Every finding on record at Ashland Place Health and Rehabilitation, LLC

Based on observation and interview the facility failed to ensure 21 cups of expired yogurt were not left in the cooler. This had the potential to affect 21 of 21 residents to receive the yogurt. Findings Include: On [DATE] at 1:37 PM, during the initial tour of the kitchen the surveyor observed in the walk in cooler 21 cups of yogurt which had expired on [DATE]. On [DATE] at 8:36 AM, an interview was conducted with Employer Identifier (EI) #5 Dietary Manager. EI #5, was asked, what did they see on [DATE] that had expired. EI #5 replied, the yogurt was expired. EI #5 was asked, how often were the dates checked on foods items. EI #5 replied, daily in the am and pm. EI #5 was asked, was the date on the yogurt expired, EI #5 replied, yes. EI #5 was asked, what was the facility policy on expired foods. EI #5 replied, report it to dietary manger and throw it away immediately. EI #5 was asked, what was the potential harm in having expired food. EI#5 replied, it was highly a potential for food born illness in making the resident ill.

Based on observation, interviews, and a review of the facility's Resident Rights, the facility failed to ensure staff did not stand to feed Resident Identifier (RI) #77 the supper meal on 1/21/20. This affected one of three residents observed being fed by staff. Findings Include: A review of the facility's Resident Rights revealed . Resident Rights (a) Resident Rights. The resident has the right to a dignified existence, self determination, and communication with and access to persons and services inside and outside the facility. (e) Respect and dignity. The resident has a right to be treated with respect and dignity, . RI #77 admitted to facility on 12/2/19 with a [DIAGNOSES REDACTED]. A review of RI #77's Admitting Minimal Data Set (MDS) with an Assessment Reference Date of 12/8/19, revealed a (BIMS) Brief Interview for Mental Status score of 99, indicating severely impaired cognitive abilities. The MDS further revealed RI #77 required extensive assistance of one person for feeding. On 1/21/20 at 5:20 PM, the Certified Nursing Assistant (CNA) began feeding RI #77. The CNA was observed standing beside RI #77's chair feeding RI #77 ice cream. On 1/21/20 at 5:22 PM, the surveyor observed the CNA continued to stand while feeding RI #77 the fruit cocktail. On 1/21/20 at 5:26 PM, the surveyor observed the CNA continued to stand while feeding RI #77 the chicken patty. On 1/21/20 at 5:30 PM, the surveyor observed the CNA remained standing while she finished feeding RI #77; she then exited the resident's room. On 1/23/20 at 3:05 PM an interview was conducted with Employee Identifier (EI) #4, CN[NAME] EI #4 was asked what was the usual practice for feeding a resident. EI #4 replied, sitting beside them and communicating. EI #4 was asked if she was standing to feed RI #77. EI #4 replied, yes. EI #4 was asked why did she stand to feed RI #77. EI #4 replied, because RI #77 slides and will try to get up so she stood to the side of RI #77. EI #4 was asked how often RI #77 had tried to get up. EI #4 replied, about a month, once. EI #4 was asked if RI #77 could make any needs known. EI #4 replied, not usually, RI #77 will wave his/her hand. EI #4 was asked how would her standing to feed RI #77 affect RI #77's resident rights. EI #4 replied, it could make them feeling like being forced to do something, but she was thinking she was being safe. EI #4 was asked, what would the harm be in her standing to feed a resident. EI #4 replied, it could be a dignity issue. On 1/23/20 at 3:15 PM, an interview was conducted with EI #3, Social Service Director. EI #3 was asked, what was the practice for staff feeding a resident in the resident's room. EI #3 replied, take the tray in, prepare the resident, prepare the tray then sit down next to the resident and feed them. EI #3 was asked, when should a staff person stand to feed a resident. EI #3 replied, they probably should never stand, they should be sitting next to them. EI #3 was asked what was the problem if the staff was standing to feed a resident. EI #3 replied, it could seem like that staff person does not have patience to help the resident; it would be not treating with them with dignity. EI #3 was asked, what was the potential harm in the staff standing while feeding a resident. EI #3 replied, dignity and the staff was not taking time or patience in feeding that resident.

Based on observations, interviews, and a review of the facility's policies titled, Food Receipt and Storage and Hand-washing Guidelines, the facility failed to ensure honey thickened milks were discarded before the expiration date. The facility also failed to ensure (Employee Identifier) EI #4, a Dietary Aide, washed her hands to prevent cross contamination after putting her hands in her pocket, touching her jacket and picking up a dirty dish off the floor prior to handling the clean dishes. This deficient practice had the potential to affect 122 of 122 residents who received meals from the kitchen. Findings Include: A review of a facility policy titled, Food Receipt and Storage with an effective date of (MONTH) 23, (YEAR), revealed: .PURPOSE: Foods should be received and stored properly to prevent food borne illnesses .PR[NAME]ESS .II. Storage of Foods .e. New items should be placed on the back of shelves, with labels in view, with older items pulled to the front of the shelves for use. The First in First Out (FIFO) system should be use to rotate stock routinely . On 11/27/18 at 3:36 p.m., during the initial kitchen tour, accompanied by EI #3, DM( Dietary Manager), the surveyor observed seven honey thickened milks in the dry storage area with an expiration date of 9/11/18. EI #3 said the facility policy for rotating stock was first in, first out and staff should have rotated stock. EI #3 was asked what did the expiration date mean. EI #3 said they were supposed to dispose of it and not use it. EI #3 was asked why the seven containers of honey thickened milk were not discarded. EI #3 replied it was an oversight. EI #3 was asked what was the potential for harm. EI #3 replied, potential for food borne illness. A review of a facility policy titled, Hand-washing Guidelines, with an effective date of (MONTH) 1, 2002 revealed: .PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses PR[NAME]ESS: .I. Frequency of Hand-washing: Hands should be washed in the following situations: .after hands have touched anything unsanitary, . On 11/28/18 at 9:23 a.m., the surveyor observed EI #4 touch her jacket, put her hands in her pockets and handle the clean dishes. EI #4 also picked up a dish off the dirty floor and then continued touching clean dishes without washing her hands. An interview was conducted on 11/28/18 at 10:50 a.m. with EI #4. EI #4 was asked if she was supposed to put her hands in her pocket and then touch the clean dishes. EI #4 replied no. EI #4 was asked if she was supposed to pick up dishes off the floor and then handle the clean dishes. EI #4 replied no, she just learned today that day she was not, but it was common sense. EI #4 was asked what was the concern with touching her jacket, picking up dirty dishes off the floor and not washing her hands prior to handling clean dishes. EI #4 said contamination.

Based on observation, group interview, staff interview and a review of the Resident Handbook, the facility failed to ensure residents in the group meeting held on 11/28/18 were aware of the survey results and where they were located in the facility. The facility further failed to ensure there were signs posted in the facility indicating the location of the survey results. This deficient practice affected all 10 residents in the group meeting and had the potential to affect all 134 residents who resided in the facility. Findings Include: A review of the Resident Handbook, pages 8-11 documented: .Resident Rights .(g)(1) Information and communication .(g)(10) The resident has a right to .Examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility; . During the group meeting conducted on 11/28/18 at 10:45 a.m., all ten residents who attended stated they did not know where the survey results were located. On 11/28/18 at 11:35 a.m., the surveyor observed a white notebook in the lobby on a table labeled, State Notebook, but no sign was posted indicating where the survey results were located. On 11/29/18 at 8:22 a.m., the surveyor observed a white notebook in the lobby on a table labeled, State Notebook, but no sign was posted indicating where the survey results were located. On 11/29/18 at 9:01 a.m., there were no signs posted throughout the facility indicating where to find the survey results. On 11/29/18 at 9:52 a.m., an interview was conducted with EI(Employee Identifier) #5, Social Work Director. EI #5 was asked how were residents made aware of the survey results and where they were located in the facility. EI #5 said residents were made aware of the survey results if they requested to see them and where they were located. EI #5 was asked who was responsible for ensuring residents were aware of the survey results and where they were located. EI #5 said, Our (Social Work Department) responsibility. EI #5 was asked if there were signs posted throughout the facility indicating where the survey results were located. EI #5 said, No, not that I am aware of. EI #5 was asked why was it important for residents to be aware of the survey results and where they were located. EI #5 said, They (residents) want to know we (facility) are up to standard and in compliance.

Based on observations, interviews and a review of a facility policy titled, Federal Rights of Resident/Guest(s) and a form titled, .JOB DESCRIPTION, the facility failed to ensure residents' rooms and common areas were maintained to provide a safe, clean, comfortable homelike environment. The deficient practice affected Room Locator (RL) #'s 1-24, on three of four units and two resident common areas in the facility and had the potential to affect all 134 residents residing in the facility. Findings Include: A review of a facility policy titled, Federal Rights of Resident/Guest(s), with an effective date of (MONTH) 28, (YEAR), revealed: .PURPOSE: All resident/guest(s) in long term care facilities have rights guaranteed to them under Federal and State law. STANDARD: .(i) Safe environment. The resident/guest has a right to a safe, clean, comfortable and Homelike environment, . A review of a facility document titled, .JOB DESCRIPTION JOB TITLE: Housekeeping Technician, with an effective date of 01/01/93 revealed the following: .GENERAL PURPOSE Under the direction of the Director of Housekeeping is responsible for cleaning and maintaining the floors . cleaning of resident's room and common areas . STANDARD REQUIREMENTS .4 .report and/or correct unsafe .conditions, equipment repair and maintenance needs .ESSENTIAL JOB FUNCTIONS .3. Check equipment for proper functioning and reports any defective equipment .11 . Report to the supervisor any furniture, fixtures, etc. (and so on) that are in need of repair . During the initial tour of the facility on 11/27/18 at 4:42 p.m., the following observations were made: RL#19 - toilet bowl lid was broken in half. RL#20 - three broken slates and a 4th one had a chip missing out of it (blinds broken). RL#21 - one broken slate (at end of blind). RL#22 - two holes in the closet on the left and right side of the door. On 11/28/18 at 11:40 a.m., observations were made on the 200 hall of the following: RL #1 - chipped floor tile, ring of rust around the drain and on the faucet. RL #2 - closet door did not move, it was off track; faucet in bathroom under left handle had a crack in the metal with crumbling edges. RL#3 - closet door did not open, it was off track. RL#4 - faucet in the bathroom under the left handle had broken edges. RL#5 - the left closet door did not work. EI (Employee Identifier) #6, LPN (Licensed Practical Nurse), could not close the closet door and reported she would put in a work order. RL #6 - rust around the bathroom sink drain and faucet, broken pieces of missing tile were in the doorway and in front of the drawers under the television, there was a buildup of debris in the corner. RL #7 - buildup of debris was in the corner under the television, in front of the drawers, at the doorway and at the adjoining wall. RL#8 - rusted bathroom sink drain. RL#9 - rusted bathroom sink drain. RL#10 - rusted bathroom sink drain, missing piece of broken tile was in the doorway and the bottom of the right drawer had the front panel missing. On 11/28/18 at 12:12 p.m., the following observation was made: RL #23 - a door to the smoking area was found to have approximately 1.5 inches of rust exposed through the metal portion of the bottom of door. On 11/28/18 at 12:15 p.m., the following observation was made: RL #23 - the metal frame around the door used by residents to access the courtyard was found with pieces of flaking rust approximately 12 inches above the ground level. On 11/29/18 at 8:08 a.m., a tour of the facility was made EI #2, the Maintenance and Housekeeping Director. EI #2 was asked to describe what he observed. RL #3 - a piece missing from the bottom of the door; a piece of weather stripping was rusted. RL #1 - chipped floor tile, ring of rust around the drain and on the faucet. RL #2 under the faucet handle was corroded and cracked; closet door did not move, off track; faucet in the bathroom under the left handle had broken edges that were crumbling. RL #6- chipped floor tile was in the doorway, corner floor molding was missing, stains that appeared to be rust around the drain and two spots of what appeared to be rust under the faucet. In the corner, on floor beneath the television, appeared to be a wax buildup. EI #2 described this as surface wax that had dirt in it and was pushed up in the corner. RL #7- appeared to be the same buildup as in RL #6. RL #8- appeared to be rust stain in the bathroom sink. RL #9- the bathroom sink had a rust stain that needed to be cleaned RI #10- the same type of stain as RL #9 . RI #12- chipped tile in the doorway. EI #2 reported when the new floors were put down, the man evidently chipped it and that was about a year ago. EI #2 added the front of the drawer was missing and the corner molding was missing RI #11- there was what appeared to be rust at the caulk joint above the sink. RL #13- It definitely needs cleaning around the base of the walls and floors need cleaning. The wall needs to be wiped off. RL #14- the base of the walls and the caulk joint around the tube need to be cleaned. On 11/29/18 1:16 p.m. the surveyor continued observations with EI #2. The following observations were made: RL #15 -EI #2 reported a rusted door casing at the bathroom door. Some soft substance looked like gum on the wall. Paint flaking by the window; old finish material at bottom of the tub. RL #17 -EI #2 reported rust in the window seal, wax buildup in some corners and the bathroom paint was flaky/chalky. RL#18- EI #2 reported the corner molding was missing, the tub had old finish residue in bottom of the tub close to the drain. Wax buildup in some of the corners. The bed had rubbed the paint behind the headboard. The footboard of the first bed had exposed wood that was smooth because the finish was gone. RL#16 -EI #2 reported there was a rusted door casing and wax buildup in some of the corners. There was old finish material in the bottom of the tub. On 11/29/18 at 1:42 p.m., an interview was conducted with EI #2. EI #2 was asked what was the concern of doorway tiles being broken, missing pieces of tile and tile being unleveled and he answered a potential fall. EI #2 was asked what was the concern of persistent wax build. EI #2 answered it looked bad. EI #2 was asked if he was aware of the wax buildup in the corners of resident rooms before the survey started and he answered in some areas but not in the amount of rooms pointed out during the tour. EI #2 was asked what was the concern of old finish residue discoloring the bottom of tubs and he answered it looked bad and it did not look clean. EI #2 was asked what was the concern of the closet doors not being in working order. EI #2 answered there was a slim possibility that they could come off of the track and fall on someone. EI #2 was asked should the closet doors be in working order even if falling on a resident was not a possibility and he answered it was. EI #2 was asked what was the concern of rooms with sinks that had rust stains on the drain and/or the faucet. EI #2 answered it looked bad and was a potential for a skin tear. EI #2 was asked what was the concern with flaky, peeling paint in resident rooms and he answered it looked bad. EI #2 was asked what he saw at the door casing of two of five doors in the courtyard and he answered peeling rust. EI #2 was asked what was the concern of the peeling rust on the door casings and he answered the potential for a skin tear. EI #2 was asked what was the concern of a toilet tank lid being broken in half, with a broken half of the lid being left on the tank where a resident used the restroom unsupervised. EI #2 answered a potential for a skin tear. An interview was conducted on 11/29/18 at 3:02 p.m. with EI #1, the Administrator. EI #1 was asked what was his expectations of housekeeping staff in providing a clean environment. EI #1 answered he expected them to keep it clean like they would at their house. EI #1 was asked what was his expectations of maintenance to keep the environment safe and homelike. EI #1 answered if they see it or if they are notified about it, to fix it as soon as possible. This citation was written as a result of the investigation of complaint/report #AL 945.

Based on interview and a review of a facility document titled, Facility Assessment, the facility failed to evaluate and identify areas of the environment needing to be maintained. This deficient practice had the potential to affect all 134 residents residing in the facility. Findings Include: Cross Reference F584. A review of a document titled, Facility Assessment, dated 11/19/18, revealed the following: .The following criteria were examined and evaluated by our team . Physical environment .considerations necessary for resident population. Equipment necessary for resident population . During the recertification the survey team identified multiple environmental concerns including: missing floors tiles, rusted doorframes, rusted bathroom sinks, broken bathroom fixtures, peeling paint, dirty and wax build up on floors, broken closet doors, broken furniture and other environmental concerns. On 11/29/18 at 4:56 PM, an interview was conducted with Employee Identifier (EI)#1 Administrator. EI #1 was asked if EI #2, Maintenance Supervisor, was involved as a participant with the facility assessment. EI #1 said Yes . EI #1 was asked when was the facility assessment updated. EI #1 said, Last week . EI #1 was asked why did the facility assessment not reflect the needed maintenance repairs. EI #1 said, I don't have an answer for that. EI #1 was asked was anything (a plan) put in place to take care of the environment/maintenance concerns. EI #1 said, No. This citation was written as a result of the investigation of complaint/report #AL 945.

Based on interviews, record reviews, and a review of a facility policy titled, Federal Rights of Resident/Guest(s), the facility failed to ensure privacy was provided while a resident used the phone. This affected RI (Resident Identifier) #1, one of five residents that were individually interviewed. Findings Include: A review of the Facility's Policy & Procedure titled Federal Rights of Resident/Guest(s) with an effective date of November 28, 2016 revealed: .PURPOSE: . (g)(1) Information and communication . All resident/guest(s) in long term care facilities have rights guaranteed to them under Federal and State law. (g)(6) The resident/guest has the right to have reasonable access to the use of a telephone ., and a place in the facility where calls can be made without being overheard. This includes the right to retain and use a cellular phone at the resident/guest(s) own expense. A review of RI #1's medical record revealed the resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a quarterly Minimum Data Set assessment dated [DATE], revealed RI #1 had a Brief Interview for Mental Status score of 11 out of a possible 15. This score indicated RI #1 was moderately impaired for cognitive skills for daily decision making. During an interview with RI #1 at 4:55 p.m. on 11/14/17, RI #1 was asked where he/she made personal phone calls. RI #1 answered at the Nurse's station. RI #1 was asked if privacy was provided when they used the phone to make personal calls. RI #1 answered no. RI #1 was asked if not having privacy during phone calls mattered. RI #1 answered, Well certainly. During an interview with EI (Employee Identifier) #9, the Registered Nurse/Unit Manager, at 10:21 a.m. on 11/15/17, she was asked how privacy was provided for residents when they made phone calls at the Nurse's station. EI #9 answered staff members step away after the call was started. EI #9 was asked if the Nurse's station was a private area. EI #9 answered, It is not. EI #9 was asked if privacy should be afforded to residents during phone calls and she answered, Yes. EI #9 was asked what was the facility policy regarding resident privacy. EI #9 answered, They have the right to privacy. During an interview with EI #13, the Director of Nursing Services, at 10:56 a.m. on 11/16/17, she was asked what was the concern of residents not having privacy while on the phone. EI #13 answered, If they wish not to be overheard, there is a potential they could be overheard. EI #13 was asked what was the facility's policy regarding resident privacy. EI #13 answered, My expectation is that they receive as much privacy as possible, as much as they would receive at their own home.

Based on observations, interviews, record review, and a review of a facility policy titled, Privacy Upon Entering Resident's Room, the facility failed to ensure staff knocked on residents' door prior to entering the room. This affected RI (Resident Identifier) #s 3, 17, and 19, three of 127 residents residing in the facility. Findings Include: A review of the facility's Policy and Procedure titled Privacy Upon Entering Resident's Room with an effective date of November 6, 2014 revealed: . PURPOSE: The resident has the right to privacy and confidentiality. STANDARD: Resident right to privacy will be honored. PR(NAME)ESS: 1. Prior to entering Resident's room, knock on door and ask permission to enter. 2. If resident able to respond, await permission to enter. 3. If resident unable to respond, announce entrance. RI #3 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #3's most recent full MDS (Minimum Data Set), assessment dated [DATE], indicated the BIMS (Brief Interview for Mental Status) score of 0 out of a possible 15. This indicated RI #3's cognition was severely impaired. RI #3 required extensive to total assistance with all ADLs (Activities of Daily Living). RI #17 was admitted to the facility on [DATE] with diagonoses including, [MEDICAL CONDITION] and Dementia. RI #17's most recent Quaterly MDS, dated [DATE], revealed the BIMS score of 0 out of a possible 15. This score indicated RI #17's cognition was severely impaired. RI #19 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. RI #19's most recent quarterly MDS assessment dated [DATE], revealed the BIMS assessment was completed by staff due to RI # 19's cognition was severely impaired and rarely or never understood. RI #19 scored 0 out of 15. This indicated RI #19's cognition was severely impaired. During the initial tour of the facility on 11/13/17 EI (Employee Identifier) #12, a CNA (Certified Nursing Assistant), was observed at 1:35 p.m. entering RI #19's room without knocking or announcing her entrance. An observation was made on 11/13/17 at 5:38 p.m. of EI #15, a CNA, entering RI #17's room without knocking. An observation was made on 11/13/17 at 5:39 p.m. of EI #16, a CNA, entering RI #19's room without knocking. An observation was made on 11/13/17 at 6:06 p.m. of EI #11, a CNA, entering RI #17's room without knocking. On 11/15/17 at 10:18 a.m., EI #1, a CNA, EI #2, a CNA, and EI #3, a CNA, entered RI #3's room. EI #1 was heard by the surveyor telling EI #3 to knock on the resident's door but EI #1 nor EI #3 knocked on the resident's door prior to entering the room. EI #2 entered RI #3's room shortly thereafter and did not knock on the door. All three staff walked straight into RI #3's room without knocking and began to start care. During an interview with EI #15 (CNA) on 11/13/17 at 6:24 p.m., EI #15 was asked what she was supposed to do before entering a resident's room and she answered to knock. EI #15 was asked why and she answered respect and dignity. During an interview with EI #11 (CNA) on 11/13/17 at 6:25 p.m., EI #11 was asked what she should do prior to entering a resident's room. EI #11 answered to wash hands, knock on the door, introduce yourself, let the resident know what you are going to do, and wash hands again. EI #11 was asked why it was important to knock on the door prior to entering a room. EI #11 answered for privacy. EI #11 was asked by not knocking on the door before entering, how could that make the resident feel. EI #11 answered it could make them feel violated, like you don't respect their privacy. EI #11 was asked how she knew to knock prior to entering resident rooms. EI #11 answered she was taught in class and in orientation. During an interview with EI #16 (CNA) on 11/13/17 at 6:30 p.m., EI #16 was asked what she was supposed to do before entering a resident's room and she answered to knock first. EI #15 was asked why and she answered it was their home. During an interview with EI #1 (CNA) on 11/16/17 at 9:54 a.m., EI #1 was asked what should she do prior to entering a resident's room and she stated knock on the door. When asked why should she knock on the resident's door prior to entering, EI #1 stated, That's their privacy and home. It's a dignity issue. EI #1 was asked how could this affect the resident and she stated could make them feel upset and violated. During an interview with EI #12 (CNA) on 11/16/17 at 10:05 a.m., EI #12 was asked what she should do prior to entering a resident's room. EI #1 answered, You should knock on the door. EI #12 was asked why it was important to knock on the door prior to entering a resident's room. EI #12 answered, For the patient's dignity and it's their right. EI #12 was asked by not knocking on the door before entering how could that make a resident feel. EI #12 answered, Very uncomfortable, because it's like their house. They could feel like someone is barging in and invading their privacy. During an interview with EI #2 (CNA) at 10:15 a.m. on 11/16/17, EI #2 was asked what should she do prior to entering a resident's room. EI #2 stated knock, tell the resident their (staff) name, what they (staff) were going to do to the resident, provide privacy, and make sure the resident was covered. When asked why should she knock before entering a resident's room, EI #2 stated they never know who's in the room, provide privacy and let them know someone was coming in. EI #2 was asked how could this affect the resident and EI #2 stated the resident could feel like it was intrusion, it's their residence. During an interview with EI #8, an RN (Registered Nurse) on 11/16/17 at 10:27 a.m., EI #8 was asked what staff members were trained to do prior to entering a resident's room. EI #8 answered they should knock at the door because that is their place of residence. EI #8 was asked how could not knocking before entering make a resident feel. EI #8 answered, That is intrusion. EI #8 was asked how not knocking before entering could make a cognitively impaired resident feel. EI #8 answered, That's embarassment. During an interview with EI #13, the Director of Nursing Services, on 11/16/17 at 10:56 a.m., EI #13 what was the facility's policy regarding knocking on doors before entering a resident's room. EI #13 answered staff should knock on the door and receive permission to enter before entering from verbal residents. Staff should knock on the door and announce entrance to non-verbal residents. EI #13 was asked how it could make residents feel if staff did not knock prior to entering a resident's room. EI #13 answered, It could make them uncomfortable. EI #13 was asked about the cognitively impaired residents and she answered, It could startle them.

Based on an observation, interviews, record reviews, and a review of the facility policy titled, Diet Orders, the facility failed to ensure the Physician's diet order was followed. No meat was served at a breakfast meal for RI (Resident Identifier) #2. This affected RI #2, one of twelve residents whose meals were observed. Findings Include: A review of the facility's Policy and Procedure titled, Diet Orders, with an effective date of August 23, 2017, revealed: . PURPOSE: To provide a standardized method for the preparation of foods to resident/guests, consistent with the resident/guests' individual needs and recommended dietary allowances (RDA). STANDARD: The physician's order should specify the appropriate diet for each resident/guest to assure that the resident/guest receives and consumes foods in the appropriate form and/or the appropriate nutrition content. A review of the medical record revealed RI #2 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Annual Minimum Data Set, assessment dated [DATE], indicated RI #2 required assistance of one person for eating. A review of the November Physician's orders for RI #2 indicated RI #2 was to receive a Regular pureed diet. A review of the meal card with a list of what RI #2 was to receive for breakfast on 11/14/17 revealed: . DOUBLE PORTIONS ALL MEALS . Pureed Sliced Turkey . An observation was made at 7:48 a.m. on 11/14/17 of RI #2's breakfast meal served without the double portion of pureed turkey as indicated on the meal card. During an interview with EI (Employee Identifier) #14, a CNA (Certified Nursing Assistant), at 7:48 a.m. on 11/14/17 during the initial observation, EI #14 was asked why the pureed turkey was not on RI #2's plate. EI #14 answered, I don't know, the people in the kitchen do that. EI #14 was asked what she did when something was missing from a resident's tray and she answered, Nothing. During an interview with EI #5, a Dietary Aide, at 12:54 p.m. on 11/14/17, EI #5 was asked why RI #2 did not receive turkey with his/her breakfast. EI #5 answered, We are waiting on a truck to come in. EI #5 was asked what was indicated to be served on the meal card. EI #5 responded pureed turkey, pureed biscuits, cream of wheat, and applesauce. EI #5 was asked if it was followed and she answered, No. EI #5 was asked what was the facility's policy regarding following a resident's diet. EI #5 answered, Look at the card and make sure they get what they are supposed to have. EI #5 was asked what she should do if plating food for residents and she didn't have something they were supposed to get. EI #5 answered to find a substitute that the resident would like. EI #5 was asked who she notified that the resident did not get a double portion of meat. EI #5 named the cook, EI #6. During an interview with EI #6, the Cook, at 9:00 a.m. on 11/15/17, EI #6 was asked why RI #2 did not receive turkey with his/her breakfast. EI #6 answered, We ran out. We were waiting on the truck. EI #6 was asked if the meal card was followed for RI #2 and she answered, No. EI #6 was asked what was the facility's policy regarding following a resident's diet. EI #6 answered, All of it is supposed to be followed. EI #6 was asked what should be done if something a resident was supposed to be served was not available. EI #6 answered, Try to substitute. EI #6 was asked why that was not done for RI #2 at breakfast on 11/14/17. EI #6 answered, I just didn't know what to do. EI #6 was asked who she told about not having turkey. EI #6 answered she did not tell anyone and she was just waiting for the truck that usually arrived at 5:30 a.m. on Tuesdays. During an interview with EI #7, the Dietary Manager, at 9:33 a.m. on 11/15/17, EI #7 was asked why RI #2 did not receive turkey with his/her breakfast. EI #7 answered, We ran out, the truck was scheduled to come in. EI #7 was asked what she did and she answered, I told the cook when the truck came in to take it to (named the resident). EI #7 was asked if that happened and she answered no. EI #7 was asked if the tray card was followed for RI #2 at breakfast on 11/14/17. EI #7 answered, Except for the turkey. EI #7 was asked the importance of RI #2 getting their double portion of turkey and she answered his/her meal would be imbalanced. EI #7 was asked what was the facility's policy regarding a resident's diet order being followed. EI #7 answered, They should follow it. EI #7 was asked what should be done if something was not available that a resident was supposed to be served. EI #7 answered, Notify the Manager and we are supposed to substitute. During an interview with EI #10, the Registered Dietitian, at 10:15 a.m. on 11/16/17, EI #10 was asked what was the concern of RI #2 not getting their double portion of turkey with breakfast. EI #10 answered not getting enough protein. EI #10 was asked if the turkey was not available, what should have been done. EI #10 answered an alternate should have been offered.

Based on observations, interviews, record reviews, and a review of Potter and Perry's FUNDAMENTALS OF NURSING, the facility failed to ensure the plan of care was followed regarding meals served with items missing for RI (Resident Identifier) #1 and RI #2. This affected RI #1 and RI #2, two of fourteen residents whose care plans were reviewed. Findings Include: A review of Potter and Perry's Fundamentals of Nursing, Ninth Edition, with a Copyright date of 2017, Chapter 18 titled, Planning Nursing Care, page 248 revealed: . In any health care setting a nurse is responsible for providing a nursing plan of care for all patients. A nursing care plan includes diagnoses, goals and/or expected outcomes, specific nursing interventions, and a section for evaluations findings so any nurse is able to quickly identify a patient's clinical needs and situation. The plan gives all nurses a central document that outlines a patient's diagnoses/problems, the plan of care for each diagnoses/problem, and the outcomes for monitoring and evaluating patient progress. A well-planned, comprehensive nursing care plan reduces the risk for incomplete, incorrect, or inaccurate care. A review of RI #1's medical record revealed the resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a quarterly MDS (Minimum Data Set), assessment dated of 8/13/17, revealed RI #1 had a BIMS (Brief Interview for Mental Status) score of 11 out of a possible 15. This score indicated RI #1 was moderately impaired for cognitive skills of daily decision making. A review of the plan of care for RI #1, with a next review date of 2/7/18, revealed a care plan goal of: I WILL NOT HAVE SIGNIFICANT WEIGHT LOSS X (times) 90 DAYS . Intervention PROVIDE WITH FOOD/BEVERAGE PREFERENCES . A review of the meal card with a list of what RI #1 was to receive for dinner on 11/13/17 revealed: . Chicken & (and) Dumplings . Sliced Tomatoes . Fruit Cocktail . Iced tea - 8 oz (ounces) . An observation was made at 5:35 p.m. on 11/13/17 of RI #1's dinner meal served without any iced tea (or other beverage) as indicated on the meal card. At 6:02 p.m., the meal was completed without any staff offering the resident the tea or a substitute. During an interview on 11/13/17 at 6:15 p.m., with EI (Employee Identifier) #14, a CNA (Certified Nursing Assistant), was asked what fluids RI #1 was supposed to have been served with the evening meal. EI #14 answered she had asked the Nurse (EI #17). EI #14 reported the Nurse had looked at the meal card and said to take the tray like it was (without any fluids) because the resident was on a fluid restriction. During an interview on 11/13/17 at 6:36 p.m., EI #17 a RN (Registered Nurse) was asked what fluids RI #1 was supposed to receive with the evening meal. EI #17 answered the resident was on a fluid restriction and that dietary was supposed serve what the resident was to get. A review of the medical record revealed RI #2 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Annual Minimum Data Set, assessment dated [DATE], indicated RI #2 required assistance of one person for eating. A review of the plan of care for RI #2, with a next review date of 2/6/18, revealed a care plan goal of: I WILL NOT HAVE SIGNIFICANT WEIGHT LOSS X (times) 90 DAYS . Intervention DIET AS ORDERED PER MD (Medical Doctor) . A review of the meal card with a list of what RI #2 was to receive for breakfast on 11/14/17 revealed: .DOUBLE PORTIONS ALL MEALS . Pureed Sliced Turkey . An observation was made at 7:48 a.m. on 11/14/17 of RI #2's breakfast meal served without the double portion of pureed turkey as indicated on the meal card. During an interview with EI #8, an LPN (Licensed Practical Nurse), at 10:27 a.m. on 11/16/17, EI #8 was asked what was the concern of not following the plan of care. EI #8 answered, If the plan of care is not followed, we fall short of getting the results which were intended when the plan of care was put in place. EI #8 was asked what was the facility policy regarding following the plan of care. EI #8 answered, To implement to the letter. During an interview with EI #13, the Director of Nursing Services, at 10:56 a.m. on 11/16/17, EI #13 was asked what was the concern of not following the plan of care. EI #13 answered, The plan of care has been set up by the Interdisciplinary team to meet the resident's needs. EI #13 was asked what staff members were trained to do with the plan of care. EI #13 responded to follow the plan of care and if it was inappropriate for the resident's needs, it should be amended.

Based on observations, interviews, and record review, including Potter and Perry's Fundamentals of Nursing, the facility failed to ensure staff provided incontinence care to RI (Resident Identifier) #3 in a manner to prevent cross-contamination on a resident with a pressure ulcer. This affected RI #3, one of five residents observed for incontinence care. Findings Include: A review of Potter and Perry's Fundamentals of Nursing, Ninth Edition, with a Copyright date of 2017, Chapter 40 titled Hygiene, page 858 and 859, SKILL 40-1 BATHING AND PERINEAL CARE . revealed: . r. Wash back. (This follows both female and male perineal care.) . (3) Next move from back to buttocks and anus. Have patient remain in prone or side-lying position and keep covered to avoid chilling. Clean anus and buttocks area. (4) If fecal material is present, enclose in fold of underpad or toilet tissue and remove with disposable wipes. (5) Clean buttocks and anus, washing front to back . Clean, rinse, and dry area thoroughly. If needed, place a clean absorbent pad under patient's buttocks. RI #3 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #3's most recent full MDS (Minimum Data Set), assessment dated [DATE], indicated a BIMS (Brief Interview for Mental Status) score of 0 out of a possible 15. This indicated RI #3's cognition was severely impaired. RI #3 required extensive to total assistance with all ADLs (Activities of Daily Living) and was totally incontinent of bowel and bladder. A review of RI #3's care plans revealed: Care Plan Description . TOTALLY INCONTINENT OF BOWEL AND BLADDER, Care Plan Goal I WILL NOT HAVE COMPLICATIONS R/T (Related To) INCONTINENCE OF BLADDER AND BOWEL AEB (As Evidenced By) NO SKIN BREAKDOWN AND NO UTI (Urinary Tract Infection) X (times) 90 DAYS AEB NO FEVER, NO CLOUDY URINE. Intervention: DISPOSABLE BRIEF PROGRAM, Intervention: PERICARE AFTER EACH INCONTINENT EPISODE . On 11/15/17 at 10:25 a.m., EI (Employee Identifier) #1, a CNA (Certified Nursing Assistant), with the assistance of EI #2, a CNA, provided incontinence care to RI #3. After cleaning the front peri (perineal) area of RI #3, EI #2 rolled RI #3 onto his/her left side. EI #1 began cleaning the resident's rectal area when RI #3 had a bowel movement during the cleaning. EI #1 removed the stool from the rectal area and cleaned the rectal area but did not clean the buttocks. EI #1 removed her gloves, washed her hands, and put on new gloves. RI #3 was rolled onto his/her back and EI #1 began recleaning the front area. EI #2 rolled RI #3 his/her onto left side. After removing her gloves and washing her hands, EI #1 put on clean gloves and began cleaning the rectal area again. The buttocks of RI #3 were not cleaned. At 10:44 a.m. on 11/15/17, the wound treatment nurse began providing pressure ulcer treatment to RI #3. During the wound treatment, RI #3 had a bowel movement. After wound treatment, EI #2 (CNA) provided incontinence care to RI #3. EI #2 removed the stool with disposable wipes and cleaned the rectal area. The buttocks of RI #3 were not cleaned. During an interview with EI #1 (CNA) on 11/16/17 at 9:56 a.m., EI #1 was asked what was the process for incontinence care. EI #1 stated after cleaning the front peri area, wipe the butt cheek and then the other butt (buttock) cheek using different wipes then wipe the rectal area. EI #1 stated if the resident had a bowel movement to stop, wash hands, clean the resident then re-clean the front, then the backside again. EI #1 was asked what was the concern of not cleaning the buttocks, especially after a bowel movement, and EI #1 stated break down and odors. During an interview with EI #2 (CNA) on 11/16/17 at 10:18 a.m., EI #2 was asked what was the process for incontinence care. EI #2 stated after cleaning the front peri area, wash hands and put on gloves. EI #2 stated wipe the side of the butt cheeks from top to bottom and do both sides. EI #2 was asked what was the concern of not cleaning the buttocks, especially after a bowel movement, and EI #2 stated germs, make them have bedsores, odor, make the resident itch and chaffed. During an interview with EI #4, ADON (Assistant Director of Nursing)/Infection Control Nurse, on 11/16/17 at 11:43 a.m., EI #4, was asked if the buttocks should be cleaned during incontinence care and she stated yes. EI #4 was asked what was the concern if a resident had a bowel movement, the rectal area was cleaned but the buttocks were not. EI #4 stated skin irritation, breakdown, deterioration of the skin, and infection could possibly increase. EI #4 was asked what was the concern of a resident with a pressure ulcer on the sacrum and buttock area and the buttocks were not cleaned during incontinence care. EI #4 stated it will increase contamination of the wound and increase the chance for infection of the wound.

Based on observations, interviews, and record reviews, the facility failed to ensure: 1. Ice cream was not observed soft to the touch in the walk-in freezer during the initial tour of the kitchen on 10/17/16. 2. The inside of the ice machine was not observed soiled during the initial tour. 3. Wet nesting was not observed on pans and trays stacked in the kitchen during the initial tour. 4. Dietary staff members were not observed with earrings uncovered on two of four survey days. 5. A dietary staff member did not place the fingers of her bare hands onto the surface of clean bowls during a dish washing observation on 10/18/16. These deficiencies had the potential to affect 139 residents served meals from the kitchen. Findings include: 1. A review of the Food Code 2013 revealed: . Temperature and Time Control 3-501.11 Frozen Food. Stored frozen FOODS shall be maintained frozen. A review of the facility's Policy and Procedure titled: Food Receipt and Storage, with an effective date of August 21, 2013, revealed: . PROCESS: . II. Storage of Foods: . i. Refrigerated and frozen items should be checked to be sure the item is still cold or frozen and packages are intact. On 10/17/16 at 2:30 p.m., ice cream was observed soft in the walk-in freezer. Three of three individual containers broke when squeezed, and EI (Employee Identifier) #1, the Dietary Manager, was present during the observation. EI #1 threw the two boxes of ice cream away. 2.) A review of the facility's Policy and Procedure titled: Cleaning of Miscellaneous Equipment and Utensils, with an effective date of March 17, 2016 revealed: . 22. Ice Machine, Dispensers, Chests: (at least monthly) . · Transfer ice to clean container · Wash machine, inside and outside, including legs and handle · Rinse · Sanitize · Dry . A review of the Food Code 2013 revealed: . Frequency 4-602.11 Equipment Food-Contact Surfaces and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be cleaned: . (4) In EQUIPMENT such as ice bins and BEVERAGE dispensing nozzles and enclosed components of EQUIPMENT such as ice makers, . (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold. On 10/17/16 at 2:33 p.m., the inside of the ice machine was observed soiled with a black substance on the top of the lid. There was also a dark stain in the top, back area of the ice machine. EI #1 said the stained area on the top of the lid was possibly dust. 3. A review of the facility's Policy and Procedure titled: Three Compartment Sink Sanitization, with an effective date of April 20, 2007, revealed: PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses. PROCESS: . Step Three(:) Allow pots/utensils to air dry; Store pots upside down or covered. On 10/17/16 at 2:35 p.m., five of five pans were observed stacked wet. Water spilled out from the pans when they were lifted. On 10/17/16 at 2:40 p.m., three of three trays were observed with moisture on the surface of the trays. The trays were stacked on a table in the kitchen prep area. 4. A review of the 2013 US (United States) Food and Drug Administration Food Code revealed: Jewelry 2-303.11 Prohibition. Except for a plain ring such as a wedding band, while preparing FOOD, FOOD EMPLOYEES may not wear jewelry including medical information jewelry on their arms and hands. During the tour on 10/17/16 at 2:10 p.m., two dietary workers were observed wearing stud earrings uncovered in the dietary prep area. EI #1 had a pair of small looped earrings uncovered in the kitchen prep area. On 10/18/16 at 11:50 a.m., a dietary worker was observed on the tray line with a pair of stud earrings that were not covered by her hair restraint. The Dietary Cook, EI #3, was observed on the tray line with a looped earring not covered by her hair restraint. 5. A review of the 2013 food code revealed, . 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLESERVICE and SINGLE-USE ARTICLES and: .(E) After handling soiled EQUIPMENT or UTENSILS; (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; . On 10/18/16 at 2:15 p.m., an observation was made of dish washing. EI #2, a Dietary Aide, was observed to place the fingers of her bare hands inside plastic serving bowls. EI #2 was not observed to wash her hands before or after the observation. An interview was conducted on 10/19/16 at 4:10 p.m. with EI #2, a Dietary Aide. EI #2 was asked what was the facility's policy regarding earrings in the kitchen. EI #2 said the staff had to wear stud earrings and the earrings had to be covered up. EI #2 also said the staff were allowed to wear a wedding band. EI #2 was asked what the concern would be when earrings were worn uncovered in the kitchen while preparing food. EI #2 said if the earrings were not properly covered the staff had to take them off. EI #2 said everything was supposed to be covered. The surveyor shared the observation of EI #2 touching her clothing then reaching inside the plastic bowls and the plates, and asked what would be the concern. EI #2 answered germs and cross contamination. EI #2 was asked what was the facility's policy for drying pans, trays, plates, etc. (etcetera) EI #2 said she was not the dishwasher. EI #2 was asked what was the concern with wet nesting. EI #2 said the dishes were to air dry, everything was supposed to air dry because if the dishes were wet it could cause germs. On 10/20/16 at 9:55 a.m., an interview was conducted with EI #3. The surveyor asked EI #3 was she wearing earrings uncovered in the food prep area on 10/17/16 and 10/18//16. EI #3 stated, Yes, one small loop in the upper ear lobe. I won't wear them again. EI #3 was asked what was the potential harm for wearing earrings in the food prep area. EI #3 stated, It might fall out of my ears into the food. The surveyor asked EI #3 did she observe wet pots and pans in the kitchen on 10/17/16. EI #3 stated, Yes. EI #3 was asked what was the concern. EI #3 stated, We are not supposed to have wet nesting. It can cause illness, and make someone sick. The surveyor asked EI #3 what was the concern with the ice maker on 10/17/16. EI #3 said she did not see the dust in the machine. She said the maintenance department staff cleaned it out. She also stated the ice could have become contaminated. The surveyor asked EI #3 what was the concern with the ice cream on 10/17/16. EI #3 said the ice cream freezer was broken. She stated, It went out a few days ago. She said there was a problem with the plug, and they took the ice cream out of the ice cream freezer and put it in the walk-in freezer. When the surveyor asked EI #3 what was the concern with the soft ice cream, EI #3 stated, It should be at the correct temp (temperature). It could sour and not have good nutrition. On 10/20/16 at 10:25 a.m., an interview was conducted with EI #1. EI #1 was asked what was the concern regarding staff wearing earrings in the kitchen uncovered by hair nets. EI #1 stated, It could cause cross contamination if it falls in the food. EI #1 was asked what the concern was regarding the observation of soft ice cream during the tour of the kitchen. EI #1 stated, Food borne illness. EI #1 was asked what was the facility's policy of storing frozen items such as ice cream in the freezer. EI #1 stated it should be below zero and frozen solid. EI #1 was asked what was the concern regarding the observation of the ice machine during the tour on 10/17/16. EI #1 stated dust was inside the lid and there was a dark stain in the back of the ice machine. EI #1 was asked how often the ice machine was cleaned. EI #1 stated the machine was cleaned monthly. EI #1 was asked what was the potential concern with a soiled ice machine. EI #1 stated there was potential for cross contamination and potential for food borne illness. EI #1 stated Maintenance had cleaned the machine on 10/18/16 (after the observation was made on tour). EI #1 was asked what the concern was regarding the observations of wet nesting on 10/17/16. EI #1 stated cross contamination and infection control. The surveyor asked EI #1 what was the facility's policy on the storage of items after they were washed. EI #1 stated they should be air dried. She stated they normally laid the pots at an angle to air dry. EI #1 stated she did not know what happened during the tour. EI #1 stated their pot washer was no longer employed as of last week. EI #1 was asked what the concern was regarding an employee who was observed to touch her clothing and then place her bare hands inside plastic bowls. EI #1 stated cross contamination.

Based on observations, interviews, and record reviews, the facility failed to ensure the dumpster top was not left open on 10/17/16. The facility also failed to ensure debris was not left in and around the dumpster area as observed on two of four days of the survey. The facility further failed to ensure the dumpster was not soiled and the top was not in need of repair and was maintained in a manner to prevent the potential for harborage and feedings of pests. This was observed on two of four survey days, and had the potential to affect all 139 residents who resided in the facility. Findings include: A review of the 2013 Food Code by the United States (U.S.) Public Health Service and the Food and Drug Administration (FDA) revealed: . 5-501.15 Outside Receptacles. (A) Receptacles and waste handling units for REFUSE, . used outside the FOOD ESTABLISHMENT shall . have tight-fitting lids, doors, or covers. (B) Receptacles and waste handling units for REFUSE . shall be installed so . insect and rodent attraction . are minimized . A review of the facility's Policy and Procedure titled, Garbage and Refuse, with an effective date of February 1, 2002, revealed: . PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses. STANDARD: Garbage and refuse containers should be free from cracks or leaks and covered when not in use. PROCESS: . e. Refuse containers and dumpster's kept outside the facility should have tightly fitting lids and should be kept covered when not being loaded. f. Dumpster's should be emptied according to the facility contract; garbage should not accumulate or be left outside the dumpster . On 10/17/2016 at 2:45 p.m., the facility dumpster was observed with one lid broken and open over half of the top of the dumpster, thus leaving the dumpster open. The dumpster was covered with a dirt and a grease-like appearance. Trash was observed on the grounds surrounding the dumpster. A top to a cup, leaves, debris, a milk carton, and folded boxes were observed on the grounds surrounding the dumpster. There were also two used gloves and a spoon in the area surrounding the dumpster. An odor was present during the observation. Employee Identifier (EI) #1, a Certified Dietary Manager (CDM) and EI #5, the House Keeping, were in attendance during this observation. On 10/18/16, at 8:20 a.m., a second observation of the facility dumpster was made. Folded boxes, leaves and limbs were observed behind the dumpster. The dumpster remained extremely soiled and two insects were observed flying around the dumpster. EI #5 was present during the observation. She said the Maintenance Director, EI #7, would probably order a new dumpster. She said she would speak to him about the concern. On 10/20/16 at 10:10 a.m., an interview was conducted with EI #7. EI #7 was asked what was the concern regarding the above observations of the facility's dumpster. EI #7 said he was told it needed to be replaced and the dumpster was dirty. The surveyor asked EI #7 how often was the dumpster and the surrounding area cleaned. He said the area was pretty much cleaned every day and the dumpster can was replaced as needed. EI #7 stated when he saw the dumpster the lid was down and it had cracks in it. It was getting close to the point of breaking off and the dumpster was pretty dirty. EI #7 was asked if he had a log to show when the dumpster and dumpster areas were cleaned. EI #7 stated the facility had a log that documented the staff walked and picked up trash around the building. He said the dumpster area was included in that area. He said that was done Monday through Friday. On 10/20/16 at 10:25 a.m., an interview was conducted with EI #1. EI #1 was asked what was the concern regarding the dumpster and the surrounding area during the observation on 10/17/16. EI #1 stated it was not clean. EI #1 stated the lid was left open, there was a potential for rodents and infestation of bugs, and there was an odor. On 10/20/16 at 11:00 a.m., an interview was conducted with EI #5. EI #5 was asked what did she observe during the observation of the dumpster on 10/18/16. EI #5 stated the dumpster was nasty and dirty. There was trash on the grounds and the area was dirty. She also stated there was an odor the first day. The surveyor asked EI #5 how often was the area cleaned. She stated, Maintenance blows the area daily and house keeping helps to keep it clean.

Based on observations, interviews, and record reviews, the facility failed to ensure: RI (Resident Identifier) #9's nebulizer mask was not observed on the floor on two of four survey days. This affected one of twenty one sampled residents. Findings include: A review of the facility's Policy and Procedure titled, Nebulizer, with an effective date of May 1, 2004, revealed: PURPOSE: To administer medication through continuous aerosol nebulizer. PROCESS: . V. After completion of therapy a.) Remove nebulizer container b.) Rinse container with fresh tap water c.) Dry with clean paper towel or gauze sponge. d.) Wipe mouth piece or mask with damp paper towel or gauze sponge e.) Store in plastic bag. A review of RI #9's medical records revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The review of RI #9's Quarterly MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 09/25/16, revealed RI #9 had a BIMS (Brief Interview for Mental Status) score of 12 out of a possible 15. This indicated RI #9 had moderate cognitive impairment for daily decision making. RI #9 required limited assistance for ADLs (Activities of Daily Living). RI #9's MDS also indicated he/she became short of breath on exertion and received oxygen therapy by nasal cannula at 2 L/M (Liters per Minute) continuously. A review of physician orders [REDACTED]. 1. [MEDICATION NAME]-[MEDICATION NAME] 0.5-3(2.5)mg (milligram)/3 ml(milliliters) nebulization twice daily for shortness of breath. 2. [MEDICATION NAME]-[MEDICATION NAME] 0.5-3(2.5)mg /3 ml nebulization every 4 hours as needed for shortness of breath/wheezing. On 10/18/16 at 8:00 a.m., the surveyor observed RI #9's nebulizer mask laying face down on the floor. On 10/20/16 at 8:30 a.m., the surveyor observed RI #9's nebulizer mask laying face down on the floor. EI (Employee Identifier) #4, an LPN (Licensed Practical Nurse), observed the concern. She stated the nebulizer mask should be in a plastic bag in the resident's chest of drawers. The surveyor asked EI #4 why it was a concern. She said because of germs and infection control. On 10/20/16 at 1:50 p.m., an interview was conducted with EI #6, the DON (Director of Nursing). The surveyor discussed the observation of the nebulizer mask on the floor two of four survey days. EI #6 was asked what was the concern. EI #6 said there was the potential for a spread of infection. EI #6 was asked what was the facility's policy on the storage of nebulizer masks. EI #6 answered the nebulizer mask should be stored in a plastic bag, labeled and dated. EI #6 was asked how often were the nebulizer masks changed out. EI #6 said she thought the masks were changed out on Sundays.

Based on interviews and record reviews, the facility failed to ensure a resident without an order for [REDACTED]. This affected RI (Resident Identifier) #1, one of eight sampled residents. Findings include: A review of RI #1's medical record revealed RI #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a Quarterly MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 5/15/16, revealed RI #1 had a BIMS (Brief Interview for Mental Status) score of 11 out of a possible 15. This score indicated RI #1 was moderately impaired of cognitive skills for daily decision making. RI #1 was coded as requiring extensive to total assistance with all ADLs (Activities of Daily Living). RI #1 was coded as having moderately impaired-limited vision; not able to see newspaper headlines but can identify objects. A review of RI #1's July 2016 Physician order [REDACTED]. A review of RI #8's (RI #I's roommate) medical record revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a Quarterly MDS, with an ARD of 7/3/2016, revealed RI #8 had a BIMS Score of 12 out of a possible 15 which indicated the resident was moderately impaired of cognitive skills for daily decision making. A review of physician's orders [REDACTED].***HOLD FOR SEDATION . ; [MEDICATION NAME] SULFATE (an Opiate) IR (Instant Release) 15 MG TAB (tablet) GIVE 1 TABLET TWICE A DAY AT 6AM AND 6PM FOR PAIN**HOLD FOR SEDATION** . ; [MEDICATION NAME] 200 MG TABLET GIVE 1 TABLET PO TWICE DAILY FOR DEMENTIA LEWEY BODY/[MEDICAL CONDITION].***HOLD FOR SEDATION*** . ; [MEDICATION NAME] 0.5 MG TABLET GIVE ONE TABLET PO QAM (every AM)-[MEDICAL CONDITION].***HOLD FOR SEDATION*** . ; [MEDICATION NAME] 3 MG TABLET GIVE 1 TABLET PO EVERY DAY AT BEDTIME FOR [MEDICAL CONDITION].***HOLD FOR SEDATION*** . A review of RI #8's Administration Record indicated on 7/11/16 at 10:30 p.m., RESIDENT REMAINED ASLEEP AND LETHARGIC THIS SHIFT. V/S (vital signs) WERE TAKEN PER (name of staff). PER (EI #3's name) ORDERS, KLONOPIN, [MEDICATION NAME], WERE HELD; OTHER PO (by mouth) WERE ALSO HELD DUE TO RESIDENT'S SEDATION. V/S REMAINED STABLE. RESIDENT REMAINS ON THERAPY CASELOAD AS ORDERED 7/11/2016 10:24 PM (EI #1's name) A review of a facility document regarding RI #1 and titled, Departmental Notes, revealed a late entry 7/12/2016 at 8:15 a.m. The document revealed, LATE ENTRY 7/12/2016 4 AM CNA (Certified Nursing Assistant) REPORTED THAT WHILE MAKING HER ROUNDS RESIDENT (RI #1) WAS ACTING DIFFERENT. RESIDENT LYING IN BED .BARELY OPENING EYES EVEN WITH VERBAL AND TACTILE STIMULI, BG (BLOOD GLUCOSE) - 75, BP (Blood Pressure)- 134/68 T (Temperature) -97.5 AX (Axillary) P (Pulse)-76 R (Respiration)-16 O2 SATS (Oxygen Saturation) 96% on R/A (Room Air). 4:12 AM CALLED (EI #3's name) OFFICE WITH CONDITION REPORT AND RECEIVED ORDERS TO SEND RESIDENT TO MIMC (MOBILE INFIRMARY MEDICAL CENTER) ER (emergency room ) FOR ALTERED MENTAL STATUS PER (name of CRNP-Certified Registered Nurse Practitioner). 4:19 AM NOTIFIED (name of ambulance company) AMBULANCE FOR TRANSPORTATION TO MIMC ER. 4:27 AM NOTIFIED RESPONSIBLE PARTY (name of sponsor) OF RESIDENT CONDITION AND THAT (RESIDENT) WAS GOING TO MIMC ER (name of sponsor) VERBALIZED APPRECIATION . 4:30 AM REPORT GIVEN TO MIMC NURSE (name of nurse) 4:37 (name of ambulance) 2 ATTENDANTS ARRIVED, RECEIVED REPORT. 4:45 AM (name of ambulance) 2 ATTENDANTS TRANSPORTING RESIDENT TO MIMC ER. RESIDENT WAS CLEAN AND DRY. Signed by EI (Employee Identifier) #6, an LPN (Licensed Practical Nurse). A review of the ambulance Patient Care Report revealed, (RI #1's name) Incident: 7/12/2016 4:23 Arrived Patient: 7/12/2016 4:40 Left Scene: 4:45 Arrived Dest (Destination) 4:50 . Chief Complaint: ALTERED LEVEL OF CONSCIOUSNESS Primary Symptom: Change in responsiveness Providers Primary Impression: Altered level of consciousness . 7/12/16 04:40 BP/S (Systolic) 176 BP/D (Diastolic 72 Pulse 76 Resp Rate 18 SaO2 (Oxygen Saturation) 98 Gluc (Glucose) 75 . Narrative .H- PATIENT COMPLAINED OF ALTERED LEVEL OF CONSCIOUSNESS AT GENERAL/GLOBAL THAT HAD LASTED FOR 1 HOUR . The hospital lab report, dated 7/12/16, for RI #1 indicated, Drug Screen, Urine .Result Opiate Screen, Urine Value: POS (Positive) . A review of a document titled, IPC Admission H & P (History & Physical), with a Date of Visit: 7-14-16, revealed RI #1's name as the patient: History of Present Illness: 82 yo (year old) (resident's sex) Resident recently hospitalized for [REDACTED]. Urine Drug Screen was positive for Opiates which (he/she) was not prescribed. There was concern that he/she may have received his/her Roommates medication. Medical evaluation was negative and the patient returned to baseline. (He/She) is readmitted to (name of nursing facility) (Long Term Care). (He/She) is in no distress, alert without acute c/o (complaints). A review of RI #1's Discharge Summary from the hospital revealed, admitted : 7/12/2016 . Admitting Physician: EI #10 Admission Diagnosis: [REDACTED]. Discharge Diagnoses: [REDACTED].*No resolved hospital problems* Chief Complaint: (Name of RI #1) is a 82 y.o. (resident's sex) who was admitted for Somnolence on 7/12/2016 . Hospital Course: This is an [AGE] year-old (resident's sex) who is long-term resident of a local nursing home with a history of stroke, type 2 diabetes and dementia. He/she was found to have altered mental status at the nursing home with increase somnolence and was sent to the ER for evaluation. He/she was found on UDS to have a positive opiate screen. I discussed with the facility and he/she apparently was given medications that belonged to a different patient that included an opiate A review of a hospital record for RI #1 revealed, the resident was received in the emergency room of the hospital 4:54 a.m. on 7/12/2016 and admitted at 10:32 p.m. to the hospital. The problem list included previous [DIAGNOSES REDACTED]. History of Present Illness . Altered Mental Status this is a new problem. The most recent episode occurred today. Primary symptoms included decrease responsiveness, altered mental status.Physical Exam Patient arouses to sternal rub. Will answer 1 or 2 questions then falls back asleep.(His/Her) speech is slurred.Drug Screen Urine .Opiate Screen, Urine POS A (Positive). Hospital Course: .(He/She) was found on UDS (Urine Drug Screen) to have a positive opiate screen. I (Medical Doctor, EI#10) discussed this with the facility and he/she apparently was given medications that belonged to a different patient that included an opiate. [MEDICATION NAME] was ordered for RI #1 in the emergency room and the resident (RI #1) responded to the [MEDICATION NAME]. A review of a facility document was reviewed titled, Resident Incident Report, revealed, (RI #1's name) Incident Type: Admin. (Administration) wrong med (medication) Reported to Supervisor: Yes Date/Time: 7/13/2016 12:00 P.M. Incident reported by: (Name of Sponsor), Report Prepared by: EI #8, R.N. (Registered Nurse), Non Witnessed, Narrative of incident .: RESIDENT TRANSFERRED TO MIMC (Mobile Infirmary Medical Center) ON 7/12/2016 FOR DIFFICULTY TO AROUSE AND SLURRED SPEECH. RESIDENT'S DAUGHTER NOTIFIED FACILITY STAFF ON 7/13/2016 THAT RESIDENT'S URINE DRUG SCREEN AT MIMC WAS POSITIVE FOR MEDICATIONS THAT (RI #1) WAS NOT PRESCRIBED. URINE DRUG SCREEN WAS POSITIVE FOR OPIATES. NO INJURIES. Immediate action included notifying the Medical Director, Nurse Consultant, Pharmacy Consultant, and investigation. The Immediate Post-Incident Action: EDUCATION ON THE FIVE RIGHTS OF MEDICATION ADMINISTRATION INITIATED FOR ALL LICENSED NURSES . Investigation was started by the facility. Multiple interviews with staff were completed, all narcotic logs were checked and staff denied seeing medicine sitting on medication carts or in resident rooms. One interview with EI #1, an LPN, was present in the investigation report stating the following information. On 7/11/2016 I (EI #1) counted the cart, prepared for the shift. I then pulled RI #8's (Resident's name) at approximately 5 -5:30 P.M he/she was hard to awake, but did briefly wake and close his/her eyes I left the room and put the medications in the med (medication) cart's drawer. A few minutes later EI #2 a CRNP (Certified Registered Nurse Practitioner) entered RI #8's room . then told me to not to give RI #8's [MEDICATION NAME], Klonopin, [MEDICATION NAME] or [MEDICATION NAME]. EI #3 (Medical Doctor) wrote an order stating to hold these medications. Approximately 15 minutes later I (EI #1) searched the cart, (RI #8's room #) and all surfaces in it, the bathroom, and could not find the medications. I (EI #1) did not notify anyone. I (EI #1) asked EI #4 (Nurse's name) a R.N , 3-11 House Supervisor how to document the medications that I had pulled and signed out, he (EI #4) (Said) I write wasted in the drug log book at the entry correlated with the medication and have a nurse sign behind/at my signature. At approximately 2130 (9:30 P.M.) I asked EI #5 (Nurse's name) a LPN, Charge Nurse to sign the count sheets . A review of RI #1's facility medical record indicated the resident was not out of the facility on 7/11/2016. An interview was conducted on 7/20/2016 at 4:41 p.m. with EI #3, the Medical Director. EI #3 was asked if he was aware of the incident with RI #1 on 7/12/2016 being sent to the ER with AMS and slurred speech. EI #3 replied yes, he was notified the next morning. They (facility) have a morning report at 7:45 A.M. EI #8 (DON) met him at the facility and when he arrived, EI #8 told him RI #1 may have received another resident's medication, maybe her roommate's. EI #3 was asked what was the facility's protocol for medication administration. EI #3 replied he did not know the specific protocol. He stated he knew they train staff to identify residents using pictures and the medications were labeled per resident. EI #3 stated it appeared it was a new nurse for the facility that gave the resident (RI #1) the roommate's (RI #8) medication. EI #3 was asked if he was notified of the investigation related to the above situation. EI #3 replied yes, he was notified of the investigation and what actions were being taken by the facility. The staff involved was allowed to communicate with administration, the staff member never acknowledged that the wrong medication had been given. The facility did an immediate inservice for all nursing staff on the policy and procedure on medication administration. EI #3 stated, during the interview, he was not involved in real time with this. He stated it would be difficult to determine an outcome. Based on what roommate had ordered, there could be a potential for respiratory arrest. However, it appeared in the ER record RI #1 responded to a sternal rub. An interview was conducted with EI #6, an LPN, at 7:44 a.m. on 7/21/16. EI #6 was asked if she was familiar with RI #1. EI #6 answered yes. EI #6 was asked if she had provided care for RI #1 and what care she provided. She answered check her every two hours, test the blood glucose every a.m., and no medicines at night. EI #6 was asked if an incident had occurred on 7/12/16 that required the resident to go to the hospital and to explain. She answered yes, a CNA told her the resident was acting different and she went to look at the resident. EI #6 was unable to arouse RI #1 as usual. She did a sternal rub and RI #1 did respond and would open his/her eyes at times. EI #6 was asked who did she report this occurrence to. She answered the MD (Medical Doctor), the sponsor (daughter), and the RN Supervisor on call. EI #6 was asked if an incident report was written. She stated she had not written one. She did not know if anyone else had. It was not an incident to her. EI #6 was asked how she found the RI #1 in an unresponsive state. She stated a CNA found the resident acting different. EI #6 was asked if she was interviewed by the facility to investigate the situation. She answered yes. EI #6 was asked what her response was. EI #6 stated facility staff asked if she had ever seen medication sitting around at the bedside or on the medication cart and she answered no. EI #6 was asked if she did any type of investigation on her shift. She stated she checked the resident and vital signs thoroughly. An interview was conducted by phone with EI #1, LPN, on 7/21/2016 at 8:32 a.m. EI #1 was asked if she was familiar with RI #1. EI #1 replied somewhat, yes, and indicated she floats to different floors. EI #1 stated she had cared for the resident on the 3 p.m. - 11 p.m. shift on 7/11/2016. EI #1 was asked what type of care had she provided for RI #1. EI #1 replied she was not 100% familiar with RI #1 and was only her second time on that medication cart. EI #1 stated RI #1 was blind, in a wheelchair, non ambulatory, not sure about mobility, and stated the resident was out part of her shift with family and doctor visit. RI #1 was asleep most of the evening. EI #1 stated she put eye drops in RI #1's eyes and indicated RI #1 did not take many medications. EI #1 was asked if she was aware of the incident on 7/12/2016 in which RI #1 had to be sent to the ER. EI #1 replied she was told of that on Wednesday, 7/13/2016. RI #1 was sent out to ER because she was lethargic and RI #1 had slurred speech. An interview was conducted with EI #9, a CNA, at 3:15 p.m. on 7/21/16. EI #9 was asked if she had provided care for RI #1. She answered yes. EI #9 was asked what care she had provided for RI #1. She answered incontinence care, providing the bed pan, getting the resident up in the morning at times, bathing and dressing the resident, hair and mouth care, and changing the bed linens. EI #9 was asked if she had provided care for RI #1 on 7/12/16 and she answered yes. EI #9 was asked what happened or what state did she find RI #1 in around 4:00 a.m. on 7/12/16. She answered the resident was trying to talk to her, trying to open his/her eyes, had slurred speech, and kept falling back to sleep. EI #9 was asked what she did. EI #9 said she notified the nurse (EI #6). EI #9 was asked how the resident responded when the nurse checked him/her. EI #9 answered the same way, very sluggish. The resident's blood glucose and vital signs were checked. EI #9 was asked what was done for the resident at the time of the change in condition. She told the nurse and the resident's blood glucose and vital signs were checked and they were okay. EI #9 was asked what was done for RI #1 after the vital signs and blood glucose were checked. EI #9 answered she gave the resident a milk shake. The nurse said they were going to send her out and she stayed with the resident until the ambulance arrived. An interview was conducted on 7/21/2016 at 2:31 p.m., with EI #10, the Medical Doctor who provided care for RI #1 during hospital stay 7/12/2016 - 7/14/2016. EI #10 was asked if he was the doctor that provided care for RI #1 during the hospital admit and stay on 7/12/2016 to 7/14/2016. EI #10 replied yes. EI #10 was asked what RI #1 was treated for [REDACTED]. RI #1 had Altered Mental Status and was unarouseable. EI #10 was asked if he called the facility on 7/12/2016 and spoke with EI #11, the facility Administrator, regarding RI #1. EI #10 replied yes, he called and asked what happened and he talked to EI #11 about the laboratory findings. EI #10 was asked what was the response of EI #11. EI #10 replied EI #11 had told him RI #1 received another resident's medication. It was possible because RI #1 had received another resident's medication because RI #1 had a positive screen for opiates. RI #1 may have received roommate's medication. EI #10 was asked what was the harm to RI #1. EI #10 replied there was always a risk with any medication. RI #1 was sedated for a few hours. EI #10 was told RI #1's roommate (EI #8) was on [MEDICATION NAME] (an opiate) IR (Instant Release). EI #10 was asked if this would be a problem if RI #1 took it. EI #10 replied yes. EI #10 was asked what was the results of RI #1's urine screen. EI #1 replied opiates were found in RI #1's urine and RI #1 was not taking any opiates. An interview was conducted on 7/21/2016 at 3:28 p.m. with EI #4, RN/House Supervisor. EI #4 was asked if he was familiar with RI #1. EI #4 replied yes, that he knew almost everybody in the building and RI #1 knew him also. EI #4 was asked what type of care did RI #1 require. EI #4 replied usually assistance with one person with transfers, the staff feed RI #1, staff assist RI #1 to the bathroom and assist the resident with all activities of daily living. RI #1 can call for the staff and make needs known. On 7/21/2016 at 5:01 p.m., an interview was conducted with EI #11, the facility Administrator. EI #11 was asked if he was aware of the incident and issues that happened on 7/12/2016 related to RI #1. EI #11 replied yes, RI #1 was sent to the hospital, the resident was not normal self. They started an investigation. EI #11 was asked why an investigation was started. EI #11 replied the hospital told them (facility) RI #1 tested positive for opiates in the urine test and RI #1 had no orders for any opiates. EI #11 was asked if an incident report was completed and by who. EI #11 replied yes, EI # 8, RN/DON (Director of Nursing), completed the investigation. EI #11 was asked if he talked with EI #10, Medical Doctor, about the incident. EI #11 stated he did. EI #11 was asked what did he tell EI #10. EI #11 replied they were investigating the issue. They did not know if RI #1 received the wrong medications or another resident's medications. EI #11 was asked what was the conclusion of the facility's investigation. EI #10 stated they did not know why RI #1 tested positive. On 7/22/16 at 11:50 a.m., EI #2, CRNP (Certified Registered Nurse Practitioner) was interviewed. EI #2 was asked what time did she assess RI #8 on 7/11/16 and she stated in the afternoon around 4 to 5 p.m. She indicated it was dinner time, tray was in front of the resident. She was asked if the nurse was in the room at this time and she stated no. EI #2 was asked if RI #1 was in the room during this time and she stated no, the resident was in the dining room. EI #2 was asked if the nurse administered medication to RI #8 at this time and she stated no meds were given yet. She was asked if she saw any meds in a cup in the room or bathroom of RI #1 and RI #8 and she stated no. EI #2 was asked if she had any knowledge of RI #1 testing positive for opiates and she stated that she had been made aware of it. When asked how had she been made aware, EI #2 stated she was not sure but thinks a staff member at the facility told her. EI #2 was asked how did RI #1 test positive for opiates without an order for [REDACTED]. EI #8, DON, was not available for interview during the survey.

Based on interviews and record reviews, the facility failed to ensure medications not administered to RI (Resident Identifier) #8 were destroyed after being held per physician's orders [REDACTED].#8, one of eight sampled residents. Findings include: A review of a facility document titled, Medication Administration, Medication Administration - General Guidelines, dated 03/11. 6.2:MEDICATION ADMINISTRATION GENERAL GUIDELINES, Policy The facility maintains equipment and supplies necessary for preparation and administration of medications to residents. Procedures .23. If a resident refuses medications, document on the MAR (Medication Administration Record) or TAR (Treatment Administration Record). Refused . Refused controlled medications should be flushed and witnessed by another licensed nurse. A review of a facility document titled, Medication Administration Procedure Controlled Medication Administration, dated 03/11. 7.1 CONTROLLED MEDICATION ADMINISTRATION. Policy Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal and state laws and guidelines. Procedures .4. When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It must be destroyed in the presence of two licensed nurses and the disposal documented on the accountability record on the line representing that dose. A review of RI (Resident Identifier) #8's medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a Quarterly MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 7/3/2016, revealed RI #8 had a BIMS (Brief Interview for Mental Status) Score of 12 out of a possible 15 which indicated the resident was moderately impaired of cognitive skills for daily decision making. A review of physician's orders [REDACTED].***HOLD FOR SEDATION . ; MORPHINE SULFATE (an opiate-a controlled substance drug) IR 15 MG TAB (tablet) GIVE 1 TABLET TWICE A DAY AT 6AM AND 6PM FOR PAIN**HOLD FOR SEDATION** .; SEROQUEL 200 MG TABLET GIVE 1 TABLET PO TWICE DAILY FOR DEMENTIA LEWEY BODY/DELIRIUM.***HOLD FOR SEDATION*** . ; RISPERDAL 0.5 MG TABLET GIVE ONE TABLET PO QAM (every AM)-PSYCHOSIS.***HOLD FOR SEDATION*** . ; RISPERDAL 3 MG TABLET GIVE 1 TABLET PO EVERY DAY AT BEDTIME FOR PSYCHOSIS.***HOLD FOR SEDATION*** . A review of an untitled facility document was provided to the surveyor during the survey. It was a control log sign-out sheet for a controlled medication for RI #8. This sheet indicated, RX # 31, prescriber EI #3, resident RI #8, directions one tab (tablet) BID (Twice per Day) 6 A (A.M.) & 6 P (P.M.) for pain, Drug name Morphine Sulfate (an opiate) IR (Instant Release) 15 mg (Milligrams), date page started 7/1/2016. The entry on 7/11/2016 revealed wasted written under the Time Given column, there was no time entry, dose one, balance 15, the signatures were EI (Employee Identifier) #1 and EI #5. A review of an untitled facility document was provided to the surveyor for review. It was control log sign-out sheet for a controlled medication for RI #8. This sheet indicated, RX 01, prescriber EI #3, resident RI #8, directions Give 1 tablet by mouth 2 times a day (situational anxiety) 9AM and 9PM, Drug name Clonazepam (Klonopin) 1 mg, date page started 7-8-16. The entry on 7/11/16 revealed wasted written under the Time Given column, there was no time entry, 1 tablet, Rec'd (Received) from Pharm (Pharmacy) 26 (balance), and the signatures were EI #1 and EI #5. On 7/21/16 at 2:30 p.m., an interview was conducted with EI #1, LPN (Licensed Practial Nurse). EI #1 was asked what did she do with RI #8's meds when she did not administer them to the resident. She stated the resident would not wake up enough. She stated when she went in the room and set the meds down, the CRNP (Certified Registered Nurse Practitioner) came in. She went back to the med cart but did not have the meds. EI #1 stated she searched but could not find them and thought they would find them sooner or later. She indicated she did not report this to anyone. EI #1 was asked what was the facility's policy on destruction of meds when not given, including narcotics/controlled substances. EI #1 stated put the meds in a sharps container and a nurse watches the nurse waste the narcotic. She indicated she did not realize this until after this incident when she was called in by the facility for an interview. EI #1 was asked if she reported this information to the House Supervisor and she stated yes. He instructed her to document wasted and have someone sign. She indicated she did not tell the House Supervisor she could not find the meds. When asked what were the instructions given, EI #1 stated to write wasted and have someone co-sign. She was asked who co-signed the narcotic/controlled substance destruction. EI #1 stated EI #5's name. She indicated EI #5 did not watch the destruction because there were no meds to destroy. EI #1 stated she did not physically waste the meds because she never could find them. An interview was conducted on 7/21/2016 at 5:40 P.M. with EI #5, an LPN. EI #5 was asked if she worked the 3-11 shift on 7/11/2016 on the South Unit. EI #5 replied yes. EI #5 was asked what was the facility's policy and procedure on distruction of narcotics. EI #5 said they were to have two nurses witness the distruction when the DON (Director of Nursing) was not present. EI #5 was asked about RI #8 and asked if she signed the narcotic log sheet for Morphine IR (Instant Release) as a wasted narcotic medication on 7/11/2016 on the 3-11 shift. RI # 5 replied yes, she did sign as the witness. EI #5 was asked if she observered the Morphin wasted. EI #5 replied no, she did not. The nurse (EI #1) told her she had to get rid of it. EI #5 was asked if the nurse (EI #1) told her what was done with the Morphine. EI #5 replied she did not remember. EI #5 was asked if EI #1 told her that the Morphine was lost. EI #5 replied no. EI #5 was asked if she did not see the destruction of the Morphine why did she cosign that she did. EI #5 stated it was an error on her part and that she (EI #1) was trying to wrap up her shift and EI #1 asked her to sign that it was wasted.

Based on interviews and record reviews, the facility failed to ensure nursing staff did not document medication as wasted when the medication was lost/missing. In addition, the facility failed to ensure a nurse did not sign as a witness for the waste of medications that she did not observe wasted. This affected RI (Resident Identifier) #8, one of ** sampled residents. Findings include: A review of a facility policy titled, Medication Administration Procedures Controlled Medication Administration, dated 03/11, revealed, Policy Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal and state laws and regulations. Procedures .4. When a dose of a controlled medication is removed from the container for administration but refused by the resident or not given for any reason, it is not placed back in the container. It must be destroyed in the presence of two licensed nurses and the disposal documented on the accountability record on the line representing that dose. A review of a facility's policy titled, Medication Administration Medication Administration- General Guidelines, dated 03/11, revealed: Procedures .23. If resident refuses medication, document refusal on MAR (Medication Administration Record) or TAR (Treatment Administration Record). Refused non-controlled medications can be disposed of by flushing or by other approved methods. Refused controlled medications should be flushed and witnessed by another license nurse.25. Once removed from the package or container, unused doses should be disposed of appropriately. A review of RI #8's medical record revealed the resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of physician's orders [REDACTED].***HOLD FOR SEDATION . ; [MEDICATION NAME] SULFATE IR 15 MG TAB (tablet) GIVE 1 TABLET TWICE A DAY AT 6AM AND 6PM FOR PAIN**HOLD FOR SEDATION** A review of RI #8's physician's orders [REDACTED]. There was no time indicated on the order. A review of a facility document titled, Resident Incident Report, revealed, (RI #1's name) Incident Type: Admin. (Administration) wrong med (medication) Reported to Supervisor: Yes Date/Time: 7/13/2016 12:00 P.M. Investigation was started by the facility. Multiple interviews with staff were completed, all narcotic logs were checked and staff denied seeing medicine sitting on medication carts or in resident rooms. A statement by EI #1, an LPN, was present in the investigation report stating the following information. On 7/11/2016 I (EI #1) counted the cart, prepared for the shift. I then pulled RI #8's (Resident's name) at approximately 5 -5:30 P.M she was hard to awake, but did briefly wake and close her eyes I left the room and put the medications in the med (medication) cart's drawer. A few minutes later EI #2 a CRNP (Certified Registered Nurse Practitioner) entered RI #8's room . then told me to not to give RI #8's [MEDICATION NAME], Klonopin, [MEDICATION NAME] or [MEDICATION NAME]. EI #3 (Medical Doctor) wrote an order stating to hold these medications. Approximately 15 minutes later I (EI #1) searched the cart, (RI #8's room #) and all surfaces in it, the bathroom, and could not find the medications. I (EI #1) did not notify anyone. I (EI #1) asked EI #4 (Nurse's name) R.N , 3-11 House Supervisor how to document the medications that I had pulled and signed out, he (EI #4) (Said) I write wasted in the drug log book at the entry correlated with the medication and have a nurse sign behind/at my signature. At approximately 2130 (9:30 P.M.) I asked EI #5 (Nurse's name) a LPN, Charge Nurse to sign the count sheets . Two untitled documents were given to the surveyor during the survey. The two documents were the sign-out sheets for controlled substances for RI #8. The first document was the sign-out sheet for, RX (drug) # 31, PRESCRIBER (EI #3's name), RESIDENT NAME (RI #8's name), DIRECTIONS one tab Bid (twice a day) 6A (a.m.) and 6 P (p.m.) For pain Drug Name [MEDICATION NAME] IR (Instant Release) 15 mg (milligrams), DATE page started: 7/1/2016. The entry on 7/11/2016 had no time noted, the term wasted was in the Time Given column, Dose Given one, balance 14 and the signatures were EI #1, LPN (Licensed Practical Nurse) and EI #5, LPN. The second sign-out sheet for, RX # 01 PRESCRIBER (EI #3) RESIDENT NAME (RI #8) DIRECTIONS Give 1 tablet by mouth 2 times a day (situational anxiety) 9AM and 9PM DRUG NAME [MEDICATION NAME] 1 mg DATE page started: 7-8-16. The entry on 7/11/16 had no time noted, the term wasted was in the Time Given column, 1 tablet, balance 26, and the signatures of EI #1 and EI #5. An interview was conducted with EI # 4, RN/3-11 House Supervisor, on 7/21/2016 at 3:35 p.m. EI #4 was asked if a medication nurse asked him how to destroy medication and a narcotic on 7/11/2016. EI #4 stated the nurse asked him about med destruction and indicated he did not know anything about anything going missing. He was asked what was his response to the nurse and he stated he didn't remember. He indicated for narcotic wasting two nurses witness any wasting and signing about the observation of the wasting. EI #4 was asked why did the nurse need to destroy the medications and he stated due to the resident being lethargic. He indicated he knew the resident was lethargic. EI #4 was asked who was the resident involved and he stated RI #8. He was asked why did he tell the nurse to sign out as wasted when the meds could not be found. EI #4 stated he did not know meds couldn't be found. When asked if he should have been told the meds couldn't be found, he stated yes, he should have been notified. On 7/21/16 at 4:28 p.m., EI #1 was interviewed. EI #1 was asked what did she do with RI #8's meds when she did not give them. EI #1 stated RI #8 would not wake up enough, the CRNP came into the room and she (EI #1) went back out to the cart and didn't have the med. She indicated she searched and couldn't find them and thought she would find them sooner or later. EI #1 stated she did not report this to anyone. She stated she spoke to house supervisor and was told to document wasted and have someone sign. EI #1 stated she did not tell the House Supervisor that she could not find the meds. When asked what were the instructions she was given, EI #1 stated to write wasted and have someone co-sign. She was asked who co-signed the narcotic destruction and she stated EI #5. EI #1 stated EI #5 did not watch destruction because there were no meds to destroy. EI #1 stated she never found any of the meds and never reported it to anyone. An interview with EI #11, Administrator, was conducted on 7/21/16 at 5:01 p.m. EI #11 was asked about the incident regarding EI #1 and EI #5 and sign-out sheets. EI #11 indicated EI #1 did not follow policy and when asked what policy EI #1 did not follow, he indicated the policy for narcotic destruction. He was asked what did she fail to do and EI #11 stated EI #1 did not destroy narcotics per facility's policy. He indicated both EI #1 and EI #5 could be reported to the Alabama Board of Nursing. EI #11 was asked what did EI #1 do other than not follow policy and he stated she could not find meds and asked EI #5 to sign behind her. EI #11 was asked what did EI #5 do other than not follow policy and he stated EI #5 signed as a witness and did not observe the destruction. When asked what happened to the meds, EI #11 stated they were lost. On 7/21/16 at 5:40 p.m., EI #5 was interviewed. She was asked if she worked on 7/11/16 on 3p-11p shift and EI #5 stated yes. EI #5 was asked what was the facility's policy on destruction of narcotics. She stated 2 nurses witness the med destroyed when DON not present. EI #5 was asked if she signed on the narcotic log sheet for RI #8 as [MEDICATION NAME] wasted on the 3p to 11p shift on 711/16. She stated yes, she did sign as the witness. She was asked if she observed the medication wasted and EI #5 stated no, she did not. The nurse told her she had to get rid of it. When asked if the nurse told her what she did with it, EI #5 stated she did not remember. EI #5 was asked if the nurse told her she had lost the medications and she said no. She was asked why did she co-sign if she did not observe the wasting. EI #5 stated it was an error on her part. She (EI #5) was trying to wrap up and the nurse asked her to sign that it was wasted. A second interview was conducted with EI #1 on 7/22/16 at 3:36 p.m. EI #1 was asked to explain how she documented meds wasted when she indicated they were lost. EI #1 stated they just thought that meant she had pulled them and didn't give them. EI #1 further stated she talked to EI #4 but did not tell him they were missing. EI #1 stated she did not physically waste meds. She just never could find them.

Based on an observation, record reviews, and interviews, the facility failed to ensure a container of chicken salad and a tray of prepared sandwiches were labeled and dated with a use-by date. This had the potential to affect all 123 residents served meals from the kitchen. Findings include: A review of a facility policy, with an effective date of August 15, 2009, titled, Leftover Food Storage and Use, revealed, . PURPOSE: To assure that food bourne illnesses are avoided. STANDARD: Leftover foods should be stored under the same conditions as other foods. PROCESS: a. Leftover foods should be refrigerated promptly, in approved storage containers of appropriate size and depth, to allow prompt cooling. b. Leftover foods should be covered, labeled and dated. c. Refrigerated leftover foods should be used within 72 hours (three days). If not used within 72 hours, refrigerated foods should be discarded. These foods should be monitored for proper cooling with times and temperature recorded on a cooling log. A review of the 2013 FDA(Federal Drug Administration) Food Code, revealed, .(D) A date marking system that meets the criteria stated in ¶¶ (A) and (B) of this section may include: (1) Using a method APPROVED by the REGULATORY AUTHORITY for refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is frequently rewrapped, such as lunchmeat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; (2) Marking the date or day of preparation, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, . On 12/13/2015 at 9:33 AM, an observation was made of the kitchen cooler/refrigerator. An observation was made of a container of chicken salad with no label or use-by date anywhere on the container. A tray of sandwiches was observed with no label or use-by date. On 12/14/2015 at 3:10 PM, an interview was conducted with EI (Employee Identifier) #1, a Cook. EI #1 was asked when food should be labeled and dated with a use-by date. EI #1 responded, First day its in the refrigerator. EI #1 was asked why should food be dated and labeled with a use-by date. EI #1 stated, Because everything has to be dated and labeled with a use-by date to keep people from getting sick from it spoiling. EI #1 was asked when should chicken salad in a container be discarded. EI #1 replied, 3 (Three) days. EI #1 was asked if chicken salad should be dated and labeled with a use-by date. EI #1 said, Yes, ma'am. EI #1 was asked how long should sandwiches be kept. EI #1 said, Two days, bread gets stale and soggy. EI #1 was asked if sandwiches should be labeled and dated with a use-by date. EI #1 stated, Yes ma'am. EI #1 was asked when should sandwiches be discarded. EI #1 responded, Two days in my opinion. Policy is three. EI #1 was asked what was the potential negative outcome of not labeling and dating food with a use-by date. EI #1 stated, Not paying attention (the) residents get sick. EI #1 was asked what was the potential negative outcome of not discarding of foods in a timely manner. EI #1 responded, Make somebody sick. On 12/14/2015 at 3:30 PM, an interview was conducted with EI #2, a Certified Dietary Manager. EI #2 was asked when should food be labeled and dated with a use-by date. EI #2 said, When opened or put in the refrigerator. EI #2 was asked why should food be dated and labeled with a use-by date. EI #2 stated, To avoid foodborne illnesses. EI #2 was asked when should chicken salad in a container be discarded. EI #2 responded, Three days. EI #2 was asked if chicken salad should be dated and labeled with a use-by date. EI #2 replied, Yes. EI #2 was asked how long should sandwiches be kept. EI #2 said, Three days. EI #2 was asked if sandwiches should be labeled and dated with a use-by date. EI #2 replied, Yes. EI #2 was asked when should sandwiches be discarded. EI #2 stated, Three days. EI #2 was asked what was the potential negative outcome of not labeling and dating food with a use-by date. EI #2 stated, Food borne illness. EI #2 was asked what was the potential negative outcome of not discarding of foods in a timely manner. EI #2 said, Foodborne illness. EI #2 was asked who ensured items were dated and labeled with a use-by date and discarded timely. EI #2 responded, (The) Cooks and me.

Based on an observation, interviews, and record reviews, the facility failed to ensure dry crushed medications were dissolved in water for administration to RI (Resident Identifier) #16. This had the potential for occluding the Gastrostomy tube. This affected RI #16, one of ten residents observed for medication pass. Findings include: A review of Potter Perry Fundamentals of Nursing 7th Edition, Unit VI (6) page 718 revealed, . BOX 35 - 17 Procedural Guidelines Giving Medications Through a Nasogastric Tube, Intestinal Tube, Gastrostomy Tube, or Small-Bore Feeding Tube . 7. Administer medications in a liquid form (suspension, [MEDICATION NAME], or solution) when possible to prevent tube obstruction. 13. Dissolve crushed tablets, gelatin capsules, and powders in 15 to 30 mL (milliliters) of warm water. Dissolve each medication separately. 14. Do not give whole or undissolved medications through the feeding tube. A review of the medical record for RI #16 revealed a re-admission date of [DATE]. RI #16 was admitted with [DIAGNOSES REDACTED]. A review of the Quarterly Minimum Data Set, with an ARD (Assessment Reference Date) dated of 11/29/15, revealed RI #16 had long and short term memory deficits. RI #16 was identified as moderately impaired for decision making, requiring supervision and cues. RI #16 was assessed to require extensive assistance of two persons for transfers. The resident was also assessed to require extensive assistance of staff for all ADLs (Activities of Daily Living) with the exception of self propelling after assistance to non weight bearing device (wheelchair). A review of the Care Plan for RI #16 regarding potential for complication related to tube feeding with a Problem Onset date of 10/9/2014, revealed, . Approaches . *Observe for dislodgement, splitting, cracking, leakage or clogging of tube . An observation was made on 12/14/15 at 9:41 AM of EI (Employee Identifier) #3, an LPN (Licensed Practical Nurse), during medication pass for RI #16. EI #3 was observed to open Aspirin 81 mg (milligrams), [MEDICATION NAME] 100 mg, [MEDICATION NAME] 20 mg, Magnesium Oxide 500 mg, [MEDICATION NAME] 500 mg, [MEDICATION NAME] (HCTZ) 12.5 mg capsule, and [MEDICATION NAME] 4 mg. The HCTZ capsule was emptied into a separate medication cup and the other medications were in pill form and were crushed individually and placed in separate medication cups. EI #3 administered two liquid medications per gastrostomy tube and then flushed the tube. EI #3 poured the dry, un-dissolved pills one at a time into the syringe. When EI #3 tried to advance the Magnesium Oxide down the Gastrostomy tube, it was observed stretched tightly, pinched, and squeezed by EI #3 to advance the medication. When questioned about this technique, EI #3 responded, The Mag Ox (Magnesium Oxide) is always hard. An interview was conducted with EI #3 on 12/15/15 at 9:14 AM. EI #3 was asked if he administered medications for RI #16 on 12/14/15 at 9:41 AM. He answered, Yes. EI #3 was asked how he administered the crushed medications. He answered, Flushed before, gave the med (medication), and flushed after. EI #3 was asked if the medication was dry when he gave it and he answered, Yes. EI #3 was asked if the Magnesium Oxide was difficult to get down the tube. He answered, Yes. EI #3 was asked if this happened often and he answered because it doesn't mix well. EI #3 was informed the Magnesium Oxide was observed to not be mixed with water on 12/14/15 and was asked how did he know it did not mix well. He stated he usually gave the Magnesium Oxide last because he had a hard time with it. EI #3 was asked how he advanced the Magnesium Oxide. He answered, I just had to thread it down the tubing to try to get it to the water (previous flush) to push it down. EI #3 was asked if that would indicate water helped to advance the medication. He answered, It does, but I don't do it that way because it separates. EI #3 was asked if the water helped advance the medication and he answered, It does, but you have to play with the water and med. EI #3 was asked how this action of advancing dry crushed medications could affect the tubing of the Gastrostomy tube. He answered, I could make the tubing thinner, affect the elasticity of it. EI #3 was asked what was the potential harm of putting dry meds into the tube that are difficult to advance. He answered, That tube could be worn out and have to be replaced more frequently. EI #3 was asked if he diluted the crushed meds prior to pouring them into the tube. He answered, No. EI #3 was asked why not. He answered, Most of the time the meds collect at the bottom of the cup. An interview was conducted with EI #4, the DON (Director of Nursing), on 12/15/15 at 10:10 AM. EI #4 was asked if dry crushed meds should be poured into a Gastrostomy tube. She answered, If there was water in the tube, I would. EI #4 was asked what was the concern of having to thread the dry meds through the tubing to get the meds to advance. She answered, You could potentially stretch the tube. EI #4 was asked if this was the technique that nurses were trained to administer crushed medications. She answered, No. An interview was conducted with EI #5, the Staff Development Coordinator, on 12/15/15 at 11:15 AM. EI #5 was asked what education she gave to nurses regarding administration of crushed meds via Gastrostomy tube. She answered, I teach them not to mix meds, 30 cc (cubic centimeters) water before and after, and 5 cc between each med, and 5-10 cc (water) in with the dry pills to get it through the tube. EI #5 was asked what could be the potential harm of placing dry crushed pills in the Gastrostomy tube and having to manually advance the med by pinching and squeezing the tube. She answered, Possibility of clogging it up.

Based on observations, interviews and document reviews, the facility failed to ensure: 1) Food received frozen was maintained frozen. 2) Breakfast Pork Patties were dated after being opened and prior to being placed in the reach-in cooler. 3) The Dietary Aid and Dietary Manager washed their hands upon re-entering the kitchen from outside and preparing residents lunch trays. This had the potential to affect 114 residents receiving meals from the kitchen. Findings include: 1) A review of the facility's document titled, "DIETARY SERVICE MANUAL, Section: Food Preparation and Handling, Policy Title: Food Receipt and Storage," with an "Effective Date August 13, 2013," revealed, "... PURPOSE:" Foods should be checked for freshness when received and stored in accordance with FDA Food Code recommendations. ... Storage of Foods: ... i. Refrigerated and frozen items should be checked to be sure the item is still cool or frozen ..." On 1/26/2015 at 4:50 PM, an observation was made of ice cream in the ice cream freezer. The ice cream was soft and the lid slid off the top of the container when pushed. On 1/28/2015 at 1:20 PM, an interview was conducted with EI #5, the Dietary Manager. EI #5 was asked should ice cream be soft when touched. EI #5 stated, "No." 2) A review of the facility's document titled, "DIETARY SERVICE MANUAL, Section: Food Preparation and Handling, Policy Title: Food Receipt and Storage," with an "Effective Date August 13, 2013," revealed, "... STANDARD: Foods should be checked for freshness when received and stored in accordance with FDA Food Code recommendations. ... j. Label the case or tray... with the date they are thawed, or with a used by date which is 10 days from thaw date." On 1/26/2015 at 4:50 PM, an observation was made of an opened bag of Breakfast Pork Patties without a date, in the reach-in cooler. EI #5 verified the food item that was in the bag. On 1/28/2015 at 1:20 PM, an interview was conducted with EI #5. She was asked if food should be dated after being opened and before placing them in the cooler. EI #5 stated, "Yes." EI #5 was asked why it was important to date food after it was opened, and before it was placed in the cooler. EI #5 stated, "To keep residents from getting sick." 3) A review of the facility's policy titled, "DIETARY SERVICE MANUAL, Section: Sanitation, Safety and Infection Control, Policy Title: Hand-washing Guidelines, Policy Number DS.V-10, Effective Date: February 1, 2002, Page 1 of 2," revealed: "PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses. ... PROCESS: I. Frequency of Hand-washing: Hands should be washed in the following situations: ? Every time an employee enters the kitchen; at the beginning of the shift; after returning from break; after using the toilet ? After hands have touched anything unsanitary, i.e.(in example), garbage, soiled utensils or equipment, dirty dishes, etc (etcetera). ..." On 1/27/2015 at 11:20 AM, an observation was made during tray line of EI #5 (Dietary Manager) and EI #9 (a Dietary Aide) entering the kitchen from outside, without washing their hands. EI #5 and EI #9 then began preparing residents trays. On 1/28/2015 at 1:20 PM, an interview was conducted with EI #5. She was asked should hands be washed prior to entering the kitchen. EI #5 stated, "Yes." EI #5 was asked why hands should be washed prior to entering the kitchen. EI #5 stated, "Keep from cross contamination."