Every finding on record at Aspire Physical Recovery Center at Cahaba River

Based on interviews, Resident Identifier (RI) #264's medical record, FUNDAMENTALS OF NURSING NINTH EDITION, the facility's PROTOCOL FOR EMERGENT CARE, the facility policy titled Cardio Pulmonary Resuscitation (CPR), and a facility reported incident received by the Alabama State Survey Agency, the facility failed to honor the end-of-life wishes of RI #264, a resident with an Advanced Directive to withhold resuscitative measures in the event of cardiopulmonary cessation and an active physician's order for DNR (Do Not Resuscitate) code status. The DNR order directed staff to not initiate CPR when the resident stopped breathing and/or their heart stopped beating. During the evening shift on [DATE], RI #264 was found unresponsive with no pulse or respirations. Licensed Practical Nurse (LPN) #3 did not check RI #264's code status in accordance with the facility's protocol before she initiated CPR. As a result of initiating CPR and activating emergency medical services (EMS), facility staff performed chest compressions and EMS staff continued chest compressions with LUCAS Devise (a mechanical chest compression device), performed endotracheal intubation, performed decompression of RI #264's right lung, and obtained intravenous (IV) and intraosseous (IO) access during the attempt to resuscitate RI #264. This deficient practice placed RI #264, one of three sampled residents reviewed for advance directives and code status, in immediate jeopardy, as the failure of facility staff to honor a resident's end-of-life wishes was likely to cause serious injury, serious harm, serious impairment, or death. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.10 Resident Rights at a scope and severity of J. On [DATE] at 5:15 PM, the Administrator and Regional Administrator were provided a copy of the immediate jeopardy template and notified of the findings at the immediate jeopardy level in the area of Resident Rights at F578-Request/Refuse/Discontinue Treatment/Formulate Advance Directives. The IJ began on [DATE] and continued until [DATE] when the facility implemented corrective actions to correct the identified deficient practice and prevent recurrence; thus, immediate jeopardy past non-compliance was cited. Findings include: FUNDAMENTALS OF NURSING NINTH EDITION, with a copyright date of 2017, Chapter 23, titled Legal Implications in Nursing Practice, page 305, documented: . Advance Directives include living wills, health care proxies, and durable powers of attorney for health care .They are based on values of informed consent, patient autonomy over end-of-life decisions, truth telling, and control over the dying process . Health care providers perform CPR when needed unless there is a DNR order . The facility's policy titled Cardio Pulmonary Resuscitation (CPR), with an effective date of [DATE], documented: . PURPOSE: To circulate blood containing oxygen to vital organs pending the arrival of emergency medical services (EMS) to a resident/guest who experiences cardiac arrest (cessation of respirations and/or pulse) in accordance with the resident/guest(s) advance directives or in the absence of advance directives or a Do Not Resuscitate (DNR) order . A review of the facility's undated PROTOCOL FOR EMERGENT CARE, documented: If A Resident/Guest Is Found To Be Unresponsive To Verbal and Physical Stimuli, You Must Initiate The Following Protocol For Emergent Care: . A staff member should access E-chart (electronic health record) immediately and verify the identification of the resident/guest . and if there is an order for DNR . Have a nurse notify Physician of change in condition and whether resident/guest has a current DNR order . RI #264 was admitted to the facility on [DATE], with diagnoses of Venous Insufficiency, Hypertensive Heart Disease and Chronic Kidney Disease. RI #264's Alabama Portable Physician Do Not Attempt Resuscitation Order, No/CPR/Allow Natural Death, signed by RI #264's designated health care proxy on [DATE], documented: . I, the undersigned, am the health care proxy . designated by the patient/resident to make decisions regarding the providing, withholding, or withdrawal of life-sustaining treatment for the patient/resident. I hereby direct that resuscitative measures be withheld from the patient/resident in the event of cardiopulmonary cessation . Review of RI #264's February 2023 PHYSICIAN ORDERS, revealed an order dated [DATE] for . Status . DNR . On [DATE] at 4:33 PM, the Alabama State Survey Agency received a Facility Reported Incident (FRI) which indicated staff found RI #264 unresponsive on [DATE] at 10:15 PM. The FRI report documented Narrative summary of the incident: Life-saving measures were provided to RI #264 .The guest did expire. Afterwards, the family alerted the nurse to the fact that RI #264 had a DNR order in place . Action(s) taken by the facility in response to the incident . It does appear that there was a DNR order in place and that life-saving measures were provided . The EMS run report, dated [DATE], indicated the facility contacted EMS on [DATE] at 9:37 PM. EMS arrived to RI #264 at 9:46 PM. The Narrative Section documented the following: . Dispatched on a call for CARDIAC ARREST . Control advised that CPR was in progress .The patient was apneic and being ventilated with a BVM (Bag Valve Mask) . EMS crews immediately took over CPR efforts and placed a [NAME] Device on the patient which provided compressions . A 18 G (gauge) IV (intravenous) was placed in the Right AC (antecubital) and the patient was intubated with 7.0 endotracheal tube and ventilated with a BVM . Paramedic . decompressed his/her right lung . blood came out of the decompression needle . Treatment included IV, IO access, ALS (Advanced Life Support) assessment, Vitals monitoring, endotracheal intubation, 5x EPI (epinephrine) 1:10,000, sodium bicarbonate, calcium chloride, 750 ml (milliliters) of normal saline bolus, The patient was treated using the AHA (American Heart Association) ACLS (Advanced Cardiac Life Support) Algorithm. The patient was not transported and CPR efforts were discontinued .Time of death was called at 22:20 (10:20 PM) . The facility document titled Verification of Investigation documented the facility's investigation and review of the incident. According to the facility's investigation, it was discovered that a physician's order had been issued for RI #264 to be a DNR; however, LPN #3 failed to adhere to the established protocol while searching for RI #264's code status. The investigation further revealed, the nursing staff had been trained to check the laptop first for code status, and if unavailable, refer to the hard chart. The investigation documented that there was no evidence to suggest that LPN #3 followed either of these steps before initiating CPR for RI #264. On [DATE] at 3:46 PM RI #264's Health Care Proxy (HCP) and spouse, was interviewed. The HCP confirmed that RI #264 was a DNR, which was consistent with RI #264's end-of-life wishes and his/her end-of-life wishes for RI #264. The HCP said when he/she arrived at the facility he/she was informed that CPR was performed, and he/she let the facility know that CPR should not have been performed because RI #264 had DNR code status in accordance with both of their wishes. The HCP said it was hard seeing RI #264 after the resuscitation efforts, and he/she saw bruises on RI #264's chest. On [DATE] at 9:52 AM, an interview was conducted with LPN #3 who said she reported to work at approximately 7:00 PM on [DATE]. According to LPN #3, early in the shift and while administering medication, Certified Nursing Assistant (CNA) #6 informed her that RI #264 was experiencing difficulty breathing. Upon observation and assessment, LPN #3 said RI #264 had labored breathing and an O2 (oxygen) saturation of 74 percent (%). LPN #3 said RI #264 stopped breathing shortly after she responded. LPN #3 said she looked in RI #264's medical chart and did not find any document indicating that RI #264 was a DNR. LPN #3 said she assumed that RI #264 was a full code because she did not see anything in the chart. LPN #3 said she obtained the crash cart and then entered RI #264's room, assessed his/her pulse, and initiated CPR. LPN #3 stated that she continued performing chest compression until another nurse arrived and took over. LPN #3 said that EMS personnel took over the CPR upon their arrival. LPN #3 said after RI #264 was pronounced dead, the resident's family arrived at the facility. LPN #3 said RI #264's spouse had asked why RI #264 was intubated since he/she had DNR code status. Later during the interview, LPN #3 stated the facility policy directed staff to first access the E-Chart to determine a resident's code status and only resort to the physical chart if the E-Chart was unavailable. LPN #3 admitted to not following the policy when she relied on the physical chart to locate the code status. LPN #3 said disregarding a resident's advanced directives resident could cause the resident to experience pain and trauma resulting from the resuscitation, intubation, and IV administration. An interview was conducted with LPN #27 on [DATE] at 1:55 PM. LPN #27 said that she did not check the code status when she responded to the code involving RI #264 on [DATE], because she assumed it had already been done. LPN #27 said the importance of following a resident's advanced directives was to ensure their wishes regarding CPR and end-of-life care were honored. An interview was conducted with LPN #5 on [DATE] at 7:21 PM. LPN #5 said she responded to the code involving RI #264 on [DATE] after the code was announced. LPN #5 explained that the facility's policy indicated the code status was to be verified before initiating a code. LPN #5 said when she arrived at the code, she assumed that RI #264 was a full code. An interview was conducted with the Director of Nursing (DON) on [DATE] at 5:20 PM. The DON said the potential harm of failing to follow an advanced directive could result in death or pain if CPR was administered. An interview was conducted with the Administrator on [DATE] at 12:30 PM. When asked about RI #264, the administrator said CPR was performed on this resident who was a DNR. The administrator said that the nurse did not follow policy when she checked RI #264's code status which resulted in CPR being performed on a resident with a DNR. The administrator said it was important to follow a resident's advanced directive to ensure the resident's wishes were carried out. The administrator said the potential harm of not following an advanced directive would be loss of dignity and rights for the resident. This deficiency was cited as a result of complaint/report number AL00043289. ************************* The facility took immediate actions to correct the non-compliance and prevent reoccurrence by: - On [DATE] the facility identified that Licensed staff had initiated CPR on RI #264 when RI #264 had an active DNR order and began immediate actions to correct the noncompliance. - On [DATE] an investigation was initiated, the event was reported to ADPH on [DATE], two LPNs involved both received one on one education and education of all licensed staff was initiated. - Education of licensed nurses was completed on [DATE]. - On [DATE] mock codes were initiated and continued on [DATE] to include all licensed nurses. - On [DATE] a review of all DNRs in the building was completed. - On [DATE] an emergency Quality Assurance and Performance Improvement (QAPI) meeting was completed related to Emergency Protocols. Monitoring was established that the facility would continue to monitor DNR codes by providing emergent care protocol training with code drill upon hire, quarterly and as needed. ************************* After review of documentation supporting the above corrective actions, including the facility's investigation file, in-service/education records, QAPI documentation, and staff interviews, the survey team verified the facility implemented corrective actions including ongoing monitoring from [DATE] to [DATE], thus immediate jeopardy past non-compliance was cited.

Based on observations, interviews, medical records, and the facility policy titled Food Preparation Guidelines, the facility failed to ensure food was served at an appetizing temperature. Specifically, on 01/11/2024 during the breakfast meal, the eggs were not served at an appetizing temperature. This had the potential to affect 108 of the 109 residents receiving the breakfast meal from the facility's kitchen. Findings include: The facility's policy for Food Preparation Guidelines, dated 08/10/2018, included the following: . PURPOSE: . Food should be palatable, attractive, and at the proper temperature, as determined by the type of food, to ensure resident/guest(s) satisfaction. STANDARD: . Food . should be served attractively at proper temperatures. RI #216 was admitted to the facility on [DATE]. A review of an Admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 02/08/2023, revealed RI #216 had a Brief Interview for Mental Status (BIMS) score of 15 of 15 which indicated RI #216 was cognitively intact. On 01/10/2024 at 9:32 AM, a telephone interview with RI #216 was conducted. RI #216 stated that the food was always cold, especially breakfast. RI #42 was admitted to the facility on [DATE]. A review of the MDS assessment, with an ARD of 12/10/2023, revealed RI #42 scored a BIMS of 14 of 15 which indicated RI #42 was cognitively intact. On 01/09/2024 at 3:20 PM, RI #42 was interviewed and stated that the facility's food was cold. RI #42 stated the eggs were cold in the morning for his/her breakfast meal. On 01/11/2024 at 9:28 AM, a follow up interview was conducted with RI #42 who stated the eggs were cold that morning for breakfast. RI #42 further stated the eggs were cold every morning. A test tray was conducted for the breakfast meal on 01/11/2024 at 8:16 AM. The test tray was sampled with the Certified Dietary Manager (CDM). When asked to describe the temperature of the eggs, the CDM stated the scrambled eggs were cold. On 01/11/2024 at 4:37 PM, the CDM was interviewed. The CDM said it would not be desirable to hot foods that were cold. The CDM also stated, once cooled down, the food gets in the danger zone and could be dangerous to eat. This deficiency was cited as a result of the investigation of complaint/report number AL00043581. 47296 48195

Based on observations, interviews, residents' medical records, and the facility policy titled Federal Rights of Residents, the facility failed to ensure staff did not stand while feeding Resident Identifier (RI) #101 the lunch meal on 01/10/2024; and RI #91 the lunch meal on 01/11/2024. This deficient practice affected RI #101 and RI #91; two of four sampled residents observed being assisted with meals. Findings include: Review of a facility policy titled, Federal Rights of Residents, with an effective date of 03/01/2010, documented: . PURPOSE: All residents in long-term care facilities have rights guaranteed to them under Federal and State law. STANDARD: The resident has a right to a dignified existence . RI #101 was admitted to the facility on [DATE] and had diagnoses that included Metabolic Encephalopathy and Adult Failure to Thrive. RI #101's Admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 12/28/2023, revealed RI #101 had a Brief Interview for Mental Status (BIMS) score of one of 15, which indicated RI #101 had severely impaired cognitive skills for daily decision making. The MDS indicated that RI #101 required partial/moderate assistance with eating. On 01/10/2024 at 12:45 PM, Certified Nursing Assistant (CNA) #20 was observed feeding RI #101 the lunch meal in the resident's room. CNA #20 was standing while RI #101 was seated in a chair. On 01/10/2024 at 1:07 PM, an interview was conducted with CNA #20. She admitted to feeding RI #101 his/her lunch meal, and that she was standing while assisting with the meal. CNA #20 stated she should have been sitting. CNA #20 stated the concern of standing while feeding a resident was not having eye contact with the resident. On 01/11/2024 at 5:24 PM, an interview was conducted with the Unit Manager (UM), Licensed Practical Nurse (LPN) #21. She stated staff should be sitting next to the resident when assisting with feeding a resident. UM #21 stated staff should never stand over a resident while feeding the resident. UM #21 stated the concern of staff standing while feeding a resident was staff were presenting themselves as dominant over the resident. 2) RI #91 was admitted to the facility on [DATE]. Review of a Quarterly MDS assessment, with an ARD of 12/20/2023, assessed RI #91 as having limitations on one side of his/her the upper extremities and needing substantial/maximal assistance with eating. On 01/11/2024 at 1:00 PM, CNA #23 was observed standing while feeding RI #91 the lunch meal. RI #91 was observed laying on a low bed. On 01/11/2024 at 1:33 PM, the surveyor conducted an interview with CNA #23 who said she was in a standing position while feeding RI #91 the lunch meal. CNA #23 stated she should have been in a sitting position while feeding RI #91. CNA #23 stated the concern of standing while feeding RI #91 was that it would have made the resident feel like she was rushing. CNA #23 stated seated, and at eye level, would be more comfortable for the resident. On 01/12/2024 at 4:50 PM, the surveyor conducted an interview with the Director of Nursing (DON). The DON said staff should be sitting and at eye level when feeding a resident. 47408

Based on interviews, record review, and the facility policy titled, Person Centered Care Plan, the facility failed to ensure Resident Identifier (RI) #34 and his/her representative was informed of RI #34's quarterly care plan meetings scheduled for August and November of 2023. This affected RI #34, one of 27 residents sampled for the right to participate in care planning. Findings include: Review of a facility policy titled, Person Centered Care Plan, dated 08/15/2018, revealed the following: PURPOSE: Person centered plans of care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals of the resident/guest, consistent with the resident/guest (s) rights. STANDARD: . The interdisciplinary plan of care committee may consist of . Resident/Guest(s) family members, other representatives, as desired by the resident/guest . PROCESS: . II. Preparation for Care Plan Committee Meetings . C. The social service . should inform the resident/guest and families of the scheduled meeting, by mailing Notice of Scheduled Plan of Care Conference . III. Conducting the Interdisciplinary Person Centered Care Plan Meeting A. The team including the resident/guest and their desired representatives . should present findings from assessments . discuss suggested new goals or approaches . RI #34 was admitted to the facility on [DATE]. RI #34's admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 01/17/2023 revealed RI #34 scored a 14 of 15 on the Brief Interview for Mental Status, which indicated RI #34 was cognitively intact. On 01/09/2024 at 04:19 PM, an interview was conducted with RI #34 and his/her responsible party. RI #34 and his/her responsible party reported the facility did not communicate anything with them regarding a care plan meeting in the last six months and they had not attended a care plan meeting during that time frame. On 01/11/2024 at 11:02 AM, an interview was conducted with the Licensed Bachelor Social Worker (LBSW). The LBSW said the family should be contacted when quarterly care plan meetings were scheduled. On 01/12/2024 at 11:45 AM, an interview was conducted with Licensed Practical Nurse (LPN) #9, the MDS and Care Plan Coordinator (CPC). The CPC said the resident family/responsible party were not notified of RI #34's care plan meetings held in August and November of 2023. On 01/12/2024 at 11:54 AM, in a follow-up interview, the LBSW said RI #34's responsible party missed two quarterly care plan meetings because they had not been notified.

Based on interviews, observations, resident's medical record, and the facility policy titled, . Self-Administration of Medications, the facility failed to ensure Medical Assistant Certified (MAC) #11 and License Practical Nurse (LPN) #12 did not leave the room while Resident Identifier (RI) #54 received nebulizer treatments. RI #54 had not been assessed for the ability to self-administer medication. This deficient practice affected RI #54; one of three residents sampled for receiving nebulizer treatments. Finding include: A review of the facility's policy titled, . Self-Administration of Medications, with a reviewed date of 04/2020, documented: Policy Residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility. An order to self-administer must be given by the physician . 2. Facility staff will administer the resident's medication until the interdisciplinary team completes an assessment and a physician's order is obtained . RI #54 was admitted to the facility on [DATE], with a diagnosis of Chronic Obstructive Pulmonary Disease. RI #54's Physicians Orders for January 2024 documented: . IPRATROPIUM BR (Bromide) 0.02% SOLN (solution) GIVE ONE UNIT DOSE VIA (by way of) NEBULIZER EVERY 6 HOURS FOR SOB (shortness of breath)/wheezing (order date was 11/09/2023) . Albuterol 2.5MG (milligrams)/3ML (milliliters) SOL (solution) Give ONE UNIT DOSE VIA NEBULIZER EVERY 6 HOURS DAILY FOR SOB/WHEEZING (order date was 10/17/2023) . On 01/09/2024 at 3:11 PM, the surveyor observed RI #54 receiving a breathing treatment, which was a nebulizer treatment. RI #54's mask was connected to the nebulizer machine mist coming from the machine and no licensed staff were present. On 01/09/2024 at 3:11 PM, during an interview with RI #54, the resident stated he/she received a nebulizer treatment three times a day. RI #54 further stated the nurse put the medication in the tubing, RI #54 turned on the nebulizer machine, and the nurse left the room. The resident was asked if he/she was care planned to self-administer the medication and RI #54 stated he/she was not sure. On 01/12/2024 at 09:52 AM, an interview was conducted with LPN #12. She was asked if she gave RI #54 his/her nebulizer treatment on 01/09/2024. LPN #12 said yes, according to the Medication Administration Review (MAR) she signed the medication as administered. LPN #12 stated she did not stay in the room with RI #54 during his/her nebulizer treatment. LPN #12 was asked if RI #54 was assessed to self-administer his/her nebulizer treatment. LPN #12 was unable to locate a physician's order for RI #54 to self-administer his/her breathing treatment. LPN #12 was asked what was the potential harm of not staying in the room with RI #54 when the resident was receiving a nebulizer treatment. LPN #12 said the resident could have removed his/her mask and not received the treatment. On 01/11/2024 at 12:45 PM, the surveyor observed RI #54 in his/her room receiving a nebulizer treatment. The mask was connected to the nebulizer machine and mist was coming from the machine. No staff were present in the room. On 01/11/2024 at 12:48 PM, an interview was conducted with MAC #11. The MAC stated she administered RI #54's nebulizer treatment of Albuterol and she did not stay in the room with the resident while RI #54 received the nebulizer treatment. When asked if the resident was care planned to self-administer his/her medication, she replied no. The MAC said she should have stayed in the room with RI #54 when administering his/her nebulizer treatment because RI #54 could have taken the mask off, not received his/her treatment, and started coughing.

Based on interviews, observations, residents' medical records, and the facility policy titled, Person Centered Care Plans, the facility failed to ensure Resident Identifier (RI) #54 and RI #314 had a care plan developed for the use of their oxygen. This deficient practice affected RI #54 and RI #314, two of 25 residents whose care plans were reviewed. Findings include: A review of a facility's policy titled, Person Centered Care Plans, with an effective date of 08/15/2018 documented: . PURPOSE: Person centered plans of care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals of the resident/guest . STANDARD: . the facility develops a comprehensive person centered plan of care for each resident/guest that includes measurable objective and timetables to meet a resident/guest(s) medical, nursing . needs that are identified in the comprehensive assessment . PROCESS: . d) Comprehensive Plan of Care-completed within 7 days of admission . 1) RI #54 was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease. RI #54's Physicians Orders for January 2024 revealed an order (dated 10/13/2023) for OXYGEN @ (at) 4 (four) L( liters)/MIN (minute) PER NASAL CANNULA CONTINUOUS EVERY SHIFT D/T (due to) SOB (Shortness of Breath) . (an order dated 12/18/23 [2023]) NOCTURNAL O2 (Oxygen) ONLY (DOES NOT NEED DURING DAY) . RI #54's care plans were reviewed and there was no documentation of a care plan developed for his/her oxygen use. On 01/12/2024 at 12:16 PM, an interview was conducted with the Licensed Practical Nurse (LPN) #9, Care Plan Coordinator (CPC). She was asked if RI #54 required the use of oxygen. The CPC said yes, but no comprehensive care had been developed for RI #54's oxygen use. The CPC said RI #54 should have had a care plan developed, but it was missed. The CPC further said the purpose of the care plan was to direct the care and needs of the resident. 2) RI #314 was admitted to the facility on [DATE] with a diagnosis of Malignant Neoplasm of Unspecified Part of Unspecified Bronchus or Lung. RI #314's Physicians Orders for January 2024 revealed an order dated 01/10/2024, for . OXYGEN AT 3L (liters) CONTINUOUS THROUGH NASAL CANNULA . On 01/09/2024 at 3:03 PM, the surveyor observed RI #314 sitting in a recliner in his/her room with his/her O2 infusing via nasal cannula. On 01/10/2024 at 9:11 AM, the surveyor observed RI #314 coming out of his/her bathroom using a walker, with the O2 infusing per nasal cannula. On 01/12/2024 at 12:09 PM, an interview was conducted with the CPC. The CPC said she was responsible for developing care plans. She was asked if a care plan was developed for the use of RI #314's oxygen use. The CPC said no, but a care plan should have been developed because RI #314 required the use of oxygen. The CPC further stated the purpose of the care plan was to direct the care and needs of the resident.

Based on interviews, observation, residents' medical records, and the facility policy titled, Oxygen Administration, the facility failed to ensure Resident Identifier (RI) #54's nebulizer mask was covered when not in use. The facility further failed to ensure RI #314's and RI #85's oxygen tubing was labeled/dated. This deficient practice affected RI #54, one of three residents reviewed for proper storage of respiratory supplies; and RI #314 and RI #85, two of three residents reviewed for respiratory care. Findings include: The facility's policy titled, Oxygen Administration, with an effective date of 12/08/2005, documented: . PURPOSE: To administer high purity oxygen for the treatment of certain disease or conditions . PROCESS . 11. Cannulas and masks should be changed weekly . 14. O2 cannula/mask should be stored in plastic bag when not in use . 1) RI #54 was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease. RI #54's Physicians Orders dated 11/09/2023 documented: . IPRATROPIUM BR (Bromide) 0.02% SOLN (Solution) GIVE ONE UNIT DOSE VIA (by way of) NEBULIZER EVERY 6 HOURS FOR SOB (shortness of breath)/wheezing . (an order dated 10/17/23) . Albuterol 2.5MG (milligram) /3ML (milliliters) SOL (solution) Give ONE UNIT DOSE VIA NEBULIZER EVERY 6 HOURS DAILY FOR SOB/WHEEZING. On 01/10/2024 at 9:59 AM, the surveyor observed RI #54's nebulizer machine in a recliner, with the nebulizer mask on top of the machine, uncovered. On 01/10/2024 at 10:00 AM, an interview was conducted with the Unit Manager (UM)/Licensed Practical Nurse (LPN) #8. UM #8 stated RI #54's nebulizer machine was sitting in his/her recliner and the mask was not in a bag. UM #8 said the nebulizer mask should be covered to prevent bacteria. 2) RI #85 was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease w (with)/Acute Exacerbation. RI #85's January 2024 Physicians Orders revealed: OXYGEN @ (at) 3 (three) L(liters)Min (Minute) VIA (by way of) NC (nasal cannula) CONT (continuous) FOR SHORTNESS OF BREATH . On 01/09/2024 at 2:32 PM, the surveyor observed RI #85 lying in bed with O2 (oxygen) on infusing at three liters per nasal cannula. There was no label/date on the tubing. On 01/10/2024 at 9:01 AM, the surveyor observed RI #85 sitting up in bed eating breakfast, with his/her O2 on infusing at three liters per nasal cannula. There was no label/date on the tubing. On 01/10/2024 at 9:33 AM, an interview was conducted with UM #8. UM #8 said she did not see a label/date on RI #85's oxygen tubing but there should have been. UM #8 stated, the concern with not having a label and date on the tubing was not getting the tubing changed and staff would not know when to change the tubing. 3) RI #314 was admitted to the facility on [DATE] with a diagnosis of Malignant Neoplasm of Unspecified Part of Unspecified Bronchus or Lung. RI #314's January 2024 physicians' order documented: . OXYGEN AT 3L CONTINUOUS THROUGH NASAL CANNULA . On 01/09/2024 at 3:03 PM, the surveyor observed RI #314 with O2 infusing; there was no label/date on the tubing. On 01/10/2024 at 9:11 AM, the surveyor observed RI #314 with O2 infusing and the oxygen tubing was not labeled or dated. On 01/10/2024 at 9:23 AM, an interview was conducted with UM #8. UM #8 said there was no label/date on RI #314's oxygen tubing, but there should be. UM #8 stated she was responsible for checking to ensure oxygen tubing was dated.

Based on RI #215's medical record, interviews, facility pharmacy records titled CONSOLODATED DELIVERY SHEETS, and the facility policy titled, Ordering and Receiving Medications from Provider Pharmacy the facility failed to ensure Resident Identifier (RI) #215's Clonazepam was available for administration on 04/05/2023, 04/06/2023, 04/07/2023, and 04/11/2023. This deficient practice affected RI #215; one of three residents sampled for medication availability. Findings include: The facility policy titled, Ordering and Receiving Medications from Provider Pharmacy, dated 04/2020 revealed: Policy Medications and related products are received from the provider pharmacy on a timely basis. The facility maintains accurate records of medications order and receipt. RI #215 was admitted to the facility 04/05/2023 with a diagnosis of Vascular Dementia without Behaviors. A review of RI #215's discharge orders revealed: . date 04/05/2023 Scheduled Medications . Clonazepam (Klonopin) 0.5 mg (milligrams) oral Daily at bedtime . A review of RI #215's Medication Administration Record (MAR) for April 2023 revealed the Clonazepam was not administered on 04/05/2023, 04/06/2023, 04/07/2023 and 04/11/2023. The MAR indicated Registered Nurse (RN) #25, Licensed Practical Nurses (LPN) #24, and (LPN #26), documented the medication was not administered. The CONSOLIDATED DELIVERY SHEETS from the pharmacy dated 04/12/2023 indicated RI #215's Clonazepam was not delivered to the facility until 04/12/2023. On 01/09/2024 at 6:56 PM, a telephone interview with RI #215's sponsor who indicated staff did not administer RI #215's Clonazepam for several days. On 01/09/2024 at 8:24 PM, a telephone interview was conducted with Registered Nurse (RN) #25. The RN said she did not know why RI #215 missed four (4) doses of Clonazepam. RN #25 said the N on the MAR indicated the medication was not administered. On 01/11/2024 at 4:34 PM, an interview was conducted with the Pharmacist. The Pharmacist said the Clonazepam was filled and delivered on 04/11/2023, because the hard copy of the prescription had to be signed before the medication could be filled. She said the facility had to get the hard copy, and usually the provider who discharged the resident would provide it to the facility. The Pharmacist said controlled substances could not be filled unless the facility sent the signed copy of the prescription. She said the RI #215's admission orders did not have a signed prescription for the Clonazepam. On 01/11/2024 at 4:47 PM, during an interview with the Director of Pharmacy (DOP), the DOP said medications should always be available. The DOP said the facility needed the hard signed copy of the prescription for RI #215's Clonazepam. The DOP said the prescription needed was not received by the pharmacy until 04/11/2023. On 01/11/2024 5:16 PM, during an interview with the Director of Nursing (DON), she said residents' medications should be available when the resident arrived at the facility. The DON said a hard copy for a controlled medications should be obtained upon admission. The DON said medications should never be marked as not available. The DON said staff should call the doctor or the Nurse Practitioner if the medications were not available. This deficiency was cited as a result of complaint/report number AL00044814.

Based on interviews, medical record review, a review of POTTER AND PERRY'S, FUNDAMENTALS OF NURSING, and review of the pharmacy CONSOLIDATED DELIVERY SHEETS, the facility failed to ensure Resident Identifier (RI) #1 received a [MEDICATION NAME] on 3/7/2020 as ordered by the physician. This affected one of four sampled residents reviewed to ensure medications were given as ordered by the physician Findings Include: A review of POTTER AND PERRY'S, FUNDAMENTALS OF NURSING, NINTH EDITION, CHAPTER 23 Legal Implications in Nursing Practice, page 311, revealed: .Health Care Provider Orders. The health care provider (physician or advanced practice nurse) is responsible for directing medical treatment. Nurses follow health care providers' orders unless they believe that the orders are in error, violate agency policy, or are harmful to the patient. RI #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of RI #1's Physician order [REDACTED]. [MEDICATION NAME] 4% (percent) PATCH APPLY 2 PATCHES [MEDICATION NAME] TO AFFECTED AREA EVERY DAY X (times) 14 DAY D/T (due to) PAIN . A review of the pharmacy CONSOLIDATED DELIVERY SHEETS, dated 3/6/2020, revealed the facility received medications from the pharmacy for RI #1 at 9:27 PM. However, the [MEDICATION NAME] 4% patches were not included in the delivery. A review of the Medication Administration Record [REDACTED]. This dose was marked on the MAR indicated [REDACTED]. An interview was conducted on 11/5/2020 at 6:05 p.m. with EI #2, Registered Nurse (RN)/Director of Nursing (DON). EI #2 explained that [MEDICATION NAME] 4% patches were an over the counter (OTC) medication and the facility usually provided that medication and not the pharmacy. EI #2 further stated the nurse should have called Central Supply or Administration if she needed the medication. A follow up interview was conducted on 11/7/2020 at 7:41 a.m. with EI #2. EI #2 stated RI #1's [MEDICATION NAME] was due to be given on 3/7/2020 at 9:00 a.m., but according to the MAR indicated [REDACTED]. EI #2 replied, the nurse responsible for his/her care. A phone interview was conducted on 11/5/2020 at 7:45 p.m. with EI #1, the LPN that signed the MAR indicated [REDACTED]. EI #1 was asked why the [MEDICATION NAME] was not given on 3/7/2020 at 9:00 a.m EI #1 replied, she did not remember, but she should have called pharmacy if she did not have the patch available. When asked about the patches being an OTC medication, EI #1 was unaware the [MEDICATION NAME]es were over the counter. An interview was conducted on 11/6/2020 at 12:46 p.m. with the Manager of the Pharmacy. The manager was asked why the [MEDICATION NAME] was not received from Pharmacy with the other medications for RI #1. The manager explained that [MEDICATION NAME] 4% patch was an over the counter (OTC) product and OTC medications were pulled from the facility stock supply. The manager further explained that, in the event that the patches are not in stock, the facility can purchase it from a local store. This deficiency was cited as a result of the investigation of complaint/report number AL 421.

Based on interviews, review of a document provided by the facility titled, Routine COVID-19 ([MEDICAL CONDITION] Disease) Testing, review of Employee Identifier (End I) #4's COVID-19 testing results and HOURS WORKED SIMPLIFIED REPORT, the facility failed to ensure EI #4 was tested weekly for COVID 19 based on the facility's county positivity rate. This affected one of three sampled employees reviewed for COVID-19 testing requirements. Findings Include: Review of a document provided by the facility titled Routine COVID-19 Testing revealed the facility's county positivity rates from 9/18/2020 through 10/30/2020 were as follows: Week of 9/18/2020- 9.7% Week of 10/2/2020- 7.3% Week of 10/16/2020- 6.2 % Week of 10/30/2020- 6.9% This document indicated the minimal testing frequency for each of these dates was once per week due to a county positivity rate of 5-10%. Review of EI #4's HOURS WORKED SIMPLIFIED REPORT for 9/1/2020 through 10/31/2020 revealed EI #4 worked each week from 9/18/2020 through 10/30/2020. However, Lab Summary Reports for EI #4 revealed she was only tested on ,[DATE], 9/22, 10/2, and 11/4/2020. An interview was conducted on 11/5/2020 at 8:20 a.m. with EI #4, a Certified Nursing Assistant. EI #4 was asked if the facility had told her she needed to be tested for COVID 19. EI #4 replied, yes. EI #4 stated they were testing every two weeks but now it is every week, on Tuesdays. When asked if she had been tested every week, EI #4 replied, no. EI #4 was asked, why not. EI #4 replied, she would be running out the door when she finished working her shift and it slipped her mind. EI #4 was asked, what did the facility teach her about COVID 19. EI #4 replied, some people have symptoms and some do not, and you can spread it to others and not know you have it. EI #4 was then asked why she had not been tested every week if they were supposed to be tested weekly. EI #4 replied, screening was done in the morning, and she thought if she did not have symptoms, she was okay. EI #4 was asked what could be done to prevent the spread of COVID 19. EI #4 replied, go get tested , and further stated she could have gotten tested during her 15 minute break instead of waiting until the end of her shift. An interview was conducted on 11/4/2020 at 4:30 p.m. with EI #5, Assistant Director of Nursing/ Infection Control Preventionist (ICP). EI #5 explained staff were being tested every week, on Tuesdays, and if they cannot be tested on Tuesday, they can get tested any other day that week. EI #5 was asked if EI #4 had been tested every week during the months of September and October 2020. EI #5 reviewed testing results and replied no, not every week. EI #5 was asked, why not. EI #5 said EI #4 had not taken it upon herself to come get tested weekly, despite receiving education on weekly testing and the facility having flyers posted everywhere. When asked who was responsible for seeing to it that the employees are tested , EI #5 stated it was ultimately her responsibility as the ICP. EI #5 was asked, what was the harm in not testing EI #4 weekly. EI #5 replied, she could be asymptomatic and spread COVID to guests and employees.

Based on observation, interview, and the (YEAR) Food and Drug Administration (FDA) Food Code, the facility failed to ensure: 1.) the dishwasher drain pipe did not extend into the floor drain by one inch, 2.) the table stand mixer's wire bowl guard did not have a white-yellow dried residue on the bottom wire when the cook used the mixer to make chocolate pudding for lunch on 9/17/19, and 3.) the Tuna Salad, Pasta Salad, and Oreo Fluff Parfait served for lunch on 9/17/19 were maintained at 41 degrees Fahrenheit (F) or lower during holding for service. This had the potential to affect 99 residents receiving meals from the kitchen, 99 of 100 residents. Findings include: 1.) The (YEAR) FDA Food Code included the following: . 5-402.11 Backflow Prevention. (A) . a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. During the initial kitchen tour on 9/16/19 at 3:55 PM, the drain pipe from the dishwasher was observed to extend down into the floor drain and therefore below the level of the floor. On 9/16/19 at 4:07 PM, an interview began with Employee Identifier (EI) #3, the Maintenance Director. EI #3 measured how far the dishwasher drain pipe extended down into the floor drain. EI #3 said the dishwasher drain pipe extended one inch into the floor drain. When asked what would be the concern with the dishwasher drain pipe extending into the floor drain, EI #3 said it had the potential for backflow. Upon being asked what would be the proper length for the dishwasher drain pipe, EI #3 said it should be above the floor. On 9/17/19 at 4:58 PM, an interview was conducted with EI #4, the Consultant Registered Dietitian (RD). When asked how the dishwasher drain pipe being below floor level and extending into the floor drain had the potential to negatively affect the residents, EI #4 said back-siphonage of sewage. 2.) The (YEAR) FDA Food Code included the following: . 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. During the initial kitchen tour on 9/16/19 at 4:05 PM, the surveyor observed the table stand mixer's wire bowl guard had a white-yellow dried residue build-up along the bottom edge of the wire bowl guard, which was located over the mixer bowl. During a follow-up kitchen visit on 9/17/19 at 9:29 AM, the surveyor observed the white-yellow dried residue build-up was still present on the table stand mixer's wire bowl guard. On 9/17/19 at 11:03 AM, EI #5 (an AM Cook) was observed dipping out chocolate pudding from the table stand mixer bowl into individual dishes for the Oreo Fluff Parfait to be served at lunch on 9/17/19. EI #5 was asked when was the last time she used the table stand mixer. EI #5 said she used it that morning to make the chocolate pudding. When asked if she noticed the white-yellow dried residue build-up on the table stand mixer's wire bowl guard when she made the pudding, EI #5 replied no. EI #5 was asked what type of residue did it look like. EI #5 replied it looked like food residue. On 9/17/19 at 11:12 AM, an interview was conducted with EI #6, the Regional Registered Dietitian (RD) Consultant. EI #6 was shown the white-yellow dried residue build-up on the table stand mixer's wire bowl guard. When asked what was the potential problem with having the residue on the equipment, EI #6 said it could fall into the food. Upon being asked what was the potential problem if the residue fell into the food, EI #6 said contamination. 3.) The (YEAR) FDA Food Code included the following: . 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (C) . TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: . (2) At . (41 . (degrees) . F) or less. On 9/17/19 the monitoring of food temperatures for the resident lunch tray service was observed for the 200/400 Halls in the Nourishment Room/Finishing Kitchen on 200 Hall and for the 100/300 Halls in the Nourishment Room/Finishing Kitchen on 100 Hall. At 12:28 PM in the Nourishment Room/Finishing Kitchen on 200 Hall, EI #7, an AM Cook, calibrated the thermometer in an ice slush. EI #7 then checked the cold food temperatures with the following results: Tuna Salad at 51 degrees F, Pasta Salad at 52 degrees F, and Oreo Fluff Parfait at 57 degrees F. At 12:40 PM in the Nourishment Room/Finishing Kitchen on 100 hall, EI #1, the Executive Chef, used a calibrated thermometer to check the cold food temperatures with the following results: Tuna Salad at 49.5 degrees F and Pasta Salad at 46.4 degrees F. At 12:44 PM, when asked what temperature should the salads be, EI #1 replied under 41 degrees F. At 12:45 PM, service began for lunch on the 100 hall and residents were served plates with the Tuna Salad and Pasta Salad. On 9/17/19 at 4:58 PM, an interview was conducted with EI #4, the RD Consultant. EI #4 was asked at what temperature should cold food be held on the serving line. EI #4 replied 41 degrees F or below to avoid the danger zone and bacterial growth.

Based on observation, interview, and the (YEAR) Food and Drug Administration (FDA) Food Code, the facility failed to ensure one of two dumpster's had the doors closed and further failed to ensure the outside refuse storage area was kept clean to discourage vermin. This had the potential to affect 100 out of 100 residents living in the facility. Findings include: The (YEAR) FDA Food Code included: . 5-501.15 Outside Receptacles. (A) Receptacles and waste handling units for REFUSE, . used with materials containing FOOD residue and 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 that accumulation of debris and insect and rodent attraction and harborage are minimized and effective cleaning is facilitated around . the unit. 5-501.110 Storing Refuse, Recyclables, and Returnables. REFUSE, . shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, . shall be kept covered: . (B) With tight-fitting lids or doors if kept outside the FOOD ESTABLISHMENT. 5-501.115 Maintaining Refuse Areas and Enclosures. A storage area and enclosure for REFUSE, . shall be . clean. On 09/16/19 at 4:11 PM, during a tour of the dumpster area with Employee Identifier (EI) #1, the Executive Chef, the following was observed: The doors were open on one of two dumpster's and approximately 3 flies were flying around the dumpster. Just outside the dumpster with the open doors, there was a large black trash bag broken open with its contents spilled out onto the cement ground surface. The large mound of food spillage included milk containers, fruit cups, beverage cups, cucumber slices, bread, and other food waste. EI #1 said the bulk of it looked like cooked apples. EI #1 was asked approximately how much spilled garbage was mounded upon the ground. EI#1 stated, At least 20 pounds. When asked what could result from the garbage being on the ground, EI #1 stated, It can bring maggots, flies, and critters. When asked how that could be a problem for the residents, EI #1 stated, Critters can bring disease. On 09/17/19 at 4:58 PM, EI #4, the Consultant Registered Dietitian (RD), was asked how could approximately 20 pounds of food refuse on the ground by the dumpster negatively affect the residents. EI #4 said it had the potential to attract pests and rodents.

Based on observation, interview, the facility's Cycle Menus policy, the facility's Menu Changes policy, the facility's Menu Diet Guide Sheet, and the facility's Menu Measurement Conversion Factors, the facility failed to ensure the planned lunch menus for the Pureed and the Mechanical Soft diets were followed on Tuesday, 9/17/2019. This had the potential to affect the eighteen residents receiving mechanically altered diets, eighteen of 99 residents receiving their meals from the kitchen and eighteen of 100 residents in the facility. Findings include: The facility's Cycle Menus policy, effective date 10/01/2005, included the following: . PURPOSE: To meet the nutritional needs of resident/guest(s), . standard menus are utilized. PR[NAME]ESS: . c. Menus should have portions stated in ounces, and/or measurements. A helpful conversion factors chart is attached as an exhibit to this policy. g. Menus should include but are not limited to the following: * Two cups milk or equivalent daily * Six ounces meat, poultry, fish or protein equivalent daily * Four servings of fruits and vegetables . Menu Measurement Conversion Factors . 1 ounce . #30 scoop 2 ounces . #16 scoop 3 ounces . #12 scoop 4 ounces . #8 scoop 6 ounces . #6 scoop . The facility's Menu Changes policy, effective 8/10/2018, included the following: . PURPOSE: Cycle menus are designed to meet the daily food allowance requirements . for residents/guest(s). STANDARD: The cycle menus should be followed whenever possible. When situations arise that prevent adherence to the menu, the FNS (Food and Nutrition Services) Manager should select food replacements that are of similar value. Process: a. Menu changes should be indicated on the menu, prior to meal service by Dietary Manager or R.D. (Registered Dietitian) . The facility's 2019 Spring/Summer menu Diet Guide Sheet for Lunch, Day 10 (Week 2 - Tuesday) indicated the following items were to be served for residents receiving a Pureed diet on 9/17/2019: Pureed Soft Tuna Salad 3 oz. (ounces) Pureed Pasta Salad ½ cup Pureed Marinated Broccoli Salad ½ cup Pureed Crackers 4 packages Pureed Oreo Fluff Parfait 1 each The facility's 2019 Spring/Summer menu Diet Guide Sheet for Lunch, Day 10 (Week 2 - Tuesday) indicated the following items were to be served for residents receiving a Mechanical Soft diet on 09/17/2019: Tuna Salad on Lettuce 3 oz. Pasta Salad ½ cup Marinated Broccoli Salad ½ cup Crackers 4 packages Oreo Fluff Parfait 1 each During a kitchen observation on 9/17/19 at 9:50 AM, the surveyors were given the facility's menu for Monday, 9/16/2019 through Thursday, 9/19/2019 by Employee Identifier (EI) #4, the Consultant RD. The menu received at this time only included Regular and CCD (Consistent Carbohydrate Diabetic) diets. The menu documented that the Regular diet lunch for Day 10 (Week 2 - Tuesday) on 9/17/2019 was to be Tuna Salad on Lettuce, Marinated Broccoli Salad, Pasta Salad, Crackers, and Oreo Fluff Parfait. There were no Pureed or Mechanical Soft selections listed for Day 10 (Week 2 - Tuesday) on this menu sheet titled, New alternates 2019 S/S (Spring/Summer) . (Facility's Name) . menu Diet Guide Sheet. On 9/17/19 at 11:03 AM, EI #5, an AM Cook, was observed using the mixer bowl to dip out chocolate pudding into individual cups for the Oreo Fluff Parfait. A #30 scoop was being used to portion the chocolate pudding into each dish. According to the Menu Measurement Conversion Factors, a #30 scoop was equivalent to one ounce. On 9/17/19 at 11:07 AM, EI #5 was asked if all of the residents were to get the Oreo Fluff Parfait for dessert. EI #5 responded no and said the residents on a CCD diet got diet pudding and no cookie. EI #5 further said the diet pudding used for the CCD diet was pre-packaged in individual cups. When asked what did the residents on Pureed and Mechanical Soft diets receive. EI #5 stated the residents on Pureed diets got either Ensure (a dietary supplement) pudding or the diet (sugar-free) pudding and the residents on Mechanical Soft diets got the pudding and whipped topping, but no cookie. On 9/17/19 at 11:45 AM, EI #5 was observed preparing pureed tuna salad, for 5 residents, using the [NAME]ot Coupe. EI #5 selected a #6 scoop (6 oz.) and a #16 scoop (2 oz.) to portion the salad. EI #6, the Regional Registered Dietitian (RD) Consultant, informed EI #5 that a #12 scoop (3 oz.) was needed for the tuna salad and a #8 scoop (4 oz.) was needed for each non-meat salad. EI #6 stated that she would repost the equivalency poster for explaining which scoop size to use. EI #5 then used a 3 oz. utensil to portion the pureed tuna salad into 4-ounce bowls. On 9/17/19 at 11:58 AM, EI #6 was asked when was the scoop equivalency poster first put up. EI #6 stated she believed there was an equivalency poster for scoops posted in (MONTH) of 2014. EI #6 further said (name of EI #4, the Consultant RD) was printing out a chart for scoop sizes to post today. On 9/17/19 at 12:01 PM, EI #5 was observed making pureed pasta salad. EI #5 was then observed using a #8 scoop (4 oz.) to portion the puree pasta salad onto each of the five plates next to the bowl of pureed tuna salad. EI #5 then put an empty 4-ounce bowl on each plate with the pureed tuna salad and the pureed pasta salad. When asked what the empty bowl was for, EI #5 said soup. At 12:12 PM on 9/17/19, the pre-portioned and wrapped Pureed plates were placed on the delivery carts. An individual cup of pre-packaged sugar-free (diet) chocolate pudding was put atop each of the wrapped Pureed plates. During an interview on 9/17/19 at 4:58 PM, EI #4, the Consultant RD, was asked who planned the menu for the residents. EI #4 responded the chef, with her approval. When asked why should planned menus be used, EI #4 said to ensure the meals are nutritionally adequate, have variety, and are safe for the current population. When asked who approved the menus and why, EI #4 said she did so the staff would know what to cook to meet the needs of the population. When asked what diets were included on the extended therapeutic diet menu, EI #4 stated Regular and CCD. Upon being asked what pertinent information was included on the extended therapeutic diet menu, EI #4 said what to serve and portion sizes. When asked if Pureed and Mechanical Soft diets were served to the facility's residents, EI #4 said yes, you mean consistencies. EI #4 was asked how did staff know what food items and serving sizes to provide for the Pureed and Mechanical Soft diets. EI #4 stated there was a diet guide in a book in the main kitchen, the Diet Guide. EI #4 was then asked if the staff was expected to follow the Regular diet and change the texture, why did they not puree the Marinated Broccoli Salad and puree the Oreo Fluff Parfait. EI #4 stated that was unfortunate because it (the Diet Guide) is there for them to use. At this point during the interview, EI #4 provided the surveyors with a copy of the Diet Guide she was referencing, it was titled New alternates 2019 S/S (Spring/Summer) . (Facility's Name) . menu Diet Guide Sheet and it included menus for Regular, Mechanical Soft, Pureed, and CCD diets. Upon being asked why the Pureed diets did not get the Pureed Soft Tuna Salad, Pureed Pasta Salad, Pureed Marinated Broccoli Salad and Pureed Oreo Fluff Parfait, EI #4 said that was a lack of supervision and direction. The surveyor shared the observation from lunch on 9/17/19 about soup being exchanged for the Marinated Broccoli Salad for those receiving a Puree Diet and a four-ounce bowl being used. When asked if four ounces of soup would be sufficient, EI #4 said possibly not. When asked what would be an adequate portion of chocolate pudding to count as a serving of milk, EI #4 said it should probably be about four ounces. EI #4 was asked why would the cook give each of the Pureed diets a diet (sugar-free) chocolate pudding when none of them were on a CCD diet. EI #4 said the surveyor would have to ask the cook, it did not make any sense to her. When asked if the menus were being followed, EI #4 said not fully. EI #4 further said the menu serving sizes and pureed items were not being followed. EI #4 was asked if she thought the cooks had been instructed on the menus. EI #4 said it was either by choice or knowledge deficit.

Based on the facility's policy titled, Tube Feeding-Formula Documentation, observation and interviews, the facility failed to ensure Resident Identifier (RI) # 87's tube feeding pump water flush rate was set at 80 cubic centimeter (cc) an hour (per the physician orders), and not set at 50 cc an hour. The failed practice affected one of two residents receiving tube feeding. Findings include: A Review of the facility's policy titled, Tube Feeding-Formula Documentation, effective date (MONTH) 1, 2012, revealed, . Process: . 4. physician's orders [REDACTED]. Flush every frequency/ hr (hour) with total cc H2O (water) . RI #87 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A review of RI #87's (MONTH) 2019 physician's orders [REDACTED]. 8/5/19 . Flush with 80 cc H2O q (every) 1 hour . 9/12/19 . On 09/17/19 at 9:51 am, the Surveyor observed hanging in RI #87's room [MEDICATION NAME] 1.5 per pump with a rate of 55 ml (milliliter) an hour. The water bag, dated 9/16/19, was hanging with a flush rate of 50 ml an hour. On 9/18/19 at 9:47 am, the Surveyor made a second observation of RI# 87 tube feeding [MEDICATION NAME] bottle infusing per pump at 55 ml per hour. The water bag was hanging with a flush or 50 cc per hour. Both bottle and bag had a handwritten date or 9/18/19. A Third observation was made by the Surveyor on 9/18/19 at 12:53 pm. Employee Identifier (EI) #11, Registered Nurse / Unit Manager was also present. The Surveyor and EI # 11 observed the setting on the feeding pump for the water infusion. The Surveyor observed the pump set at 50 cc an hour for the water flush. On 09/18/19 at 12:59 pm, the Surveyor conducted an interview with EI # 11. EI # 11 was asked, what was the setting for the water flush. EI # 11 replied, 50 ml every one hour. EI # 11 was asked, who was responsible for setting the flush on the pump. EI # 11 replied, the nurses, when the order was written they will set it up. EI # 11 was asked, when if ever, would the feeding or the flush rate change. EI # 11 replied, they have to have a physician or nurse practitioner order. EI # 11 was asked, what was RI # 87 physician order [REDACTED].# 11 replied, flush rate was 80 cc of water every one hour. EI # 11 was asked, should the feeding pump be set at 80 cc an hour for water flush for Resident # 87. EI # 11 replied, yes ma'am. EI # 11 was asked, what was the flush rate set on the pump. EI # 11 replied, 50 cc an hour. EI # 11 was asked, why was the flush rate set on the pump at 50 cc an hour. EI # 11 replied, she was not sure. She would have to ask the nurse. EI # 11 was asked, what was the potential harm with the pump rate set at 50 cc hour when the physician order [REDACTED]. EI # 11 replied, dehydration for RI # 87 . On 09/19/19 at 12:22 pm, the Surveyor conducted an interview with EI # 13, Assistant Director of Nursing. EI # 13 was asked, how were the settings on the tube feeding pump determined. EI # 13 replied, per the physician's orders [REDACTED]. EI # 13 replied, it depended on the situation. EI # 13 was asked, what would be the potential harm with the flush rate being lower than the physician's orders [REDACTED]. EI # 13 was asked, why was the physician order [REDACTED].# 87's tube feeding flush. EI # 13 replied, he did not know, he would have to look into it and see why it was not followed.

Based on observation, interview, resident tray tickets, medical record review, and a review of the facility's policies for Person Centered Care Plans and Tray Tickets, the facility failed to ensure that requested or preferred food items were served to Resident Identifier (RI) #86 and RI #7 at lunch on 9/18/19. This affected two of 99 residents receiving meals from the kitchen, two of 100 residents residing in the facility. Findings include: The facility policy titled, Tray Tickets, with an effective date of 8/10/18 included: . PURPOSE: Tray tickets should be used to assist dietary staff to serve the resident/guest(s) meal according to food preference . STANDARD: . Menu items for the resident/guest should be consistent with . the resident/guest(s) preference for foods . The facility policy titled, Person Centered Care Plans with an effective date of 8/15/18 included: . STANDARD: . the facility develops a comprehensive person centered plan of care for each resident/guest . based upon the resident/guest(s) goals and preferences . 1.) RI #86 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #86's care plan revealed the following: Care Plan Description POTENTIAL FOR WEIGHT LOSS R/T (related to) IMPAIRED COGNITION AND MOBILITY. Care Plan Goal I WILL NOT HAVE SIGNIFICANT WEIGHT LOSS X (times) 90 DAYS AEB (as evidenced by) WEIGHT REVIEW . Intervention . PROVIDE WITH FOOD/BEVERAGE PREFERENCES . Start Date 8/31/2019 . A review of RI #86's physician orders [REDACTED]. . MECHANICAL SOFT NAS (No Added Salt) DIET . A review of the tray ticket for RI #86 revealed the following: . NAS - Mech Soft Wednesday . Lunch 9/18/2019 . Turkey Sandwich . On 9/18/19 at 12:39 PM, during the tray line observation, RI #86 did not receive a turkey sandwich as listed on RI #86's tray ticket. Employee Identifier (EI) #7, the AM Cook, who was plating the food, was verbally reminded by EI #8, the Dietary Aide, that RI #86 needed a turkey sandwich on the tray. EI #7 said they did not have any turkey. RI #86's lunch tray was placed on the food cart without a turkey sandwich on it. On 9/18/19 at 4:30 PM, the surveyor attempted to interview RI #86 and found the resident to be not interviewable. On 9/18/19 at 4:32PM, an interview was conducted with RI #86's private sitter who was present at the bedside. RI #86's sitter said she stayed with RI #86 during the day from Monday through Saturday every week and had done so even before he/she entered the facility. When asked what was on RI #86's lunch tray that day, the sitter replied lima beans, greens, pork chop, cornbread, and butterscotch dessert. The sitter was asked who requested that RI #86 get a turkey sandwich. The sitter replied his family. The sitter said the resident was supposed to get a turkey sandwich every day. When asked why there was a daily request for a turkey sandwich, the sitter said because the resident ate a lot and liked turkey. The sitter was asked when was the last time the resident got a turkey sandwich. RI #86's sitter replied one day last week. On 9/19/19 at 8:28 AM, an interview was conducted with EI #7, the AM Cook. EI #7 was asked what was it called when a resident or family requested extra items or a different item on the meal tray. EI #7 said a special request. Upon being asked when did they honor a special request or preference, EI #7 replied when it was called in. When asked what if it was an item to be included with lunch. EI #7 said every day. EI #7 was asked how did she know what a resident special request or preference was. EI #7 said when it was called in or it was on the tray ticket. EI #7 was asked what did she do if a special requested item or preference item was not available. EI #7 replied they substituted the item. When asked how did she know what to substitute that item with. EI #7 said someone would ask the resident what they wanted. EI #7 was asked why did (name of RI #86) not get a turkey sandwich on his/her lunch tray the day before. EI #7 replied there was no sliced deli turkey. When asked what was the turkey sandwich substituted with, EI #7 replied (name of RI #86) did not get anything. Upon being asked what should she have done if sliced deli turkey was not available, EI #7 said to let the manager know. EI #7 was asked when a special request or preference item was not provided, what was the potential negative affect on the resident. EI #7 replied maybe they would not eat. On 9/19/19 at 12:29 PM, an interview was conducted with EI #6, the Regional Registered Dietitian (RD) Consultant. EI #6 was asked what was the concern if RI #86 did not receive the turkey sandwich each day. EI #6 said, not meeting the preference each day and the resident may not eat enough without it. 2.) RI #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #7's physician orders [REDACTED]. . REGULAR NAS (no added salt) DIET . A review of RI #7's care plans revealed the following: . Care Plan Description POTENTIAL FOR WEIGHT LOSS R/[MEDICAL CONDITION] AND OTHER CONDITIONS/MEDICATIONS . Care Plan Goal I WILL NOT HAVE SIGNIFICANT WEIGHT LOSS X 90 DAYS . Intervention . PROVIDE WITH FOOD/BEVERAGE PREFERENCES . Start date 3/13/18 . Intervention . FROZEN NUTRITIONAL TREAT ADDED DAILY FOR SUPPLEMENT . Start date 7/27/18 . Care Plan Description POTENTIAL FOR DEHYDRATION . Care Plan Goal MY HYDRATION STATUS WILL BE MAINTAINED . Intervention . OFFER/ENCOURAGE FLUIDS HONORING PREFERENCES . Start date 3/13/19 . A review of the tray ticket for RI #7 included the following: . NAS Wednesday . Lunch 9/18/19 . ice cream . milk . ice water . On 9/18/19 at 1:08 PM, RI #7 was observed sitting in his/her room eating lunch. The tray ticket listed the following items: fried pork chops, seasoned turnip greens, buttered baby lima beans, cornbread, ice cream, butterscotch tart, milk, sweet tea, ice water. There was no ice water, milk, or ice cream observed on tray. When asked what was missing from the tray, RI #7 said there was no ice cream. During an interview on 9/19/19 at 12:35 PM, EI #6, the Regional RD Consultant, was asked what would be the concern with no ice cream, milk and ice water not being on the tray for RI #7 as per the tray ticket documentation. EI #6 replied not providing the additional calories needed for weight stabilization and by not receiving the preferred beverage it might result in the resident not drinking enough. This regulation is cited as a result of the investigation of complaint/report # AL 405.

Based on a facility's policy titled, Isolation Food Trays, observation and interviews, the facility failed to ensure a disposable tray was utilized for Resident # 22 on isolation for [MEDICAL CONDITION] and was not served a meal on a non disposable meal tray on 09/18/19. The failed practice affected one of one resident who was on isolation. Findings include: Review of the facility's policy titled, Isolation Food Trays, effective date: (MONTH) 10. 2002, revealed, . PURPOSE: To prevent the spread of bacteria from one resident/guest to another resident/ guest. Process: . d. All utensils and dishes entering the isolation room should be disposable. e. No left over foods or utensils should be returned to the dietary department; rather, they should be disposed of in the isolation room. RI #22 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #22's [DIAGNOSES REDACTED]. RI #22's (MONTH) 2019 physician orders [REDACTED]. On 09/18/19 at 1:12 pm, the Surveyor observed RI #22 eating a lunch meal his/her room on a non disposable tray. On 09/18/19 at 1:13 pm, the Surveyor conducted an interview with Employee Identifier (EI) #9, Patient Care Assistant (PCA). EI#9 was asked, what type of meal tray did RI # 22 have for the lunch meal on 09/18/19. EI #9 replied, regular. EI #9 was asked, what type of isolation was RI # 22 on. EI#9 replied, she really did not know. she thought [MEDICAL CONDITION]. EI #9 was asked, what type of material was RI # 22's lunch tray and plate made out of on 09/18/19. EI #9 replied, tray was plastic, plate was glass, bowel was plastic and cup was plastic. On 09/18/19 at 1:22 pm, the Surveyor conducted an interview with EI #10, PC[NAME] EI #10 was asked, did she take RI # 22's lunch meal tray into the resident's room on 09/18/2019. EI #10 replied, yes ma'am she did. EI #10 was asked what materials was the actual tray made of. EI #10 replied, it was the same as every one else's tray. EI #10 was asked what material was the lunch meal plate made of. EI #10 said it was a glass plate. EI #10 was asked what type isolation was RI #22 on. EI #10 replied, RI # 22 had [MEDICAL CONDITION]. EI #10 was asked what material should RI # 22's tray be made from. EI #10 replied, something that was disposable. EI #10 was asked, why was RI # 22's lunch meal not served on disposable meal tray items. EI #10 replied, she was not sure about that. EI #10 was asked, what was the facility's policy regarding RI # 22 meal tray after consumption of the meal. EI #10 replied, she was told when they pick up RI # 22's non disposable meal tray to immediately take it downstairs to the kitchen. EI #10 was asked, who told her to immediately take the meal tray downstairs. EI #10 replied, EI #11. EI #10 was asked, who was EI #11. EI #10 replied, the unit manager. EI #10 was asked when did EI #11 tell her that. EI #10 replied, the day before, 09/17/19. EI #10 was asked why did EI#11 tell her that. EI #10 replied, she guessed because RI # 22 was on precautions and got a regular tray (non disposable). EI #10 was asked, where did she take RI # 22's used tray downstairs. EI #10 replied, to the kitchen. EI #10 was asked, where in the kitchen. EI #10 replied, she had not taken the non disposable tray down there before. EI #10 was asked, what was the harm with serving a meal to a resident on isolation on a non disposable tray. EI #10 replied, it could spread the precautions that RI # 22 was on to other residents. On 09/18/19 at 4:20 PM, the Surveyor conducted an interview with EI #11, Registered Nurse/Unit Manager. EI #11 was asked, what type of isolation was RI # 22 on. EI #11 replied, [MEDICAL CONDITION]. EI #11 was asked, what did that mean. EI #11 replied, [MEDICAL CONDITION] was in RI #22 feces. EI #11 was asked, what type of isolation was RI # 22 on. EI #11 replied, contact isolation. EI #11 was asked, what personal protective equipment (PPE) were required for contact isolation. EI #11 replied, gown, glove and mask. EI #11 was asked, what type of meal tray should a resident with [MEDICAL CONDITION] contact precaution be using. EI #11 replied, disposable tray. EI #11 was asked, what type tray did RI # 22 receive for lunch on 9/18/19. EI #11 replied, a regular tray non disposable. EI #11 was asked, what was regular. EI #11 replied, hard plastic tray and regular porcelain plate with a silver lid. EI #11 was asked, who cleaned the meal tray for RI # 22. EI #11 replied, they take it directly down to dietary. EI #11 was asked, who took the lunch meal tray from RI # 22's room that day, 09/18/19. EI #11 replied, she thought EI#9. EI #11 was asked, what was the potential harm with using a non disposable meal tray for RI # 22, on isolation precautions for C- diff. EI#11 replied, contaminating other residents and staff. EI#11 was asked, were RI # 22's meal tray and equipment cleaned in the room prior to exiting room with it. EI#11 replied, not to her knowledge. 09/18/19 5:02 PM, the Surveyor conducted a second interview with EI #11. EI #11 reviewed the facility's policy titled, Isolation Food trays. EI #11 was asked, what did the facility's policy Isolation Food Trays read regarding disposable food trays. EI #11 replied, disposable tray service should only be utilized for resident/guest in isolation. EI #11 was asked, what was the purpose of the facility's policy titled, Isolation Food Trays. EI #11 replied, to prevent the spread of bacteria from one resident/guest to another resident/guest. EI #11 was asked, what did the process under d read of the policy. EI #11 replied, all utensils and dishes entering the isolation room should be disposable. EI #11 was asked, why should the items be disposable. EI #11 replied, to prevent spread of bacteria from one guest to another. On 09/19/19 at 09:00 am, the Surveyor conducted a second interview with EI #9. EI#9 was asked, what type of lunch tray did she remove from RI # 22 room after lunch on 09/18/19. EI #9 replied, a regular tray, a non disposable tray. EI #9 was asked, what time was that. EI #9 replied, probably like one. EI #9 was asked how did she know the time. EI #9 replied, they had got the trays about 12:45 so she normally picked up trays about 30 minutes after they passed them out. EI #9 was asked, what did she do with the non disposable meal tray that had been in RI # 22's room. EI #9 replied, she took it straight to the cafeteria. EI #9 was asked, who did she give it to. EI #9 replied, she gave it to one of the dietary people down there. EI #9 was asked, was she wearing PPE. EI #9 replied, no she it off in the room. EI #9 was asked, did she clean the tray and contents in RI # 22's room. EI #9 replied, no ma'am. EI #9 was asked, did she remove RI #22's breakfast tray from the isolation room that day, 09/19/19. EI #9 replied, no ma'am. EI#9 said EI #11 told her not to get it. EI#9 was asked why. EI #9 replied, the dietary are supposed to get it. On 09/19/19 at 12:17 pm, the Surveyor conducted an interview with EI #13, Assistant Director of Nursing/ Infection Control Registered Nurse. EI #13 was asked, what was the facility policy regarding meal trays and residents on isolation. EI #13 replied, residents on isolation use isolation trays/ disposable trays. EI #13 was asked, was the facility's policy followed for RI # 22 on isolation, with the meal trays on 09/18/19. EI #13 replied, no it was not. EI #13 was asked how was the policy not followed. EI #13 replied, a disposable meal tray was not used for RI # 22's meals. EI #13 was asked, what was the potential harm for not using a disposable meal tray for a resident on isolation. EI #13 replied, it could spread infection. EI #13 was asked, what type meal tray should have been used on a resident on isolation. EI #13 replied, disposable. EI #13 was asked, should a non disposable meal tray be removed from an isolation room and taken to the kitchen to be cleaned. EI #13 replied, no. EI #13 was asked, why. EI #13 replied, it could spread infection.

Based on interviews, medical record review, review of a facility document titled Resident Status History List and a facility policy titled, Change of Room or Roommate, the facility failed to ensure the family of Resident Identifier (RI) #1 was notified of the residents's room change from the 400 hall to the 200 hall. This deficient practice affected RI #1, one of six sampled residents reviewed for change of room notification. Findings Include: A facility policy titled, Change of Room or Roommate with an effective date of (MONTH) 28, (YEAR), revealed: PURPOSE: Room changes can be frightening for a resident/guest unless the resident/guest is informed in advance and given the opportunity to have input in the decision . PR[NAME]ESS: .1. Informing the resident/guest and family, as soon as possible, of the room or roommate change. RI #1 was admitted to the facility on [DATE]. A review of a facility document titled Resident Status History List documented RI #1's room changes. The document revealed that RI #1 moved to room [ROOM NUMBER] 402 on 10/16/18. The document further revealed RI #1 moved from room [ROOM NUMBER] 402 to another room on 11/15/18. A review of progress notes revealed no documentation of RI#1's family was notified of resident's room change on 11/15/18. On 3/14/19 at 10:15 a.m, an interview was conducted with EI (Employee Identifier) #1, Assistant Executive Director. EI #1 was asked when did RI #1 move rooms. EI #1 said I don't remember the exact date, I will have to look at the records. EI #1 was asked why was RI #1 moved. EI #1 said he spoke with RI# 1's daughter and they requested to be close to the nurse's station. He said they did not have a room available that day. EI #1 was asked if there was documentation that reflected RI #1's family was notified of the room change. EI #1 said, No, I don't have any documentation. EI #1 was asked why was it important to notify sponsors/resident representative about resident room changes. EI #1 said communication was important so that they can communicate about the resident's care. On 3/14/19 at 3:35 p.m., an interview was conducted with EI #2, Social Worker. EI #2 was asked what was the process for resident/family to change rooms. EI #2 said when a family or a resident request a room change, social services is notified and they find out if a room is available. If a a room is available, they (social services) make a note and complete a UDA (User Defined Assessment), and notify other staff members. EI #2 was asked what was next in the process. EI #2 said to make a note that the resident is changing to a different room and the sponsor is always notified. EI #2 was asked had social services received a request from RI#1 or the family. EI #2, replied, To my knowledge no ma'am. EI #2 was asked if there was any documentation that RI #1's family was notified of the change. EI #2 said, No ma'am.

Based on observations, interviews, a review of the facility's policies titled, Food Receipt and Storage, Handling Serviceware/Silverware, Cleaning of Miscellaneous Equipment and Utensils and the United States Public Health Service Food and Drug Administration (YEAR) Food Code, the facility failed to ensure: 1. staff wore hair nets upon entering the kitchen and hair was kept fully contained; 2. the dry storage area floor, as well as the kitchen area floor, were clean and free of debris; 3. large silver containers, placed on green shelves, were clean and free of grease and dried debris on the inside of the containers; 4. plates in the plate warmer did not have stuck on particles, during service of the lunch meal on 02/12/19; 5. the grease trap was free of an accumulation of a black, brownish dark slimy substance; 6. the fryer was free of a large amount of dark brownish debris and dark residue; 7. the stove top tray lined with foil did not have an accumulation of cooked, stuck on debris and food; 8. the opening beneath the stove top area was free of debris and food particles; and 9. trays and plate covers/lids were not wet nesting and dietary staff allowed trays and plate covers to air dry by not using a paper towel repeatedly to dry them during lunch and supper on 02/12/19. This had the potential to affect 92 of 94 residents receiving meals from the kitchen. Findings Include: On 2/12/19 at 08:00 AM during the tour of the kitchen, observations were made in the following area: A review of the Food Code, U.S. (United States) Public Health Service U.S. FOOD & (and) DRUG ADMINISTRATION (YEAR) page 54, revealed the following: . Hair Restraints 2-402.11 Effectiveness. (A) . FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, . that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS . 1. A non dietary staff was observed to enter the kitchen and walk to the office without placing a net over her hair. A dietary staff entered the kitchen without placing a hairnet over her hair. An observation was also made of hair not fully contained under the hairnet of a staff. On 2/12/2019 at 09:45 AM, Employee Identifier (EI) #9, non dietary staff, was interviewed. She was asked what she had on her head/hair with she entered the kitchen. She replied nothing. She was asked what she should have had covering her head/hair. EI #9 replied a hairnet. A review of the facility's policy titled, Food Receipt and Storage, with an effective date of (MONTH) 23, (YEAR), revealed the following: . PR[NAME]ESS: . Storage of Foods: . d. Disassemble and properly discard empty boxes . 2. A large box containing broken boxes was observed placed in front of the hand washing sink. An observation was also made of the dry storage area. Observed on the floor were the following: a powered substance, empty boxes and plastic covers. A review of the Food Code, U.S. (United States) Public Health Service U.S. FOOD & (and) DRUG ADMINISTRATION (YEAR) page 142, revealed the following: . 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch . 3. Large silver containers, placed on the green shelves, were observed with grease and dried debris on the inside of the containers. 4. Plates in the plate warmer was observed with stuck on particles, during service of the lunch meal on 02/12/19. A review of the Food Code, U.S. (United States) Public Health Service U.S. FOOD & (and) DRUG ADMINISTRATION (YEAR) page 142, revealed the following: . 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (B) The Food-Contact Surfaces of cooking Equipment . shall be kept free of encrusted grease deposits and other soil accumulations. 5. The grease trap was observed with an accumulation of a dark slimy substance. 6. The fryer was observed to have a large amount of an accumulation of dark brownish debris and dark residue. A review of the Food Code, U.S. (United States) Public Health Service U.S. FOOD & (and) DRUG ADMINISTRATION (YEAR) page 142, revealed the following: . 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (C) NON FOOD-CONTACT SURFACES OF EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 7. The stove top tray covered with foil was observed with an accumulation of cooked, stuck on debris and food. 8. The opening beneath the stove top area, that contained utensils used for cleaning the stove, was observed covered with debris and food particles. A review of the Food Code, U.S. (United States) Public Health Service U.S. FOOD & (and) DRUG ADMINISTRATION (YEAR) page 151, revealed the following: . 4-901.11 Equipment and Utensils, Air Drying Required. After cleaning and SANITIZING, EQUIPMENT AND UTENSILS: (A) Shall be air-dried . 9. Trays and plate covers/ lids were observed wet nesting. Dietary staff were also observed using the same paper towel repeatedly to dry trays and plate covers/ lids. On 2/12/2019 at 1:55 PM, an interview was conducted with EI #4, dietary aide. EI #4 admitted to using a paper towel to wipe the trays and plate covers dry after washing. EI #4 was asked was it the policy and procedure to dry trays and covers with paper towels. She replied no. EI #4 was asked what she should have used. She replied a dish towel. On 2/14/2019 at 08:00 AM, an interview was conducted with EI #3, the Executive Chef. EI #3 was asked what she was responsible for. EI #3 replied she was responsible for ensuring the kitchen floors were clean, the cleaning and sanitization of all pots, pans and dishes. She was also responsible for the cleaning and proper functioning of all equipment. When EI #3 was asked who was responsible for ensuring staff did not enter the kitchen without hairnets and that hair was enclosed under the nets. She replied, she was.

Based on observations of medication administration on 02/13/2019, a review of a facility policies titled Medication Administration, Individual Facility Medication Administration Times and staff interviews, the facility failed to ensure the medication error rate was less (<) than 5%. The medication error rate was 15.3%, with six errors with 39 opportunities. This affected Resident Identifier (RI) #4, #5 and #6, three of five resident's who were administered their medications later than sixty minutes after the scheduled time, by two nurses on the day shift. Finding's Include: A review of a facility policy titled Medication Administration with a date of 03/11, documented the following: . Procedures . 8. Medications are administered within 60 minutes of scheduled time, except before or after meal orders. A review of the facility's policy titled Individual Facility Medication Administration Times, with a date of 2011, revealed the medication administration times based on the frequency according the physician's orders [REDACTED]. The policy also listed 8 A and 8 P for the frequency Q12H (every 12 hours). 1. RI #4 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of RI #4's (MONTH) 2019 physician's orders [REDACTED]. On 2/13/19 at 9:18 am, an observation was made of Employee Identifier (EI) #5 Registered Nurse (RN) administering the medication [MEDICATION NAME] ([MEDICATION NAME]) to RI #4. 2. RI #5 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of RI #5's (MONTH) 2019 physician's orders [REDACTED]. On 2/13/19 at 9:03 am, an observation was made of EI #6 RN/Unit Manager, administering the medications Calcium 600 Vitamin D3 tablet and [MEDICATION NAME] to RI #5. 3. RI #6 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of RI #6's (MONTH) 2019 Physican's Orders included the MEDICATION ORDERS FOR [REDACTED]. On 2/13/19 at 9:22 am, an observation was made of EI #6 administering the medications Eliquis, [MEDICATION NAME] and [MEDICATION NAME] to RI #6. On 2/13/19 at 12:15 pm, an interview was conducted with EI #5. She was asked why RI #'4's [MEDICATION NAME] was not given until later. EI #5 said the medication was not on the cart and EI #6 had to get it from the Stat Box. On 2/13/19 at 12:35 pm, a review of computer documentation was conducted with EI #6, Unit Manager. She was asked what time RI #5's medications were due. She replied 8 am. EI #6 was asked what time were they given. She replied 9:20. EI #6 was then asked what time RI #6's medications were due. She replied 8 am. When asked what time they were given, EI #6 replied 9:43 am. EI #6 was asked were the medications given as scheduled and per the policy and standards of practice. She replied no.

Based on observations, interviews, medical record reviews and a review of the facility's policy titled, Federal Rights of Resident/Guest(s), the facility failed to ensure Resident Identifier (RI) #5 and RI #11's Electronic (E) MAR's (Medication Administration Record) were not left up and open for public view. This affected two of five residents observed during medication administration with the E-MAR left up and open with resident information viewable to the public. Findings Include: A review of the facility's policy titled, Federal Rights of Resident/Guest (s) with an effective date of (MONTH) 28, (YEAR), revealed the following: . Standard . (h) Privacy and confidentiality. The resident/guest has a right to personal privacy and confidentiality of his or her personal and medical records. 1. RI #5 was admitted to the facility on [DATE] for aftercare following joint replacement. On 02/13/19 at 9:44 AM, the following was observed during medication administration: Employee Identifier (EI) # 5, Registered Nurse/RN entered RI #5's room, with her back to the medication cart on the hallway, out of view of the cart and other staff on the hall. RI #5's E-MAR was left up and open to the public view. RI #5's name, allergies, physician's name, room number, medications, vital signs and skin tear information was left viewable on the computerized screen. On 02/13/19 at 9:47 AM, an interview was conducted with EI #5. EI #5 was asked what was left up and open when she entered the resident's room. She replied the med screen. EI #5 was asked if the med cart was within her view. She said no. EI #5 was asked what was left up to public view. She said the resident's name, medications, the skin tear, room number and doctor. EI #5 was asked what potential harm that could cause. She replied someone could get the medical information. 2. RI #11 was admitted to the facility on [DATE] with an admit [DIAGNOSES REDACTED]. On 02/13/19 at 1:00 PM, the following was observed during medication administration: EI #7, Licensed Practical Nurse/LPN was observed in RI #11's room, at the resident's bedside, with her back facing the medication cart, positioned in the doorway. RI #11's E-MAR was left up and open to public view. RI #11's name, allergies, physician's name, room number, medications, and vital signs were left viewable on the computerized screen. On 02/13/19 at 1:05 PM, an interview was conducted with EI #7. She was asked what was left up and open for view for other staff on the hall. EI #7 replied RI #11's MAR. She was asked who was responsible for the med cart. EI #7 said she was. EI #7 was asked what the potential harm was with the screen being left up. She said someone could see the resident's record. EI #7 was asked what was in view on the screen. She replied the resident's name, physician's name, allergies and vital signs. EI #7 was asked if the MAR indicated [REDACTED]. She replied no ma'am.