Every finding on record at Arbor Woods Health and Rehab

Based on interviews, observations and the facility's policy titled, Foods Brought by Family/ Visitors, the facility failed to ensure food and drink items, that were in the resident's refrigerators' on the East and Wing West, were clearly distinguishable from faciity-prepared food. Specially, the resident's food was not labeled with the resident's name, and the use by date. This deficient practice affected 41 out 41 residents, who resided in the facility. Findings Included: A review of the facility policy titled, Foods Brought by Family/ Visitors, with a revised date of October 2017, revealed: . Policy Interpretation and Implementation . 7. Food brought by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that it is clearly distinguishable from facility-prepared food. b. Containers will be labeled with the residents's name, the item and the use by, date On 05/05/22 at 10:29 AM, the surveyor observed the resident's refrigerator on the East Wing accompanied by Employee Identifer (EI) #1, LPN, Licensed Practical Nurse. The surveyor observed a black bowl with a plastic lid covering with fish and hush puppies, a Snap Apple Juice 16 ounces, and a Snap Water 16 ounces. The food and drink items were not labeled. An interview was conducted with EI #1 at 10:29 AM. EI #1 was asked if the bowl with the fish and hush puppies were labeled with a name and date. EI #1 said no, it was not. EI #1 was asked if the Snap Apple Juice and Snap Water was labeled with a name and date. EI #1 said no, it was not. EI #1 was asked if the food and drink items belong to a resident. EI #1 said, yes. EI #1 was asked if the food and drink items should be labeled. EI #1 said yes. EI #1 was asked what should be on the label. EI #1 said the resident's name and the date the food was put in the refrigerator. EI #1 was asked who was responsible for ensuring the food items was labeled. EI #1 said the Nurses, CNAs (Certificate Nursing Assistant), and who ever put the food in the refrigerator. EI #1 confirmed the name and date was supposed to be put on the food and drinks. On 05/05/22 at 10:38 AM, the surveyor observed the resident's refrigerator on the West Wing accompanied by EI #2, Registered Nurse (RN)/Director of Nurses (DON). The surveyor observed a Ritz, Balance cheese and crackers snack bowl, a hot pocked in a plastic wrap and a French Vanilla monster triple shot drink 15 ml (milliters). The food and drinks items were not labeled. An interview was conducted with EI #2 at 10:38 AM. EI #2 was asked if the food and drink items, a Ritz Balance Cheese and Crackers snack bowl, a hot pocket and a French Vanilla monster triple shot drink was labeled. EI #2 said, no they were not labeled. EI #2 was asked should the food and drink items be labeled. EI #2 said they should have been labeled. EI #2 was asked what should be on the label. EI #2 said the resident's name and the date the food was put in the resident's refrigerator. EI #2 was asked what was the harm with food and drink items not being labeled. EI #2 said you do not know how long it has been in the refrigerator and the owner of the food and drink items.

Based on observation , interviews and review of the facility policy titled, Perineal Care, the facility failed to ensure staff washed their hands between glove changes during incontinent care. This affected RI #37, one resident observed during incontinent care. Findings Include: A review of an undated facility policy titled, Perineal Care revealed: .Policy Explanation and Compliance Guidelines: All staff members involved in performing perineal care to residents will promote cleanliness, prevent infections . RI #37 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 6/20/18 at 10:47 AM, Employee Indentifer (EI) #2 and EI #3, both Certified Nursing Assistants (CNA) were observed performing perineal care for RI #37. Both EI #2 and EI #3 washed their hands and put on gloves. EI #2 removed the brief from RI #37 and cleaned RI #37's front area with wipes. EI #2 removed her gloves and put on a clean pair of gloves. Both CNA's assisted to turn RI #37 on the right side. EI #3 took wipes and wiped the buttock with a smear of bowel movement. EI #3 changed gloves without washing her hands and completed the task. Both CNAs, when changing gloves, did not wash their hands. On 6/20/18 at 11:05 AM an interview was conducted with EI #2 and EI #3. Both were asked what was the policy on when to wash hands. EI #2 replied, before, after and in between care. Both were asked when should you wash your hands with glove changing. EI #3 replied, in between the glove changes. Both were asked if they washed their hands between glove changes. Both EI #2 and EI #3 replied, no. Both were asked what was the harm in changing gloves and not washing their hands before putting on new gloves. EI #2 replied, passing germs. On 6/21/18 at 8:42 AM an interview was conducted with EI #1, Director of Nursing (DON). EI #1 was asked what was the policy on washing hands with glove changes. EI #1 replied, staff should wash their hands before putting on clean gloves. EI #1 was asked what was the risk of not washing hands between glove changes. EI #1 replied, spread of infection.

Based on observations, interviews, facility policies titled Food Receiving and Storage and Resource: Taking Accurate Temperatures, and the 2013 Food Code, the facility failed to ensure: 1) an opened box of sausage patties contained an open and use by date, 2) a use by date was on an opened five pound bag of grits, 3) the stem/probe of the thermometers were not touching the bottom of the glass while being calibrated, 4) after being dropped, a thermometer was sanitized properly, 5) one of seven sprinkler heads in the kitchen was free of dust, 6) the Dietary Manager, Employee Identifier (EI) #4, changed her gloves, removed her apron and washed her hands prior to leaving the dirty side, and before entering the clean side of the dish area and touching a clean rack of glasses, and 7) a Dietary Cook, EI #10, did not place her bare thumb on the inside of clean plates and divided plates, when removing the plates from the dish rack. These deficient practices had the potential to affect all 44 residents receiving meals from the kitchen. Finding Include: 1) A review of a facility policy titled, Food Receiving and Storage, with a revision date of July 2014, documented: Policy Statement Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation .7. All foods in the refrigerator or freezer will be covered, labeled and dated (use by date) . On 05/02/17 at 1:07 p.m., during the initial tour of the kitchen, the surveyor observed in the upright freezer in the dry storage room a carton of opened patties. The surveyor asked the Dietary Manager, EI #4, when was the box of patties opened. EI #4 said the box was opened today (05/02/17). The surveyor asked EI #4 was there an open and use by date on the box. EI #4 said no. On 05/04/17 at 11:40 a.m., the surveyor conducted an interview with EI #4. The surveyor asked EI #4 what was the purpose of having an open and use by date on food items. EI #4 replied, If it's open you want to use it first. The use by date lets my staff know when it should be used by. The surveyor asked EI #4 what could food items not having an open or use by date on them cause. EI #4 said the resident could get sick or it could cause illness. 2) On 05/02/17 at 1:09 p.m., during the initial tour of the kitchen, the surveyor observed in the Walk-in Cooler, a five pound bag of opened grits on the inside of a Ziploc bag. The Ziploc bag had an open date of 05/01/17 on the bag. There was no use by date on the bag. The surveyor asked EI #4 should there be a use by date on the bag of grits. EI #4 said yes. On 05/04/17 at 11:40 a.m., the surveyor conducted an interview with EI #4. The surveyor asked EI #4 who was responsible for ensuring opened items had an open and use by date on them. EI #4 said it was the responsibility of who ever opened the food item. EI #4 said her responsibility was to make rounds and make sure everything was done. 3) A review of a facility policy titled Resource: Taking Accurate Temperatures, dated 2013, documented: . Calibrating the Thermometer . 2. Put the thermometer probe into the ice water mixture it is important to wait about 30 seconds without having the probe touch the sides or bottom of the container . On 05/02/17 at 5:32 p.m., the surveyor observed two thermometers in a glass of ice and water. The stems/probes of the thermometers were touching the bottom of the glass. On 05/04/17 at 11:25 a.m., the surveyor observed three thermometers in a glass of ice and water. The stems/probes of the thermometers were touching the bottom of the glass. On 05/04/17 at 11:27 a.m., the surveyor conducted an interview with EI #10, the cook who was calibrating the thermometers. The surveyor asked EI #10, how she calibrated a thermometer. EI #10 said, get a glass of ice and stick the thermometer in the ice and make sure it reads 32. The surveyor asked EI #10, when the surveyor observed the thermometers in the glass of ice water earlier, was she holding the thermometers or were they sitting in the ice water. EI #10 said the thermometers were sitting in the ice water. The surveyor asked EI #10 had she ever been told the stem/probe of the thermometer should not touch the bottom of the container when it was being calibrated. EI #10 said no. On 05/04/17 at 11:40 a.m., the surveyor conducted an interview with EI #4. The surveyor asked EI #4 how should the thermometer be calibrated. EI #4 said you would place the thermometer in a cup of ice water. EI #4 said the thermometer should reach 32 and if not, you use a thermometer stick to change it. The surveyor asked EI #4 should the stream/probe touch the bottom of the container. EI #4 said she was not sure. The surveyor asked EI #4 did she realize on 05/02/17, the stem/probe of the thermometers was touching the bottom of the glass. EI #4 said yes. The surveyor asked EI #4 what did the facility's policy say about the stem or probe. EI #4 replied, It shouldn't touch the bottom. 4) On 05/02/17 at 5:33 p.m., the surveyor observed EI #4, the Dietary manager drop a thermometer on the floor. On 05/02/17 at 5:36 p.m., the surveyor observed EI #4 place the dropped thermometer on the counter next to the stem table. On 05/04/17 at 11:40 a.m., the surveyor conducted an interview with EI #4. EI #4 said she should have put the dropped thermometer in a sanitizing solution. The surveyor asked EI #4 why she should have placed the dropped thermometer in the sanitizing solution. EI #4 replied, Because it fell on the floor and the floor is dirty. 5) On 05/02/17 at 5:55 p.m., the surveyor observed seven sprinkler head in the ceiling of the kitchen. One sprinkler head, over the area where liquids and clean glasses were sitting, was observed to have dust like particles on the sprinkler head. On 05/04/17 at 11:40 a.m., the surveyor conducted an interview with EI #4. The surveyor asked EI #4 what did it look like was on the sprinkler head. EI #4 replied, Dust. The surveyor asked EI #4 what was there a potential for when dust was over clean items. EI #4 said the dust could contaminate the dishes. 6) A review of the United States Food and Drug Administration Food Code 2013 documented: . 2-3 PERSONAL CLEANLINESS . 2-301.14 When to Wash FOOD EMPLOYEES shall clean their hands . immediately before . working with . clean EQUIPMENT and UTENSILS . (E) After handling soiled EQUIPMENT or UTENSILS . On 05/03/17 at 8:22 a.m., the surveyor observed EI #4 on the dirty side of the dishwashing area. EI #4 had on her hair restraint, gloves and an apron. EI #4 was observed scraping food off of plates, placing lids, plates and cups in the dish racks and putting the dish racks in the dishwasher. On 05/03/17 at 8:33 a.m., the surveyor observed EI #4 walk to the clean side of the dishwashing area and pull a rack of clean glasses down the clean counter, with her contaminated gloves still on, then walk back to the dirty side of the dishwashing area and continue to work. On 05/03/17 at 8:39 a.m., the surveyor observed EI #4 again walk to the clean side of the dishwashing area and pull a rack of clean glasses and cups down the clean counter, with her contaminated gloves still on, then walk back to the dirty side of the dishwashing area and continue to work. On 05/04/17 at 11:40 a.m., the surveyor conducted an interview with EI #4. The surveyor shared with EI #4 the above observations and asked EI #4 what should she have done with her gloves before going to the clean side of the dish room and touching the clean dish rack. EI #4 said she should have took her gloves off and washed her hands. The surveyor asked EI #4 what was it called when going from a dirty area to a clean area and then touch items. EI #4 replied, Cross contamination. 7) On 05/03/17 at 8:42 a.m., the surveyor observed EI #10, a cook, remove plates from the clean dish racks and place the plates in the plate storage rack. EI #10's bare thumb touched the inside of each plate removed from the clean dish rack. EI #10 was also observed to removed three divided plates from the clean dish rack, touching the inside of each plate with her bare thumb. On 05/04/17 at 11:27 a.m., the surveyor conducted an interview with EI #10. The surveyor asked EI #10 if she had on gloves when she removed the clean plates from the clean dish rack. EI #10 said no. The surveyor asked EI #10 if she realized her bare thumb was touching the insides of the plates. EI #10 said no. The surveyor asked EI #10 what would it be considered when bare hands or a thumb touched the inside of a clean plate. EI #10 replied, Cross contamination.

Based on observations and interviews, the facility failed to ensure residents were not served milk in disposable paper cartons. This deficient practice affected eight of 28 residents observed during the lunch meal in the dining room on 05/03/17, and 11 of 23 residents observed during the dinner meal in the dining room on 05/03/17. Findings Include: On 05/03/17 at 12:20 p.m., the surveyor observed 28 residents being served the lunch meal in the dining room. Eight of the 28 residents were served milk in disposable paper cartons. On 05/03/17 at 6:05 p.m., the surveyor observed 23 residents being served the dinner meal in the dining room. Eleven of the 23 residents were served milk in disposable paper cartons. On 05/04/17 at 11:40 a.m., the surveyor conducted an interview with Employee Identifier (EI) #4, the Dietary Manager. The surveyor asked EI #4, when the residents were served milk in cartons, what should the staff who were passing the trays out do. EI #4 said staff should open the milk and put it in a glass. On 05/04/17 at 7:45 p.m., the surveyor conducted an interview with EI #1, the Director of Nursing. The surveyor asked EI #1, how should residents milk be served. EI #1 replied, In glasses. The surveyor asked EI #1, when this was not done, what could it be considered. EI #1 replied, A dignity issue.

Based on observation, interviews, and review of the facility policy titled, Storage of Medications, the facility failed to ensure a licensed nurse, Employee Identifier (EI) #2, kept the medication cart locked while out of her line of sight. On 05/02/17, EI #2 was observed during the evening Medication Administration Observation to leave the medication cart unlocked and unattended. This deficient practice affected one of four medication nurses observed during the medication pass administration, and one of four medication carts. Findings Include: The facility's policy titled: Storage of Medications with a revised date of April 2007, documented the following: Policy Statement The facility shall store all drugs and biologicals in a safe, secure and orderly manner . 7. Compartments (including but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others . On 05/02/17 at 3:43 p.m., during the evening Medication Administration Observation, the medication cart was observed placed in front of RI #1's doorway by EI #2, the medication nurse. EI #2 left the medication cart unlocked and unattended as she entered RI #1's room to administer medication by way of RI #1's Gastrostomy Tube (Feeding Tube). On 05/02/17 at 3:50 p.m., EI #7, a Certified Nursing Assistant (CNA), was walking in the hallway and passed by the doorway of RI #1's room. EI #7 looked into RI #1's room during the administration of the medication through the Gastrostomy Tube. EI #7 proceeded to pull the privacy curtains and close the door to RI #1's room, leaving the medication cart unlocked, unattended and out of the line of sight of EI #2. On 05/02/17 at 4:00 p.m., the surveyor conducted an interview with EI #1, the Director Of Nursing (DON). The surveyor asked EI #1, should the nurse leave the medication cart unlocked or unattended. EI #1 stated, No sir, it's a safety hazard to the residents. On 05/02/17 at 5:27 p.m., the surveyor conducted an interview with EI #2, the medication nurse. The surveyor asked EI #2, should she leave the medication cart unlocked and unattended. EI #2 stated, No, because anyone could get into it.

Based on observations, interview, medical record review and review of a facility policy titled, Administering Medications, the facility failed to ensure a Licensed Nurse, Employee Identifier (EI) #2, administered eight milliliters (ml) of Valporic Acid and Artificial Tears to Resident Identifier (RI) #1 on 05/02/17, as ordered by the physician, during the evening medication pass. Thirty-three opportunities were observed with two errors occurring. This resulted in a 6.0% (Percent) medication error rate. This affected RI #1, one of seven residents observed during medication administration and one of four medication nurses observed administering medications. Findings Include: A facility policy titled Administering Medications with a revised date of December 2012, documented the following: Policy Statement Medications shall be administered in a safe and timely manner, and as prescribed . Policy Interpretation and Implementation . 3. Medications must be administered in accordance with the orders . 7. The individual administering the medication must check the label THREE (3) times to verify the right . dosage . RI #1 was originally admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of RI #1's physician order [REDACTED]. On 05/02/17 at 3:43 p.m., during the evening Medication Administration Observation, the surveyor observed EI #2, the medication nurse administering medications to RI #1 per the Gastrostomy Tube. The surveyor observed EI #2 pour the Valporic Acid in a 30 cc (cubic centimeters) calibrated cup to the 10 ml line. The surveyor asked EI #2 how did she ensure that there was 8 ml of Valporic Acid in the cup. EI #2 said she did not measure it exactly for 8 ml. During the reconciliation of the medication pass, it was revealed RI #1's Artificial Tears, one drop in each eye 2 times a day was not administered during the evening medication pass by EI #2. On 05/02/17 at 4:00 p.m., the surveyor conducted an interview with EI #1, the Director Of Nursing (DON). The surveyor asked EI #1 how should the nurse ensure, that if eight ml of medication was ordered, that the medication was obtained from the bottle. EI #1 stated, It should be drawn up with a syringe to ensure it is eight ml. The surveyor asked EI #1 what was done to address the concerns with the nurse (EI #2). EI #1 stated, Inserviced one on one with the nurse . ensuring the correct dosage of liquid medication (is given). On 05/02/17 at 5:27 p.m., the surveyor conducted an interview with EI #2, the medication nurse. The surveyor asked EI #2, how did she measure the correct amount of Valporic Acid and ensure it was eight ml. EI #2 stated, I didn't measure it. I poured the medication in the cup close to the 10 ml line.

Based on observation, interviews, medical record review, review of a facility policy titled, Administering Medications through an Enteral Tube, the facility failed to ensure a licensed practical nurse (LPN), Employee Identifier (EI) #2, provided appropriate treatment and services by not checking for gastric tube residual on Resident Identifier (RI) #1, and instilling approximately 60 cc's (cubic centimeters) of air into the resident's stomach during the evening Medication Administration Observation on 05/02/16. This deficient practice affected RI #1, one of two residents observed for Gastrostomy tube ([DEVICE]) medication administration, and EI #2, one of four medication nurses observed. Findings Include: The facility's RESIDENT CENSUS AND CONDITIONS OF RESIDENTS form, dated 05/04/2017, documented two residents in the facility with tube feedings. A facility policy titled Administering Medications through an Enteral Tube, Revised March 2015, documented: Purpose The purpose of this procedure is to provide guidelines for the safe administration through an enteral tube. Preparation . 3. Assemble the equipment and supplies as needed . Steps in the Procedure . 18. Confirm placement of feeding tube . RI #1 was originally admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #1's May 2017 physician's orders [REDACTED]. On 05/02/17 at 3:43 p.m., during the evening Medication Administration Observation, the surveyor observed RI #1 out of bed sitting in a geri-chair in the room. The feeding pump with formula was turned off and not infusing at this time. The surveyor observed EI #2, the medication nurse, attach the Gastrostomy Tube to a 60 cc syringe, and flush the Gastrostomy Tube (with water). The medication ([MEDICATION NAME]) was given by [DEVICE] per gravity, the [DEVICE] was flushed with 10 cc's of air, followed with approximately 30 cc's of air and water. EI #2 pushed approximately 30 more cc's of air into RI #1's stomach with the plunger. Another medication was given by EI #2 with 10 cc's of water and pushed into the resident's stomach. The [DEVICE] was then flushed by EI #2 with 20 cc's of water that was pushed with the plunger. EI #2 crushed another medication and administered it with 15 cc's of water using the plunger. During this procedure RI #1 was noted to start coughing. EI #2 failed to check RI #1's Gastrostomy Tube placement by Gastric residual (aspiration) or auscultation (listening with a stethoscope). On 05/02/17 at 4:00 p.m., the surveyor conducted an interview with EI #1, the Director Of Nursing (DON). The surveyor asked EI #1, how should the nurse administer medications by way of the Gastrostomy Tube ([DEVICE]). EI #1 said, they should check for placement with a stethoscope. On 05/02/17 at 5:27 p.m., the surveyor conducted an interview with EI #2, the medication nurse. The surveyor asked EI #2, how she checked for [DEVICE] placement. EI #2 stated, Inject air and listen with your stethoscope. EI #2 was asked if she checked RI #1's [DEVICE] for residual. EI #2 stated, No sir I didn't. The surveyor asked EI #2 should she inject air into a resident's stomach. EI #2 stated, No sir, this could make them sick. The surveyor asked EI #2 if the air could cause anything to happen to the resident. EI #2 stated, It could cause the resident abdomen to distend and cause (him/her) to throw-up (vomit).

Based on observations, interview and record review, the facility failed to ensure Resident Identifier (RI) #3, a resident totally dependent on staff for toileting, and who was on a Prompt and Assist toileting program was assisted to the toilet. On 05/04/17 from 9:45 a.m. to 12:30 p.m., RI #3 was observed in the dining room. During this time frame, no one made any attempt to assist RI #3 to the toilet. This deficient practice affected RI #3, one of three residents sampled for bowel and bladder concerns. Findings Include: RI #3 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #3's care plan titled Requires assist with ADL's (Activities of Daily Living) R/T (related to) Impaired Mobility . with a Problem Onset date of 07/02/15, documented: . *Prompt and Assist toileting program every 2 hours and as needed with perineal care . A Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 02/23/17, assessed RI #3 as scoring a 5 on the Brief Interview for Mental Status (BIMS), indicating severe impaired cognition. RI #3 was also assessed to be totally dependent on staff for toilet use and personal hygiene and was frequently incontinent of bowel and bladder. A review of RI #3's Quarterly Elder Care Plan Meeting dated 03/02/17, documented: . He/She has been put on the Prompt and Assist Program . On 05/03/17, from 9:45 a.m. through 12:30 p.m., a period of two hours and 45 minutes, RI #3 was observed in the dining room sitting in the resident's wheelchair. No staff approached RI #3 during this time frame to prompt or assist RI #3 to the bathroom. On 05/04/17 at 7:45 p.m., the surveyor conducted an interview with EI #1, the Director of Nursing. The surveyor asked EI #1 the type care RI #3 required with toileting. EI #1 said RI #3 was a one person prompt and assist. The surveyor asked EI #1 was RI #3 on a toileting program. EI #1 replied, Yes Ma'am, every 2 hours. The surveyor asked EI #1 what was the purpose of a resident being on a prompt and assist program. EI #1 replied, Try to train the bladder to keep him/her from being incontinent.

Based on observations, interviews and record review, the facility failed to ensure Resident Identifier (RI) #3, a resident identified as being at risk for aspiration, was not provided a straw in his/her tea during the dinner meal on 05/02/17, and a straw in the resident's water pitcher at the bedside on three of three days of the survey. This deficient practice affected RI #3, one of 11 sampled residents. Findings Include: RI #3 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #3's Fiberoptic Endoscopic Examination of Swallowing dated 01/05/17, documented: . Patient Complaint: Coughing intermittently with liquids . rule out aspiration . Pharyngeal Swallow Function: . Signs of [MEDICAL CONDITION] Backflow/Reflux Penetration with thin liquid via (by way of) straw . RI #3's Physician order [REDACTED]. (1) Diet change to Regular c (with) no straws. A Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 02/23/17, assessed RI #3 as scoring a 5 on the Brief Interview for Mental Status (BIMS), indicating severe impaired cognition. RI #3 was also assessed as being independent with eating. RI #3's May 2017 Physician order [REDACTED].> . PATIENT IS SAFE ON REGULAR/THIN AND NO STRAWS . A review of RI #3's Supper Tray Card documented: . No straws . On 05/02/17 at 4:00 p.m., the surveyor observed a water pitcher at RI #3's bedside. The water pitcher had a straw in it. On 05/02/17 at 6:20 p.m., the surveyor observed RI #3's dinner meal being served. The staff member setting up RI #3's dinner tray on the bedside table placed a straw in RI #3's tea. On 05/03/17 at 9:07 a.m., the surveyor observed RI #3's water pitcher at the bedside with a straw in the pitcher. On 05/04/17 at 8:07 a.m., the straw remained in RI #3's water pitcher at the bedside. On 05/04/17 at 2:07 p.m., the surveyor conducted an interview with Employee Identifier (EI) #5, a Licensed Practical Nurse. The surveyor asked EI #5 if RI #3 was supposed to use a straw. EI #5 replied, No Ma'am. The surveyor asked EI #5 if the water pitcher at RI #3's bedside had a straw in it. EI #5 said it did. The surveyor asked EI #5 why was RI #3 not to use a straw. EI #5 said that came from therapy. On 05/04/17 at 3:14 p.m., the surveyor conducted a telephone interview with Employee Identifier (EI) #9, a Speech Language Pathologist. The surveyor asked EI #9, on RI #3's Fiberoptic Endoscopic Examination of Swallowing, what did penetration with thin liquids by straw mean. EI #9 said it meant when RI #3 drank with a straw RI #3 was impulsive and took several sips at one time. EI #9 said RI #3 was at risk for aspiration when he/she used a straw. The surveyor asked EI #9 if that included straws that were made for certain water pitchers. EI #9 said that included all straws. The surveyor asked EI #9 should RI #3 have a water pitcher with a straw in it at the bedside. EI #9 said no. The surveyor asked EI #9 what was the potential if RI #3 used a straw. EI #9 said risk for aspiration. On 05/04/17 at 7:45 p.m., the surveyor conducted an interview with EI #1, the Director of Nursing. When asked if RI #3 was at risk for aspiration, EI #1 replied, He/She has the no straw because of the risk for penetration or aspiration.

Based on observations, interviews and record review, the facility failed to ensure the care plan of Resident Identifier (RI) #3 was followed in order to check the resident's incontinent status every two hours and as needed. RI #3 is a resident identified by the facility as being frequently incontinent of bowel and bladder. This deficient practice affected RI #3, one of three residents sampled for bowel and bladder concerns. Findings Include: RI #3 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #3's care plan titled, Requires assist with ADL's (Activities of Daily Living) R/T (related to) Impaired Mobility . with a Problem Onset date of 07/02/15, documented: . *Prompt and Assist toileting program every 2 hours and as needed with perineal care . A Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 02/23/17, assessed RI #3 as scoring a 5 on the Brief Interview for Mental Status (BIMS), indicating severe impaired cognition. RI #3 was also assessed to be totally dependent on staff for toilet use and personal hygiene and was frequently incontinent of bowel and bladder. On 05/03/17, from 9:45 a.m. through 12:30 p.m., a period of two hours and 45 minutes, RI #3 was observed in the dining room sitting in the resident's wheelchair. No staff approached RI #3 during this time frame to check on RI #3's incontinent status. On 05/03/17 at 12:43 p.m., the surveyor conducted an interview with Employee Identifier (EI) #8, the Certified Nursing Assistant assigned to care for RI #3 on 05/03/17 on the 7 - 3 shift. EI #8 said RI #3 was to be checked and assisted to the toilet every 2 hours. On 05/03/17 at 12:47 p.m., EI #8 assisted RI #3 to the bathroom. A small amount of urine was observed in RI #3's adult incontinent brief when the resident's incontinence status was checked. On 05/04/17 at 2:07 p.m., the surveyor conducted an interview with EI #5, a Licensed Practical Nurse. The surveyor asked EI #5 if RI #3 was continent or incontinent. EI #5 said RI #3 was incontinent. The surveyor asked EI #5, according to RI #3's plan of care, when should RI #3 be toileted. EI #5 said RI #3 was to be checked every 2 hours as and needed. The surveyor shared with EI #5 that the surveyor observed RI #3 from 9:45 a.m. until 12:30 p.m. in the dining room. The surveyor asked EI #5, during those times frames, if no one checked RI #3 for his/her incontinence status, was his/her plan of care followed. EI #5 replied, No Ma'am.

Based on observation, interviews, medical record review, review of a facility policy titled, Administering Medications through an Enteral Tube, and review of Potter and Perry's FUNDAMENTALS OF NURSING, the facility failed to ensure a licensed practical nurse (LPN), Employee Identifier (EI) #2, checked Resident Identifier (RI) #1's gastric residual during the evening Medication Administration Observation on 05/02/16. This deficient practice affected RI #1, one of two residents observed for Gastrostomy tube medication administration, and EI #2, one of four medication nurses observed during the medication pass. Findings Include: The facility's RESIDENT CENSUS AND CONDITIONS OF RESIDENTS form, dated 05/04/2017, documented two residents in the facility with tube feeding. A facility policy titled Administering Medications through an Enteral Tube, revised March 2015, documented: Purpose The purpose of this procedure is to provide guidelines for the safe administration through an enteral tube . Steps in the Procedure . 20. Check gastric residual volume (GRV) . A review of Potter and Perry's FUNDAMENTALS OF NURSING, Ninth Edition, with a copyright date of 2017, page 636, Unit V, Foundations for Nursing Practice documented: Administering Medications Through an Enteral Tube . Steps . 14. Assess gastric residual volume (GRV) . RI #1 was originally admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #1's May 2017 physician's orders [REDACTED]. CHECK RESIDUAL EVERY SHIFT BEFORE ADMINISTERING MEDS . On 05/02/17 at 3:43 p.m., during the evening Medication Administration Observation, the surveyor observed EI #2, the medication nurse, attach the Gastrostomy Tube to a 60 cc (cubic centimeters) syringe and flush the Gastrostomy Tube (with water). EI #2 failed to check RI #1's Gastrostomy Tube for placement by aspirating gastric contents. On 05/02/17 at 4:00 p.m., the surveyor conducted an interview with EI #1, the Director Of Nursing (DON). The surveyor asked EI #1, how should the nurse administer medications by way of the Gastrostomy Tube. EI #1 said, they should check for placement with a stethoscope. The surveyor asked EI #1 what other methods should the nurse check for placement. EI #1 said, check for residual. On 05/02/17 at 5:27 p.m., the surveyor conducted an interview with EI #2, the medication nurse. The surveyor asked EI #2 if she checked RI #4's [DEVICE] for residual. EI #2 stated, No sir, I did not.

Based on interview, record review and review of a facility policy titled Goals and Objectives, Care Plans, the facility failed to ensure Resident Identifier (RI) #4's care plan was updated to reflect RI #4's Cognitive status on the Quarterly Minimum Data Set ((MDS) dated [DATE]. This deficient practice affected RI #4, one of 11 sampled residents whose care plans were reviewed. Findings Include: A review of a facility policy titled Goals and Objectives, Care Plans, revised April 2009, documented the following: Policy Statement Care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence . Policy Interpretation and Implementation . 5. Goals and objectives are reviewed and /or revised: . d. At least quarterly . RI #4 was originally admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of RI #4's Quarterly MDS with an Assessment Reference Date of 10/20/16, assessed RI #4 in Section C - Cognitive Patterns, to have a Brief Interview for Mental Status (BIMS) score of 5, indicating severe impairment in cognitive skills for daily decision making. RI #4 had a care plan with a Problem Onset: (no date) titled: Falls Multiple: (Resident's name) has a hx (history of) multiple falls as a result of nonadherence to plan of care (cognitively intact) . has a chair and wheelchair alarm . will turn them off if . able to reach the switches . has a history of multiple falls prior to admission to the facility . The careplan Approaches included Encourage (RI #4) to use call light when (he/she) needs to get up . A review of RI #4's Fall careplan did not reveal an update to include RI #4's severe cognitive status as assessed on the Quarterly MDS, dated [DATE]. On 05/04/17 at 2:05 p.m., the surveyor conducted an interview with Employee Identifier (EI) #3, the Care Plan Coordinator. The surveyor asked EI #3 if RI #4's careplan was updated related to RI #4's cognitive status before the 11/19/16 fall incident. EI #3 stated, According to the careplan, no.

Based on observations, interviews and review of the DIRECTOR OF MAINTENANCE JOB DESCRIPTION, the facility filed to ensure: 1) ceramic tile pieces were not missing from the bathroom floor in Room Locator (RL) #1, 2) Resident Identifier (RI) #3's right siderail foam padding was not torn, and 3) chipped paint was not on the trim and door frame in the dining room. These deficient practices were observed on three of three days of the survey and affected RL#1, one of 16 rooms on the West Unit, the dining room, and RI #3, one of 11 sampled residents. Findings Include: Review of the DIRECTOR OF MAINTENANCE JOB DESCRIPTION, not dated, documented: . General Purpose: To plan, organize and direct the overall operation of the department in accordance with current federal, state and local standards, ensuring that the facility is maintained in a safe, comfortable condition . Essential Job Functions: A. Maintenance Functions Duties: . coordinate maintenance services with other departments . ensure proper maintenance of the facility including . painting . 1) On 05/02/17 at 1:31 p.m., the surveyor observed missing pieces of ceramic tile from the floor of the bathroom in RL #1. On 05/03/17 at 5:52 p.m., the surveyor observed that pieces of the ceramic tile remained missing from the floor of the bathroom in RL #1. On 05/04/17 at 8:17 a.m., pieces of ceramic tile remained missing from the floor of the bathroom in RL #1. 2) On 05/02/17 at 4:00 p.m., the surveyor observed the black foam on RI #3's right siderail was torn. On 05/03/17 at 5:53 p.m., the surveyor observed the black foam on RI #3's right siderail remained torn. On 05/04/17 at 8:07 a.m., the black foam on RI #3's right siderail remained torn. On 05/04/17 at 2:07 p.m., the surveyor conducted an interview with Employee Identifier (EI) #5, the Licensed Practical Nurse Unit Manager. The surveyor asked EI #5 who was responsible for ensuring the foam on a resident's siderail was not torn. EI #5 said whoever noticed the foam was torn could complete a maintenance work order. The surveyor asked EI #5 should maintenance have been made aware of the torn foam on RI #3's siderail. EI #5 replied, Yes Ma'am. 3) On 05/02/17 at 1:20 p.m., the surveyor observed chipped paint on the trim and on the door frame in the dining room. On 05/03/17 at 9:53 a.m., the surveyor observed the paint on the trim and on the door frame in the dining room remained chipped. On 05/04/17 at 1:40 p.m., the paint on the trim and on the door frame in the dining room remained chipped. On 05/04/17 at 2:46 p.m., the surveyor conducted an interview with EI #6, the Maintenance Director. The surveyor asked EI #6 if he was responsible for replacing missing tiles on the bathroom floor. EI #6 said yes. On 05/04/17 at 2:52 p.m., the surveyor accompanied EI #6 to RL #1. The surveyor asked EI #6 if the missing tile on the floor of RL #1 needed replacing. EI #6 replied, Yes, most definitely. On 05/04/17 at 2:53 p.m., the surveyor accompanied EI #6 to RI #3's room. The surveyor asked EI #6 if the foam on RI #3's siderail needed to be replaced. EI #6 replied, Yes Ma'am. On 05/04/17 at 2:55 p.m., the surveyor accompanied EI #6 to the dining room. The surveyor asked EI #6 if the trim and the door frame needed to be repainted. EI #6 replied, Yes Ma'am.

Based on observation, interviews, medical record review and review of a facility policy titled, Verifying Placement of Feeding Tube, the facility failed to ensure a Licensed Practical Nurse, Employee Identifier (EI) #2, provided privacy while administering medication through RI (Resident Identifier) #1's Gastrostomy Tube on 05/02/17. This affected RI #1, one of two residents with feeding tubes observed during the Medication Administration Observations. Findings Include: The facility's RESIDENT CENSUS AND CONDITIONS OF RESIDENTS form, dated 05/04/2017, documented two residents in the facility with tube feedings. The facility's policy titled Verifying Placement of Feeding Tube (not dated), documented: . How You Do It - . 3. Provide privacy . RI #1 was originally admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. On 05/02/17 at 3:43 p.m., RI #1 was observed out of bed up in a geri chair in the room. The door remained open as EI #2 pulled RI #1's gown up and exposed the Gastrostomy Tube (Feeding Tube). EI #2's roommate was in the adjacent bed and the privacy curtains were not pulled between the two residents as EI #2 exposed RI #1's abdominal area. EI #2 attached the Gastrostomy Tube to a 60 cc (cubic centimeters) syringe, and flushed the Gastrostomy Tube (with water). Then EI #2 used the plunger to push medications through the tube. When EI #2 flushed RI #1's Gastrostomy tube, this procedure could have been seen by anyone who was in the hallway passing by RI #1's room. EI #2 failed to maintain full visual privacy while performing this procedure. On 05/02/17 at 3:50 p.m., EI #7, a Certified Nursing Assistant (CNA), was walking in the hallway and passed by the doorway of RI #1's room. EI #7 looked into RI #1's room during the administration of the medication through the Gastrostomy Tube. EI #7 proceeded to pull the privacy curtains and closed the door to RI #4's room. On 05/02/17 at 4:00 p.m., the surveyor conducted an interview with EI #1, the Director Of Nursing (DON). The surveyor asked EI #1, when giving medications through a Gastrostomy Tube, how should privacy be maintained. EI #1 said close the door, pull the privacy curtains and make sure the (window) blinds are closed. On 05/02/17 at 5:27 p.m., the surveyor conducted an interview with EI #2, the medication nurse. The surveyor asked EI #2, when providing medications through a Gastrostomy tube (an invasive procedure), should privacy be maintain and how. EI #2 said yes sir. EI #2 said close the door, close the blinds if open, and pull the curtains between roommates.

Based on observation, record review and interview, the facility failed to ensure: 1. A use by date was placed on a large bag of shredded cheese in the walk in cooler, 2. Dented food cans were not combined with the regular food cans, 3. A thermometer was calibrated before taking food temperature, 4. Food temperatures were written down immediately after tempting and 5. A dietary worker washed her hands after touching a cloth removed from a red bucket with a cleaning solution. This had the potential to affect 48 of 50 residents who receive meals from the kitchen. Findings Include: 1) On 8/9/2016 at 3:30 p.m., the Surveyor observed shredded cheese in a large Ziploc bag in the walk in cooler. There was no use by date on the bag. On 8/11/2016 at 2:17 p.m., an interview was conducted with EI #1 (Employee Identifier) Dietary Manager. EI #1 was asked what was the use by date on the large bag of cheese in the walk in cooler. EI #1 replied, there was no use by date. EI #1 was asked why was there no use by date on the item. EI #1 replied, she did not know it was suppose to have a use by date. EI #1 was asked who was responsible for putting use by dates on food items. EI #1 replied, whoever used the item. EI #1 was asked when should use by dates be put on food items. EI #1 replied, whenever opened. EI #1 was asked what was the facility policy on when to put a use by date on a food item. EI #1 replied, when received. EI #1 was asked what was the potential harm when food items did not have a use by date on them. EI #1 replied, it can cause food borne illness. 2) A review of a facility policy titled, Dry Storage Areas with no revised date revealed: .Procedure: . 4.dented cans and . should be disposed of promptly . A review of a facility policy titled, DENTED CANS with no revised date revealed: .PROCEDURE: .4. Damaged cans .are to be separated from other food items On 8/9/2016 at 3:30 p.m., the surveyor observed dented cans mixed together with regular food cans. The dented cans were two fifty ounces of cream of chicken and one fifty ounce of tomato soup. On 8/11/2016 at 2:24 p.m., an interview was conducted with EI #1, Dietary Manager. EI #1 was asked what dented cans were on the shelf with the regular food cans. EI #1 replied, chicken noodles, but did not remember the contents of the other cans. EI #1 was asked why were there dented cans on the shelf. EI #1 replied, the person who stocked them did not place the cans in the dented can container. EI #1 was asked who was responsible for removing dented cans from the shelf. EI #1 replied, dietary manager, whoever placed the dented cans on the shelf and whoever received the cans. EI #1 was asked when should dented cans be removed from the shelf. EI #1 replied, they were not to be on the shelf, but in the dented can container. EI #1 was asked what was the facility's policy on dented cans. EI #1 replied, store them away in a separate container from the other cans. EI #1 was asked what was the potential harm when dented cans were in with regular cans and the cans were opened to be prepared to be cooked for the residents. EI #1 replied, it can cause a illness. 3) A review of a policy titled, Food Temperatures with no revised date revealed: Policy: The temperatures of the food items will be taken and properly recorded for each meal. On 8/10/2016 at 10:45 a.m., the surveyor observed the cook not calibrating the thermometer used to take the temperature of the food on the tray line. On 8/11/2016 at 2:00 p.m., an interview was conducted with EI #2, Dietary Aide. EI #2 was asked when should dietary staff calibrate a thermometer. EI #2 replied every day. EI #2 was asked who was responsible for calibrating the food thermometer. EI #2 replied, the cook and any employee available. EI #2 was asked what was the facility's policy on calibrating a thermometer that will be used on the tray line. EI #2 replied it should be calibrated everyday. EI #2 was asked what was the potential harm when a thermometer was not calibrated right and food left the kitchen at the wrong temperature. EI #2 replied, food poisoning. EI #2 was asked what time did she calibrate her thermometer on 8/10/16. EI #2 replied, 5:35 a.m. on 8/10/2016. 4) On 8/10/2016 at 10:45 a.m., the surveyor observed the cook taking temperatures of the food on the tray line. The cook took the temperatures of each food item on the tray line. The surveyor compared temperatures with the cook. The cook could not remember the temperature of the chicken and dumplings and the mixed vegetables because she did not write down the temperatures as she tempted each food item. On 8/11/2016 at 1:47 p.m., the surveyor conducted an interview with EI #2. EI #2 was asked when should temperatures be written down on the tray line. EI #2 replied, as soon as they come out of the oven and before serving. EI #2 was asked why should temperatures be written down immediately after each item was tempted on the tray line. EI #2 replied so they will know it was at the proper temperature. EI #2 was asked who was responsible for writing down the temperature when food was tempted on the tray line. EI #2 replied, the cook, or whoever was available. EI #2 was asked why did she not record each food item on the tray line immediately. EI #2 replied, she did not have her book. She was in a hurry to get the trays out in time. EI #2 was asked what was the importance of writing temperatures down immediately. EI #2 replied, so they will not forget. EI #2 was asked what was the potential harm when food items on the tray line was not recorded. EI #2 replied, because the residents may get food that was cold or not the right temperature. EI #2 was asked what was the facility's policy on writing down temperatures of food items on the tray line. EI #2 replied, food temperatures should be logged immediately. EI #2 was asked did all of her food temperatures match the surveyor's. EI #2 replied no. EI #2 was asked why not. EI #2 replied, because she forgot. 5) A review of a policy titled, Hand Washing with no revised date revealed: Policy: .Procedure: 1. When to Wash Hands: . After handling soiled equipment or utensils. On 8/10/2016 at 10:45 a.m., the surveyor observed a dietary worker taking a cloth out of a red bucket and washing a food cart. After washing the food cart, she went to the freezer and starting putting ice packs in the bottom of a cooler. She started taking milk, and juice out of the freezer and putting it on top of the ice packs in the cooler. The worker never washed her hands after washing off the food cart. On 8/11/2016 at 2:02 p.m., the surveyor conducted an interview with EI #3, dietary aide. EI #3 was asked did she wash a food cart off on 8/10/2016 with a cloth from the red bucket. EI #3 replied, yes ma'am. EI #3 was asked when should she wash her hands. EI #3 replied, after every task. EI #3 was asked what did she proceed to do after washing off the cart. EI #3 replied take the milk out of the freezer. EI #3 was asked did she wash her hands before putting milk into a cooler and handling trays on the tray line. EI #3 replied, no ma'am. EI #3 was asked why did she not wash her hands. EI #3 replied she was rushing. EI #3 was asked what was the facility policy on washing her hands. EI #3 replied wash after every task. EI #3 was asked what was the potential harm when she did not wash her hands and a cloth from the red bucket was used to wash a food cart and she proceeded to handle food items. EI #3 replied, contamination.

Based on observation, record review and interview, the facility failed to ensure the lid on the dumpster was closed securely on two of three days of the survey. This had the potential to affect all fifty residents who reside at the facility. Findings Include: A review of a facility's document titled, Waste Disposal with no revised date revealed: .Procedure: .2 Trash will be deposited into a sealed container outside the premises. On 8/9/2016 at 3:30 p.m., the surveyor observed, with the Dietary Manager, the lid of the dumpster was opened. Trash bags on the inside of the can was pushing it open. The surveyor observed the lid opened on 8/10/2016 at 8:29 a.m. On 8/11/2016 at 2:33 p.m., the surveyor conducted an interview with EI #1 (Employee Identifier), Dietary Manager. E#1 was asked was the dumpster closed on the right side. EI #1 replied, no ma'am. EI #1 was asked why not. EI #1 replied, there was an overload in the dumpster instead of going to the next dumpster. EI #1 was asked who was responsible for making sure the dumpster lids were closed. EI #1 replied, Dietary Manager and Housekeeping. EI #1 was asked when the dumpster lid should be closed. EI #1 replied at all times after use. Based on observation, record review and interview, the facility failed to ensure the lid on the dumpster was closed securely on two of three days of the survey. This had the potential to affect all fifty residents who reside at the facility. Findings Include: A review of a facility's document titled, Waste Disposal with no revised date revealed: .Procedure: .2 Trash will be deposited into a sealed container outside the premises. On 8/9/2016 at 3:30 p.m., the surveyor observed, with the Dietary Manager, the lid of the dumpster was opened. Trash bags on the inside of the can was pushing it open. The surveyor observed the lid opened on 8/10/2016 at 8:29 a.m. On 8/11/2016 at 2:33 p.m., the surveyor conducted an interview with EI #1 (Employee Identifier), Dietary Manager. E#1 was asked was the dumpster closed on the right side. EI #1 replied, no ma'am. EI #1 was asked why not. EI #1 replied, there was an overload in the dumpster instead of going to the next dumpster. EI #1 was asked who was responsible for making sure the dumpster lids were closed. EI #1 replied, Dietary Manager and Housekeeping. EI #1 was asked when should the dumpster lid be closed. EI #1 replied at all times after use. EI #1 was asked what was the facility policy on keeping the lids on the dumpster closed. EI #1 replied, make sure they were closed at all times. EI #1 was asked what was the potential harm when dumpster lids were opened. EI #1 replied, it could cause flies and odor. EI #1 replied, make sure they were closed at all times. EI #1 was asked what was the potential harm when dumpster lids were opened. EI #1 replied, it could cause flies and odor.

Based on observations, interview, and record reviews, the facility failed to ensure the residents' living environment was maintained in good repair. This affected 4 of 20 resident rooms on the West Wing, Room Locator (RL) #s 1 through 4, and 4 of 19 resident rooms on the East Wing, RL #s 5 through 8. Also, on the East Wing, the facility failed to ensure the tile outside the soiled utility room remained free of cracks and missing tile and the shower room doorframe remain free of rust and chipped paint. Findings Include: An undated facility policy titled, MAINTENANCE DEPARTMENT POLICIES documented: . 3. Maintenance Standards: .The building is maintained in good repair and kept free of hazards such as those created by any damaged or defective parts of the building .in compliance with state and local codes and regulations . 4. Services to be Performed: Routine repair and maintenance services are to be performed in the following categories: .Carpentry and small scale remodeling .Preventive Maintenance is scheduled by Maintenance Supervisor and is determined by the frequency of maintenance required for equipment and parts; appliances; structures which included walls, ceilings, roof, floors . A review of an undated facility document titled ARBOR WOODS HEALTH AND REHAB CENTER DIRECTOR OF MAINTENANCE JOB DESCRIPTION revealed the following: .General Purpose: To plan, organize and direct the overall operation of the department in accordance with current federal, state and local standards, ensuring that the facility is maintained in a safe, comfortable condition . On 08/09/2016 at 3:16 p.m., during the initial tour of the facility, the following observations were made on the East Wing Hall: RL #5 was noted to have both sides of the wall edges of the built in cabinet area scratched with missing dry wall extending approximately 3 feet up from the floor and a missing section of baseboard in the same area. RL #6's wall by the bed was observed to have three large (approximately 12 inches by 12 inches) unpainted plaster marks. The bottom half of the wall by the built in cabinets had multiple scratches and missing paint. RL #7's door and doorframe had multiple horizontal scratches and scuffs on the bottom half of the door and doorframe. RL #8's closet door and doorframe had multiple scrapes and missing paint extending the length of the door and doorframe. The floor tile outside of the dirty utility room on the East Wing Hall was observed to be cracked and missing a piece of tile approximately 12 inches by 6 inches in size. The shower room doorframe on the East Wing Hall was noted to be rusted from the bottom of the doorframe extending halfway up the frame on both sides of the doorframe. During the initial tour of the facility on 08/09/2016 at 4:10 p.m. the following observations were made on the West Wing Hall: RL #1's tile flooring was observed to have lumps/bulks. RL #2's wall at the side of the bed was observed to have scratch marks through the paint and plaster. RL #3's nightstand was observed to be in need of painting. RL #4's door was observed to have a scratch and the wall was observed to have a white plaster mark. Employee Identifier (EI) #4, Maintenance Director, was interviewed on 08/11/2016 at 1:34 pm. The surveyor along with EI #4 toured the West Wing and East Wing Halls noting the above mentioned concerns. When asked to give his description of the environmental concerns, he explained they were caused by wear and tear and they were mostly easy fixes. He agreed that the areas looked bad and said I think we get use to seeing it. When asked whose responsibility it was to maintain the residents' rooms and living environment, EI #4 explained it was his responsiblilty, and he checked for needed repairs when he had the time. but the staff should also send in a work order when they see an issue. EI #4 further explained that the facility was renovating and hoped to have the residents' rooms done by the end of winter. When asked if there was any reason the repairs were not taken care of before now, EI #4 replied, Not really, I can have most of them fixed by tomorrow. When asked what could be a negative outcome for the residents living in an environment that's in need of repair, EI #4 responded, I wouldn ' t want it to be like this in my house.

Based on record review and interviews, the facility failed to ensure the Surety Bond covered the amount managed in the Resident Trust Fund Account. This had the potential to affect 60 residents with a Resident Trust Fund account. Findings Included: The Facility's policy for "Surety Bond" dated December 2006, and revised 5/17/10, documented: "Our facility has a current surety bond or provides self-insurance to assure the security of all residents' personal funds deposited with the facility. Policy Interpretation and Implementation 1. This facility holds a surety bond to guarantee the protection of residents' funds managed by the facility on behalf of its residents. 2. A Surety bond is an agreement between the facility, the insurance company, and the resident or the State acting on behalf of the resident, wherein the facility and the insurance company agree to compensate the resident for any loss of residents' funds that the facility holds, safeguards, manages, and accounts for. 3. The purpose of the surety bond is to guarantee that the facility will pay the resident for losses occurring from any failure by the facility to hold, safeguard, manage, and account for the residents' funds (i.e., losses occurring as a result of acts or errors of negligence, incompetence or dishonesty). ..." On 8/28/14 at 3:20 p.m., the Resident Trust Fund Account was audited. The bookkeeper, Employee Identifier (EI) #6 who manages the fund provided needed information. There were 65 resident accounts pooled into the Resident Trust fund account. The Resident Trust Fund Account Balance Sheet provided the following information: All funds were deposited to the bank. The total amount of funds in the Trust Fund Prior to 7/01/14 $28,438.50 The running account balance: Receipts for the month (deposits) $44,420.80 Interest posted 1.25 Disbursements (Cash & Check Withdrawals) -52,082.52 Trust Fund Total $20,778.03 EI #6 stated that when the checks come in they are first put into the Resident Trust Fund Account then the liability owned to the facility for the resident's nursing home bill will be withdrawn out of the account. Therefore when the account had deposited the resident checks, and there already was an account balance, the amount was greater than the $50,000.00. The surveyor asked EI #6 how long the checks remained in the Resident Trust account before the liability withdrawals. EI #6 said, it all depended on when the checks came in. EI #6 said between one day to several days. EI #6 said, "usually a couple of days." The surveyor asked her if she realized the amount in the Resident Trust fund account often was over $50.000.00. EI #6 said, yes. While doing the audit, EI #6 was asked if there was a surety bond on the Resident Trust Fund Account. EI #6 provided a surety bond in the amount of $30,000.00 which was dated 5/16/14 through 5/16/15. The surveyor asked EI #6 if she realized the amount in the Resident Trust fund account often was over $50.000.00. EI #6 said, yes. When the surveyor informed EI #6 that the surety bond was not large enough to cover the resident trust fund at all times EI #6 said she did not know why the facility had lower the amount. The Administrator, EI #5 was interviewed on 8/28/14 at 4:30 PM. EI #5 said, she did not know what had happened or when the Surety Bond had been lowered. On Tuesday, 09/02/14 the facility faxed in more Resident Fund Surety Bonds. One bond was dated 2/28/09 for the amount of $52,000. Another bond was dated 8/27/2007 and was increasing the Surety bond from $35,000.00 to $42,500.00.

Based on interviews and record review, the facility failed to ensure two signatures were obtained on the non-narcotic "Medication Destruction Record" sheets. This was found in three of five months of the non-narcotic medication destruction record sheets which were reviewed. Finding Include: On 08/28/14 at 9:10 a.m., the surveyor reviewed the non-narcotic Medication Destruction Record sheets. For the month of September 2013, there were four (4) of the five (5) non-narcotic medication destruction record sheets reviewed which only had one signature (the consulting Pharmacists). For the months of December 2013 and February 2014, four (4) of the four (4) non-narcotic medication destruction record sheets reviewed only had one signature (the consulting Pharmacists). On 08/28/14 at 2:40 p.m., the surveyor conducted an interview with EI #1, the DON (Director of Nursing). The surveyor asked EI #1 how often did the Pharmacist destroy medications. EI #1 said usually every two to three months. The surveyor asked EI #1 how many signatures were needed on the non-narcotic medication Destruction Record sheets. EI #1 said she had been told by the former consulting pharmacist it was one. EI #1 said the Pharmacist usually signed the sheets and she would sometimes go ahead and sign the sheets with him. On 08/28/14 at 4:25 p.m., the surveyor conducted an interview with EI #4, the former Consulting Pharmacist. The surveyor asked EI #4 how many signatures were required on the non-narcotic medication destruction record sheets. EI #4 replied two. The surveyor asked EI #4 had he ever told any staff at the facility that only one signature was enough. EI #4 replied no. The surveyor asked EI #4 what was the purpose of having more than one person to sign when destroying medications. EI #4 said so there would be an accurate count and a witness that the medications are truly being destroyed.

Based on observations, interviews and record review, the facility failed to ensure privacy was maintained for Resident Identifier (RI) #'s 13, 16, 18, 19, and 20 when the licensed nurses did not close the door, pull the privacy curtain or close the blind at the windows during the Medication Administration Observation Pass on 8/27/14. This affected five of 9 residents observed during the Medication Administration Observation. Findings Include: A review of a "Medication Administration Audit" form used by the facility's pharmacy, dated 05/2012, documented: "... 20. Resident privacy is respected ..." 1. RI #13 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #13's physician's orders [REDACTED]. "... METOCLOPRAM ([MEDICATION NAME]) TAB (tablet) 5 MG (milligrams) TAKE 1 TABLET BY MOUTH 4 TIMES DAILY BEFORE MEALS & (and) AT BEDTIME ..." On 08/27/14 at 10:05 a.m., the surveyor observed a medication nurse, Employee Identifier (EI) #2, punch a [MEDICATION NAME] 5 mg tablet from a medication card into a medication cup. EI #2 knocked on RI #13's door and entered the room. RI #13 was sitting on the right side of the room and the blinds at the window were observed to be opened. RI #13 also had a visitor in the room. EI #2 poured the tablet into RI #13's mouth and gave the resident a cup of water to drink. RI #2 failed to ensure the door was closed, the privacy curtain was pulled and the blind at the window was closed before administering RI #13 the medication. 2. RI #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #16's physician's orders [REDACTED]. "... QUEtiapine ([MEDICATION NAME]) 200 mg TAB TAKE 1 TABLET BY MOUTH 4 TIMES DAILY ..." On 08/27/14 at 10:58 a.m., the surveyor observed another medication nurse, EI #3, punch a [MEDICATION NAME] 200 mg tablet from a medication card into a medication cup. EI #3 knocked on RI #16's door. RI #16 was sitting on the right side of the room and the blinds at the window were observed to be opened. EI #3 handed RI #16 the medication cup and RI #16 took the medications along with a drink of water. The blinds remained opened throughout the medication procedure. 3. RI #18 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #18's physician's orders [REDACTED]. "... CARB/LEVO ([MEDICATION NAME]) TAB 25-100 MG TAKE 1 TABLET BY MOUTH 3 TIMES DAILY ... [MEDICATION NAME] SULF (Sulfate) TAB 325 MG TAKE 1 TABLET BY MOUTH 3 TIMES DAILY ..." On 08/27/14 at 11:45 a.m., the surveyor observed EI #2 place a [MEDICATION NAME] 325 mg tablet and a Carb/Levo 25-100 mg tablet into a medication cup. EI #2 knocked on RI #18's door and entered the room. RI #18 was sitting on the right side of the room and the blinds at the window were observed to be opened. EI #2 administered RI #18 the medications leaving the door open, the privacy curtain was not pulled nor were the blinds at the window closed during the medication pass administration observation. 4. RI #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #19's physician's orders [REDACTED]. "... [MEDICATION NAME] ([MEDICATION NAME]) EX (extended) CAP 100 MG TAKE 1 CAPSULE BY MOUTH AT NOON ..." On 08/27/14 at 11:50 a.m., the surveyor observed EI #2 punch a [MEDICATION NAME] 100 mg capsule from the medication card into a medication cup. EI #2 knocked on RI #19's door and entered the room. The blinds at RI #19's window was observed to be opened. EI #2 handed RI #19 the medication cup and RI #19 took the medication. RI #19's door remained opened, the privacy curtain was not pulled and the blind at the window remained opened throughout the observation of the administration of RI #19's medication. 5. RI #20 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #20's physician's orders [REDACTED]. "... [MEDICATION NAME] ([MEDICATION NAME]) TAB 500 MG ... TAKE 1 TABLET BY 3 TIMES DAILY ... [MEDICATION NAME] 1 MG TAB TAKE 1 TABLET BY MOUTH 4 TIMES DAILY ... Pain/fever (Tylenol) tab 500 mg 1 tab po (by mouth) 4 times day ..." On 08/27/14 at 11:25 a.m., the surveyor observed EI #3 place a [MEDICATION NAME] 1 mg tablet, a [MEDICATION NAME] 500 mg tablet and a Tylenol 500 mg tablet into a medication cup. EI #3 entered RI #20's room leaving the door open. RI #20's roommate was sitting in the room and the blind at the window was observed to be opened. EI #3 placed the medications in RI #20's mouth and the resident drank grape juice from the lunch tray to swallow the medications. The blinds at the window remained opened, the privacy curtain was not pulled between the residents and the door remained opened throughout the observation of the medication pass administration. On 08/28/14 at 2:00 p.m., the surveyor conducted an interview the medication nurse, EI #3. The surveyor asked EI #3 how should privacy be provided when administering medications. EI #3 replied pull the privacy curtain and close the door. On 08/28/14 at 2:20 p.m., the surveyor conducted an interview with a second medication nurse, EI #2. The surveyor asked EI #2 how is privacy provided when administering medications. EI #2 replied pull the privacy curtain and close the blind if the resident is next to the window. On 08/28/14 at 2:40 p.m., the surveyor conducted an interview with EI #1, the DON (Director of Nursing). The surveyor asked EI #1 how should the nurses provide for privacy when administering medications. EI #1 said the nurses should knock on the door, wait to be told to come in, either close the door or pull the privacy curtain. The surveyor asked EI #1 what should be done with the blind at the window if it was opened. EI #1 replied, "Close it."