Every finding on record at Bellarose Nursing And Rehab

Based on record review, resident interviews and staff interviews, the facility failed to protect the residents' right to privacy when Resident #76 and Resident #67 had money removed from their rooms and placed in their individual resident trust accounts without their knowledge. This deficient practice affected 2 of 2 residents reviewed for personal privacy. Findings included: On 12/7/2022 at 2:00 p.m. during the Resident Council meeting, Resident #76 stated she discovered on 12/5/2022, forty dollars was missing out of her pocketbook and Resident #67, her roommate, was also missing one hundred dollars. She stated she reported the missing money to the Activity Director on 12/5/2022. a. Resident #76 was admitted to the facility on [DATE]. The modified quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #76 was cognitively intact and displayed no behaviors. On 12/7/2022 at 3:55 p.m. in a private interview with Resident #76, she stated she had about forty-five dollars in her pocketbook that was kept in the bottom of her clothing cabinet. She stated in the afternoon of 12/5/2022 when she went to get some money out of her pocketbook to buy a coke drink, she discovered the money was not in the pocketbook. When she told her roommate of the missing money, the roommate, Resident #67, also discovered she was missing some money. She stated she informed the Activity Director on 12/5/2022 she was missing money out of her pocketbook and Resident #67 was missing money too. She stated no one should be going through her pocketbook. Resident #76 stated she was told a woman in the office had the money but could not recall who told her. She stated she had not asked anyone to take the money out of her pocketbook or for the money to be placed in her resident trust account. b. Resident #67 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #67 was cognitively intact and had displayed no behaviors. On 12/7/2022 at 4:07 p.m. in a private interview with Resident #67, she stated she kept money (four $20 bills, two $10 bills, and 1-$5 bill) in an envelope in her top drawer of the bedside table, and she last saw the money on 12/2/2022. She stated after lunch on 12/5/2022 when her roommate, Resident #76, discovered money missing from her pocketbook she checked and discovered her money was missing from the envelope in the top drawer of the bedside table. She stated she told Resident #76 that she was missing money ($100-$105) too, and Resident #76 reported to the Activity Director that they both were missing money. She stated the Social Worker learned on 12/5/2022 that she and Resident #76 were missing money and informed the office staff. She stated she was informed her money was not missing and a nurse (no specific nurse was mentioned) had the money. She was unable to recall who told her that information. She stated she did not know where her money was and wanted her money in her possession. She stated she had a trust account and knew to go to the business office to get money as needed. She stated she did not give anyone permission to get the money out of the envelope, and she didn't feel good about someone going into her closed top drawer and taking her money out of the envelope. She stated that person invaded her privacy. On 12/7/2022 at 2:40 p.m. in an interview with the Activity Director, she stated Resident #76 reported to her on 12/5/2022 that she and Resident #67 were missing money out of their room, and she informed the Social Worker. On 12/7/2022 at 4:20 p.m. in an interview with the Social Worker, she stated on 12/5/2022 the Activity Director informed her Resident #76 and Resident #67 were missing some money. She stated on 12/5/2022 she verified with Resident #76 she was missing money, and on 12/5/2022, she informed the Administrator and Director of Nursing Resident #76 and Resident #67 reported they were missing money that was kept in their room. She stated the Administrator stated he would investigate the allegation. She stated on 12/6/2022, she learned the money had been located and placed in each residents' individual trust account, and she informed Resident #76 and Resident #67 of this information. On 12/7/2022 at 3:21 p.m. in an interview with the Business Office Manager, she stated upon arriving to work around 6:00 a.m. on 12/6/2022, an envelope with For Trust deposits: [Resident #76's last name] $40 and [Resident #67's last name] $100 written on the outside of the envelope was found located in a locked box outside the business office. She stated when she questioned the Administrator about the money left in the locked box for Resident #76 and Resident #67, he stated both residents had reported the money stolen and instructed her to place the money in their individual trust accounts. She stated Resident #76's forty dollars and Resident #67's one hundred dollars was deposited into their trust accounts on 12/6/2022. On 12/7/2022 at 4:43 p.m. in an interview with the Administrator, he stated on the afternoon of 12/5/2022, the Social Worker reported to him Resident #76 and Resident #67 were missing money that was kept in their room. On the morning of 12/6/2022, he stated he was informed by the Business Office Manager Resident #76's forty dollars and Resident #67's one hundred dollars were found in an envelope in a locked box outside the business office, and the Social Worker informed Resident #76 and Resident #67 where their money was located on 12/6/2022. When the Administrator was asked how Resident #76's and Resident #67's money got from her room to the locked box outside the business office, he stated he did not know. He stated Resident #76's and Resident #67's missing money was found, and an investigation was not conducted. He further stated it was his decision to place Resident #76's forty dollars and Resident #67's one hundred dollars into their trust accounts and did not discuss with either resident where they wanted the money that went missing from their rooms. A review of Resident #76's and Resident #67's trust account verified the Administrator's statement that the money was deposited into their trust accounts on 12/6/22.

Based on record review, resident interviews and staff interviews, the facility failed to record grievances reported verbally for 2 of 2 residents (Resident #76 and Resident #67) reviewed for grievances. Findings included: The facility's Notice of Procedure for Filing/Submitting Grievances or Complaints not dated stated grievances and/or complaints may be submitted orally or in writing, and upon receipt of a grievance and/or complaint, the Administrator's designees will investigate the allegations and prepare a written report of such findings which will be submitted to the Administrator within five business days of receiving the grievance and/or complaint. 1. Resident #76 was admitted to the facility on [DATE]. The modified quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #76 was cognitively intact and displayed no behaviors. On 12/7/2022 at 2:00 p.m. during the Resident Council meeting, Resident #76 stated she discovered on 12/5/2022, forty dollars was missing out of her pocketbook and Resident #67, her roommate, was also missing one hundred dollars. She stated she reported the missing money to the Activity Director on 12/5/2022. On 12/7/2022 at 3:55 p.m. in a private interview with Resident #76, she stated on 12/5/2022 when she went to get some money out of her pocketbook to buy a coke drink, she could not find any money in her pocketbook. She said her pocketbook was kept in the bottom of her clothes cabinet. She stated about forty five dollars was missing from her pocketbook, and she went and informed the Activity Director of the missing money. She stated she had not spoken to the Administrator about her missing money. She stated she was told the money was in an office somewhere. She stated she did not know where to go find her money to spend if needed and wanted her money in her possession. On 12/7/2022 at 2:40 p.m. in an interview with the Activity Director, she stated when Resident #76 reported on 12/5/2022 she was missing money from her pocketbook, she informed the Social Worker. On 12/7/2022 at 4:20 p.m. in an interview with the Social Worker, she stated on 12/5/2022 the Activity Director informed her Resident #76 was missing some money. She stated when she informed the Administrator and the Director of Nursing about Resident #76's missing money, the Administrator stated he would investigate the incident. She stated when anything was missing of the residents, a grievance report was completed, and she usually completed a grievance. She stated on 12/6/2022 she learned Resident #76's missing money had been placed in her trust account at the facility, and she did not complete a grievance report. On 12/7/2022 at 4:43 p.m. in an interview with the Administrator, he stated the Social Worker reported Resident #76 was missing some money on the afternoon of 12/5/2022, and Resident #76's money was found in the locked money box outside the business office on the morning of 12/6/22. He stated items not found within twenty four hours were reported on a grievance form, and Resident #76's missing money was found in less than twenty four hours. He stated since Resident #76's money was discovered, he did not conduct an investigation, and he had not spoken with Resident #76 about the missing money. He stated the Social Worker informed Resident #76 her money was found and where it was located on 12/6/2022. The Administrator stated he did not investigate how the money got from Resident #76's room to the locked box outside the business office. He stated he encouraged residents not to keep a large amount of money in their rooms, and he made the decision to place the money in her trust account and did not discuss with Resident #76 what she wanted to do with the money. 2. Resident #67 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #67 was cognitively intact and had displayed no behaviors. On 12/7/2022 at 2:00 p.m. during the Resident Council Meeting, Resident #67 stated she was missing one hundred dollars from her room. On 12/7/2022 at 4:07 p.m. in a private interview with Resident #67, she stated on 12/5/2022 she discovered one hundred dollars was missing from inside the top drawer of her bedside table. She stated Resident #76 told the Activity Director they both (Residents #67 and #76) were missing money on 12/5/2022. The Social Worker was told on 12/5/2022 she was missing some money and when the Social Worker went to the office, she was told the money was not missing. She stated she did not know where the money was currently located and wanted the money in her possession. On 12/7/2022 at 4:20 p.m. in an interview with the Social Worker, she stated on 12/5/2022 the Activity Director informed her Resident #67 was missing some money. She stated Resident #67 told her at lunch time on 12/5/2022 someone had gotten her money. She stated when she informed the Administrator and the Director of Nursing on 12/5/2022 about Resident #67's missing money, the Administrator stated he would investigate the incident. She stated when anything was missing of the residents, a grievance report was completed, and she usually completed a grievance. She stated on 12/6/2022 when she learned Resident #67's missing money had been placed in her trust account at the facility, she did not complete a grievance report. The Social Worker further stated on 12/6/2022 she informed Resident #67 that the money was turned into her trust account. On 12/7/2022 at 4:43 p.m. in an interview with the Administrator, he stated the Social Worker reported Resident #67 was missing some money on the afternoon of 12/5/2022, and Resident #67's money was found in the locked money box outside the business office on Tuesday morning, 12/6/2022. He stated items not found within twenty four hours were reported on a grievance form, and Resident #67's missing money was found in less than twenty four hours. He stated since Resident #67's money was discovered, he did not conduct an investigation, and he had not spoken with Resident #67 about the missing money. He stated the Social Worker informed Resident #67 her money was found and where it was located on 12/6/2022. The Administrator stated he did not investigate how the money got from Resident #67's room to the locked box outside the business office. He stated he encouraged residents not to keep large amount of money in their rooms, and he made the decision to place the money in her trust account and did not discuss with Resident #67 what she wanted to do with the money.

Based on observation, record review, and staff interview, for one (Resident # 1) of three sampled residents, the facility failed to assure a Nurse Aide safely assisted a resident with personal care. Nurse Aide # 1 attempted to dress Resident # 1 on a shower bed with the safety rail down. While the Nurse Aide assisted Resident # 1, the resident rolled off the shower bed and sustained a [CONDITION(S)] which required surgical repairment. The findings included: Resident # 1 was admitted to the facility on [DATE] and had a diagnosis of Alzheimer's disease. Resident # 1's last quarterly assessment, dated 1/17/22, coded Resident # 1 as being severely cognitively impaired. The resident was also assessed to need extensive assistance with her bed mobility, dressing, and hygiene. She was totally dependent on staff for bathing and transferring. According to the assessment, she had not sustained any falls since the prior quarterly assessment. On 3/15/22 at 12:52 PM Nurse # 1 entered the following information into Resident # 1's facility record. The nurse was called to Resident # 1's room by a Nurse Aide (NA). Upon entering she observed Resident # 1 on the floor on her back side with blood on the left side of her head. The NA stated that upon rolling Resident # 1 on the shower stretcher to dry and dress her she rolled off the shower stretcher onto the floor. The NA had tried to stop the momentum of the fall but was unable to prevent the fall. Resident # 1 was immediately sent to the emergency room . Resident # 1's hospital records, for the dates of 3/15/22 to 3/19/22, were reviewed and revealed Resident # 1 sustained a left [CONDITION(S)] from the fall. The bone was comminuted (broken in at least two places), and mildly displaced (out of alignment.) Resident #1 underwent surgery for the [CONDITION(S)] on 3/16/22. According to the hospital records, Resident # 1 had an injury above her left eye which was documented to be superficial. Resident # 1 was readmitted back to the facility on [DATE] for care. Resident # 1 was observed on 4/5/22 at 11:20 AM with Nurse # 2. Resident # 1 did not verbally respond, but it was observed she had a slight tremor in her arm. Nurse # 2 commented her eyes seemed to be squinched and the tremor was possibly because of pain. Nurse # 2 stated Resident # 1 had pain medication and she would administer. NA # 1 had been the Nurse Aide who had cared for Resident # 1 on the day of her fall. NA # 1 was interviewed on 4/5/22 at 12:45 PM and again at 2:35 PM and reported the following details. On the day of the incident, she had obtained the assistance of another Nurse Aide to transfer Resident # 1 to the shower bed using a mechanical lift. Once Resident # 1 was on the shower bed, she (NA # 1) was able to shower her independently. Following the shower, she rolled the shower bed into Resident # 1's room so that the shower bed was beside Resident #1's bed in a parallel position. She decided to dress Resident # 1 on the shower bed, get the mechanical lift sling beneath her, and then get another staff member's assistance to use the mechanical lift to transfer her back to bed. She left a gap between the resident's bed and the shower bed so that she could go around the shower bed to assist Resident # 1. Therefore, the shower bed was not up against the resident's bed. She placed Resident # 1's shirt completely on and her pants partially on. By that point, she (NA # 1) was on Resident # 1's left side. She had also gotten the mechanical lift sling under Resident # 1's right side and needed to pull it through to the left side. She rolled Resident # 1 toward the right side away from her in order to pull the sling completely from underneath Resident # 1; using the sling to help her move the resident as she was moving her and pulling it on through. Resident # 1 moved her left leg at that time and started to roll off the right side of the shower bed. The safety rail was not up on the right side of the shower bed. The NA reported she had left it down because she was going around the shower bed while assisting to dress her. She could not stop Resident # 1 from rolling off the bed. During the 2:35 PM interview, NA # 1 was accompanied to view the shower bed she had been using. The shower bed was observed to have a narrower bed surface than a standard bed. The bed surface was stationary at a level which would be at the waist level of working staff members. On 4/5/22 measurements of the facility's beds and the shower bed were confirmed with the Quality Assurance Nurse. (QA) The shower bed was 26.5 inches in width. The resident's standard bed was 35 inches in width. The QA nurse was interviewed on 4/5/22 at 2:10 PM and 2:50 PM and reported the following. They had investigated the fall and worked to determine the root cause of the incident. According to the QA nurse the NA should not have been trying to dress and maneuver Resident # 1 on the shower bed with a mechanical lift sling. The QA nurse stated the surface area was narrower than a standard bed, the surface could still have been slippery, and there needed to have been a draw sheet beneath the resident rather than pulling on the mechanical lift sling to maneuver the resident. The QA nurse reported that NA #1 had been Resident # 1's long term NA, often cared and dressed for Resident # 1 alone and there had never been any incidents because Resident # 1 was always in the bed. The QA nurse felt NA # 1's decision to attempt to dress her on a shower bed before getting help to transfer her back to bed and dress her had contributed to the fall. Following their investigation, they had implemented a plan of correction which involved In-service training for all their nurse aides regarding safety in showering and dressing residents who required the use of the shower bed. The nurse aides had been taught to always transfer residents back in bed from the shower bed prior to dressing a resident, to always use a draw sheet to position a resident, and to keep the safety rail up on the shower bed when not in attendance. They had also initiated audits where they observed nurse aides who required the use of the shower bed. The QA nurse presented documentation of their plan of correction. The plan of correction was directed to assure all residents who required showering on a shower bed received care safely. The plan of correction included the following: Identified Area: Shower Bed Dressing: Root cause analysis/What led to the deficient practice. Resident fell off shower bed. NA dressed resident on shower bed. NA did not realize shower bed was still slippery. NA used mechanical lift pad to turn resident from side to side. NA did not know she needed to put resident back in bed before dressing. NA did not realize fall would occur from dressing on shower bed. The resident had a witnessed fall while being dressed on the shower bed. All residents, who required the use of the shower bed, were identified to be at risk for the deficient practice and the plan of correction addresses their risk. The procedure for implementing the acceptable plan of correction for the deficient practice: All NAs were in-serviced on transferring residents that use the shower bed back to bed before dressing. All new staff will be in-serviced during orientation. Resident was sent out to be examined by ER immediately after fall. The staff development. Inservice training was conducted by the staff development coordinator. The training was begun on 3/15/22 with target completion date of 3/18/22. The QA team met on 3/15/22 and decided to include this issue within their quality assurance program and initiate monitoring procedures to ensure that the plan of correction is effective and that the deficient area remained in compliance: Monitoring began on 3/16/22 by the Quality Assurance Nurse. Monitoring included: Staff will be observed for proper techniques dressing residents who use the shower bed after shower, 2 residents 2 X a week X 4 weeks and then 2 residents 1 X a week X 4 weeks and then 2 residents 1 X a week for a total of 12 weeks. The results from these audits will be brought to the QA meeting monthly for review and continued monitoring if needed. Title of the person responsible for implementing the plan of correction: QA Nurse/SDC (Staff Development Nurse) Facility's planned date when corrective action will be completed by 3/18/22 The facility's corrective action plan was validated on 4/5/22 by the following. Nurse Aides (including Nurse Aide # 1) from different shifts were interviewed and reported they had received Inservice training about falls. Nurse Aides reported they would use 2 people to transfer a resident back to bed after using a shower bed, keep the rail up if not by that side of the shower bed, and always dress the resident in the bed and not on the shower bed. Inservice training logs were reviewed and revealed nurse aides had signed they attended the facility's education following the incident or were called via phone and received training. Quality assurance monitoring logs were reviewed and revealed audits were begun on 3/16/22 and continued per the facility's plan of correction timeline. Residents were interviewed during the survey and reported they felt Nurse Aides cared for them in a safe manner. On 4/5/22 it was validated with the facility's QA nurse that Inservice training for nurse aides had been completed on 3/21/22 rather than 3/18/22. The facility is found to be back in compliance effective 3/21/21; which corresponds to the date the QA nurse stated in-service training was complete and audits were documented to be under-way.

Based on observation and staff interviews, the facility failed to dispose of expired medication on one of three medication carts reviewed for expired medications. Findings included: On 7/13/2021 at 10:30 AM the medication cart on the Springs hall was reviewed for expired medications. A box with a vial of insulin was found with a label stating it was opened 6/8/21 and expired 7/5/21. The label contained the Resident ' s name, dose, route, time and diagnosis. Noted on the label was expires 28 days after opening. Nurse #1, who was present, acknowledged the medication was out of date. The Consulting Pharmacist was interviewed 7/13/2021 at 11:30 AM and stated the expired medication had been identified the week before and was mistakenly put back on the medication cart. On 7/16/2021, the Director of Nursing stated the expired medication should have been disposed of.

Based on staff interview and record review, the facility failed to initiate a screening for a level II Pre-Admission Screening and Resident Review (PASRR) for one of one residents reviewed for PASRR (Resident #63). Findings included: A review of the medical record revealed Resident #63 was admitted [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] noted Resident #63 to be severely impaired for cognition and needed supervision to limited assistance for all Activities of Daily Living with the physical help of one person. The MDS indicated Resident #63 had a PASRR level I. A level II screening would indicate if Resident #63 had a need for certain services appropriate for his mental diagnosis. On 3/20/2019 at 11:21 AM, in an interview, the facility Social Worker stated she did not know why Resident #63 did not have a Level II PASRR screening, and she would call the former facility and find out. The Social Worker noted Resident #63 should have had a PASRR level II screening because of the Bi-polar diagnosis. In an interview on 3/20/2019 at 3:00 PM, the facility Administrator stated he had spoken with the Director of the NC MUST (Medicaid Uniform Screening Tool), and was told that the hospital had not revealed the Bi-polar [DIAGNOSES REDACTED]. The Administrator stated a change in condition would be filed with MUST and a screener would come to the facility to perform a level II PASRR screening. On 3/22/2019 at 11:16 AM the facility Administrator stated his expectation was the PASRR level II screening should have been completed.

Based on staff interview and record review, the facility failed to develop a comprehensive care plan for pressure ulcers for one of three residents reviewed for pressure ulcers (Resident #60). Findings included: A review of the medical record revealed Resident #60 was admitted [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] noted Resident #60 to be cognitively intact and needed extensive assistance for all Activities of Daily Living with the help of one to two persons. The Care Area Assessment noted a focus of pressure ulcer and indicated that area went to care plan. On 3/20/2019 at 9:40 AM, an observation was made of the treatment for [REDACTED]. The treatment nurse stated the treatment was ordered by the physician. Interview with the MDS Nurse on 3/21/2019 at 10:31 AM, who stated the care plan had not been put into place yet. The MDS Nurse indicated areas for care plan are brought up in the facility morning meeting and she care plans the same day. The MDS Nurse stated she did not know why she had not developed a pressure ulcer care plan for Resident #60 yet, but would put the care plan in that day. In an interview on 3/22/2019 at 9:25 AM, the MDS Nurse stated the care plan was usually started when the pressure ulcer was found or was discussed in the morning meeting. The MDS Nurse stated she attended the weekly wound meetings and Resident #60's pressure ulcer would have been discussed in that meeting. The Nurse agreed the pressure ulcer was found on 3/12/2019 and the wound meeting was on 3/13/2019, and again on 3/20/2019, but was not care planned until 3/21/2019. The MDS Nurse indicated the wound meetings discussed how the pressure ulcers were doing. The MDS Nurse stated her expectation was the care plan would be done right away when the pressure ulcer was found, since the plan of care for the wound should be written. On 3/22/2019 at 9:52 AM, in an interview, the facility Administrator stated his expectation was that staff would do their jobs and the care plan would be developed timely.

Based on observations, staff and the consultant Registered Dietitian (RD) interviews, and a review of the facility ' s menus, the facility failed to provide the portion sizes specified by the planned menus for 13 of 13 residents during a lunch meal service. The findings included: A review of the 3/6/18 census revealed 13 residents currently resided at the facility. A Diet Type Report dated 3/6/18 indicated 9 residents received a Regular diet with Regular textures, 2 residents received a Regular diet with Mechanical Soft (ground meat) textures, and 2 residents received a Regular diet with Pureed textures. On 3/6/18 at 11:45 AM, an observation was made as the facility ' s cook transported food and serving utensils from the main kitchen to the satellite kitchen. In the presence of the Food Service Director, the serving utensils brought to the satellite kitchen for meal service were inspected. The serving utensils were: two - 3 ounce (oz.) slotted spoodles (a measured, ladle-like spoon), two - 2 oz. spoodles, serving spoons (which did not have a standardized measurement), and one set of tongs. The Food Service Director reported the cook brought the serving utensils down to the satellite kitchen specifically for this meal service because no serving utensils were otherwise kept at that location. No serving utensils for ½ cup portions were in the satellite kitchen for the lunch meal service. An observation of the satellite kitchen conducted at that time also revealed there was no menu in the satellite kitchen for review. Upon inquiry, the Food Service Director confirmed she did not see a menu in the satellite kitchen. An interview was conducted on 3/6/18 at 12:00 PM with the cook in the main kitchen. Upon inquiry as to where the menu was kept, the cook pointed to an 8 ½ inch by 11 inch piece of paper placed on top of a recipe binder by the stovetop in the main kitchen. This paper listed menus for all three meals for the week of 3/5/18 through 3/11/18. However, the listing of food items on the menu did not include portion sizes nor menu items for mechanically altered (or therapeutic) diets. When the cook was asked how she knew what the correct portion size would be for each of the food items served, she responded by saying the weekly menu was all she had to go by. The cook reported she had already brought the spoodles always used for meal service down to the satellite kitchen to use for the lunch meal. The cook was accompanied as she returned to the satellite kitchen with food that had been reheated for the steam table. No additional serving utensils were brought to the satellite kitchen at that time. An observation was conducted on 3/6/18 at 12:05 PM as the lunch meal service began from the satellite kitchen by the cook and the Food Service Director. The meal service was completed at 12:15 PM. On 3/6/18 at 12:17 PM, an interview was conducted with the Food Service Director in the Dietary Office within the main kitchen. The Food Service Director reported she had just located a bound book on the bookshelf in the office which contained the daily menu spreadsheets approved and signed by a Registered Dietitian (RD). A review of the menu spreadsheets revealed they included specified portion sizes for individual food items and menu extensions for the mechanically altered and therapeutic diets. The Food Service Director was observed as she returned to the satellite kitchen on 3/6/18 at 12:20 PM and informed the cook of the location and availability of the daily menu spreadsheets. She also explained that the daily menu spreadsheets included portion sizes and extensions for mechanically altered and therapeutic diets. Upon inquiry, the cook stated she did not know there was a menu in the kitchen that included portion sizes and extensions. The Food Service Director reported this was only her second day working at the facility and confirmed she had just found the daily menu spreadsheets with the extensions in the Dietary Office. A review of the daily menu spreadsheet for lunch on 3/6/18 revealed the portions specified for a Regular diet with Regular textures included ½ cup rice and ½ cup vegetables; a Regular diet with Mechanical Soft textures included ½ cup rice and ½ cup vegetables; and, a Regular diet with Pureed textures included a ½ cup portion for the starch (mashed potatoes). None of the serving utensils available in the satellite kitchen for the lunch meal service on 3/6/18 yielded a ½ cup portion. The only measured serving utensils in the satellite kitchen at that time were 3-oz. spoodles (yielding a 3/8 cup portion) and 2-oz. spoodles (yielding a ¼ cup portion). A follow-up interview was conducted with the Food Service Director on 3/7/18 at 10:18 AM. During the interview, the Food Service Director discussed the portion sizes served during the 3/6/18 lunch meal. She confirmed that a 3 oz. slotted spoodle was used for the rice and vegetables (which yielded a 3/8 cup portion instead of the ½ cup planned portion). The Food Service Director stated additional serving utensils were purchased by the facility on 3/6/18 and included more of the 4 ounce (1/2 cup) scoops. A follow-up interview was conducted with the facility ' s cook on 3/7/18 at 10:30 AM. During the interview, the cook reported she had cooked and served every meal at the facility since she started working on 2/19/18. When asked, the cook reiterated that she did not know the facility had a daily menu spreadsheet that specified portion sizes. The cook confirmed that she used the same sized serving utensils observed yesterday at lunchtime (3/6/18) as she had used for each meal since she started working at the facility. The cook reported a 3-oz. spoodle was always used for serving vegetables. At that time, she stated a serving spoon (not a measured quantity) was used for the mashed potatoes served for lunch on 3/6/18. However, the cook reported during another follow-up interview on 3/7/18 at 1:05 PM that she typically used an ice cream-type scoop (a dish scoop) for the portioning of mashed potatoes. An inspection of the dish scoop identified by the cook revealed it was a #10 scoop, which yielded a portion size of 3/8 cup. An interview was conducted on 3/7/18 at 1:20 PM with the facility ' s consultant Registered Dietitian (RD). During the interview, the RD reported her expectation was that the Dietary staff would serve the correct portion of food items based on what was indicated on the menu extension (spreadsheet) approved and signed by an RD.

Based on observations, resident, staff and consultant Registered Dietitian (RD) interviews, and record review, the facility failed to provide a nourishing snack and obtain resident group approval for greater than 14 hours to elapse between the provision of a substantial evening meal and breakfast the following day for 13 of 13 residents residing at the facility. The findings included: A review of the 3/6/18 census revealed 13 residents resided at the facility. A Diet Type Report provided by the facility (dated 3/6/18) indicated all 13 residents received an oral diet. On 3/7/18 at 10:18 AM, an interview was conducted with the facility ' s Food Service Director. The Food Service Director reported she began working at the facility on 3/5/18. She reported the scheduled meal times at the facility were 8:00 AM, 12:00 PM, and 5:00 PM each day. When asked if she had a concern about the scheduled meal times, the Food Service Director stated the facility needed, to put somethings into place, like bedtime snacks. The Food Service Director stated she told the Interim Administrator last evening (3/6/18) they needed to stock the satellite kitchen refrigerator with meat sandwiches and milk for the residents to have as bedtime snacks. An interview was conducted on 3/7/18 at 11:29 AM with the facility ' s Interim Administrator. During the interview, the Administrator was asked about the scheduling of mealtimes at the facility. He reported the previous Administrator had set up the meal schedule to include breakfast at 8:15 AM, lunch at 12:15 PM, and supper at 5:15 PM. The Interim Administrator reported he changed the scheduled meal times to 8:00 AM, 12:00 PM, and 5:00 PM each day. However, he noted the time which elapsed between the evening meal and breakfast the next day did not change when each of the scheduled meal times were moved up by 15 minutes. On 3/7/18 at 12:00 PM, a review of the facility ' s Resident Council Meeting Minutes was conducted. The Resident Council met on 12/8/17, 1/12/18 and 2/9/18. No notations were made to indicate the Resident Council discussed or approved a meal schedule that allowed more than 14 hours to elapse between their evening meal and breakfast the following day. An interview was conducted on 3/7/18 at 1:05 PM with the facility ' s cook. The cook reported she worked from 7:00 AM until 5:45 PM – 6:00 PM each day since starting at the facility on 2/19/18. The cook was the sole Food Service Department employee from 2/19/18 until the Food Service Director began working at the facility on 3/5/18. When asked what was made available for the residents ' evening snacks, the cook stated she brought a basket of cracker packets down to the satellite kitchen prior to leaving each day. She also reported juice was kept for the residents in the satellite kitchen refrigerator. An interview was conducted on 3/7/18 at 1:20 PM with the facility ' s consultant Registered Dietitian (RD). When asked about the facility ' s meal schedule, the RD reported she had not been previously aware there was a 15-hour time span between the residents ' evening meal and breakfast the next day. Upon inquiry as to whether or not cracker packets would be considered a nourishing evening snack, the RD stated she would have expected a protein and a carbohydrate food item to be provided to the residents. When asked, the RD reported her expectation would be for the facility to observe the regulation specifying the appropriate time frame that may elapse between meals. An interview was conducted on 3/7/18 at 4:35 PM with the facility ' s Resident Council President. During the interview, the Resident Council President was asked whether or not she recalled the residents discussing the facility ' s mealtimes or spacing of meals during one of their meetings. The Resident Council President stated, We really haven't gotten into that kind of thing.

Based on observations, staff and consultant Registered Dietitian interviews, and record review, the facility: 1) Failed to maintain the rinse cycle temperature of the high temperature sanitizing dish machine at or above 180 degrees Fahrenheit per manufacturer recommendations for 2 of 2 observations and failed to routinely monitor and record the dish machine wash and rinse cycle temperatures when used to wash dishware for 22 of the last 22 days (2/14/18 through 3/7/18); and, 2) Failed to obtain food temperatures in the satellite kitchen prior to serving 1 of 2 meals observed. The findings included: 1) An observation was made on 3/7/18 at 1:12 PM and 1:14 PM of two wash and rinse/sanitizing cycles of dishware in the facility ' s high temperature sanitizing dish machine operated by the facility ' s cook. The loaded dish rack washed in the dish machine was observed to have a wash cycle temperature of 165 degrees Fahrenheit (o F) with a rinse cycle temperature of 120o F. The second loaded dish rack run through the dish machine was noted to have a wash cycle temperature of 168o F and a rinse cycle temperature of 120o F. The cook did not record the rinse or wash temperatures of the dish machine at that time. No dish machine temperature log was observed to be in the dishwashing area. An interview was conducted on 3/7/18 at 3:00 PM with the facility ' s cook, in the presence of the Food Service Director. During the interview, the cook confirmed she had started working at the facility on 2/19/18 and reported she had cooked, served, and washed the dishes for all three meals each day at the facility since then. The cook also confirmed she was the sole Food Service Department employee from 2/19/18 until the Food Service Director began working at the facility on 3/5/18. When asked what orientation or training she had received on the use of the facility ' s dish machine, the cook recalled the former Administrator and a Medical Records staff member were in the kitchen with her on her first day of work. The cook reported she did wash the dishes that day and stated the wash and rinse temperatures of the dish machine were discussed some with the former Administrator. The cook reported she thought the former Administrator monitored the dish machine temperatures, but did not recall being told the required temperatures for the dish machine. Upon inquiry, the cook reported she did not know what the wash or rinse temperatures of the dish machine needed to be. The cook also stated she had not monitored the temperatures of the dish machine since she started working at the facility. When asked, the Food Service Director reported she expected the wash and rinse temperatures of the dish machine to be checked and recorded each meal. A review of the manufacturer ' s equipment manual for the facility ' s dish machine was conducted on 3/8/18 at 8:33 AM. The manual included the following information which read, in part: .Wash tank temperature should be 140°F for chemical sanitizing and 160°F for hot water sanitizing .In high temperature (thermal kill) sanitizing, the surface of the dishware must reach a temperature of 165o F for a minimum of ten seconds. This is accomplished by spraying 180o F water over the dishware during the final rinse . Upon her request, an interview was conducted on 3/8/18 at 9:30 AM with the Food Service Director. During the interview, the Food Service Director reported the reason the dish machine rinse cycle temperature was too low during yesterday ' s observation of the dish washing process was because the cook forgot to turn on the dish machine ' s booster heater. Use of the booster heater on the dish machine was required to obtain hot water sanitizing. An interview was conducted on 3/8/18 at 9:31 AM with the facility ' s cook. The cook confirmed she forgot to turn on the dish machine ' s booster heater when she washed the lunch dishes the previous day (3/7/18) during the observation. Upon further inquiry, the cook stated she washed all of the dishes for that meal without realizing the booster heater was not turned on. However, she did notice the booster heater was off later that same afternoon. The cook reported she turned on the booster prior to washing the supper dishes on 3/7/18. On 3/8/18 at 9:32 AM, the Food Service Director was observed as she ran a dish rack through the dish machine with the booster heater turned on. The water temperature for the wash cycle of the dish machine was 168o F and the water temperature for the rinse cycle was noted to be 182o F. The Food Service Director reported she would expect the dish machine ' s rinse cycle temperature to be at least 180o F in order to sanitize the dishes. Upon her request, an interview was conducted on 3/8/18 at 11:45 AM with the Medical Records staff member. During the interview, the Medical Records staff member reported that a member of the Maintenance Department checked the dish machine water temperatures once daily. She provided a copy of the dish machine temperature logs for review. A review of the dish machine temperature logs from 2/14/18 to 3/7/18 included the following, in part: --The (MONTH) (YEAR) log revealed only rinse cycle dish machine temperatures were recorded. All rinse cycle temperatures were noted to be 180o F. However, no dish machine temperatures were documented on 4 of the 15 days from 2/14/18 to 2/28/18. The dish machine rinse cycle temperatures were not recorded on 2/17/18, 2/18/18, 2/24/18 or 2/25/18. --The (MONTH) (YEAR) log revealed only rinse cycle dish machine temperatures were recorded. All rinse cycle temperatures were noted to be 180o F. However, no dish machine temperatures were documented on 2 of the 7 days from 3/1/18 to 3/7/18. The dish machine rinse cycle temperatures were not recorded on 3/3/18 or 3/4/18. An interview was conducted on 3/8/18 at 12:10 PM with the Maintenance staff member who assumed responsibility for checking the dish washer temperatures. Upon review of the temperature logs provided by Medical Records, the Maintenance staff member stated he began taking the dish machine temperatures in (MONTH) of (YEAR). He reported he took the dish machine temperatures once a day, 5 days a week, at various times of the day when dietary staff were not using the machine. The Maintenance staff member confirmed that he only checked and recorded the dish machine ' s rinse cycle temperatures. 2) An observation was made on 3/6/18 at 8:13 AM as the facility ' s cook brought a food cart from the main kitchen to the facility ' s satellite kitchen/dining room for meal service. A continuous observation was made of the breakfast meal service from this satellite kitchen. The meal consisted of scrambled eggs, bacon, toast, cereal (hot and cold), biscuits, milk, and juice. No food temperatures were taken throughout the duration of the meal service in the satellite kitchen. An interview was conducted 3/6/18 at 8:30 AM with the cook. Upon inquiry as to where food temperatures were recorded, the cook reported she had taken and recorded the food temperatures in the main kitchen prior to transporting the food to the satellite kitchen. An interview was conducted on 3/6/18 at 11:25 AM with the facility ' s Food Service Director. At that time, the Food Service Director was asked when food temperatures would be taken and recorded for the 12:00 PM meal. The Food Service Director reported the cook had already taken the temperatures there in the main kitchen, but noted the cook would be checking them again in the satellite kitchen. At that time, the continuous observation of the previous meal service (breakfast) was discussed with the Food Service Director and it was reported the food temperatures had not been taken in the satellite kitchen. When asked what her expectation was, the Food Service Director reported she would expect food temps to be taken in the satellite kitchen. She stated the temperatures needed to be checked in the satellite kitchen as they could change with holding and transportation from the main kitchen. An interview was conducted on 3/7/18 at 11:29 AM with the facility ' s Interim Administrator. During the interview, the Interim Administrator was asked what his expectations were in regards to when and where food temperatures needed to be obtained. The Interim Administrator reported he expected temperatures to be taken at the point of service to the residents. He noted the meal service tray line used to be from the main kitchen up until last week, when it was moved to the satellite kitchen. An interview was conducted on 3/7/18 at 1:20 PM with the facility ' s consultant Registered Dietitian (RD). Upon inquiry as to when and where she would expect food temperatures to be obtained, the RD stated she would expect them to be taken on the tray line prior to service. When asked if she would expect temperatures to be taken in the satellite kitchen when meal service was conducted out of that kitchen, the RD stated, Yes.

Based on staff interviews and record reviews, the facility failed to employ a qualified director of food and nutrition services with the competencies and skills required to carry out food and nutrition services for 19 days (2/14/18 – 3/4/18) of the last 20 days prior to the survey review. The findings included: An interview was conducted with the facility ' s cook on 3/7/18 at 10:30 AM. During the interview, the cook reported she had cooked, served, and washed the dishes for all three meals each day at the facility since she started working on 2/19/18. The cook confirmed she was the sole employee working in the Food Service Department from the date she started working at the facility (2/19/18) until the date the Food Service Director started on 3/5/18. An interview was conducted on 3/7/218 at 11:29 AM with the facility ' s Interim Administrator. During the interview, a request was made to review the Food Service Department staff schedule from 2/1/18 to present. The Interim Administrator responded by stating, I don ' t know that there was one. He explained the facility had hired a Food Service Director prior to opening the facility, but that employee quit sometime in December. The former Administrator attempted to fill in for this position by working in the kitchen until the Interim Administrator came in (MONTH) to help. When the Interim Administrator came to the facility, he began to cook, wash dishes, and place food orders for the department. The current facility ' s cook took over most of these duties when she started working at the facility. The new Food Service Director (a Certified Dietary Manager) started work on Monday, 3/5/18. A review of the employment dates for individuals who worked in the Food Service Department was conducted on 3/8/18 at 8:46 AM. The staffing report indicated a Food Service Director was hired on 11/6/17 and quit on 12/23/17. The Interim Administrator started working in the Food Service Department on 1/24/18, and the current cook started working on 2/19/18. A telephone interview was conducted on 3/8/18 at 9:05 AM with the facility ' s Registered Dietitian (RD). During the interview, the consultant RD stated she worked at the facility every other week on Friday afternoons. She reported she worked an average of 6 to 10 hours per month at the facility and stated she primarily assumed a clinical role at the facility. When asked what role she had in the kitchen, the RD stated she did a walk-through each time she was in the building. She reported she had not identified any issues or concerns in the kitchen during her visits. When asked if her role as a consultant had changed between the time the first Food Service Director left and the new Food Service Director started on 3/5/18, the RD stated it had not. A follow-up interview was conducted on 3/8/18 at 10:45 AM with the Interim Administrator. During the interview, inquiry was made as to who was designated to be the director of food and nutrition services prior to the new Food Service Director starting on 3/5/18. The Interim Administrator reported the former Administrator (a Registered Nurse) would have been the designated director of food and nutrition services from 12/24/17 up until the time he started in the kitchen on 1/24/18. After 1/24/18, the Interim Administrator stated he would have been the one to assume that role. When asked if he had food service management qualifications or certifications, the Interim Administrator indicated he did not. However, he stated the facility did have a consultant Registered Dietitian they could call if there were any questions.

Based on record review and staff interviews the facility failed to provide coverage for the resident trust fund account. Findings included: Review of facility records revealed the facility did not have a surety bond or similar protection for the resident trust fund. Review of the resident trust fund account report on 3/7/18 at 3:02 PM revealed the resident trust fund contained $765.07. During an interview on 3/7/18 at 3:03 PM the Business Office Manager stated the balance in the resident trust account was $765.07. She stated the first account was opened on 12/13/17. She stated there was no surety bond at that time but she believed the Owner of the facility was working on it and would be a better person to ask about surety bonds. During an interview on 3/7/18 at 3:18 PM the Owner of the facility stated they did not currently have a surety bond for the resident funds because the insurance company had contacted him and stated they needed financial records for the facility before giving the facility a surety bond. He stated because the facility was new he did not have the information and was advised to send the financial information from the other nursing home he owned which would allow the insurance company to issue the surety bond to the facility. He stated he was getting ready to send the information to the company when the state survey began and he had not gotten to it yet but was working on it. He further stated he had not thought about getting a surety bond for the facility until residents began placing their money in the resident fund account. He further stated it was his expectation the facility had a surety bond for the resident funds held by the facility prior to opening resident accounts and it was not done.