Every finding on record at Arbor Lake Health and Rehab

Based on observation, interview, the 2022 United States (U.S.) Food and Drug Administration (FDA) Food Code, the facility's policies for Cleaning and Sanitation of Dining and Food Service Areas, Cleaning Dishes/Dish Machine, Dish Machine Temperature Log, Food Storage, Use and Storage of Food Brought in by Family or Visitors, and Cleaning Instructions: Food Carts, the Dishwasher Temperature/Chemical Record for August 2023, the Sanitizing Sink Temperature/Chemical Record for August 2023, and the posted Cleaning Assignments; the facility failed to ensure the kitchen and storage room floors were clean, kitchen equipment was clean, food safety logs were accurate, food and paper products were properly stored, interior of drawers were not rusted, and leftovers were labeled with Use-By dates so as to prevent the potential for cross contamination and to ensure food safety. This had the potential to affect 74 of 74 residents receiving meals from the kitchen. Finding Include: The facility's policy for Cleaning and Sanitation of Dining and Food Service Areas, undated, included the following: Policy: The food and nutrition services staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. Procedure: 1. The director of food and nutrition services will determine all cleaning and sanitation tasks needed for the department. 2. Tasks shall be designated to be the responsibility of specific positions in the department. 5. A cleaning schedule will be posted for all cleaning tasks, and staff will initial the tasks as completed. The facility's policy for Cleaning Dishes/Dish Machine, dated 2021, included the following: Policy: All flatware, serving dishes, and cookware will be cleaned, rinsed, and sanitized after each use. The dish machines will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitizing. Procedure: Staff will follow these procedures for washing dishes: 1. Prior to use, proper temperatures and/or chemical concentrations and machine function should be verified. The facility's policy for Dish Machine Temperature Log, dated 2021, included the following: Policy: Dishwashing staff will monitor and record dish machine temperatures to assure proper sanitizing of dishes. Procedure: . 2. Staff will record dish machine temperatures for the wash and rinse cycles at each meal. The facility's policy for Food Storage, dated 2021, included the following: Policy: Sufficient storage facilities will be provided to keep foods safe, wholesome, and appetizing. Food will be stored in an area that is clean, dry, and free from contaminants. Food will be stored, at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Procedure: . 10. Food should be stored a minimum of 6 inches above the floor. 11. Refrigerators should maintain food temperatures at or below 41 (degrees) F (Fahrenheit) . 12. Leftover food should be . clearly labeled and dated before being refrigerated. Leftover food must be used within 7 days or discarded . 13. Refrigerated food storage: . d. Refrigerators/freezers on nursing units should be supplied with thermometers and monitored for appropriate temperatures. f. All foods should be covered, labeled, and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their safe use by dates, . or discarded. The facility's policy for Use and Storage of Food Brought in by Family or Visitors, dated June 2018, included the following: Policy: It is the right of the residents of this facility to have food brought in by family or other visitors, however, the food must be handled in a way to ensure the safety of the resident. Policy Explanation and Compliance Guidelines: . 2. b. All refrigeration units will have internal thermometers to monitor temperatures. All units must be maintained at internal temperatures that are deemed safe for food storage according to sate (sp: state) and federal standards. The facility's policy for Cleaning Instructions: Food Carts, undated, included the following: Policy: Food carts will be cleaned and sanitized immediately after each use. Procedure: 1. Clean and sanitize the inside and outside of each food cart daily. If the cart has removable shelves, remove them so the interior can be cleaned. Use hot soapy water, rinse, and then sanitize. The 2022 U.S. FDA Food Code included the following: . 3-304.11 Food Contact with Equipment and Utensils. FOOD shall only contact surfaces of: (A) EQUIPMENT and UTENSILS that are cleaned . and SANITIZED . 3-305.11 Food Storage. (A) . FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm [centimeters] (6 inches) above the floor. 3-307.11 Miscellaneous Sources of Contamination. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306. 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control . TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: . (2) At 5 C [Centigrade] (41 F) or less. 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) . refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. 4-501.116 Warewashing Equipment, Determining Chemical Sanitizer Concentration. Concentration of the SANITIZING solution shall be accurately determined by using a test kit or other device. 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. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) . cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. 6-501.11 Repairing. PHYSICAL FACILITIES shall be maintained in good repair. 6-501.12 Cleaning, Frequency and Restrictions. (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. 6-501.111 Controlling Pests. The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: . (D) Eliminating harborage conditions. During the initial kitchen observation on 08/06/2023 at 1:15 PM, Employee Identifier (EI) #5, a PM Dietary Aide, was washing dishes on the clean side of the dishwashing machine. EI #5 said he worked the 11 AM to 8 PM shift. EI #5 checked the chlorine concentration of the dishwashing machine with a test strip, which read 50 ppm (parts per million). EI #5 recorded this and the temperature of the dishwashing machine on the August 2023 Dishwasher Temperature/Chemical Record for Lunch on August 6, 2023. This log had no entries recorded from August 4, 2023 Breakfast until EI #5 recorded the chlorine ppm and temperature for Lunch on August 6, 2023. The 3-Compartment Sink's Sanitizing Sink Temperature/Chemical Record for August 2023, also had no record after August 4, 2023 Breakfast. EI #5 started to fill in the log with information for Breakfast, but when he admitted to not working that morning and not being there; it was explained that he should not record the information for Breakfast if he was not there to check it at that time. At 1:40 PM, trash was observed under the dishwashing machine. Also a build-up of grime was seen on the floor beneath the ice machine and the tea brewing machine table. In addition, there was a build-up of residue inside the tea urn (brew container). A build-up of residue was also observed on the frame of the standing floor mixer and all along the bowl holder; it was a thick, black, sticky residue with a sprinkling of what appeared to be freshly spilled white flour. At 1:45 PM, the Heat on Demand activator was observed to have residue upon it, along with white and brown particles all over it. At 1:46 PM, the stove's drip tray was seen to have dried grease residue. The grill drip tray was full of greasy liquid and a pile of food residue. There was also a heavy amount of food and grease residue behind the stove and the fryer that appeared to be much more than 24 hours old. At 1:55 PM, the dry storage room was observed with EI #2, the Dietary Manager. The tiled floor looked stained and dirty. Two empty cardboard boxes were seen on the floor underneath the shelving. EI #2 said the floor was swept and mopped once or twice a week, usually after the food truck delivery days on Tuesday and Friday. Two 35-pound boxes of Canola oil and one box of 16-ounce foam cups, each with a delivery tag dated 8/4/2023, were observed directly on the floor. There were also two opened boxes of hinged foam containers directly on the floor. When EI #2 was asked why food and paper goods should not be stored on the floor, EI #2 said, Items can get dirty. At 2:00 PM the Walk-in Cooler was observed with EI #2. Five blue plastic, rectangular trays/boards were seen stacked haphazardly on a bottom shelf and these trays/boards were stained with a residue of brown spillage. EI #2 said the blue trays were cooling trays for food. Also observed were leftover breakfast items (bacon, biscuits) with the date of 8/6/23 on the identity labels. There was also a pan of Au Gratin Sliced Potatoes with a date of 8/5/23. EI #2 was asked if these were the Use-By dates. EI #2 said no, the staff was incorrectly using the preparation date. When asked why it was important to record the Use-By date on each leftover food, EI #2 said because you would not know when it was prepared and when to throw it out. At 2:16 PM, the preparation table with the attached can opener was observed. The shelf beneath where the can opener was located had a build-up of residue, apparently from spillage due to opening cans. At 2:22 PM, three in-use storage drawers were observed. The drawer handles had an oily feel, as though they were soiled with grease. The drawer interiors were rusted and contained debris along with the stored contents. On 08/06/23 at 2:24 PM, documents were requested from EI #2. At 4:00 PM, the documents received from EI #2 included the 3-Compartment Sink and the Dishwashing Machine August 2023 logs, the Sanitizing Sink Temperature/Chemical Record and Dishwasher Temperature/Chemical Record. Each of these logs had been filled in with data for 8/4/2023 Lunch through 8/6/2023 Breakfast, when those spaces had been blank on 8/6/2023 at 1:20 PM. On 08/07/23 at 5:30 PM, during a meeting with EI #2, the Dietary Manager, and EI #3, the Registered Dietitian, it was revealed that nourishments were provided for the three resident units as needed and that there was only one nourishment refrigerator, which was located in the Courtyard DR. On 08/07/23 at 5:50 PM, EI #2, the Dietary Manager, was interviewed and EI #3, the Registered Dietitian, was allowed to attend. When asked who entered the data from August 4, 2023, Lunch through 8/6/2023 Breakfast on the 3-Compartment Sink and Dishwashing Machine logs; EI #2 said the initials belonged to EI #5, a PM Aide. EI #5 was not currently on duty. EI #2 said EI #5 did it after I had the staff correcting the kitchen issues. Upon being asked why it was important to check the ppm values and the temperatures, EI #2 said the temperatures and the ppm of the sanitizer are important to kill the bacteria that could contaminate food. When asked if the data from August 4, 2023, Lunch through 8/6/2023 Breakfast for the 3-Compartment Sink and Dishwashing Machine logs could be considered true and correct; EI #2 said probably not. When asked the concern about the documentation; EI #2 said for those three days, we don't know if it is real information or not. On 08/08/2023, breakfast preparation and tray line were observed from 6:05 AM to 8:14 AM. At 6:45 AM, the five enclosed carts for serving and returning resident trays were observed. All five carts had residual stains and dried drip residue inside and also had small food particles on the bottom of the interior floors. The #5 cart had an unwrapped, bent straw on the interior floor. At 7:27 AM, the AM Cook (EI #6) started plating breakfast for trays to be delivered to the residents' rooms and dining rooms. Three staff were on the serving line; the AM Cook, the Dietary Manager (EI #2), and the AM Aide. At 7:34 AM, the AM Aide exited kitchen with serving cart #1. At 7:35 AM, serving cart #2 was being filled with resident trays. At 7:38 AM, EI #2, the Dietary Manager, confirmed that all five carts were for the nursing home residents; carts #1 through #3 were for one side and carts #4 and #5 were for the back halls. At 7:40 AM, the AM Aide exited kitchen with serving cart #2. EI #2 began filling cart #3 with resident trays. At 7:49 AM, the AM Aide exited kitchen with serving cart #3. Serving cart # 4 began to be loaded. At 7:58 AM, the AM Aide exited kitchen with serving cart #4. Serving cart # 5 began to be loaded. At 8:14 AM, the AM Aide exited kitchen with serving cart #5. At 8:15 AM, the AM Aide delivered serving cart #5 for service to Hall 3 and Hall 2. Breakfast service was observed on 08/08/2023 from 8:15 AM to 8:41 AM for the Outback dining room, Hall 2, and Hall 3. At 8:16 AM, a CNA took possession of the cart. The CNA pushed the cart and stopped in front of the nursing station between Hall 2 and Hall 3 by the Outback DR. Trays were served to residents in the Outback dining room. At 8:19 AM, CNAs began serving trays to residents in their rooms. At 8:38 AM, serving cart #5 was observed to still have the opened, bent straw inside on the floor of the cart. At 8:41 AM, all trays had been served. At 8:53 AM, dirty trays were being placed back on serving cart #5. On 08/08/2023 at 11:54 AM, the one Nourishment Refrigerator was observed in the Courtyard Dining Room. There was a temperature log posted on the refrigerator with the heading Refrigerator Temperature Log and with the following directions: Safe Range: 36 to 46 . If temperature is out of range, complete the comments/actions taken section and recheck temperature at a later time. If temperature remains out of range, notify maintenance. On 08/08/2023 at 2:11 PM, EI #6, the AM Cook, was interviewed. When asked what cleaning duties the AM Cook had, EI #6 said keeping everything clean; the cook surface area, the work serving area, and the prep sink area near the hand washing sink. EI #6 said she used the can opener and preferred to send it through the dishwasher to keep build-up from collecting on it; however, she further said I don't always wipe under there. When asked if she used the grill; EI #6 said I don't like that grill, if I can avoid it, I will. EI #6 further said I will avoid using the mixer if I can. Upon being asked if there was a cleaning check off list/schedule to follow; EI #6 said no, I don't think I have seen one since I have been here. On 08/08/23 at 4:01 PM, EI #2, the Dietary Manager, was interviewed. When asked if there was an established cleaning schedule/check-off for the kitchen posted; EI #2 said it was posted on the board by the schedule, but there was no check-off or sign-off list. EI #2 further said upon hire staff were given duties to perform each day for cleaning. EI #2 said the accumulation of food/grease residue, trash, and grime on the floor can cause accidents. EI #2 said food and paper goods should not be stored on the floor due to the cross contamination concern. EI #2 said food and supplies should be stored six inches from the floor to protect from possible rodents. EI #2 said cross contamination would be the problem with residue build-up on the inside of the tea urn and on the frame of the standing floor mixer. EI #2 said the stove drip tray should be clean of accumulated grease/food residue to prevent roaches. EI #2 said the problem with the cooling trays stained with brown residue/spillage was that they were dirty. EI #2 said the greasy drawer handles and interior drawers with rust and debris could be a potential cause for bugs. EI #2 said the potential problem with Heat on Demand activator not being clean was that the stuff could be transferred to the bases (the heated bases placed under the resident's meal plates). EI #2 said bacteria and dirt cross contamination was the problem with tray delivery carts #1 through #5 having residue build-up and food particles inside, including the unwrapped, bent straw in the #5 cart at breakfast. EI #2 said Use-By dates needed to be recorded on refrigerated left-overs so we will know when they expire and when to throw them out. When asked the problem with the posted safe temperature range of 36 to 46 degrees Fahrenheit on the nourishment refrigerator log, EI #2 said the refrigerator temperature could be in the food danger zone and it might not be reported. EI #2 was asked to make a copy of the posted cleaning duties. The provided copy of Cleaning Assignments, as posted on the Kitchen Bulletin Board, listed the following tasks with employee names for standing assignment: Dry Storage, Cooler/Freezer, Dish Area and Other Kitchen Areas, and Equipment with no other instructions or direction included.

Based on observation, interview, the facility's policies for Menu Planning and Accuracy and Quality of Tray Line Service, the facility's 2023 Spring/Summer Menu, Week 3, Tuesday, and the facility's posted alternate menu for supper Week 3, Tuesday; the facility failed to provide Oatmeal in 6-ounce portions at breakfast and Country Fried Steak in 3-ounce portions at supper on Tuesday, August 8, 2023. This had the potential to affect 74 of 74 residents receiving meals from the kitchen. Findings Include: The facility's policy for Menu Planning, dated 2013, included the following: Policy: Nutritional needs of individuals will be provided in accordance with the recommended dietary allowances of the food and Nutrition Board of the National Research Council, National Academy of Sciences (adjusted for age, gender, activity level and disability), through nourishing, well-balanced diets, unless contraindicated by medical needs. Procedure: 1. Regular and therapeutic menus are written to provide a variety of foods served on different days of the week, adjusted for seasonal changes, and in adequate amounts at each meal to satisfy recommended daily allowances. 4. Menus are written to include at least three meals daily at regular times, in amounts consistent with nutritional needs. The facility's policy for Accuracy and Quality of Tray Line Service, undated, included the following: Policy: Tray line positions and set up procedures are planned for efficient and orderly delivery. All meals are checked by food service personnel for accuracy, and by the employees serving the meals prior to serving to the individual. Procedure: 1. The menu extension sheet displays food items and amounts for each regular or therapeutic diet. 4. The meal is checked against the therapeutic diet spread sheet to assure that foods are served as listed on the menu. 7. Each meal will be checked for: . Proper portion sizes . On 08/07/23 at 5:30 PM, during a meeting with EI #2, the Dietary Manager, and EI #3, the Registered Dietitian, it was revealed that daily menus with alternates were generated by the menu system and then those menus were posted for resident review. The facility's 2023 Spring/Summer Menu, Week 3, for Tuesday as served on Tuesday, August 8, 2023, included the following for breakfast: 6 oz (ounces) Oatmeal for the Regular, Mechanical Soft, Puree, Low Concentrated Sweet, and No Added Salt diets. On 08/08/2023, breakfast preparation and tray line were observed from 6:05 AM to 8:14 AM. Employee Identifier (EI) #6, the AM Cook, placed cooked oatmeal on the serving line at 6:34 AM. At 7:05 AM, EI #6 identified the serving utensil in the oatmeal as a 4-ounce spoodle. At 7:27 AM, the AM Cook (EI #6) started plating breakfast for trays to be delivered to the residents' rooms and dining rooms. Three staff were on the serving line; the AM Cook, the Dietary Manager (EI #2), and the AM Aide. The serving sizes were adequate except for the 4-ounce serving of oatmeal, which was listed as 6 oz on the menu. On 08/08/2023 at 2:11 PM, EI #6, the AM Cook, was interviewed. When asked how she knew how much to serve of each food item, EI #6 said it is on the menu and you should know the standard serving sizes. EI #6 confirmed the Spring/Summer Menu, Week 3, Tuesday was the correct menu for today. EI #6 was given the menu and asked what amount of oatmeal should be served according to the menu. EI #6 said six ounces. EI #6 further said I thought it would be four ounces like the grits. EI #6 said she should have used the 6-ounce spoodle and the insulated soup bowls to serve the oatmeal. On 08/08/2023 at 4:01 PM, EI #2, the Dietary Manager, was interviewed. EI #2 said six ounces of oatmeal should have been served at breakfast according to the menu. EI #2 further said the white, side bowls, which were used, will only hold three to four ounces. EI #2 said the residents were not getting the calories they should with the proper amount of food. On 08/08/2023 at 5:01 PM, EI #3, the Registered Dietitian, was interviewed. EI #3 was asked to identify the concern about four ounces of oatmeal being served instead of six ounces. EI #3 said less calories for the resident. The facility's posted alternate menu for Tuesday supper of Week 3, as served on Tuesday, August 8, 2023, included the following: Country Fried Steak. On 08/08/2023 at 5:45 PM, the alternate menu item for supper, Country Fried Steak, was observed. The portion looked small. EI #4, the PM Cook, provided the box the meat came in. The information on the box included the following: 2.25-ounce Beef Breaded Country Fried Steak (beef fritter), Raw, one portion, 71 portions per box. On 08/08/2023 at 5:50 PM, EI #8, the District Manager for the facility's contract food service, observed the meat portion of Country Fried Steak. EI #8 said the menu portion should be three ounces protein at lunch and at supper. EI #8 told EI #4, the PM Cook, that two pieces of the Country Fried Steak (2.25 ounces per piece) would have to be served; because you could go higher than three ounces, but not lower than that for a serving. On 08/08/2023 at 5:54 PM, EI #2, the Dietary Manager, said she heard and agreed with the exchange between EI #8 and EI #4 about the minimum 3-ounce protein serving for lunch and supper.

Based on observations, interviews and review of a facility policy Shower Cleaning Policy, the facility failed to ensure the shower in Resident Identifier (RI) #20's room was free of orange/yellow and brown discoloring in the shower and on the shower curtain. This was observed on 8/6/23 and again on 8/8/23. This affected one of one resident shower room. Findings Include: A review of facility policy Shower Cleaning Policy dated 8/9/23 revealed, 1. Showers are cleaned and disinfected daily. 3. Spray Broad-Cide 128 onto shower walls, shower curtains and shower floors. RI #20 was admitted to the facility 12/23/21. A review of RI #20's Quarterly Minimal Data Set (MDS) with an Assessment Reference Date of 05/18/2023 revealed RI #20 was independent for bathing and walking. On 08/06/2023 at 4:38 PM during observation and interview with RI #20, RI #20 stated the bathroom floor was dirty with mold in the shower and on the shower curtain. RI #20 said look at my shower. RI #20 stated he/she had asked them to clean it and they have not. On 08/06/2023 at 4:50 PM the surveyor observed a brownish discolored stain around the shower drain, faucet, grab bar, floor, and shower curtain. The surveyor asked RI #20 how often he/she used the shower. RI #20 responded daily. On 08/06/2023 at 5:00 PM during an interview with Employee Identifier (EI) #10, Maintenance Director, while observing RI #20's shower, he was asked what was on the shower floor, and he responded, that is mold. On 08/08/2023 at 2:34 PM, the surveyor observed RI #20's shower. In the shower observed was a orange/yellow colored stain on seat, dark brownish discoloring on shower curtain and around area where hand rail attached to the wall. On 08/08/2023 at 5:46 PM, EI #9, Housekeeping Supervisor was interviewed while observing RI #20's shower with the surveyor. EI #9 was asked to describe what she observed on the seat, said a stain. EI #9 was asked if the stain should be there; she said it should not. When EI #9 was asked how often showers were cleaned; she said every day. EI #9 was asked what she saw on the grab bar; she said mold. EI #9 was asked when mold should be on grab bars, EI #9 said never. She was asked what she saw on the shower curtain and said mildew. EI #9 was asked when the shower curtain should have mildew on it, she said never. When asked why there was mildew and mold in the shower, EI #9 said it was not being cleaned properly. EI #9 was asked what the concern could be with mold and mildew in the shower; she said the resident breathing in the mold could cause problems. EI #9 was asked how often RI #20 used his/her shower; she said every day. 48195

Based on interview, record review and review of a facility policy titled Destruction of Unused Drugs, the facility failed to ensure the Non-Controlled Medication Destruction Sheets contained the two required signatures. This affected two of eight months ([DATE] and [DATE]) of Non-Controlled Medication Destruction Sheets reviewed. Findings Include: A facility policy titled Destruction of Unused Drugs, with a revised date of [DATE], revealed the following: Policy: All unused, contaminated, or expired prescription drugs shall be disposed of in accordance with state laws and regulations. Policy Explanation and Compliance Guidelines: . 4. The actual destruction of drugs conducted by our facility must be witnessed by the consultant pharmacist and one of the following individuals: a. An agent of the State Board of Pharmacy; b. The facility administrator; or c. The director of Nursing Services. 5. A Non-Controlled Medication Destruction Record must be maintained . The following information shall be included on this record: .j. The signature of the consultant pharmacist destroying the medications; and k. The signature of the person(s) witnessing the destruction of the medications. On [DATE] at 9:41 AM, the surveyor reviewed the Non-Controlled Medication Destruction Sheets for [DATE] through [DATE]. On the [DATE]. 2022 Non-Controlled Medication Destruction Sheets there was only one signature on the sheet: and on the [DATE]. 2023 Non-Controlled Medication Destruction Sheet there were no signatures on the sheet. On [DATE] at 11:47 AM, Employee Identifier (EI) #1, the Assistant Director of Nursing was interviewed. When asked how many signatures there should be on the Non-Controlled Medication Destruction Sheet. EI #1 said two. The surveyor showed the Non-Controlled Medication Destruction Sheets to EI #1 then asked which months did not have the required signatures. EI #1 said [DATE], and [DATE]. EI #1 was asked who was responsible for signing the sheets. EI #1 said usually the Director of Nursing (DON) and the pharmacist, if the DON was not available, a nurse and the pharmacist should, it should have two signatures. When EI #1 was asked if the proper signatures were on those destruction sheets, she said no, there should be the two signatures.

Based on observation, interview, the facility's policies for The Person Centered Dining Approach, Dining and Meal Service, and Dining Room Service, and the facility's Resident Rights; the facility failed to ensure disposable Styrofoam cups were not used for serving coffee at breakfast on Tuesday, August 8, 2023, although re-usable insulated coffee mugs were available. This had the potential to affect 74 of 74 residents receiving meals from the kitchen. Findings Include: The facility's policy for The Person Centered Dining Approach, undated, included the following: Policy: Person centered care allows individuals to live as normal a life as possible. To that end, person centered care and hospitality services are adapted as much as possible into the everyday living arrangement, including dining. Procedure: . 4. All individuals are treated with the utmost courtesy, respect and dignity. Each person is treated as if they were the most special guest. The facility's policy for Dining and Meal Service, undated, included the following: Policy: The dining experience will be person centered with the purpose of enhancing each individual patient's/resident's quality of life . The facility's policy for Dining Room Service, undated, included the following: Policy: . Effective equipment shall be provided, . A review of the facility Resident Rights, Appendix L in the facility's Resident Handbook, dated 11/01/2022 revealed the following: . The resident has a right to a dignified existence . Breakfast service was observed on 08/08/2023 from 8:15 AM to 8:41 AM for the Outback dining room, Hall 2, and Hall 3. On 08/08/2023 at 8:29 AM, coffee was observed being obtained from a one-cup service coffee machine located in the staff/unit kitchen on Hall 2. Styrofoam cups were being used for serving the coffee to the residents. A Certified Nursing Assistant (CNA) was observed serving hot coffee, two Styrofoam cups at a time, from the staff/unit kitchen, while another CNA was serving trays from the delivery cart on Hall 3. At 8:40 AM, Employee Identifier (EI) #7, a CNA/Supply Clerk, was observed serving the last resident tray. EI #7 was asked why coffee was being served in Styrofoam cups. EI #7 said, Because they did not send coffee cups. On 08/08/2023 at 8:51 AM in the Hall 2 staff/unit kitchen, EI #1, the Assistant Director of Nursing, was asked if actual coffee cups were ever provided for the residents instead of Styrofoam. EI #1 said, sometimes. On 08/08/2023 at 4:01 PM, EI #2, the Dietary Manager, was interviewed. EI #2 was asked why no reusable coffee cups were available for the resident breakfast service that morning. EI #2 said she ordered 12-ounce Styrofoam cups for the halls to use. EI #2 further said that at one time there were insulated coffee cups, which Nursing got from the kitchen and Dietary then washed after receiving them from the dirty tray carts. EI #2 said she was not sure when the complete change to Styrofoam was made and was unsure of how many insulated coffee cups were available in the main kitchen and storage area. On 08/08/2023 at 5:01 PM, EI #3, the Registered Dietitian, was interviewed. The observation of the service of coffee in Styrofoam cups at breakfast was discussed. EI #3 said a reusable coffee cup was more like home than a Styrofoam cup. On 08/08/2023 at 5:38 PM, EI #2 said she had found some insulated coffee cups in storage. 19 blue, insulated mugs (cups), which matched the insulated domes used for meal service, were observed in the kitchen.

Based on observation, interview, record review and review of facility policy titled, Hand Hygiene for Long Term Care the facility failed to ensure: 1. a medication nurse did not put on gloves and a gown, then enter the resident's room and move the floor mat, then with the same gloves, administer Resident Identifier (RI) #7's tube feeding and medications; 2. a Certified Nursing Assistant (CNA) did not touch RI #60's bun with her bare hands while serving the supper meal on 7/22/19 and 3. a CNA did not provide pericare for RI #60, without washing her hands between glove changes. This affected one of one resident observed for medication and tube feeding, one of one resident observed for meal assistance and one of two residents observed for pericare. Findings Include: 1. RI#7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI#7's Physicians Orders revealed . [MEDICATION NAME] 10 mg (milligram) . per tube .Aspirin 81 mg .per tube .[MEDICATION NAME] 20 mg .per tube .[MEDICATION NAME] 10 mg .per tube .Carvedilol 25 mg . per tube .[MEDICATION NAME] 1.5 . On 7/24/19 at 9:00 AM Employee Identifier (EI) #2, Licensed Practical Nurse, prepared the medications and tube feeding for RI#7. EI#2 put on gloves and a gown before entering the room. She placed the medications, syringe and cups on a clean surface on the overbed table. EI#2 stepped on the floor mat beside the bed then bent over and picked up floor mat moving it out of the way. Wearing the same gloves she touched the floor mat with, EI#2 then took cups into the bathroom and filled them with water. At the bedside, she poured water into five cups containing medications, picked up five straws and stirred the medications, touched the gastrostomy tube and verified the placement of the tube. EI#2 then picked up the can of tube feeding and administered it via the gastrostomy tube. She then picked up each medication cup containing medications and administered them and the water, all the while wearing the same gloves she touched the floor mat with. On 7/24/19 at 9:30 AM an interview was conducted with EI#2. EI#2 was asked, did she move the floor mat while wearing clean gloves, then continue with tube feeding and medications wearing the same gloves she touched the floor mat with. EI#2 replied, yes. EI#2 was asked, when should she use clean gloves to move a floor mat, then use the same gloves to administer tube feeding and medications. EI#2 replied, never. EI#2 was asked, what was the harm in touching the floor mat, then proceeding with administration of tube feeding and medications, while wearing the same gloves. EI#2 replied, contamination. EI#2 was asked, after moving the floor mat, what items did she touch with the same gloves. EI#2 replied, table, stethoscope, bed, syringe, medication cups and [DEVICE]. On 7/25/19 at 8:25 AM an interview was conducted with EI #8, Registered Nurse, Infection Control Nurse. EI #8 was asked how should staff handle moving a floor mat then administering a resident tube feeding and medication. EI #8 replied, remove the mat as needed with hands or feet, but before performing the tube feeding or medications, they should wash their hands and put on new gloves. EI #8 was asked when should the medication nurse move a floor mat, then with same gloves administer a resident's tube feeding and medication. EI #8 replied, they should not ever do that. EI #8 was asked what was the harm in the medication nurse moving a floor mat then continuing with the same gloves and administering a tube feeding and medications. EI #8 replied, transfer of germs from the mat to the feeding, medications and the resident. 2. RI #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/22/19 at 5:32 PM, the surveyor observed the supper meal service for RI #60. The CNA, Employee Identifier (EI ) #3 placed the plate on the table. The plate contained corn, a Philly steak sandwich and potatoes. EI #3 used the fork to open the sandwich placing the top bun on the plate beside the bottom bun. EI #3 put mustard, ketchup and mayonnaise on the sandwich. EI #3 then picked up the top bun with her bare hand and placed it on top of the bottom bun. EI #3 then picked up the fork and knife and cut the sandwich in half. On 7/23/19 at 4:45 PM, an interview was conducted with EI #3 regarding the observation made the evening before. EI #3 was asked when should she handle resident food with her bare hands. EI #3 replied, never. When asked what food she touched with her bare hand, she replied the resident's bun to the sandwich. EI #3 was asked what was the harm in touching resident food with a bare hand. EI #3 replied, cross contamination. In 7/25/19 at 8:25 AM, an interview was conducted with EI #8 Registered Nurse, Infection Control Nurse. EI #8 was asked when should a CNA touch a resident's bun/bread with their bare hand. EI #3 replied, they should not touch food with their bare hands. EI #8 was asked how should the staff handle a resident's bun or bread. EI #8 replied, with gloves or with utensils. EI #8 was asked what was the harm in a CNA touching a resident's bun/bread with their bare hand. EI #8 replied, their bare hand contaminates the resident's food. 3. A review of a facility policy titled, Hand Hygiene for Long Term Care, with a last revised date of 8/17 revealed: . Indications for Hand Hygiene: Before: . donning gloves, . After: .removing gloves, . RI #60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/23/19 at 11:20 AM, a staff member took RI #60 to the room for toileting and pericare. During the task of providing pericare in the bathroom, the CNA, EI #5 changed her gloves after wiping the frontside and after wiping the buttock area of the resident. After providing the pericare task of RI #60, EI #5 removed her gloves, put on new gloves and placed a clean brief on the resident. EI #5 did not wash her hands at anytime between the glove changes. On 7/23/19 at 11:30 AM, an interview was conducted with CNA, EI #5. EI #5 was asked what was the policy on washing hands with glove changes. EI #5 replied, before starting and when finished. EI #5 was asked when are you to wash your hands during pericare. EI #5 replied, before they start and when they finish, only in between if resident had bowel movement. EI #5 added the resident did not. EI #5 was asked if she washed her hands when she changed gloves. EI #5 replied, no they were not supposed to. EI #5 was asked what was the harm in not washing hands between glove changes. EI #5 replied, there was no harm. On 7/25/19 at 8:25 AM, an interview was conducted with EI #8, Infection Control Nurse. EI #8 was asked when should staff wash hands during pericare. EI #8 replied, before starting, between back to front and when gloves are visibly soiled and when changing gloves. EI #8 was asked when should staff wash hands with glove changes. EI #8 replied, if removing gloves they should do hand hygiene. EI #8 was asked when would it be acceptable for a CNA to change gloves during pericare and not wash their hands before putting on clean gloves. EI #8 replied, it should not be acceptable, if they need to change their gloves they need to do some type of hand hygiene. EI #8 was asked what was the harm in staff changing gloves during pericare, but not washing their hands between the glove changes. EI #8 replied, contamination of the clean gloves they are putting on.

Based on observations, interview, record review and a review of a facility's policy titled, Discharges for Long Term Care the facility failed to ensure a discharge summary was completed for RI (Resident Identifier) #84, who discharged from the facility on 05/02/2019. This affected one of three sampled residents for closed record review. Findings include: The facility's policy titled Discharges for Long Term Care, issued 10/90, last revised 11/17, and last reviewed 11/18 stated: . The facility provides appropriate transfers and discharges per facility requirements. Procedures: . 4. f. The necessary information, including a copy of the resident's discharge summary, and any other documentation needed to ensure a safe and effective transition of care. RI #84 was admitted to the facility on [DATE] with admitting [DIAGNOSES REDACTED]. Other [DIAGNOSES REDACTED]. RI #84 was discharged home on 5/02 2019 at 3:30 PM. A review of RI #84's medical record revealed no documentation of a discharge summary. On 7/24/19 at 4:40 PM an interview was conducted with EI (Employee Identifier) #1, the Director of Nursing. EI #1 was given RI #84's medical record to locate the resident's discharge summary. When asked if there was a discharge summary, EI #1 replied, No, we do not have a discharge summary form in the chart that I can see. EI #1 was asked who was responsible for completing the discharge summary. EI #1 responded the nurse that was discharging the resident. EI #1 was also asked what the discharge summary should include. EI #1 answered the facility's discharge summary included: name, date of birth, medical record number, the physician, date admitted , date discharge, where discharged to, transportation, who accompanied the resident, status on discharge, skin condition, vital signs on discharge, weight on discharge, and discharge instructions with nurses' signature.

Based on observations, interviews, review of the facility's policy titled Blood Glucose Monitoring, the ACCU-CHEK Performa BLOOD GLUCOSE METER Owner's Booklet, an article and document from the Centers for Disease Control and Prevention, the facility failed to follow acceptable cleaning and disinfecting procedures for the multi-use glucometer. Employee Identifier (EI) #9, a Licensed Practical Nurse (LPN) failed to disinfect a multi-use glucometer after she had obtained a finger stick blood sugar for Resident Identifier (RI) #66 on 5/23/2018. While the facility's policy indicated how the multi-use glucometer should be cleaned and disinfected, interviews with the licensed nursing staff, to include the Director of Nursing, Assistant Director of Nursing (ADON)/Infection Control Nurse and Staff Development Coordinator revealed the staff had only been trained to clean and disinfect the multi-use glucometer with a 70% [MEDICATION NAME] alcohol prep pad. The current standards established by the Centers for Disease Control and Prevention, indicated the facility should utilize a disinfectant solvent that is effective against Human Immunodeficiency Virus ,[MEDICAL CONDITION]., [MEDICAL CONDITION] and [MEDICAL CONDITION]. The guidance further indicated 70% [MEDICATION NAME] solutions were not effective against [MEDICAL CONDITION] bloodborne pathogens . The ACCU-CHEK Performa Blood Glucose Monitoring System Operator's Manual for Multiple Patient Use provided to the survey team by the manufacturer, with a copyright date of (YEAR) documented . To disinfect the meter, use the following procedures. 3. Use a fresh Super Sani-Cloth (squeeze our any excess) to disinfect by gently wiping the front, back, and sides of the meter three times horizontally and three times vertically . This deficient practice affected RI #66 and placed the resident in immediate jeopardy for serious injury, harm and/or death, with the potential to affect the remaining 22 residents in the facility who received finger stick blood sugar monitoring. On 5/25/2018 at 10:00 PM, the Administrator, Director of Nursing, Assistant Director of Nursing/Infection Control Nurse, Wound Care Nurse, Executive Director of Senior Services, Vice President of Clinical Services and two other licensed nurses were notified of the findings of immediate jeopardy in the area of Infection Prevention & Control, F 880. Findings include: According to an article published by the Centers for Disease Control and Prevention, titled Frequently Asked Questions (FAQs) regarding Assisted Blood Glucose Monitoring and Insulin Administration last updated 8/19/2016, documented . Blood Glucose Meters . 2. What products are acceptable for cleaning and disinfection of blood glucose meters? FDA has recently released guidance for manufacturers regarding appropriate products and procedures for cleaning and disinfection of blood glucose meters . An excerpt from this guidance reads: The disinfections solvent you choose should be effective [MEDICAL CONDITION].[MEDICAL CONDITION], and [MEDICAL CONDITION] virus. Outbreak episodes have been largely due to transmission of [MEDICAL CONDITION] and [MEDICAL CONDITION]. However, of the two, [MEDICAL CONDITION] virus is the most difficult to kill. Please note that 70% [MEDICATION NAME] solutions are not effective against [MEDICAL CONDITION] bloodborne pathogens and the use of 10% bleach solutions may lead to physical degradation of your device . Healthcare personnel should consult the manufacturers of blood glucose meters in use at their facilities to determine what products, meeting the criteria specified by the FDA, are compatible with their meter prior to using any EPA-registered disinfectant for disinfection purposes. If manufacturers are unable to provide this information then the meter should not be used for multiple patients . The facility's policy titled Blood Glucose Monitoring with a review date of (MONTH) (YEAR), documented Policy Under the supervision of the Director of Nursing/Designee, qualified facility nurses will perform blood glucose monitoring according to physician orders [REDACTED]. Specimen collection, preservation, calibration, quality control checks, and cleaning will be performed per facility guidelines . Cleaning: . 2. Clean and disinfect the monitor between each resident use. Clean the glucometer to remove any visible blood. Disinfect the glucometer by gently wiping the meter's surface with a soft cloth slightly dampened with one of the following cleaning solutions: a. Super sani-cloth b. 70% Rubbing alcohol (alcohol wipes) c. Bleach wipes d. 10% household bleach solution (1 part bleach, plus 9 parts water made the same day e. Approved facility disinfectant ensuring the product stays on the glucometer for the required amount of time . The facility provided a document from the Centers for Disease Control and Prevention (CDC) titled Infection Prevention during Blood Glucose Monitoring and Insulin Administration last updated 6/8/2017, which documented . Blood Glucose Meters are devices that measure blood glucose levels. Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared. A simple rule for safe care: If shared, blood glucose meters should be cleaned and disinfected after every use . During medication pass observation on 5/23/2018 at 4:30 PM, EI #9, a LPN applied gloves and wiped (cleaned) the front and back of the glucometer with an alcohol prep pad. After the finger stick blood sugar was obtained for RI #66, EI #9 wiped (cleaned) the glucometer, an ACCU-CHEK Performa, with an alcohol prep pad and placed the glucometer in the medication cart. EI #9 acknowledged she had no more finger stick blood sugars to do until 9:00 PM. When asked how many she had already done, EI #9 said two. Page 55 of the ACCU-CHEK Performa BLOOD GLUCOSE METER Owner's Booklet provided by the facility to the survey team, with a copyright date of 2006, referenced how to clean the meter (glucometer). The booklet did not specify how to disinfect the glucometer. The ACCU-CHEK Performa Blood Glucose Monitoring System Operator's Manual for Multiple Patient Use provided to the survey team by the manufacturer, with a copyright date of (YEAR), documented . Chapter 6: Cleaning and Disinfecting the Meter WARNING *It is important to keep the meter clean and disinfected to help minimize the risk of disease transmission . NOTE . use only Super Sani-Cloths . If dedicating blood glucose meters to a single patient is not possible, the meters must be properly cleaned and disinfected after every use following the guidelines on the following pages . Acceptable Cleaning and Disinfecting Solution Only use Super Sani-Cloth to clean and disinfect the meter . How to Clean the Meter . 3. Use a Super Sani-Cloth (squeeze out any excess) to gently wipe the front, back, and sides of the meter . How to Disinfect the Meter . 3. Use a fresh Super Sani-Cloth (squeeze out any excess) to disinfect by gently wiping the front, back, and sides of the meter three times horizontally and three times vertically . During an observation on 5/24/2018 at 11:16 AM, the facility was noted to have three ACCU-CHEK Performa BLOOD GLUCOSE METERs; each of the three medication carts in the facility was observed to have one ACCU-CHEK Performa BLOOD GLUCOSE METER. In an interview on 5/24/2018 at 4:53 PM, EI #9, a LPN who works the second shift on hall 1 in the facility, acknowledged she had been trained on how to use, clean and disinfect the glucometer. When asked what type training she had received on cleaning and disinfecting the glucometer, EI #9 stated she was in-serviced when she first came to the facility 3/26/2018. When asked how she disinfected the glucometer, EI #9 explained she was taught to use two alcohol prep pads, one for the front of the glucometer and the other one for the back. EI #9 was asked, how long she had been disinfecting the glucometer with an alcohol prep pad. EI #9 replied, since she had been working at the facility. During a telephone interview on 5/24/2018 at 11:42 AM, EI #7, a LPN, was asked when she was last in-serviced on cleaning and disinfecting the multi-use glucometer. EI #7 replied, (MONTH) (YEAR). When asked how she was trained to disinfect the glucometer, EI #7 explained to place it on a clean napkin on the medication cart and use a 70% alcohol pad to clean the front and back of the entire machine and let it dry for one minute. In an interview on 5/24/2018 at 4:08 PM, EI #8, a LPN who works on hall 2 in the facility, was asked how she disinfected the glucometer. EI #8 stated she used an alcohol prep pad to disinfect the glucometer and then let it air dry. When asked how long she had been cleaning and disinfecting the glucometer in this manner, EI #8 said since (MONTH) of last year (2017). On 5/24/2018 at 5:22 PM, EI #19, a second-shift LPN employed with the facility for one and a half years, was asked how he cleaned and disinfected the glucometer. EI #19 stated he washed his hands, then put on gloves and used alcohol wipes to clean the front, back and sides of the glucometer. EI #19 stated the percent of alcohol was right for disinfecting. When asked what was the percentage of alcohol wipe (prep pad), EI #19 replied he believed it was 70%. On 5/25/2018 at 1:08 PM, EI #12, a LPN who works the first and second shift on the weekend, was asked how she had been trained on how to clean and disinfect the glucometer. EI #12 replied, to wash her hands and clean the front, back and sides of the glucometer with an alcohol pad. When asked what she used to disinfect the glucometer, EI #12 said an alcohol pad. During an interview on 5/25/2018 at 1:50 PM, EI #15, a first shift LPN was asked how she disinfected the glucometer between resident use. EI #15 stated, she cleaned and disinfected the glucometer with an alcohol wipe (prep pad). In an interview on 5/25/2018 at 2:13 PM, EI #13, a LPN who acknowledged she worked first and some third shifts in the facility, stated she cleaned and disinfected the glucometer with an alcohol prep pad. During an interview on 5/25/2018 at 5:24 PM, EI #2, the Director of Nursing (DON) was asked how the staff disinfected the glucometer between resident use. EI #2 replied, with an alcohol wipe. When asked what was the potential harm in not disinfecting a multi-use (shared) glucometer between resident use, EI #2 stated cross contamination. In an interview on 5/25/2018 at 8:34 PM, EI #3, the Infection Control Nurse explained the facility's policy instructed the staff to disinfect the glucometer by gently wiping the meter surface with a soft cloth slightly dampened with one of the cleaning solutions such as 70% rubbing alcohol, super sani-cloth, bleach wipes or 10% household bleach solution or an approved hospital disinfectant. When asked what the facility used to disinfect the glucometer, EI #3 stated 70% alcohol. During a telephone interview with a representative of the ACCU-CHEK Performa Blood Glucose meter's manufacturer on 5/29/2018 at 3:00 PM, the representative stated the ACCU-CHEK Performa BLOOD GLUCOSE METER Owner's Booklet provided by the facility to the survey team was an outdated manual for consumer, single-use that was distributed in Australia. The respresentative stated the healthcare professional manual distributed in the United States, with a copyright date of (YEAR), did specify how the meter should be cleaned and disinfected. An undated, untitled typed document provided by the facility staff indicated 23 residents, who resided on all three halls in the facility, had orders for finger stick blood sugar monitoring. ************************* On 5/29/2018 at 5:55 PM, the facility submitted an acceptable Allegation of Compliance (A[NAME]), which documented On 5/24/18 a review of all twenty-three residents who received glucose monitoring was conducted to ensure no resident had a [DIAGNOSES REDACTED]. No resident was found to have a [DIAGNOSES REDACTED]. The Director of Nursing did this review. On 5/25/18 at 10:45 PM the facility made changes to the cleaning of equipment policy to reflect FDA (Food and Drug Administration) guidelines for cleaning and disinfecting blood glucose meters to include using the germicidal wipes Super Sani-Cloth an EPA approved product (Environmental Protection Agency) that is a registered disinfectant approved to clean and disinfect glucometers. Policy changes were made by the Administrator, Executive Director of Senior Services, Vice President of Clinical Services, Director of Infection Control, Medical Director and Director of Nursing. On 5/25/18 training for all RN's and LPN's that provide glucose monitoring began on third shift. A checklist was created by the ADON and RN supervisor to be utilized to train all RNs and LPNs that reflect the new policy of the cleaning and disinfecting. The Director of Nursing checked off the Assistant Director of Nursing (ADON). The ADON and staff development coordinator checked off the RNs and LPNs. The ADON, staff development nurse and the 3 to 11 RN supervisor trained, all three shifts. Any deviations in the process will result in an immediate re-education. This training was completed on 5/27/2018 at 3:15PM with all staff who had worked leading up to this date. All RNs and LPNs not working at this time will be educated on the new policy before being allowed to work. Four of twenty-three nurses have not been trained. One LPN is on vacation in Canada. Two LPNs are scheduled to come in later this week. One LPN only works per diem and is not working until this weekend. On 5/25/18 at 10:45PM the medical director was educated on policy and practice changes regarding cleaning and disinfecting glucometer meters. On 5/25/18 at 10:45PM the QA (Quality Assurance) committee agreed to make changes to the facility's blood glucose monitoring policy and implement the changes. The QA committee members consisted of the Medical Director, Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, the Executive Director of Senior Services and the Administrator. ************************* After reviewing the facility's information provided in their A[NAME] and verifying the immediate actions had been implemented, the scope/severity level of F 880 was lowered to a E level on 5/29/2018, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on an observations, interviews, review of FUNDAMENTALS OF NURSING NINTH EDITION, the ACCU-CHEK Performa BLOOD GLUCOSE METER Owner's Booklet , ACCU-CHEK Performa Blood Glucose Monitoring System Operator's Manual for Multiple Patient Use, an article from the Centers for Disease Control and Prevention, Employee Identifier (EI) #6, the Staff Development Coordinator (SDC)'s job description and the 70% [MEDICATION NAME] alcohol prep pad, the facility failed to train their licensed nursing staff on acceptable procedures for cleaning and disinfecting the multi-use glucometer. The facility further failed to educate the licensed nursing staff on the difference between cleaning and disinfecting the multi-use glucometer according to the accepted standards of practice. EI #9, a Licensed Practical Nurse (LPN) failed to disinfect a multi-use glucometer after she had obtained a finger stick blood sugar for Resident Identifier (RI) #66 on 5/23/2018. While the facility's policy indicated how the multi-use glucometer should be cleaned and disinfected, interviews with the licensed nursing staff, to include the Director of Nursing, Assistant Director of Nursing (ADON)/Infection Control Nurse and Staff Development Coordinator revealed the staff had only been trained to clean and disinfect the multi-use glucometer with a 70% [MEDICATION NAME] alcohol prep pad. The current standards established by the Centers for Disease Control and Prevention, indicated the facility should utilize a disinfectant solvent that is effective against Human Immunodeficiency Virus ,[MEDICAL CONDITION]., [MEDICAL CONDITION] and [MEDICAL CONDITION]. The guidance further indicated 70% [MEDICATION NAME] solutions were not effective against [MEDICAL CONDITION] bloodborne pathogens . The ACCU-CHEK Performa Blood Glucose Monitoring System Operator's Manual for Multiple Patient Use provided to the survey team by the manufacturer, with a copyright date of (YEAR) documented . To disinfect the meter, use the following procedures. 3. Use a fresh Super Sani-Cloth (squeeze our any excess) to disinfect by gently wiping the front, back, and sides of the meter three times horizontally and three times vertically . This deficient practice affected RI #66 and placed the resident in immediate jeopardy for serious injury, harm and/or death, with the potential to affect the remaining 22 residents in the facility who received finger stick blood sugar monitoring. On 5/27/2018 at 6:59 PM, the Administrator, Director of Nursing, Assistant Director of Nursing (ADON)/Infection Control Nurse, Maintenance Director and Executive Director of Senior Services were notified of the findings of immediate jeopardy in the area of Competent Nursing Staff, F 726. Findings include: During medication pass observation on 5/23/2018 at 4:30 PM, EI #9, a LPN applied gloves and wiped (cleaned) the front and back of the glucometer with an alcohol prep pad. After the finger stick blood sugar was obtained for RI #66, EI #9 wiped (cleaned) the glucometer, an ACCU-CHEK Performa, with an alcohol prep pad and placed the glucometer in the medication cart. On 5/24/2018 at 4:53 PM, an interview was conducted with EI #9, the LPN observed performing a finger stick blood sugar on 5/23/2018. EI #9, who works the second shift on Hall 1 in the facility, acknowledged she had been trained on how to use, clean and disinfect the glucometer. When asked what type training she had received on cleaning and disinfecting the glucometer, EI #9 stated she was in-serviced when she first came to the facility 3/26/2018. When asked how she disinfected the glucometer, EI #9 explained she was taught to use two alcohol prep pads, one for the front of the glucometer and the other one for the back. EI #9 was asked, how long she had been disinfecting the glucometer with an alcohol prep pad. EI #9 replied, since she had been working at the facility. When asked who was responsible for the training of the staff on how to clean and disinfect the glucometer, EI #9 named three staff members, one of which was EI #6, the SDC. During a telephone interview on 5/24/2018 at 11:42 AM, EI #7, a LPN, was asked when she was last in-serviced on cleaning and disinfecting the multi-use glucometer. EI #7 replied, (MONTH) (YEAR). When asked how she was trained to disinfect the glucometer, EI #7 explained to place it on a clean napkin on the medication cart and use a 70% alcohol pad to clean the front and back of the entire machine and let it dry for one minute until the next resident. On 5/26/2018, the facility provided the survey team with the alcohol prep used for cleaning and disinfecting the multi-use glucometer between resident use. The front of the prep pad was labeled COVIDIEN REF6818 Webcol Alcohol Prep 2 Ply, Medium Made in USA Saturated with 70% [MEDICATION NAME] Alcohol For external use only. In an interview on 5/24/2018 at 4:08 PM, EI #8, a LPN who works on Hall 2 in the facility, was asked if she had been trained on how to clean and disinfect the multi-use glucometer. EI #8 said yes. When asked what type training she had received on how to disinfect the glucometer. EI #8 stated she had hands on training by three Registered Nurses (RNs) at the facility, to include EI #3, the ADON/Infection Control Nurse and EI #6, the Staff Development Coordinator (SDC). According to EI #8, they demonstrated by washing their hands with soap, then placing gloves on to clean the top, bottom and all the way around the glucometer with an alcohol prep pad. When asked how she was trained to disinfect the glucometer, EI #8 said with an alcohol prep and then let it air dry. When asked how long she had been cleaning and disinfecting the glucometer in this manner, EI #8 said since (MONTH) of last year (2017). On 5/24/2018 at 5:22 PM, EI #19, a second shift LPN employed with the facility for one and a half years, was asked what type training he had been provided on how to clean and disinfect the glucometer. EI #19 stated to wash your hands, then put on gloves and use alcohol wipes to clean the front, back and sides of the glucometer. EI #19 stated the percentage of alcohol was right for disinfecting. When asked what was the percentage of alcohol wipe (prep pad), EI #19 replied he believed it was 70%. On 5/25/2018 at 1:08 PM, EI #12, a LPN who works the first and second shift on the weekend, was asked if she had been trained on how to clean and disinfect a multi-use glucometer between resident use. EI #12 said yes. When asked how she had been trained on how to clean and disinfect the glucometer. EI #12 replied, to wash her hands and clean the front, back and sides of the glucometer with an alcohol pad. EI #12 explained she had been cleaning and disinfecting the glucometer in this manner for one year. When asked what she used to disinfect the glucometer, EI #12 said an alcohol pad. EI #12 was asked, who provided the training on how to clean and disinfect the glucometer. EI #12 replied, EI #6, the SDC and other licensed nursing staff. EI #12 was asked, as a licensed nurse was an alcohol prep pad effective at destroying blood borne pathogens such as Human Immunodeficiency Virus ,[MEDICAL CONDITION]., [MEDICAL CONDITION] and [MEDICAL CONDITION]. EI #12 said yes. When asked what the difference was between cleaning and disinfecting, EI #12 stated cleaning and disinfecting was the same thing. When asked what the harm was in not disinfecting the glucometer between resident use, EI #12 said the spread [MEDICAL CONDITION] other blood borne pathogens. Chapter 29 titled Infection Prevention and Control page 455 of FUNDAMENTALS OF NURSING NINTH EDITION with a copyright date of (YEAR), documented . Cleaning is the removal of organic material or inorganic material from objects and surfaces . Cleaning occurs before disinfection . Disinfection describes the process that eliminates many or all microorganisms, with the exception of bacterial spores, from inanimate objects . During an interview on 5/25/2018 at 1:50 PM, EI #15, a first shift LPN was asked if she had been trained on cleaning and disinfecting the glucometer. EI #15 said yes. When asked how she was trained to disinfect the glucometer between resident use. EI #15 stated, to clean the front and back of the glucometer with an alcohol wipe (prep pad) before use on another resident. EI #15 was asked, who provided the training on how to clean and disinfect the glucometer. EI #15 replied, oriented with a licensed nurse, shadowed other nurses and completed an in-service check-off with EI #3, the ADON/Infection Control Nurse. EI # 15 was asked, as a licensed nurse was a 70% alcohol prep pad effective at destroying blood borne pathogens such [MEDICAL CONDITION].[MEDICAL CONDITION] and [MEDICAL CONDITION]. EI #15 said yes. When asked what the difference was between cleaning and disinfecting, EI #15 said cleaning can be wiping something off without alcohol but disinfecting is using alcohol. EI #15 explained she disinfected the glucometer by wiping the glucometer off with an alcohol prep pad. When asked what the potential harm was in not disinfecting the glucometer between resident use, EI #15 replied that it could cause cross contamination. In an interview on 5/25/2018 at 2:13 PM, EI #13, a LPN who acknowledged she worked first and some third shifts in the facility, was asked if she had been trained on how to clean and disinfect the glucometer. EI #13 said yes. When asked how she was trained to clean and disinfect the glucometer, EI #13 said to use an alcohol prep to clean and disinfect the glucometer. EI #13 stated she had been cleaning and disinfecting the glucometer with an alcohol prep pad for four years. When asked, as a licensed nurse was 70% alcohol effective at destroying blood borne pathogens such [MEDICAL CONDITION].[MEDICAL CONDITION] and [MEDICAL CONDITION], EI #13 said yes. EI #13 was asked, what the difference was between cleaning and disinfecting. EI #13 replied, nothing. When asked what the potential harm was in not disinfecting a multi-use glucometer between resident use, EI #13 said the spread of infection and bacteria if the glucometer is not cleaned and disinfected properly. During an interview on 5/25/2018 at 5:00 PM, EI #6 was asked what her position was here at the facility. EI #6 stated she was the SDC, the supervisor for Side (Hall) 3 and she did new employee education. When asked how she had instructed the licensed staff to clean and disinfect the glucometer, EI #6 stated with a 70% alcohol pad. When asked how long she had been instructing the staff to clean and disinfect the glucometer with a 70% alcohol pad, EI #6 said for the last three and a half years. When asked if 70% [MEDICATION NAME] Alcohol was effective at destroying blood borne pathogens such [MEDICAL CONDITION].[MEDICAL CONDITION] and [MEDICAL CONDITION], EI #6 said yes. When asked what the difference was between cleaning and disinfecting, EI #6 stated cleaning and disinfecting is the same thing. Page 55 of the ACCU-CHEK Performa BLOOD GLUCOSE METER Owner's Booklet provided by the facility to the survey team, with a copyright date of 2006, referenced how to clean the meter (glucometer). The booklet did not specify how to disinfect the glucometer. During a telephone interview with a representative of the ACCU-CHEK Performa Blood Glucose meter's manufacturer on 5/29/2018 at 3:00 PM, the representative stated the ACCU-CHEK Performa BLOOD GLUCOSE METER Owner's Booklet provided by the facility to the survey team was an outdated manual for consumer, single-use that was distributed in Australia. The representative stated the healthcare professional manual distributed in the United States, with a copyright date of (YEAR), did specify how the meter should be cleaned and disinfected. The ACCU-CHEK Performa Blood Glucose Monitoring System Operator's Manual for Multiple Patient Use provided to the survey team by the manufacturer, with a copyright date of (YEAR), documented . Chapter 6: Cleaning and Disinfecting the Meter WARNING *It is important to keep the meter clean and disinfected to help minimize the risk of disease transmission . NOTE . use only Super Sani-Cloths . If dedicating blood glucose meters to a single patient is not possible, the meters must be properly cleaned and disinfected after every use following the guidelines on the following pages . Acceptable Cleaning and Disinfecting Solution Only use Super Sani-Cloth to clean and disinfect the meter . How to Clean the Meter . 3. Use a Super Sani-Cloth (squeeze out any excess) to gently wipe the front, back, and sides of the meter . How to Disinfect the Meter . 3. Use a fresh Super Sani-Cloth (squeeze out any excess) to disinfect by gently wiping the front, back, and sides of the meter three times horizontally and three times vertically . The facility provided a document from the Centers for Disease Control and Prevention (CDC) titled Infection Prevention during Blood Glucose Monitoring and Insulin Administration last updated 6/8/2017, which documented . Blood Glucose Meters are devices that measure blood glucose levels. Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared. A simple rule for safe care: If shared, blood glucose meters should be cleaned and disinfected after every use . EI #6's job description titled Staff Development Coordinator - Education Coordinator NURSING HOME last updated 6/2/2015, documented . Performance Criteria . 1.6 Ensures staff compliance with policies and procedures that are in compliance with state and federal guidelines. 1.7 Plans, evaluates, revises and leads appropriate division-wide ongoing training . Ensures staff is educated on new policies and procedures that arise . Performance Criteria . 4.4 Reviews and revises program content as needed and at least monthly . Performance Criteria . 7.4 Stays current with technical skills; keeping up with current developments and trends in area of expertise . Performance Criteria . 8.1 Identifies and demonstrates adherence to all applicable regulating agencies such as ADPH (Alabama Department of Public Health . In follow-up interview on 5/26/2018 at 5:38 PM, EI #6, the SDC was asked who was responsible for the training of the licensed nursing staff on home to clean and disinfect the multi-use glucometers used in the facility. EI #6 stated she was the primary trainer/educator. When asked when she became aware of the interpretative guidance regarding blood glucose meters listed in Appendix PP of the State Operations Manual, EI #6 stated on yesterday, 5/25/2018. EI #6 was asked why the facility's training/education program for the licensed nursing staff on how to clean and disinfect the multi-use glucometers should reflect current accepted standards of practice. EI #6 replied, it was important to be aware of what was to be used to prevent cross contamination. When asked if the facility's training/education program was in compliance with current standards on how to clean and disinfect the multi-use glucometers, EI #6 said no. When asked if the licensed nursing staff was trained on how to clean and disinfect the multi-use glucometers per guidance from the CDC and Food and Drug Administration (FDA), EI #6 said no. In an interview on 5/24/2018 at approximately 10:00 AM, EI #3, the ADON/Infection Control Nurse was asked how the facility licensed nurses disinfected the multi-use glucometer between resident use. EI #3 said with a 70% ([MEDICATION NAME]) alcohol prep pad. When asked what the current CDC guidelines were for disinfecting a multi-use glucometer, EI #3 stated she would have to look it up. In a follow-up interview on 5/25/2018 at approximately 4:00 PM, EI #3, the ADON/Infection Control Nurse was asked how she was trained to clean and disinfect the multi-use glucometer. EI #3 stated after hand hygiene was performed to use an alcohol wipe and clean the surface and it allow it to dry. After performing the finger stick blood sugar, use an alcohol wipe and clean the surface again. EI #3 acknowledged she was trained to clean and disinfect the multi-use glucometer in the same manner, with an alcohol prep pad. When asked how long she had been cleaning and disinfecting the multi-use glucometer with an alcohol prep pad, EI #3 said she had been in the facility for four year and that is how long she had been doing it. When asked the difference between cleaning and disinfecting, EI #3 replied, disinfecting is removing germs and antimicrobials and cleaning was removing what you could see. EI #3 was asked if she felt wiping the multi-use glucometer with a 70% [MEDICATION NAME] alcohol prep pad was disinfecting the glucometer. EI #3 replied, yes. During an interview on 5/25/2018 at 5:24 PM, EI #2, the Director of Nursing (DON) was asked what training had been provided the licensed nursing staff on how to clean and disinfect the glucometer. EI #2 stated the staff are trained on hire, annually and retraining was available whenever necessary. When asked how the staff was trained to clean and disinfect the glucometer, EI #2 said before and after use, to use an alcohol wipe and wipe the surface area, then use two or three more alcohol wipes, or as much as needed, and let it air dry after placing it on a clean area. EI #2 was asked who provided the training to the licensed staff and she stated herself, EI #6, the Assistant Director of Nursing/Infection Control Nurse and other Registered Nurse (RN) Supervisors. EI #2 was asked, as a licensed nurse, was 70% [MEDICATION NAME] alcohol effective against blood borne pathogens such [MEDICAL CONDITION].[MEDICAL CONDITION] and [MEDICAL CONDITION]. EI #2 said yes based on the research out there and the manufacturer's recommendations. When asked what the difference was between cleaning and disinfecting, EI #2 said the terms are interchangeable depending on the agent used. ************************* On 5/29/2018 at 5:55 PM, the facility submitted an acceptable Allegation of Compliance (A[NAME]), which documented On 5/25/18 at 10:45 PM the facility made changes to the cleaning of equipment policy to reflect FDA (Food and Drug Administration) guidelines for cleaning and disinfecting blood glucose meters to include using the germicidal wipes Super Sani-Cloth an EPA approved product (Environmental Protection Agency) that is a registered disinfectant approved to clean and disinfect glucometers. Policy changes were made by the Administrator, Executive Director of Senior Services, Vice President of Clinical Services, Director of Infection Control, Medical Director and Director of Nursing. On 5/25/18 training for all RN's and LPN's that provide glucose monitoring began on third shift. A checklist was created by the ADON and RN supervisor to be utilized to train all RNs and LPNs that reflect the new policy of the cleaning and disinfecting. The Director of Nursing checked off the Assistant Director of Nursing (ADON). The ADON checked off the DON. The ADON checked off the staff development nurse. The ADON and staff development coordinator checked off the RNs and LPNs. The ADON, staff development nurse and the 3 to 11 RN supervisor trained, all three shifts. Staff is now trained in cleaning and disinfecting the glucometer using the Super Sani-Cloth. Any deviations in the process will result in an immediate re-education. This process was completed on 5/27/18 at 3:15PM. All RNs and LPNs not working at this time will be educated on the new policy before being allowed to work. Four of twenty-three nurses have not been trained. One LPN is on vacation in Canada. Two LPN's are scheduled to come in later this week. One LPN only works per diem and is not working until this weekend. ************************* After reviewing the facility's information provided in their A[NAME] and verifying the immediate actions had been implemented, the scope/severity level of F 726 was lowered to a E level on 5/29/2018, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on interviews, review of Resident Identifier (RI) #80's medical record, the facility's policy titled Lifts, the Safety Instructions for the SARA 3000, the facility's standup lift, and the facility's investigation file, the facility failed to ensure Employee Identifier (EI) #10, a Certified Nursing Assistant (CNA) did not use the standup lift to transfer RI #80 from the shower chair to the bed on 3/21/2018. RI #80, assessed as requiring one person assist for transfers, had not been assessed or care planned to use the standup lift. During the transfer, the resident unhooked the straps without staff knowledge and fell while being assisted to the bed. The resident hit his/her head on the dresser and floor and sustained a knot above the right eye, a bruise on the right arm and a skin tear to the right arm. The facility further failed to ensure EI #21, a CNA utilized the standup lift when she transferred RI #28 on 4/21/2018. During the transfer, the resident's leg hit against the bed and caused a bruise. These deficient practices affected RI #28 and RI #80, two of three sampled residents reviewed for accidents. Findings include: The facility's policy titled Lifts issued (MONTH) (YEAR), documented . PURPOSE: This policy is intended to demonstrate and advance the goal of Oak Park of providing appropriate, high-quality care for each of its residents. POLICY: All resident care will be provided in a safe, appropriate and timely manner in accordance with the individual's Care Plan. All residents will be assessed by the facility Care Plan team with regard to the need for assistance with transfer activities, mobility or repositioning in accordance with MDS procedures and requirements . The Safety Instructions for the SARA 3000 (facility's standup lift) documented Intended use SARA 3000 is a mobile raising aid, . intended to be used on a horizontal surface for raising to a standing position and short transfer of residents (e.g. raising from bed and transit to wheelchair, or from wheelchair to toilet) in hospitals, nursing homes or other health care facilities where the resident has been clinically assessed . Warning: Before attempting to use SARA 3000, a full clinical assessment of the resident his/her condition, and suitability must be carried out by a qualified person . 1) RI #80 was admitted to the facility on [DATE] with an admit [DIAGNOSES REDACTED]. RI #80's Annual Minimum Data Set with an assessment reference date of 1/31/2018, indicated the resident required extensive assistance of one person for transfers. According to the Oak Park Nursing Home Incident Report on 3/21/2018 at 8:10 PM, during a transfer from the shower chair to the bed by Employee Identifier (EI) #10, a Certified Nursing Assistant (CNA), used the standup lift. RI #80 fell from the lift and sustained a knot above the right eye, a bruise on the right arm and a skin tear to the right arm. The knot above the right eye measured 6.6 x 5.2 centimeters (cm); the bruise on the right arm measured 19.3 x 6.2 cm; and the skin tear on the right arm measured 3.2 x 2.9 cm. The report revealed neurological checks, an x-ray and a Computed Tomography (CT) of the head was performed. Contained within the facility's investigation was a statement from RI #80 taken by the Licensed Practical Nurse (LPN), EI #28, who responded to RI #80's fall which stated the resident stated he/she fell , didn't mean to fall, he/she hit his/her head and that he/she was sorry. The OAK PARK NURSING HOME STATEMENT FORM from EI #10, the CNA who transferred RI #80 on 3/22/2018, read . I was transferring (RI #80) over to the bed with the standup lift, when I went to move the lift I realize (RI #80) unhooked it without me knowing . (RI #80) hit (his/her) head on the dresser and then on the floor . Contained within the facility's investigation was typed statement signed by EI #10, the CNA and EI #3, the Assistant Director of Nursing (ADON), which read On 03/22/2018 at approximately 2:45pm this nurse, in the company of EI #29, met with (EI #10) CNA to discuss the incident on 03/21/2018 with (RI #80). The CNA was asked to describe the incident and what occurred. She stated that she was using the stand-lift to transfer the resident from the shower chair to the bed and the resident undid the straps. The CNA states the resident appeared seated on the bed, so the CNA began to remove the lift not realizing the resident had un-hooked the strap and resident began to fall to the right sliding off the bed and into the floor. The CNA was asked why she used the stand-lift for the transfer . CNA was instructed not to go by what someone told her to but by the resident profile on the back of the door and the care plan in the chart . Again, it was stressed with CNA that she follow the plan of care. CNA was asked, besides the resident removing the safety strap (himself/herself), what did she think contributed to the resident falling and CNA explained that next time she would sit resident further back onto the bed which would have possibly kept (him/her) from the floor when (RI #80) leaned. She also stated that the nurse last night had already talked to her about looking at the profile and following the plan of care. The Post Fall Huddle Assessment Documentation dated 3/22/2018, indicated the root cause of the fall as The resident unbuckled the straps during the transfer in trying to assist CNA But the CNA also did not follow the CP (care plan). The undated OAK PARK RESIDENT PROFILE for RI #80 indicated at the time of the fall on 3/21/2018, the resident required a one-person pivot assist for transfers. During a telephone interview on 6/29/2018 at 12:14 PM, EI #10, the CNA was asked what happened when RI #80 fell on [DATE]. EI #10 stated she was getting ready to take RI #80 to the shower. EI #10 explained that she transferred the resident with the standup lift. EI #10 stated she sat the resident down on the bed. The resident unhooked the straps on the lift, leaned over to the side and fell to the floor. After the resident fell , EI #10 stated she went and got the nurse. When asked how the resident was supposed to be transferred, EI #10 said with one person; the resident can pivot. EI #10 acknowledged at the time of the fall, RI #80 was not assessed or care planned to use the standup lift. In a telephone interview on 6/29/2018 at 4:06 PM, EI #28, the LPN who responded to RI #80's fall on 3/21/2018, stated the CNA came and told him that RI #80 fell . EI #28 stated he ran to the resident's room to assess the situation. EI #28 stated as he was assessing RI #80, the resident told him twice that he/she was fine, that he/she loved him and he/she didn't mean for this to happen. EI #28 stated the resident did not complain of pain. EI #28 stated he notified the physician and implemented neurological checks as the protocol outlined. EI #28 stated the resident's vital signs and neurological checks were stable. EI #28 stated he treated the resident's skin tear, measured the hematoma and continued to monitor the resident throughout the shift. When asked what he knew about the fall, EI #28 stated the resident always tried to be helpful and it was his understanding the resident pulled (unhooked) the straps and the CNA was unaware. As the CNA was adjusting the lift, the resident fell . RI #80's LICENSED NURSES PROGRESS NOTES documented . 3/21/18 2020 (8:30 PM) Resident was being transferred to (his/her) bed from the shower chair when (he/she) fell on the floor and also hit (him/her) head on the dresser. a knot formed above the right eye 6.6 x 5.2 cm within an hour of the incident, a bruise was noted on the right arm 19.3 x 6.2 and a skin tear 3.2 x 2.9 cm. Resident's (spouse) was notified at 2025 (8:25 PM) . 3-22-18 0300 (3:00 AM) Resident awake in bed and verbally responsive and able to make needs know. No complaint of pain at this time . 3-22-19 10:40am . This nurse assessed resident. Bruise & swelling noted to resident forehead. Resident states I didn't even know it was bruised! It doesn't hurt! Bruising noted to right hand & forearm area. No swelling. Resident states that (he/she) felt find & I had no pain . xrays of hand, arm & head . A review of RI #80's NEUROLOGICAL ASSESSMENT FLOWSHEET indicated neurological checks were performed every 15 minutes times four, every hour times four, every two hours times four then every shift for 72 hours, beginning at 8:15 PM on 3/21/2018 and ending on 3/2/2018, with no abnormal findings. On 3/22/2018, an x-ray of RI #80's right forearm and right hand was performed. The x-ray revealed no acute abnormality of the right forearm and no obvious, acute grossly displaced [MEDICAL CONDITION] hand. RI #80's Computed Tomography (CT) indicated on 3/2/ , a CT Brain without contrast was done as the result of a fall. The Impression was listed as . No acute abnormality seen. 2) RI #28 was admitted to the facility on [DATE]. RI #28's Quarterly Minimum Data Set with an assessment reference date of 2/28/2018 indicated the resident was cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 14. RI #28 was assessed as extensive assistance of one person for transfers. RI #28's care plan titled Resident is at risk for injuries . with a problem onset date of 1/11/2017 and last reviewed (MONTH) (YEAR), had an approach of . staff to use sit to stand lift . The undated OAK PARK RESIDENT PROFILE for RI #28 indicated the resident required one-person assist for transfers and utilized the sit/stand lift. Contained within the facility's investigation was a typed statement written by the facility's Administrator, EI #1, dated 4/24/2018, which read . On 4/22/2018 (RI #28) a resident of Oak Park nursing home, told (his/her) nurse (EI #13) LPN, (his/her) CNA on 4/21/2018 did not use lift resulting in hurting (RI #28's) leg. (EI #13) found a bruise on (RI #28's) leg and an investigation was started. (RI #28) BIMS score is 14 and says the bruise occurred when (his/her) leg hit the bed during a transfer without the lift on 4/21/2018. The CNA who did the transfer was (EI #21). (EI #21) admits to not using the lift on 4/21/2018 and says she knew she was supposed to. (EI #21) says she did not mean to hurt (RI #28) but remembers (RI #28) saying my leg hurts. (RI #28) does not feel (EI #21) meant to hurt (him/her) during the transfer . (EI #21) was suspended during the investigation and inserviced on what the appropriate actions should be. The Licensed Nurse Weekly Skin Assessment for RI #28 dated 4/22/2018, indicated the resident had a bruise and swelling to the left lower leg. A review of EI #21's personnel file indicated the CNA began her employment with the facility on 3/26/2018 and had met the performance objective of . Resident Safety . 2. Use of Assistive Devices: a. C.N.A. will use assistive devices as per assignment; i.e. lifts . EI #21's personnel file further indicated EI #21's employment was terminated on 4/24/2018 for . On 4/21/2018 (EI #21) did not follow the plan of care and did not use the lift on one of her residents. This resulted in the resident receiving a bruise. (EI #21) acknowledged she was trained on the lift and should have used it but did not . Due to the resident being injured because the lift was not used the employee is being terminated during her probationary period . During an interview with RI #28 on 6/28/2018 at 5:25 PM, the resident was asked about the incident when the staff did not use the sit to stand lift. According to RI #28, the CNA (EI #21) came into the room, to transfer the resident from the bed to the wheelchair. RI #28 stated told the CNA that the lift should be used but the CNA didn't use it. RI #28 stated when the CNA raised her slightly from the wheelchair, the resident pivoted a little to sit on the bed. With the resident's left leg/thigh area against the side rail, the resident said his/her leg began hurting. The CNA (EI #21) then lifted the resident's legs and placed them on the bed.

Based on observations and review of the (YEAR) Food Code, the facility failed to ensure four expired eight ounce (oz) nutritional supplements were discarded after the use by date and a dietary staff member's hair was not hanging loosely from under the hairnet and strands of hair were not exposed outside of the hairnet. This deficient practice had the potential to affect all 85 residents who received food from the kitchen. receiving meals from dietary services. Findings include: 1) A review of a document titled, Food Code U.S. Public Health Service FDA (YEAR) page 96 revealed the following: .on-premises preparation . ,[DATE].17 . commercial processed food . (B) Except as specified . (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety . On [DATE] at 5:56 PM, an observation was made of an 8 oz Glucerna creamy strawberry supplement with a manufacturer use by date of (MONTH) 1, (YEAR), in the walk in cooler. A second observation was made of the 8 oz Glucerna creamy strawberry on [DATE] at 11:35 a.m. inside of the walk in cooler. At 2:42 p.m., on the same date, both the surveyor and the Dietary Supervisor, EI (Employee Identifier) #11 made an observation of the 8 oz Glucerna with the use by date of (MONTH) 1, (YEAR). On [DATE] at 5:59 PM, an observation was made of three 8 oz Glucerna creamy supplements with a manufacturer use by date of (MONTH) 1, (YEAR) in the dry storage area. On [DATE] at 11:32 AM, a second observation was made of the three 8 oz Glucerna creamy strawberry supplements. On the same date at 2:45 PM, an observation was made by both the surveyor and EI #11. On [DATE] at 1:03 PM, an interview was conducted with EI #11, Dietary Supervisor. EI #11 was asked, why should food items be discarded after the use by date. EI #11 said, because it would be out dated and no longer good to maintain as it related to food safety. EI #11 was asked, what process did dietary have in place to ensure expired food items were discarded on or by the use by date. EI #11 explained they monitored when it was to be discarded. EI # 11 was asked, what was the potential harm of not discarding food items by the use by date. EI #11 said, it could cause an illness. 2) A review of a document titled, Food Code U.S. Public Health Service FDA (YEAR) page 53 revealed the following: HYGIENIC PRACTICES . ,[DATE] Hair Restraints . ,[DATE].11 Effectiveness. (A) . FOOD EMPLOYEES shall wear hair restraints ., that are designed and worn to effectively keep their hair from contacting exposed FOOD . On [DATE] at 11:35 AM, during the lunch tray-line, an observation was made of a dietary staff member, EI #27, who placed plates inside of the insulated base and placed lids over the plated food, with strands of hair hanging from under her hairnet from the back of her head. On [DATE] at 5:36 PM, an interview was conducted with the Dietary Supervisor, EI #11 . EI #11 was asked, how were staff to wear hairnets. EI #11 explained, they were to cover their hair completely with the hairnet. EI #11 was asked, when should hair hang from under the hairnet. EI #11 said, never. EI #11 was asked, why should hair be covered entirely with the hairnet. EI #11 explained, because it could get in the food or on the plates and the hairnet prevented contamination. EI #11 was asked, what was the potential harm of having hair hanging from under the hairnet and hair strands sticking out of the hairnet. EI #11, explained it (hair) could fall into the food.

Based on interview, review of Resident Identifier (RI) #80's medical record and the facility's policy titled Comprehensive Care Plan for Long Term Care, the facility failed to revise RI #80's Activities of Daily Living care plan. The Annual Minimum Data Set (MDS) assessment dated [DATE] and the resident's OAK PARK RESIDENT PROFILE, located on the back of the resident's door that informed the staff how to care for the resident, all indicated the resident required one person assistance for transfers;however, the care plan reviewed on 2/6/2018, indicated the resident required two person assist for transfers. This deficient practice affected RI #80, one of 30 sampled residents Findings include: The facility's policy titled Comprehensive Care Plan for Long Term Care with a revised date of (MONTH) (YEAR), documented PURPOSE: The facility shall develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. POLICY: The comprehensive care plan shall be: . 3. Reviewed and revised by the interdisciplinary team after each assessment, including both the annual comprehensive and quarterly review assessments . RI #80 was admitted to the facility on [DATE] with an admit [DIAGNOSES REDACTED]. RI #80's Annual Minimum Data Set (MDS) with an assessment reference date of 1/31/2018, indicated the resident required extensive assistance of one person for transfers. RI #80's care plan titled Activities of Daily Living . with a problem onset date of 7/10/2013 and last reviewed 2/6/2018 had an approach of . Resident requires 2 person assist for transfers . The undated OAK PARK RESIDENT PROFILE, located on the back of the resident's door that informs the staff how to care for the resident, for RI #80 indicated the resident required a one-person pivot assist for transfers. During an interview on 6/30/2018 at 10:30 AM, EI #14, the MDS Coordinator acknowledged RI #80's care plan titled Activities of Daily Living . was not correct. EI #14 stated the care plan should read one person assist for transfers. EI #14 explained the care plan did not get updated after the assessment. When asked who was responsible for updating the care plan, EI #14 stated she was.

Based on interview, review of Resident Identifier (RI) #28's medical record and the facility's investigation file, the facility failed to ensure Employee Identifier (EI) #21, a Certified Nursing Assistant followed RI #28's care plan during the transfer of the resident from the wheelchair to the bed on 4/21/2018. EI #21 did not use the sit to stand (sit/stand or stand up) lift, as care planned. During the transfer, the resident's leg hit against the bed and caused a bruise. This affected RI #28, one of three sampled residents reviewed for accidents. Findings include: The facility's policy titled Comprehensive Care Plan for Long Term Care with a revised date of (MONTH) (YEAR), documented PURPOSE: The facility shall develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment . RI #28 was admitted to the facility on [DATE]. RI #28's Quarterly Minimum Data Set with an assessment reference date of 2/28/2018 indicated the resident was cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 14. RI #28 was assessed as extensive assistance of one person for transfers. RI #28's care plan titled Resident is at risk for injuries . with a problem onset date of 1/11/2017 and last reviewed (MONTH) (YEAR), had an approach of . staff to use sit to stand lift . The undated OAK PARK RESIDENT PROFILE for RI #28 indicated the resident required one-person assist for transfers and utilized the sit/stand lift. Contained within the facility's investigation was a typed statement written by the facility's Administrator, EI #1, dated 4/24/2018, which read . On 4/22/2018 (RI #28) a resident of Oak Park nursing home, told (his/her) nurse (EI #13) LPN, (his/her) CNA on 4/21/2018 did not use lift resulting in hurting (RI #28's) leg. (EI #13) found a bruise on (RI #28's) leg and an investigation was started. (RI #28) BIMS score is 14 and says the bruise occurred when (his/her) leg hit the bed during a transfer without the lift on 4/21/2018. The CNA who did the transfer was (EI #21). (EI #21) admits to not using the lift on 4/21/2018 and says she knew she was supposed to. (EI #21) says she did not mean to hurt (RI #28) but remembers (RI #28) saying my leg hurts. (RI #28) does not feel (EI #21) meant to hurt (him/her) during the transfer . (EI #21) was suspended during the investigation and inserviced on what the appropriate actions should be. The Licensed Nurse Weekly Skin Assessment for RI #28 dated 4/22/2018, indicated the resident had a bruise and swelling to the left lower leg. A review of EI #21's personnel file indicated the CNA began her employment with the facility on 3/26/2018 and had met the performance objective of . Resident Safety . 2. Use of Assistive Devices: a. C.N.A. will use assistive devices as per assignment; i.e. lifts . EI #21's personnel file further indicated EI #21's employment was terminated on 4/24/2018 for . On 4/21/2018 (EI #21) did not follow the plan of care and did not use the lift on one of her residents. This resulted in the resident receiving a bruise. (EI #21) acknowledged she was trained on the lift and should have used it but did not . Due to the resident being injured because the lift was not used the employee is being terminated during her probationary period . During an interview with RI #28 on 6/28/2018 at 5:25 PM, the resident was asked about the incident when the staff did not use the sit to stand lift. According to RI #28, the CNA (EI #21) came into the room, to transfer the resident from the bed to the wheelchair. RI #28 stated told the CNA that the lift should be used but the CNA didn't use it.

Based on observation of the dumpster area on 04/04/17, a review of the facility's policy titled, Dumpster Area, and staff interview, the facility failed to ensure the dumpster area was free of a ceramic commode and two metal poles, and cardboard boxes and used gloves were on the ground beside the dumpster. These deficient practices had the potential to affect all residents in the facility. Findings Include: The facility's policy titled, Dumpster Area, issue date of 10/2009, documented: The facility Dietary and House Keeping department will pick up trash around the dumpster area as they take trash out daily. The House Keeping Supervisor or designee will check the dumpster area daily for trash around the dumpster. Maintenance will check area once a week for large items that have been left outside the dumpster and remove or dispose of items as needed. On 04/04/17 at 6:15 p.m., the following observation was made of the dumpster area: There were three cardboard boxes on the ground, a ceramic commode, two metal poles and a pink glove on the ground beside the dumpster. On 04/06/17 at 4:30 p.m., Employee Identifier (EI) #2 was asked who was responsible to keep the dumpster area clean. EI #2 replied usually the Housekeeping Supervisor. EI #2 was asked who monitored the dumpster area and how often. EI #2 replied dietary and housekeeping. EI #2 was asked why were there cardboard boxes, a commode and metal poles in the dumpster area. EI #2 replied she did not know, but it should not be there.

Based on observations a review of the facility's policy's titled, Sanitary and Safe Equipment Policy, and staff interview, the facility failed to ensure: 1) the double ovens were free of a build up of a black colored residue inside the ovens; 2) the ice machine was free of a build up of a brown colored substance on the lid and a splattered substance on the base; 3) the on/off knobs and the switch on the steam table was free of a build up of dark colored debris; and 4) the grease vat outside was free of a large accumulation of grease sediment inside. Findings Include: The facility's policy titled Sanitary and Safe Equipment Policy issued 07/2009 documented: . POLICY . Large and small food handling equipment is maintained in good working order . and kept clean and sanitary. PURPOSE . Equipment is kept in good condition to be safe to use; and clean, sanitary equipment reduces the opportunity for incidental cross contamination of food. PROCEDURE 1. Sanitary equipment design Equipment is located to reduce cross contamination by preventing splashing or spillage from one piece to another . On 04/04/17 at 5:53 p.m., during the initial tour in the kitchen the following observations were made: 1) the double ovens had a build up of black colored residue inside the ovens on the bottom shelves; 2) the ice machine had a build up of a brown colored substance on the lid and a splattered substance on the base; 3) the on/off knobs and switch on the steam table had of a build up of dark colored debris; and 4) the grease vat outside had a large accumulation of grease sediment inside. On 04/06/17 at 4:30 p.m. Employee Identifier (EI) #2, Dietary Manager, was asked who was responsible to clean the double ovens and how often. EI #2 replied dietary staff and it should be done weekly. EI #2 further commented that it was not on the schedule to be cleaned weekly. EI #2 was asked who was responsible to clean the outside of the ice machine and how often. EI #2 replied it should be wiped down everyday. EI #2 was asked why the knobs and on/off switch were coated with a substance. EI #2 replied the steam table was thirty years old and needed to be replaced. EI #2 was asked how often the grease vat was dumped. EI #2 replied every three months. EI #2 was asked who monitored the grease vat for more frequent cleaning. EI #2 replied the cook who dumped the grease.

Based on observations of wound care, record reviews and interviews, the facility failed to ensure a Licensed staff member, Employee Identifier (EI) #9, cleaned Resident Identifier (RI) #9's right heel wound after touching the wound with a contaminated measuring device and before applying a clean dressing. This deficient practice affected RI #9, one of two sampled resident who were observed during wound care. Findings Include: RI #9 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #9's Significant Change Minimum Data (MDS) assessment dated [DATE] revealed RI #9 had short and long term memory loss and was severely impaired in cognitively skills for daily decision making. The MDS documented RI #9 had a pressure ulcer. On 04/05/17 at 3:15 p.m., the following was observed during wound care: EI #9, Licensed Practical Nurse/Treatment Nurse, obtained a plastic measuring device from the cart. The measuring device was not contained in any packaging. EI #9 cleaned RI #9's wound to the right heel. EI #9 obtained a measuring device to measure the depth of the wound. EI #9 touched the wound by going in and out of the wound bed several times without changing the position of the measuring device. EI #9 did not clean the wound before she applied a clean dressing. On 04/05/17 at 4:15 p.m., during an interview with EI #9, the surveyor asked after measuring the wound when did she re-clean the wound with normal saline. EI #9 stated she did not think she had, but she should have re-cleaned the wound after she measured the wound. The surveyor asked why. EI #9 stated because the measuring device was not in a sealed container and she had touched the wound bed, contaminating the wound. EI #9 further stated she should have cleaned the wound before she put the dressing on.

Based on observations, record reviews, a review of the facility's information titled, Self Administration of Medication Protocol, and staff interviews, the facility failed to ensure Resident Identifier (RI) #5 and RI #20 were assessed to see if they could safely administer medications to their selves. This deficient practice affected RI #5, one of one resident observed administering an inhaler to his/herself on 04/04/17 and RI #20, one of eight residents observed during medication administration on 04/06/17. Findings Include: A review of the facility's protocol titled, Self-Administration of Medication Protocol without a date documented: Purpose: To determine resident's capacity for self-administration of the medications by physician's evaluation . Protocol: Residents may be permitted to self-administer medication only after evaluated and ordered by the attending physician. Procedure: . 2. the physician's medical evaluation shall determine the capability of understanding prior to offering the option to self-administer medications . 1) RI #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #5's Admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status score of 7 out of 15, which indicated RI #5 was severely impaired in cognition. On 04/04/17 during a review of RI #5's care plan titled, Risk for Shortness of Breath, with a Problem Onset date of 12/13/2016, there was no approach in regards to RI #5 being care planned for self administration of medication. On 04/04/17 at 6:55 PM, RI #5 was observed self administering his/her [MEDICATION NAME] inhaler medication. On 04/06/17 at 10:18 a.m., Employee Identifier (EI) #1/Director of Nurses, was asked was there a self administration evaluation completed for RI #5 to self administer his/her inhaler medication. EI #1 replied she did not see a written one in RI #5's chart. 2) RI #20 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #20's Significant change MDS dated [DATE], revealed a Brief Interview for Mental Status score of 13, which indicated the resident was cognitively intact. On 04/06/2017 at 8:52 a.m., an observation was made during Medication Administration. EI #3 LPN (Licensed Practical Nurse) entered RI #20's room and emptied the [MEDICATION NAME] vial into the nebulizer spacer and handed it to the resident, and exited the room. On 04/06/2017 at 11:34 a.m., an interview was conducted with EI #3. EI #3 was asked did RI #20 have a physician's order to self administer him/her medication. EI #3 said no. EI #3 was asked what did she do after putting the vial of [MEDICATION NAME] into the nebulizer. EI #3 said she turned it on and walked out. EI #3 was asked should she have left the room with the resident receiving the [MEDICATION NAME]. EI #3 said no she should have stayed in the room until the medication was completed. EI #3 was asked why should she have stayed in the room. EI #3 said to ensure that the resident received the entire medication. On 04/06/2017 at 5:25 p.m., an interview was conducted with EI #8, Registered Nurse (RN) Infection Control. EI #8 was asked should a resident be left alone to administer a [MEDICATION NAME] treatment that had no physician's order to self administer. EI #8 said no. EI #8 was asked why should the resident not be left alone. EI #8 said because she would not know how much medication the resident actually received.

Based on interview, observation of medication administration, medical record reviews, a review of the facility's policy titled, Medication Discrepancies and Adverse Reactions, and Potter and Perry Fundamentals of Nursing, the facility failed to ensure a physician's orders [REDACTED].#19's Refresh eye drops were to be placed in one eye or both eyes. This deficient practice affected RI #19, one of 24 residents whose physician's orders [REDACTED]. Findings Include: A review of the facility's policy and procedure titled, Medication Discrepancies and Adverse Reactions with a revised date of 01/09, revealed the following: . Purpose: To establish uniform guidelines concerning the handling of medication discrepancies . Standard: Medication discrepancies . are documented and reported to the resident's attending physician . A review of Potter and Perry Fundamentals of Nursing 9th Edition, page 632, revealed the following: . Components of Medication Orders . Dosage . Route of administration . RI #19 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of a RI #19's April 2017 physician's orders [REDACTED]. Refresh [MEDICATION NAME] Advanced . use 1 (one) drop twice a day ([MEDICAL CONDITION] Med (Medication)) . On 04/06/2017 at 8:15 a.m., the following was observed during medication administration: Employee Identifier (EI) #4, Licensed Practical Nurse, administered Refresh eye drops to both RI #19's eyes. On 04/06/17 at 9:25 a.m., during an interview with EI #5, RN/Unit Manager, after EI #5 reviewed the Refresh [MEDICATION NAME] eye drop physician's orders [REDACTED]. EI #5 stated the order did not document which eye. EI #5 also stated the nurse, EI #6, RN, was responsible to clarify the order, because EI #6 wrote the order. EI #5 also stated that policy is to clarify the order to document which eye for the drops, but policy had not been followed for the Refresh eye drops. On 04/06/17 at 5:20 p.m., during an interview with EI #6, RN, the surveyor asked who was responsible for clarification of the physician's order.#6 also stated policy stated when reviewing, obtaining, and signing orders, ensure directions are clear on how medications are to be given, but policy was not followed for the Refresh eye drops.

Based on observations of wheelchair (w/c) arms rests, record reviews, interviews, and a review of the facility's policy titled, Accidents/Incidents, the facility failed to ensure w/c arm rests for Resident Identifier's (RI) #8 and RI #14, residents identified as being on a blood thinner medication, were not torn, cracked, and rough to the touch. This deficient practice affected RI #8 and RI #14, two of 17 sampled residents with w/c or geri chairs. Finding Include: The facility's policy titled, Accidents/Incidents, issued 12/03 documented: PURPOSE: To enhance the quality of resident care and safety, to provide a safe environment for that care, to facilitate prompt response to potential safety issues . PROCEDURE: In the event of an accident . 1. Take immediate action to insure that the residents situation is stabilized and the particular incident will not be immediately repeated . 1) RI #14 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A physician's orders [REDACTED].#14 documented: . Aspirin 81 mg (milligram)take (1) By Mouth Every Day . 04/05/17 at 5:01 p.m., the left arm rest of RI #14's w/c was observed cracked, torn and rough to touch. On 04/06/17 at 5:10 p.m. Employee Identifier (EI) #11, Maintenance Director, was asked who was responsible to monitor w/c's for needed repairs. EI #11 replied he guessed it was the Certified Nursing Assistants. EI #11 was asked how did he monitor w/c's for needed repairs. EI #11 replied he depended on the staff to let him know and there was a log book at the front lobby. EI #11 was asked did he have a preventive maintenance program. EI #11 replied he did not. EI #11 was asked did he make rounds and look at w/c for needed repairs. EI #11 replied no. EI #11 was asked what would be a concern for a resident on a blood thinner with w/c arm rests that were torn or cracked. EI #11 replied they could get cut. EI #11 was asked was the process he had in place working or not. EI #11 replied it was not. 2) RI #8 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #8 physician's orders [REDACTED].#8 documented: . Plavix 75 mg Take one tablet by mouth once daily . On 04/04/17 at 5:06 p.m., the left arm rest on RI #8's w/c was observed cracked. On 04/06/17 at 5:10 p.m. EI#11, Maintenance Director, was asked who was responsible to monitor w/c's for needed repairs. EI #11 replied he guessed it was the Certified Nursing Assistants. EI #11 was asked how did he monitor w/c's for needed repairs. EI #11 replied he depended on the staff to let him know and there was a log book at the front lobby. EI #11 was asked did he have a preventive maintenance program. EI #11 replied he did not. EI #11 was asked did he make rounds and look at w/c for needed repairs. EI #11 replied no. EI #11 was asked what would be a concern for a resident on a blood thinner with w/c arm rests that were torn or cracked. EI #11 replied they could get cut. EI #11 was asked was the process he had in place working or not. EI #11 replied it was not.

Based on observation of Medication Administration, a review of the facility's policy titled, Administering Medications via (per) Nasogastric/Gastrostomy Tube and interview with licensed staff, the facility failed to ensure licensed staff member, Employee Identifier (EI) #3, did not push Gastrostomy ([DEVICE]) medications during administration of medication via (by way of ) [DEVICE]. This deficient practice affected Resident Identifier (RI) #7, one of one residents observed during Medication Administration. Findings Include: A review of the facility's policy titled, Administering Medications via Nasogastric/Gastrostomy Tube with a revised date of 2011, revealed the following: . PURPOSE: To provide proper administration of medication via feeding tube when the resident is unable to take medication by mouth . PROCESS: . 6. Administer medications by gravity . RI #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #7's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/04/2016, revealed RI #7 had a feeding tube. On 04/06/2017 at 9:20 a.m., an observation was made of EI #3 Licensed Practical Nurse (LPN) during Medication Administration. EI #3 checked placement of the [DEVICE], attached the syringe and poured the medication into the syringe. The medications would not flow by gravity. EI #3 placed the plunger inside of the syringe and pushed three medications via the [DEVICE]. On 04/06/2017 at 11:35 a.m., an interview was conducted with EI #3. EI #3 was asked what should be done when administering [DEVICE] medications. EI #3 said just put the plunger in the top of the syringe to cause pressure, but do not push the medication in. EI #3 was asked why [DEVICE] medication should not be pushed. EI #3 said it can cause pain and can cause gas.