Every finding on record at Athens Health and Rehabilitation LLC

Based on interviews, a review of RI (Resident Identifier) #1's medical record, RI #1's Resident Incident Report, and the facility's policy titled, Person Centered Care Plans, the facility failed to ensure RI #1's care plan for a fall mat beside the bed was consistently implemented. This deficient practice affected RI #1, one of three sampled residents reviewed for falls. Findings Include: A review of a facility policy titled, Person Centered Care Plans, with an effective date of 8/15/18, 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, consistent with the resident/guest(s) rights. STANDARD: . According to federal regulations, the facility develops a comprehensive person centered plan of care for each resident/guest that includes measurable objectives and timetables to meet a resident/guest(s) medical, nursing and mental/psychosocial needs that are identified in the comprehensive assessment . PR[NAME]ESS: I.(f) .will ensure care plan intervention(s) are entered into Care Guide ADLs/Intervention in the electronic medical record that are considered outside of routine care. This will provide the CNA with individualized information needed to meet the resident's care needs. RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1's Significant Change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 9/27/19, indicated RI #1 was cognitively intact, with a BIMS(Brief Interview for Mental Status) score of 14. RI #1's Resident Incident Report, prepared by EI (Employee Identifier) #1, RN (Registered Nurse), DON (Director of Nursing Services), indicated on 11/30/19 at 8:35 p.m., CNAs (Certified Nursing Assistants) EI #2 and E#3 called the nurse to the resident's room. The resident was lying on his/her left side, on the floor, beside the bed. RI #1's care plan titled, Potential for Falls: r/t (related to) bilateral AKA, lists the following interventions: Mat beside bed, with a start date of 9/10/19. On 12/11/19 at 9:30 a.m., an interview was conducted with EI #4, a CN[NAME] EI #4 was asked to tell the surveyor about the incident that happened on 11/30/19 involving RI #1. EI #4 said she was coming out of another resident's room and heard RI #1 hollering for help. EI #4 was asked what happened after hearing the resident. EI #4 said she, EI #2 and EI #3 all entered RI #1's room about the same time. EI #4 was asked what she saw when she entered the resident's room. EI #4 said RI #1 was on the floor. The resident told them he/she rolled over and fell . EI #4 was asked if she saw the fall mat in the room. EI #4 said no, after the fact she saw it in the closet because the closet door was open. EI #4 was asked if RI #1 was care planned for a fall mat. EI #4 said yes, it was on the care plan. On 12/11/19 at 12:31 p.m., an interview was conducted with EI #2, CN[NAME] EI #2 was asked if she found RI #1 on the floor on 11/30/19 at about 8:30 p.m. EI #2 said yes. EI #2 was asked what she saw when she entered RI #1's room. EI #2 said the resident was lying on his/her left side, on the floor facing the television. EI #2 was asked how she knew the resident was on the floor. EI # 2 said she heard the resident screaming for help. EI #2 was asked if she was the first person to enter the room. EI #2 said she and EI #3 entered the room at the same time. EI #2 was asked did she or EI #3 put RI #1's fall mat by RI #1's bed. EI #2 said no. EI #2 was asked who was responsible for putting the mat on the floor bedside. EI #2 said EI #3 and she were both responsible. EI #2 was asked was the care plan followed if the fall mat was not on the floor, bedside. EI #2 said no. On 12/11/19 at 3:15 p.m., an interview was conducted with EI #3, a CN[NAME] EI #3 was asked if he was assigned to care for RI #1 on 11/30/19 when the resident fell . EI #3 said he, EI #2 and EI #4, another CNA, were doing rooms together. EI #3 was asked where RI #1 was prior to the fall. EI #3 said the resident was in the wheelchair and he and EI #2 put the resident in the bed. EI #3 was asked if he or EI #2 put the fall mat on the floor by RI #1's bed. EI #3 said no, he did not put the fall mat on the floor. EI #3 was asked if he saw EI #2 put the fall mat on the floor. EI #3 said he did not know about the fall mat and when he was in the room he did not see a fall mat. EI #5 told him the resident needed to have the fall mat, after the fact, and pointed out that the fall mat was in the closet. EI #3 was asked if he saw the fall mat in the closet. EI #3 said yes, EI #5 pointed it out to him and he saw it in the closet. On 12/12/19 at 2:39 p.m., an interview was conducted with EI #1, Registered Nurse/ Director of Nursing. EI #1 was asked what the facility determined was the cause of the fall after the investigation. EI #1 said RI #1 was rolling himself/herself over to the left side and the resident kept rolling and hit the floor. EI #1 was asked if all of RI #1's interventions were in place when the resident had the fall. EI #1 said no, the mat was not in place. EI #1 was asked if the facility determined why the mat was not on the floor. EI #1 said the staff reported it was in the closet. EI #1 was asked if the staff followed the care plan. EI #1 said no, they did not. EI #1 was asked if the staff should have followed the care plan. EI #1 said yes. EI #1 was asked what the facility did to correct the problem. EI #1 said they had an emergency QA (Quality Assurance) meeting on 12/4/19 to put a plan in place. Education began on 12/1/19 to all staff about fall prevention and following interventions on care plans. The care plans for all residents at risk for falls were reviewed and updated. On 12/2/19 all care guides were reviewed for interventions. The RN Managers on each unit audited fall care plans and began monitoring them weekly. As the result of the staff not following RI #1's care plan intervention for a fall mat at bedside, the facility implemented the following action plan to ensure this deficient practice does not reoccur. 1. DON/Designee provided 1:1 in-service with the 2 CNAs on 12/1/2019 that failed to ensure RI #1's care plan intervention of a fall mat at bedside was implemented regarding fall prevention and following care plans. 2. DON/Designee will complete an audit of current active residents to ensure that current resident's care planned for fall mats are updated and implemented. Residents identified with a fall mat on their care plan will have a list in the CNA notebook at the nurse's station to communicate with CNAs. Any concerns noted will be addressed/corrected. The audit was completed by 12/2/19. 3. ADON (Assistant Director of Nursing)/Designee will in-service all nursing staff to ensure they are following and implementing residents care plans. Residents identified with a fall mat on their care plan will have a list in the CNA notebook at the nurse's station to communicate with CNAs. Any concerns noted will be addressed/corrected. These in-services were completed by 12/4/19. 4. DON/Designee will monitor residents' care plans that include fall mats 2 days a week x 4 weeks, then monthly thereafter for 3 months to ensure residents' care planed for fall mats are being utilized. Any concerns noted will be addressed/corrected, additional education will be provided and monitoring will continue. A copy of these checks will be kept in a binder in the Administrator's office.

Based on interviews, record reviews and a review of a facility policy titled, Abuse Prevention, the facility failed to ensure resident narcotic medications were not missing. This deficient practice affected RI #87, #48, #222, #223 and #224, five of five residents who were investigated for missing narcotic medication. Findings Include: A review of a facility policy titled Abuse Prevention, with an effective date of [DATE] , revealed: The following are definitions of specific types of abuse: . D) Misappropriation of Resident/ . Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's . belongings or money without the resident's consent . (1) RI #87 was admitted to the facility on [DATE]. A [DIAGNOSES REDACTED]. A review of RI #87's (MONTH) 2019 Medication Administration Record [REDACTED]. [DATE] 6:35 pm, an interview with Employee Identifier (EI) #15, Licensed Practical Nurse(LPN) Charge Nurse was conducted. EI #15 was asked was she familiar with RI #87. EI #15 said yes. EI #15 was asked when she worked on [DATE] did RI #87 complain of pain during her shift. EI #15 said RI #87 sometimes would, he/ she would say his/ her head hurt or he/ she hurt all over. EI #15 was asked when was the last time she had to give RI #87 pain medication. EI #15 said she did not remember, hospice started the medication and she may have given pain medication one time. EI #15 was asked what was the narcotic. EI #15 said it was [MEDICATION NAME]. EI #15 was asked was RI #87 presently on this drug. EI #15 said no, it was stopped. EI #15 was asked what, if any, did RI #87 take for pain since the [MEDICATION NAME] had been stopped. EI #15 said if RI#87 needed pain medication, RI #87 will take a Tylenol. EI #15 was asked how did she know RI #87 was missing pain medication. EI #15 said because she fussed about it everyday, because she had to count that many pills every day; hospice sent a lot of narcotics so on that day she did not have many to count, so when she counted with EI #16 at the start of her shift, she noticed one card was gone. EI #15 was asked what did she say to EI#16. EI #15 said she looked and said to EI #16, RI #87 was missing a card of medication. EI #15 said EI #16 attempted to change the subject, so EI #15 said she went to the nurse and asked her did she sign with EI #16 zeroing the card out. EI #15 said she showed another nurse the paper, that nurse said that was not her signature on the form. EI #15 said she then called EI #2, Assistant Director of Nursing (ADON) and she said to keep EI #16 there and to call the Director Of Nursing (DON). EI #15 said told the ADON she could not keep EI #16 there. EI #15 was asked when she worked, had she known of narcotics being missing before this incident. EI #15 said no, she had not. EI #15 was asked what was the procedure for counting narcotics. EI #15 said the oncoming nurse count with the off going nurse, they call out the resident name, narcotic name and the amount of tablets, then the oncoming nurse will say out loud the number of tablets and both nurse's will look at the narc book, both nurse's sign the sheet; they are not supposed to take the keys until the count is correct. EI #15 was asked how did she know the sheet was wrong. EI #15 said the entire sheet and card was gone; EI #16 took a narcotic log sheet and wrote zero on that sheet. (2) RI #222 was admitted to the facility on [DATE]. A [DIAGNOSES REDACTED]. A review of RI #222's (MONTH) 2019 MAR indicated [REDACTED]. On [DATE] at 10:15 am, the surveyor conducted an interview with EI # 9 LPN. EI #9 was asked when working on [DATE], while counting the narcotic for RI # 222, was there any narcotic medication discrepancy. EI #9 said no. EI #9 was asked how was she made aware of the missing narcotic for RI #222. EI #9 said her DON made her aware and she gave a statement. EI #9 was asked what was the procedure for counting narcotics. EI #9 said the same procedure as they had before and after in the case of RI #224. EI #9 was asked did she have any knowledge of the missing medication for RI #224. EI #9 said no she did not. EI #9 was asked was she aware of any staff members taking residents narcotic medication. EI #9 said no. On [DATE] at 1:55 pm, an interview with EI #7 Registered Nurse (RN). EI #7 was asked was she familiar with RI #223 and RI #222. EI #7 said yes. EI #7 was asked what knowledge did she have on missing narcotics cards for these residents. EI #7 said she worked for three or four days and the cart was full of narcotics then she was off for two days and when she came back, she noticed there was not as many cards, but there had been a lot of discharges and the cards may have been sent with the patients, so she did not think anything about the cards being gone because of the discharges. EI #7 said when she counted with the off going nurse she made her aware of the cards being missing on RI#223 and RI #222. EI #7 was asked who was the nurse. EI #7 said another nurse she was not sure of her last name, she was a RN that worked 3rd shift when ever necessary. EI #7 said after counting they both went to the DON. EI #7 was asked what happened next. EI #7 said they told the DON and gave a statement. EI #7 was asked while on her shift had she given RI #223 or RI #222 pain medication. EI #7 said yes. EI #7 was asked how did she count narcotics on her shift. EI #7 said they have to count the amount of cards and bottles, after that they have to count each individual card, bottle, boxes stating the resident's name, medication name and the amount, then they both sign. EI #7 was asked what was the old way. EI #7 said they count the number of tablets in the card or the amount of liquid narcotic, number of patches. EI #7 was asked how did this differ from the old process to the new process. EI #7 said they count each card, not just the tablet, for example they would count maybe, say 15 cards or five bottles. EI #7 was asked where was this documented. EI #7 said on the narcotic flow sheet found in the front of the book,they documented how many cards or bottles in the cart, each nurse sign this each shift, if they add or take away a card two nurses must sign. EI #7 was asked when she signed with EI #16 to zero out a card, what did she do. EI #7 said she signed. EI #7 was asked when she looked at the card were there any pills on the card. EI #7 said no. EI #7 was asked what was the resident name on the zeroed out card. EI #7 said she did not remember. EI #7 was asked had EI #16 asked her to do this before. EI #7 said she did not recall. EI #7 was asked did she have any knowledge of a staff member taking narcotics from the medication cart for personal use. EI #7 said no. EI #7 was asked did she have any knowledge of this incident. EI #7 said no. On [DATE] at 11:39 am, an interview with EI #13 LPN by phone, was conducted. EI #13 was asked was she familiar with RI # 223 and RI # 222. EI #13 said yes. EI #13 was asked what could she tell the surveyor about the missing narcotic medication. EI #13 said she could not tell the surveyor anything about missing medications. EI #13 was asked how did she count narcotics. EI #13 said before this incident one nurse would have the narcotic book and the other nurse would call out the number of pills on the card. EI #13 was asked how did she count narcotics now. EI #13 said the same way, but in addition they counted the number of cards of narcotic and keep a log both nurse's sign. EI #13 was asked did she have any knowledge of staff taking narcotics from the cart, EI #13 said no. On [DATE] at 6:00 pm, an interview with EI #14/LPN was conducted. EI #14 was asked was she familiar with RI #223 and RI #222. EI #14 said yes. EI #14 was asked when she worked with RI #223 and RI #222 did they ask her for pain medications. EI #14 said they normally asked at bed time. EI #14 was asked when they asked for pain medications did she have pain medication in the cart for these residents. EI #14 said yes. EI #14 was asked when was she made aware of medication, particularly narcotics being missing from the cart. EI #14 said when another nurse went to discharge RI #222 she noticed he/she was missing one card; the nurse asked her to co-sign with her. EI #14 was asked what happened next. EI #14 said the nurse called the DON. EI #14 was asked when RI #222 was discharged did he/she have narcotics to take home. EI #14 said yes. EI #14 was asked who may have taken one of RI #222 cards of narcotics. EI #14 said she did not know. EI #14 was asked when working her shift had any one told her about a staff member taking cards of narcotics. EI #14 said no. EI #14 was asked what was the procedure for counting narcotics. EI #14 said they count each card to make sure the number match the sheet, they match the name with the card, now they count all the cards in the cart to make sure they are in the cart; when narcotics come in they log them onto the narcotic sheet; when they take a card out they subtract from the narcotic sheet. EI #14 was asked how many nurse's must sign the narcotic sheet. EI #14 said two. (3) RI #223 was admitted to the facility on [DATE]. A [DIAGNOSES REDACTED]. A review of RI #223's (MONTH) 2019 MAR indicated [REDACTED]. On [DATE] at 10:15 am, an interview with EI # 9/LPN was conducted. EI # 9 was asked when working on [DATE], while counting narcotics for RI #223, were there any discrepancy with the narcotic count. EI #9 said no. EI #9 was asked how was she made aware of missing narcotic for RI #223. EI #9 said her DON made her aware and she gave a statement. EI #9 was asked what was the procedure for counting narcotics. EI #9 said the same procedure as before and after in the case of RI #224. EI #9 was asked did she have any information on missing narcotics for RI # 223. EI #9 said no she did not. EI #9 was asked was she aware of any staff members taking any resident's narcotic medications. EI #9 said she no. (4) RI # 48 was admitted to the facility on [DATE]. A [DIAGNOSES REDACTED]. A review of RI #48's (MONTH) 2019 MAR indicated [REDACTED]. On [DATE] at 8:25 am, an interview was conducted with EI # 12 LPN. EI #12 was asked what made her aware of RI #48 missing narcotics. EI #12 said because she thought she remembered seeing three cards and she noticed there was only two cards. EI #12 said she could not remember signing in three cards for RI #48 or if another nurse signed them in and she co-signed. EI #12 was asked what did she do next. EI #12 said the next morning she asked the day shift nurse if she removed a card of narcotics on RI #48. EI #2 said the nurse told her she had turned one card in to the DON. EI #12 said she asked the DON where was the paper that they had to sign, who ever takes the paper to the DON, they both have to sign; the nurse and the DON both have to sign when it is for destruction. EI #12 was asked what happened next. EI #12 said the DON started trying to tell her why they had to get the card out, the DON was telling her something about a new script. EI #12 said when she left EI #10 was looking for the paper. EI #12 was asked what happened next. EI #12 said she was still looking for the sheet and she said she would get the DON to sign the sheet. EI #12 said when she got home EI #10 called her and said EI #12 was right, that was not the card that was turned in, the prescription number did not match, the one that they destroyed. EI #12 said she kept saying she did not understand because all three cards came in together, so if one was expired all three would have been expired; EI # 10 kept saying no. EI #12 was asked why would EI #10 say no they had destroyed the drug. EI #12 said she believed EI #10 had it mixed up with some other drug. EI #12 said to EI #10 she and the DON need to find the sheets, but she did call and say that there was one card missing. EI #12 said she came back in the next night and she was told the DON had taken care of it. EI #12 was asked did she have any knowledge of any staff member taking the resident's narcotic. EI #12 said no. EI #12 was asked what was the procedure for counting narcotic. EI #12 said the old way was the oncoming nurse would be in the cart and the off going nurse would have the book calling out the resident name, drug name and how many. EI #12 was asked what was the new process. EI #12 said before they count the pills, the off going nurse will tell the oncoming nurse the total number of cards in the cart and then they will count, the oncoming will be counting in the cart and the offgoing nurse would be in the book calling out the resident name, drug name and number of tablets. EI #12 was asked did she have any other information to offer. EI #12 said no. EI #12 was asked who did she count off with on [DATE]. EI #12 said she thought it was EI #11. (5) RI #224 was admitted to the facility on [DATE]. A [DIAGNOSES REDACTED]. A review of RI # 224 (MONTH) 2019 MAR indicated [REDACTED]. On [DATE] at 9:45 am, an interview with EI # 9/ LPN was conducted. EI #9 was asked where was she working on [DATE] from ,[DATE] am. EI #9 said 1st East Hall. EI #9 was asked when she worked with RI #224 did she administer pain medications. EI #9 said no she did not. EI #9 was asked when she worked with RI #224 did she/ he complain of pain. EI #9 no. EI #9 was asked when her shift ended who did you count with. EI #9 said she counted with EI #3, she was the unit manager and was working that weekend she counted with her. EI #9 was asked what was the procedure for counting narcotics. EI #9 said the procedure then was she would stand at the book, oncoming nurse would stand at the narcotic drawer, she would call out the resident name, medication and number of tablets, the oncoming would verify what was on the card to what EI #9 called out and the oncoming would look at the book also to verify what EI #9 had called out. EI #9 was asked when she counted off on [DATE] were there any discrepancy with the medication narcotic count on this date. EI #9 said no. EI #9 was asked what was the new procedure for counting narcotics at the end of her shift. EI #9 said at the beginning and end of every shift they have a form that the oncoming and offgoing nurse will sign and it has to list how many cards are in the narcotic drawer, this included liquid bottle narcotic, narcotic patches, everything was accounted, for example if there was 23 narcotic in the drawer both nurse's sign and write 23, if a card was empty, there was a place to write the resident name, prescription number, name of the medication and both nurse's sign; there was a ledger that will say R-removed, D-destruction, the same procedure was used for receiving a medication to the cart, list resident name, medication name and prescription number. EI #9 was asked how was she made aware of the missing medications for RI #224. EI #9 said her DON called her in to give a statement. EI #9 was asked did she have any knowledge of the missing medications for RI #224. EI #9 said no she did not. On [DATE] at 12:09 pm, an interview was conducted with EI # 10/LPN Charge Nurse, by phone. EI #10 was asked when working with RI #224 did she administer pain medications. EI #10 said no. EI #10 was asked did RI #224 ask for pain medications during the day time. EI #10 said RI #224 took it at night to help rest. EI #10 said she thought she gave it a few times, here or there. EI #10 was asked when she worked with RI #224 did the resident complain of pain. EI #10 said the resident would sometimes and she offered the resident medication but RI #224 would decline, saying it would make him/ her drowsy, so he/ she would wait until night, due to therapy during the day. EI #10 was asked when her shift ended did she count with the oncoming nurse. EI #10 said yes, she counted at every shift change. EI #10 was asked what was the procedure for counting narcotics. EI #10 said there had to be two nurse's, oncoming and offgoing, the patient's name, medication name and number of pills. EI #10 was asked were the two nurse's required to sign. EI #10 said yes, the narcotic record sheet, both nurse's would sign that the count are correct and accounted for. EI #10 was asked when she counted at the end of her shift had she found any discrepancies with the narcotic count. EI #10 said no and if she had she would called the DON. EI #10 was asked was she aware of any missing medications. EI #10 said she was aware of RI #224 having missing medications and this had been reported. EI #10 was asked did she have any other knowledge of missing medication. EI #10 said she know medications were missing, it was reported, investigated and that nurse was reported to the Board of Nursing and the police was involved. EI #10 was asked was she aware of any nurse taking medications. EI #10 said she was not aware of this until the incident had occurred and being reported, she never suspected any nurse's of taking medications. On [DATE] at 4:54 pm, interview with EI #11/RN Charge Nurse. EI #11 was asked was she familiar with RI #48, RI #223 and RI # 224. EI #11 said she was familiar with RI #48. EI #11 was asked what could she tell the surveyor about missing narcotics on RI #48. EI #11 said she could not recall what happened but could remember RI #224. EI #11 was asked what happened with RI #224. EI #11 said it was a Sunday, she was not sure this was the day, she came to work, and EI #16 was working there; and EI #16 went to count, EI #11 counted all the narcotic and took the keys, it was in the evening. EI #11 said the resident asked for pain pills,so she went to the cart, opened the narcotic box and she figured out there was one more card that should have had some pills on it but it was not there, so she had to use a new card, she did not remember if some was used from the new card, she did remember, she had to use from a new card. EI #11 said the day shift nurse usually would remove the card and take it to the office, if the card was expired, but she was still thinking the card was not empty. She said she talked to EI #10 the next day and EI #10 agreed there should have been some left, on the same day EI #16 was working on the other hall, so EI #10 and herself called over to talk EI #16. EI #11 was asked what happened next. EI #11 said she and EI #10 asked EI #16 about RI #224 saying there was two cards. EI #11 was asked what did EI #16 say. EI #11 said, EI #16 said she emptied one card. EI #11 was asked what did she or EI #10 say. EI #11 said they asked her where was the sheet with two nurse's signing. EI #11 was asked what did EI #16 say. EI #11 said EI #16 said she put it on the top of the door rack to the med room, then she said she may have laid it on the desk. EI #11 was asked what did she say. EI #11 said they said okay, they searched and could not find it. EI #11 was asked what did she do next. EI #11 said EI #10 reported to the DON. EI #10 said she did not remove the card, she was sure then it was another card of medication. EI #11 was asked what was the procedure for counting narcotics during shift change. EI #11 said two nurse's have to count with the resident name, dosage, milligrams, drug name quantity and they both sign. EI #11 was asked what was the new procedure. EI #11 said they count the number of cards each resident have, when they remove the card two nurses write the resident name, drug name and both nurses sign it; when they receive the card both nurses will sign so every one will know what came in or went out. EI #11 was asked did she know of any staff member that have taken the resident medications particularly the narcotic. EI #11 said no except for this incident. EI #11 was asked what made her suspect EI #16 as being the person to remove the narcotic from the cart. EI #11 said because every hall EI #16 had worked something had been missing and EI #16 was changing her story. EI #11 said they never had this problem on their hall since she started working there. EI #11 was asked when did she think or hear of issues with narcotics being missing on other halls. EI #11 said it was when they looked at their cart, EI #10 and herself, then they started talking among themselves and they made night shift aware and they also said they noted issues on other halls. EI #11 was asked who on the night shift said they noticed missing medications. EI #11 said she did not remember, they did not have these types of issues on their hall since she started working there, until this happened. On [DATE] at 5:50 pm, an interview with EI #3/RN Unit Manager/Rehab was conducted. EI #3 was asked was she familiar with RI #224. EI #3 said she could not remember. EI #3 was asked was she familiar with RI #48. EI #3 said she was. EI #3 was asked what could she tell the surveyor about these resident missing narcotics. EI #3 said she just remembered seeing a card with 11 or 12 tablets on RI #224, from the backup pharmacy. EI #3 was asked what made her remember 11 or 12 tablets on RI #224. EI #3 said because the tablets were from back-up pharmacy. EI #3 was asked who did she count with on [DATE]. EI #3 said she would have counted off with EI #11. EI #3 was asked how many cards of narcotic did RI #224 have. EI #3 said she didn't recall .EI #3 was asked what was the procedure for counting narcotics at the end of the shift. EI #3 said the oncoming and off going nurse's would count the cards, bottles and they write down the total number and sign, then the oncoming nurse count the actual narcotic as the off going nurse called out the resident name, drug name, number of tabs and they must match, then both nurse's signed the control log sheet. EI #3 was asked where were these sheets kept. EI# 3 said in the front of the narcotic book. EI #3 was asked did she have any knowledge of the staff taking the resident's narcotics. EI #3 said she did not have any knowledge personally. The Alabama Department of Public Health Online Incident Reporting System received facility reports regarding the misappropriation of resident property on [DATE], [DATE] and [DATE]. As a result of these facility reports an onsite visit was conducted, in conjunction with the recertification survey. This deficiency is cited as a result of the investigations of complaint/report #AL 378, #AL 303 and #AL 296.

Based on interview, record review and review of a facility policy titled, Change in Medical Condition of Resident/Guest(s), the facility failed to ensure Resident Identifier (RI) #272's family/responsible party was notified of a new order written on 4/19/19, for [MEDICATION NAME] DR (Delayed Release) 125 MG (milligrams) sprinkle by mouth at hour of sleep. This deficient practice affected RI #272, one of 25 sampled residents. Finding Include: A facility policy title: Change in Medical Condition of Resident/Guest (s), with an effective date of 11/28/2016 revealed the following: .STANDARD: Notification . legal representative, or interested family member, should occur promptly, according to federal regulations, when there is a change in the resident/guest (s) condition, . *A need to alter treatment . to commence a new form of treatment . RI #272 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of RI #272 Physician order [REDACTED]. The orders also included an order for [REDACTED]. On 8/29/19 5:52 p.m., the surveyor conducted an interview with Employee Identifier (EI) #3, Registered Nurse Unit Manager/Supervisor. The surveyor asked EI #3 was there an order for [REDACTED].#3 how could she verify that an order had been given. EI #3 stated what she had been told by this company was that you do not have to have a written order, you can put verbal orders directly into the computer. The surveyor asked EI #3 when did the physician write the order. EI #3 stated she did not know why the physician did not hand write the order. The surveyor asked EI #3 was this a usual practice. EI #3 stated, not generally. The surveyor asked was the family/responsible party notified of the new order. EI #3 stated it did not look like they were notified. The surveyor asked EI #3 where would the evident be that family was notified if there were evident. EI #3 stated in the nurses notes. The surveyor asked EI #3 was there evident in the nurses notes. EI #3 stated there was no record of it. The surveyor asked EI #3 who would have been responsible for notifying the family. EI #3 stated the nurse that put the order in. The surveyor asked did RI #272 receive [MEDICATION NAME] the entire time he/she was at the facility. EI #3 stated yes, it looked like he/she got it because they (nursing) were signing off that he/she got it. The surveyor asked EI #3 was there a new order for additional [MEDICATION NAME] 20 MG to be given on 4/24/19 for three days. EI #3 stated yes, give [MEDICATION NAME] 20 MG tablet by mouth at noon daily times three days in addition to morning dose. The surveyor asked EI #3 why was there a new order for the additional [MEDICATION NAME] 20 MG on 4/24/19 to be given one everyday at noon for three days. EI #3 stated she did not know, she guest the resident had some [MEDICAL CONDITION]. The surveyor asked EI #3 where would there be evident that the family was notified of that new order. EI #3 stated the LPN (License Practical Nurse) that took the order off should have notified the family. The surveyor asked EI #3 where did she note it in her notes. The surveyor gave EI #3 a copy of the nurse's notes. EI #3 stated it did not look like there was a note. This citation is written as a result of the investigation of complaint/report #AL 292.

Based on interview, record review and review of a facility policy titled Medication Orders, the facility failed to ensure Resident Identifier (RI) # 272 received additional [MEDICATION NAME] for three days, as ordered. This deficient practice affected RI #272, one of 25 sampled residents. Finding Include: A facility policy title: Medication Policies Prescriber Medication Orders dated 03/11 revealed the following, Policy Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe. Procedures 1. Elements of the Medication Order . (4) Time or frequency of administration. RI #272 was admitted to the facility on [DATE]. A [DIAGNOSES REDACTED]. The Physician order [REDACTED].#272, with an order start date of 4/24/19 and a stop date of 4/26/19. The order was to give [MEDICATION NAME] 20 MG (milligram) tablet- take one tablet everyday at noon for three days. On 8/29/19 at 5:52 p.m., the surveyor conducted an interview with Employee Identifier #3, Register Nurse (RN) Unit Manager. The surveyor asked EI #3 was RI #272 admitted to the facility on [MEDICATION NAME] 20 MG. EI #3 stated yes, they were admitted on [MEDICATION NAME] 20 MG daily. The surveyor asked EI #3 when was the RI #272 discharged from the facility. EI #3 stated it looked like he/she was discharged on [DATE]. The surveyor asked EI #3 did he/she receive the [MEDICATION NAME] the entire time he/she was at the facility. EI #3 stated yes they (nursing) were signing off that he/she got the [MEDICATION NAME]. The surveyor asked EI #3 was there a new order for additional [MEDICATION NAME] 20 MG to be started on 4/24/19 and given for three days. EI #3 stated, give [MEDICATION NAME] 20 MG tablet by mouth at noon daily times three days in addition to morning dose. The surveyor asked EI #3 why was there a new order for the additional [MEDICATION NAME] 20 MG on 4/24/19 to be given one everyday at noon for three days. EI #3 stated she did not know, she guest he/she had some [MEDICAL CONDITION]. The survey asked EI #3 to look at the eMAR (electronic Medication Assessment Record) for (MONTH) 24th through the 26th. The surveyor then asked EI #3 did RI #272 receive [MEDICATION NAME] as ordered by the physician. EI #3 stated, he/she received two of the three dosages. The surveyor asked EI #3 how many dosages of [MEDICATION NAME] were missed. EI #3 stated, one. The surveyor asked EI #3 were the physician's orders [REDACTED]. EI #3 stated no. On 8/29/19 at 2:48 p.m., the surveyor conducted an interview with EI #7, RN Charge Nurse. The surveyor asked EI #7 did she remember RI #272. EI #7 stated yes she did remember the resident. The surveyor asked EI #7 what order did the physician give RI #272 for [MEDICATION NAME]. EI #7 stated, [MEDICATION NAME] 20 MG one table everyday at noon for three days. The surveyor asked EI #7 did she document the order. EI #7 stated it was her hand writing, so it had to be her. The surveyor asked EI #7 how many days was RI #7 given the new order for [MEDICATION NAME]. EI #7 stated it was two days, the 25th and the 26th of April. The surveyor asked EI #7 was the doctor's order followed for the order of [MEDICATION NAME]. EI #7 stated, not according to record. The surveyor asked EI #7 what was given according the records. EI #7 stated it looked like it was given two days. The surveyor asked EI #7 was that the new order given for [MEDICATION NAME] on 4/24/19. EI #7 stated, yes. The surveyor asked EI #7 was that RI #272's only order for [MEDICATION NAME]. EI #7 stated the resident had one other order for 8 am. The surveyor asked EI #7 what was that order. EI #7 stated it was for [MEDICATION NAME] 20 mg one tablet daily for [MEDICAL CONDITION]. The surveyor asked EI #7 why was that new order given. EI #7 stated she was going to assume it was for swelling because that was why they give [MEDICATION NAME]. The surveyor asked EI #7 had she ever observed any swelling on RI #272. EI #7 stated she remembered the resident having swelling in his/her feet and ankles. The surveyor asked EI #7 what were the results of new order of [MEDICATION NAME]. EI #7 stated the swelling went down in his/her feet and ankles. This citation is written as a result of the investigation of complaint/report #AL 292.

Based on observations, interview, record review and review of a facility policy titled, Oxygen Administration , the facility failed to ensure oxygen masks and distilled water bottles were dated. This deficient practice had the potential to effect Resident Identifier (RI) #105, RI #274 and RI #275, three of three residents observed for oxygen therapy. Findings Include: A review of the facility policy titled, Oxygen Administration, effective date 12/08/2005, revealed, . Process: . 11. Cannula's and masks should be changed weekly . 14. O2 cannula/mask should be stored in a plastic bag when not in use. 1) RI #105 was re-admitted to the facility on [DATE]. A [DIAGNOSES REDACTED]. Physician Orders included an order, dated of 7/24/19, for O2 (Oxygen) at 2 L/M (Liter per Minutes) via NC (Nasal Cannula) as needed for SOB (Shortness of Breath). A care plan, dated 8/6/19, included, . Administer oxygen therapy as ordered. On 8/27/19 at 4:02 p.m., the surveyor observed RI #105's NC tubing and distilled water bottle on the oxygen concentrator were not dated. On 8/29/19 at 7:50 a.m., a second observation was made of the NC tubing and the distilled water bottle on the oxygen concentrator not dated 2) RI #274 was admitted to the facility on [DATE]. A [DIAGNOSES REDACTED]. A Physician's Orders included Oxygen at 2 L/M via nasal cannula, dated 8/22/19. A care plan included Administer oxygen therapy as ordered , dated 8/23/19. On 8/27/19 at 0:00 a.m., the surveyor observed RI #274's NC tubing and the distilled water bottle on the oxygen concentrator were not dated. On 8/27/19 at 3:27 p.m., during a second observation the surveyor observed that the NC tubing and distilled water on the oxygen concentrator were not dated. On 8/28/19 at 9:06 a.m., during a third observation the surveyor observed that the NC tubing and the distilled water bottle on the oxygen concentrator were not dated. 3) RI #275 was admitted to the facility on [DATE]. A [DIAGNOSES REDACTED]. A Physician's Order included O2 at 2 L/M prn (give as needed), with an order date of 8/24/19. A care plan included Administer oxygen therapy as ordered, dated 8/25/19. On 8/27/19 at 9:30 a.m., the surveyor observed RI #275's NC tubing was not dated while oxygen was being administered. On 8/28/19 at 9:13 a.m., during a second observation the surveyor observed NC tubing without a date. At this time the surveyor did observe the oxygen mask was dated 8/27/19 but was not in a bag/container. On 8/29/19 at 7:47 a.m., during a third observation the surveyor observed NC tubing without a date. On 8/29/19 at 2:06 p.m., during an interview with Employee Identifier (EI) #2, ADON (Assistance Director of Nursing) the surveyor asked her how often were the nasal cannula's changed. EI #2 said as needed and once per week. The surveyor asked EI #2 when should a date be placed on the NC tubing and the distilled water bottle on the concentrator. EI #2 stated when you change the NC tubing or the distilled water bottle. The surveyor asked EI #2 if there was no date on the NC tubing or distilled water bottle how would you know that they have been changed. EI #2 stated you would not know. The surveyor asked EI #2 what was the policy on dating the NC tubing and the distilled water bottle on the concentrator. EI #2 stated to change it weekly and the bottles are changed as needed if empty.

Based on observation, interviews, record review and a review of the facility's policy and procedure titled, Person Centered Care Plans, the facility failed to ensure staff developed a comprehensive care plan for a regular diet with nectar thickened liquids. This deficient practice affected RI (Resident Identifier) #24, 1 of 29 sampled residents. Findings Include: Review of the facility's policy titled Person Centered Care Plans dated (MONTH) (YEAR) states, PURPOSE: Person centered care plans of care are developed by the interdisciplinary team, to coordinate and communicate care approaches approaches and goals of the resident,,,. RI #24 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. On 7/18/18 at 8:00 AM an observation of RI 24's tray was made with EI # 4, Certified Nursing Assistant (CNA) present. EI #4 stated the resident was on nectar thickened liquids but did not know why. On 7/18/18 at 8:42 AM, RI #24's chart was reviewed with EI #2, Registered Nurse (RN) Supervisor of East I. The surveyor asked EI #2 what diet RI #24 was currently receiving according to physician's orders [REDACTED].#2 stated that from the 7/10/18 orders and readmission, the resident is on a regular diet with nectar thickened liquids. On 7/18/18 at 9:08 AM, an interview was conducted with EI #3, the Certified Dietary Manager (CDM). The surveyor asked what diet was the resident on when he was readmitted on [DATE]. EI #3 reviewed a dietary Communication Form dated 7/17/18 and said that she got a communication form from EI #2, the RN Unit Manager, putting RI #24 on a regular diet with nectar thick liquids. 07/19/18 09:38 AM an interview was conducted with EI #13, the MDS/Minimum Data Set Coordinator, The surveyor asked who is responsible for the care plan for diet changes. EI #13 stated, it is the unit manager or the person taking that order off. The surveyor asked where the care plan was for RI #24's diet for thickened liquids after readmission on 7/10/18. EI #13 said there is no care plan. The surveyor asked what was the purpose of a care plan. EI #13 stated it was to inform the resident, family and staff of the plan of care for that resident. EI #2, the RN Unit Manager was asked on 7/19/18 at 9:51 AM during an interview, what care plan was put in place on RI #24's admission on 7/10/18 regarding nectar (thickened) liquids. EI #2 stated, there should have been a care plan for a regular diet with nectar thickened liquids. Care plans were reviewed with EI #2 at this time and there was no diet care plan. The surveyor asked EI #2, after she sent a dietary communication form dated 7/17/18, what care plan did she put in place. EI #2 said she did not put a care plan in place. The surveyor asked EI #2 if she should have put a diet care plan in place. EI 2# stated, she should have. The surveyor asked what the purpose of a care plan is when there is a change in the residents care per physician's orders [REDACTED].#2 stated, So that every one knows the plan of care for that patient to ensure that the resident is receiving what the doctor has ordered. The surveyor asked was that done for RI #24. EI #2 stated, No.

Based on observations, staff interviews, medical record reviews, review of Potter and Perry's Fundamentals of Nursing, Ninth Edition and a facility policy titled Medication Administration Guidelines, the facility failed to ensure licensed nursing staff, Employee Identifier (EI) #14, followed Resident Identifier (RI) #25's Physician order [REDACTED]. This deficient practice affected RI #25, one resident observed receiving eye drops. Finding Include: 1. A review of Potter and Perry's Fundamentals of Nursing, ninth edition, with a copyright date of (YEAR), Chapter 23, Legal Implications in Nursing Practice, page 311, documented: . Health Care Providers' Orders . Nurses follow health care providers' orders unless they believe that the orders are in error . RI #25 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the medical record for RI #25 revealed the following Physician order [REDACTED]. . REFRESH [MEDICATION NAME] 1% EYE DROPS INSTILL TWO DROPS IN BOTH EYES THREE TIMES A DAY FOR DRY EYES, ARTIFICIAL TEARS --- (HOUSE ST[NAME]K) GIVE 1 DROP OU (BOTH EYES) AT BEDTIME NIGHTLY . On 7/18/18 at 9:00 a.m., during the Medication Administration Observation, the surveyor observed EI #14, the medication nurse administer Artificial Tears, two drops in each eye of RI #25. The medications were reconciled by the surveyor via (by way of) RI #25's Physician order [REDACTED]. The physicians's orders revealed EI #25 had not followed the physician orders [REDACTED].#25. The eye drops which were ordered and scheduled for this time (9:00 a.m.) were REFRESH [MEDICATION NAME] 1% EYE DROPS. On 07/18/18 10:56 AM, the surveyor conducted an interview with EI #14. The surveyor asked EI #14 if she administered RI #25 Artificial Tears 2 drops (gtts) in ou (both eyes), or Refresh [MEDICATION NAME] 1% eye gtts. EI #14 said she did not give RI #25 the Refresh eye drops. EI #14 said she has never given RI #25 gel eye drops(Refresh [MEDICATION NAME] 1% eye gtts). EI #14 said she always gave RI #25 Artificial tears. The surveyor asked EI #14, according to RI #25's Physician orders, what eye drops should RI #25 receive? EI #14 said, the Refresh [MEDICATION NAME] 1% three times a day.

Based on record review, interview and a review of the facility's policy titled, Discharge Summary and Plan of Care, the facility failed to ensure licensed staff completed a discharge summary for RI (Resident Identifier) #113's discharge from the facility. This was evident during the review of 1 of 4 discharges. Findings Include: The facility's policy titled Discharge Summary and Plan of Care dated 11/28/16 states: Purpose: Appropriate discharge planning and communication of necessary information to the continuing care provider, after discharge of a resident/guest from the facility, help the new care provider understand the resident/guests goals and needs. The process in this policy includes what the dscharge smmary should include which is: *A recapitulation of the residentguest's stay *A final summary of the resident/guest's status at the time of discharge *A post discharge plan of care developed with the resident/guest and his/her family which will assist the resident/guest to adjust to his/her new living environment . Medical review review conducted for RI # 113 revealed this resident was admitted to the facility on [DATE] and was discharged from the facility on 5/24/18. An interview was conducted with Employee Identifier (EI) #6, LPN/Licensed Practical Nurse, Charge nurse on 07/19/18 12:15 PM. The surveyor asked where the discharge summary was for RI #113. EI #6, stated, there was no d/c summary for RI #113. The policy and procedure regarding discharge summaries was referenced with EI #6, and asked if the resident should have a discharge summary. EI #6 stated, Yes. When EI #6 was asked if the discharge summary policy and procedure was followed, EI #6 stated, No.

Based on observation, interviews and record review, the facility failed to ensure the nails of Resident Identifiers (RI) #3 and #31 were maintained in a trimmed condition. This affected two of five sampled residents for whom an observation of the feet and toes was made. Findings included: The facility policy titled, Nail Care dated (MONTH) 1, 2010, cites the purpose as: Routine nail care helps reduce the potential for infection, prevents intrusion of the nail into the skin, prevents possible injuries and promotes a feeling of well being for the resident. The standard specifies: Nail care is a routine part of grooming each day. Foot care should be provided as a part of a tub or shower bath. The policy further recommends .a Podiatrist provides foot care for residents with Diabetes or [MEDICAL CONDITION] . 1) RI #3 has resided in the facility since 11/06/17, with [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 07/12/18, identified RI #3 as cognitively intact. The care plan related to Activities of Daily Living for RI #3, (dated 11/07/17) included, Nail care as needed. During an interview on 07/17/18 at 8:44 AM, the surveyor questioned RI #3 about the care of his/her feet. In response, RI #3 removed his/her shoes. The toenails on RI #3's left foot were long, particularly the great toe, which extended approximately 1/2 beyond the end of the toe. When questioned further, RI #3 explained he/she had been on the list to see the facility podiatrist for nearly a year, and had made numerous requests for podiatry assistance. On 07/18/18 at 5:05 PM, the facility Administrator, Employee Identifier (EI) #1 accompanied the Surveyor to RI #3's room, and viewed his/her feet. When asked, EI #1 stated it was the nurses' responsibility to ensure each resident's toe nails were trimmed. EI #1 then affirmed the nails on the resident's left foot (particularly the great toe) were in need of a trim. EI #1 described the left great toe nail as long, thick and curled. When asked if she knew when RI #31's toenails were last trimmed and by whom, EI #1 did not know. The resident stated he/she had someone cut the toenails about three months earlier, When asked if she knew why RI #3's toenails had not been trimmed before now, EI #1 did not know--and in particular, the great toenail. In response to a question of potential harm in failing to keep RI #3's nails in a trimmed condition, EI #1 said the toenail could break and cause discomfort. The resident (RI #3) added, the toenail could curl around and cause pain. 2. RI #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. On 7/18/18 at 11:21 AM, an observation of the toenails were made by the surveyor along with EI #10, RN, Unit Manager. This observation revealed that on the right foot, the right great toe and 4th toe needed cutting along with the 3rd, 4th and 5th toes on the left foot needing cutting. EI #10 stated at the time of the observation that the toes needed clipping and described the toenails as curled onto themselves and usually a Podiatrist cuts the toenails. EI #10 was asked what the potential for harm was. EI #10 stated that RI #31 could scratch him/herself, could get infected, or have ingrown toe nails. When EI #10 was asked if RI #31 should be on the Podiatrist list, she responded by saying, yes he should be. When asked how often the Podiatrist comes, RI #10 stated she though every 3 months. Review of the medical record revealed RI #31 had seen the Podiatrist on 11/1/17 and on 2/22/18.

Based on observations of medication storage on 3 of 5 units, and review of the facility's policy titled Medication Storage, Storage of Medications and Biologicals, the facility failed to ensure that medications that were expired were not available for use. Expired medications were located on one of the three units observed. Findings include: Review of a facility policy titled Medication Storage, Storage of Medications and Biologicals, Policy 3.1, 03/11 states: Policy Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier . Procedures 11. Outdated, contaminated or deterioriated medications and those in containers that are cracked, soiled, or without secure clusures are removed from stock, disposed of according to procedures for medications disposal . During an observation on 7/18/18 at 2:39 PM, with EI #9, a Licensed Practical Nurse (LPN), of the rehab. medication storage room, two vials of flu vaccine were observed. These two vials had expiration dates of 6/22/18. During an interview with EI #9, on 7/18/18 at 2:43 PM, she was asked who is responsible for removing expired medications. EI #9 said, any of the nurses (could remove expired medications). When asked if there is a potential for harm for administering expired medications, EI #9 responded by saying, they could have a reaction. When asked if expired medications should be in the refrigerator, EI #9 said, no.

Based on observations, interviews, and a review of the facility policies titled Hand Hygiene, Blood Glucose/PT/INR Machine Cleaning Guidelines, and Using Gloves, this facility failed to ensure that infection control practices were utilized to prevent the spread of infection. This deficient practice had the potential to affect 3 of 3 residents, RI #'s 57, 49 and 313. Findings include: A review of the facility's policy Infection Prevention & Control Manual, Policy Title: Hand Hygiene, effective date (MONTH) 1, (YEAR), Purpose: To provide guidelines to employees for proper and appropriate hand washing techniques that will aide in the prevention of the transmission of infections. Standard: Hand washing should be performed between procedures with resident/guest(s) based upon the principle that all blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucus membranes may contain transmissible infectious agents. III. Hand Hygiene Hand hygiene continues to be the primary means of preventing the transmission of infections. The following is a list of some situations that require hand hygiene. * .before and after direct residnet/guest contact . Before and after perfoerming any invasive procedure (e.g. fingerstick blood sampling). A facility policy titled, Using Gloves dated (MONTH) 1, 2009 revealed, Standard: Gloves should be worn when . possibly infectious materials are anticipated. A facility document titled Blood Blucose/PT/INR Machine Cleaning Guidelines with a revision date of 11/5/11 included the following: 3. Don first pair of gloves, do procedure, place glucometer on contaminated towel/surface. 4. Wash hands and put on a second pair of gloves. 5. Clean glucometer with disinfectant wipe, place on clean surface . EI (Employee Idenntifier) #7 Licensed Practical Nurse (LPN), was observed during the medication pass observation on 7/17/18 at 3:39 PM. 1. At 3:45 PM, EI #7 performed a finger stick blood sugar (FSBS) on RI #57. After obtaining the FSBS, EI #7 was observed to remove her gloves, and not perform hand hygiene. EI #7 cleaned the glucometer with her bare hands and placed the glucometer bck on the same barrier (unclean surface). Hand hygiene was not performed until after the staff cleaned the glucometer. 2. At 3:56 PM, EI #7 obtained a FSBS on RI #49. EI #7 was then observed to reach down into a magazine basket with her gloved hand. After EI #7 removed her gloves and cleaned the glucometer before performing hand hygiene. 3. On 7/17/18 at 4:05 PM, hand hygiene was not done before putting on gloves and performing a FSBS on RI #313. At 4:10 PM, EI # 7 cleaned the glucometer but did not do hand hygiene till after she cleaned machine. EI #7 gave RI #313 insulin but did not wear gloves while doing so. Again at 5:02 PM, EI #7 gave RI #313 insulin and did not wear gloves. [MEDICATION NAME] 10 units in the right upper abdomen, no gloves were worn. On 7/18/18 at 4:29 PM, an interview was conducted with EI #7, LPN. EI #7 was asked when she should wash her hands during med pass? EI #7 replied, before and after each med pass and each resident. EI # 7 was asked, what is the potential for harm of not performing hand hygiene? EI #7 replied infection, bacteria, and spreading germs. On 7/18/18 at 4:29 PM, EI #7 was asked what she should have done before cleaning the glucometer? EI # 7 replied, put on gloves EI #7 was asked, what should you do before putting soiled glove in a resident's magazine rack? EI #7 replied, I don't know, took that glove off and put another glove on. When asked what should be worn before you give an injection? EI #7 replied, Gloves. When asked what is the potential for harm? EI # 7 replied,spreading germs. On 7/18/18 at 4:07 PM, an interview was conducted with EI #5, the Director of Nursing (DON). EI #5 was asked, during med pass, when should the nurse wash their hands? EI#5 replied, when they enter the room, before they prepare medications, and if they touch anything they need to (wash their hands) before they go back to the med cart. EI #5 was asked what should be done before putting a soiled gloved hand in resident's magazine rack? EI #5 replied, Remove glove before touching anything in the environment. EI #5 was asked, what should be worn before you give an injection? EI #5 replied, Need to have gloves on. EI #5 was asked, what is the potential harm? EI #5 replied, infection to the residents.

Based on observations, review of the facility's policy titled: Food Cooking and Serving Temperatures dated May 25, 2012, review of the 2013 Food Code and interviews with facility staff, the facility failed to ensure: 1. The thermometer was calibrated correctly prior to taking food temperatures on the tray line. 2. Monitored all foods on the tray line. 3. No use by dates on frozen shakes. 4. No dish racks were stored on the floor in the dish washing area. 5. Dishware (sectioned plates) were free of food debris, chips and stains. 1. Thermometer Calibration A facility policy titled: Food Cooking and Serving Temperatures with an effective date of 5/25/2012 revealed: . PURPOSE: Safe and sanitary food handling practices include effective control of food temperatures, in order to prevent food borne illnesses. STANDARD: According to federal regulations, food should be prepared according to tested recipes; .utilizing correct methods to conserve nutritive value and retain quality, .; and should be served attractively at proper temperatures. PROCESS: . III. General Guidelines: a. A calibrated thermometer should be used for taking food temperatures. The final bullet under General Guidelines states, Pierce center of food items . The 2013 Food Code revealed: 4-201.11 Good Repair and Calibration. (B) FOOD TEMPERATURE MEASURING DEVICES shall be calibrated in accordance with manufacturer's specifications as necessary to ensure their accuracy . On 5/31/2017 at 10:45 AM, an observation was made during the calibration of the thermometers. The thermometer was placed inside a cup filled with ice only and no water. On 6/1/2017 at 10:55 AM, an interview was conducted with EI #4, Certified Dietary Manager (CDM). EI #4 was asked what was the standardized methods for thermometer calibration. EI #4 said, to use ice and water. EI #4 was asked why did the cook fail to follow the standardized method on 5/31/2017. EI #4 said, carelessness. EI #4 was asked how did this affect the accuracy of the food temperatures. EI #4 said, if the thermometers were not properly calibrated, the food temperatures could not assured to be correct. 2. Monitor and document temperatures of all foods. The 2013 Food Code 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding revealed . (A) (1) At 57*C (Celsius) (135*F (Fahrenheit) or above . On 5/31/2017 at 10:45 AM temperatures were observed on the tray line. When obtaining food temperatures poor placement of the thermometer was used. The thermometer was not placed in the middle of the food where the temperature was being taken and the temperature was obtained and documented prior to placing the food on the tray line. During a second observation on 5/31/17 at 11:15 AM, a temperature was not taken of the hamburger patties and mashed potatoes on the tray line. On 6/1/2017 at 10:55 AM an interview was conducted with EI #4, CDM. EI #4 was asked did the staff ensure all foods, hamburger patties and mashed potatoes, were maintained at 135*F. EI #4 said, no. EI #4 was asked how did the deficient practice affect the residents. EI #4 said the potential for bacterial growth due to the hot foods not at an accurate temperature. 3. Frozen and thawed shakes. The 2013 Food Coded revealed: 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (B) . CLEARLY MARKED, AT THE TIME THE ORIGINAL CONTAINER IS OPENED IN A food establishment AND IF THE food IS HELD FOR MORE THAN 24 (TWENTY FOUR) HOURS, TO INDICATE THE DATE OR DAY BY WHICH THE food SHALL BE CONSUMED ON THE premises . On 5/31/2017 at 5:45 PM an observation was made of 4 ounce shakes. 5 of 28 shakes on resident's meal trays in the dining room were observed with a label date of 5/28 without a discard date. On 6/1/2017 at 10:55 AM, an interview was conducted with EI #4, CDM. EI #4 was asked what was the Food Code requirement for labeling items with an expiration date. EI #4 said, should be dated with date of expiration. EI #4 was asked how did the facility label the shakes. EI #4 said, with the thawed date. EI #4 was asked what was the potential negative outcome. EI #4 said, potential for bacterial contamination. 4. Potential for cross contamination. On 5/30/2017 at 5:45 PM an observation was made in the dish washing area. Four dish racks were observed on the floor beneath the sink. On 5/30/2017 at 5:45 PM an interview was conducted with Employee Identifier (EI) #1, Cooks Helper. EI #1 was asked why were the dish racks on the floor. EI #1 said, I just put them there earlier and forgot to pick them up. On 6/1/2017 at 10:55 AM, an interview was conducted with EI #4, CDM. EI #4 was asked, when dish racks were not in use, where should they be stored. EI #4 said, the dish racks should be stored on a rolling dollie under the sink. EI #4 was asked why the dish racks were laying on the floor and not on a rolling dollie. EI #4 said, carelessness. EI #4 was asked what was the potential harm to residents when dish racks are placed on the floor and not on a rolling dollie. EI #4 said, potential for bacterial contamination. 5. Poor cleaning and sanitizing of equipment. The 2013 Food Code revealed: . 4-601.11 Equipment FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch . On 5/31/2017 at 10:55 AM, an observation was made of stored sectional plates. One of five plates were badly stained and four of the plates were observed with food adhered to the surface area and two plates were chipped. On 5/31/2017 at 10:55 AM, an interview was conducted with EI #2, Cook. EI #2 was asked what did she see on the plates. EI #2 said, It is dirty and stained. On 5/31/2017 at 10:55 AM, an interview was conducted with EI #3, Kitchen Manager. EI #3 was asked what did she see on the plates. EI #3 said chipped and somebody put it up dirty. On 6/1/2017 at 10:55 AM an interview was conducted with EI #4, CDM. EI #4 was asked what condition were the sectional plates found in. EI #4 said, stained, chipped with food debris. EI #4 was asked how did those things happen. EI #4 said the staff failed to properly inspect prior to stacking in storage. EI #4 was asked what was the potential negative outcome for the stained, chipped and food on plates. EI #4 said, unappetizing for the residents and potential for cross contamination.

Based on observations, interviews with facility staff and review of a facility policy titled, Infection Prevention & (and) Control and Potter and Perry, Fundamentals of Nursing. The facility failed to ensure a licensed staff member did not place her ungloved fingers inside a medication cup during medication pass. This affected one of ten residents observed during medication pass. A facility policy titled: Infection Prevention & Control Section: General Infection Prevention .with an effective date of December 1, 2009 revealed: PURPOSE: To provide guidelines to employees . that will aid in the prevention of the transmission of infections . Potter and Perry, Fundamental of Nursing, Ninth Edition, Copyright 2017, Unit V (five), page 448 revealed: . NURSING KNOWLEDGE BASE . The meticulous of specific infection prevention practices reduces the risk of cross-contamination and transmission of infection . An unsampled resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/31/2017 at 4:30 PM, Employee Identifier (EI) #5, License Practical Nurse (LPN) placed her ungloved fingers inside a medication cup to pick it up. She placed four medications inside the cup and provided the medication to the unsampled resident. On 5/31/2017 an interview was conducted with EI #5, LPN. EI #5 was asked how did she pick up the medication cup when preparing medications for the unsampled resident. EI #5 said, she placed her fingers inside the cup. EI #5 was asked how should a medication cup be picked up. EI #5 said, from the bottom. EI #5 was asked should ungloved fingers be placed inside the medication cup when picking the cup up. EI #5 said, never. EI #5 was asked what was the potential harm to a resident when ungloved fingers are placed inside a medication cup. EI #5 said, transfer of bacteria. On 6/1/2017 at 8:33 AM, an interview was conducted with EI #6, LPN/Infection Control. EI #6 was asked how should a licensed nurse retrieve a medication cup during medication pass. EI #6 said, sides and bottom. EI #6 was asked was it an appropriate practice of that facility for a licensed nurse to place her ungloved fingers inside of a medication cup to pick it up. EI #6 said, no. EI #6 was asked what was the potential harm to residents when a licensed nurse placed her ungloved finger inside of a medication cup when it was picked up. EI #6 said, transmission of infection and bacteria.

Based on observations, record review and interview: The facility failed to assure utensils were cleaned and sanitized correctly between uses as evidenced by: a) Food contact surfaces on dinnerware (sectional plates) were free of stains, chips and were air dried; b) Tea urn spigots were free of a brown build up residue; c) Tray delivery carts were effectively cleaned/disinfected between use for return of soiled trays and delivery of food trays. The above practices posed the potential for food contamination and compromised food safety. This had the potential to affect all residents receiving meal trays from dining services. Findings include: 1. According to the 2013 Food Code by the United States Public Health (USPHS) and the Food and Drug Administration (FDA): 4-601.11 Equipment, Food contact surfaces .and utensils. (A)Equipment, food-contact surfaces shall be clean to sight and touch . Drying 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface SANITIZING solutions), before contact with FOOD; . On 5/10/2016 at 7:08 PM, sectional plates stored on the trayline were observed for food delivery. Five plates were examined. Four of the five were either stained, chipped or with rolling water. On 05/10/16 at 7:08 PM, the Dietary Aide, EI (Employee Identifier) #4, responsible for the clean side of the dishmachine was asked, why the plates were not air dried (before storage) and why they were not clean to sight/touch. EI #4 responded that she had made a mistake. During an interview on 5/12/2016 at 9:00 AM, the Certified Dietary Manager, EI #3, was asked about the number of residents who received food served on sectional plates and EI #3 said there were ten. EI #3 indicated a potential negative outcome as a result of stained, chipped plates which were not air dried would be cross-contamination and that someone could get sick. b) The 2013 Food Code by the United States Public Health (USPHS) and the Food and Drug Administration (FDA) included the following: 4-6 CLEANING OF EQUIPMENT AND UTENSILS - Frequency 4-602.11 (E) (2) Surfaces of Utensils and Equipment contacting food that is not time/temperature control for safety food shall be cleaned: At least every 24 hours for iced tea dispensers . The facility policy titled Cleaning of Miscellaneous Equipment and Utensils, Policy Number DS.V-34, with an effective date of March 17, 2016, documented, . 5. Coffee & Tea Urns: a. Daily Cleaning * Unplug and drain * Make sure faucet is closed * Rinse and drain * Wipe spigots with clean cloth soaked in sanitizing solution (100 ppm (parts per million) chlorine or 200 ppm quaternary solution. b. Weekly Cleaning Remove and disassemble spigots, soak in warm, soapy water to remove build-up rinse, immerse in sanitizing solution (100 ppm chlorine or 200 ppm quaternary solution for 1 minute. On 5/10/2016 at 6:45 PM, 1 of 2 Tea Urn Spigots was disassembled by the Certified Dietary Manager, EI #3. The plunger contained a heavy build up of a brown substance. EI #3 was interviewed on 5/10/16 at 6:55 PM. EI #3 indicated that the Tea Urn Spigot should be cleaned daily, and that the evening Beverage Aide was responsible. The potential outcome identified by EI #3 was that someone could be sick due to potential bacterial contamination. The evening Beverage Aide EI #4 was interviewed on 5/11/16 and indicated that the spigot was to be cleaned once a week on Tuesdays. c) A review of the facility policy titled: Cleaning of Miscellaneous Equipment and Utensils, Policy number Ds.V-34, .10. Dish Carts and Dollies (weekly and as needed) . * Rinse, *Sanitize, and *Air Dry . The Oasis 146 Multi-Quat Sanitizer manufacturer's technical data sheet directs consumers for non-food contact surfaces non-porous surfaces must be thoroughly wetted, .treated surfaces must remain wet for 60 seconds. On 5/11/2016 at 7:15 PM, dietary staff was observed cleaning returned tall open carts with a wetted cloth, wiping rungs, shelves etc. The Dietary Aide was asked what was in the red bucket (used to rinse cloth). She answered Quat. On 5/10/2016 at 7:20 PM, the Assistant Dietary Manager, EI #5 tested the chemical concentration of the solution in the red bucket (in the presence of the CDM EI #3). When checked the value was 100 ppm, not the standard of 200 ppm. The CDM EI #3 was asked what the potential harm was (if the concentration was not 200 ppm) and EI #3 said cross-contamination because the chemical was not effective. On 5/12/2016 at 8:10 AM, the Kitchen Supervisor, Assistant Dietary Manager, EI #5 was asked: How staff was trained to clean/disinfect meal delivery carts and who was responsible. EI #5 said staff was trained on first hired and that the Evening Cook and Beverage Aide were responsible. EI #5 was asked how the chemical was to be used and if the chemical concentration met standard on 5/10/2016. EI #5 said the carts should be thoroughly wetted and no, the chemical concentration was not adequate. EI #5 was asked, why the standard ppm was not met. EI #5 said the Beverage Aide made the Quat at 3:00 PM, the Cook should have changed and tested the sanitizer bucket. Based on observations, record review and interview: The facility failed to assure utensils were cleaned and sanitized correctly between uses as evidenced by: a) Food contact surfaces on dinnerware (sectional plates) were free of stains, chips and were air dried; b) Tea urn spigots were free of a brown build up residue; c) Tray delivery carts were effectively cleaned/disinfected between use for return of soiled trays and delivery of food trays. The above practices posed the potential for food contamination and compromised food safety. This had the potential to affect all residents receiving meal trays from dining services. Findings include: 1. According to the 2013 Food Code by the United States Public Health (USPHS) and the Food and Drug Administration (FDA): 4-601.11 Equipment, Food contact surfaces .and utensils. (A)Equipment, food-contact surfaces shall be clean to sight and touch . Drying 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface SANITIZING solutions), before contact with FOOD; . On 5/10/2016 at 7:08 PM, sectional plates stored on the trayline were observed for food delivery. Five plates were examined. Four of the five were either stained, chipped or with rolling water. On 05/10/16 at 7:08 PM, the Dietary Aide, EI (Employee Identifier) #4, responsible for the clean side of the dish machine was asked, why the plates were not air dried (before storage) and why they were not clean to sight/touch. EI #4 responded that she had made a mistake. During an interview on 5/12/2016 at 9:00 AM, the Certified Dietary Manager, EI #3, was asked about the number of residents who received food served on sectional plates and EI #3 said there were ten. EI #3 indicated a potential negative outcome as a result of stained, chipped plates which were not air dried would be cross-contamination and that someone could get sick. b) The 2013 Food Code by the United States Public Health (USPHS) and the Food and Drug Administration (FDA) included the following: 4-6 CLEANING OF EQUIPMENT AND UTENSILS - Frequency 4-602.11 (E) (2) Surfaces of Utensils and Equipment contacting food that is not time/temperature control for safety food shall be cleaned: At least every 24 hours for iced tea dispensers . The facility policy titled Cleaning of Miscellaneous Equipment and Utensils, Policy Number DS.V-34, with an effective date of March 17, 2016, documented, . 5. Coffee & Tea Urns: a. Daily Cleaning * Unplug and drain * Make sure faucet is closed * Rinse and drain * Wipe spigots with clean cloth soaked in sanitizing solution (100 ppm (parts per million) chlorine or 200 ppm quaternary solution. b. Weekly Cleaning Remove and disassemble spigots, soak in warm, soapy water to remove build-up rinse, immerse in sanitizing solution (100 ppm chlorine or 200 ppm quaternary solution for 1 minute. On 5/10/2016 at 6:45 PM, 1 of 2 Tea Urn Spigots was disassembled by the Certified Dietary Manager, EI #3. The plunger contained a heavy buildup of a brown substance. EI #3 was interviewed on 5/10/16 at 6:55 PM. EI #3 indicated that the Tea Urn Spigot should be cleaned daily, and that the evening Beverage Aide was responsible. The potential outcome identified by EI #3 was that someone could be sick due to potential bacterial contamination. The evening Beverage Aide EI #4 was interviewed on 5/11/16 and indicated that the spigot was to be cleaned once a week on Tuesdays. c) A review of the facility policy titled: Cleaning of Miscellaneous Equipment and Utensils, Policy number Ds.V-34, 10. Dish Carts and Dollies (weekly and as needed) . * Rinse, *Sanitize, and *Air Dry . The Oasis 146 Multi-Quat Sanitizer manufacturer's technical data sheet directs consumers for non-food contact surfaces non-porous surfaces must be thoroughly wetted, treated surfaces must remain wet for 60 seconds. On 5/11/2016 at 7:15 PM, dietary staff was observed cleaning returned tall open carts with a wetted cloth, wiping rungs, shelves etc. The Dietary Aide was asked what was in the red bucket (used to rinse cloth). She answered Quat. On 5/10/2016 at 7:20 PM, the Assistant Dietary Manager, EI #5 tested the chemical concentration of the solution in the red bucket (in the presence of the CDM EI #3). When checked the value was 100 ppm, not the standard of 200 ppm. The CDM EI #3 was asked what the potential harm was (if the concentration was not 200 ppm) and EI #3 said cross-contamination because the chemical was not effective. On 5/12/2016 at 8:10 AM, the Kitchen Supervisor, Assistant Dietary Manager, EI #5 was asked: How staff was trained to clean/disinfect meal delivery carts and who was responsible. EI #5 said staff was trained on first hired and that the Evening Cook and Beverage Aide were responsible. EI #5 was asked how the chemical was to be used and if the chemical concentration met standard on 5/10/2016. EI #5 said the carts should be thoroughly wetted and no, the chemical concentration was not adequate. EI #5 was asked, why the standard ppm was not met. EI #5 said the Beverage Aide made the Quat at 3:00 PM, the Cook should have changed and tested the sanitizer bucket.

Based upon observation, record review and interview the facility failed to provide RI (Resident Identifier) #2 a three compartment plate as careplanned during the lunch meal on 5/11/2016 and during the breakfast meal on 5/12/2016. The facility further failed to provide RI #2 the total amount of fluids as indicated on the plan of care during the breakfast meal on 5/12/2016. This affected one of 14 sampled residents whose care plans were reviewed. Findings include: RI #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A care plan, with a problem onset date of 1/31/16 documented, Potential for not consuming adequate calories or fluids . Potential for reduced intake due to depression, dementia,[MEDICAL CONDITION]([MEDICAL CONDITION] Reflux) . Approaches included: .provide food/beverage preferences, encourage to eat . Has use of 3 compartment plate to help with feeding self. Tremors noted to upper extremities . During the lunch meal on 05/11/16 at 11:30 AM, RI #2 was observed to have the meal served on a regular plate. The resident's tray card for breakfast on 5/12/2016 revealed RI #2 should have had 6 ounces of coffee, two 8 ounce cups of water and 8 ounces of skim milk. RI #2 did not receive the coffee nor the two 8 ounces of water. An interview with the Certified Nursing Assistant (CNA) Employee Identifier (EI) #8 at 8:15 AM on 5/12/2016, confirmed that during the noon meal on 5/11/2016, the resident was served on a regular white plate, not the planned divided plate. On 5/12/2016 at 8:20 AM, the Assistant Dietary Manager, EI #5 was asked who was responsible for placing the water on the tray. EI #5 responded, the Beverage Aide. On 05/12/16 at 8:20 a.m. the Beverage Aide, EI #9 was interviewed and asked why the tray was not provided the designated water. EI #9 stated that he overlooked it.

Based on observation, interview and record review, the facility failed to ensure a pressure wound, present with slough (necrotic tissue) on admission, was not assessed as a Stage II (two) wound. According to the National Pressure Ulcer Advisory Panel, a wound with slough would be a category/Stage III (three). This affected RI (Resident Identifier) #4, one of two residents sampled for pressure ulcers. Findings include: A review of the NATIONAL PRESSURE ULCER ADVISORY PANEL Quick Reference Guide for Pressure Ulcer Treatment dated 2009, page 6, revealed the following: .Unstageable . Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III (three) or IV (four) . A review of the facility policy titled Pressure Ulcers with an effective date of 10/1/2010 revealed the following: .STANDARD: .1.Stage III Full thickness tissue loss .Slough may be present . Unstageable Slough and/or eschar . As wounds progress through the various stages of healing, it should be noted that they are not reverse staged . RI #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #4's Wound Assessment Report with an assessment date of 3/31/2016 revealed the following: .Wound Location Right Buttock . Unstageable due to slough/eschar . RI #4's admission MDS (Minimum Data Set) with an Assessment Reference Date of 4/6/2016 revealed a BIMS (Brief Interview for Mental Status) score of 14 which indicated intact cognition. The MDS also revealed two unstageable pressure ulcers due to slough and/or eschar. RI #4's Wound Assessment Report with an assessment date of 4/27/2016, signed by EI (Employee Identifier) #6, Wound Nurse/LPN (Licensed Practical Nurse), revealed the following: .Wound Location Right Buttock . Stage 2 (two) . RI #4's Departmental Notes dated 5/6/2016, revealed the following: .Healing progress with Stage 2 wound to right buttocks . An observation of RI #4's wound on 5/12/2016 at 8:20 AM, revealed a pink wound bed with a dark outer edge on the right buttocks. EI #6 stated, the wound was almost closed and was a Stage II (two) after therapy debrided (removed) the slough. On 5/12/2016 at 10:35 AM EI #6 was asked what the facility's policy says about staging wounds as they heal. EI #6 said, wounds are not to be staged down as they heal. When asked what stage a wound that contained slough would be, EI #6 said it would be at least a Stage III. EI #4 was asked why the unstageable wound on RI #4's buttocks with slough, was staged a Stage II after the slough was debrided. EI #4 said, because there was no slough left on the wound after debridement. When asked if a Stage II wound ever contain slough, EI #4 said, no. On 5/12/2016 at 1:25 PM, EI #6 was asked what the tissue in the wound bed was on RI #4's admission. EI #6 said, one hundred percent slough. On 5/12/2016 at 1:50 PM, EI #6 was asked why she did not stage the wound at least a three since it previously had slough. EI #6 said, because it had previously been unstageable. EI #6 was asked to explain reasons why not to down stage a wound. EI #6 said, the tissues have been damaged, contain scar tissue, and would never have one hundred percent strength. EI #6 was asked what the potential for harm was in an inaccurate wound assessment. EI #6 said, the treatment might not be appropriate. On 5/12/2016 at 2:50 PM, EI #1 was asked what the lowest stage would be for a wound that contained slough. EI #1 said, III. When asked about the facility policy for down staging, EI #1 said, We don't downstage. Whatever stage it is, it stays. When asked what it means when a wound contains slough, EI #1 said, that means it is not healthy tissue. When asked what stage a wound would be if there was slough present, EI #1 said, by definition, at least a III or IV (four) or unstageable.

Based on record review, observation, and interviews the facility failed to ensure a Certified Nursing Assistant (CNA) washed her hands after removing gloves and before applying a clean brief during incontinent care of Resident Identifier (RI) #7, a resident with a history of urinary tract infections. This affected one resident observed for incontinent care. Findings include: RI #7 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of the facility Policy titled Perineal Care with an effective date of 11/10/2014 revealed the following: .PURPOSE: Good perineal care helps prevent infection . A review of the facility policy titled Hand Hygiene with an effective date of 12/01/2009 revealed, .Standard: Hand washing should be performed between procedures with residents based upon the principle that all blood, body fluids, may contain transmissible infectious agents . A review of RI #7's most recent Minimum Data Set ((MDS) dated [DATE] revealed RI #7 was severely cognitively impaired for decision making. A review RI #7's Patient Care Plan with an onset date of 01/16/2016 revealed the resident as .Requires assistance to complete daily activities of care safely R/T (related to) poor cognition Totally incontinent of bowel and bladder .Pericare after each incontinent episode . On 5/11/16 at 10:15 am EI #2, CNA, was observed during incontinent care for RI #7. EI #2 washed the residents perineal area, removed gloves and applied a brief without washing her hands. On 05/11/16 at 12:15 PM an interview was conducted with EI #2, CNA. She was asked if she washed her hands before applying the brief. EI #2 replied No I didn't. She was also asked what was the potential harm, to which she replied, Infection. On 05/12/16 at 2:15 PM an interview with EI #1, RN/DON (Registered Nurse/Director of Nursing) was asked what was the facility policy regarding incontinent care. EI #1 stated, She is suppose to wash her hands before putting on the clean brief. EI #1 was then asked what could be the potential harm in not washing your hands to which she replied, Infection Risk.

Based on observation, record review and interviews the facility failed to ensure waste was properly contained in dumpster's (doors closed) and were maintained in a manner to prevent the harborage and feedings of pests. This was observed on three of six sliding doors and two of three dumpsters. This had the potential to affect all residents who reside in the facility. Findings include: The 2013 Food Code by the United States Public Health Service (USPHS) and the Food and Drug Administration (FDA) included the following: . 5-501.15 Outside Receptacles. (A) Receptacles and waste handling units for REFUSE . used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers. (B) Receptacles and waste handling units for REFUSE . shall be installed so that . debris and insect and rodent attraction and harborage are minimized . A reviewed of the facility policy titled: Garbage and Refuse Policy number DS.V.3-8 with an effective date of February 1, 2002, revealed the process item e documented .the facility should have tightly fitting lids ., but failed to give guidance relating to doors. On 5/12/2016 at 8:55 AM, outdoor refuse disposal was viewed with the Dietary Manager, EI #3. There were three metal dumpsters with six doors. Three of six sliding doors were not closed with an approximate six inch open space on each. On 5/12/2016 at 9:25 AM, the EI #3 was asked what the facility policy was about dumpster doors. EI #3 said, They (doors) should be tightly closed at all times. EI #3 indicated that three of six doors were not completely closed and the potential harm was for critters to get in and cross-contaminate.

Based on record review, observation and interview, the facility failed to ensure that cottage cheese and bologna was discarded by the use by date and sliced cheese had a use by date on 4/7/15. The facility further failed to ensure the filters in the stove hood were free of a dust and grease like substance on 4/8/15. This had the potential to affect 121 of 125 residents who receive meals from the kitchen. Findings Include: A review of the facility's policy titled, "Leftover Food Storage and Labeling" with an effective date of February 1, 2012 revealed: "... PROCESS: ... d.... frozen food should be discarded...." 1) On 4/7/2015 at 3:10 PM, the surveyor observed a pack of bologna and cottage cheese with a use by date of 4/4/15 and sliced cheese had no use by date. On 4/7/15 at 3:20 PM, an interview was conducted with EI #4 (Employee Identifier) kitchen worker. EI #4 was asked was the policy and procedure followed regarding labeling food products in the walk in cooler. EI #4 replied no it was not followed. EI #4 was asked was the food product cottage cheese with a manufacture best by use date of 4/4/15 to be discarded after that date. EI #4 replied yes it should have been discarded. EI #4 was asked why was it not discarded. EI #4 replied we did not pay attention to the date. EI #4 was asked was the food product, the bologna ,with a manufacture best use by date of 4/4/15 not discarded after the use by date. EI #4 replied it should have been discarded. EI #4 was asked did the sliced cheese have a use by date on it. EI #4 replied no. EI #4 was asked what was the potential harm in not discarding products after the the use by date. EI #4 replied residents could get sick and get a food borne illness. A review of the facility's policy titled, "...Cleaning of Miscellaneous Equipment and Utensils" with an Effective Date of May 1, 2003 revealed: "... 32. Hold Filter over Stove: (monthly) ..." On 4/8/2015 at 10:35 AM, the surveyor observed a grease dust like substance in the stove hood filters. On 4/8/2015 at 11:50 AM, an interview was conducted with EI #3, Certified Dietary Manager. EI #3 was asked what did she see in the stove hood filters. EI #3 replied grease, dust and moisture. EI #3 was asked where were the stove hood filters located. EI #3 replied over the stove and fryer. EI #3 was asked why was there grease and dust in the stove's filters. EI #3 replied they need to be cleaned. EI #3 was asked when was the filters cleaned last. EI #3 replied once since August 2014. EI #3 was asked who was responsible for cleaning the stove's filters. EI #3 replied a contract service. EI #3 was asked how often should the stove's filters be cleaned. EI #3 replied every three months. EI #3 was asked why should the filters be cleansed. EI #3 replied to keep the dust from accumulating and getting into the food. EI #3 was asked what was the potential harm when dust and grease were in the stove hood filters. EI #3 replied it could get into the food. EI #3 was asked what was the facility's policy on dust and grease in the stove's hood filters. EI #3 replied she did not know. On 4/9/2015 at 4:15 PM, an interview was conducted with EI #4, Kitchen Manager. EI #4 was asked what did she see in the stove hood filters. EI #4 replied lent and grease. EI #4 was asked when was the filters cleaned last. EI #4 replied January 2015. EI #4 was asked who was responsible for cleaning the stove's filters. EI #4 replied maintenance and (name of outside contract company). EI #4 was asked why should the filters be cleaned. EI #4 replied for the excess grease. EI #4 was asked what was the potential harm with dust and grease in the filters located over the stove. EI #4 replied inadequate ventilation and fire.

Based on observation, interview and record review, the facility failed to ensure staff knocked on RL (Resident Locator) # 1's door prior to entering on 4/8/15. This affected 1 of 14 resident's rooms located on South Hall. Findings Include: A review of a facility policy titled, "Knocking on Resident Room Doors" with no effective date revealed the following: "It is the policy of this facility that all staff knock on the resident's door(even if open) prior to entering the room...." On 4/8/15 at 11:00 AM, an observation was made of EI (Employee Identifier) #2, CNA(Certified Nursing Assistant) entering RL #1's room without knocking prior to entering. On 4/8/15 at 11:03 AM, an interview was conducted with EI #2 . EI #2 was asked what was the facility's policy and procedure when entering a resident's room. EI #2 explained that staff was to knock and make the resident aware and make sure it was okay to come in. EI #2 was asked was that what she did. EI #2 stated no ma'am, she did not. EI #2 was asked what was the potential harm in not knocking prior to entering residents rooms. EI # 2 stated that the resident could not be clothed and they may feel violated or they could be standing behind the door. On 4/9/15 at 5:04 PM, an interview was conducted with EI #1, DON(Director of Nursing). EI #1 was asked what was the facility's policy and procedure regarding knocking on resident's doors prior to entering their rooms. EI #1 explained that staff was to knock prior to entering the resident's room and to wait for a response. EI #1 was asked why should staff knock on residents doors prior to entering. EI #1 explained that it was the resident's home and its their dignity and it was courteous. EI #1 was asked what was the potential harm in not knocking on a resident's door prior to entering. EI #1 explained that it could be offensive to some residents and that it went back to dignity especially if the resident was alert, it could be discourteous to them.