Every finding on record at Attalla Rehabilitation and Nursing Center

Based on observations, interviews, review of facility policies titled, Water Temperatures, Safety Of and Management of the Laundry, review of facility Maintenance Repair Log sheets, review of facility Water Temp (temperature) Log Sheets, and review of the laundry department's Dryer Log, the facility failed to: 1) monitor and maintain safe hot water temperatures, which were found to be up to 145 degrees Fahrenheit (F), on all residential wings/units of the facility, including the dementia unit. Further, staff failed to implement the system for reporting and acting upon ongoing concerns related to excessively hot water in resident care areas. Specifically, direct care staff with knowledge of excessively hot water temperatures did not record this information on the facility's Maintenance Repair Log sheets as the concerns were identified. In addition, maintenance staff were not performing weekly routine checks of facility water temperatures to ensure they were within safe ranges, nor did the facility implement any additional checks or safety precautions when they became aware there were concerns with their boiler system. This deficient practice placed all 89 residents in the facility in immediate jeopardy (IJ), as it was likely to result in serious injury, serious harm, serious impairment, or death. On 02/03/2022 at 1:03 PM, Employee Identifier (EI) #1, the Administrator, was notified of the findings of substandard quality of care at the IJ level in the area of Quality of Care/Free of Accident Hazards/Supervision/Devices, F689; and 2) Further, the facility failed to ensure lint was removed from underneath the facility's dryer. These deficient practices had the potential to affect all 89 residents residing in the facility. Findings include: 1) Cross Reference F835 and F908. A review of a facility policy titled, Water Temperatures, Safety of, dated April 2010, revealed: Tap water in the facility shall be kept within a temperature range to prevent scalding of residents. Policy Interpretation and Implementation 1. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 110 [degrees] F (Fahrenheit), or the maximum allowable temperature per state regulation. 2. Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log. 3. Maintenance staff shall conduct periodic tap water temperature checks and record the water temperatures in a safety log. 4. If at any time water temperatures feel excessive to the touch (i.e., hot enough to be painful or cause reddening of the skin after removal of the hand from the water), staff will report this finding to the immediate supervisor. On 01/31/2022 at 10:16 AM, while talking with Resident Identifier (RI) #82 in his/her room on the E Unit, the surveyor turned on the hot water faucet, noting the hot water seemed hotter than expected. The surveyor left the room and returned at 10:29 AM with a thermometer to check the water temperature. RI #82's bathroom sink water temperature was noted to be 124.8 degrees F. After noting this water temperature exceeded 110 degrees F, the surveyors began checking water temperatures throughout the facility. According to the facility's floor plan, the facility consisted of seven units, referred to as the A through G Units. Per the facility's Matrix listing all residents residing in the facility, residents resided on all units, except the B Unit. The following observations were made, listed by unit: A Unit: - On 01/31/2022 at 3:11 PM, observation revealed RI #31 and RI #9's shared bathroom had a hot water temperature at the sink of 131.8 degrees F. - On 01/31/2022 at 3:19 PM, observation revealed RI #23 and RI #52's shared bathroom had a hot water temperature at the sink of 118.2 degrees F. - On 01/31/2022 at 3:23 PM, in the shower room between Hall A and Hall C, the sink hot water temperature was 135.5 degrees F and the shower hot water was 131.0 degrees F. C Unit: - On 01/31/2022 at 2:37 PM in RI #79's bathroom, the hot water temperature was 120.4 degrees F. RI #79 stated the/she used to be a [NAME] and noted that the water from the sink was hot. - On 01/31/2022 at 3:02 PM RI #2's bathroom hot water temperature was 119.2 degrees F. D Unit: - On 01/31/2022 at 2:40 PM, the hot water temperature in the bathroom sink between Rooms D1 and D2 was 133 degrees F. - On 01/31/2022 at 2:40 PM, the hot water temperature in the bathroom sink between Rooms D3 and D4 was 128 degrees F. - On 01/31/2022 at 2:41 PM, the hot water temperature in the bathroom sink between Rooms D9 and D10 was 118 degrees F. - On 01/31/2022 at 2:41 PM, the hot water temperature in the bathroom sink between Rooms D11 and D12 was 118 degrees F. E Unit: - On 01/31/2022 at 10:34 AM, RI #78 stated that the hot water was warm but acceptable, noting they were able to simply turn on hot and cold water together. The surveyor checked the water temperature with a thermometer and found the hot water in RI #78's bathroom was 127 degrees F. F Unit (Dementia Unit): - On 01/31/2022 at 11:14 AM, the hot water temperature in the bathroom sink shared by Rooms F14 and F15 on the Dementia Unit was found to be 137 degrees F. - On 01/31/2022 at 11:28 AM, the hot water temperature in the bathroom sink shared by Rooms F8 and F9 on the Dementia Unit was found to be 140 degrees F. - On 01/31/2022 at 2:20 PM, the hot water temperature in the bathroom sink shared by Rooms F16 and F17 on the Dementia Unit was found to be 145 degrees F. The two residents in Room F17 were ambulatory and utilized water from the sink. - On 01/31/2022 at 2:42 PM, the Dementia Unit shower room's hot water temperature was found to be 136 degrees F. Per staff, this shower was used for any resident desiring a shower/scheduled for a shower on the unit. G Unit: - On 01/31/2022 at 11:10 AM, RI #139's bathroom sink hot water temperature was found to be 127 degrees F. RI #139, who was cognitively intact, stated the water was hot, but the resident had not gotten burned from the water. - On 01/31/2022 at 11:21 AM, the G Wing shower room water temperature was found to be 136 degrees F. - On 01/31/2022 at 11:35 AM, RI #140's bathroom sink hot water temperature was found to be 136 degrees F. RI #140, who was cognitively intact, stated he/she had been using the hot water from the sink, but had not been burned. On 01/31/2022 at 4:12 PM, Employee Identifier (EI) #1, the Administrator, was informed there was an issue with hot water temperatures. At that time, a request was made to review hot water temperature logs and interview staff from the Maintenance Department. Review of the Water Temp Log Sheets provided by the facility, revealed weekly water temperature checks on each unit of the facility, up until the last entry dated 01/11/2022. There was no evidence the subsequent weekly water temperature monitoring had been performed. On 01/31/2022 at 4:17 PM, two maintenance staff were assembled in EI #1's office. EI #1 stated EI #4, the Maintenance Director, had only been at the facility since December of 2021, and EI #5, the Maintenance Assistant, had only been at the facility one week. EI #4, the Maintenance Director, went with a surveyor to verify water temperatures. Hot water temperatures were measured, in degrees F, with EI #4 on 01/31/2022 at the times noted below: -4:21 PM: shower room sink at the beginning of the DEFG wings measured 137.3 per EI #4's thermometer and 138 per the surveyor's thermometer -4:23 PM: shower at the beginning of the DEFG wings measured 136.4 per EI #4's thermometer and 138 per the surveyor's thermometer. -4:25 PM: The shared bathroom for Rooms D1 and D2 measured 133.7 per EI #4's thermometer and 133 per the surveyor's thermometer. -4:27 PM: The shared bathroom for Rooms D3 and D4 measured 130.1 per EI #4's thermometer and 128 per the surveyor's thermometer. -4:29 PM: The shared bathroom for Rooms D9 and D10 measured 114.6 per EI #4's thermometer and 118 per the surveyor's thermometer. -4:31 PM: The shared bathroom for Rooms D11 and D12 measured 115.1 per EI #4's thermometer and 118 per the surveyor's thermometer. -4:38 PM: The shared bathroom for Rooms F8 and F9 measured 140 per EI #4's thermometer and 140 per the surveyor's thermometer. During and after verification of hot water temperatures with EI #4 throughout the facility, surveyors questioned residents as well as staff regarding their knowledge of hot water temperature issues: During an interview on 01/31/2022 at 11:51 AM, RI #57, a cognitively intact resident who resided on the F Unit, stated the hot water temperature was so hot it could have scalded them during their last shower. RI #57 stated the water temperature was uncontrollable. On 01/31/2022 at 2:42 PM, an interview was conducted with EI #27, Certified Nursing Assistant (CNA), regarding water temperatures. EI #27 stated they had worked at the facility since September 2021 and, during that time, the water in the F Unit shower room was always hot or cold and that there seemed to be no in-between. EI #27 stated she was unable to give a decent shower because the hot water temperatures were so hot, it was scalding. EI #27 stated that maintenance staff had been aware of the issue for months. Per EI #27, sometimes staff took the F Unit residents to the D Unit shower room for better water pressure, but the water was just as hot in the D shower room as in the F shower room. On 01/31/2022 at 04:15 PM, an interview was conducted with EI #17, a CNA working on the F Unit (Dementia Unit). EI #17 stated they had worked at the facility since September of 2021. Per EI #17, water in the F Unit shower was seemingly either hot or cold, stating there was no in-between. EI #17 reported it took forever for the water to heat up but stated once the water warmed up it was super-hot. EI #17 reported it had been like that since she started working at the facility back in September. Per EI #17, staff knew there were water issues, but maintenance never fixed it. On 01/31/2022 at 4:30 PM, an interview was conducted with EI #19, a Registered Nurse (RN) who had worked at the facility since December of 2021. EI #19 stated water temperatures had been an issue since she began working at the facility. Per EI #19, the water on the F Unit would get really hot or cold and, in the shower, there was just a trickle of water at times. Per EI #19, the water concerns had been brought to EI #1's attention for months, but the issue was not fixed. On 01/31/2022 at 4:14 PM, an interview was conducted with EI #57, a CNA who was working on the D Unit. EI #57 said she believed the water temperature between Rooms D1 and D2 was too hot. EI #57 stated that when a resident was brought into the bathroom, the hot water would not be turned on all the way; instead, both the hot and cold water were turned on at the same time and adjusted as needed. However, EI #57 stated the facility had not provided any training addressing how to check if the water was too hot. On 01/31/2022 at 4:21 PM, an interview was conducted with EI #23, LPN, who revealed they had previously noticed water temperatures being too hot and having to regulate it with cold water. EI #23 stated problems with water could be reported via a work order in the maintenance log book located at the nurse's station; however, EI #23 confirmed she had not reported the problem with the water temperature in the maintenance log book. On 01/31/2022 at 5:12 PM, a meeting was attended by EI #1 (Administrator), EI #4 (Maintenance Director), EI #5 (Maintenance Assistant) , EI #6 (Regional Life Safety Director), and the survey team. EI #6 stated he was a resource if the new maintenance staff had any questions or problems. EI #6 stated he would come to the facility to help if needed. EI #6 stated EI #4 and EI #5 were new employees. EI #6 stated the facility had worked on their boiler system twice in January of 2022. He stated the facility saw problems with water temperatures up to 110, 111, and 114 degrees F and the facility had made adjustments. He said water temperatures began getting high, noting he did not like the hot water temperature to rise above 109 degrees F. During the meeting, EI #1 stated the hot water started fluctuating and temperatures were getting high. EI #1 indicated 01/10/2022 was when the facility started to notice the water temperatures fluctuating and getting high. EI #1 further indicated they had outside contractors come to the facility on [DATE] and 01/21/2022, respectively. When asked how often water temperatures were measured, EI #6 stated, one time a week. He further explained that he instructed maintenance staff to take the water temperature in one room on each wing of the facility. During the meeting on 01/31/2022, the survey team asked about the Water Temp Log Sheets that had no log entries recorded after 01/11/2022. It was noted that two routine water temperature monitoring entries were missing for the dates of 01/18/2022 and 01/25/2022 to bring the log up to date, given the expected frequency of measurements, per EI #1 and the facility policy. EI #1 stated if an entry was not on the log, then it was not done. EI #1 stated the dates of the missing entries were around the time that they were identifying issues. During the meeting, EI #6 explained the facility's boiler and the chiller provided the hot water to the halls. EI #6 indicated if you mess with the boiler temperature, you must adjust the water to the halls. EI #6 stated it was a complicated system, and someone would have to be called in to work on it. EI #6 was asked if he was familiar with the Maintenance Repair Log entry on 11/26/2021 for the G shower room, which documented water temperatures hot enough to scald. EI #6 stated he had not seen it, and that would have been when EI #55, a former employee, was employed as the Maintenance Director. During the meeting, EI #4, the current Maintenance Director, acknowledged signing off on a shower issue and recalled trying to adjust the water temperature. EI #4 stated these issues may have been going on for some time and may have been a valve issue. EI #4 was asked how water temperatures were adjusted. EI #4 stated he had to adjust the temperature with the dial on the hot water heater. EI #4 stated that, after he made adjustments, it was not re-tested to determine what water temperatures it was producing after that. During the meeting, EI #1 stated it was not uncommon for water temperatures to fluctuate; however, too many water temperature issues alerted them to the problem. EI #1 stated they wanted to keep the water temperature between 105 and 110 degrees F and EI #6 concurred, noting the hot water temperature should not exceed 110 degrees F. EI #1 stated they would have to make an adjustment or get an outside contractor to come if the hot water temperature was over 110 degrees F. When questioned why no additional monitoring of water temperatures had been performed after making adjustments to the water heater, EI #1 agreed it would have been critical to check temperatures after maintenance was conducted. A review of the facility-provided Maintenance Repair Logs for 11/2021 through 1/2022 ( a log for staff to record concerns/issues requiring maintenance intervention) revealed the following entries related to water temperatures: - an entry dated 11/26 (2021). This entry documented the G shower room had an issue of, water temp is scalding hot + [and] there is standing water that is pooling by the walls. There was no signature of the staff member who made this entry onto the log. In addition, the completion/repair date for this entry was blank. The maintenance signature, indicating this issue had been addressed, was also blank. - An entry dated 12/19 (2021). This entry documented the residents were complaining about the shower room on the F Unit not having water pressure and the temperature going from extreme hot to cold. This entry was not signed by the staff member that made the entry onto the log; however, it was initialed by EI # 4, the Maintenance Director on 1/22/2022. - An entry dated 12/29 (2021). This entry documented a shower water temperature issue in an unspecified shower room. There was no signature of the staff member who made this entry onto the log; however, it was noted EI #4 initialed this entry as completed/repaired with a date of 12/21/2021, indicating a repair date eight days prior to staff reporting the concern. Following the meeting with facility staff regarding the water temperature concerns, the following additional hot water temperatures were measured, in degrees F, with EI #5 on 01/31/2022 at the times noted below: -5:36 PM: The bathroom of Room E5 measured 116 per EI #5's thermometer and 124.8 per the surveyor's thermometer. -5:38 PM: The bathroom of Room E8 measured 125.2 per EI #5's thermometer and 127 per the surveyor's thermometer. -5:41 PM: The bathroom of Room G11 measured 129.9 per EI #5's thermometer and 127 per the surveyor's thermometer. -5:44 PM: The bathroom of Room G13 measured 131.7 per EI #5's thermometer and 136 per the surveyor's thermometer. -5:47 PM: The shared bathroom of Rooms F14 and F15 measured 136.7 per EI #5's thermometer and 137 per the surveyor's thermometer. -5:49 PM: The shared bathroom of Rooms F16 and F17 measured 136.7 per EI #5's thermometer and 145 per the surveyor's thermometer. -5:50 PM: The F Unit shower measured 135 per EI #5's thermometer and 136 per the survey's thermometer. On 01/31/2022 from 5:57 PM to 6:08 PM, EI #4 measured the following hot water temperatures with the facility's thermometer: -Room C5's sink water was 116.7 degrees F -Room C13's sink water was 116.6 degrees F -Room A3 and A4's bathroom sink water was turned off. EI #4 stated he was unaware why the water was turned off and turned it back on below the sink. The temperature of the hot water was 123.2 degrees F. After obtaining the temperature and turning the water off at the sink, the water kept running, and EI #4 turned the water off below the sink and stated they would need to fix the sink. -Room A7 and A8's shared bathroom sink water was 126.5 degrees F -Room A999's sink water was 123.5 degrees F -While the surveyor accompanied EI #4 to obtain these temperatures, it was noted there were no maintenance logs located on the A/C Units during this time. On 2/01/2022 and 02/02/2022, the following additional water temperature observations and additional resident and staff interviews were obtained by the survey team: On 02/01/2022 at 9:17 AM, the G Unit shower room hot water temperature was found to be 129 degrees F. On 02/01/2022 at 9:20 AM, RI #139's bathroom sink hot water temperature was found to be 126 degrees F. On 02/01/2022 at 9:27 AM, the hot water temperature in the bathroom sink shared by Rooms F16 and F17 on the Dementia Unit was found to be 139 degrees F. On 02/01/2022 at 9:27 AM, RI #35, a cognitively intact resident, revealed the water in his/her bathroom sink was very hot. Per RI #35, a couple days prior, he/she had burned his/her hands when washing them in the sink. RI #35 reported his/her hands did not blister, but they were very red. RI #35 could not recall the specific day or time the incident occurred. On 02/01/2022 at 9:35 AM, an interview was conducted with EI #28, CNA. EI #28 stated that the water in the resident showers had been too hot. Per EI #28, the hot water had been an issue for a couple of months. On 02/01/2022 at 3:50 PM, an interview was conducted with EI #11, Staff Development Coordinator, who stated an in-service was conducted in the middle of January of 2022 after she noticed the water in the sink behind the nurse's station was too hot. Review of a typed document provided by the facility revealed the following: JANUARY 12, 2022 .ANY EMPLOYEE WHO HEARS OR SEES ANY ISSUES WITH WATER TEMPERATURES SHOULD REPORT THESE FINDINGS TO YOUR SUPERVISOR IMMEDIATELY AND PLACE THESE ISSUES IN THE MAINTENANCE LOG FOR THAT HALL The facility also provided two copies of a Record of Inservice Training and Attendance Form with this document. This form was also dated 01/12/2022 and listed a topic of Temps, and was signed off on by EI #11. These two forms contained only 34 total staff signatures of varying different job titles. During a follow-up interview with EI #11 on 02/03/2022 at 9:40 AM, EI #11 confirmed she had noticed the water temperature was too hot in mid-January of 2022. EI #11 said she reported the concern to EI #4, the Maintenance Director, as well as EI #1, the Administrator. However, EI #11 indicated she did not work the floor, so she was unsure if the water temperatures were actually fixed. On 02/01/2022 at 3:55 PM, an interview was conducted with EI #49, RN. EI #49 had worked at the facility for four to five months. EI #49 stated the water temperatures on the F Unit (Dementia Unit) had been hot. EI #49 was unsure who, if anyone, had reported it to maintenance staff. When asked why EI #49 did not report it to maintenance herself, EI #49 responded that she was too busy on the unit with the residents and had a heavy medication pass and had not taken the time to report it to maintenance. On 02/02/2022 at 8:33 AM, RI #290, identified by the facility as only requiring set-up assistance for bathing, was interviewed regarding his/her showers. RI #290 confirmed he/she had taken a few showers since being admitted to the facility 01/28/2022. RI #290 explained that an aide went with them to shower, but RI #290 turned the shower on and bathed them self. RI #290 stated that the water was too hot, and he/she had to turn on the cold water to 'tweak' it to make it a comfortable temperature. RI #290 stated that they had never been injured from the hot water, but if they were unable to add the cold water, the water would be too hot to shower. On 02/02/2022 at 8:34 AM, a telephone interview was conducted with the heating and cooling repairman who had provided service to the boiler in January 2022. According to the repairman, he had been contacted to specifically replace the start ignition control board, as it was not sparking to ignite the flame. The repairman stated his company did not usually work on boilers or chillers but did it that time to help the facility out on a late Friday afternoon. On 02/02/2022 at 8:45 AM, a telephone interview was conducted with an electric motor repairman, who also addressed issues with the facility's boiler in January 2022. This repairman also stated he did not usually work on boilers, but the facility's boiler would not fire, and he was able to clean the eye so that it would. The repairman explained that temperature parameters needed to be set so that the water temperatures would remain within that range. He further stated that the temperature of the water needed to be checked frequently. On 02/02/2022 at 10:02 AM, a hired construction manager contacted by the facility during the survey to see what was causing their water temperature issues, stated that he had determined the facility's boiler mixing valve had failed, which was creating the issue with elevated water temperatures. On 02/02/2022 at 10:10 AM, EI #4, Maintenance Director, took the surveyor through the facility to show the location of hot water heaters and boilers for the facility. EI #4 told the surveyor that they never knew where the mixing valve was located. During the tour of the facility's water heaters and boilers, when EI #4 was asked why the temperature logs had not been completed since 01/11/2022, EI #4 said that there were so many things that needed to be fixed and so many issues since he started, that he had not been able to do everything. EI #4 stated that he and EI #5 did not get much training. EI #4 noted he attended 'stand up' (a short, stand-up meeting) every morning and could meet with EI #1 as needed. EI #4 stated that all staff had to go through EI #1 for cost of repairs, noting that some repairs also had to go through corporate for approval. EI #4 explained that there were not a lot of places that used boilers now, and it was not easy to find anyone who worked on them. On 02/02/2022 at 1:05 PM, a Resident Group Meeting was conducted with six (RI #58, #48, #13, #70, #5, and #43) cognitively intact residents in attendance. During the meeting, RI #58 stated, The water is so hot on C Hall. A CNA told me I couldn't take a shower [because] it was so hot. On 02/02/2022 at 1:07 PM, an interview was conducted with EI #2, the Director of Nursing. EI #2 said about three weeks prior, EI #4 told her the sink water behind the nurse's station was too hot. Per EI #2, EI #1 (Administrator) was notified of the concern, and someone came out to look at it. EI #2 noted she took no other actions because EI #1 handled it. EI #2 denied any further knowledge of water temperature concerns. EI #2 further denied any knowledge of residents receiving [CONDITION(S)] but acknowledged water temperatures that were too hot could be a potential problem. On 02/02/2022 at 3:24 PM, EI #1 was asked what prompted the work on the boiler on 01/10/2022. EI #1 stated a potential problem had been noticed with the heat (air heating system also associated with the facility's boiler system), noting a contractor had been called to work on it. EI #1 stated the boiler operated both the heating and water systems. EI #1 stated he then called another contractor on 01/21/2022 and this contractor installed a new part. EI #1 stated someone said something about the water temperature around that time, but he could not remember who. EI #1 stated the person who may have first mentioned the hot water was EI #11, but he was not sure. EI #1 stated they checked and did not find issues, so they went on as usual. EI #1 stated they did not have logged temperatures for a week, which he noted he should have caught, but he did not recall anyone having major issues with water during that time. EI #1 was asked what temperature could cause a burn, and he stated, 110 [degrees F]. EI #1 was asked if the facility's water temperatures had exceeded 110 degrees F. EI #1 stated, yes, that has been identified. EI #1 acknowledged they had a hiccup in the facility's system of monitoring and acting upon hot water temperatures. On 02/03/2022 the following additional staff interviews were conducted regarding staff knowledge on how to report maintenance concerns, including excessively hot water temperatures: On 02/03/2022 at 7:54 AM, an interview was conducted with EI #28, a CNA. EI #28 stated water temperatures had been too hot for months and that maintenance staff were aware of the hot temperatures because she had seen maintenance staff working on it. However, EI #28 said she had not reported the concern in the maintenance log, because she thought maintenance staff were already aware. On 02/03/2022 at 9:28 AM, EI #13, LPN, stated that she reported maintenance problems by paging the maintenance department. EI #13 reported that maintenance staff did not check the Maintenance Repair Log books often. EI #13 said she has to chase maintenance staff down and indicated she did not know why they were not keeping a check on the Maintenance Repair Log books. On 02/03/2022 at 9:30 AM, an interview was conducted with EI #33, RN. EI #33 reported she began working at the facility in November of 2021. EI #33 reported she did not know where the maintenance log was kept for the G Unit. On 02/03/2022 at 9:35 AM, EI #63, Housekeeper, reported no knowledge of a maintenance log or its location. On 02/03/2022 at 9:36 AM, EI #8, CNA, stated that she reported maintenance problems to the charge nurse. EI #8 further stated there was supposed to be a book on each hall staff could write down any problems/concerns in but indicated she had not seen one on her hall. EI #8 did confirm having knowledge of hot water concerns and indicated the prior week she had reported to the nurse that the water temperatures were too hot. EI #8 was unable to give a specific date, time, or the name of the nurse she reported the issue to. According to EI #8, the nurse had told her they were handling it. On 02/03/2022 at 9:59 AM, EI #61, a CNA, stated she had heard many complaints from residents about the water being too hot initially, then getting cold and not being warm enough. EI #61 stated she had knowledge of the maintenance logs but had not put anything on it yet, noting she had just been telling someone verbally. On 02/03/2022 at 9:54 AM, EI #4, the Maintenance Director, was asked about the Maintenance Repair Log books. EI #4 said he was unsure where the maintenance logs were located on the A and C Units. EI #4 stated he did not check off on the log until an issue had been resolved/completed. EI #4 stated that they had not checked the log on the A and C Units and could not provide a date they last checked the logs on those halls. ****************** The facility submitted an acceptable Removal Plan on 02/05/2022 for F689 that outlined the following: . 1. When the surveyor informed administration that an abnormal temperature was discovered on January 31, 2022, facility staff were immediately notified of the issue and all 87 residents in house were observed for any [CONDITION(S)] on January 31, 2022 by Nursing Management, with no [CONDITION(S)] noted. 2. On January 31, 2022, the facility Administrator educated D.O.N., I.C.P. [Infection Control Preventionist] and Maintenance on water temperature policy. On January 31, 2022 the facility D.O.N. and I.C.P. educated Nurses, CNA's, Business Office Manager, Medicaid Specialist, Human Resource Director Environmental Services and Dietary on identification of water temperatures that should be maintained between 100 - 110 degrees F, and the adverse consequences that can be caused to the resident when water temperatures are outside of the normal range. Education also included the Maintenance Log and location of Maintenance Log. Education started on January 31, 2022 and continued through February 3, 2022. All employees not educated on the water temperature policy will be educated by February 4, 2022. Any facility employee not educated on the water temperature policy, maintenance log, location of maintenance, thermometer use and location of thermometer(s) by February 4, 2022, will not be allowed to return to work until education is received. On February 1, 2022, the facility Administrator educated the I.C.P. on the use of thermometers to check water temperatures, and that thermometers will be located in the shower room and all units. Any facility employee(s) not educated by February 4, 2022 on the use of thermometers to check water temperatures and their location, will not be allowed to work their schedule until education is received. The facility Medical Director was also notified on February 3, 2022 of water temperature issues and that none of the 87 in house residents were burned. 3. Maintenance started checking water temperatures on January 31, 2022 throughout the building in all resident bathrooms, showers, nursing station sinks and visitor bathrooms and determined that water temperatures in the noted areas were in excess of 110 degrees F. On January 31, 2022, direct care staff were educated and instructed to provide assistance to residents with hand washing. On February 1, 2022, contractor shut off all hot tempered water. On February 2, 2022, new mixing valve was installed, and hot water turned on to circulate through pipes. Water temperatures on February 2nd and 3rd were noted to be in the range 75 - 114 degrees F throughout the noted areas. On February 4, 2022, water temperatures were check in the noted areas and ranged from 101 - 107 degrees F and continue to be within normal limits. 4. Contractor was called and on site on 1-31-22 to inspect the boiler and identified an issue with the mixing valve. All hot water was turned off on 2-1-22, until the new mixing valve was installed on 2-2-2 [TRUNCATED]

Based on interviews and review of the facility's, Administrator Job Description, administration failed to provide training and oversight to ensure the facility was free from the potential for injury related to identified concerns regarding elevated hot water temperatures. During the survey, the survey team identified hot water temperatures throughout all residential units/wings of the facility, including the Dementia Unit, that exceeded 110 degrees Fahrenheit (F). Temperatures were found to be as high as 145 degrees F in resident bathroom sinks, as well as resident shower rooms. This deficient practice placed all 89 residents in the facility in immediate jeopardy (IJ), as it was likely to result in serious injury, serious harm, serious impairment, or death. On 02/03/2022 at 1:03 PM, Employee Identifier (EI) #1, Administrator, was notified of the findings of IJ in the area of Administration/F835. Findings include: During the survey, concerns were identified with hot water temperatures in excess of 110 degrees Fahrenheit (F). Hot water temperatures exceeding 110 degrees F were noted on all residential wings/units of the facility, including the Dementia Unit, despite prior staff knowledge about water temperature concerns. In addition, it was determined facility staff were not implementing the facility's system for reporting identified concerns requiring Maintenance intervention, nor was Maintenance staff consistently monitoring and addressing reported concerns related to hot water temperatures. Cross Reference F689 and F908. A review of the facility's Administrator Job Description, dated 06/01/2017, revealed: .Summary .Lead and direct the overall operation of the facility in accordance with resident needs, government regulations and Company policies so as to maintain care for the residents while achieving the facility's business objectives . On 02/01/2022, a review of the facility's maintenance staff members EI #4's (Maintenance Director) and EI #5's (Maintenance Assistant) personnel and training files was conducted. A review of competency documentation revealed maintenance staff received no specific training for water temperature monitoring to protect residents. A review of EI #4's and EI #5's job descriptions, which were signed by the staff members, revealed they would be responsible to conduct preventive maintenance, including keeping facility logs of water temperatures. EI #4 and EI #5's signed job descriptions also indicated their Supervisor was EI #1, the facility Administrator. On 02/01/2022 at 12:20 PM, an interview was conducted with EI #1, the Administrator, regarding orientation for maintenance staff. EI #1 stated that the maintenance staff received general orientation like all employees. EI #1 was not aware of specific maintenance competency check-offs or requirements. EI #1 stated that most of the training was on-the-job training with another maintenance supervisor or regional maintenance staff. On 02/02/2022 at 3:24 PM, EI #1 was asked what prompted work on the facility's boiler on 01/10/2022. EI #1 stated a potential problem had been noticed with the heat (air heating system), noting a contractor had been called to work on it. EI #1 stated the boiler operated both the heating and water systems. EI #1 stated he then called another contractor on 01/21/2022 and this contractor installed a new part. EI #1 stated someone said something about the water temperature around that same time, but he could not remember who. EI #1 stated the person who may have first mentioned the hot water was EI #11, Staff Development, but he was not sure. EI #1 stated they checked and did not find issues, so they went on as usual. EI #1 stated they did not have logged temperature monitoring for a week, which he noted he should have caught. EI #1 was asked what temperature could cause a burn, and he stated, 110 [degrees F]. EI #1 was asked if the facility's water temperatures had exceeded 110 degrees F. EI #1 stated, yes, that has been identified. EI #1 acknowledged they had a hiccup in the facility's system of monitoring and acting upon hot water temperatures. During this same interview, EI #1 was asked to describe maintenance staff training. EI #1 stated maintenance staff went through orientation. EI #1 stated EI #6, the Regional Life Safety Director, assisted with some of the maintenance training and was available by phone to answer any questions. EI #1 stated EI #14, the Corporate Environmental Life Safety Administrator, had now begun to assist with some of the training. EI #1 stated the maintenance staff had changed more than once since he started at the facility in April or May of 2021. EI #1 described how it was difficult to find people who knew how to work on boiler systems. EI #1 stated EI #4 was maintenance savvy but was not a boiler expert, so the facility relied on outside help. EI #1 stated they had no boiler-certified person on staff and were limited on the training that could be provided about boilers. EI #1 acknowledged training could be better, but indicated staff turnover made training difficult. EI #1 stated nursing homes were not the easiest place to work, and people got tired of being called on the weekends. During the same interview, EI #1 was asked if there was a check-off list used when training maintenance staff that included the things they would be responsible for. EI #1 stated EI #4 was an MDS nurse prior to taking the maintenance position and was aware of a lot of protocols for long-term care. EI #1 stated EI #4 had expressed an understanding of what needed to be done, but he had not had any help until about one week ago. EI #1 stated EI #5 was hired as a Maintenance Assistant about one week prior. He stated he had not had any time to spend with EI #5 yet. During the same interview, EI #1 was asked if he did environmental rounds himself. EI #1 stated most of the rounds were conducted informally. EI #1 stated he would get a notebook and pen, grab a maintenance person, and hit the floor. EI #1 stated they were not formal-type rounds and were not officially documented anywhere. During the same interview, EI #1 was asked what was on the top of the list that EI #4 was working on before the survey team entered. EI #1 stated the list could change day to day and was just whatever was needed for him to do, including blowing off debris from the parking lot or looking at the smoking area. EI #1 stated EI #4 had been there a month, running around by himself, and had to do a lot of things on his own. EI #1 stated EI #4 had not had help. During the same interview, EI #1 was asked how he provided oversight to the maintenance staff. EI #1 replied, in morning meetings. EI #1 stated he asked maintenance if their logs (Maintenance Repair Logs) were up to date, but indicated he did not ask them to bring the logs with them each day for him to review. EI #1 stated if he had inspected the Maintenance Repair Logs, he would have known about the hot water temperatures. EI #1 stated that at the end of the day, 'the buck stopped' with him. EI #1 stated he needed to look at logs daily or establish a system to review the logs weekly or biweekly. ****************** The facility submitted an acceptable Removal Plan on 02/05/2022 for F835 that outlined the following: . 1. On January 31, 2022, when the surveyor informed administration that an abnormal temperature was discovered, contractor was immediately notified to inspect the boiler. 2. Contractor was called on 1-31-22 to inspect the boiler and identified an issue with mixing valve. On 2-1-22, hot water to the facility was turned off and remained off until a new mixing valve was installed on 2-2-22. No further issues noted with excessive hot water temperatures in resident bathroom, showers, nursing station sinks and visitor bathrooms. 3. On January 31, 2022, Administrator instructed Maintenance staff to immediately check water temperatures in resident bathrooms, showers, nursing station sinks and visitor bathrooms, and identified additional abnormal water temperatures. At that time, the administrator educated Maintenance staff on correct water temperatures that should range between 100 - 110 degrees F. The Regional Environmental Director educated Administrator and Maintenance staff on monitoring water temperatures February 4, 2022. The Regional Environmental Director also educated on water temperature logs, maintenance logs, follow up of monitoring water temperatures and prioritization of entries in Maintenance Repair Log on February 4, 2022. Maintenance will also bring Repair Log to the daily morning meeting for review beginning February 4, 2022 for 60 days. 4. Maintenance will assess and do water temperature audits on 1 different unit weekly. The Regional Environmental Director will come to the facility 1 x per week for 2 months and 1 x per month for 3 months to provide oversight to Maintenance Department, education, checking water temperatures, reviewing the Maintenance Repair Log and inspection of boiler. The likelihood and/or potential of injury to all 87 in house residents began to be negated on January 31, 2022 r/t [related to] staff education on water temperatures policy along with additional education that included use and location of thermometers to check water temperatures, Maintenance Repair Log, and location of Maintenance Log on February 1, 2022 that will continue until all facility staff are educated by February 4, 2022. After this date, staff will not be allowed to work their schedule until education is completed. Member of Governing Body met with Administrator and is in agreement with the steps of the removal plan on February 4, 2022. On 02/06/2022 at 6:30 PM, after review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations of safe hot water temperatures in the facility, the survey team determined the facility implemented the immediate corrective actions as of 02/04/2022 and the scope and severity was lowered to an F level, to allow the facility time to further address and monitor the deficient practice in order to achieve compliance.

Based on observations, interviews, review of a facility policy titled, Water Temperatures, Safety Of, review of facility Maintenance Repair Log sheets, and review of facility Water Temp Log Sheet documents, the facility failed to monitor and maintain the water heating/boiler system in safe operating condition to prevent hazardous hot water temperatures. Water temperatures were observed in excess of 110 degrees Fahrenheit (F) on all residential wings/units of the facility, including the Dementia Unit. Temperatures as high as 145 degrees Fahrenheit (F) were observed in resident bathrooms and shower rooms throughout the facility. This deficient practice placed all 89 residents in the facility in immediate jeopardy (IJ), as it was likely to result in serious injury, serious harm, serious impairment, or death. On 02/03/2022 at 1:03 PM, Employee Identifier (EI) #1, the Administrator, was notified of the findings of IJ in the area of Essential Equipment/Safe Operating Condition, F908. Findings included: During the survey, concerns were identified with hot water temperatures in excess of 110 degrees Fahrenheit (F). Hot water temperatures exceeding 110 degrees F were noted on all residential wings/units of the facility, including the Dementia Unit, despite prior staff knowledge about water temperature concerns. Cross Reference F689 and F835. A review of a facility policy titled, Water Temperatures, Safety of, dated April 2010, revealed: Tap water in the facility shall be kept within a temperature range to prevent scalding of residents. Policy Interpretation and Implementation 1. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 110 [degrees] F (Fahrenheit), or the maximum allowable temperature per state regulation. 2. Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log. 3. Maintenance staff shall conduct periodic tap water temperature checks and record the water temperatures in a safety log. 4. If at any time water temperatures feel excessive to the touch (i.e., hot enough to be painful or cause reddening of the skin after removal of the hand from the water), staff will report this finding to the immediate supervisor. Review of the Water Temp Log Sheets provided by the facility, revealed weekly water temperature checks on each unit of the facility, up until the last entry dated 01/11/2022. There was no evidence the subsequent weekly water temperature monitoring had been performed. A review of the facility-provided Maintenance Repair Logs for 11/2021 through 1/2022 ( a log for staff to record concerns/issues requiring maintenance intervention) revealed the following entries related to water temperatures: - an entry dated 11/26 (2021). This entry documented the G shower room had an issue of, water temp is scalding hot + [and] there is standing water that is pooling by the walls. There was no signature of the staff member who made this entry onto the log. In addition, the completion/repair date for this entry was blank. The maintenance signature, indicating this issue had been addressed, was also blank. - An entry dated 12/19 (2021). This entry documented the residents were complaining about the shower room on the F Unit not having water pressure and the temperature going from extreme hot to cold. This entry was not signed by the staff member that made the entry onto the log; however, it was initialed by EI # 4, the Maintenance Director on 1/22/2022. - An entry dated 12/29 (2021). This entry documented a shower water temperature issue in an unspecified shower room. There was no signature of the staff member who made this entry onto the log; however, it was noted EI #4 initialed this entry as completed/repaired with a date of 12/21/2021, indicating a repair date eight days prior to staff reporting the concern. On 01/31/2022 at 5:12 PM, a meeting was attended by EI #1 (Administrator), EI #4 (Maintenance Director), EI #5 (Maintenance Assistant) , EI #6 (Regional Life Safety Director), and the survey team. EI #6 stated the facility had worked on their boiler system twice in January of 2022. He stated the facility saw problems with water temperatures up to 110, 111, and 114 degrees F and the facility had made adjustments. He said water temperatures began getting high, noting he did not like the hot water temperature to rise above 109 degrees F. During the meeting, EI #1 stated the hot water started fluctuating and temperatures were getting high. EI #1 indicated 01/10/2022 was when the facility started to notice the water temperatures fluctuating and getting high. EI #1 further indicated they had outside contractors come to the facility on [DATE] and 01/21/2022, respectively. When asked how often water temperatures were measured, EI #6 stated, one time a week. He further explained that he instructed maintenance staff to take the water temperature in one room on each wing of the facility. During the meeting on 01/31/2022, the survey team asked about the Water Temp Log Sheets that had no log entries recorded after 01/11/2022. It was noted that two routine water temperature monitoring entries were missing for the dates of 01/18/2022 and 01/25/2022 to bring the log up to date, given the expected frequency of measurements, per EI #1 and the facility policy. EI #1 stated if an entry was not on the log, then it was not done. EI #1 stated the dates of the missing entries were around the time that they were identifying issues. During the meeting, EI #6 explained the facility's boiler and the chiller provided the hot water to the halls. EI #6 indicated if you mess with the boiler temperature, you must adjust the water to the halls. EI #6 stated it was a complicated system, and someone would have to be called in to work on it. EI #6 was asked if he was familiar with the Maintenance Repair Log entry on 11/26/2021 for the G shower room, which documented water temperatures hot enough to scald. EI #6 stated he had not seen it, and that would have been when EI #55, a former employee, was employed as the Maintenance Director. During the meeting, EI #4, the current Maintenance Director, acknowledged signing off on a shower issue and recalled trying to adjust the water temperature. EI #4 stated these issues may have been going on for some time and may have been a valve issue. EI #4 was asked how water temperatures were adjusted. EI #4 stated he had to adjust the temperature with the dial on the hot water heater. EI #4 stated that after he made adjustments, it was not re-tested to determine what water temperatures it was producing after that. During the meeting, EI #1 stated it was not uncommon for water temperatures to fluctuate; however, too many water temperature issues alerted them to the problem. EI #1 stated they wanted to keep the water temperature between 105 and 110 degrees F, and EI #6 concurred, noting the hot water temperature should not exceed 110 degrees F. EI #1 stated they would have to make an adjustment or get an outside contractor to come if the hot water temperature was over 110 degrees F. When questioned why no additional monitoring of water temperatures had been performed after making adjustments to the water heater, EI #1 agreed it would have been critical to check temperatures after maintenance was conducted. ****************** The facility submitted an acceptable Removal Plan on 02/05/2022 for F908 that outlined the following:: The facility failed to monitor and maintain the water heating / boiler system in safe operating condition to prevent hazardous hot water temperatures On January 31, 2022, the state surveyor notified administration of water temperatures in the range of 124 - 145 degrees F. [Fahrenheit] D.O.N. [Director of Nursing], I.C.P. [Infection Control Preventionist] and Nurse Management educated Nursing and CNAs [certified nursing assistants] on January 31, 2022 on the water temperature policy, Maintenance Repair Logs, and location of Repair Log. On January 31, 2022, when the surveyor informed administration that an abnormal temperature was discovered contractor was immediately notified and came to the building on January 31, 2022 to inspect the boiler. Administrator educated Maintenance staff on correct water temperature policy on January 31, 2022. The Regional Environmental Director educated Maintenance staff on monitoring and preventative maintenance of boiler operations on February 4, 2022. The Regional Environmental Director educated Maintenance on, Repair Maintenance Log, and follow up on monitoring water temperatures. Contractor was called on 1-31-22 to inspect the boiler and identified an issue with mixing valve and a new mixing valve was installed on 2-2-22 with no further issues noted with excessive hot water temperature. The hot water to the boiler was cut off on 2-1-22 and remained disconnected until mixing valve was replaced on 2-2-22. The likelihood and/or potential of injury to any of the 87 in house residents began to be negated on January 31, 2022 r/t [related to] staff education on water temperatures and new mixing valve installed on February 2, 2022. Employees not educated on water temperature policy, thermometer usage and thermometer location by February 4, 2022 will not be allowed to work their schedule until education is received. Member of Governing Body met with Administrator on February 4, 2022 and is in agreement with these steps of the removal plan. On 02/06/2022 at 6:30 PM, after review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations of safe hot water temperatures in the facility, the survey team determined the facility implemented the immediate corrective actions as of 02/04/2022 and the scope and severity was lowered to an F level, to allow the facility time to further address and monitor the deficient practice in order to achieve compliance.

Based on observations, interviews, review of the Food and Drug Administration (FDA) Food Code, and review of the facility's policies titled, Food: Preparation, Food Storage: Dry Goods, Food Storage: Cold Foods, Dispose of Garbage and Refuse, Warewashing, and Proper Hand Hygiene: Dining Services Employees, the facility failed to ensure: 1) one item was properly labeled and dated, and two items were used or disposed of by date on package; 2) five boxes of food were stored off the walk-in freezer floor; 3) soap was available for staff to wash hands at the only handwash sink in the kitchen; 4) opened bags of food in dry storage were closed, labeled, and dated; 5) the floor and shelves in dry storage are were clean from foods; 6) sanitizing buckets contained the appropriate concentration of sanitizer for cleaning the kitchen; 7) kitchen staff maintained clean and dirty areas in the dishwasher area to prevent contamination of clean dishes with unclean gloved hands; and 8) the dishwasher contained chemicals needed for washing and sanitizing the dishes. This had the potential to affect all residents who received meals from the kitchen. Findings included: 1) A review of a facility policy titled, Food: Preparation, with a revised date of 09/2017, revealed, .All TCS (Time/Temperature Control of Safety) food that are to be held for more than 24 hours at a temperature of 41 degrees Fahrenheit or less, will be labeled and dated with a prepared date (Day 1) and a use by date (Day 7) . On 01/31/2022 at 8:54 AM, Employee Identifier (EI) #41, Certified Dietary Manager (CDM), accompanied the surveyor during the initial tour of the kitchen. In the walk-in cooler, the surveyor and EI #41 observed the following: (1) a bag containing ham with no label to indicate the use-by date; (2) a bag with hamburger steak dated 01/30/2022; and (3) a bag of chicken patties dated 01/29/2022. An interview with EI #41 was conducted at 8:54 AM on 01/31/2022. EI #41 was asked if those items should be in the walk-in refrigerator and the reply was no. EI #41 immediately took the bags and threw them in the garbage. EI #41 said that probably over the weekend, staff had not checked dates on the refrigerated items. 2) A review of the facility policy titled, Food Storage: Cold Foods, revised 04/2018, noted that All food items will be stored at least 6 inches above the floor and 18 inches below the sprinkler unit. On 01/31/2022 at 8:54 AM, Employee Identifier (EI) #41 accompanied the surveyor during the initial tour of the kitchen, which included the walk-in freezer. A box of frozen breaded fish was found sitting directly on the freezer floor. EI #41 stated that the food should not be on the floor and moved it onto a crate to get it off the floor. On 02/04/2022 at 11:13 AM, during a return visit to the kitchen, the surveyor found a box of thawed and refrozen ice cream on the floor of the walk-in freezer. A box of biscuits that had burst open was found on the freezer floor. An unopened box of Mighty Shakes (supplements) and potatoes were also on the freezer floor. Two additional boxes of frozen foods were noted to be stacked on top of the frozen supplements. EI #42, Dietary Cook, took the box of biscuits and ice cream to the outside dumpster. EI #42 stated that those items should not have been on the floor. 3) A review of the policy dated (revised) 09/2017, titled, Food: Preparation, began with, .All staff will practice proper hand washing techniques and glove use . On 02/04/2022 at 10:40 AM, the surveyor found that the only handwashing sink in the kitchen contained no soap in the soap dispenser. EI #42 was unaware that it was empty and contacted housekeeping to replace the soap in the dispenser. Employee Identifier (EI) #43, a Certified Dietary Manager from a sister facility, stated that the soap dispenser should never be empty. 4) A review of the facility policy titled, Food Storage: Dry Goods, revised 09/2017, stated that .All packaged and canned food items will be kept clean, dry and properly sealed . It also stated that it would be .date marked as appropriate . On 02/04/2022 at 12:43 PM, a plastic bag containing dry cereal was observed in the dry storage area with no label to indicate open date or use-by date, and the plastic bag was open. EI #42 stated that the bag should have been closed and labeled. 5) The surveyor noted on 02/04/2022 at 12:43 PM that there was dry cereal on three of the shelves and also on the floor in various areas of the dry storage room. EI #43 stated on 02/04/2022 at 1:20 PM that food should not be on the floor because it could attract rodents and pests. 6) On 02/04/2022 at 1:09 PM, the surveyor asked EI #42 to check the concentration of the chemicals in the sanitizing bucket in the food preparation area and at the three-compartment sink. The bucket under the food prep table was found to be at 150 parts per million (ppm), and EI #42 stated it should be at least 200 ppm. 7) A review of the policy titled, Warewashing, which had been revised on 09/2017, stated that the .Dining Staff will be knowledgeable in the proper technique for processing dirty dishware through the dish machine and proper handling of sanitized dishware . On 02/04/2022 at 1:38 PM, Employee Identifier (EI) #44, Dietary Aide, washed their hands and donned gloves to begin washing dishes. EI #44 stated that usually it was their responsibility to empty the dirty trays but that day they would be filling the empty trays with dirty dishes and running them through the dishwasher. EI #44 took one of the trays and filled it with dirty cups from lunch. When it was full, EI #44 pulled it into the dishwasher and started the cycle and then started filling the next tray with dirty dishes. When the first load was washed and rinsed, EI #44 opened the dishwasher and pulled the clean tray of dishes with their dirty (gloved) left hand. EI #44 then continued placing dirty dishes in the next tray to be washed. When that tray was full, EI #44 pulled it into the dishwasher and pulled the handle down to begin the wash cycle. After the dishwasher had completed the two trays of dishes, the surveyor asked EI #44 about using the dirty gloved hand to remove the clean tray of dishes. EI #44 stated that it was not their usual job to fill the dishwasher, but to empty dirty dishes as they were returned from the residents. EI #43, the certified Dietary Manager from a sister facility, stated that staff needed to keep clean dishes clean and not touch them with dirty hands, or gloved hands, because the gloves are dirty. 8) During an observation on 02/04/2022 at 1:38 PM, as EI #44 and EI #43 were washing dishes with the dishwasher, the surveyor asked EI #44 how often the dishwasher sanitizing solution was checked, and EI # 44 promptly answered during each meal. When asked if it could be checked at that time, EI #44 asked EI #43 to test with the strips. EI #43 came over to the dishwasher to retrieve the strips and then tried to test in the water below the rack when the lid was open and the strip did not change colors. So EI #43 tried another strip on the dishes which had just been washed and were still wet, and there was no change in color. EI #43 then told the surveyor that the machine was different than the one at the facility where EI #43 usually worked. EI #43 then made a telephone call to EI #41 and found that the correct place to check the water was below where the water was released from the dishwasher. After checking a strip in that location, there was still no change in the color of the strip. EI #43 moved the chemical buckets under the dishwasher and found that the bucket containing the sanitizing agent was empty.

Based on observations, interviews, review of facility policies titled, Management of the Laundry, Interim Recommendations for Routine & Terminal COVID-19 Isolation Room/Unit Cleaning, and review of the facility's Maintenance Repair Logs, the facility failed to ensure a safe, clean, comfortable, homelike environment for residents in the facility. Specifically, the facility failed to ensure: 1. housekeeping services were provided to prevent soiled floors, a soiled over bed table, and/or soiled resident care equipment in Resident Identifier (RI) #80's room; 2. sufficient linens, including bath towels and washcloths, were available for resident care on Units D, E, F, and G; 3. Unit F and Unit G did not have general maintenance items which had not been identified or addressed for repair, which included a torn shower seat, exposed sharp metal edges in a shower room, exposed wires in residents' rooms, overhead lighting in poor repair, missing air conditioner grill covers, and a broken window; and 4. RI #43, RI #61, and RI #70's rooms were maintained at comfortable temperatures. These deficiencies were observed on Units D, E, F, and G, four of six units in the facility utilized as residential areas. Findings included: 1. A review of a facility policy titled Interim Recommendations for Routine & Terminal COVID-19 Isolation Room/Unit Cleaning, dated 02/18/2021 and provided in response to a request for a housekeeping policy, revealed no guidance regarding the general cleaning of nursing units or resident rooms. An observation conducted in RI #80's room on 01/31/2022 at 4:25 PM with Employee Identifier (EI) #19, Registered Nurse (RN), revealed dried tube-feeding formula stains on the floor, the legs of an overbed table, and the legs of the tube feeding pump's pole. The room also had black buildup of grime and dirt along the baseboards in the room. An interview with EI #19 at that time revealed housekeeping only dumped the trash and cleaned handrails, but conducted no deep cleaning of the floors or other items. Per EI #19, the floors on the F Unit (Dementia Unit) had been dirty for months. During an interview on 02/01/2022 at 3:55 PM with EI #49, RN, the nurse stated housekeeping was not cleaning the unit. EI #49 commented that she heard the dayshift housekeeper was lazy and that RI #80's room was always dirty with tube feeding formula dried on the floor. On 02/04/2022 at 10:15 AM, an interview was conducted with EI #56, Housekeeper. EI #56 stated her daily housekeeping role was to sweep/mop the floors, dump trash, wipe down bedside tables and nightstands, and clean the shower rooms after nurse aides completed showers for the day. The surveyor took EI #56 to Room RI #80's room and showed EI #56 the tube-feeding stains that were on the floor, on the over-bed table, and on the tube-feeding pump pole, as well as the black grime along the baseboards since at least 01/31/2022. EI #56 stated housekeepers were not responsible for cleaning tube-feeding poles, noting that was nursing's responsibility. EI #56 stated she had cleaned the floor in the room. EI #56 had no explanation regarding why the floor contained the same stains and dirt if mopped daily. On 02/04/2022 at 10:35 AM, an interview and tour of Unit F was conducted with EI #37, Housekeeping and Laundry Director. EI #37 was shown the soiled floor, overbed table, and tube-feeding pole in RI #80's room. EI #37 stated it was nursing's responsibility to clean resident care equipment such as the tube-feeding pole. Per EI #37, the floors, overbed tables, and furniture such as nightstands were the responsibility of the housekeeping department. On 02/06/2022 at 10:15 AM, an interview was conducted with EI #2, Director of Nursing, regarding housekeeping concerns. EI #2 stated that restorative nursing staff was responsible for cleaning resident care equipment such as tube-feeding poles, scales, and Hoyer lifts. 2. A review of the facility policy titled Management of the Laundry, revised in January of 2016, revealed, .Stage 1: ESTABLISHING LINEN PARS A linen par is the amount of linen needed to satisfy the daily needs of each and every resident . The RULE OF THUMB is that linen pars should be a minimum of 3 times your total linen inventory, 8 times your total inventory for wash cloths. Facilities will be in danger of receiving an F-tag [a federal tag corresponding to a specific regulation with the Code of Federal Regulations] if linen pars are not maintained at this minimum . During an interview with Employee Identifier (EI) #17, Certified Nursing Assistant (CNA), on 01/31/2022 at 6:00 PM, EI #17 stated they had insufficient linens on Unit F almost every day. At 6:20 PM, EI #17 stated and showed the surveyor that there was only one bath towel on the unit, no washcloths, and two pillowcases. Observation of the linen cart and linen room revealed no further towels were available for use. Further interview with EI #17 revealed the unit was frequently short of linens. On 01/31/2022 at 6:15 PM, EI #19, Registered Nurse (RN), confirmed there were not enough towels or washcloths for aides to clean the residents. EI #19 also stated there were never enough linens, particularly bath towels, when she worked over multiple times/shifts. On 01/31/2022 at 6:20 PM, observation of Unit F revealed there were 28 residents on the unit but only one bath towel and a few washcloths available for resident care. On 01/31/2022 at 6:25 PM, observation of Unit G revealed there were five bath towels and two washcloths available for eight residents on the unit. On 01/31/2022 at 6:40 PM, observation of a shared linen closet and carts on Unit E for use on Unit D and Unit E revealed there were 14 bath towels and 12 washcloths for the two units. An interview with EI #51, CNA, revealed there were often not enough linens on the unit. EI #51 stated staff made do with what they had, but she had to go to other units on multiple occasions to round up linens to clean incontinent residents. On 02/01/2022 at 7:48 AM, observations conducted of linen carts/rooms revealed: - The shared linen closet for Units D and E had no washcloths and one towel, for approximately 37 residents as indicated by the facility's census listing. -Unit D linen cart had seven towels and four washcloths -Unit E linen cart had no towels or washcloths -Unit G linen closet had six towels and five washcloths, for approximately eight residents as indicated by the facility's census listing. On 02/01/2022 at 7:57 AM, observations were made of Unit F's linen supply. Unit F was observed to have 10 towels and 11 washcloths, for approximately 28 residents as indicated by the facility's census listing. On 02/04/2022 at 10:45 AM, a tour was conducted with EI #37, Housekeeping and Laundry Director, to observe the number of linens available on Units D, E, F, and G. The following was observed: - Unit F had 11 bath towels. - Unit G had three bath towels. - Unit D and Unit E had eight bath towels. An interview with EI #37, conducted at the time of the above observations, revealed he did not believe there were sufficient linens for the number of residents on the units. EI #37 reported having 200 spare towels in a linen closet on the COVID-19 Unit. On 02/04/2022 at 11:42 AM, observation of the spare linen closet revealed there were not 200 towels but only 60 towels available. On 02/28/2022 at 12:20 PM, EI #2, the Director of Nursing, stated she would expect staff to report concerns with linens to unit managers, who were to then follow the appropriate chain of command of notification. EI #2 further stated it was discovered that staff and/or residents had been hoarding linens in resident rooms which resulted in an insufficient linen supply. On 02/28/2022 at 10:15 AM, Resident Identifier (RI) #48 and RI #58 were interviewed about the supply of linens/towels. Both residents stated prior to the survey, there had been issues with not having enough linens. RI #48 said there were a few times the resident had to wait a short time, defined by RI #48 as later in the day, to take a shower when there were no towels on the unit. On 02/28/2022 at 11:38 AM, RI #57 stated they did not have towels half the time. RI #57 said the last time he/she took a shower there was only one towel. Per RI #57, the carts did not have linens on them. On 02/06/2022 at 12:00 PM, an interview was conducted with EI #1, Administrator. EI #1 reported he was aware of concerns with insufficient linens and said one of the issues was that the nursing staff were not taking the dirty linens back to the laundry room timely so they could be washed and sent back to the unit. On 02/28/2022 at 11:55 AM, EI #1 stated the concerns with the linens should have been reported to EI #37. EI #1 stated room rounds were recently completed and it was found that staff and residents had been hoarding linens in resident rooms. EI #1 noted linens were available but they were hidden and not in circulation. 3. Random observations of Unit G and Unit F between 01/31/2022 and 02/05/2022 revealed maintenance items which had not been addressed. On 02/05/2022 at 11:15 AM, a tour of Unit G and Unit F was conducted with Employee Identifier (EI) #4, Maintenance Director, and EI #14, Corporate Environmental Life Safety Administrator, which revealed the following: - The Unit G shower room contained a resident shower chair that had a torn plastic seat exposing the upholstery. EI #4 expressed he was unaware the chair required repair. EI #14 stated he planned to order a new seat cover for the shower chair. - The Unit F and Unit G shower room's metal doorway baseboard was rusted with sharp edges. EI #14 stated the doorway would be fixed either by replacing some of the metal or filing down the metal and repainting it. - The Unit F shower room water knobs were not flush and exposed sharp tile edges. EI #14 stated the knobs needed percussion caps applied to make them safer. The shower head was loose from inside of the wall. EI #14 stated the shower fixture needed to be redone and mounted in the wall. - Rooms F16 and F9 had old phone jack wires hanging from the wall. The plastic jack boxes were broken, and wires were hanging from outside of the boxes. EI #14 stated the boxes were no longer in use and they all should be removed. - In Room F17 on the A side of the room, an overbed light was not working, was tilted, and was pulling away from the wall. EI #14 stated it needed to be repaired and mounted securely to the wall. - Rooms F9 and F10 had heat/air conditioning units that had missing grill covers. EI #14 stated the grill covers needed to be replaced. - Room F8 had a broken window that was covered with what appeared to be medical tape. EI #14 stated it appeared the window was broken by a rock when mowing occurred, but was not repaired. EI #14 stated the window needed to be replaced. During this tour, EI #4, the Maintenance Director, indicated he had no rounding tool or checklist to use to monitor for items needing repairs. On 02/06/2022 at 12:00 PM, EI #1, Administrator, stated the building was old and needed many repairs and it was a lot for just one maintenance person. Per EI #1, administration was working with corporate staff for the needed repairs. 4. On 02/02/2022 at 9:34 AM, while in RI #43's room for medication pass observation, the surveyor noted the room was very cold. RI #43 stated his/her heat was not working but, per the resident, maintenance staff was supposed to be working on it. On 02/05/2022 at 10:15 AM, while in RI #43's room, the surveyor noted the interior of the room was still cold. An interview with RI #43 at that time revealed the room's heat had not worked all winter long. Per RI #43, maintenance staff was aware of the heating issues in the room because they had been in the room/bathroom attempting to fix it. The resident was noted to be under five blankets at the time. A review of Maintenance Repair Logs for October 2021 through February 2022 revealed the following entries regarding room temperatures: - On 11/03/2021, it was documented RI #43 indicated heat only made room colder. No documentation on the log revealed the repair was completed. - On 12/19/2021, it was documented RI #43 indicated the heater vent was blowing cold air in his/her room. No documentation on the log revealed the repair was completed. - On 02/04/2022, it was documented RI #43 reported that his/her heat was not working. There was no documentation on the log indicating the repair had been completed. On 02/05/2022 at 11:25 AM, an interview was conducted with EI #4, Maintenance Director, regarding room temperatures. EI #4 stated he was not monitoring resident room temperatures and there were no logs to track room temperatures. EI #4 was not aware of a policy or any regulatory requirement for maintaining room temperatures in a particular temperature range. EI #4 admitted the facility had no way to check room temperatures, since the facility had no thermometers to do so. Initially EI #4 stated he was not aware of heating issues in resident rooms. However, further interview revealed EI #4 was aware the boiler system that provided heat to Units A, D, E, and parts of C and F had not been working correctly, which affected the room temperatures. EI #4 stated when the facility had the boiler issue, there were complaints regarding low temperatures. On 02/05/2022 at 11:30 AM, EI #4 accompanied the surveyor to the office of EI #1, Administrator, where EI #15, Owner, and EI #14, Corporate Environmental Life Safety Administrator, were also present. EI #1 stated that the facility had not been checking the temperature of the rooms, had not kept temperature logs, and had no current way of checking accurate temperatures in residents' rooms due to not having a thermometer capable of that. EI #1 was asked if the facility had a room temperature policy or range in which the room temperatures were to be kept. EI #1 stated it was dependent upon each resident's preference. On 02/05/2022 at 1:32 PM, a group interview was conducted with EI #1, EI #14, and EI #15 regarding room temperatures. EI #14 explained that different parts of the facility had different heating sources, noting some rooms were heated via a boiler system, some rooms were heated by a central heating system, and yet other rooms were heated by PTAC (packaged terminal air conditioner; a type of self-contained heating and air conditioning system) located in some resident rooms. EI #1 was asked what the expectations were to address multiple entries in the maintenance log regarding resident room heat not working. EI #1 stated that maintenance should have been checking the maintenance log daily or three to four times a day, addressing the concerns, and signing off on the concerns after the items were fixed.

Based on observations, interviews, record reviews, and review of the facility's policies titled, Gastric Tube Feeding via Continuous Pump and Administering Medications through an Enteral Tube, the facility failed to ensure Resident Identifier (RI) #80 and RI #67 received services and treatment to prevent complications. Specifically, the facility failed to ensure: 1. RI #80's head of the bed (HOB) was elevated to a level of 30-40 degrees while the tube feeding pump was running and the Registered Nurse (RN) checked RI #80's tube feeding residual before administering medications through the gastrostomy tube (G-tube) and did not use a syringe to force a medication through RI #80's G-tube that had become clogged. In addition, staff failed to clean RI #80's gastrostomy tubing daily with soap and water and put a clean gauze to the site daily as ordered by the physician; and 2. RI #67's HOB was elevated to a level of 30-40 degrees while the tube feeding pump was running. This deficient practice affected RI #80 and RI #67, two out of three sampled residents reviewed for G-tubes. Findings include: A review of the facility's policy titled, Gastric Tube Feeding via Continuous Pump, dated October 2010, revealed, .4. Always keep resident receiving continuous feedings in semi-fowlers (in semi-fowlers position, the patient/resident is usually on their back with the bed angle between 30 degrees and 45 degrees) or higher position . A review of the facility's policy titled, Administering Medications through an Enteral Tube, revised October 2010, revealed, 14. Assist the resident to semi or high-Fowler's position (30-40 [degrees sign]) if tolerated by the resident's physical or medical condition .21. Administer medication by gravity flow 1. A review of RI #80's Face Sheet revealed the facility admitted the resident on 05/14/2014 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #80's Care Plan, dated 08/10/2015, revealed the resident had an altered nutritional status, had a feeding tube, and was NPO (took nothing by mouth). A review of RI #80's February 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff were to clean the G-tube with soap and water and apply new gauze daily and as needed, per an order dated 05/26/2021. An observation of RI #80 on 01/31/2022 at 9:20 AM revealed the resident was lying in bed receiving continuous tube feeding. The head of bed (HOB) was measured to be only 16 degrees (utilizing the iGradient application). Another observation of RI #80 on 02/01/2022 at 1:10 PM revealed the resident lying in bed receiving continuous tube feeding with the HOB elevated to only eight degrees. Employee Identifier (EI) #20, Registered Nurse (RN), stated the resident's HOB should be 30 degrees or more. On 02/02/2022 at 8:10 AM, a medication pass observation was conducted with EI #20 for RI #80's morning medications. The resident's HOB was elevated to only 17 degrees. EI #20 prepared the medications and placed them on the bedside table. Prior to administering the medications, EI #20 turned the tube feeding off and checked for placement. EI #20 was not observed to check for tube feeding residual in the stomach. EI #20 was then observed to administer two open capsules of medications. EI #20 opened the capsules, which contained beads of medication. EI #20 administered the medication beads (mixed with water-the beads did not dissolve), down the G-tube, which clogged the G-tub. EI #20 was observed attempting to force the medication beads down the G-tube by firmly pushing the plunger of the syringe, instead of using gravity flow as directed by the facility policy. After the medication pass, the surveyor asked to observe the resident's G-tube stoma (a surgical opening into the stomach) area. It was found that the split 4 centimeter (cm) x 4 cm gauze that was supposed to be changed daily had not been changed and was dated 01/31/2022, two days prior. The gauze was half covered with a large amount of yellow-green, dried, crusty drainage. EI #20 stated night shift was responsible for changing the gauze out every night. On 02/22/2022 at 10:00 AM, an interview was conducted with EI #2, the Director of Nursing (DON), regarding RI #80's medication pass observations. EI #2 stated expectations included checking for residual and administering medications via gravity flow, not forced with a syringe. EI #2 stated that the split gauze should have been changed on the night shift. 2. A review of RI #67's Face Sheet revealed the facility admitted the resident on 12/22/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .). A review of RI #67's Care Plan, dated 12/22/2020, revealed the resident had an altered nutritional status, had a feeding tube (gastrostomy tube/G-tube), and was NPO (took nothing by mouth). A review of RI #67's February 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation of RI #67 on 02/01/2022 at 9:10 AM revealed the resident's tube feeding pump was running, but the HOB was not elevated. The HOB was measured to be only 25 degrees (using the iGradient application). The surveyor asked RI #67's nurse, EI #33, a Registered Nurse, what the resident's HOB should be elevated to. EI #33 was not sure what the facility's policy was but stated they would check and get back with the surveyor. On 02/01/2022 at 1:13 PM, EI #33 returned to the surveyor and stated they had found the tube feeding policy which revealed the resident's HOB should be kept at 30-45 degrees. EI #33 stated the nurse aides had probably not raised the resident's HOB high enough earlier. The surveyor and EI #33 then followed-up with EI #29, the Certified Nursing Assistant (CNA) assigned to RI #67. EI #29 was asked how high a resident's HOB should be when receiving tube feeding. EI #29 stated she knew it was supposed to be raised, but was not sure how much. On 02/03/2022 at 12:00 PM, an observation of RI #67 revealed the resident's HOB was only 18 degrees. The surveyor identified the CNAs caring for the resident at the time, EI #32 and EI #48. An interview with EI #32 and EI #48 revealed both knew RI #67's HOB should be elevated 30 degrees or more. However, when asked how they are able to tell if the bed is elevated enough, they indicated they just 'eye' it. They indicated some of the beds have a gauge under them to indicate the elevation of the HOB, but after looking at RI #67's bed, said it did not have a gauge. On 02/06/2022 at 10:15 AM, an interview with EI #2, Director of Nursing, revealed it was expected that the facility nursing staff follow the policy and procedure and ensure residents on tube feedings had their HOB elevated from 30 to 45 degrees to prevent aspiration.

Based on observations, interviews, record reviews, and review of facility policies titled, Administering Medication through an Enteral Tube, Administering Oral Medications, Insulin Administration, and review of the manufacturer's instructions for the [MEDICATION(S)] insulin pen, the facility failed to maintain a medication error rate less than 5%. There were seven errors in 29 opportunities, which resulted in a 24% medication error rate for Resident Identifier (RI) #43, RI #78, and RI #80, three of four residents observed during medication pass. Specifically, the facility failed to ensure: 1. RI #80, who received medications via gastrostomy tube (G-Tube), was given complete doses of Calcitriol, [MEDICATION(S)] and [MEDICATION(S)] as ordered by the physician. In addition, staff failed to dilute a liquid potassium chloride dose prior to administration; 2. RI #43 received a physician-ordered dose of D2 (vitamin) and did not receive the wrong dose of an [MEDICATION(S)] inhaler; and 3. RI #78 was not administered sliding scale insulin via an insulin pen, not in accordance with the manufacturer's instructions to ensure an accurate dose of insulin. These failures had the potential to affect RI #43, RI #78, and RI #80, three of four residents observed during medication administration. Findings included: A review of the facility's policy titled, Administering Medication through an Enteral Tube, dated October 2010, revealed, .The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube .1. Request liquid forms of medications from the pharmacy, if possible . A review of the facility's policy titled, Administering Oral Medications, dated October 2010, revealed, .The purpose of this procedure is to provide guidelines for the safe administration for oral medications .1. Verify that there is a physician's medication order for this procedure .8. Check the medication dose. Re-check to confirm the proper dose . 1. RI #80 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #80's February 2022 Physician Orders, revealed the resident had a G-Tube in which all of the resident's medications were ordered to be administered. Orders included the following: Calcitriol 0.25 mcg (micrograms) capsule via G-tube, [MEDICATION(S)] 60 mg (milligrams) capsule via G-tube, and [MEDICATION(S)] DR 20 mg capsule via G-tube. On 02/02/2022 at 8:10 AM, Employee Identifier (EI) #20, a Registered Nurse (RN), was observed during medication administration for RI #80 via G-tube. EI #20 was utilizing a 60-cc (cubic centimeter) syringe with gravity flow. EI #20 was observed to dispense a Calcitriol 0.25 mcg gel capsule by cutting the top off the capsule and squeezing the contents of the capsule into a medication cup to administer down the G-tube. The nurse was asked if anyone had asked the physician or pharmacist about an alternate medication that could more accurately and easily be administered via the G-tube. The nurse's response was they just administered the medication that was ordered by the doctor. It was noted that the nurse struggled to squeeze the gel capsule and get all the medication from the capsule. Thus, it was an inaccurate administration of the medication. EI #20 then dispensed potassium chloride liquid (20 milliequivalents/15 milliliters [ml]) 15 ml to administer to RI #80. On the outside of the bottle, it revealed the liquid should be diluted. A review of the prescription label on the bottle revealed it was to be diluted with 4 ounces of water. EI #20 was observed to begin pouring the potassium chloride down the resident's G-tube when the surveyor asked if it needed to be diluted, and EI #20 said no. EI #20 continued to pour the undiluted medication down the G-tube, meanwhile commenting, Honey, it's just like a pill. The nurse failed to follow the manufacturer's recommendation and prescription instructions to dilute the medication prior to administration. EI #20 was observed to open the [MEDICATION(S)] 60 mg capsule and the [MEDICATION(S)] DR 20 mg capsule. The inside of the capsules were medication beads. EI #20 mixed each opened capsule (beads) with a small amount of water, but they did not dissolve. The nurse administered the opened capsules (beads) and water down the G-tube. After administering the beads of [MEDICATION(S)] and [MEDICATION(S)], the G-tube was observed to become clogged. The medications and water flushes would not go down the tube via gravity flow. EI #20 then took the plunger of the syringe and tried to forcibly push the medication beads down the G-Tube. When doing so, the tip of the syringe dislodged from the G-tube port, and multiple beads of [MEDICATION(S)] and [MEDICATION(S)] sprayed all over the resident's abdomen and sheets. The resident did not receive the full doses of [MEDICATION(S)] and [MEDICATION(S)]. After the medication pass and reconciliation, a follow-up interview was conducted with EI #20 on 02/02/2022 at 9:55 AM. When asked if the physician had been notified that the resident did not receive the full doses of Calcitriol, [MEDICATION(S)], and [MEDICATION(S)], the nurse admitted to not calling the physician. On 02/02/2022 at 10:00 AM, EI #2, the Director of Nursing (DON), was notified of the medication concerns and errors observed during RI #80's medication pass. EI #2 stated all the medications should be appropriate to be administered down the G-tube and if not, the nurse should have called the physician. 2. A review of RI #43's Face Sheet, dated 02/04/2022, revealed the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 02/02/2022 at 9:34 AM, EI #24, RN, was observed during medication administration for RI #43's morning medications. The observation revealed the resident received an [MEDICATION(S)] HFA (the type of propellant in the inhaler) 90 mcg inhaler dose. EI #24 shook the inhaler and handed it to the resident, instructing the resident to take two puffs of the medication, which the resident completed. On 02/02/2022 at 10:15 AM, reconciliation of medication pass was completed with EI #24. A review of RI #43's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was also supposed to receive Vitamin D2 2000-unit tablet which was ordered by the physician on 01/05/2022, which was omitted. An interview with EI #24 at the time revealed the nurse did not realize the [MEDICATION(S)] inhaler was just one dose, and the nurse admitted mistakenly missing the Vitamin D2 dose. 3. A review of the facility's policy titled, Insulin Administration, dated October 2010, revealed generalized insulin administration instructions for nursing staff. The policy did not give specific guidance on how nursing staff were to utilize insulin pens. A review RI #78's Face Sheet, dated 02/04/2022, revealed the resident was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of RI #78's Physician Orders, dated 12/07/2021, revealed the resident was to have sliding scale [MEDICATION(S)] insulin twice a day dependent upon blood sugar glucometer readings. On 02/02/2022 at 5:20 PM, Employee Identifier (EI) #23, Licensed Practical Nurse, was observed to check the resident's blood sugar. The resident's blood sugar was 265. A review of the resident's Physician Orders, dated 12/07/2021, revealed the resident was to receive nine units of [MEDICATION(S)] insulin for a blood sugar of 251-300. The observation of the administration of the [MEDICATION(S)] insulin revealed EI #23 obtained the [MEDICATION(S)] insulin pen, dialed the pen to 9 units, administered the insulin into the resident's abdomen, and left the insulin pen needle in the abdomen for approximately 2-3 seconds before removing the needle. An interview with EI #23 at the time revealed the nurse did not believe the insulin pen needed to be air shot (air bubbles removed) prior to dialing the nine units. When asked about the time required to keep the needle in the skin, EI #23 stated that [MEDICATION(S)] pens only required a three-second hold time. On 02/02/2022 at 5:30 PM, reconciliation of medication was completed with a review of the [MEDICATION(S)] manufacturer's instructions for the insulin pen. It was found that the pen EI #23 used required a 2-unit air shot before each injection to ensure air in the syringe was expelled prior to administering the injection. The manufacturer's instructions further revealed that the nurse should have kept the needle in the skin for at least six seconds to ensure that the full dose has been given. On 02/02/2022 at 5:30 PM, an interview was conducted with EI #2, the Director of Nursing (DON), regarding the medication pass observation concerns and errors. EI #2 stated the [MEDICATION(S)] insulin pen required an air shot and a needle hold time.

Based on observations, interviews, and review of a facility policy titled, Storage of Medications, the facility failed to label and store medications in three of three medication carts and failed to ensure medications were secured in medications carts in accordance with acceptable principles. Specifically, staff failed to label medications upon opening with an open date and expiration date, and failed to ensure the G Unit medication cart did not contain loose pills inside the drawers. This was observed with opened medications belonging to 10 out of 89 residents in the facility. Findings include: A review of the facility's policy titled, Storage of Medications, dated April 2007, revealed: .The facility shall store all drugs and biologicals in a safe, secure, and orderly manner The nursing staff shall be responsible for maintaining medication storage AND preparation areas in a clean, safe, and sanitary manner .The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals .Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use .Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems . On 02/02/2022 at 11:20 AM, medication storage observation was conducted on the D Unit medication cart, accompanied by Employee Identifier (EI) #24, Registered Nurse (RN). The medication cart was found to contain the following: -RI #14's [MEDICATION(S)] insulin vial was opened and not dated, only good 28 days after opening. -RI #15 had two [MEDICATION(S)] insulin vials opened and not dated, only good 28 days after opening. -RI #15 had a [MEDICATION(S)] insulin pen opened and not dated, only good 28 days after opening. -RI #79 had a [MEDICATION(S)] insulin pen opened and not dated, only good 28 days after opening. -RI #48 had a [MEDICATION(S)] insulin pen opened and not dated, only good 28 days after opening. -RI #20 had a [MEDICATION(S)] insulin pen opened and not dated, only good 28 days after opening. -RI #24 had a Breo inhaler opened and not dated, only good for 28 days after opening. -RI #4 had [MEDICATION(S)] [MEDICATION(S)] nebulizer ampules with foil packaging opened and not dated, only good for two weeks after opening. An interview with EI #24 revealed the nurse was not aware that the ampules had a limited shelf life after the foil package was opened. On 02/02/2022 at 1:25 PM, medication storage observation was conducted on the E Unit medication cart, accompanied by EI #33, RN. The medication cart was found to contain the following: -RI #22 had a [MEDICATION(S)] insulin pen and a [MEDICATION(S)] vial, both opened and undated, good for 28 days after opening. -RI #21 had a [MEDICATION(S)] insulin pen opened and not dated, good for 42 days after opening. -RI #78 had a [MEDICATION(S)] vial opened and undated, good for 28 days after opening. On 02/02/2022 at 1:35 PM, medication storage observation was conducted on the G Unit medication cart, accompanied by EI #33. The medication cart was found to contain the following: -The drawers of the medication cart had multiple loose white tablets. EI #33 was unsure what the medication was or how it had gotten dumped into the drawers of the medication cart. -There was a bottle of Prostat protein supplement which had been opened and not dated, only good for three months after opening. EI #33 did not realize the bottle needed to be dated or that it had a limited shelf life after being opened. On 02/02/2022 at 1:53 PM, an interview was conducted with EI #2, the Director of Nursing (DON). Per EI #2, all insulins should be dated when opened EI #2 further stated that pharmacy staff would come out and audit medication carts for any concerns needing to be addressed, but EI #2 could not recall how often or when they were last audited.

Based on record review, interviews, and review of facility policies titled, Care of Fingernails/Toenails, and Shaving the Resident, the facility failed to ensure activities of daily living (ADL) care tasks related to nail care and shaving were provided for Resident Identifier (RI) #67. This deficient practice affected RI #67, one of three residents sampled for ADL care. Findings include: A review of the facility policy titled, Care of Fingernails/Toenails, last revised in October of 2010, revealed, .The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections .General Guidelines 1. Nail care includes daily cleaning and regular trimming .Documentation .The following information should be recorded in the resident's medical record: 1. The date and time that nail care was given. 2. The name and title of the individual(s) who administered the nail care . A review of the facility policy titled, Shaving the Resident, last revised in October of 2010, revealed, .The purpose of this procedure is to promote cleanliness and to provide skin care .Documentation .The following information should be recorded in the resident's medical record: 1. The date and time that the procedure was performed. 2. The name and title of the individual(s) who performed the procedure. RI #67 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #67's quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had severe cognitive impairment according to the Staff Assessment for Mental Status, was not ambulatory, and was totally dependent on staff for personal hygiene needs. A review of RI #67's Care Plan, with a problem onset date of 12/22/2020, revealed the resident was at risk for self-care deficits and needed assistance with ADLs. Per the care plan, the resident was to receive assistance with bathing and grooming by the certified nursing assistants. On 01/31/2022 at 10:54 AM, observation of RI #67 revealed the resident was unshaven (appearing to be multiple days' growth) with long fingernails and brown substances noted under multiple fingernails. On 02/01/2022 at 4:30 PM, an interview was conducted with RI #67's Certified Nurse Aide (CNA)/Restorative Aide, Employee Identifier (EI) #36. EI #36 showed the surveyor a shower book and reported the resident was on the shower schedule for Mondays, Wednesdays, and Fridays during the day shift. EI #36 was unsure the last time the resident received a bath or shower as no such care encounter was documented in the shower book. On 02/03/2022 at 9:24 AM, observation of RI #67 revealed the resident was lying in bed. RI #67 continued to be unshaven with long fingernails with a brown substance underneath multiple fingernails. An interview was conducted on 02/03/2022 at 12:15 PM with EI #21, Registered Nurse (RN)/Unit Manager. EI #21 stated every bath schedule was in a book. EI #21 checked a shower book, which revealed RI #67 was to receive showers every Monday, Wednesday, and Friday. EI #21 reviewed the shower book but was unable to find documented entries or initials of staff to indicate they had completed the resident's bath. EI #21 then checked with EI #3, Regional Nurse, and inquired where aides charted baths in the computer system. EI #21 found computer documentation showing staff documented the completion of baths for RI #67 on 01/31/2022, 02/01/2022, and 02/02/2022. However, EI #21 confirmed via observation with the surveyor at that time that RI #67 was unshaven and had long nails with brown substances underneath them, despite documentation in the computer denoting that bathing had occurred over the prior three days. On 02/06/2022 at 10:15 AM, an interview was conducted with EI #2, Director of Nursing. EI #2 stated each resident's shower schedule should be followed by staff and include all ADL tasks, including shaving, nail care, and bathing. Per EI #2, ADL care should also be provided as needed if a resident was dirty.

Based on observation, interviews, and record review, the facility failed to ensure Resident Identifier (RI) #139 received [MEDICATION(S)] ([MEDICATION(S)]) as ordered, due to not having the medication available for administration. This failure affected one out of five sampled residents reviewed for pain management. Findings include: RI #139 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #139's Care Plan, dated 01/20/2022, revealed the resident was at risk for pain related to a recent hospitalization , generalized weakness, and recent hip fracture. To control the resident's pain level, staff were to assess the resident's pain level and provide medications as ordered by the physician. A review of RI #139's admission Minimum Data Set (MDS) assessment, dated 01/27/2022, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which revealed intact cognition. This assessment also indicated RI #139 reported having pain frequently at a pain level of 4 out of 10. A review of RI #139's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation conducted on 02/03/2022 at 2:45 PM revealed RI #139 sitting in the hallway by the medication cart. RI #139 reported to the surveyor he/she had not received their [MEDICATION(S)] medication in days. On 02/03/2022 at 3:00 PM, a review of RI #139's Medication Administration Record (MAR) was conducted with the resident's Registered Nurse, Employee Identifier (EI) #33. The resident was scheduled to receive [MEDICATION(S)] 300 mg at 9:00 AM and 5:00 PM. It was found that the resident's [MEDICATION(S)] 300 mg dose had been missed for the following days: - On 02/01/2022, the 9:00 AM dose was documented on the MAR as given by EI #33, but the nurse admitted documenting giving it in error because the medication was not available. The 5:00 PM dose was documented N, which indicated the medication was not given. - On 02/02/2022, the 9:00 AM dose was documented on the MAR as given by EI #33, but the nurse admitted documenting giving it in error because the medication was not available. The 5:00 PM dose was documented N, which indicated the medication was not given. - On 02/03/2022, the 9:00 AM dose was documented on the MAR as given by EI #33, but the nurse admitted documenting giving it in error because the medication was not available. Further interview with EI #33 on 02/03/2022 at 3:00 PM revealed the resident's [MEDICATION(S)] was not available. EI #33 was asked if the facility had an emergency kit (E-kit) for medication availability. EI #33 knew about an E-kit in the medication room, but said it was for regular medications and not narcotics or scheduled drugs. On 02/03/2022 at 3:15 PM, an interview was conducted with EI #2, Director of Nursing (DON), and EI #11, Infection Preventionist/Staff Development, about a narcotic E-kit. EI #1 and EI #11 both stated the facility did have a narcotic/controlled substance E-kit, and it was kept on EI #33's mediation cart. EI #11 went to the unit and showed EI #33 that the narcotic E-kit had been on the nurse's medication cart locked in the narcotic drawer the entire day, which contained [MEDICATION(S)] 300 mg capsules available to administer to the resident. EI #11 confirmed that none of the [MEDICATION(S)] medication was taken out of the E-kit to administer to the resident. On 02/04/2022 at 6:33 PM, a telephone interview was conducted with EI #47, Consultant Pharmacist. EI #47 stated the pharmacy provided narcotic and routine medication E-kits for the facility to ensure they had medications on hand. EI #47 stated that [MEDICATION(S)] was a medication that was typically in the E-kit and available to give if the prescription refill was delayed. Per EI #47, all staff had to do was call the pharmacy, notify them they were removing the medication from the E-kit, get a code, open the box, retrieve the medication, and administer it to the resident. Per EI #47, the pharmacy monitored the removal of medication from the E-Kits and restocked/refilled the E-kits as supplies depleted.

Based on observation, interview, record review, and review of a facility policy titled, End-Stage [CONDITION(S)], Care of a Resident with, the facility failed to ensure Resident Identifier (RI) #140 received care and services related to [CONDITION(S)] that were consistent with professional standards. This deficient practice affected RI #140, one of two residents sampled for [CONDITION(S)] care and services. Findings included: On 02/01/2022, a copy of the facility's [CONDITION(S)] policy was requested. The nursing department provided the facility's policy, titled, End-Stage [CONDITION(S)], Care of a Resident with, dated September 2010. The policy did not specifically indicate how the facility was to provide care and services to residents receiving [CONDITION(S)]. The policy only mentioned, The resident's comprehensive care plan will reflect the resident's needs related to [CONDITION(S)] [end-stage [CONDITION(S)]]/[CONDITION(S)] care. A review of RI #140's Face Sheet, dated 02/04/2022, revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of RI #140 on 01/31/2022 at 9:10 AM revealed the resident was sitting in bed with their shirt off. The resident had what appeared to be a central catheter (intravenous port) in their right upper chest. The catheter was covered with a 4 centimeter (cm) x 4 cm gauze which was partially covered in dry blood. The gauze was not dated. Observation of RI #140 on 02/01/2022 at 8:55 AM revealed the resident was sitting in bed without wearing a shirt. The central catheter in the right upper chest was still covered by the undated 4 cm x 4 cm gauze that had the same dried blood stain as the day before. On 02/01/2022 at 11:07 AM, a review of RI #140's clinical record revealed no physician's order for a central catheter. A review of RI #140's care plan revealed it made no mention of the central catheter or the care and services needed for the catheter. On 02/01/2022 at 1:15 PM, an interview was conducted with RI #140's nurse, Employee Identifier (EI) #33, Registered Nurse (RN). EI #33 was asked about the resident's central catheter. EI #33 stated the resident was a [CONDITION(S)] resident, and the catheter was used for [CONDITION(S)]. Per EI #33, the resident went to [CONDITION(S)] every Tuesday, Thursday, and Saturday. EI #33 did not know what type of central line the resident had, nor did the nurse know what type of care the catheter required. EI #33 reviewed the resident's clinical record and was unable to find a physician's order for [CONDITION(S)], for the central catheter (permacath; tunneled hemodialysis catheter), or for permacath care. On 02/01/2022 at 1:34 PM, an interview was conducted with EI #2, Director of Nursing. EI #2 reported the resident was receiving [CONDITION(S)] but was not sure what type of central line the resident had. In a follow up interview on 02/01/2022 at 1:44 PM, EI #2 stated the resident had a permacath for [CONDITION(S)]. EI #2 was in the process of getting orders for [CONDITION(S)] and developing a care plan. On 02/01/2022 at 4:10 PM, an interview was conducted with EI #3, Regional Nurse. EI #3 was asked about expectations when a resident needing [CONDITION(S)] was admitted to the facility. EI #3 stated the expectation was for RI #140 to be assessed from head to toe when admitted , which would have led to identification of the permacath. A care plan should have been developed within 48 hours. EI #3 noted that orders should have been obtained for the permacath care and [CONDITION(S)]. Per EI #3, EI #2 called the [CONDITION(S)] center and they told her the facility would need to have an order to change the dressing if it was soiled between [CONDITION(S)] days. On 02/01/2022 at 4:20 PM, another interview was conducted with EI #2. EI #2 stated when RI #140 was admitted , part of the admission paperwork was completed by EI #2 and part of the paperwork was completed by EI #35, RN. Since the admission was split between the two nurses, obtaining orders for [CONDITION(S)], the permacath, and developing a care plan for [CONDITION(S)] care was missed.

Based on observation, interview, and record review, the facility failed to ensure medications were available for administration as ordered by the physician for Resident Identifier (RI) #139, one of five sampled residents reviewed for medication availability. Findings include: RI #139 was admitted to the facility on [DATE] with diagnoses of Anxiety Disorder, Chronic Migraine, and Fracture of the Medial Wall of Right Acetabulum (pelvis). A review of RI #139's admission Minimum Data Set (MDS) assessment, dated 01/27/2022, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which revealed intact cognition. A review of RI #139's Physician's Orders, dated 01/22/2022, revealed orders for [MEDICATION(S)] 300 mg (milligrams) twice a day for pain. There was also an order dated 01/31/2022, for [MEDICATION(S)] 0.25 (anti-anxiety medication) milligrams (mg) one tablet twice a day as needed for anxiety due to Anxiety Disorder. An observation conducted on 02/03/2022 at 2:45 PM revealed RI #139 sitting in the hallway by the medication cart. RI #139 reported to the surveyor he/she had not received their [MEDICATION(S)] medication in days. At this time, RI #139 also stated facility staff had informed them earlier that morning that their [MEDICATION(S)] medication was not available. On 02/03/2022 at 3:00 PM, a review of RI #139's Medication Administration Record (MAR) was conducted with the resident's Registered Nurse, Employee Identifier (EI) #33. The resident was scheduled to receive [MEDICATION(S)] 300 mg at 9:00 AM and 5:00 PM. It was found that the resident's [MEDICATION(S)] 300 mg dose had been missed for the following days: - On 02/01/2022, the 9:00 AM dose was documented on the MAR as given by EI #33, but the nurse admitted documenting giving it in error because the medication was not available. The 5:00 PM dose was documented N, which indicated the medication was not given. - On 02/02/2022, the 9:00 AM dose was documented on the MAR as given by EI #33, but the nurse admitted documenting giving it in error because the medication was not available. The 5:00 PM dose was documented N, which indicated the medication was not given. - On 02/03/2022, the 9:00 AM dose was documented on the MAR as given by EI #33, but the nurse admitted documenting giving it in error because the medication was not available. Further review of RI #139's MAR revealed the last doses of [MEDICATION(S)] had been administered on 02/01/2022 and 02/02/2022. Further interview with EI #33 on 02/03/2022 at 3:00 PM revealed the resident's [MEDICATION(S)] and [MEDICATION(S)] were not available. EI #33 was asked if the facility had an emergency kit (E-kit) for medication availability. EI #33 knew about an E-kit in the medication room, but said it was for regular medications and not narcotics or scheduled drugs. Review of RI #139's Controlled Drug Record (a separate record for signing out narcotics and listing current counts) for the [MEDICATION(S)] revealed the facility received 14 tablets of RI #139's [MEDICATION(S)] on 01/24/2022, with the last one signed out as given on 02/02/2022. Review of RI #139's :Controlled Drug Record for the [MEDICATION(S)] revealed the facility had received 14 capsules of RI #139's [MEDICATION(S)] from the pharmacy on 01/24/2022, with the last capsule signed out on 01/31/2022, leaving no further doses available until the pharmacy delivered it again. This record also indicated RI #139 had 46 capsules remaining on their prescription. Per the Controlled Drug Record for the next [MEDICATION(S)] delivery, the facility did not have RI #139's [MEDICATION(S)] available to give until later in the day on 02/03/2022. On 02/03/2022 at 3:15 PM, an interview was conducted with EI #2, Director of Nursing (DON), and EI #11, Infection Preventionist/Staff Development. EI #1 and EI #11 both stated the facility did have a narcotic/controlled substance E-kit, and it was kept on EI #33's mediation cart. EI #11 went to the unit and showed EI #33 that the narcotic E-kit had been on the nurse's medication cart locked in the narcotic drawer the entire day, which contained [MEDICATION(S)] 300 mg capsules and [MEDICATION(S)] 0.25 mg tablets available to administer to the resident. EI #11 confirmed that none of the [MEDICATION(S)] medication was taken out of the E-kit to administer to the resident. EI #11 also confirmed that no [MEDICATION(S)] had been removed from the E-kit for the resident since 01/21/2022. On 02/04/2022 at 6:33 PM, a telephone interview was conducted with EI #47, Consultant Pharmacist. EI #47 stated the pharmacy provided narcotic and routine medication E-kits for the facility to ensure they had medications on hand. EI #47 stated that [MEDICATION(S)] was a medication that was typically in the E-kit and available to give if the prescription refill was delayed for any reason. Per EI #47, all staff had to do was call the pharmacy, notify them they were removing the medication from the E-kit, get a code, open the box, retrieve the medication, and administer it to the resident. Per EI #47, the pharmacy monitored the removal of medication from the E-Kits and restocked/refilled the E-kits as supplies depleted.

Based on observations, record review, and staff interviews, the facility failed to screen one (1) of one (1) visitor, who entered the facility and had potential access to 57 of 57 residents . The failure occurred during a COVID-19 pandemic. The findings include: During an observation on 07/20/2020 at 1:15 p.m., the Social Worker (SW) allowed visitor access into the building, and no screening was completed. The visitor met with staff, and had access to all resident care areas. During an interview on 07/20/2020 at 1:49 p.m., the SW stated, she forgot to complete the screening of the visitor. The Regional Nurse Consultant stated, she expected screening to be completed, immediately upon entry into the facility. Review of facility records provided by the facility, revealed, there were 54 residents confirmed positive for COVID-19, and three (3) residents laboratory results pending. Review of the facility protocol entitled, COVID-19: Screening Checklist - for Visitors and Staff, revealed, several screening questions were to be completed by the screener. The form also was to be signed and dated by the visitor or staff, as part of the screening process.

Based on interviews, review of Resident Identifier (RI) #58's medical record, the facility's policy titled Notification of Changes and a complaint received by the Alabama State Survey Agency, the facility's licensed nursing staff failed to notify RI #58's physician, responsible party and the facility's Administrative staff of the actual events that took place when RI #58 was found deceased in the facility on [DATE]. The licensed nursing staff was aware that RI #58 had received a Regular diet that consisted of a chicken sandwich instead of a Pureed diet, which was ordered for the resident. When the Certified Nursing Assistant (CNA), Employee Identifier (EI) #5, went to pick up RI #58's meal tray at 5:45 PM, the CNA found RI #58 sitting straight up in the bed, with his/her head tilted to the left side of the pillow, with his/her eyes partially opened and mouth wide open with drool going down the mouth. EI #5 stated she also noticed the resident had blue and white discoloration to the face and lips. RI #58 was unresponsive. Instead of notifying RI #58's physician, the resident's responsible party and the Administrative staff that RI #58 had received the wrong diet order/meal tray for the supper meal, the licensed nursing staff informed RI #58's physician and responsible party that the resident had eaten supper, wanted to go bed, the staff assisted the resident to bed and upon returning to check on RI #58, the staff found the resident deceased . RI #58's physician stated it would have been beneficial to know what actually occurred because being given a chicken sandwich instead of the Pureed diet could have caused RI #58 to choke and could have contributed to the resident's death. This deficient practice placed RI #58, one of four sampled residents reviewed for therapeutic diets, in immediate jeopardy for serious injury, harm, impairment or death. On [DATE] at 3:55 PM, the Administrator, Director of Nursing (DON) and Corporate Nurse were notified of the finding of immediate jeopardy in the area of Resident Rights/Notify of Changes, F 580 and given a copy of the Immediate Jeopardy (IJ) template. Findings include: The facility's undated policy titled Notification of Changes documented Policy The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notify, consistent with his or her authority, resident's representative when there is a change requiring notification. Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: . 2. Significant change in the resident's physical, mental or psychosocial conditions such as deterioration in health, mental or psychosocial status. This may include: a. life-threatening conditions; or b. Clinical complications . Additional considerations: . Death of a resident: The resident's physician is to be notified immediately in accordance with State law . On [DATE], the State Agency received a complaint regarding RI #58. The anonymous caller reported on [DATE], RI #58, who has a [DIAGNOSES REDACTED]. The caller stated the resident was ordered to have a Pureed diet but was given a regular diet. The kitchen staff, the nursing staff nor the CNA that served the meal, noticed this mistake. The caller further stated, the resident ate the food, got choked and died . RI #58 was admitted to the facility on [DATE], with a medical history to include [DIAGNOSES REDACTED]. In an interview on [DATE] at 5:47 PM, EI #5, CNA, acknowledged that she worked the 3:00 PM to 11:00 PM shift on [DATE]. EI #5 was asked if she was the CNA that passed out RI #58's dinner (supper) meal tray on [DATE]. EI #5 stated she was not, that the meal tray was passed out by EI #6, the other CNA assigned to care for RI #58. When asked what happened on [DATE], EI #5 said when the meal trays came to the hall, the other CNA (EI #6) took RI #58's meal tray to the resident's room. EI #5 said after the trays were all passed out, she checked on the residents that needed help and then EI #6 asked her (EI #5) to pick up the meal trays. When asked what happened after she picked up the meal trays, EI #5 stated she went to the last room, which was RI #58's room. EI #5 said she noticed RI #58 was sitting straight up in the bed, with his/her head tilted to the left side of the pillow, with his/her eyes partially opened and mouth wide open with drool going down the mouth. EI #5 stated she also noticed the resident had blue and white discoloration to the face and lips. EI #5 said she tried to arouse RI #58 by touching the resident on his/her arm and calling his/her name, but RI #58 did not respond. After no response from the resident, EI #5 said she immediately notified the nurse, EI #3. According to EI #5, when EI #3 entered the resident's room, she showed her RI #58's meal tray ticket and told her that it didn't match. EI #5 stated she was told by the nurse (EI #3) to put the ticket on the tray and take the meal tray out of the room to the food cart. When asked if RI #58 had eaten the food on the meal tray, EI #5 said she didn't observe the resident eat the food, but when she picked the meal tray up, there was approximately 75% to 80% of the food had been eaten. EI #5 was asked what kind of diet RI #58 received for the supper meal on [DATE]. EI #5 replied, the resident got a regular meal tray that consisted of a chicken sandwich, potato salad, a dessert, water and sweet tea. When asked how she knew the meal tray was wrong, EI #5 said when she picked the tray up and looked at the ticket, the ticket had the resident's name on it with Puree Diet and the room number, but the food items left on the meal tray were not Puree items. EI #5 said again, RI #58 had received the wrong meal tray. When asked to describe the food items left on RI #58's supper meal tray, EI #5 said there was a quarter size left of a chicken sandwich; 25% of a serving of potato salad; approximately 60 cubic centimeters (cc) of 120cc of sweet tea; and 120cc of water that had not been drank. EI #5 stated the meal ticket said Puree diet but the food on the tray was a Regular diet. In a telephone interview on [DATE] at 1:11 PM, EI #6, the CNA who delivered RI #58's supper meal tray on [DATE] stated she delivered RI #58's meal tray between 5:00 PM and 5:30 PM. EI #6 acknowledged that she gave RI #58 a regular meal tray that consisted of a chicken sandwich, potato salad, and some other items that she could not remember. EI #6 stated she cut the chicken sandwich up into fourths, gave it to the resident and the resident began eating. After setting RI #58's meal tray up, EI #6 stated she went to the dining room to assist with feeding and stayed there until 7:00 PM. As EI #6 took residents back to their room from the dining room, she stated she saw EI #5 come out of RI #58's room in a hurry. According to EI #6, EI #5 told her that RI #58 might have choked and died . EI #6 stated she asked the EI #5 what she meant, then EI #5 explained to EI #6 that the resident's meal ticket said Regular Puree diet but the resident had received a Regular diet. EI #6 stated EI #5 told her the resident had one-fourth of a chicken sandwich and some potato salad still left on the meal tray. When asked if she told anyone that she had delivered the wrong meal tray to RI #58, EI #6 said she didn't the nurse, EI #3, because she was upset after hearing the resident may have choked. EI #6 stated she was informed by the nurse to provide post-mortem care to RI #58. According to EI #6, during post-mortem care EI #5 became upset and had to leave the resident's room. EI #6 stated she then walked to the resident's room door and found EI #4, a nurse from another hall and asked her (EI #4) if she could assist her (EI #6) in providing RI #58's post-mortem care. EI #6 stated while she and EI #4 provided post-mortem care, she informed EI #4 that she had made an honest mistake. EI #6 stated she wanted to tell the truth from the beginning but was afraid that she would lose her job. EI #6 stated since she didn't know what to do, she along with EI #5, went to talk with the Admissions Nurse, EI #8. According to EI #6, she told the Admissions Nurse that RI #58's death may have been her fault because she had given the resident the wrong meal tray and the resident may have choked and diet. EI #6 said the Admissions told her that if it was a resident's time to go, that God didn't make any mistakes. When asked who she should have told about the incident once she realized that RI #58 had received the wrong supper meal tray, EI #6 said she should have told the nurse but she didn't because she was scared. During an interview on [DATE] at 3:44 PM, EI #4, a Licensed Practical Nurse (LPN) acknowledged that she worked in the facility on [DATE]. EI #4 stated she left her hall when she noticed EI #5, a CNA, was upset. According to EI #4, the CNA (EI #5) told her she was upset because she had found RI #58 in the bed deceased . After finding EI #6 upset, EI #4 stated she told the other CNA, EI #6, that she would assist her in cleaning RI #58 up until EI #5 could return. When asked what happened while she and EI #6 were providing post-mortem care to RI #58, EI #4 said she had not told anyone this before but EI #6 told her that this was her (EI #6) fault and God is going to punish me for this and that RI #58 might have choked. When asked why she thought the resident had choked, EI #4 stated the CNA (EI #6) told her that she had given RI #58 a chicken patty and cut it in half. Also, the resident was supposed to have a Pureed diet but was given a Regular diet. EI #4 was asked if she informed anyone that the CNA told her the resident may have choked, she said no. When asked should she have told anyone, EI #4 said yes ma'am. EI #4 was asked why did she not tell anyone and she stated because she was scared as to what would happen. EI #4 stated the rumor in the facility that was told to her by EI #10, a CNA that the nurse (EI #3) and EI #6, the CNA were saying the resident didn't choked instead he/she died of a [MEDICAL CONDITION]. In an interview on [DATE] at 2:37 PM, EI #8, the Admissions Nurse acknowledged that she worked in the facility on [DATE]. When asked if EI #5 and EI #6, both CNAs came to her office around 7:00 PM on [DATE], EI #8 said yes. EI #8 was asked what EI #6 told her. EI #8 replied that EI #6 said RI #58's death may have been her fault because she gave the resident the wrong meal tray. According to EI #8, EI #6 told her that when she delivered RI #58's supper meal tray, the resident was sitting up in the bed and didn't see anything wrong with the resident while she (EI #6) was in the room. EI #8 stated she asked EI #6 did she look at the resident's meal ticket and she said she couldn't remember what EI #6 said. EI #8 stated she told EI #6 that it was not her fault, that if it was your time to go, when it was your time to go. EI #8 was asked if she advised EI #6 that she should report her concerns to the nurse. EI #8 replied that she didn't know. When asked if she reported the concern to her supervisor and/or Administrator, EI #8 said no. When asked should she have reported this to her supervisor and/or Administrator, EI #8 replied, she guessed. EI #8 was asked why didn't she report this concern to her supervisor and/or Administrator and she stated, she didn't know. In an interview on [DATE] at 3:34 PM, EI #3, a Registered Nurse (RN) stated when she walked into RI #58's room around 5:45 PM, after being told the resident was unresponsive, she found RI #58 in bed in an upright position. EI #3 stated she checked RI #58's pupils and pulse but got no tactile response. The resident's eyes and mouth were partially open and drool was coming out the left side of RI #58's mouth. EI #3 stated she called the resident's name and there was no response. EI #3 explained that since RI #58 was a DNR (Do Not Resuscitate), there was not a need to start CPR (Cardiopulmonary Resuscitation). EI #3 acknowledged that she contacted the physician, EI #7, and informed her that RI #58 had expired. When asked what she had communicated to the physician, EI #7, regarding RI #58 being found unresponsive, EI #3 stated she told EI #7 that RI #58 had expired and the resident was a DNR. EI #3 commented, that was all she remembered telling the physician, EI #7. After notifying the physician, EI #3 stated she asked the CNAs (EI #5 and EI #6) to perform post-mortem care on RI #58. In a telephone interview with RI #58's responsible party on [DATE] at 9:40 AM, she stated she couldn't remember the name of the person who called her, but she received a call on [DATE] around 6:00 PM. According to RI #58's responsible party, the caller stated RI #58 had passed away about 10 minutes ago. RI #58's responsible party stated she was told the resident had eaten supper and then wanted to go to bed. When the staff went back to check on the resident, RI #58 had passed away. In an interview with EI #7, the facility's Medical Director and RI #58's attending physician on [DATE] at 1:03 PM, she acknowledged that she received a call on [DATE] that RI #58, whose code status was DNR, was found unresponsive. EI #7 stated she was told RI #58 had eaten dinner, the staff had taken the resident back to his/her room to get ready for bed and when the staff when to check on the resident again, RI #58 had expired in the bed. EI #7 stated the nurse told her that RI #58 had no pulse, no heart rate and there had been no complications prior to finding the resident and there was no mention of any difficulty with the dinner meal. EI #7 stated since the resident was in his/her 90s, had a code status of DNR and a history of [MEDICAL CONDITION], she felt RI #58's cause of death was probably a coronary event. During an interview on [DATE] at 9:02 PM, EI #2, the DON was asked what she knew about RI #58's death in the facility. EI #2 stated she was aware the resident expired in the facility on [DATE] and during the survey of the facility by the State Survey Agency, there was an accusation made that RI #58 received the wrong diet. EI #2 stated since the accusation was made, the facility started an investigation. When asked what she would have expected staff to do related to the events surrounding RI #58 on [DATE], EI #2 stated that she would have expected the staff to notify her immediately and for the CNA to report her concerns to the Charge Nurse, who in turn should have notified the DON immediately. On [DATE] at 9:19 PM, an interview was conducted with EI #1, Administrator. EI #1 said he was not aware of the incident with RI #58 that occurred on [DATE], until the unit manager informed him what EI #5 was alleging on [DATE]. When asked what he expected staff to do in this situation, he said he would expect that it would have been reported to appropriate staff for follow-up for determination if it it needed to be reported to the State Agency or not and to start an investigation immediately. EI #1 said whether it be the person in charge or a subordinate, that either person would acknowledge something inappropriate happened. In a follow-up interview with EI #7, the facility's Medical Director and RI #58's attending physician, on [DATE] at 7:12 PM, she was informed that RI #58 had been served a regular diet instead of a Pureed diet on [DATE]. EI #7 was also notified that when the CNA went to pick RI #58's meal tray up at 5:45 PM, she found the resident unresponsive and reported to the nurse that the resident had received the wrong diet. EI #7 commented that it would have been beneficial for her to know what had occurred. EI #7 stated she was only told the resident had eaten dinner and was in the bed and later when the staff went to check on RI #58, the resident was found deceased . When asked if RI #58 was ordered a Pureed diet, EI #7 said yes. When asked why RI #58 was ordered a Pureed diet, EI #7 stated because the resident had several [MEDICAL CONDITION] over the years, with cerebral hemorrhage and the resident had gotten more confused and demented. EI #7 was asked, in her medical opinion, what was the likelihood of the resident getting a regular diet that consisted of a chicken sandwich and potato salad, could this have contributed to the resident's death. EI #7 replied, yes the chicken sandwich could have possibly caused the resident to choke. ************************* On [DATE] at 5:30 PM, an acceptable Removal Plan was received which documented: F 580 I. Facility Licensed Nursing staff, failed to follow facility Policy and Procedures for notification 1. Facility Medical Director was notified May, 4 2019 of the events surrounding RI #58 being found deceased 2. Audit of Resident's charts, that have expired in the facility since (MONTH) 18, 2019 was conducted by the Nurse Consultant and Director of nursing with no notification issues noted 3. Administrator and Director of Nursing were educated (MONTH) 4, 2019 (by Nurse Consultant) on Notification of Changes Policy The Director of Nursing, (witnessed by the Administrator) did a one on one in-service on (MONTH) 4, 2019 on Notification of Change with RN. This nurse was also suspended (MONTH) 4, 2019 for failure to communicate to physician that resident RI #58 received the wrong meal tray As of (MONTH) 5, 2019, 17 of 37 licensed staff have been in-serviced on the Notification of Change Policy All licensed facility employees not in-serviced on (MONTH) 5, 2019, will not work until education has been completed 4. All licensed nursing staff (not in-serviced on Notification Policy) by (MONTH) 5, 2019 will be notified and not allowed to clock in nor return to work until education has been completed, by the Director of Nursing, Unit Manager and/or Supervisor. Director of nursing will review all records for completion. All new licensed staff, hired on or after (MONTH) 5, 2019 will be in-serviced during new employee orientation on the Notification of Change Policy). The Director of Nursing will review all records for completion. All facility deaths will be discussed in the morning meeting and chart reviewed to insure accurate documentation beginning (MONTH) 4, 2019 The likelihood for serious harm to recipient to no longer exist is (MONTH) 5, 2019 Member of Governing Body met with Administrator, Director of Nursing, Unit Manager, Dietary Manager and Facility Medical Director on (MONTH) 5, 2019 and are in agreement with these steps of the removal plan. Follow up QA meeting will be conducted (MONTH) 8, 2019. ************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F 580 was lowered to a D level on [DATE], to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 241.

Based on interviews, review of the facility's policy titled Attalla Health and Rehab; Food and Nutrition Services, a complaint received by the Alabama State Survey Agency, Resident Identifier (RI) #58 and RI #136's medical records, the facility's diet spreadsheet, and investigation file, the facility failed to ensure RI #58 received a Pureed diet during the supper (dinner) meal on [DATE]. On [DATE], RI #58, a cognitively impaired resident assessed by the facility as requiring set up help only with eating, was ordered a Pureed diet. RI #58 has a medical history to include a [DIAGNOSES REDACTED]. During the supper meal on [DATE], the Certified Nursing Assistant (CNA) that delivered RI #58's dinner meal tray did not thoroughly read the tray ticket, to ensure the correct diet was given to the resident. When a different CNA went to pick up the dinner meal tray on [DATE], she found the resident sitting up in the bed, with his/her head tilted to the left, eyes partially opened, mouth open with drool going down the resident's mouth, with blue and white face and lips. When the CNA was unable to arouse the resident, she notified the Registered Nurse (RN). The CNA also stated she informed the RN that the resident had received the wrong meal tray/diet. The CNA stated she observed ¼ size of chicken sandwich, 25% left of a serving of potato salad, 60 cc of the 120cc of sweet tea; and 120cc of water. According to RI #58's death certificate, the resident was pronounced deceased on [DATE] at 5:45 PM. This deficient practice placed RI #58, one of four sampled residents reviewed for therapeutic diets, in immediate jeopardy for serious injury, harm, impairment or death. On [DATE] at 3:55 PM, the Administrator, Director of Nursing (DON) and Corporate Nurse were notified of the finding of immediate jeopardy in the area of Food and Nutrition Services/Food in Form to Meet Individual Needs, F 805 and given a copy of the Immediate Jeopardy (IJ) template. Findings include: The facility's policy titled Attalla Health and Rehab; Food and Nutrition Services revised (MONTH) (YEAR), documented Policy Statement Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident . Policy Interpretation and Implementation . 6. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident . On [DATE], the State Agency received a complaint regarding RI #58. The anonymous caller reported on [DATE], RI #58, who has a [DIAGNOSES REDACTED]. The caller stated the resident was ordered to have a Pureed diet but was given a regular diet. The kitchen staff, the nursing staff nor the Certified Nursing Assistant (CNA) that served the meal, noticed this mistake. The caller further stated, the resident ate the food, got choked and died . RI #58 was admitted to the facility on [DATE], with a medical history to include [DIAGNOSES REDACTED]. RI #58's Speech Therapy Treatment Encounter Note(s) dated [DATE], documented . Downgrade pt (patient) to puree consistency solids. RI #58's physician orders [REDACTED]. RI #58's Annual Minimum Data Set (MDS) with an assessment reference date of [DATE] indicated the resident was moderately impaired in cognitive skills for daily decision making, with a Brief Interview for Mental Status (BIMS) of 8. RI #58 was assessed as requiring set up help only and supervision (oversight, encouragement or cueing) with eating. According to this MDS, RI #58 had no natural teeth or tooth fragments and received a mechanically altered diet. RI #58's care plan titled (RI #58) has alteration in nutritional status . requires cueing assistance with eating . is edentulous (without teeth) . last reviewed [DATE] had an approach of . Provide diet per MD (Medical Doctor) orders . RI #58's Annual Nutrition assessment dated [DATE] indicated . Diet: Pureed . In an interview on [DATE] at 5:47 PM, Employee Identifier (EI) #5, a Certified Nursing Assistant (CNA), acknowledged that she worked the 3:00 PM to 11:00 PM shift on [DATE]. When asked if she was assigned to care for RI #58, EI #5 said she was one of the CNAs. When asked who the nurse was assigned to care for RI #58, EI #5 said it was EI #3, a Registered Nurse (RN). EI #5 was asked if she was the CNA that passed out RI #58's dinner (supper) meal tray on [DATE]. EI #5 stated she was not, that the meal tray was passed out by EI #6, the other CNA assigned to care for RI #58. When asked what happened on [DATE], EI #5 said when the meal trays came to the hall, the other CNA (EI #6) took RI #58's meal tray to the resident's room. EI #5 said after the trays were all passed out, she checked on the residents that needed help and then EI #6 asked her (EI #5) to pick up the meal trays. When asked what happened after she picked up the meal trays, EI #5 stated she went to the last room, which was RI #58's room. EI #5 said she noticed RI #58 was sitting straight up in the bed, with his/her head tilted to the left side of the pillow, with his/her eyes partially opened and mouth wide open with drool going down the mouth. EI #5 stated she also noticed the resident had blue and white discoloration to the face and lips. EI #5 said she tried to arouse RI #58 by touching the resident on his/her arm and calling his/her name, but RI #58 did not respond. After no response from the resident, EI #5 said she immediately notified the nurse, EI #3. According to EI #5, when EI #3 entered the resident's room, she showed her RI #58's meal tray ticket and told her that it didn't match. EI #5 stated she was told by the nurse (EI #3) to put the ticket on the tray and take the meal tray out of the room to the food cart. EI #5 said after she placed RI #58's meal tray on the food cart, she went back into the resident's room but when she started crying and having a panic attack, the nurse (EI #3) asked her to leave the room. When asked who found RI #58 unresponsive, EI #5 said she did and she immediately notified EI #3, the RN. When asked if RI #58 had eaten the food on the meal tray, EI #5 said she didn't observe the resident eat the food, but when she picked the meal tray up, there was approximately 75% to 80% of the food had been eaten. EI #5 was asked what kind of diet RI #58 received for the supper meal on [DATE]. EI #5 replied, the resident got a regular meal tray that consisted on a chicken sandwich, potato salad, a dessert, water and sweet tea. EI #5 acknowledged again that RI #58's supper meal tray was delivered to the resident by EI #6, a CNA. When asked how she knew the meal tray was wrong, EI #5 said when she picked the tray up and looked at the ticket, the ticket had the resident's name on it with Puree Diet and the room number, but the food items left on the meal tray were not Puree items. EI #5 said again, RI #58 had received the wrong meal tray. When asked to describe the food items left on RI #58's supper meal tray, EI #5 said there was a quarter size left of a chicken sandwich; 25% of a serving of potato salad; approximately 60 cubic centimeters (cc) of 120cc of sweet tea; and 120cc of water that had not been drank. EI #5 stated the meal ticket said Puree diet but the food on the tray was a Regular diet. According to the facility's diet spreadsheet, the regular supper meal for [DATE] was a chicken breast, mashed potatoes & gravy, cucumber & onion salad, a brownie, roll/margarine and milk/beverage. The Pureed supper meal for [DATE] was Pureed chicken breast, mashed potatoes & gravy, Pureed cucumber & onion salad, a Pureed brownie, Pureed white bread and milk/beverage. In a telephone interview on [DATE] at 1:11 PM, EI #6, the CNA who delivered RI #58's supper meal tray on [DATE] stated she delivered RI #58's meal tray between 5:00 PM and 5:30 PM. EI #6 acknowledged that she gave RI #58 a regular meal tray that consisted of a chicken sandwich, potato salad, and some other items that she could not remember. EI #6 stated she cut the chicken sandwich up into fourths, gave it to the resident and the resident began eating. After setting RI #58's meal tray up, EI #6 stated she went to the dining room to assist with feeding and stayed there until 7:00 PM. As EI #6 took residents back to their room from the dining room, she stated she saw EI #5 come out of RI #58's room in a hurry. According to EI #6, EI #5 told her that RI #58 might have choked and died . EI #6 stated she asked the EI #5 what she meant, then EI #5 explained to EI #6 that the resident's meal ticket said Regular Puree diet but the resident had received a Regular diet. EI #6 stated EI #5 told her the resident had one-fourth of a chicken sandwich and some potato salad still left on the meal tray. When asked if she told anyone that she had delivered the wrong meal tray to RI #58, EI #6 said she didn't the nurse, EI #3, because she was upset after hearing the resident may have choked. EI #6 stated she was informed by the nurse to provide post-mortem care to RI #58. According to EI #6, during post-mortem care EI #5 became upset and had to leave the resident's room. EI #6 stated she then walked to the resident's room door and found EI #4, a nurse from another hall and asked her (EI #4) if she could assist her (EI #6) in providing RI #58's post-mortem care. EI #6 stated while she and EI #4 provided post-mortem care, she informed EI #4 that she had made an honest mistake. EI #6 stated she wanted to tell the truth from the beginning but was afraid that she would lose her job. EI #6 stated since she didn't know what to do, she along with EI #5, went to talk with the Admissions Nurse, EI #8. According to EI #6, she told the Admissions Nurse that RI #58's death may have been her fault because she had given the resident the wrong meal tray and the resident may have choked and diet. EI #6 said the Admissions told her that if it was a resident's time to go, that God didn't make any mistakes. When asked who she should have told about the incident once she realized that RI #58 had received the wrong supper meal tray, EI #6 said she should have told the nurse but she didn't because she was scared. EI #6 explained that she had made an honest mistake and had lied to a lot of people about the events that happened on [DATE]. EI #6 stated she wrote a statement when asked to do so, but that what she wrote in her statement and gave to the facility was not true. EI #6 stated she wrote down in her statement that the resident had received a Pureed diet but that was not true. Contained within the facility's investigation file was a written statement signed by EI #6 and dated [DATE] 9:24 PM, which documented I (EI #6) help pass out trays on E hall. I look at all tray cards and match them with the trays as I always do. I also took (RI #58) (his/her) tray there was no issues with (his/her) tray. In a follow-up interview with EI #6, a CNA, on [DATE] beginning at 6:48 PM, she was asked why she gave RI #58 a Regular meal tray when the resident was ordered to have a Pureed meal tray. EI #6 replied, that she didn't read the entire meal ticket. EI #6 explained that it wasn't until EI #5 had told her that RI #58 had received the wrong meal tray that she recognized that she had given the resident the wrong meal tray. During an interview on [DATE] at 3:44 PM, EI #4, a Licensed Practical Nurse (LPN) acknowledged that she worked in the facility on [DATE]. EI #4 stated she left her hall when she noticed EI #5, a CNA, was upset. According to EI #4, the CNA (EI #5) told her she was upset because she had found RI #58 in the bed deceased . After finding EI #6 upset, EI #4 stated she told the other CNA, EI #6, that she would assist her in cleaning RI #58 up until EI #5 could return. When asked what happened while she and EI #6 were providing post-mortem care to RI #58, EI #4 said she had not told anyone this before but EI #6 told her that this was her (EI #6) fault and God is going to punish me for this and that RI #58 might have choked. When asked why she thought the resident had choked, EI #4 stated the CNA (EI #6) told her that she had given RI #58 a chicken patty and cut it in half. Also, the resident was supposed to have a Pureed diet but was given a Regular diet. EI #4 was asked if she informed anyone that the CNA told her the resident may have choked, she said no. When asked should she have told anyone, EI #4 said yes ma'am. EI #4 was asked why did she not tell anyone and she stated because she was scared as to what would happen. EI #4 stated the rumor in the facility that was told to her by EI #10, a CNA that the nurse (EI #3) and EI #6, the CNA were saying the resident didn't choked instead he/she died of a [MEDICAL CONDITION]. EI #4 explained that after the CNA, EI #5, returned to RI #58's room, to finish assisting EI #6 with post-mortem care, she went back to her assigned hall. In an interview on [DATE] at 2:37 PM, EI #8, the Admissions Nurse acknowledged that she worked in the facility on [DATE]. When asked if EI #5 and EI #6, both CNAs came to her office around 7:00 PM on [DATE], EI #8 said yes. EI #8 was asked what EI #6 told her. EI #8 replied that EI #6 said RI #58's death may have been her fault because she gave the resident the wrong meal tray. According to EI #8, EI #6 told her that when she delivered RI #58's supper meal tray, the resident was sitting up in the bed and didn't see anything wrong with the resident while she (EI #6) was in the room. EI #8 stated she asked EI #6 did she look at the resident's meal ticket and she said she couldn't remember what EI #6 said. EI #8 stated she told EI #6 that it was not her fault, that if it was your time to go, when it was your time to go. EI #8 was asked if she advised EI #6 that she should report her concerns to the nurse. EI #8 replied that she didn't know. When asked if she reported the concern to her supervisor and/or Administrator, EI #8 said no. When asked should she have reported this to her supervisor and/or Administrator, EI #8 replied, she guessed. EI #8 was asked why didn't she report this concern to her supervisor and/or Administrator and she stated, she didn't know. During an interview with EI #9, a LPN on [DATE] at 9:10 AM, she stated she was called to RI #58's room during the evening of [DATE] by EI #5, the CNA and the nurse, EI #3. EI #9 stated when she entered RI #58's room, the resident was in the bed with the head of the bed at a 45 degree angle and she noticed the resident had a white frothy liquid coming from his/her mouth. EI #9 stated she checked the resident's pulse and respiration but there was no pulse or respiration. EI #9 stated during her assessment of the resident, no one was in the room with her but the resident's roommate (RI #136), who was sitting on his/her side of the room. EI #9 stated the nurse, EI #3, may have been at the doorway but she was not present at her side, when EI #9 completed her assessment of the resident. EI #9 stated after she completed her assessment of the resident, she was informed by EI #3 (RN) that RI #58 was a DNR (Do Not Resuscitate). On [DATE] at 9:40 AM, an interview was conducted with RI #136, the roommate of RI #58 on [DATE]. RI #136 stated he/she ate the supper meal in the dining room on [DATE]. RI #136 stated when he/she came back to the room, he/she glanced over at RI #58, who was in the bed and noticed the resident appeared to be choking. RI #136 stated he/she pulled the privacy curtain because he/she didn't want to see that. When asked if he/she ever saw a regular meal tray in the resident's room, RI #136 said yes. When asked when he/she saw a regular meal tray in the resident's room, RI #136 stated the day RI #58 died . RI #136 was asked if he/she knew what happened, the resident stated he/she heard the staff talking as they were coming in and leaving out of the room say the resident (RI #58) choked on some chicken and that the resident got a regular tray instead of a Pureed meal tray. When asked if he/she remembered anything else about the day RI #58 expired in the facility, RI #136 stated all he/she knew was that RI #58 choked on some chicken and died . RI #136 was admitted to the facility on [DATE] and has a medical history to include [DIAGNOSES REDACTED]. RI #136's Quarterly MDS with an assessment reference date of [DATE] indicated RI #136 was moderately impaired in cognitive skills, with a BIMS of 12. During this assessment period, RI #136 displayed no altered level of consciousness, disorganized thinking or inattention. In an interview on [DATE] at 3:34 PM, EI #3, a RN stated when she walked into RI #58's room around 5:45 PM, after being told the resident was unresponsive, she found RI #58 in bed in an upright position. EI #3 stated she checked RI #58's pupils and pulse but got no tactile response. The resident's eyes and mouth were partially open and drool was coming out the left side of RI #58's mouth. EI #3 stated she called the resident's name and there was no response. EI #3 explained that since RI #58 was a DNR, there was not a need to start CPR (Cardiopulmonary Resuscitation). EI #3 was asked why type of diet was RI #58 ordered and she said, a Pureed diet. When asked if she had been told that RI #58 had received the wrong meal tray, EI #3 said no. EI #3 was asked if she was familiar with RI #58 and she stated on [DATE] was the first time she had ever been assigned to care for RI #58. EI #3 acknowledged that she contacted the physician, EI #7, and informed her that RI #58 had expired. After notifying the physician, EI #3 stated she asked the CNAs (EI #5 and EI #6) to perform post-mortem care on RI #58. RI #58's Departmental Notes dated [DATE] 9:20 PM written by EI #3, a RN, documented At 5:45 PM CNA entered room and found Resident deceased . VS (vital signs) checked by two nurses. Absence of VS for period of fifteen minutes. CNAs instructed to provide death care. UM (Unit Manager) notified. MD (Medical Director) notified. DON notified. Resident's sponsor notified . (name) is the funeral home with Resident's policy. They arrived to pick up Resident's body at 8:25 PM and departed the facility at 8:31 PM . During an interview on [DATE] at 9:02 PM, EI #2, the DON was asked what she knew about RI #58's death in the facility. EI #2 stated she was aware the resident expired in the facility on [DATE] and during the survey of the facility by the State Survey Agency, there was an accusation made that RI #58 received the wrong diet. EI #2 stated since the accusation was made, the facility started an investigation. When asked what she would have expected staff to do related to the events surrounding RI #58 on [DATE], EI #2 stated she would have expected the CNA that delivered the tray to have verified it was the correct diet and if it was not, to send it back to the kitchen for the correct tray. EI #2 further stated that she would have expected the staff to notify her immediately and for the CNA to report her concerns to the Charge Nurse, who in turn should have notified the DON immediately. In an interview on [DATE] at 11:27 AM, EI #11, the Certified Dietary Manager was asked, had a meal tray ever left the kitchen that was incorrect according to the physician order. EI #11 replied, yes. On [DATE] at 2:25 PM, EI #12, a dietary aide was asked how RI #58 could have received the wrong meal tray on [DATE]. EI #12 replied, if somebody was not paying attention to the meal ticket. On [DATE] at 2:36 PM, EI #13, a dietary aide was asked how RI #58 could have received the wrong meal tray on [DATE]. EI #13 replied, from not looking at the tray card. In an interview with EI #7, the facility's Medical Director and RI #58's attending physician on [DATE] at 1:03 PM, she acknowledged that she received a call on [DATE] that RI #58, whose code status was DNR, was found unresponsive. EI #7 stated she was told RI #58 had eaten dinner, the staff had taken the resident back to his/her room to get ready for bed and when the staff when to check on the resident again, RI #58 had expired in the bed. EI #7 stated the nurse told her that RI #58 had no pulse, no heart rate and there had been no complications prior to finding the resident and there was no mention of any difficulty with the dinner meal. EI #7 stated since the resident was in his/her 90s, had a code status of DNR and a history of [MEDICAL CONDITION], she felt RI #58's cause of death was probably a coronary event. According to an untitled facility document, RI #58's meal intake percentage (the amount of food consumed by the resident) for the dinner meal on [DATE] was NOT AVAIL (available) Resident Expired. In a follow-up interview with EI #7 on [DATE] at 7:12 PM, she was informed that RI #58 had been served a regular diet instead of a Pureed diet on [DATE]. EI #7 was also notified that when the CNA went to pick RI #58's meal tray up at 5:45 PM, she found the resident unresponsive and reported to the nurse that the resident had received the wrong diet. EI #7 commented that it would have been beneficial for her to know what had occurred. EI #7 stated she was only told the resident had eaten dinner and was in the bed and later when the staff went to check on RI #58, the resident was found deceased . When asked if RI #58 was ordered a Pureed diet, EI #7 said yes. When asked why RI #58 was ordered a Pureed diet, EI #7 stated because the resident had several [MEDICAL CONDITION] over the years, with cerebral hemorrhage and the resident had gotten more confused and demented. EI #7 was asked, in her medical opinion, what was the likelihood of the resident getting a regular diet that consisted of a chicken sandwich and potato salad, could this have contributed to the resident's death. EI #7 replied, yes the chicken sandwich could have possibly caused the resident to choke. RI #58's death certificate revealed RI #58 date and time of death as [DATE] at 5:45 PM, with the immediate cause of death listed as Cardiopulmonary Arrest. ************************* On [DATE] at 5:30 PM, an acceptable Removal Plan was received which documented: F 805 II Food in form to meet individual needs: 1. When the matter of the incorrect diet was brought to the attention of administration, on (MONTH) 30, 2019, an investigation was immediately initiated and Investigative Summary will be completed within 5 working days. 2. The facility suspended the CNA ([DATE]) that delivered the supper meal tray on (MONTH) 18, 2019, that failed to insure the correct diet was delivered. This CNA will be terminated (MONTH) 4, 2019 for failure to report in a timely manner, and falsification of an investigative statement The facility suspended the CNA ([DATE]) that picked up the supper meal tray on (MONTH) 18, 2019, that failed to report her concerns about the delivery of the wrong tray to Administration. This CNA was terminated (MONTH) 4, 2019, for failure to report in a timely manner RN Admission Nurse was suspended ([DATE]) and subsequently terminated ([DATE]) for failure to report knowledge of incorrect diet being delivered to resident RI #58 on (MONTH) 18, 2019, to Administration in a timely manner LPN that assisted with Post Mortem Care was suspended ([DATE]) and subsequently terminated ([DATE]) for failure to report knowledge of incorrect diet being delivered to resident RI #58 on (MONTH) 18, 2019 to Administration in a timely manner RN Charge Nurse was suspended ([DATE]) for failure to communicate to physician and other administrative staff that resident had received the wrong meal tray Facility Medical Director was notified (MONTH) 4, 2019 of incorrect supper meal being delivered to RI #58 on (MONTH) 18, 2019 3. Administrator and Director of Nursing were educated (MONTH) 4, 2019 (by Nurse Consultant) on Food and Nutrition Services Policy The Director of Nursing educated Facility Unit Managers and Nursing Supervisor (MONTH) 4, 2019, on Food and Nutrition Services Policy All licensed staff working 7am - 7pm, (MONTH) 4, 2019 were educated by the Unit Manager on Food and Nutrition Services Policy All licensed staff working 7pm - 7am, (MONTH) 4, 2019, were educated by the Unit Manager on: Food and Nutrition Services Policy All CNA's working the ,[DATE] shift ([DATE]) were educated by the Unit Managers and Nursing Supervisor on Food and Nutrition Services Policy All CNA's working the ,[DATE] shift ([DATE]) were educated by the Unit Managers and Nursing Supervisor on Food and Nutrition Services Policy As of (MONTH) 5, 2019, 17 of 37 licensed staff have been educated on Food and Nutrition Services Policy As of (MONTH) 5, 2019, 33 of 61 CNA's have been educated on Food and Nutrition Services Policy All Dietary staff working the evening shift ([DATE]) were educated on Food and Nutrition Services Policy As of (MONTH) 5, 2019, 8 of 20 Dietary employees have been educated on Food and Nutrition Services Policy All licensed nursing staff, CNA's and Dietary staff (not in-serviced on Food and Nutrition Policy) by (MONTH) 5, 2019 will be notified and not allowed to clock in nor return to work until education has been completed, by the Director of Nursing, Unit Manager and/or Supervisor. All new licensed staff, CNA's, and Dietary staff hired on or after (MONTH) 5, 2019 will be in-services during new employee orientation on the Food and Nutrition Policy). The Director of Nursing will review all records for completion. 4. All pureed supper meals served (MONTH) 4, 2019 were observed for appropriate diet orders by the Director of Nursing and Dietary Manager with no issues noted, All pureed breakfast meals served (MONTH) 5, 2019 were observed by Unit Managers and Dietary Manager for appropriate diet orders, with no issues noted. All pureed lunch meals served on (MONTH) 5, 2019 were observed by Unit Managers and Dietary Manager for appropriate diet orders, with no issues noted All licensed nursing staff, CNA's and Dietary staff (not in-serviced on Food and Nutrition Services Policy) by (MONTH) 5, 2019 will be notified and not allowed to clock in nor return to work until education has been completed, by the Director of Nursing, Unit Manager and/or Supervisor. Director of Nursing will review all records for completion. The likelyhood (likelihood) for serious harm to recipient to no longer exist is (MONTH) 5, 2019 Member of Governing Body met with Administrator, Director of Nursing, Unit Manager, Dietary Manager and Facility Medical Director on (MONTH) 5, 2019 and are in agreement with these steps of the removal plan. Follow up QA meeting will be conducted (MONTH) 8, 2019. ************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F 805 was lowered to a D level on [DATE], to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 241.

Based on interviews, review of Resident Identifier (RI) #58's medical record, facilities' policies titled Death of a Resident, Documenting, Charting and Documentation, Vital Signs, an unlabled facility document, and a complaint received by the Alabama State Survey Agency, the facility's licensed nursing staff failed to document in RI #58's medical record an accurate description of the events surrounding the resident being found deceased in the facility on [DATE]. The licensed staff further failed to document in RI #58's medical record, a complete assessment of the resident, to include vital signs, the findings from the assessment, the time of pronouncement and the name of the individual who pronounced RI #58 deceased to ensure RI #58's medical record validated the accuracy of the resident's death in the facility. Without a complete documented description of the details leading up to RI #58 being found unresponsive, to include what happened when the resident was found unresponsive and how staff responded, the facility cannot be assured staff was compliant with following the facility's policies, the Standards of Practice for a licensed nurse and Federal and State regulations. This deficient practice placed RI #58, one of one sampled resident reviewed for death in the facility, in immediate jeopardy for serious injury, harm, impairment or death. On [DATE] at 3:55 PM, the Administrator, Director of Nursing (DON) and Corporate Nurse were notified of the finding of immediate jeopardy in the area of Administration/Resident Records, F 842 and given a copy of the Immediate Jeopardy (IJ) template. Findings include: The facility's policy titled Death of a Resident, Documenting revised (MONTH) 2010, documented Policy Statement Appropriate documentation shall be made in the clinical record concerning the death of a resident. Policy Interpretation and Implementation . 2. All information pertaining to a resident's death (i.e. (for example), date, time of death, the name and title of the individual pronouncing the resident dead, etc.(and so on)) must be recorded on the nurses' notes . The facility's policy titled Charting and Documentation revised [DATE], documented Policy Statement All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. Policy Interpretation and Implementation 1. All observations, medications administered, services performed, etc., must be documented in the resident's clinical records . The facility's policy titled Vital Signs reviewed [DATE], documented Policy: The purpose of this policy is to provide guidelines for the measurement and reporting of vital signs. Definition: Vital signs are indicators of health status, including temperature, pulse, blood pressure, respiratory rate, oxygen saturation, and pain. Policy Explanation and Compliance Guidelines: 1. Routine vital signs include: temperature, pulse, blood pressure and respiratory rate. 2. Oxygen saturation and pain are to be obtained and interpreted by licensed nurses. 3. Vital signs shall be documented at least in the following circumstances: . e. When the resident's general condition changes . An unlabeled facility document with a revised date of (MONTH) (YEAR), documented . Purpose: To establish the procedure for the registered nurse or nurse practitioner to follow when pronouncing a resident in a skilled nursing facility . B. Responsibilities of the nurse at the nursing home . 9. Document in the medical record: the time of pronouncement; findings from the assessment of the patient that substantiated the conclusion that death has occurred; notification of the physician, family, and funeral home; removal of the body; disposal of medications. On [DATE], the State Agency received a complaint regarding RI #58. The anonymous caller reported on [DATE], RI #58, who has a [DIAGNOSES REDACTED]. The caller stated the resident was ordered to have a Pureed diet but was given a regular diet. The kitchen staff, the nursing staff nor the Certified Nursing Assistant (CNA) that served the meal, noticed this mistake. The caller further stated, the resident ate the food, got choked and died . RI #58 was admitted to the facility on [DATE], with a medical history to include [DIAGNOSES REDACTED]. RI #58's Departmental Notes dated [DATE] 9:20 PM written by Employee Identifier (EI) #3, a Registered Nurse (RN), documented At 5:45 PM CNA entered room and found Resident deceased . VS (vital signs) checked by two nurses. Absence of VS for period of fifteen minutes. CNAs instructed to provide death care. UM (Unit Manger) notified. MD (Medical Director) notified. DON notified. Resident's sponsor notified. She stated that she is in the hospital preparing to have surgery and asked that I notify second contact person. I called (name) and notified her of Resident's expiration. She became upset and hung up the phone. Resident's sponsor contacted again and she stated that she could not remember which funeral home was to be used but that she had a policy at one of them. After several calls, (name) is the funeral home with Resident's policy. They arrived to pick up Resident's body at 8:25 PM and departed the facility at 8:31 PM. (Name of funeral home) phone number is (number). In an interview on [DATE] at 3:34 PM, EI #3, a RN stated when she walked into RI #58's room around 5:45 PM, after being told the resident was unresponsive, she found RI #58 in bed in an upright position. EI #3 stated she checked RI #58's pupils and pulse but got no tactile response. The resident's eyes and mouth were partially open and drool was coming out the left side of RI #58's mouth. EI #3 stated she called the resident's name and there was no response. EI #3 explained that since RI #58 was a DNR (Do Not Resuscitate), there was not a need to start CPR (Cardiopulmonary Resuscitation). In a follow up interview on [DATE] at 7:49 PM, EI #3 was asked did she document in RI #58's medical record, the time the resident's death and the name of the individual that pronounced the resident deceased . EI #3 replied, no. When asked if she followed the facility's policy with documenting the death of RI #58 on [DATE], EI #3 stated, evidently not. EI #3 was asked why she should document the time the resident's death and the name of the individual that pronounced the resident deceased . EI #3 stated, for the official record, it validates the accuracy of the medical record for the death of RI #58. When asked what according to the facility's policy what she should have documented as related to RI #58's vital signs, EI #3 answered, temperature, pulse, respirations, blood pressure, oxygen saturation, pain and health status. When asked if she followed the facility's policy when she documented RI #58's vital signs in the resident's medical record on [DATE], EI #3 said no. During an interview with EI #9, a Licensed Practical Nurse (LPN) on [DATE] at 9:10 AM, she stated she was called to RI #58's room during the evening of [DATE] by EI #5, the CNA and the nurse, EI #3. EI #9 stated when she entered RI #58's room, the resident was in the bed with the head of the bed at a 45 degree angle and she noticed the resident had a white frothy liquid coming from his/her mouth. EI #9 stated she checked the resident's pulse and respiration but there was no pulse or respiration. EI #9 stated during her assessment of the resident, no one was in the room with her but the resident's roommate (RI #136), who was sitting on his/her side of the room. EI #9 stated the nurse, EI #3, may have been at the doorway but she was not present at her side, when EI #9 completed her assessment of the resident. EI #9 stated after she completed her assessment of the resident, she was informed by EI #3, the RN, that RI #58 had a code status of DNR. When asked where she documented her assessment of RI #58, EI #9 said she did not document it. EI #9 was asked why she did not document and she stated she presumed EI #3 had documented. When asked what information was communicated from EI #3 to her, EI #9 stated she was only told the resident was a DNR. When asked what the facility's policy was for documenting a resident assessment, EI #9 replied that she should have documented her assessment. EI #9 was asked who was responsible for documenting the vital signs that she obtained. EI #9 said she should have. When asked did she document RI #58's vital signs that she obtained on [DATE], EI #9 answered no. On [DATE] at 9:02 PM, an interview was conducted with EI #2, the DON. EI #2 was asked if the licensed nursing staff followed the facility's policy titled . EI #2 answered, no. When asked what should the licensed nursing staff have documented in RI #58's medical record regarding the resident's death in the facility on [DATE], EI #2 replied, the date, time of death, the name and title of the individual, that pronounced RI #58 deceased should have been documented in the nursing notes. EI #2 was asked what did vital signs consist of and she replied, temperature, pulse, respiration, blood pressure, oxygen status, pain and health status. When asked if RI #58s' vital signs were documented on [DATE], EI #2 said no. It was explained to EI #2 that the licensed nursing staff only obtained RI #58's pulse and respiration then asked, did the staff obtain the resident's vital signs as directed by the facility's policy. EI #2 answered, no. When asked if the licensed nursing staff documented appropriate documentation for the death of RI #58, EI #2 replied no. EI #2 was asked why should RI #58's nursing notes indicate the time in which the resident was pronounced deceased . EI #2 stated, to validate the accuracy of the medical record for the death of the resident. During an interview with EI #1, the Administrator, on [DATE] at 9:19 PM, he was asked did the licensed nursing staff follow the facility's policy for documenting the death of RI #58 that occurred in the facility on [DATE]. EI #1 answered, no. During an interview with EI #14, the Nurse Consultant, on [DATE] at 9:41 PM, she was asked did the licensed nursing staff follow the facility's policy for documenting the death of RI #58 that occurred in the facility on [DATE]. EI #14 answered, no. ************************* On [DATE] at 5:30 PM, an acceptable Removal Plan was received which documented: F 842 III Resident records - identifiable records 1 RN failed to document vital signs and pronouncement of death in RI #58 medical record on (MONTH) 18, 2019 * RN received one on one education by the Director of Nursing (witnessed by Administrator) that included: Documentation of Death and Pronouncement of Death ([DATE]) * RN will be in-serviced (if and when allowed to return to work) on Vital Sign Policy 2 A (An) audit of resident's charts (that have expired in the facility since (MONTH) 18, 2019) were conducted by the Nurse Consultant and Director of Nursing, with no issues noted. This audit was conducted on (MONTH) 4, 2019 3 The Director of Nursing educated Facility Unit Managers on Pronouncement of Death, Documenting of Death and Vital Signs * All licensed staff working 7am - 7pm ([DATE]) were educated by the Unit Manager on facility policies that include: Pronouncement of Death, Documenting of Death and Vital Signs. The Director of Nursing will review all records for completion * All licensed staff working 7pm - 7am ([DATE]) were educated by the Unit Manager on facility policies that include: Pronouncement of Death, Documenting of Death and Vital Signs. * As of (MONTH) 5, 2019, 17 of 37 licensed staff have been in-serviced on Pronouncement of Death, Documenting Death and Vital Signs 4 The Nurse Consultant and Director of Nursing reviewed the only other in facility death since (MONTH) 18, 2019 with no issues related to documentation of death and pronouncement of death All facility deaths will be discussed in the morning meeting and chart reviewed to insure accurate documentation beginning (MONTH) 4, 2019 All licensed nursing staff (not in-serviced on Vital Signs, Pronouncement of Death and Documenting the Death of a Resident) by (MONTH) 5, 2019 will be notified and not allowed to clock in nor return to work until education has been completed, by the Director of Nursing, Unit Manager and/or Supervisor. All new licensed staff hired on or after (MONTH) 5, 2019 will be in-serviced during new employee orientation on Pronouncement of Death, Documenting of Death and Vital Signs). The Director of Nursing will review all records for completion The likelihood for serious harm to recipient to no longer exist is (MONTH) 5, 2019 Member of Governing Body met with Administrator, Director of Nursing, Unit Manager, Dietary Manager and Facility Medical Director on (MONTH) 5, 2019, and are in agreement with the steps of the removal plan. Follow up QA meeting will be conducted (MONTH) 8, 2019. ************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F 842 was lowered to a D level on [DATE], to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 241.

Based on observation, interviews, and the facility's policy titled Standard Precautions Infection Control, the facility failed to ensure Employee Identifier (EI) #15, a laundry aide, washed her hands after touching a door knob in the soiled utility room, walked into the clean utility room, and began folding linen without washing her hands, and did not touch her upper area of her uniform top, prior to folding clean F Hall resident's linen. This had the potential to affect one of seven halls, the F Hall where 34 of 157 residents in the facility reside. Findings include: The facility's policy titled Standard Precautions Infection Control, with a copyright date of (YEAR) revealed, . 1. Hand Hygiene. After touching .contaminated items . Laundry. Handle in a manner that prevents transfer of microorganisms to others and to the environment . On 5/2/2019 at 7:45 AM, EI #15, a laundry aide, opened the door to the soiled utility room, touched the door knob with her hands, walked into the clean utility room, and started folding linen from F Hall without washing her hands. EI #15 was observed to take F Hall residents' linen from the laundry bin, she then touched the upper area of her uniform top prior to folding the following items: ten residents' bed pads, one resident sheet, and two resident blankets. On 5/2/2019 at 2:30 PM, the surveyor conducted an interview with EI #15. EI #15 was asked when she folded the ten residents' bed pads, one sheet, and two blankets from the laundry bin in the clean utility room, did the clean line touch the upper area of her top uniform to the abdomen area. EI #15 stated yes. EI #15 was asked should clean linen removed from a laundry bin, touch an employee's top uniform. EI #15 stated no and it could cause cross contamination. EI #15 was asked did she wash her hands or gel her hands after opening the door in the soiled utility room and walking into the clean utility room, before folding linen from F Hall. EI #15 stated no. EI #15 was asked what would be the concern with not washing her hands after opening a door on the soiled utility room, walking into the clean utility room, and then folding residents' linen. EI #15 stated germs from the door knob. EI #15 further stated that these germs could transfer to the residents. EI #15 was asked what the facility's policy was on handwashing after touching an item that could be contaminated. EI #15 stated to wash or gel your hands, after touching items that could be contaminated. EI #15 was asked if the facility's policy was followed when she opened the door into the soiled utility room, walked into the soiled utility room, and then began folding residents' linen without washing her hands. EI #15 stated no. EI #15 further stated that she was folding the linen from this laundry bin for F hall residents. In an interview on 5/2/2019 at 2:44 PM, EI #16, the temporary Infection Control Preventionist was asked what would be the concern with an employee taking residents' clean linen out of a laundry bin and touching their upper top uniform with the clean linen prior to folding the linen. EI #16 stated it could cause germs to be transferred to a resident. EI #16 was asked what would be the concern with an employee not washing their hands after opening a door on the soiled utility room, walking into the clean utility room, and began folding clothes. EI #16 stated it could cause germs to be transferred to a resident from not washing her hands. EI #16 was asked what the facility's policy was on handwashing, after touching a contaminated item. EI #16 stated to wash or gel their hands after touching a contaminated item.

Based on observation, interviews, and the facility's policy titled Required Training, Certification and Continuing Education of Nurse Aides, the facility failed to ensure Employee Identifier (EI) #17, a Certified Nursing Assistant (CNA) received Continuing Education Units (CEUs) on Dementia Training from the period of 4/4/2018 to 4/4/2019. This affected one of five CNAs reviewed for Dementia Training. Findings include: The facility's undated policy titled Required Training, Certification and Continuing Education of Nurse Aides, revealed Policy Explanation and Compliance Guidelines . 6. In-service training . Minimum training will include: . b. Dementia management and care of the cognitively impaired . On 5/2/2019 at 8:54 AM, EI #17's CNA CEUs revealed that EI #17 was hired on 4/4/2017 and EI #17 had not receiving any dementia training for the time period 4/4/2018 to 4/4/2019. On 5/2/2019 at 10:02 AM, EI #2, the Director of Nursing, was asked who the Staff Education Coordinator was. EI #2 stated that she was the temporary education coordinator. EI #2 was if EI #17 had received CEU Dementia Training during 4/4/2018 to 4/4/2019. EI #2 stated no, and there is no recording of the CNA receiving Dementia Training during this time period. EI #2 was asked what date the CEU Dementia Training was done during the period of 4/4/2018 to 4/4/2019. EI #2 stated the CEU Dementia Training was done during the (MONTH) (YEAR) Staffing In-Service. EI #2 was asked if EI #17's signature was on the Record of In-Service Training and Attendance Form for (MONTH) (YEAR). EI #2 stated no. EI #2 was asked why EI #17 did not receive CEU Dementia Training during the period of 4/4/2018 to 4/4/2019. EI #2 stated that she had just became aware of this and was unsure at this moment. EI #2 was asked why EI #17, a CNA, should have received CEU Dementia Training during the period of 4/4/2018 to 4/4/2019. EI #2 stated it helps the CNA deal with dementia patients, to know how to care for dementia residents, and understand their disease process.

Based on observation, interview and review the (YEAR) Food Code, the facility failed to ensure the prep table and areas around the microwave, mixer and Robot Coupe were clean; food items in the reach-in and walk-in cooler were labeled and dated; expired food items were discarded; and food items served for the lunch meal on [DATE] were reheated to the appropriate temperature. These deficient practices had the potential to affect 138 residents who received food from the kitchen. The RESIDENT CENSUS AND CONDITIONS OF RESIDENTS (Form CMS-672) dated [DATE] indicated the facility had a total of 146 residents. The facility's Physician order [REDACTED]. Findings include: According to the (YEAR) Food Code, . ,[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § ,[DATE].12, and except as specified in (paragraph) (E) and (F) of this section, refrigerated, READY-TOEAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1 . (B) Except as specified in (paragraph) (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PR[NAME]ESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (paragraph) (A) of this section and: (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer ' s use-by date if the manufacturer determined the use-by date based on FOOD safety. (C) A refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD ingredient or a portion of a refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is subsequently combined with additional ingredients or portions of FOOD shall retain the date marking of the earliest-prepared or first-prepared ingredient . During the initial tour of the kitchen on [DATE] at 10:30 AM, conducted with Employee Identifier (EI) #18, the cook/supervisor, the following was observed: 1) The prep table was dirty with debris on top and underneath the table. The prep table was cluttered with numerous paper products, two loose onions, Clorox spray, an Eco Lab Lemon lift spray bottle, one can of soup, and individual cereal packs on top and underneath the table. 2) The area around the microwave, mixer and Robot Coupe was dirty. 3) In the reach-in cooler, there were a total of eight sandwiches, peanut butter and jelly and pimiento cheese, that were undated. EI #18 stated she was not sure when the sandwiches were made. There was an undated container of pureed dessert. EI #18 stated she was sure when the dessert was made. Also observed in the reach-in cooler was chicken noodle soup dated [DATE]. EI #18 said it was from last night; however, could not specify whether the [DATE] date was the prepared date or the use-by-date. 4) In the walk-in cooler, there was two undated bowls of chicken noodle soup; uncovered apple sauce; uncovered and undated mandarin oranges; chocolate pudding with a use-by-date of [DATE]; green beans with a use-by-date of [DATE]; and peaches with a use-by-date of [DATE]. During the lunch meal trayline observation on [DATE] at 10:50 AM, the Creamed Corn for the mechanical soft diets temperature registered 122 degrees Fahrenheit (F) on the trayline. The staff reheated the Creamed Corn to 135 degrees Fahrenheit (F) and then began to prepare lunch meal trays. Also, the oriental vegetables for the alternate meal temperature registered 130 degrees Fahrenheit. The staff reheated the oriental vegetables to 149 degrees Fahrenheit, then began to prepare lunch meal trays. Also observed debris observed under the trayline, on the floor near the trayline and puddles of water was noted underneath the trayline. In an interview on [DATE] at 9:30 AM, EI #7, the Certified Dietary Manager (CDM) stated the prep table should be clean and the items that were observed on top and underneath the table were usually stored in different places. EI #7 stated the area around the microwave, mixer and Robot Coupe should be clean. When asked why, EI #7 said for contamination purposes. EI #7 stated the items in the reach-in and walk-in cooler should be labeled and dated and expired items should be discarded. EI #7 was asked what temperature should the Creamed Corn and Oriental vegetables be reheated to. EI #7 said 165 degrees Fahrenheit. When asked about the potential harm for not reheating to the appropriate temperature, EI #7 said bacteria. This deficiency was cited as a result of the investigation of complaint/report number AL 881.

Based on observation, interview, review of the facility's policy titled Attalla Health and Rehab; Food and Nutrition Services, the Diet Spreadsheet and the Physician order [REDACTED]. This deficient practice affected all 13 of residents who are ordered a pureed diet. Findings include: The facility's policy titled Attalla Health and Rehab; Food and Nutrition Services dated (MONTH) (YEAR), documented Policy Statement Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary need . The facility's Diet Spreadsheet for 10/9/2018 indicated for the pureed diet for the lunch meal included: Pureed Hamburger Steak, Mashed Potatoes with Gravy, Pureed Creamed Corn, Pureed Frosted Gelatin, Poke Cake, Pureed Buttered White Bread and Milk/Beverage. During the lunch meal trayline observation on 10/9/2018 at 10:50 AM, no Pureed Buttered White Bread was observed on the trayline. In an interview on 10/10/2018 at 9:30 AM, Employee Identifier (EI) #7, the Certified Dietary Manager (CDM) was asked if Pureed Buttered White Bread bread should have been made for the lunch meal on 10/9/2018. EI #7 replied, yes and explained it should have been made and served separately. When asked why it was not made, EI #7 said she was not sure and the staff may have forgot to make it. EI #7 explained the Pureed Buttered White Bread should have been made because the residents who received pureed diets would not receive the grains from the bread and they would miss part of the their diet. The RESIDENT CENSUS AND CONDITIONS OF RESIDENTS (Form CMS-672) dated 10/9/2018 indicated the facility had a total of 146 residents. The facility's Physician order [REDACTED]. This deficiency was cited as a result of the investigation of complaint/report number AL 881.

Based on interviews, review of Resident Identifier (RI) #1's medical record, Fundamentals of Nursing and the 2010 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Employee Identifier (EI) #2, a Licensed Practical Nurse (LPN), failed to honor the resident rights of Resident Identifier (RI) #1, a resident with Full Code status. Code status describes what type of intervention a health care facility will conduct should a resident stop breathing and/or their heart stops beating. Full Code status means when a resident stops breathing and/or their heart stops beating, staff are to immediately initiate emergency medical services, Cardiopulmonary Resuscitation (CPR), in an attempt to revive the resident. During the 3:00 p.m. - 11:00 p.m. shift on [DATE], EI #1, a Certified Nursing Assistant (CNA), entered RI #1's room and found the resident without a pulse. EI #1 then informed EI #2, the LPN Charge Nurse. EI #2 went to the door of RI #1's room, looked in and saw that RI #1 looked pale. Instead of assessing RI #1's condition and activating the emergency response system, EI #2, who was CPR certified, left the resident's room door and went to the nurses' station to call the Registered Nurse (RN) Supervisor, EI #3. After EI #3 walked to the side of the facility where RI #1's room was located, she initiated the activation of the emergency response system and started CPR on RI #1, a resident with Full Code status. According to the AHA, the lone rescuer should immediately activate the emergency response system, get an AED (Automated External Defibrillator)/defibrillator, if available, and start CPR with chest compressions. CPR should be continued without interruptions until more experienced rescuers assume care. This deficient practice affected RI #1, one of three sampled residents reviewed for emergency response, and placed RI #1 in immediate jeopardy of serious injury, harm or death. On [DATE] at 6:11 p.m., the facility's Interim Administrator and Director of Nursing were notified of the findings of immediate jeopardy in the area of Resident Rights, F 155. Findings include: Cross reference F 309 The 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care with a copyright date of 2010 documented . Part 4: CPR Overview . The Universal Adult Basic Life Support (BLS) Algorithm is a conceptual framework for all levels of rescuers in all settings. It emphasizes the key components that any rescuer can and should perform. When encountering a victim of sudden adult [MEDICAL CONDITION], the lone rescuer must first recognize that the victim has experienced a [MEDICAL CONDITION], based on unresponsiveness and lack of normal breathing. After recognition, the rescuer should immediately activate the emergency response system, get an AED (Automated External Defibrillator), if available, and start CPR with chest compressions . Page 853 of Potter and Perry Fundamentals of Nursing Eighth Edition with a copyright date of 2013, documented: . Restoration of Cardiopulmonary Functioning . A [MEDICAL CONDITION] is a sudden cessation of cardiac output and circulation . A lone health care provider who sees an adult in [MEDICAL CONDITION] should activate the emergency response system, get and use an automatic external defibrillator (AED) if available, and give CPR . On [DATE], the State Agency received a complaint regarding the care RI #1 received on [DATE]. According to the complainant, she received an anonymous call on [DATE] that stated RI #1 died in the facility as the result of staff negligence. RI #1 was admitted to the facility on [DATE] with a medical history to include: [MEDICAL CONDITION], Hypoxic Ischemic [MEDICAL CONDITION], Heart Failure and [MEDICAL CONDITION]. RI #1's physician's orders [REDACTED]. . CODE STATUS: Full . RI #1's physician's orders [REDACTED].#1 had Full Code status. On [DATE] at 12:28 p.m., an interview with EI #1, the CNA who found RI #1 without a pulse during the 3p - 11p shift on [DATE] was conducted. EI #1 explained that when she entered RI #1's room, she checked the resident for a pulse and RI #1 did not have a pulse. EI #1 said she went to the nurse (EI #2, the LPN Charge Nurse) and informed the nurse that she could not find a pulse on RI #1. On [DATE] at 9:22 a.m., an interview was conducted with EI #2, the LPN assigned to care for RI #1 during the 7a - 7p shift on [DATE]. EI #2 was asked, if RI #1 was a Full Code. EI #2 said, yes. On [DATE] at 3:21 p.m., an interview with EI #3, the RN Supervisor on [DATE] was conducted. EI #3 was asked, what did the AHA CPR guidelines instruct staff to do when they find a resident unresponsive. According to EI #3, the staff should know if the person is a code (Full Code) or no code (DNR/Do Not Resuscitate). EI #3 said if the person is a code, the staff should start CPR. EI #3 was asked if EI #2 initiated CPR on RI #1. EI #3 replied, No. In a follow-up telephone interview on [DATE] at 1:58 p.m., EI #3 (RN Supervisor) acknowledged that when EI #2 (the LPN) met her in the hallway, EI #2 told her that she did not think RI #1 was breathing. EI #3 further acknowledged that EI #2 had not called a code blue. When asked, if she asked the LPN (EI #2), why a code was not called. EI #3 said, No. EI #3 said she did not think to ask EI #2 why she had not called a code when she found RI #1 unresponsive. When asked, what should have been done, EI #3 replied, She (EI #2) should have gone in the room, checked for a pulse and then called a code. ************************* On [DATE] at 6:44 p.m., the facility submitted an Allegation of Credible Compliance, which documented: This allegation of credible compliance is being submitted in compliance with specific regulatory requirements. The preparation and or execution of this allegation of credible compliance does not constitute admission of agreement by the provider of the facts alleged and conclusions set forth. Please accept this credible allegation of compliance as the facilities written credible allegation that the alleged deficiencies to be cited have been corrected by the date or dates indicated. F 155 1. RI #1, a resident with wishes to be a full code expired in route to hospital on [DATE]. 2. All residents with wishes to be a full code, charts were audited on [DATE] by the DON (Director of Nursing) and unit managers to ensure the residents chart reflected the residents wish to be a full code. All charts audited contained or reflected the residents code status wish. 3. All staff were re-educated by DON/designee on honoring residents rights who wishes to be a full code. This was completed on [DATE]. 4. No residents have expired in the facility since [DATE]. ************************* After reviewing the facility's information provided in their Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F 155 was lowered to D level on [DATE], to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 249.

Based on interviews, review of Resident Identifier (RI) #1's medical record, the facility's policy titled Cardiopulmonary Resuscitation (CPR) and Basic Life Support and the 2010 American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, the facility failed to ensure Employee Identifier (EI) #2, a Licensed Practical Nurse (LPN) assessed the condition of RI #1 after a CNA (Certified Nursing Assistant) was reported to her that RI #1, a resident with Full Code status, did not have a pulse. EI #1 also failed to follow the AHA guidelines for providing Cardiopulmonary Resuscitation to RI #1, a resident with Full Code status. Code status describes what type of intervention a health care facility will conduct should a resident stop breathing and/or their heart stops beating. Full Code status means when a resident stops breathing and/or their heart stops beating, staff are to immediately initiate emergency medical services, CPR, in an attempt to revive the resident. According to the AHA, the lone rescuer should immediately activate the emergency response system, get an AED (Automated External Defibrillator)/defibrillator, if available, and start CPR with chest compressions. CPR should be continued without interruptions until more experienced rescuers assume care. During the 3:00 p.m. - 11:00 p.m. shift on [DATE], EI #1, a CNA reported to EI #2, the LPN, that RI #1 did not have a pulse. Instead of assessing the resident's condition, EI #2 looked at RI #1 from the resident's doorway, turned around and walked down the hall to the nurses' station. EI #2 did not immediately activate the emergency response system or call a code. Instead, EI #2 made a non-emergent call for the Registered Nurse (RN) Supervisor (EI #3) to come to the side of the facility where RI #1 resided. When EI #2 met EI #3 walking down the hall, EI #2 informed EI #3 that she did not think RI #1 was breathing. After EI #3 entered RI #1's room, EI #3 assessed the resident's condition, initiated CPR and directed EI #2 to activate the emergency response system (911) and to call all available nurses for assistance. These deficient practices affected RI #1, one of three sampled residents reviewed for emergency response, and placed RI #1 in immediate jeopardy of serious injury, harm or death. On [DATE] at 6:11 p.m., the facility's Interim Administrator and Director of Nursing were notified of the findings of substandard quality of care at immediate jeopardy in the area of Quality of Care, F 309. Findings include: On [DATE], the State Agency received a complaint regarding the care RI #1 received on [DATE]. According to the complainant, she received an anonymous call on [DATE] that stated RI #1 died in the facility as the result of staff negligence. The facility's policy titled Cardiopulmonary Resuscitation (CPR) and Basic Life Support (BLS) with a revised date of [DATE], documented: Purpose The purpose of this procedure is to provide guidelines for the initiation of Cardiopulmonary Resuscitation (CPR)/Basic Life Support (BLS) in victims of sudden [MEDICAL CONDITION] . General Guidelines 1. [MEDICAL CONDITION] is defined as inadequate cardiac contractions resulting in insufficient blood flow throughout the body (pulselessness) . 8. The goal of early delivery of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advanced Life Support (ALS). 9. If an individual (resident, visitor, or staff) is found unresponsive and not breathing normally, a licensed staff person who is certified in CPR/BLS shall initiate CPR unless: a. It is known that a Do Not Resuscitate (DNR) order . Steps in the Procedure The facility's procedure for administering CPR shall incorporate the steps covered in the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care . The 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care with a copyright date of 2010 documented . Part 4: CPR Overview . The Universal Adult Basic Life Support (BLS) Algorithm is a conceptual framework for all levels of rescuers in all settings. It emphasizes the key components that any rescuer can and should perform. When encountering a victim of sudden adult [MEDICAL CONDITION], the lone rescuer must first recognize that the victim has experienced a [MEDICAL CONDITION], based on unresponsiveness and lack of normal breathing. After recognition, the rescuer should immediately activate the emergency response system, get an AED (Automated External Defibrillator), if available, and start CPR with chest compressions. If an AED is not close by, the rescuer should proceed directly to CPR. If other rescuers are present, the first rescuer should direct them to activate the emergency response system and get the AED/defibrillator; the first rescuer should start CPR immediately . If an AED/defibrillator is not available, continue CPR without interruptions until more experienced rescuers assume care . rescuers should start CPR immediately if the adult victim is unresponsive and not breathing or not breathing normally . CPR improves the victim's chance of survival by providing heart and brain circulation. Rescuers should perform chest compressions for all victims in [MEDICAL CONDITION], regardless of rescuer skill level, victim characteristics, or available resources . RI #1 was admitted to the facility on [DATE] with a medical history to include: [MEDICAL CONDITION], Hypoxic Ischemic [MEDICAL CONDITION], Heart Failure and [MEDICAL CONDITION]. RI #1's physician's orders [REDACTED]. . CODE STATUS: Full . RI #1's physician's orders [REDACTED].#1 had Full Code status. On [DATE] at 12:28 p.m., an interview was conducted with EI #1, the CNA who found RI #1 without a pulse during the 3p - 11p shift on [DATE]. EI #1 said when she entered RI #1's room, RI #1 looked pale, and when checked, the resident did not have a pulse. EI #1 said she went to the nurse, EI #2 (LPN Charge Nurse), and informed her she could not find a pulse on RI #1. On [DATE] at 9:22 a.m., an interview was conducted with EI #2, the LPN assigned to care for RI #1 during the 7a - 7p shift on [DATE]. According to EI #2, around 3:45 p.m./4:00 p.m., she was at the nurses' station when a CNA came and informed her that RI #1 did not have a pulse. Instead of going into RI #1's room, EI #2 acknowledged she stood in the resident's doorway and noticed RI #1 was pale in color. EI #2 did not assess RI #1's condition or check the resident's vital signs after EI #1 reported to her that RI #1 did not have a pulse. EI #2 left RI #1's doorway and proceeded to the nurses' station to call the nursing supervisor, EI #3. EI #2 paged overhead for the supervisor, EI #3, to come to the hall where RI #1 resided. EI #2 did not call code blue, as indicated in the facility's policy. As EI #2 was walking back to RI #1's room, she observed EI #3 walking from the other hall. According to EI #2, she told EI #3 that she needed her to come to RI #1's room. EI #2 said when she and EI #3 entered RI #1's room they assessed the resident's vitals. EI #3 assessed RI #1's pulse and told EI #2 to go and find out what RI #1's code status was. When asked, what RI #1's code status was, EI #2 said RI #1 was a Full Code. When asked, who initiated CPR, EI #2 stated she did not know as she was at the nurses' station making copies. EI #2 was asked, why she did not enter RI #1's room to assess the resident. EI #2 said she felt like RI #1's color was pale and she needed to get another nurse to help her. EI #2 was asked, what did the AHA CPR guidelines state should be done when a person is found unresponsive. EI #2 said, she thought the guidelines said to call for help. When asked, what could have been done differently for RI #1, EI #2 said she did not know what she could have done differently. According to EI #2, she has been a licensed nurse for [AGE] years. EI #2's personnel file revealed she was certified in Basic Life Support for Healthcare Providers/CPR and AED Program on [DATE], with an expiration date of [DATE]. In a follow-up interview on [DATE] at 10:44 a.m., EI #2 said what she could have done differently, was to ring RI #1's call light for help in the resident's room. On [DATE] at 3:21 p.m., the surveyor conducted an interview with EI #3, the RN Supervisor on [DATE]. The surveyor asked EI #3 can an unresponsive resident be assessed from the doorway of a room. EI #3 said, no. According to EI #3, when the CNA (EI #1) informed EI #2 (the LPN) that RI #1 was pale and without a pulse, EI #2 should have gone into RI #1's room to assess the resident. EI #3 was asked, what the AHA CPR guidelines instructed a staff to do when they find a resident unresponsive. EI #3 said if the person is a Full Code you should start CPR. When asked if EI #2 initiated CPR, EI #3 replied, No. EI #3 said CPR was initiated after she assessed RI #1 and found the resident without breath sounds, a heartbeat or a pulse. EI #3 explained how she started chest compressions and told EI #2 to go to the desk and call all available nurses and 911. In a follow-up telephone interview on [DATE] at 1:58 p.m., EI #3 acknowledged that when EI #2 (the LPN) met her in the hallway, EI #2 told her that she did not think RI #1 was breathing. EI #3 further acknowledged that EI #2 had not called a code blue. When asked, if she asked the LPN (EI #2), why a code was not called. EI #3 said, No. EI #3 said she did not think to ask EI #2 why she had not called a code when she found RI #1 unresponsive. When asked, what should have been done, EI #3 replied, She (EI #2) should have gone in the room, checked for a pulse and then called a code. On [DATE] at 8:02 a.m., EI #6, the Staff Educator stated CPR was reviewed in staff orientation. EI #6 explained that it was the charge nurse's responsibility to take charge in an emergency situation. EI #6 was asked, what should staff do if they find a resident unresponsive. EI #6 said if a resident is found unresponsive, the nurse would go in and assess the resident. EI #6 further stated, if a code should be called, the nurse should pull the call light to activate the emergency light. When a staff member responds to the call light, the charge nurse should instruct the staff to call code blue and activate the emergency response system (911). The charge nurse should immediately start chest compressions and as others come, designate other duties as needed. When asked if a resident could be assessed from the doorway, EI #6 said no. In an interview on [DATE] at 8:43 a.m., EI #7, the RN Unit Manager was asked, what did the facility's policy dictate the nurse to do if a resident was found unresponsive and without a pulse. EI #7 said, if a resident was found unresponsive or without a pulse, the nurse should call for help, go ahead and start chest compressions and once someone comes to the door designate that a code and 911 be called. During an interview with the EI #5, the Director of Nursing on [DATE] at 10:17 a.m., she acknowledged the appropriate steps a nurse should take when a resident is found without a pulse. EI #5 said, the nurse who found a resident unresponsive should immediately do a tactile, visual assessment to determine the status of the resident. The nurse should immediately start CPR if the resident is found without a pulse or respiration. The nurse should call for help, by pulling the call light out of the wall for assistance. The nurse should follow the protocol for CPR. EI #5 was asked, what the AHA guidelines dictated a first responder to do. EI #5 said, do not leave your resident. When asked, what should EI #2 have done, EI #5 replied, EI #2 should have gone in RI #1's room and assessed the resident. ************************* On [DATE] at 6:44 p.m., the facility submitted an Allegation of Credible Compliance, which documented: This allegation of credible compliance is being submitted in compliance with specific regulatory requirements. The preparation and or execution of this allegation of compliance does not constitute admission of agreement by the provider of the facts alleged and conclusions set forth. Please accept this credible allegation of compliance as the facilities written credible allegation that the alleged deficiencies to be cited have been corrected by the date or dates indicated. F309 1. The LPN responsible for the care of RI #1 on [DATE] was given 1 on 1 inservice on [DATE] on how to respond when a resident is found without a pulse and how to immediately activate the Emergency Response System (ERS). 2. All licensed staff except three were re-educated on what to do when a resident is found without a pulse and how to immediately activate the ERS. This was completed on [DATE] by the DON, unit managers, and staff development. The three licensed staff who have not been educated will not work until the education has occurred. 3. The DON/designee did a mock code on [DATE] and [DATE] to ensure all licensed staff responding to residents with wishes to be a full code were able to initiate CPR/basic life support. Return demonstration was done on [DATE] and [DATE]. All licensed staff involved in the mock code were able to demonstrate and acknowledge when basic CPR was to be initiated. 4. Don/designee reviewed the personnel files of all licensed staff to ensure they were CPR certified. All reviewed licensed personnel files reflected CPR certifications were up to date. This was completed on [DATE]. On [DATE], the facility updated the policy to reflect all licensed staff should respond to residents with wishes to be a full code and should initiate CPR/basic life support immediately. ************************* After reviewing the facility's information provided in their Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F 309 was lowered to D level on [DATE], to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 249.

Based on interviews, review of Employee Identifier (EI) #3's job description and Fundamentals of Nursing, EI #3, the Registered Nurse Supervisor failed to inform the Administrative Staff that the Cardiopulmonary Resuscitation (CPR) was not immediately initiated and the emergency response system (911) was not immediately activated when Resident Identifier (RI) #1, a resident who was Full Code status, was initially found without a pulse on [DATE]. During the 3:00 p.m. - 11:00 p.m. shift on [DATE], EI #1, a Certified Nursing Assistant (CNA) reported to EI #2, the LPN, that RI #1 did not have a pulse. Instead of assessing the resident's condition, EI #2 looked at RI #1 from the resident's doorway, turned around and walked down the hall to the nurses' station. EI #2 did not immediately activate the emergency response system or call a code. Instead, EI #2 made a non-emergent call for the Registered Nurse (RN) Supervisor (EI #3) to come to the side of the facility where RI #1 resided. When EI #2 met EI #3 walking down the hall, EI #2 informed EI #3 that she did not think RI #1 was breathing. After EI #3 entered RI #1's room, she assessed the resident's condition, initiated CPR and directed EI #2 to activate the emergency response system (911) and to call all available nurses for assistance. This deficient practice affected RI #1, one of three sampled resident reviewed for emergency response, and placed RI #1 in immediate jeopardy of serious injury, harm or death. On [DATE] at 6:11 p.m., the facility's Interim Administrator and Director of Nursing were notified of the findings of immediate jeopardy in the area of Administration, F 490. Findings include: Cross reference F 155 and F 309 Unit 3 titled Critical Thinking in Nursing Practice page 245 of Chapter 18 titled Planning Nursing Care of Potter and Perry Fundamentals of Nursing Eighth Edition with a copyright date of 2013, documented . Change of Shift . It is a critical time when nurses collaborate and share important information that ensures the continuity of care for a patient and prevents errors or delays in providing nursing interventions . EI #3's CHARGE NURSE - RN Job description date ,[DATE], documented: . LANGUAGE, MATHEMATICAL & REASONING SKILLS . Ability to effectively present information to top management . Residents' Rights Functions *Understands, compliance and promotes all rules regarding Resident's Rights . In an interview on [DATE] at 12:28 p.m., EI #1 (the Certified Nursing Assistant) stated when she entered RI #1's room, RI #1 looked pale, and when checked, the resident did not have a pulse. EI #1 said she went to the nurse, EI #2 (LPN Charge Nurse), and told her she could not find a pulse on RI #1. On [DATE] at 9:22 a.m., an interview was conducted with EI #2, the LPN assigned to care for RI #1 during the 7a - 7p shift on [DATE]. According to EI #2, around 3:45 PM/4:00 PM, she was at the nurses' station when a CNA came and informed her that RI #1 did not have a pulse. Instead of going into RI #1's room, EI #2 acknowledged that she stood in the resident's doorway and noticed that RI #1 was pale in color. EI #2 did not assess RI #1's condition or check the resident's vital signs after she was informed by EI #1 that RI #1 did not have a pulse. EI #2 left RI #1's doorway and proceeded to the nurses' station to call the nursing supervisor, EI #3. EI #2 paged overhead for the supervisor, EI #3, to come to the hall where RI #1 resided. EI #2 did not call code blue, as indicated in the facility's policy. As EI #2 was walking back to RI #1's room, she observed EI #3 walking from the other hall. According to EI #2, she told EI #3 that she needed her to come to RI #1's room. EI #2 said when she and EI #3 entered RI #3's room they assessed RI #1's vitals. EI #3 assessed RI #1's pulse and told EI #2 to go and find out what RI #1's code status was. When asked, who initiated CPR, EI #2 stated she did not know as she was at the nurses' station making copies. EI #2 was asked, why she did not enter RI #1's room to assess the resident. EI #2 said she felt like RI #1's color was pale and she needed to get another nurse to help her. On [DATE] at 3:21 p.m., the surveyor conducted an interview with EI #3, the RN Supervisor on [DATE]. The surveyor asked EI #3 can an unresponsive resident be assessed from the doorway of a room. EI #3 said, no. According to EI #3, when the CNA informed EI #2 that RI #1 was pale and without a pulse, EI #2 should have gone into RI #1's room to assess the resident. EI #3 was asked, what the AHA CPR guidelines instructed a staff to do when they found a resident unresponsive. EI #3 said if the person is Full Code you should start CPR. When asked if EI #2 initiated CPR, EI #3 replied, No. EI #3 said CPR was initiated after she assessed RI #1 and found the resident without breath sounds, a heartbeat or a pulse. EI #3 explained how she started chest compressions and told EI #2 to go to the desk and call all available nurses and 911. On [DATE] at 10:17 a.m., an interview was conducted with EI #5, the Director of Nursing (DON). EI #5 acknowledged that she was informed on Monday, [DATE] that RI #1 had expired. According to EI #5, EI #3 (the RN Supervisor) told her that RI #1 crashed, CPR was started, 911 was called and RI #1 was sent to a local hospital per the family's preference. In a follow-up telephone interview on [DATE] at 1:58 p.m., EI #3 was asked if she informed EI #5 (DON) when she talked with her on Monday ([DATE]) that EI #2 (the LPN) did not call a code when RI #1 was initially found pale, unresponsive and without a pulse. EI #3 said she did not remember if she did or not. In a follow-up interview on [DATE] at 5:25 p.m., EI #5 acknowledged that she was not informed by EI #3 (the RN Supervisor) that when the resident (RI #1) was initially found by EI #2 (the LPN) that the resident was not breathing. EI #5 was not aware that EI #2 had not called a code blue when the CNA (EI #1) first reported to EI #2 that RI #1 did not have a pulse. When asked, what she would have done if the events surrounding RI #1 being found without a pulse had been reported to her on Monday [DATE], EI #5 stated she would have begun an investigation relating to how to respond to an unresponsive resident. ************************* On [DATE] at 6:44 p.m., the facility submitted an Allegation of Credible Compliance, which documented: This allegation of credible compliance is being submitted in compliance with specific regulatory requirements. The preparation and or execution of this allegation of credible compliance does not constitute admission of agreement by the provider of the facts alleged and conclusions set forth. Please accept this credible allegation of compliance as the facilities written credible allegation that the alleged deficiencies to be cited have been corrected by the date or dates indicated. F 490 1. The RN weekend supervisor in charge on [DATE] received 1 on 1 inservice on the importance of informing administrative staff when there has been a failure to initiate the ERS (emergency response system) correctly. This was completed by the DON. 2. A review of resident charts reveals that there has not been a need to activate the ERS since [DATE]. This review was completed on [DATE] by the DON and unit managers. 3. DON/designee educated all supervisors on [DATE] on the importance of informing administrative staff when there has been a failure to initiate the ERS correctly. On [DATE], an emergency response occurrence review form was developed by the administrative staff to be used when a code has been done to ensure the code was initiated correctly. 4. No residents have expired in the facility since [DATE]. ************************* After reviewing the facility's information provided in their Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F 490 was lowered to D level on [DATE], to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 249.

Based on interviews, record review and review of a facility policy titled "Notification Of Change Of Condition" and "Resident Incident/Accident Reports-Quality Assurance", the facility failed to immediately notify Resident Identifier (RI) #1's and RI #2's physicians of an inappropriate sexual behavior on 08/23/12, after RI #1 and RI #2 were observed engaged in oral sex. According to EI #5, the LPN (Licensed Practical Nurse) charge nurse, RI #2 remained on the secure dementia unit that night and was not placed on 1:1 supervision. According to the facility's psychiatrist, he stated if he had been notified of the inappropriate sexual act he would have had the facility to send RI #2 back to the Geri-psychiatric unit. This deficient practice affected RI #1 and RI #2, two of four residents sampled for inappropriate sexual behaviors, and had the potential to affect all 20 female resident's residing on the facility's secure unit. On 09/14/12 at 4:40 PM, the facility's Interim Administrator, the DON (Director of Nursing), and the Regional Clinical Nurse were notified of the findings of immediate jeopardy in the area of Resident's Rights, Notification at F 157. After reviewing the facility's information provided in their Allegation of Credible Compliance (AOC), conducting interviews with the Physicians and sponsors of RI #1 and RI #2, conducting interviews with licensed staff, and reviewing the facility's in service records to determine if the facility implemented their AOC, the survey team abated the Immediate Jeopardy. The facility's Administrator was informed the scope and severity was lowered to "D" on 10/01/12 at 3:35 PM. Findings include: A facility policy and procedure titled "NOTIFICATION OF CHANGE OF CONDITION" with an original date of May 16, 2002, documents: "Policy /Objective: Federal regulations require the facility to immediately inform the resident, consult with the resident's attending physician, and notify the resident's legal representative or interested family when there is: ... 2. A significant change in the resident's physical, mental, or psychosocial status ... 3. A need to alter treatment significantly ... 3b. When a new form of treatment needs to be started to deal with a problem ... 4. A decision to transfer or discharge the resident from the facility ... Procedure ... 4. Every attempt will be made to notify all required, appropriate individuals in a proper amount of time as determined by the seriousness of the situation presented." Another facility policy and procedure titled "Resident Incident/ Accident Reports-Quality Assurance" with an Effective Date of 10/11, documents: POLICY: It is the policy of (name of Corporation) that all resident incidents/accidents are recorded, reviewed and trends determined in order to, as much as possible, provide for resident, staff, and visitor safety PROCEDURE: ... 3. Resident's family or responsible party will be notified in all incidents. ... RI #1 RI #1 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #1's Quarterly MDS (Minimum Data Set), with an Assessment Reference Date (ARD) of 04/27/12 identified RI #1 as sometimes understood - ability is limited to making concrete requests and sometimes understands others - responds adequately to simple, direct communication only. RI #1 was assessed as needing supervision with walking in the room and in the corridor and with locomotion on the unit and needing extensive assistance for bed mobility, dressing, eating, toilet use and personal hygiene. RI #1's Annual MDS, with an ARD of 07/25/12, identified RI #1 as having short and long term memory loss and severely impaired cognitive skills for daily decision making. RI #1 was assessed as needing supervision with walking in the room and on the corridor and with locomotion on the unit, needing limited assistance with transfers, needing extensive assistance with bed mobility, dressing, eating and personal hygiene. An Accident/Incident Report Form documents: "... Date of Report 08/24/12, Date of Incident 08/23/12, Time of incident 6: PM (6:00 PM), Person involved (RI #1's and RI #2's name) Witness: (EI #4's) ... Type of Incident: ... Resident to Resident Incident ... Other: behavior - sexual ... (name of EI #4) was picking up trays on F-Hall. Upon entering (name of RI #2's) room she (EI #4) found (name of RI #1) having oral sex with (name of RI #2). She (RI #1) was removed from room and taken to dining room". RI#2 RI #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/17/12 RI #2 was readmitted to the facility with [DIAGNOSES REDACTED]. RI #2's Admission MDS, with an ARD of 07/24/12, identified RI #2's BIMS (Brief Interview for Mental Status) score was 13 (thirteen), indicating he was cognitively intact. Under Section C1300; Signs and Symptoms of [MEDICAL CONDITION], RI #2 was coded as having a fluctuation of Inattention and Disorganized thinking behaviors. RI #2 was assessed as needing supervision with eating, needing limited assistance with bed mobility, transfers, walking in the room, with locomotion on and off the unit, with toilet use and personal hygiene and needing extensive assistance with walking in the corridor and dressing. On 09/08/12 at 3:35 PM, the surveyor conducted a phone interview with RI #2's physician. RI #2's physician stated he didn't remember being informed that facility staff observed RI #2 with his penis in a female resident's mouth on 08/23/12. On 09/12/12 at 1:30 PM, the surveyor conducted a phone interview with the sponsor of RI #2. The surveyor asked RI #2's sponsor did the facility notify her that on 08/23/12, RI #2 had his penis in a female resident's mouth. RI #2's sponsor gasped and stated, 'O my God no.' RI #2's sponsor stated the facility told her he had inappropriate contact with a female resident and had not gone into details. The sponsor went on to say that she had told the staff that she wanted them to be honest with her about RI #2's behaviors but the facility had not told her what the surveyor did. On 09/17/12 at 1:48 PM, the surveyor conducted a phone interview with EI #5, the LPN (Licensed Practical Nurse) charge nurse assigned to care for RI #1 and RI #2 on 08/23/12. The surveyor asked EI #5 why was the incident report done on 08/24/12 and not on 08/23/12. EI #5 stated she guessed she was in shock and forgot to do it. EI #5 stated when she came to work the next day she did the incident report. EI #5 stated she didn't remember notifying RI #2's physician. EI #5 stated if she had notified RI #2's physician it would be in the nurses notes or in the incident report. Review of the incident report and the nurses note revealed there was no documentation that an attempt had been made to notify RI #2's physician of the incident occurring on 08/23/12. EI #5 stated one-on-one monitoring was not done with RI #2 on that night. During an interview on 9/6/12 at 5:05 PM, EI #5 stated RI #2 was not moved off the unit the next morning. EI #5 also stated she had not notified RI #1's or RI #2's family because she wasn't sure what to do. On 09/08/12 at 9:36 AM, the surveyor conducted an interview with EI #6, the facility's Social Worker. EI #6 stated she notified RI #1's family of the 08/23/12 incident on 08/27/12. EI #6 stated she did not notify RI #1's physician. EI #6 stated she was not sure what the time frame for notifying the family was. EI #6 stated she did not notify the family of RI #1 within 24 hours. On 09/09/12 at 4:50 PM, the surveyor conducted an interview with EI #7, the DON. The surveyor asked EI #7 when was RI #1's sponsor notified of the incident occurring between RI #2 and RI #1 on 08/23/12. The DON reviewed the medical records of RI #1. EI #7 stated RI #1's sponsor was notified on 08/27/12 (referring to documentation in the Social Progress Notes). The surveyor asked EI #7 was there a time frame for notification. EI #7 stated, "At least immediately or within the shift it occurred." EI #7 stated the physicians should have been notified in the same time frame as notifying the family. EI #7 stated it would have been the responsibility of the nurse to notify the physician. On 09/10/12 at 4:27 PM, the surveyor conducted a phone interview with the facility's Psychiatrist. The surveyor asked the facility Psychiatrist if the facility informed him that RI #2 had been observed having oral sex with a cognitively impaired female resident at the facility on 08/23/12. The facility Psychiatrist stated he was not aware of that. The facility's Psychiatrist stated he thought RI #2 had been sexually inappropriate as far as what he was told, touching a female. This deficiency was written as a result of the investigation of complaint/report #AL 416. ****************************************************** On 09/17/12 at 6:32 PM, the facility submitted the following Allegation of Compliance as to how they would relieve the Immediate Jeopardy at F 157. This Allegation of Compliance is being submitted in compliance with specific regulatory requirements and preparation and/or execution of this Allegation of Compliance does not constitute admission or agreement by the provider of the facts alleged or conclusions set forth. Please accept this Allegation of Compliance as the facilities written credible allegation that all alleged deficiencies to be cited have been corrected by the date or dates indicated. F157 Notification 1. Corrective measures for residents found to have been affected by the deficient practice ... ? On 9/8/12, the Medical Director attended an emergency Quality Assurance meeting with the facility's Administration Staff concerning the survey and actions to be taken to correct issues identified. Those in attendance were: Nursing Home Administrator, Director of Nursing, Regional Vice President of Operations ... ? On 9/13/12, RI#2's Physician, EI#20, was notified regarding incident ... 8/23/12. ? On 9/15/12, RI#1's physician was notified of incidents on ... 8/23/12. ? On 9/14/12, The Physician on call for the Medical Director attended an emergency Quality Assurance meeting with the Nursing Home Administrator and Management of the facility to review plans being implemented by facility to address issues identified by the survey team. Those in attendance were the Physician on call, Nursing Home Administrator, Director of Nursing, Regional Vice President of Operations. ? On 9/15/12, the Sponsor of RI#2 was notified of incident that occurred on ... and was given specifics of 8/23/12 incident ... 2. How the facility identified other residents having the potential to be affected by the same deficient practice. ? On 9/14/12 - 9/15/12, the charts of all residents on the secure unit were audited for notification of any incident and accident ... No issues were identified with this audit. 3. Systemic Measures taken to ensure that the deficient practice does not reoccur. ? On 9/10/12 to 9/13/12, all direct care staff, Registered Nurses, Licensed Practical Nurses and Certified Nursing Assistants were inserviced on notification of Physician and Sponsor when incidents and accidents occur. Staff not on schedule will be inserviced prior to reporting to their next assigned shift. 4. How does the facility plan to monitor the systemic measures put into place? ? On 9/15/12, the Director Of Nursing reviewed results of audit and no issues were identified. ************************************************** On 09/17/12, contact had been made by the surveyor with the physicians and sponsors of RI #1 and RI #2 to ensure both had been notified of the 08/23/12 incident. Both physicians and sponsors had been notified of the incident. On 09/15/12 - 09/17/12, interviews were conducted with licensed staff to ensure staff was aware when to notify the physician and sponsor. All interviewed were able to state when physicians and sponsors were to be notified. On 09/17/12, inservice sheets were reviewed to ensure licensed staff had been inserviced on when to notify physician and sponsors. After reviewing the facility's information provided in their Allegation of Credible Compliance (AOC), conducting interviews with the physicians and sponsors of RI #1 and RI #2, conducting interviews with staff at the facility, and reviewing the facility's inservice sheets to determine if the facility implemented their AOC, the survey team abated the Immediate Jeopardy.

Based on review of the Job Description of the Social Worker, Employee Identifier (EI) #6, record review and interviews, EI #6 failed to ensure that Resident Identifier (RI) #2, a resident with a [DIAGNOSES REDACTED].#2's sexually inappropriate behaviors when the behaviors progressively worsened. EI #6 failed to ensure that information regarding RI #2's behaviors, both while in the facility and after hospitalization , was reviewed and appropriately addressed through a behavior management plan, so that staff were aware of how to address the resident's known sexually inappropriate behaviors when he returned from the hospital. On 05/31/12, RI #2 made a comment about a confused female resident (RI #1) to EI #1, a Certified Nursing Assistant (CNA). EI #1 stated RI #2 said, if RI #1 did not quit hounding herself with her hands down her pants, someone was going to give her a good screwing. EI #1 stated he informed EI #2, a Licensed Practical Nurse (LPN) and EI #16, a LPN in orientation of the comment RI #2 made regarding RI #1. EI #2 stated she was not aware if RI #2 was on a behavior management plan of care to address his behavior. EI #16, the LPN, documented the comment that RI #2 made in the nursing notes in RI #2's medical record. The facility documented RI #2 was redirected by informing him that the manner in which he spoke about RI #1 was inappropriate. On 9/13/12, an interview with EI #6, the Social Worker, revealed she was unaware of the comment RI #2 made toward RI #1 on 05/31/12 because she did not review RI #2's medical records after he was discharged from the facility or upon readmission. On 9/13/12, EI #7, the Director of Nursing (DON) stated that RI #2 should have been placed on behavior monitoring after the comment was made. Four days later, on 06/04/12, RI #2 made another inappropriate comment regarding RI #1 to a different CNA, EI #3. According to EI #3, he also witnessed RI #2 touch RI #1's groin/genital area on this same day. RI #2 was sent out of the facility to a local hospital and was subsequently committed to a Psychiatry unit for treatment. RI #2 returned to the facility on [DATE] to the same secure unit where he had exhibited the sexually inappropriate behaviors toward RI #1. Once readmitted , there was no behavior management plan developed for how to address or monitor the behaviors that RI #2 exhibited before he was discharged to the hospital. On 8/23/12, RI #2 was witnessed having oral sex with RI #1. RI #1, being confused was unable to consent to this sexual act. This deficient practice affected RI #'s 1 and 2, and had the potential to affect 38 residents identified with behavioral symptoms according to the Resident Census and Condition provided by the facility on 09/05/12. On 09/14/12 at 4:40 PM, the facility's Interim Administrator, the DON, and the Regional Clinical Nurse were notified of the findings of immediate Jeopardy in Social Services (F 250). After reviewing the facility's information provided in their Allegation of Credible Compliance (AOC), conducting interviews with EI #6, the facility's Social Worker, reviewing the inservice done with EI #6, reviewing documentation where the Consultant Social Worker had been notified of her need for increased oversight of the facility's Social Worker, and reviewing inservice records to determine if the facility implemented their AOC, the survey team relieved the immediate Jeopardy. The facility's Administrator was informed the scope and severity was lowered to "D" on 10/01/12 at 3:35 PM. Findings include: The facility's Job Description for the Social Worker, with a Revised date of 2/0, 3/11, documents: "Department: Social Services ... SUMMARY Provides services to respond to the psycho social needs of residents and their family members ... ESSENTIAL DUTIES AND RESPONSIBILITIES This list is subject to individual facility policies, procedures and practices, which may require additional duties and responsibilities ... Conducts and documents a social service evaluation, including identification of Resident problems/needs and arranges for appropriate social services... Implements social service interventions that achieve treatment goals, address resident needs, links social supports, physical care and physical environment to enhance quality of life ..." RI #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #2 was readmitted on [DATE] with an added [DIAGNOSES REDACTED]. RI #2's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/24/12, identified RI #2 as having a fluctuation of Inattention and Disorganized thinking behaviors. RI #2 was assessed as needing supervision with eating, needing limited assistance with bed mobility, transfers, walking in the room, with locomotion on and off the unit, with toilet use and personal hygiene, needing extensive assistance with walking in the corridor, dressing and bathing. RI #1 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. According to RI #1's Annual MDS (Minimum Data Set), with an Assessment Reference Date (ARD) of 07/25/12, RI #1 had short and long term memory loss and severely impaired cognitive skills for daily decision making. RI #1 was assessed as needing supervision with walking in the room and on the corridor and with locomotion on the unit, needing limited assistance with transfers and needing extensive assistance with bed mobility, dressing, eating and personal hygiene. Review of RI #2's medical record revealed the following documentation by nursing staff: "5/31/12 at 12:30 p (PM), Informed via (by) CNA (name of EI #1) that while pt. (patient) was in the shower, he was questioning about another resident's (RI #1's) alertness - who is severely cognitively impaired; adding in sexual suggestions saying if she didn't "stop hounding herself down the front of her pants, someone will end up giving her a good screwing. It may not be me ... but someone would ..." On 09/07/12 at 12:57 PM, the surveyor conducted an interview with EI #2, the LPN charge nurse assigned to care for RI #1 and RI #2 on 06/04/12. EI #2 stated on 06/04/12, she witnessed RI #2 being more aggressive and walking toward RI #1. EI #2 stated she asked EI #3, the CNA assigned to care for RI #2 to go ahead and take RI #2 to the shower. EI #2 stated EI #3 informed her RI #2 said if RI #1 kept putting her hands down her pants he was going to help her out because he is a man. On 09/07/12 at 2:25 PM, the surveyor conducted an interview with EI #3, the CNA assigned to care for RI #2 on 06/04/12 on the 7 AM - 3 PM shift. EI #3 stated as he was coming down the hall way RI #1 was walking toward him and RI #2 was walking away from him. EI #3 stated they both stopped and RI #2 placed his hand between RI #1's legs. EI #3 stated by the time he made it to where the residents were, RI #2 had taken his hand away. RI #3 stated RI #2 did not grab and hold on. EI #3 stated the whole thing lasted maybe two seconds. EI #3 stated he told his charge nurse, EI #2. EI #2 stated she notified the DON, EI #7. EI #2 stated they did one-on-one supervision with RI #2 and got him sent out a local hospital. Review of a Resident Transfer Form for RI #2 dated 06/04/12, completed by EI #17 (RN (Registered Nurse)) documents: "... Behavioral or Social Issues and Interventions: Sexually inappropriate behavior. Groping ... Reason For Transfer (i.e. (for example), What Happened?) Inappropriate sexual behavior ..." On 7/17/12, RI #2 was readmitted back to this facility on the secure unit, the same unit where the above behaviors were documented to occur and where RI #1 continued to reside. NN for RI #2 dated 08/23/12 at 7 PM (7:00 PM) documents: "... Sexually inappropriate behavior this shift ..." An Accident/Incident Report Form documents: "... Date of Report 08/24/12, Date of Incident 08/23/12, Time of incident 6: PM (6:00 PM), Person involved (RI #1's and RI #2's name) Witness: (EI #4's) ... Type of Incident: ... Resident to Resident Incident ... Other: behavior - sexual ... (name of EI #4) was picking up trays on F-Hall. Upon entering (name of RI #2's name) room she (EI #4) found (name of RI #1) having oral sex with (name of RI #2). She (RI #1) was removed from room and taken to dining room". On 9/13/2012 at 11:06 AM, an interview was conducted with EI #6, the facility's social worker. During this interview, it was revealed that EI #6 was told that the facility had sent RI #2 to the hospital because of inappropriate behavior. When asked what the inappropriate behavior was, EI #6 replied that she was told that RI #2 said something about RI #1. EI #6 said the person did not elaborate and that she did not ask any questions and just said okay. EI #6 said she was not told anything about inappropriate touching. When EI #6 was asked how she evaluated residents that were sent out of the facility and readmitted , she stated that when a resident is readmitted , she only looks at the active record. When EI #6 was asked why RI #2's behaviors of sexual comments and touching behavior were not on the care plan, EI #6 stated that the behaviors would not have been within the seven day look back period. She stated we (the facility) normally only look back at behaviors that have occurred within the last seven day look back period. When asked who is responsible for ensuring behaviors are captured or put on the behavior care plan if there is a need, EI #6 replied, the social worker and that would be her. When asked where she would get the information from, EI #6 responded, from the assessment and interviews. When asked how staff would know that RI #2 had inappropriate touching behaviors, EI #6 responded by saying they (staff) would look at the inappropriate sexual behavior/comment care plan. She stated she did not do one until 8/23/12. When asked how she was made aware of RI #2's inappropriate touching, RI #6 stated she was made aware when the DON told her on 08/23/12. On 09/13/12 at 5:22 PM, the surveyor conducted an interview with EI #7, the DON. The surveyor asked EI #7 if the facility had a policy and procedure for behavior management. EI #7 stated no. This deficiency was written as a result of the investigation/report #AL 416. ******************************************************** On 09/17/12 at 6:32 PM, the facility submitted an Allegation of Compliance as to how the facility would relieve the immediacy of F 250 This Allegation of Compliance is being submitted in compliance with specific regulatory requirements and preparation and/or execution of this Allegation of Compliance does not constitute admission or agreement by the provider of the facts alleged or conclusions set forth. Please accept this Allegation of Compliance as the facilities written credible allegation that all alleged deficiencies to be cited have been corrected by the date or dates indicated. F250 Social Services 1. Corrective measures for residents found to have been affected by the deficient practice ? On 9/15/12, EI #6, The facility's Social Worker, was inserviced by the Nursing Home Administrator on completing admission evaluations on all residents being admitted to the nursing home. ? On 9/15/12, the Social Service consultant was contacted regarding the need to increase the oversight of the documentation of the social worker at the facility and to ensure appropriate evaluations will be completed on admission. 2. How the facility identified other residents having the potential to be affected by the same deficient practice. ? On 9/15/12, an audit was completed to review care plans and Kardex ' s of all residents at the facility with behaviors to ensure residents with behaviors have been identified and addressed. No issues identified. 3. Systemic Measures taken to ensure that the deficient practice does not reoccur. ? On 9/14/12, all direct care staff were inserviced on the Behavior Outburst Form and the procedures to follow when behaviors occur. Staff not on schedule will be inserviced prior to reporting to their next assigned shift. 4. How does the facility plan to monitor the systemic measures put into place? ? On 9/15/12, the Director of Nursing reviewed the audits that were completed on 9/15/12 for the facility and no issues were identified. ******************************************************** On 09/17/12, the Social Worker, EI #6, was interviewed on her responsibilities. EI #6 stated she had been inserviced on reviewing all records, closed or active when residents are admitted or readmitted to the facility. On 09/17/12, the inservice sheet for EI #6 was reviewed. On 09/17/12, communication where the Consultant Social Worker had been contacted to ensure EI #6 had increased oversight and assistance was reviewed. On 09/17/12, inservice sheets were reviewed where licensed staff were inserviced on the proper form to complete when residents exhibited behaviors. On 09/17/12, licensed staff were interviewed on what procedure to follow when residents exhibited inappropriate behaviors. All licensed staff interviewed knew what procedure to follow. After reviewing the facility's information provided in their Allegation of Credible Compliance (AOC), conducting interviews with staff at the facility, and reviewing the facility's inservice sheets to determine if the facility implemented their AOC, the survey team relieved the immediate Jeopardy and the scope and severity was lowered to "D" on 09/17/12 at 9:00 PM.

Based on observations, interviews and record review, the facility failed to provide adequate supervision of RI (Resident Identifier) #2, a resident admitted with Vascular Dementia with behavioral disturbances, after he made inappropriate sexual comments about RI #1 and inappropriately touched RI #1, a severely cognitively impaired female resident. On 05/31/12, two days after RI #2 was admitted to the facility, RI #2 asked a CNA (Certified Nursing Assistant), EI (Employee Identifier) #1 about RI #1's alertness and made the comment if RI #1 "did not quit hounding herself with her hands down her pants, someone was going to give her a good screwing." Four days later RI #2 made another inappropriate sexual comment and touched RI #1 on her crotch (genital area). EI #2, the assigned LPN (Licensed Practical Nurse) charge nurse assigned to care for RI #1 and RI #2 on 6/4/12 on the 7:00 AM - 3:00 PM shift, observed RI #2 becoming more aggressive during this shift. EI #2 stated as RI #1 walked down the hall, RI #2 stared at her and followed her around. EI #2 stated she attempted to redirect RI #2 by asking him to attend an activity in the dining room but he refused. EI #2 separated the residents by asking a CNA, EI #3, to take RI #2 to the shower. EI #2 stated she took RI #1 to the dining room for an activity. EI #2 stated she informed EI #7, the DON (Director of Nursing), about RI #2 being aggressive. EI #2 stated while RI #2 was in the shower he told EI #3 if RI #1 kept putting her hands down her pants he was going to help her out because he was a man. EI #3 stated he witnessed RI #2 walk up to RI #1 and grab her crotch. EI #3 stated he told EI #2. The physician was called and orders were received to send RI #2 out to a local hospital for evaluation. RI #1 was sent out for a psychiatric evaluation on 6/4/12 and subsequently was committed to a psychiatry center for 32 days. On 7/17/12, upon returning from the psychiatric center, RI #2 was readmitted to his same room on the facility's secure unit. According to staff assigned to work the secure unit on the 3 PM - 11 PM shift, staff were to monitor and keep RI #2 and RI #1 separated. On 08/23/12 on the 3 PM - 11 PM shift, RI #1 was being assisted with the dinner meal by a CNA, EI #13. According to EI #13, RI #1 was hollering and disturbing other residents in the dining room. RI #1 was allowed to leave the dining room unassisted after completing her meal. EI #4, the CNA assigned to care for RI #1 was feeding another resident in the resident's room. EI #4 stated she was the only staff on the hall at this time. EI #11, another CNA who was also feeding a resident in the dining room stated she saw RI #2 leave the dining room after he completed his meal. EI #4 stated when she left the room of the resident she was feeding, she passed by RI #2's room. EI #4 stated she saw RI #2 standing in front of RI #1. EI #4 stated RI #1 was sitting on RI #2's bed and RI #2's penis was in RI #1's mouth. RI #2 was moving in a back and forth motion. EI #4 stated she immediately separated the residents and took RI #1 to the dining room and informed the charge nurse, EI #5. EI #5 stated RI #2 remained on the secure unit that night. RI #2 was not provided with one on one supervision to prevent further contact with RI #1. The facility could not provide evidence that RI #1 was assessed that night for injuries or complications associated with the sexual act. EI #19, the RN (Registered Nurse)/3-11 supervisor confirmed she attempted to notify EI #7 (the DON) on her cell phone. However, EI #7 did not become aware of the incident until the next morning. On 08/24/12, EI #7 (the DON) stated when she arrived at the facility that morning at 6:30 AM, she was made aware of the incident occurring between RI #1 and RI #2. EI #7 stated she instructed staff to remove RI #2 from the secure unit at that time. EI #7 stated she would have expected the staff to separate the residents immediately, call her, and place RI #2 on one-on-one. The facility's Psychiatrist stated he too hoped the facility would have placed RI #2 on one-on-one monitoring after the incident occurred. This deficient practice affected RI #1, one of four residents sampled for inappropriate sexual behaviors, and had the potential to affect all 20 female resident's residing on the facility's secure/locked unit. On 09/14/12 at 4:40 PM, the facility's Interim Administrator, the DON, and the Regional Clinical Nurse were notified of the findings of immediate jeopardy in the area of Supervision (F 323). After reviewing the facility's information provided in their Allegation of Credible Compliance (AOC), conducting interviews with female residents at the facility, conducting interviews with staff at the facility, and reviewing the facility's inservice sheets to determine if the facility implemented their AOC, the surveyor relieved the Immediate Jeopardy. The facility's Administrator was informed the scope and severity was lowered to "D" on 10/01/12 at 3:35 PM. Findings Include: RI #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of RI #2's medical record revealed the following documentation by nursing staff: "5/31/12 at 12:30 p (PM), Informed via (by) CNA (name of EI #1) that while pt. (patient) was in the shower, he was questioning about another resident's (RI #1's) alertness - who is severely cognitively impaired; adding in sexual suggestions saying if she didn't "stop hounding herself down the front of her pants, someone will end up giving her a good screwing. It may not be me ... but someone would ..." On 09/07/12 at 3:55 PM, the surveyor conducted a phone interview with EI #1, the CNA assigned to care for RI #2 on 05/31/12 on the 7 AM - 3 PM shift. EI #1 stated RI #2 asked him if that lady (EI #1) was oriented or if she was crazy or some comment about her mental status. EI #1 said RI #2 said if EI #1 didn't quit hounding herself with her hands down her pants like that, someone was going to give her a good screwing. EI #1 stated he went and told the nurse, EI #2 (LPN charge nurse). EI #1 stated he thought EI #2 told the RCM (Resident Care Manager), EI #9. Nurses Notes for RI #2 dated 6/4/12 (no time) documents: "Summary of events. Earlier this shift (name of RI #2) was seen in the hallway c (with) a female resident (RI #1) and (name of RI #2) had his hands down female residents pants. Asked to stop and (name of RI #2) got verbally aggressive c (with) staff. 1 on 1 supervision put in place until Geri-psych (psychiatric) returns call for a room. Still agitated at this time. (Name of doctor) gave order to send to (name of hospital's Geri psych unit). Still awaiting a room. Oncoming nurse to monitor ..." This note was documented by EI #2 (LPN). (Although this nurse's note was documented, there was no corroborating evidence that RI #2 had his hands down the pants of RI #1). The facility's DON (Director of Nursing), EI #7 and EI #26, the Interim Administrator documented a telephone conversation they had with EI #2 on September 6, 2012 at 10:00 PM, regarding the nurse note entry of 6/4/12 on (name of RI #2's) chart. This documentation included the following: "... His (RI #2's) hands were not down her pants, her (RI #1) hands were down her pants, He (name of RI #2) made suggestive comments about 'helping her out' if she continued to have her hands down her pants ... I reported to (name of EI #7) DON that he (RI #2) was following (name of RI #1) (the female resident) around and making inappropriate comments to her; this was what was reported to me. I have no idea why I charted what I did ... " RI #2's physician's orders [REDACTED]. "Send to (Name of local hospital) Geri-psych thru ER (emergency room )." Review of a Resident Transfer Form for RI #2 dated 06/04/12, completed by EI #17 (RN (Registered Nurse)) documents: "... Behavioral or Social Issues and Interventions: Sexually inappropriate behavior. Groping ... Reason For Transfer (i.e. (for example), What Happened?) Inappropriate sexual behavior ..." On 09/07/12 at 12:57 PM, the surveyor conducted an interview with EI #2, the LPN charge nurse assigned to care for RI #1 and RI #2 on 06/04/12. EI #2 stated on 06/04/12, she witnessed RI #2 being more aggressive and walking toward RI #1. EI #2 stated she asked EI #3, the CNA assigned to care for RI #2 to go ahead and take RI #2 to the shower. EI #2 stated while in the shower, RI #2 stated that if RI #1 kept putting her hands down her pants he was going to help her out because he is a man. EI #2 stated she notified the DON, EI #7. On 09/07/12 at 2:25 PM, the surveyor conducted an interview with EI #3, the CNA assigned to care for RI #2 on 06/04/12 on the 7 AM - 3 PM shift. EI #3 stated as he was coming down the hall way RI #1 was walking toward him and RI #2 was walking away from him. EI #3 stated they both stopped and RI #2 placed his hand between RI #1's legs. EI #3 stated by the time he made it to where the residents were, RI #2 had taken his hand away. RI #3 stated RI #2 did not grab and hold on. EI #3 stated the whole thing lasted maybe two seconds. EI #3 stated he told his charge nurse, EI #2. On 09/17/12 at 3:00 PM, the surveyor conducted a phone interview with RI #1's physician. RI #1's physician stated if he had been aware of the inappropriate sexual comments and the sexual inappropriate touching he would have had the facility to keep RI #1 and RI #2 separated and closely supervise the male resident. RI #1's physician stated it sounded like RI #2 had some bad behaviors. On 09/09/12 at 4:50 PM, the surveyor conducted an interview with EI #7, the facility's DON. The surveyor asked EI #7 was she made aware that on 06/04/12, on the 7 AM - 3 PM shift that RI #2 touched RI #1 in an inappropriate manner. EI #7 stated she was not told about physical contact. EI #7 stated the nurse, EI #2 (LPN), told her that RI #2 was verbally aggressive toward RI #1. EI #7 stated after the surveyor brought the concerns to her and the Administrator (Interim Administrator) on 06/05/12, was when she was told by EI #3, the CNA assigned to care for RI #2 on 06/04/12 (7 AM - 3 PM shift), that RI #2 grabbed RI #1's crotch. The surveyor asked EI #7 why was RI #2 admitted back to the locked unit on 7/17/12. EI #7 stated RI #2 was an elopement risk from what she was told and there were no other behaviors. A facility form titled "Discharge Summary" with a Date of Admission of 05/29/12 and a Date of Discharge of 06/04/12, documents: " ... Follow-up and Discharge Medication (instructions to patient) He (RI #2) was transferred on 6/4/12 to Geri-Psych at local hospital due to inappropriate sexual behavior ..." A Progress Note (from name of local hospital) for RI #2 dated 6/4/12 at 2330 (11:30 PM) documents: "... admitted b/c (because) he grabbed a girl in the crotch at (name of nursing home) ..." RI #2's Psychiatric History And Physical with an admitted [DATE], documents" "REASON FOR ADMISSION: This patient is readmitted from (name of nursing home) to the gero psychiatric unit for inappropriate sexual behavior. Allegedly he grabbed someone in the genital area. MENTAL STATUS EXAMINATION: He is alert and responsive. He presents knowing his name, place, situation and time ... PAST PSYCHIATRIC HISTORY: Please note the patient has had several psychiatric admissions lately here to (name of hospital), the last being May 20, 2012 through May 29, 2012 for dementia with behavioral problems ... TREATMENT RECOMMENDATIONS: Admit to gero psychiatric unit and observe behaviors, redirect as necessary ..." A Psychosocial Assessment (from name of local hospital) for RI #2 dated 06/05/12 (no time) documents: "Reason for Admission/Diagnoses: [REDACTED].? Sexually inappropriate behaviors at NH (nursing home) ..." A Consult Report documented by a hospital physician on 06/05/12 (from name of the hospital RI #2 admitted from) revealed the following: "... admitted last night from (name of nursing home) Alzheimer's unit after sexually inappropriate behavior, appropriate groping a nurse. He has ischemic dementia with behavioral problems in the past including violence, paranoia, sexually inappropriate behavior and elopement ... He now states that he does not bother a nurse but it was one of the other patients who walks around holding both hands over her privates and she would not get out of his way. He was going from the day room to his bedroom, and she stood in his way and would not move when he asked her nicely, he recalls ... Diagnoses: [REDACTED]. A Petition For Involuntary Commitment for RI #2 dated 06/05/12, documents: "... 1. (Date: 6/4/12) Sexually inappropriate at the nursing home. Was just discharged from the geriatric unit on 5/31/12. History of disruptive behaviors. 2. (Date: On unit) Was discharged just a week ago. Hx (history) of being disruptive behaviors on the unit. Hx of hospitalization s due to behaviors. Failed numerous nursing home placements. 3. (Date: 6/5/12) (name of psychiatrist) recommends longer term treatment than is locally available. Diagnosis: [REDACTED]. A Physician order [REDACTED]. "Discharge to (name of Psychiatry Center) today." A Discharge Summary (from name of Psychiatry Center) for RI #2, with an admission date of [DATE] and a discharge date of [DATE], documents: "... HOSPITAL COURSE: Reason of Admission and Brief HPI (History and Physical Information): Allegedly, patient pushed a female in the area of her genitals. They claim it was inappropriate touching. Patient stated that she was standing over him and he was just reaching around and pushing her away. Brief HPI: (Name of RI #2) "... admits to having some memory problems and states that he has never had any behavioral problems other than the fact that this patient who he claims was very intrusive was standing over him and he pushed her away. He claims that he did not pay attention to where he was pushing her, he was just trying to get her away from him. However, the staff at the facility said he pushed her in the area of the genitals, which they state was inappropriate touching, and he was subsequently committed ..." RI #2's Admission Data Collection Form with a Date of Admission of 07/17/12, documents: "... Diagnosis: [REDACTED]. RI#2 was readmitted to the secure unit where RI #1 still resided. RI #2's Nursing Assistant Kardex, with an admission date of [DATE], documents: "Nursing Consideration ... Resident has inappropriate sexual behaviors ... Problem Continues ... history of inappropriate behaviors, history of disruptive behaviors, history/potential for inappropriate sexual behavior/comments ... Interventions ... 1:1 as needed ..." A Progress Note for RI #2 from (name of psychiatric center) dated 07/23/12 revealed this center called the nursing home to check on the progress of this resident. Documentation by the psychiatric center's social worker reveals: "SW Weekly/Casework. Pt. currently on 2 wk (week) temp (temporary) visit to (name of nursing home). Writer spoke c (name of EI #9), supervisor, who said pt was doing well and had exhibited none of the behaviors shown that initiated commitment. He does stare at the lady with whom he was obsessed that led to his commitment, but does not bother her." RI #2's Annual MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 07/24/12 coded RI #2 as having a fluctuation of Inattention and Disorganized thinking behaviors. RI #2 was assessed as needing supervision with eating, needing limited assistance with bed mobility, transfers, walking in the room, with locomotion on and off the unit, with toilet use and personal hygiene, needing extensive assistance with walking in the corridor, dressing and bathing. NN for RI #2 dated 08/23/12 at 7 PM (7:00 PM) documents: "... Sexually inappropriate behavior this shift ..." An Accident/Incident Report Form documents: "... Date of Report 08/24/12, Date of Incident 08/23/12, Time of incident 6: PM (6:00 PM), Person involved (RI #1's and RI #2's name) Witness: (EI #4's) ... Type of Incident: ... Resident to Resident Incident ... Other: behavior - sexual ... (name of EI #4) was picking up trays on F-Hall. Upon entering (name of RI #2's name) room she (EI #4) found (name of RI #1) having oral sex with (name of RI #2). She (RI #1) was removed from room and taken to dining room". On 09/10/12 at 6:12 PM, the surveyor conducted an interview with EI #13. EI #13 stated she fed RI #1 on 08/23/12. EI #13 stated she saw RI #2 in the dining room on the secure unit during the dinner meal. EI #13 stated RI #1 was hollering and screaming so when she (EI #13) finished feeding RI #1, she (EI #13) let her (RI #1) go to walk in the hallway on the secure/locked unit. EI #13 stated she continued to feed someone else after RI #1 left the dining room. EI #13 stated she should have known something was wrong because RI #1 was so quiet. On 09/06/12 at 3:24 PM, the surveyor conducted an interview with EI #4, the CNA assigned to care for RI #1. EI #4 stated she was picking up the dinner trays around 6:00 PM. EI #4 stated she saw RI #1 and RI #2 in RI #2's room. EI #4 stated RI #1 was sitting on RI #2's bed. EI #4 stated RI #2's pants were halfway down and his penis was in RI #1's mouth. EI #4 stated she told EI #5, the LPN charge nurse what happened. The surveyor asked EI #4 if she left the two residents alone. EI #4 stated no. EI #4 stated she got RI #1's hand and took her to the dining room. The surveyor asked EI #4 what happened with RI #2 the rest of the night. EI#4 stated she observed RI #2 walking up and down the hallways. EI #4 stated RI #2 was not her resident and she did not know if he was being monitored. The surveyor asked EI #4 why did she think the incident occurred between RI #1 and RI #2. EI #4 stated because RI #2 wasn't watched more. On 09/06/12 at 5:03 PM, the surveyor conducted an interview with EI #5, the LPN charge nurse. EI #5 stated she had just finished passing medications. EI #5 stated EI #4 was picking up dinner trays. EI #5 stated EI #4 came to her and told her when she went in RI #2's room RI #1 was doing oral sex on RI #2. EI #5 stated EI #4 separated the residents and took RI #1 to the dining room. EI #5 stated she went and informed the supervisor, EI #19. On 09/11/12 at 5:05 PM, the surveyor conducted a second interview with EI #5, LPN charge nurse. The surveyor asked EI #5 if she thought RI #1 and RI #2 were being monitored by facility staff on 08/23/12. EI #5 stated she would have to say no. EI #5 stated she knew most of her staff was in the dining room feeding and EI #4 was picking up trays. The surveyor asked EI #5, with RI #2's known history of making inappropriate sexual comments about RI #2, and him allegedly groping RI #1, should RI #2 have been monitored. EI #5 stated she was not aware of anything RI #2 had said sexually since he had been back. EI #5 stated no one had told her RI #2 had tried to touch RI #1 again so she couldn't say. On 09/17/12 at 1:48 PM, the surveyor conducted a third interview with EI #5, the LPN charge nurse. The surveyor asked EI #5 if one-on-one monitoring was done with RI #2 on 08/23/12 (after the incident occurring between RI #1 and RI #2). EI #5 stated no. On 09/10/12 at 6:32 PM, the surveyor conducted an interview with EI #19, the 3 PM - 11 PM shift supervisor on 08/23/12. EI #19 stated her shift did not conduct close supervision of RI #2, but she did instruct the on coming shift to watch RI #2 closely. On 09/11/12 at 8:20 AM, the surveyor conducted an interview with EI #22, the 11 PM - 7 AM supervisor assigned to work on 08/23/12. EI #22 stated she was made aware that RI #1 and RI #2 were engaged in oral sex by EI #5, the charge nurse assigned to care for RI #1 and RI #2 on 08/23/12 on the 3 PM - 11 PM shift. EI #22 stated she was told that one of the CNA's walked in and RI #1 was performing oral sex on RI #2. The surveyor asked RI #22 if RI #2 was placed on one-one-one monitoring after the incident. EI #22 stated she didn't think so. On 09/06/12 at 11:55 PM, the surveyor conducted a phone interview with EI #15, the LPN charge nurse assigned to care for RI #1 and RI #2 on the 11 PM - 7 AM shift on 08/23/12. EI #15 stated she was not sure about the date, but she was told by EI #5, the 3 PM - 11 PM charge nurse, that an inappropriate behavior in sexual form had occurred between RI #1 and RI #2. EI #15 stated to her knowledge after this incident occurred, no close supervision was provided for RI #2 on her shift. On 09/06/12 at 11:15 PM, the surveyor conducted a phone interview with EI #24, the CNA assigned to care for RI #2 on the 11 PM - 7 AM shift on 08/23/12. EI #24 stated she was not given details and was told there was something inappropriate that had happened between RI #1 and RI #2. EI #24 stated she was told they were not allowed to discuss it. EI #24 stated she did not recall if she was told to monitor RI #2's whereabouts or not that night. EI #24 stated chances are RI #2 was out of bed on her shift because he gets out of bed every night. EI #24 stated one-on-one was not done with RI #2 on her shift. On 09/06/12 at 10:56 PM, the surveyor conducted a phone interview with EI #23, the CNA assigned to care for RI #1 on the 11 PM - 7 AM shift on 08/23/12. EI #23 stated the 3 PM - 11 PM shift really didn't go into detail about what happened between RI #1 and RI #2. EI #23 stated she was told something happened and it was "hush hush". EI #23 stated it was a couple of days later when someone said RI #2 had coerced RI #1 into performing oral sex on him. The surveyor asked EI #23 if she recalled if she was told to monitor the residents that night. EI #23 stated she couldn't remember. EI #23 stated if RI #2 was on the hall, he probably was up. On 09/08/12 at 9:36 AM, the surveyor conducted an interview with EI #6, the facility's social worker. The surveyor asked EI #6 when she was made aware that RI #2 had his penis in RI #1's mouth on 08/23/12. EI #6 stated she found out about it on 08/24/12. EI #6 stated EI #7 (the DON) notified her when she came in that morning. EI #6 stated EI #7 said the staff had seen RI #1 giving RI #2 oral sex. EI #6 stated RI #2 was moved off the Dementia unit at that time. On 09/09/12 at 4:50 PM, the surveyor conducted an interview with EI #7, the facility's DON. The surveyor asked EI #7 when was she made aware that RI #2 and RI #1 had engaged in oral sex. EI #7 stated she was told this at 6:30 AM on 08/24/12. EI #7 stated she was told by the 11 PM - 7 AM supervisor (EI #22), a CNA had walked by the room (RI #2's room) and saw that RI #2 was standing up and RI #1 was sitting on his bed and they were engaged in oral sex. EI #7 stated at that time she told her staff to move RI #2 off the unit. On 09/13/12 at 10:52 AM, the surveyor conducted a phone interview with RI #1's physician. The surveyor asked this physician if RI #1 was cognitively intact enough to give consent to any type sexual act. RI #1's physician stated no. RI #1's physician stated RI #1 is just like a child, she can't tell you anything. On 09/18/12 at 8:30 AM, the surveyor conducted a phone interview with RI #2's physician. The surveyor asked RI #2's physician what would he have instructed staff to do if he had been made aware RI #2 had his penis in RI #1's mouth. RI #2's physician stated he would have had staff to contact the facility's Psychiatrist and see if he could have given them guidance. RI #2's physician stated he usually calls the Psychiatrist when the facility have residents with behaviors. On 09/10/12 at 4:27 PM, the surveyor conducted a phone interview with the facility's Psychiatrist. The surveyor asked the Psychiatrist if the facilty informed him that RI #2 had been observed having oral sex with a cognitively impaired female resident at the facilty. The Psychiatrist stated he was not aware of that. The Psychiatrist stated he thought RI #2 had been sexually inappropriate as fas as what he was told, touching a female. On 09/17/12 at 10:30 AM, the surveyor conducted a second interview with the Psychiatrist. The surveyor asked the Psychiatrist what would he have done if the facilty had informed him RI #2 was observed with his penis in a female resident's mouth on 08/23/12. The Psychiatrist stated he would have told the facility to send RI #2 back to the Geri-psych unit and hoped the facility would have placed RI #2 on one-on-one monitoring. This deficient practice was cited as a result of investigation/report number AL 416. ***************************************************** On 09/17/12 at 6:32 PM, the facility submitted an Allegation of Compliance as to how they would relieve the Immediate Jeopardy cited at F 323. This Allegation of Compliance is being submitted in compliance with specific regulatory requirements and preparation and/or execution of this Allegation of Compliance does not constitute admission or agreement by the provider of the facts alleged or conclusions set forth. Please accept this Allegation of Compliance as the facilities written credible allegation that all alleged deficiencies to be cited have been corrected by the date or dates indicated. F323 Incidents and Accidents 1. Corrective measures for residents found to have been affected by the deficient practice. ? On 8/24/12, RI#2 was relocated from the secure unit and moved to another unit, close to the nursing station for increased monitoring. ? On 8/28/12, RI#2 was placed on one-to-one monitoring ? On 9/9/12, RI#2 was evaluated by EI#18, the facility Psychiatrist and a medication adjustment was made. ? On 9/15/12, RI#2 was discharged from the facility. ? On 9/15/12, staff was increased on the Secure unit to provide increased supervision of residents. 2. How the facility identified other residents having the potential to be affected by the same deficient practice. ? On 9/15/12, all care plans and Kardex for residents on the secure were reviewed and updated to ensure residents requiring supervision were care planned for supervision and the care plan reflected supervision. No issues were identified. ? On 9/15/12, all care plans and Kardex for male residents with history of inappropriate behavior (entire facility) were reviewed and updated to ensure residents requiring supervision were care planned for supervision and the care plan reflected supervision. No issues were identified. 3. Systemic Measures taken to ensure that the deficient practice does not reoccur. ? INSERVICES 8/25/12 through 9/15/12, Staff were inserviced on the following topics: SBAR (Situation, Background, Assessment and Request) Form, discharge, Transfers, New interventions for Behaviors, Kardex, Resident safety check list and documentation, Notification of family and MD and 24 hour report sheet, new abuse policy, obligation to report, prevention, reporting to Abuse Coordinator and Psych interventions, Appropriate interventions for Behavior outburst, Review of closed records, referral of patients with behaviors, When and who to report to, INTERACT II, (Interventions to prevent Acute Care Transfers) Stop and Watch change of condition tool, Documentation, Transfer form and use of the 24 hour report. How to find care information on resident, How to evaluate residents on admission (Social Worker education) 4. How does the facility plan to monitor the systemic measures put into place? On 9/15/12, the Director of Nursing reviewed the audits that was completed on 9/15/12 for the facility and no issues were identified. ********************************************** From 09/04/12 - 09/15/12, RI #2 was observed in a private room with a sitter. From 09/04/12 - 09/17/12, RI #1 was observed on the facility's secure locked unit with staff in attendance at all times. On 09/17/12, interviews were conducted with alert and oriented female residents at the facility. No female resident interviewed had been approached in an inappropriate sexual manner by any male resident at the facility. On 09/17/12, inservice sheets were reviewed . Staff assigned to work the secure locked/unit names appeared on these inservice sheets. On 09/17/12, interviews were done with staff to ensure staff knew what to do when residents exhibit inappropriate sexual behaviors. All staff interviewed knew what to do. After reviewing the facility's information provided in their Allegation of Credible Compliance (AOC), conducting interviews with female residents at the facility, conducting interviews with staff at the facility, and reviewing the facility's inservice sheets to determine if the facility implemented their AOC, the survey team abated the Immediate Jeopardy.