and left foot. There was no other documentation in the medical record of the appearance of the surrounding skin or of the wound bed to include viable and/or non-viable tissue and the presence or absence of undermining, tunneling, or drainage. On 7/23/2015 at 12:55 PM, EI (Employee Identifier) #3, LPN (Licensed Practical Nurse) admitted that she was responsible for wound documentation. When asked why there was not a description of the wounds to include tissue type, color, odor, or drainage for RI's #2 and #13, EI #3 stated that it was an oversight on her part. When asked why it was important to document wound descriptions, EI #3 replied, to determine healing or decline of the wound. 2) RI #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #14's nurses notes dated 2/6/2015 at 3:45 PM revealed that the resident was located on the side of the building by staff. Review of the facility's investigative reports revealed there were no witness statements obtained and there were no witnesses documented on the reports when RI #14 was found on 2/6/2015. RI #14's nurses notes dated 5/13/2015 at 6:50 PM, revealed that the resident exited the facility, ran around to the front of the building and began walking down the street. An unidentified CNA (Certified Nursing Assistant) saw the resident and brought him back into the facility. Review of the facility's investigative reports revealed there were no documented witness statements and there were no witnesses identified on the reports for RI #14's 5/13/2015 incident. On 7/23/2015 at 2:40 PM, EI #3, LPN (Licensed Practical Nurse) was asked if witness statements were taken. EI #3 replied, no. EI #3 admitted that the facility had a witness statement form but no statements were completed. When asked why the facility's policy was not followed, EI #3 stated that the nurses did not follow the policy and she failed to pick up on it.

Based on observations, interview, and review of facility policies, the facility failed to ensure: 1) Dietary staff members' hoop style earrings were contained by a hairnet; 2) Staff checked the temperature of the milk prior to serving to ensure the temperature was 41 degrees Fahrenheit (F) or below; and 3) Gravy was reheated to a 165 degrees F for 15 seconds prior to serving. This had the potential to affect all 36 of 36 residents receiving meals from the kitchen. Findings include: 1) Review of the facility's undated policy titled "Personnel Adherence to Sanitary Procedures" revealed the following: " ... Policy Interpretation and Implementation 1. In addition to employee personnel policies food services and dietary personnel will be required to adhere to the following sanitary standards ... b ... (Note: Employees with pierced ears may wear only small Non-dangling earrings) ... " During the initial tour of the kitchen on 05/19/2015 beginning at 1:44 PM, two dietary staff members, Employee Identifiers (EI) #s 4 and 5, were both observed wearing quarter-sized hoop style hearings, not contained by a hairnet. EI #5 was observed preparing tuna salad. EI #6, the Certified Dietary Manager (CDM), was interviewed on 05/20/2015 at 1:55 PM. During the interview, EI #6 stated if staff wore earrings in the kitchen the earrings should be covered by their hairnet because of the potential for physical contamination. 2) Review of the facility's policy titled, "Taking and Recording of Milk Temperatures", revised 09/20/2010, revealed the following: " ...Policy: Milk carton temperatures must be taken at the beginning of each meal to ensure proper temperature before serving to residents. Purpose: To ensure all milk served is within proper temperatures 41 degrees F or below to decrease the possibility of food-borne illness through proper milk temperature control ... " On 05/20/2015 at 11:17 AM, the surveyor entered the kitchen to observe tray line proceedings. Dietary staff were observed checking temperatures of the hot food items on the steam table prior to serving residents' trays; however, no milk temperature was checked. Staff began plating residents' trays at 12:02 PM, and at 12:07 PM, the first cart of trays left the kitchen. On top of each cart was a plastic cooler containing cartons of milk. The surveyor then reviewed the "DIETARY DAILY SHIFT REPORT" and saw that the section for the lunch milk temperature was blank. During an interview on 05/20/2015 at 1:55 PM, EI #6, the CDM, explained all hot and cold items, including milk, should be checked to ensure proper temperature prior to serving residents. When ask what potential harm could occur if staff did not check the temperature of the milk prior to serving, EI #6 said it was possible the milk could be too warm and spoil, causing food poisoning. 3) Review of the facility's policy titled "SAFETY IN FOOD TEMPERATURE DURING COOKING AND HOLDING", revised 07/21/2011, revealed the following: " ... Purpose: To provide nutritious meals for residents in a manner to decrease possibility of food-borne illness through proper food temperature controls. Policy: The facility will measure temperature of food during cooking cycle to ensure temperature is within safe range of 140 Degrees F or greater for all "hot" foods ... Procedures: ...5. If a food item is found to be out of compliance during any of the temperature cycles, it will be ... reheated to 165 Degrees F for at least 15 seconds. 6. If an item is being reheated ... it must be heated to a temperature of 165 Degrees or higher ... " On 05/20/2015 at 11:17 AM, the surveyor entered the kitchen to observe tray line proceedings. At 11:22 AM, EI #7, the cook, checked the temperature of the gravy. It measured 120 degrees F. EI #7 then turned the burner under the gravy up and began stirring the gravy to reheat it. At 11:30 AM, EI #7 again checked the temperature of the gravy and stated it "went up to 140 degrees F." EI #7 immediately placed the gravy on the steam table. At 11:53 AM, EI #7 took a second set of temperatures of all items on the steam table, just prior to serving residents' trays. The gravy again measured 140 degrees F. Staff began plating residents' trays at 12:02 PM, and at 12:07 PM, the first cart of trays left the kitchen. During an interview on 05/20/2015 at 1:55 PM, EI #6, the CDM, explained that when an item is reheated it should be placed back on the stove and heated to 165 degrees F for 15 seconds. After discussing the observation of the gravy only reaching 140 degrees F, EI #6 said that improperly reheating items could potentially lead to food poisoning.

Based in observations, interviews and record review, the facility failed to ensure opened vials of insulin for Resident Identifier (RI) #10 and Unsampled Residents (UR) #s 1, 2, and 3 were labeled with an open date and an expiration date upon opening the vials. This affected 1 sampled resident, 3 unsampled residents and two of four medication carts. Findings include: Review of a facility policy dated 5/20/2015 titled "Labeling of Insulin" revealed: "Policy: This facility dates and initials all insulin when the vial is opened. Purpose: To ensure all insulin administered are at full potency to allow optimal glycemic control. Procedure: ... 2. Nurse will unseal vial. 3. Nurse will date label with date and initial upon opening... 5. Using "Expidator", Nurse will determine last date of use and fill in the date and initial on the label. 6. All nurses are responsible for checking expiration date prior to use..." A review of the manufacturers information for Levemir Insulin revealed that Levemir Insulin is only good for 42 days after being taken out of the refrigerator. During medication pass observation on 05/19/2015 at 3:56 PM, the surveyor observed Employee Identifier (EI) #1, an LPN (Licensed Practical Nurse) giving medications from the Block 2 medication cart and drawing up Novolog insulin to be administered to RI #10. The opened vial did not have an open date or expiration date listed on the vial. EI #1 administered the insulin to RI #10. On 05/19/2015 at 4:30 PM, the surveyor along with EI #1 reviewed the insulin vials on the Block 5 medication cart. The surveyor observed 3 opened Levemir insulin vials in the cart. These three opened vials had labels affixed to them but did not have the open date nor expiration date filled in. The surveyor had EI #1 read each insulin vial and affirm that there were no open dates, no expiration dates and to whom the insulins belonged. EI #1 verified that Block 5 Medication cart contained the following: 1 vial of Levemir insulin with no open date, no expiration date, partially used,which belonged to UR #1. 1 vial of Levemir insulin with no open date, no expiration date, partially used which belonged to UR #2. 1 vial of Levemir insulin with no open date, no expiration date, partially used which belonged to UR #3. On 05/19/2015 at 4:08 PM, the surveyor interviewed EI #1 about labeling insulin. EI #1 stated that the nurse was supposed to discard insulin and get a new vial if it is not dated with an open date and expiration date. EI #1 further stated she had not looked at the date prior to administering the insulin to RI #10. When asked what the potential for harm would be in administering insulin without the vial being labeled with an open date or expiration date, EI #1 stated if the insulin is outdated, it would not do the resident any good. On 05/20/2015 at 2:45 PM, the surveyor interviewed EI #2, an LPN/Infection Control and Quality Assurance Nurse. EI #2 was asked how insulin vials should be labeled. EI #2 stated that the vials should have a date, expiration date and open date on them. When asked what staff needed to do after opening insulin vials, EI #2 stated staff should date the vials with a date and expiration date, as well as their initials. When asked what the potential for harm would be in not labeling the vials with an open date and expiration date, EI #2 stated if used past the expiration date there would be decreased effectiveness and diabetes would be uncontrolled.

Based on interviews and record review, the facility failed to ensure a post-fall investigation was conducted following Resident Identifier (RI) #4's fall with injury on 01/18/2015 in an attempt to determine causal factors and to implement interventions to prevent future recurrences. This affected 1 of 3 residents sampled for falls. Findings include: Review of the facility's undated policy titled "ACCIDENTS AND INCIDENTS- INVESTIGATING AND RECORDING" revealed the following: " ...Policy Statement All accidents or incidents occurring on our premises must be investigated ... Policy Interpretation and Implementation ... 4. Investigative Action: ... b. The following data, as it may apply, must be included on the Accident Investigation Report Form: ...5. The name(s) of any witnesses and their accounts of the accident or incident; 6. The injured person's account of the accident or incident ... 11. Any corrective action taken; 12. Follow-up information ... " RI #4 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #4's Quarterly Minimum Data Set (MDS) Assessment, dated 12/23/2014, documented RI #4 as cognitively intact. RI #4 required one person physical assistance for bed mobility and transfers. A Resident Interview was conducted with RI #4 on 05/19/2015 at 5:15 PM. During the interview, RI #4 detailed an incident where two aides rolled (RI #4) off of the bed onto the floor. RI #4 could not recall exactly when the incident had occurred or the names of the aides involved. Review of RI #4's medical record revealed a Nurses' Note by Employee Identifier (EI) #1, a Licensed Practical Nurse (LPN), documenting the following: " ... 1-18-15 8p (8:00 PM) CNA (Certified Nursing Assistant) & Resident slipped and resident fell into arms of CNA while they fell to the floor where resident fell on top of CNA ... his L (left) elbow hit the edge of the BS (bedside) table ... Resident has area size of dime to L elbow (slightly above) red beginning to bruise bluish in color tear of skin weeping ... (EI #2, LPN) notified of incident ... " On 05/20/2015 at 7:45 AM, the surveyor requested any incident reports involving RI #4. EI #2, the nurse responsible for following up to any incidents, stated she did not have any accident or incident reports for RI #4. Later, at 10:10 AM, EI #2 returned to the surveyor and stated there had been an incident on 01/18/2015 but there was no incident report because EI #2 had not received any paperwork related to the incident. On 05/20/2015 at 4:55 PM, EI #2 was interviewed regarding what actions had been taken at the time of RI #4's 01/18/2015 incident. EI #2 stated an investigation and follow-up had not been done. EI #2 explained an investigation and follow-up was important, especially with the elderly population, because injuries do not always show up at the time of the incident. EI #2 stated they also needed to look for the causative factors to hopefully prevent a recurrence of similar incidents. EI #2 said they had not determined the causal factor of RI #4's incident. When asked what should have been done following RI #4's fall with injury on 01/18/2015, EI #2 stated an incident report should have been completed and turned in the following day so an investigation could be initiated. EI #2 also said she would have talked with the CNA involved, as well as RI #4, to determine what happened. EI #2 said that because the facility had not investigated and followed up to RI #4's incident, RI #4 was at risk for a recurring fall. EI #2 also stated RI #4 could have potentially been injured and not received the needed follow-up On 05/20/2015 at 5:16 PM, EI #1, the nurse who completed the 01/18/2015 Nurses' Note, was asked what she could recall about the 01/18/2015 incident involving RI #4. EI #1 stated a CNA was putting RI #4 to bed and they slipped and fell to the floor, with RI #4 landing on top of the CNA. EI #1 stated she notified EI #2, LPN, of the incident and explained an investigation was usually done for all incidents.