Every finding on record at Cavalier Healthcare of Trussville

Based on interviews, record review, and review of a facility policy titled, Investigating Grievances/Complaints, the facility failed to ensure that a grievance was completed and the family member was informed of the findings of the investigation when a grievance was received regarding a complaint from Resident Identifier (RI) #1's family member concerning the resident's dressing to his/her stump not being changed as ordered by the physician. This affected RI #1, one of one resident reviewed for grievances. Findings Include: Review of a facility policy titled, Investigating Grievances/Complaints, with a revised date of 04/2008, revealed the following: . Policy Statement Our facility investigates all grievances and complaints filed with the facility. Policy Interpretation and Implementation 1. The Administrator has assigned the responsibility of investigating grievances and complaints to the Director of Social Services and, in his or her absence, the Director of Nursing. 2. Upon receiving a grievance and complaint report, the Grievance Coordinator will begin an investigation into the allegations . 3. The Resident Grievance/Complaint Investigation Report Form must be filed with the Administrator within five (5) working days of the incident. 4. The resident, or person acting on behalf of the resident, will be informed of the findings of the investigation, as well as any corrective actions recommended, within 5 working days of the filing of the grievance or complaint. 5. A copy of the Resident Grievance/Complaint Investigation Report Form must be attached to the Resident Grievance/Complaint Investigation Report Form and filed in the business office. 6. Copies of all reports must be signed and will be available to the resident or person acting on behalf of the resident . RI #1 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include Acquired Absence of Left Leg Below Knee and Acquired Absence of Right Leg Above Knee. Review of email communication dated 12/29/2022, from RI #1's family member to Employee Identifier (EI) #1, the former Administrator revealed the following: . From (name of RI #1's family member) . Sent: Thursday, December 29, 2022 7:47 AM To: (name of RI #1) . Subject: (RI #1) . (His/Her) doctor wrote an order on 12/19/22 for (his/her) leg dressings on surgery site to be changed DAILY, these orders were provided to (name of facility) on 12/19/22, they are not doing that . Review of email communication dated 12/29/2022, from EI #1 to RI #1's family member revealed the following: From (name of EI #1) . Date: Thu (Thursday), Dec (December) 29, 2022, 8:17 AM Subject: Re (concerning): (name of RI #1) To: (name of RI #1's family member) . Thanks so much for letting me know about your concerns . I will definitely be looking into these concerns and addressing them . I will be looking into the concern and will get back to you with the outcome and what will be done differently . On 06/07/2023 at 7:25 PM, a telephone interview was conducted with the family member of RI #1. The family member of RI #1said that the dressings were to be done daily and the facility nurses never did that. RI #1's family member said even after she complained of the dressings not being changed, the nurses still did not change them the way they should have. RI #1's family member said she thought she spoke with the Administrator (EI #1 the former Administrator) about her concerns. RI #1's family member said she was told the matter would be looked into but no one had called her back to tell her what had been done. On 06/08/2023 at 1:28 PM, a telephone interview was conducted with EI #1. The Administrator, EI #1, said the procedure for receiving a complaint from a family member was that the facility immediately started an investigation to determine if there was a problem or not. EI #1 said if the family member emailed the complaint it would be handled in the same way. EI #1 said if there was evidence that RI #1's family member's email was received 12/29/2022, it should be addressed on a grievance form. EI #1 said if the family member had filed a grievance, a resolution should be reached within five days and documented on the grievance form. EI #1 said if RI #1's family filed a grievance Social Services may have it with the grievance log. On 06/08/2023 at 6:50 PM, a telephone interview was conducted with EI #3, the Social Service Director. EI #3 said that she thought she was also sent the email back in December of 2022 from RI #1's family member regarding a grievance. EI #3 said a grievance form should have been completed but she did not complete one. EI #3 said it should only take five days for a resolution for a complaint/concern to be resolved. EI #3 said when a resolution is reached it should be placed on the grievance form and the family should be informed of the resolution. EI #3 admitted she had not informed RI #1's family member of the resolution from the concern made in December of 2022, and that was something that she usually did.

Based on interviews, record review and review of a facility policy titled . Clean Dressing Change Policy, the facility failed to provide evidence wound care was provided to Resident Identifier (RI) #1's: (1) Right AKA (Above Knee Amputation) stump; and (2) Stage II sacrum ulcer as ordered by the physician. This deficient practice affected RI #1; one of three residents sampled for wound care. Findings Include: Review of a facility policy titled . Clean Dressing Change Policy, with an implemented date of 09/01/2020, revealed the following: Policy: . Physician's orders will specify type dressing and frequency of changes . RI #1 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include Absence of Left Leg Below Knee and Acquired Absence of Right Leg Above Knee. RI #1's Order Summary Report (Physician's Orders) for January 2023, revealed RI #1 had a physician's order to Cleanse right stump (surgical site) with WDC (wound cleanser), pat dry, and cover with dry dressing daily and PRN (as needed) for soilage/dislodgement every day shift for surgical site . Cleanse sacrum with WDC, pat dry, place triad to wound and cover with dry dressing daily and PRN for soilage/dislodgement every day shift for wounds . RI #1's undated care plan, titled . I HAVE A SURGICAL SITE: right stump, THAT REQUIRES TREATMENT/MONITORING . had the intervention . PROVIDE TREATMENT AS ORDERED . Another undated care plan for RI#1, titled . The resident has stage 2 pressure ulcer sacrum r/t (related to) Immobility . had the intervention . Administer treatments as ordered and monitor for effectiveness . A review of RI #1's Treatment Administration Record (TAR) for December 2022, revealed RI #2 did not receive treatment to the sacrum 12 of 23 days during the month of December (Start Date 12/09/2022); and did not receive treatment to the right stump 12 of 22 days as ordered by the physician (Start Date 12/09/2022). On 06/08/2023 at 9:09 AM, an interview was conducted with Employee Identifier (EI) #4, the treatment nurse. EI #4 said when RI #1 was readmitted to the facility in December 2022, the treatments ordered were to clean the right stump with WDC, pat dry and cover with dry dressing daily and PRN. EI #4 said this was the responsibility of all nurses. EI #4 said evidence of the treatments would be on the TAR. EI #4 said looking at the December 2022 TAR there were days missing where treatments were not done. EI #4 also said RI #1 had an order to clean his/her sacrum area with wound cleanser, pat dry, apply Triad, cover with Mepilex daily. EI #4 said this would also be the responsibility of all nurses. EI #4 said she provided treatments whenever she worked and the nurses would provide the care when she was not available. EI #4 said it wound be important to provide wound treatments as ordered by the physician for healing purposes. 06/08/2023 at 2:25 PM an interview was conducted with EI #5 an LPN (Licensed Practical Nurse) who had provided care for RI #1 before. When asked, looking at RI 1#'s December 2022 MAR what type of treatment was being rendered, EI #5 said to cleanse the right stump with wound cleanser, pat dry and cover with dry dressing daily, and PRN for soilage or dislodgement and cleanse sacral area with wound cleanser every day shift. EI #4 said looking at RI #1's December 2022 MAR, it looked like (EI #4) signed off the days she provided the care and there were a couple of days that no one signed as providing the wound care. EI #5 said it would be important to provide wound treatments as ordered by the physician for wound healing. On 06/08/2023 at 4:05 PM, an interview was conducted with EI #2, the DON (Director of Nursing). EI #2 said the treatment nurse was responsible for providing wound care while she was there, and if she was not there, the nurses on the cart would have been responsible. EI #2 said there would be evidence wound care had been provided on the eTAR. EI #2 said it would be important to provide wound care to RI #1's pressure ulcer and stump as ordered by the physician to keep down infection and bacteria and to promote healing. This deficiency was cited as a result of the investigation of complaint/report #AL00042836.

Based on observations, interviews, record review and review of the facility policy, the facility failed to accommodate the needs of one (1) of 43 sampled residents, by not ensuring the Resident Identifier (RI) #296's call light was accessible. Findings include: Review of the facility's policy titled Call Lights: Accessibility and Timely Response dated 8/21/2020 revealed With each interaction in the resident's room or bathroom, staff will ensure the call light is within reach of resident and secured, as needed. RI #296 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of RI #296's comprehensive Care Plan dated 4/28/21 revealed the resident was care planned for: I need assistance with my Activities of Daily Living (ADLs) R/T (related to): Weakness and medical problems with interventions that included Staff to ensure my call light is within reach but anticipate my needs and meet them accordingly, I have alteration in bowel and bladder related to I am incontinent of bowel and bladder, I require assist with toileting, and I wear briefs with interventions that included keep light within reach but anticipate needs due to cognitive decline, and; I am at risk for constipation R/T decreased mobility and medication use with interventions that included ask/encourage me to use call light and report need to toilet PRN. Review of RI #296's Minimum Data Set (MDS) Admission assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 8 of 15 which indicated the resident had moderate impairment in cognition. The resident required extensive assistance of one-person physical assist for bed mobility, transfers, walking in room, dressing, toilet use, and personal hygiene. During an observation on 5/11/21 at 10:30 a.m. RI #296 was observed in his/her room sitting up in his/her wheelchair. RI #296's call light was not in reach. A bed side table was between the resident and the bed, the call light was located on the bed. RI #296 was asked if s/he could reach the call light. The resident attempted to reach the call light and could not reach it. When asked how s/he would call for help if s/he needed it, the resident stated that if s/he cannot reach the call light, s/he does not get help. The resident stated that s/he would have to wait for help. During an interview on 5/12/21 at 11:18 a.m. with Certified Nursing Aide (CNA) #1 s/he stated that the residents' care plans were located on the resident cardex in the CNA Kiosk. CNA #1 stated that this was where s/he went to review the care plan and to chart on the resident. CNA #1 stated that s/he received training on call light placement and knew to keep the call light within reach of the resident. During an observation on 5/12/21 at 4:20 p.m. RI #296 was observed lying in bed. The resident stated that s/he did not feel well and wanted help. When asked if the resident could call for help s/he looked around for his/her call light. The resident's call light was clipped to the right side of the bed above the resident's head. RI #296 attempted to reach the call light but was unable to do so. The resident asked the surveyor if s/he could get the nurse. The surveyor informed Licensed Practical Nurse (LPN) #7 that RI #296 needed assistance. During an interview on 5/13/21 at 11:19 a.m. with the Director of Nursing (DON). The DON stated call lights were the responsibility of all staff. The DON stated that s/he expected staff to ensure that the call light was within reach for the resident. The DON stated that RI #296 had never pressed the call light since s/he had been there, but that the resident was assessed for the ability to press the call light and was able. An interview was conducted on 5/13/21 at 1:18 p.m. with the facility's Administrator. The Administrator stated that it was his/her expectation that call lights were within reach, that staff followed the facility policies and procedures, and staff followed the residents' care plan and that s/he expected the call light to be in reach of the resident.

Based on observations, interviews, record review, and facility policy review, the facility failed to implement care plan interventions related to call lights being within the reach for one (1) of 43 sampled residents, Resident Identifier (RI) #296. Findings include: Review of the facility's policy titled Comprehensive Care Plans dated 8/21/2020 revealed It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. RI #296 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of RI #296's comprehensive Care Plans dated 4/28/21 revealed the resident was care planned for: I need assistance with my ADL's R/T (related to): Weakness and medical problems with interventions that included Staff to ensure my call light is within reach but anticipate my needs and meet them accordingly. I have alteration in bowel and bladder related to I am incontinent of bowel and bladder, I require assist with toileting, and I wear briefs with interventions that included keep light within reach but anticipate needs due to cognitive decline, and; I am at risk for constipation R/T decreased mobility and medication use with interventions that included ask/encourage me to use call light and report need to toilet PRN (as needed). Review of RI #296's Minimum Data Set (MDS) Admission assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of eight (8) of 15 which indicated the resident had moderate impairment in cognition. The resident required extensive assistance of one-person physical assist for bed mobility, transfers, walking in room, dressing, toilet use, and personal hygiene. An observation on 5/11/21 at 10:30 a.m. revealed RI #296 was sitting up in his/her wheelchair in his/her room with the call light not in reach. A bedside table was located between the resident and the bed, the call light was located on the bed. When the surveyor asked the resident if s/he could reach the call light, the resident attempted to reach the call light but was unsuccessful. RI #296 stated that if s/he cannot reach the call light, s/he does not get help if needed and would have to wait for help. During an Interview with Certified Nursing Aide (CNA) #1 on 5/12/21 at 11:18 a.m. revealed resident's care plans were located on the resident cardex in the CNA Kiosk. CNA #1 stated that this was where s/he went to review the care plan and to chart on the resident. An observation on 5/12/21 at 4:20 p.m. revealed RI #296's call light was clipped to the right side of the bed above the resident's head. RI #296 attempted to reach the light but was unable to reach the call light. The resident asked the surveyor if s/he could get the nurse so the surveyor informed Licensed Practical Nurse (LPN) #7 that RI #296 needed assistance. An interview on 5/13/21 at 11:19 a.m. with the Director of Nursing (DON) revealed that all staff should ensure that care plan interventions were in place. The DON stated call lights were the responsibility of all staff. The DON stated that s/he expected staff to ensure that the call light was within reach for the resident. An interview with the Administrator on 5/13/21 at 1:18 p.m. revealed it was his/her expectation that call lights were within reach, that staff followed the facility's policies and procedures, and that staff followed the residents care plans. The Administrator stated that if the care plan stated the call light was to be within reach, s/he expected the call light to be in reach.

Based on interviews, and review of Resident Identifier (RI) #4 and RI #5's medical record reviews, the facility failed to ensure all residents, and/or their responsible party were notified when there was a confirmed case of COVID-19 in the facility. This deficient practice affected RI #4, one of eight sampled residents, with the potential to affect the remaining 86 residents, who currently reside in the facility. Findings include: RI #4 was admitted to the facility on [DATE]. RI #4's Quarterly Minimum Data Set with an assessment reference date of 8/24/2020 indicated RI #4 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. In an interview on 9/2/2020 at 1:47 PM, RI #4 stated he/she was upset and concerned that the he/she was not being informed of the COVID-19 positive cases within in the facility, as he/she should be. According to RI #5's Laboratory Report on 8/27/2020, it was reported to the facility that RI #5 tested positive for [DIAGNOSES REDACTED]-COV (COVID-19). During an interview on 9/3/2020 at 6:17 PM, Employee Identifier (EI) #1, the Administrator was asked had she been following the Centers for Medicare & Medicaid Services (CMS) guidelines for notifying the residents and responsible parties about new COVID-19 cases in the facility. EI #1 said she thought she had but realized she had not. She further stated she did not notify residents and/or resident representatives of the one positive resident on 8/27/2020 because she had put a statement on the 7/23/2020 letter that they would contact them specifically if their loved one was suspected or diagnosed and thought that would be sufficient. EI #1 further stated that she did not know that they had to be informed every time there was a positive. When asked what was the concern with not keeping the families and residents updated of new cases of COVID-19 in the facility, EI #1 answered that they would want to know the numbers and see how at risk they were. This deficiency was cited as a result of the investigation of complaint/report number AL 925.

Based on observation, interviews, and review of the facility's policy titled Hand Hygiene, the facility failed to ensure Employee Identifier (EI) #5, a Registered Nurse (RN) washed and/or sanitized her hands before she put gloves on to administer eye drops to Resident Identifier (RI) #3. This deficient practice affected RI #3, one of three residents observed for medication administration. Findings include: The facility's policy titled, Hand Hygiene, with a date reviewed/revised of 4/15/2019, documented POLICY Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Policy Explanation and Compliance Guidelines: . 3. Hand hygiene is indicated wand will be performed under the conditions listed in, but not limited to, the attached hand hygiene table . According to the Hand Hygiene Table, either antimicrobial soap and water or alcohol based hand rub should be performed before applying and after removing personal protective equipment (PPE), including gloves. During medication pass observation on 9/2/2020 at 11:48 AM, EI #5, a RN did not wash and/or sanitize her hands before she put gloves on to administer RI #3's eye drops. In a telephone interview on 9/3/2020 at 2:19 PM, EI #5, a RN was asked when she should wash her hands when administering eye drops. EI #5 replied, wash before putting gloves on. When asked if she washed and/or sanitized her hands before she put gloves on to administer RI #3's eye drops, EI #5 replied, she couldn't remember. In an interview on 9/2/2020 at 3:17 PM, EI #2, the Director of Nursing/Infection Control Preventionist acknowledged that it would be contamination and an infection control issue if a nurse didn't wash her hands before she put gloves on to administer eye drop medication.

Based on observation, interviews and review of Resident Identifier (RI) #16's medical record, the facility failed to ensure RI #16, who was assessed as being frequently incontinent of bladder and requiring extensive assistance with toileting, was provided timely incontinent care. This deficient practice affected RI #16, one of two sampled residents reviewed for incontinence. Findings include: RI #16 was admitted to the facility on [DATE] with an admitting [DIAGNOSES REDACTED]. RI #16's Quarterly Minimal Data Set with an assessment reference date of 4/8/2019 indicated the resident was moderately impaired in cognitive skills for daily decision making, with a Brief Interview for Mental Status (BIMS) of 9. RI #16 was assessed as requiring extensive assistance with toileting and frequently incontinent of bowel and bladder. RI #16's care plan initiated on 8/15/2018 and titled I HAVE A Potential for skin breakdown R/T (related to) . INCONTINENT OF B&B (bowel and bladder) . had an intervention of PROVIDE ME WITH Incontinent care Q (every) 2 hrs (hours) and prn (as needed) . On 6/26/2019 at 3:30 PM, the surveyor observed RI #16 in the wheelchair self propelling in the halls of the facility. The surveyor observed fluid dripping from the back of the wheelchair. On 6/26/2019 at 3:32 PM, RI #16 was asked when the last time his/her incontinent brief had been changed. RI #16 replied, this morning when Employee Identifier (EI) #11, a Certified Nursing Assistant (CNA) had gotten him/her up. On 6/27/2019 at 3:40 PM, EI #12, a CNA assisted RI #16 to the bed so the resident's incontinent brief could be changed. EI #12 was asked what was in RI #16's wheelchair. EI #12 replied, a puddle of something fluid like, urine. EI #12 was asked to describe how wet RI #16's pants was. EI #12 replied, visibly wet. EI #12 was asked if the brief was also wet. EI #12 replied, yes very wet; it could be rung out if she tried. EI #12 was asked if RI #16 was a heavy wetter. EI #12 replied no, not like that. When asked who was assigned to care for RI #16 during the prior shift, EI #12 replied, EI #11. EI #12 was asked if RI #16 had any skin irritation and she said no. When asked how often residents are to be changed, EI #12 answered every two hours. On 6/27/2019 at 9:00 AM, an interview was conducted with EI #11, a CNA. EI #11 acknowledged that she was assigned to RI #16 on 6/26/2019 and got the resident up around 10:00 AM. EI #11 explained that after RI #16 was gotten out of bed, the resident went to activities. EI #11 stated after RI #16 returned from activities, she checked RI #16's incontinent brief around 11:30 AM and the resident was dry. EI #11 acknowledged that she should have checked RI #16 for incontinence around 1:34 PM but she did not check RI #16 anymore for incontinence after 11:30 AM. EI #11 was asked how often did she check and change residents. EI #11 replied, every two hours. When asked what the harm was for RI #16 not being checked and changed every two hours, EI #11 replied, the resident could get skin breakdowns. On 6/27/2019 at 10:00 AM, an interview was conducted with EI #2, the Director of Nursing (DON). EI #2 was asked how often should residents be checked and changed. EI #2 replied, every two hours. EI #2 was asked what the harm was in a resident being saturated with urine that was also dripping from the chair. EI #2 replied, skin breakdown. This deficiency was cited as a result of the investigation of complaint/report number AL 325.

Based on observation, interview and review of Resident Identifier (RI) #10's medical record, the facility failed to ensure Employee Identifier (EI) #8, a Certified Nursing Assistant changed gloves before placing a clean incontinence brief on the resident. This deficient practice affected RI #10, one of two residents observed for incontinence care. Findings include: RI #10 was admitted to the facility on [DATE]. During the provision of incontinence care on 6/27/2019 at 6:20 AM, Employee Identifier (EI) #8, a Certified Nursing Assistant (CNA), rolled up RI #10's soiled brief and placed a clean brief on the resident, while wearing soiled gloves. In an interview on 6/27/2019 at 6:35 AM, EI #8, a CNA was asked when gloves should be changed. EI #8 replied, once removing the soiled brief and before placing the clean brief. EI #8 was asked if he changed gloves. EI #8 replied, he did not. EI #8 was asked what the harm was in not changing gloves before placing the clean brief. EI #8 replied, cross contamination. On 6/27/2019 at 10:00 AM, an interview was conducted with EI #2, the Director of Nursing (DON). EI #2 was asked, when staff should change gloves during incontinence care. EI #2 replied, when soiled. EI #2 was asked, when should a CNA clean a resident then with the same gloves place a clean brief. EI #2 replied, never they should wash their hands, put on clean gloves, and then place the clean brief. EI #2 was asked, what the harm was in the staff not changing gloves and washing their hands before placing a clean brief. EI #2 replied, the CNA should have on clean gloves to place a clean brief. This deficiency was cited as a result of the investigation of complaint/report number AL 325.

Based on observation, interview, record review, and review of a facility policy titled Medication Administration via Enteral Tube, the facility failed to ensure licensed staff checked Resident Identifier (RI) #94's gastrostomy tube for placement prior to use and did not push water into the gastrostomy tube with a syringe. This affected RI #94, one of one resident observed with a gastrostomy during medication administration. Findings include: Review of the facility policy titled Medication Administration via Enteral Tube, reviewed/revised 11/27/2017, revealed the following: .Policy Explanation and Compliance Guidelines: . 8. Enteral tube placement must be checked via auscultation and/or aspiration before any fluids or medication are administered. RI#94 was admitted to facility on 3/7/18 and readmitted [DATE] with a [DIAGNOSES REDACTED]. On 4/10/19 at at 4:30 PM, RI #94 was observed during medication administration performed by Licensed Practical Nurse (LPN), Employee Identifier (EI) #3, who failed to check for placement of RI #94's gastrostomy tube. EI #3 also pushed 200 cc (cubic centimeters) of water into RI #94's gastrostomy tube, instead of allowing the water to flow into the tube by gravity. EI #3 was interviewed on 4/11/19 at 3:34 PM. When asked what should be done before administering fluids or medication into an enteral gastric tube, EI #3 said she should check the tube for placement, by drawing back and checking for residual (aspiration). When asked what potential harm could occur if that was not done, EI #3 said it could be in their lungs and potentially cause aspiration. EI #3 was then asked how fluids should be administered via gastric tube during medication administration. EI #3 said by gravity. EI #2, Registered Nurse, was interviewed on 4/11/19 at 4:44 PM. When asked what should be done prior to administering medication by enteral gastric tube, EI #2 said auscultate and check for residual before doing anything. When asked if a water flush should be pushed, EI #2 said it should flow by gravity. EI #2 explained that the concern in pushing the flush instead of allowing it to flow by gravity would be if the tube was stopped up by anything, it could dislodge and potentially affect the tube.

Based on observations, interviews, and record review, the facility failed to ensure a Certified Nursing Assistant (CNA) did not contaminate Resident Identifier (RI) #61's [MEDICAL CONDITION] collar while wearing gloves worn and soiled during incontinent care. This affected RI #61, one of two residents sampled for [MEDICAL CONDITION] care. Findings include: Review of an undated facility form titled Hand Hygiene Table for conditions requiring hand hygiene, revealed the following condition . After handling items potentially contaminated with . body fluids, secretions, or excretions . When, during resident care, moving from a contaminated body site to a clean body site . RI #61 was readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of RI #61's quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 2/25/19 revealed RI #61 had severely impaired cognitive skills for daily decision making and received [MEDICAL CONDITION] care. On 4/9/19 at 11:15 AM, RI #61 was observed while CNAs performed incontinent care. Employee Identifier (EI) #1, CNA, cleaned bowel movement from RI #61, and then, while wearing the same gloves, wiped RI #61's [MEDICAL CONDITION] collar and placed a cloth across RI #61's chest under the [MEDICAL CONDITION] collar. On 4/11/19 at 9:39 AM, EI #1, CNA, was asked when she should wash her hands or use hand sanitizer, during incontinent care. EI #1 said, before the care and when the care is done. EI #1 was asked when she should change her gloves. EI #1 said, if her gloves become soiled she should change them before she touched something clean. When asked what could happen if she provided [MEDICAL CONDITION] care with gloves used during incontinent care, EI #1 said, it would be cross contamination. EI #1 was asked what she remembered doing during incontinent care. EI #1 replied, she changed the cloth and wiped secretions from RI #61's [MEDICAL CONDITION] collar. EI #1 was asked why she did that with contaminated gloves. EI #1 said, she was not thinking of changing gloves. On 4/11/19 at 4:16 PM, EI #2, Registered Nurse/Infection Control, was asked why a CNA would wear soiled gloves used during incontinent care and touch a [MEDICAL CONDITION] collar. EI #2 stated, that should not happen. When asked what should be done, EI #2 said, they should change their gloves and wash their hands.

Based on observations, interviews, record review, review of facility policies titled Hand Hygiene and MEDICATION ADMINISTRATION-GENERAL GUIDELINES, and review of a document titled Hand Hygiene Table, the facility failed to ensure: 1) Certified Nursing Assistants (CNAs) performed hand hygiene and glove changes when they became soiled before touching clean items, and did not contaminate incontinent care supplies (gloves, wipes, perineal wash placed back into circulation in Resident Identifier (RI) #61's room) during incontinent care provided to RI #61; 2) licensed staff washed their hands after removing gloves and before applying gloves while administering gastrostomy tube medication and [MEDICAL CONDITION] inhalation medication for RI #94; and 3) licensed staff washed her hands after administration of medication to RI #26, before touching a medication computer and before providing a resident in the hallway with a cup. This affected two of two incontinent care observations for RI #61, and 2 of 5 residents observed during medication administration. Findings include: Review of a facility policy titled Hand Hygiene, reviewed/revised 11/27/17, revealed the following: Policy: Staff involved in direct resident contact will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Review of a facility policy titled MEDICATION ADMINISTRATION-GENERAL GUIDELINES, effective (MONTH) (YEAR), revealed the following: . Procedures A. Preparation . 2) Handwashing and Hand Sanitization: The person administering medications adheres to good hand hygiene, which includes washing hands thoroughly .after coming into direct contact with a resident . b. Hand sanitization is done with an approved sanitizer. * between hand washings, when returning to the medication cart or preparation area (assuming hands have not touched a resident or potentially contaminated surface). * at regular intervals during the medication pass such as after each room . Review of an undated facility form titled Hand Hygiene Table for conditions requiring hand hygiene, revealed hands should be washed in the following conditions: . Between resident contacts . After handling contaminated objects . Before applying and after removing personal protective equipment (PPE), including gloves . after handling items potentially contaminated with . body fluids, secretions, or excretions . When, during resident care, moving from a contaminated body site to a clean body site . 1) RI #61 was readmitted to the facility on [DATE]. Review of RI #61's quarterly MDS with an Assessment Reference Date of 2/25/19 revealed RI #61 had severely impaired cognitive skills for daily decision making, was always incontinent and required extensive assistance with personal hygiene. On 4/09/19 at 11:15 AM, RI #61 was observed while CNAs performed incontinent care. Employee Identifier (EI) #1, CNA, cleaned bowel movement from RI #61, and then, wearing the same gloves, placed a clean pad and brief under RI #61 and continued to provide care as follows: wiped RI #61's [MEDICAL CONDITION] collar, placed a cloth across RI #61's chest, removed her right glove, held the glove in her left hand and placed clean linen on RI #61. On 4/11/19 at 9:39 AM, EI #1 was asked when she should wash her hands or use hand sanitizer, during incontinent care. EI #1 said, before the care and when the care is done. EI #1 was asked when she should change her gloves. EI #1 said, if my gloves become soiled I should change them before I touch something clean. On 4/10/19 at 12:04 PM, CNAs entered RI #61's room to clean him/her up for transport to the hospital. At 12:19 PM, EI #4, a CNA, wiped RI #61's perineal area, then changed gloves without performing hand hygiene. RI #61 was wet with urine and had a medium loose bowel movement. While cleaning the bowel movement, EI #4 touched the perineal wash bottle and disposable wipes, without first washing her hands. At 12:45 PM, EI #4 bagged supplies at RI #61's bedside. EI #4 then placed the bag of supplies in RI #61's bedside table, and placed the boxes of wipes back on the shelf on the wall. The perineal wash bottle was placed into the top of the closet with RI #61's other hygiene supplies. EI #4 was interviewed on 04/10/19 at 6:30 PM. When asked what the facility's policy was for changing gloves and washing hands, EI #4 said if bowel movement gets on gloves, hands should be washed and gloves changed to make sure there is no contamination. EI #4 was asked why she had cleaned bowel movement from RI #61 and changed gloves, without washing hands. EI #4 said she forgot. When asked about the items she touched with dirty hands (the perineal wash bottle and wipes boxes), EI #4 said she had not realized she did that and placed them back into circulation for future use. EI #4 said the items should have been thrown away. On 4/11/19 at 4:16 PM, EI #2, Registered Nurse/Infection Control, was asked what should have been done when a CNA moved from a soiled area to a clean area, such as a clean brief. EI #2 said, they should remove their gloves and wash their hands. EI #2 was asked what was the potential harm in not performing hand hygiene after soiled glove removal. EI #2 said, it spreads germs. When asked what happens when items (such as the perineal wash bottle and wipes boxes) are used/handled with soiled gloves, EI #2 said they get contaminated. EI #2 further stated when placed into a bag with other supplies, the other supplies also become contaminated. EI #2 said the contaminated items should be thrown away so as not to contaminate other items in the resident's room. 2) RI #94 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 4/10/19 at 4:30 PM, RI #94 was observed while EI # 3, Licensed Practical Nurse, administered medication via gastric tube and [MEDICAL CONDITION] inhalation. EI #3 did not wash hands after removing gloves from the gastric tube administration, prior to administering inhaled medication via the [MEDICAL CONDITION]. EI #3 was interviewed on 4/11/19 at 3:34 PM. When asked what should be done when you remove gloves after giving medication via gastric tube and then start to administer a nebulizer treatment via [MEDICAL CONDITION], EI #3 said wash hands and re-glove. EI #3 said the potential harm in not doing so would be potential cross contamination. On 4/11/19 at 4:44 PM, EI #2, Registered Nurse/Infection Control, was asked what the concern was in not washing hands and changing gloves between administration of medication via gastric tube and inhaled medication via [MEDICAL CONDITION]. EI #2 said you would not want to breathe in any residual from handling the feeding. EI #2 said staff should have washed hands and changed gloves prior to administering the inhaled medication. 3) RI #26 was admitted to the facility on [DATE] and readmitted on [DATE]. On 4/11/19 at 9:00 AM, EI #5, Licensed Practical Nurse, was observed administering medications to RI #26. EI #5 left the resident's bedside after giving the medication and walked directly to the medication cart and typed on the computer (without washing hands). She then handed a cup to another resident that was passing by in the hallway. After giving the resident the cup, EI #5 returned to RI #26's room, and washed her hands. EI #5 was interviewed on 4/11/19 at 11:40 AM. EI #5 was asked when she should wash hands when giving residents medication. EI #5 said after every resident. When asked what the potential harm could be in touching the computer and handing another resident a cup without first washing hands, EI #5 said if they had flu, a contagious disease, or any type of infection, it could be passed on to someone else. When asked why she had not washed her hands after administering RI #26's medications (prior to returning to the medication cart and giving another resident a cup), she said she was not aware she had done that. On 4/11/19 at 4:44 PM, EI #2, Registered Nurse/Infection Control, was asked when staff should wash their hands when administering medications. EI #2 said before and after medication administration. She said if hands are not washed after administering medication, prior to moving on to other tasks, there is the potential to spread germs.

Based on observations, staff interviews, a review of the (YEAR) Food Code and a review of the facility's Policy and Procedure for the Storage of Healthshakes, the facility failed to: 1. ensure tea urn spigots were cleaned daily; 2. prevent potential cross-contamination of utensils/dinnerware as evidenced by storing clean sanitized dinnerware in close proximity to a trash barrel used to scrape soiled food trays; ; 3. ensure frozen food (Ice Cream) received frozen, remained frozen during storage; 4. ensure clean/sanitized sectional plates were air-dried and were clean to sight/touch (no food debris); and 5. ensure Mighty Shakes (a nutritional supplement) were marked with a use by date per manufacturer's instructions. These deficient practices had the potential to affect all 90 residents who received meal trays from dining services. Findings include: 1. TEA SPIGOTS The Food Code, U.S. (United States) Public Health Service and FDA (Food and Drug Administration) (YEAR) specified the following: . 4-602.11 Equipment, Food-Contact Surfaces and Utensils .(E) .shall be cleaned: .(2) At least every 24 hours for iced tea dispensers . On 5/01/18 at 8:55 AM, an observation was made of two, five gallon Tea Urn spigots which were located in the kitchen area. The Dietary Manager (DM), Employee Identifier (EI) #1 was asked to disassemble the dispenser faucet. The plunger in the first urn contained a build-up of pinkish solid matter. The second plunger contained a dark brown solid matter, which adhered to the surface, but was removable with the thumbnail. The DM, EI #1 said, That hasn't (has not) been soaked. A request was made to the DM to view the facility cleaning schedule. The DM provided a document titled Daily Cleaning List. Tea Urns were the second item listed; however, the document/form was void of any recorded data. EI #1 stated, I do not have the one they signed off on. 2. COMPROMISED SANITARY STORAGE OF CLEAN DISHES On 5/01/18 at 9:05 AM. a Dietary Aide. EI #6 was observed to remove clean/sanitized dishware from racks and stack them on a cart positioned near a garbage can (barrel) used to deposit food from residents' soiled trays. In close proximity to the cart was a four tiered shelving which was used to stack/store the soiled dishes. On 5/01/18 at 12:45 PM, the RD/EI #2 was asked about the potential contamination and said the risk was for biological contamination. 3. FROZEN FOOD Regulation 3-501.11 Frozen Food of the (YEAR) Food Code revealed the following: .Stored frozen FOODS shall be maintained frozen. On 05/01/18 at 9:30 AM, the outside thermometer of the walk-in freezer displayed an interior temperature of 33 degrees Fahrenheit (F). The door of the adjoining walk-in freezer was standing open. Individual cups of ice cream were stored in the back of the freezer unit. Pressure was applied and finger indentations remained on the exterior of the cup. The interior temperature of the Ice Cream was measured by EI #1, DM, to be +9 degrees (F). The surveyor asked EI #1 if the ice cream was frozen solid. EI #1 replied, No Ma'am. 4. AIR DRIED, CLEAN TO SIGHT Review of the (YEAR) Food Code revealed the following: . 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A)EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried . On 05/01/18 at 11:50 AM during lunch trayline observations, the surveyor noted three sectional plates on the line, ready to be used by staff for plating. One plate had rolling water inside and two plates contained food debris. The surveyor asked if the first plate was air dried. EI #2, the RD, said no. When asked how many plates had food debris, EI #2 said two. Later, at 12:45 PM, EI #2 was asked why the sectional plates were not clean and she responded that staff failed to monitor for cleanliness. Surveyor: Pavelec, Connie 5. FOOD LABELING The facility policy related to Storage of Healthshakes, effective 07/20/16, included: . Shakes do come in frozen and are thawed under refrigeration. Shakes thaw in 2 days and are used within 14 days of thawing. When shakes are removed from their original box, they will be labeled with a top date of a thawed/arrival date and a bottom date of a use by date . On 05/03/2018 at 8:44 AM, the surveyor and DM (EI #1) observed three 4-ounce cartons of Mighty Shakes in the East Wing pantry refrigerator. None of the cartons contained a label indicating the use-by-date. When asked to explain their policy regarding the labeling of shakes, EI #1 said an adhesive label was to be attached to each carton, with a discard date for the shakes of 14 days after thawed. EI #1 stated the potential harm in not using the shakes within 14 days would be the potential souring of these dairy products.

Based on interviews, review of the facility policy titled Abuse, Neglect and Exploitation and review of the facility's investigative summary related to alleged misappropriation of resident narcotics by Employee Identifier (EI) #4, Licensed Practical Nurse (LPN), the facility failed to ensure Resident Identifier (RI) #104 and RI #157 remained free from abuse/misappropriation of property on 4/1/18 when EI #4, LPN, took Narcotic medication belonging to these residents. This affected two of four residents who were reviewed for abuse. This tag is cited as a result of the investigation of complaint/report #AL 648 for abuse/misappropriation of resident property. Findings include: On 4/1/18, the facility reported to the state agency an allegation of misappropriation of resident property (narcotics). On 4/1/18, Employee Identifier (EI) #5 DON (Director of Nurses) verified that the narcotic count was incorrect and there was a discrepancy. EI #4 LPN, had been the nurse assigned to the cart the night before. When the DON arrived at the facility and verified the discrepancy, it was determined that EI #4 had the medications (narcotics) belonging to RI #104 and RI #157. A facility policy titled, Abuse, Neglect and Exploitation with a date implemented of 11/27/2017, revealed: Policy Each resident has a right to be free from abuse . misappropriation of resident property . Residents must not be subject to abuse by anyone, including, . facility staff . Policy Explanation and Compliance Guidelines: . 2. Abuse . includes the deprivation by an individual, including a care taker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. 10. Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings . without the resident's consent. RI #104 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of RI #104's (MONTH) (YEAR) physician orders revealed an order dated 1/17/18 for [MEDICATION NAME]-[MEDICATION NAME] 10 mg/325 mg (milligrams) to be administered three times a day for pain. On 5/3/18 at 02:45 PM an interview was conducted with EI #9, LPN, the oncoming nurse on RI #104's hall on 4/1/18. EI #9 was asked what was her position on 4/1/18. EI #9 said, cart nurse. EI #9 was asked who she was relieving on the med cart on 4/1/18. EI #9 said, EI #4. EI #9 was asked what medication had a miscount on her cart. EI #9 said, RI #104 was missing [MEDICATION NAME] 7.5 mg. EI #9 stated that EI #5, the DON, was the person who found the discrepancy because she counted the cart EI #4 had been working. RI #157 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #157's (MONTH) (YEAR) physician orders revealed an order dated 3/11/18 for [MEDICATION NAME] HCl 5 mg to be administered every 8 (eight) hours as needed for pain. On 5/3/18 at 10:07 AM, an interview was conducted with EI #6, Registered Nurse (RN), the oncoming nurse on RI #157's hall on 4/1/18. EI #6 was asked what was her position on 4/1/18. EI #6 said, nurse on the medication cart. When asked who she was relieving on the medication cart on 4/1/18, EI #4 said, EI #4, LPN. EI #6 was asked what was EI #4's demeanor on 4/1/18 when she were relieving EI #4. EI #6 said, she was on edge a little bit and she had a nonchalant attitude about the miscount. EI #6 was asked what medication had a miscount. EI #6 said, RI #157 was missing a card of 60 count [MEDICATION NAME], but the sheet was still in the book. EI #6 was asked if there were any other residents who had medication missing. EI #6 was asked what she did when she discovered the miscount. EI #6 said she called the on-call person, EI #8, Admission Nurse, EI #7, LPN/Unit Manager, and EI #5, DON. When asked who came to the facility, EI #6 said, EI #5 came to the cart and EI #6 explained the miscount. EI #5 counted narcotics for RI #157. EI #5 then took her and EI #4 to the office and interviewed them separately. EI #6 was asked what occurred when EI #4 and EI #5 returned to the hall. EI #6 said, EI #4 gathered her things and EI #6 asked EI #4 if she could search her purse. EI #4 stated that EI #5 could check her bag but would not let EI #5 check her purse. EI # 6 stated she was told to call the police by EI #5. When the police arrived, EI #4 was placed in handcuffs. EI #5 and an officer found the medications in EI #4's possession. EI #6 further stated, she and EI #5 laid the medications on med cart and started separating them to identify them. An officer came out with a zip lock bag of more medications that were found in EI #4's possession. On 5/2/18 at 05:20 PM, an interview was conducted with EI #5, DON. EI #5 was asked what occurred on 4/1/18. EI #5 said, she received a call from EI #7, Unit Manager, informing her there was a card of RI #157's [MEDICATION NAME] 5 mg missing when EI #6 was relieving EI #4. EI #5 said when she arrived at the facility and looked over everything, she verified there was a card of [MEDICATION NAME] missing. She stated she took EI #4 and EI #6 to her office to ask them about the discrepancy. EI #5 said she asked EI #4 if the count was accurate the night before when she counted with EI #6 and she said yes, it was. EI #5 said she asked EI #4 if she agreed the count was wrong on 4/1/18, and she said yes. EI #5 said EI #4 reported she had not given her keys to anyone or left her cart unlocked at anytime during her shift. EI #5 then said the police were called and when they arrived at the facility, EI #4 began taking handfuls of medicine out of her purse and putting them on the medication cart. The police handcuffed EI #4 and she told them she was planning on selling the medications. EI #5 was asked if RI #104's and RI #157's medications had been on the same cart, and EI #5 said no, but EI #4 was working both of their carts on the night of 3/31/2018. Review of the facility's investigative summary related to the 4/1/18 incident, revealed the facility identified 60 missing [MEDICATION NAME] Hcl 5mg (for RI #157) and one missing [MEDICATION NAME]-[MEDICATION NAME] tablet (for RI #104). After completing their investigation, the facility substantiated misappropriation of resident property.

Based on interview, record review and review of Resident Identifier (RI) #38's hospital discharge summary, the facility failed to ensure a new [DIAGNOSES REDACTED].#38's readmission from the hospital on [DATE]. This affected one of 26 residents whose MDS was reviewed. Findings include: RI #38 was readmitted to the facility on [DATE]. RI #38's hospital discharge summary dated 11/17/17, documented the following: . PRINCIPAL DISCHARGING Diagnoses: [REDACTED]. A review of RI #38's readmission and monthly Physician orders [REDACTED]. A review of RI #38's MDS assessments, completed since readmission, with Assessment Reference Dates of 12/11/17 (quarterly assessment) and 2/26/18 (quarterly assessment)revealed Section I for Active [DIAGNOSES REDACTED].#38 had a [DIAGNOSES REDACTED]. On 5/03/18 at 6:05 PM, EI #3 MDS/Care Plan Coordinator, was asked why RI #38 went to the hospital in November. EI #3 said, she did not know. When asked why RI #38 was on the medication Levetiracetam, EI #3 replied, [MEDICAL CONDITION] disorder. EI #3 was asked why that [DIAGNOSES REDACTED]. EI #3 said, apparently the [DIAGNOSES REDACTED]. EI #3 was asked if it should it have been. EI #3 said, yes ma'am. When asked why it should have been added, EI #3 said, that was why RI #38 had been sent out, for any [MEDICAL CONDITION] activity.

Based on interview and record review the facility failed to ensure an individualized care plan was developed for Resident Identifier (RI) #38 for a [DIAGNOSES REDACTED]. This affected one of 26 residents for whom care plans were reviewed. Findings include: RI #38 was readmitted to the facility on [DATE]. RI #38's hospital discharge summary dated 11/17/17, documented the following: . PRINCIPAL DISCHARGING Diagnoses: [REDACTED]. DISCHARGING medications: [REDACTED]. Levetiracetam 500 mg (milligrams) twice a day. A review of RI #38's readmission and monthly Physician orders [REDACTED]. Review of RI #38's comprehensive care plans revealed no interventions related to the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. On 5/03/18 at 6:05 PM, EI (Employee Identifier) #3 MDS/Care Plan coordinator, was asked why RI #38 went to the hospital in November. EI #3 said, she did not know. When asked why RI #38 was on the medication Levetiracetam, EI #3 replied, [MEDICAL CONDITION] Disorder. EI #3 was asked why RI #38 was not care planned for [MEDICAL CONDITION] and the use of Levetiracetam. EI #38 said, she would have to go back and look. When asked if it should have been care planned, EI #38 replied, yes ma'am. EI #3 was asked why it should have been care planned. EI #3 said, to make the staff aware of it and to have continuity of care.

Based on observations; resident and staff interviews; and review of resident's medical records and the facility's policy titled Smoking Policy - Residents, the facility failed to assess Resident Identifier (RI) #6, RI #11, RI #12 and RI #13 to determine if the resident could smoke independently, required assistance and/or supervision of staff to smoke. RI #6, RI #11, RI #12 and RI #13 were identified by the facility as residents who smoke cigarettes while residing in the facility. Employee Identifier (EI #2), the Director of Nursing Service (DNS) stated the nursing staff failed to ensure smoking assessments were completed to identify high risk residents that needed supervision. Also, the facility failed to ensure precautions were taken for residents' individual safety, as well as the safety of others in the facility by allowing residents who required supervision to maintain disposable lighters on them; allowing residents to smoke without using smoking adaptive equipment (i.e. smoking apron, smoking blanket); and failing to have a fire extinguisher(s) in the designated smoking area. RI #6, admitted to facility on 4/4/2017 was not assessed until after the State Agency observed this resident smoking unsupervised and without fire preventative equipment on 6/13/2017. During the observation, RI #6, who also has visible hand contractures was noted to drop cigarette ashes on his/his clothing. After assessment by the facility, RI #6 was assessed to require the use of a smoking apron, supervision and one-to-one assistance for smoking. RI #13, admitted to the facility on [DATE] was not assessed until after the State Agency observed this resident smoking unsupervised, without fire preventative equipment and with a cigarette and lighter in his/her possession on 6/13/2017. After assessment by the facility, RI #13 was assessed to require the use of a smoking apron. RI #11, admitted to the facility on [DATE] was not assessed until 6/13/2017. RI #11 was observed smoking in the facility's designated smoking area, while RI #16, a resident with oxygen infusing at 2.5 liters per minute, was within close proximity. EI #3, the Activity Director was noted conversing with RI #11; however, she failed to intervene or ask either resident to move to a different area. RI #12, admitted [DATE] was not assessed until 5/17/2017, six days later. RI #20, admitted to the facility on [DATE] was observed to have in his/her possession cigarettes and a lighter. The facility's policy signed by RI #20 on 6/15/2017 forbade residents from keeping cigarettes or lighters in their personal possession. These deficient practices placed RI #6, RI #11, RI #12, RI #13 and RI #20, five of six sampled residents identified by the facility as residents who smoke and RI #16, one of one residents observed in the smoking area while other residents smoked, in immediate jeopardy as it was likely to cause serious injury, harm or death. On 6/14/2017 at 4:42 PM, Employee Identifier (EI) #1, the Administrator and EI #2, the DNS were notified of the findings of substandard quality of care at the immediate jeopardy level in the area of Quality of Care, F 323. Findings include: The facility's policy titled Smoking Policy - Residents with a revised date of December 2011, documented the following: Policy Statement This facility shall establish and maintain safe resident smoking practices. Policy Interpretation and Implementation 1. Prior to, or upon admission, residents shall be informed about any limitations on smoking, including designated smoking areas, and the extent to which the facility can accommodate their smoking or nonsmoking preferences . 10. Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking . 13. Smoking articles for residents without independent smoking privileges: a. Residents without independent smoking privileges may not have or keep any types of smoking articles, including cigarettes, tobacco, etc., except when they are under direct supervision . RI #6 was readmitted to the facility on [DATE]. RI #6 has a medical history to include: Quadriplegia and Cervical Spinal Cord Injury at C5 and C6. RI #6's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/5/2017, revealed RI #6 was cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 15. RI #6 was assessed as having functional limitations in range of motion in the upper and lower extremities on both sides. RI #13 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #13's Admission MDS with an ARD of 4/11/2017 indicated RI #13 was cognitively intact, with a BIMS score of 13. On 6/13/2017 at 3:10 PM, two male residents (later identified as RI #6 and RI #13) were observed smoking unsupervised in the facility's designated smoking area; neither resident had on a smoking apron. RI #6, with contracted hands, was observed with an ash tray in his/her lap and three cigarettes on his/her left leg. RI #6 was observed dropping cigarette ashes on his/her t-shirt. At 3:18 PM, EI #23, a housekeeper got a cigarette lighter from RI #13 and lit another cigarette for RI #6. At 3:30 PM, EI #23 acknowledged that she got a lighter from RI #13 and lit a cigarette for RI #6. After RI #6 finished the cigarette, the resident put the cigarette out and removed the ash tray from his/her lap and placed it on a table located in the smoking area. RI #13 was observed to have cigarettes and a lighter in his/her possession. On 6/14/2017 at 9:50 AM, an interview was conducted with RI #6. RI #6 was asked if the facility had discussed the smoking policy with him/her. RI #6 said no. RI #6 was asked if he/she smoked independently and the resident said yes. When asked were there designated times, RI #6 said no. RI #6 was asked if he/she was assessed on admission to be able to smoke independently. RI #6 replied that he/she did not smoke when he/she was admitted but later started to smoke in May 2017. RI #6 acknowledged that he/she kept his/her cigarettes and had a lighter. When asked if he/she had ever worn a smoking apron, RI #6 replied I never wanted to wear one and I have never worn one. RI #6 was asked did ashes ever fall on his/her clothing while smoking. RI #6 said yes, but the ashes were out. When asked if he/she ever burned himself/herself while smoking, RI #6 said no. On 6/14/2017 at 9:40 AM, an interview was conducted with RI #13, while the resident smoked in the designated smoking area unsupervised by the facility staff. When asked if the facility ever discussed with his/her the policy on smoking, RI #13 said no. RI #13 was asked who lit his/her cigarettes. RI #13 replied that he/she did. When asked if he/she usually smoked independently, RI #13 said yes. RI #13 was asked if he/she had been assessed to smoke independent, the resident said no. RI #13 acknowledged that he/she kept his/her cigarettes and lighter in a drawer in his/her room. RI #13 was asked had he/she ever dropped ashes on himself/herself. RI #13 replied not since he/she had been here at the facility. It was stated to RI #13 that he/she was observed on yesterday not wearing a smoking apron and asked if he/she had ever worn a smoking apron. RI #13 replied no. During an interview with RI #13's son on 6/17/2017 at 10:45 AM, he stated RI #13 started smoking about a week after the resident was admitted to the facility. On 6/14/2017 at 10:50 AM, EI #1, the Administrator stated the first smoking assessment for RI #6 was done on 6/13/2017. RI #6's SMOKING - SAFETY CONCERN with an effective date of 6/13/2017 4:17 PM, indicated RI #6 had dexterity problem(s) and could not light his/her own cigarette. RI #6 was assessed to require the use of a smoking apron, supervision and one-to-one assistance for smoking. The form further revealed . (RI #6) is A&O (alert and oriented) able to verbally and physically demonstrate safety while smoking but r/t (related to) [DIAGNOSES REDACTED]. Team Decision: Safe to smoke with supervision . RI #13's SMOKING - SAFETY CONCERN with an effective date of 6/13/2017 5:46 PM, indicated RI #13 was assessed to require the use of a smoking apron. In an interview on 6/14/2017 at 3:40 PM, EI #2, the DON was asked what was the facility's policy regarding smoking assessments. EI #2 replied, the assessments should be done on admission and quarterly. EI #2 further stated the facility did not have a smoking assessment policy. A handwritten note from EI #1, the Administrator dated 6/13/2017 6:10 PM, indicated the facility did not have designated smoking times and identified five residents as being able to smoke ad lib (as desired). The five residents listed were: RI #6, RI #10, RI #11, RI #12 and RI #13. RI #12 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #12's SMOKING - SAFETY SCREEN dated 5/17/2017, six days later, indicated RI #12 was safe to smoke with supervision. RI #11 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 6/13/2017 at 4:00 PM, RI #11 was observed in the designated smoking area. RI #11 had on a smoking apron. RI #11 lit his/her own cigarette and began smoking, while RI #16, a resident with oxygen infusing at 2.5 liters per minute, was within close proximity; eight to nine feet. EI #3, the Activity Director was noted conversing with RI #11; however, she failed to intervene or ask either resident to move to a different area. In an interview on 6/14/2017 at 8:45 AM, EI #3, the Activity Director was asked, what her observation of RI #11 was when she was outside with RI #11 while he/she smoked. EI #3 replied she saw a family and a resident enjoying being outside and RI #11 was smoking a cigarette. EI #3 was asked was RI #11 in close proximity of RI #16 who had on oxygen. EI #3 replied, there was a good enough distance between them. When asked what the potential harm could be with a resident on oxygen in close proximity of a resident smoking, EI #3 replied she didn't know exactly what could happen. EI #3 explained that if they were right next to each other, there could have been a fire or an explosion. In an interview on 6/14/2017 at 10:08 AM, EI #11, a Licensed Practical Nurse (LPN) was asked, if there was a smoking assessment done on RI #11 prior to 6/13/2017. EI #11 stated, No. On 6/14/2017 at 11:05 AM, an interview was conducted with RI #11. RI #11 was asked if he/she knew the facility's smoking policy. RI #11 replied, when he/she was admitted someone reviewed with him/her where and when to smoke. When asked, how often he/she smoked, RI #11 stated anytime he/she wanted to. RI #11 was asked if he kept a cigarette lighter in his/her possession. The resident said yes until yesterday (6/13/2017). When asked if he/she had been assessed, prior to 6/13/2017, to smoke without staff supervision, RI #11 said no. RI #11's SMOKING - SAFETY CONCERN with an effective date of 6/13/2017 6:25 PM, indicated RI #11 was assessed to require the use of a smoking apron and was safe to smoke without supervision. During an interview with EI #1, the Administrator on 6/13/2017 at 6:45 PM, she was asked what was available in the event of a fire in the facility's designated smoking area (located outside the building). EI #1 said the facility did not have fire blankets but there was fire extinguishers on the halls. According to EI #1, inside the building half way down the East and West wing there was a fire extinguisher. On 6/14/2017 at 8:55 AM, a fire blanket box was observed attached to a wall in the facility's designated smoking area. Two fire blankets were inside the box. A smoking apron was also observed on a hook just outside the facility's dining room door. In a follow-up interview on 6/14/2017 at 9:18 AM, EI #1, the Administrator was asked when the fire blankets were placed in the designated smoking area. EI #1 replied, this morning about 6:30 AM. EI #1 acknowledged that on yesterday (6/13/2017) she stated she would order some fire blankets, but explained after speaking with the Maintenance Director (EI #14), there was some fire blankets outside in the maintenance storage shed. EI #1 stated she had a discussion last night about the whole smoking situation and EI #14 went to the maintenance shed and found a red box that contained two fire blankets. EI #1 acknowledged the fire blankets should have been installed prior to this morning. When asked where the fire blankets were installed, EI #1 replied right behind a chair on the wall where residents sit and smoke. During a review of the facility's submitted Allegation of Credible Compliance on 6/16/2017 at 9:15 AM, RI #20, previously not identified by the facility as a resident who smokes, was observed smoking supervised by EI #8, an Occupational Therapist, in the facility's designated smoking area. A review of RI #20's medical record, revealed the resident was admitted to the facility on [DATE]. RI #20's SMOKING - SAFETY SCREEN date 6/15/2017 indicated RI #20 was alert, aware of safety and safe to smoke without supervision. During an interview on 6/17/2017 at 9:27 AM, EI #8, the Occupational Therapist was asked how long had she worked in the facility. EI #8 stated this was her first day. EI #8 acknowledged that she bought RI #20 outside to smoke this morning around 9:00 AM. When asked if RI #20 had cigarettes and a lighter when he/she came outside to smoke, EI #8 said yes. On 6/16/2017 at 9:35 AM, RI #20, recently admitted to the facility, was interviewed; EI #13, the Social Worker was also present. RI #20 was asked when he/she had been inserviced on the facility's smoking rules. RI #20 replied last night. RI #20 was asked when he/she came out to smoke this morning did he/she bring his/her own cigarettes and lighter. RI #20 replied yes. EI #13 asked RI #20 for the cigarettes and lighter at which RI #20 reached in the top of his/her top clothing and pulled out a pack of cigarettes and a lighter and gave them to EI #13. The facility's Smoking Policy - Residents signed by RI #20 on 6/15/2017 documented . 6. The Facility forbids residents from keeping cigarettes or lighters in their personal possession. Rather, cigarettes and lighters will be kept by Facility staff and provided to residents during the supervised scheduled smoking breaks . During an interview on 6/17/2017 at 1:40 PM, EI #2, the DNS was asked how she ensured the facility was maintained in a manner to ensure the residents' environment was safe. EI #2 replied to ensure the department heads are doing what they are supposed to do. EI #2 was asked in regards to the smoking incidents what happened. EI #2 replied, we failed to ensure everyone did what they were supposed to do. EI #2 stated the nursing staff failed to ensure the smoking assessments were completed to identify high risk residents who needed supervision; Maintenance and Administration failed to ensure the facility had smoking blankets and fire extinguishers in the courtyard; and the facility failed to ensure a safe environment for the residents that smoke. ************************* On 6/16/2017 at 3:05 PM, the facility submitted an Acceptable Allegation of Compliance, which documented: 1. On June 14, 2017, the Facility implemented a new smoking policy whereby residents will only be allowed to smoke during supervised scheduled smoking breaks in the Facility's designated smoking area- its Courtyard. The policy also does not permit residents to keep cigarettes or lighters in their personal possession. Rather, cigarettes and lighters will be kept by Facility staff and provided to residents during the supervised scheduled smoking breaks. The Facility has also implemented a smoking log that will identify the Facility staff member supervising each supervised smoking break as well as each resident that participated in the supervised scheduled smoking break. The policy was developed by Med Pass and revised by Administrator and Director of Nursing. Smoking Safety Screens Assessments were conducted on RI#6, RI#11, and RI#13 on June 13, 2017 by restorative nurse. The Smoking Safety Screen assessment contains the questions: (1) whether the resident has a cognitive loss; (2) whether the resident has vision deficits; (3) whether the resident has any dexterity problems; (4) how many cigarettes the resident smokes per day; (5) the time(s) the resident likes to smoke; (6) whether the resident can light his or her own cigarette; and (7) whether the resident needs adaptive equipment. The Smoking Safety Screen Assessment reflected that RI#6 was safe to smoke with supervision and that RI#11 and RI#13 were safe to smoke supervised. During the afternoon and evening of June 14, 2017, Smoking Safety Screens Assessments were completed on all remaining residents in the Facility. On June 14, 2017, the Facility's social worker spoke with RI#6, RI#11, and RI#13 to clarify the new smoking policy and supervised scheduled smoke breaks. RI#6, RI#11, and RI#13 acknowledged that they understood the new policy and had no objection to it. On June 14, 2017, the Facility's staff development nurse spoke with the family members of RI#6, RI#11, and RI#13 and explained the new policy and supervised scheduled smoking breaks. The family members of RI#6, RI#11, and RI#13 acknowledged that they understood the new smoking policy and had no objection to it. After speaking with the residents and their families, the Facility collected cigarettes and lighters from all residents in the Facility on the evening of June 14, 2017. On June 13, 2017, the Facility placed four smoking aprons on hooks in the Courtyard .On June 14, 2017, the Facility also placed a fire blanket in the Courtyard along with four fire extinguishers- one on each patio in the courtyard. The smoking blanket, smoking aprons, and fire extinguishers will be available every time RI#6, RI#11, RI#13, and any other resident(s) participate in a supervised scheduled smoking break. The blanket and aprons and facility fire extinguishers will be inspected at the beginning of every smoking break by the staff member supervising the scheduled smoking break to ensure they are in operable condition. Beginning on second shift on June 14, 2017, the Administrator, Staff Development Nurse and Social Worker in-serviced all staff in the building on the Facility's new smoking policy, the supervised scheduling smoking times, and the location and proper use of the smoking blanket and facility fire extinguishers. On June 15, 2017, the Staff Development Nurse and Maintenance Director began in-servicing all staff in the building on proper use of the smoking aprons, fire blanket, and fire extinguishers. All Facility staff have been in-serviced on the new smoking policy, supervised smoking times, and the location and use of the smoking aprons, fire blanket, and facility fire extinguishers prior to working their next shift. This will ensure that the staff providing care to RI#6, RI#11, and RI#13 and the staff supervising the smoking of RI#6, RI#11, and RI#13 have been properly educated on the Facility's new smoking policy, the supervised scheduling smoking times, and the location and use of the smoking blanket and facility fire extinguishers. On June 13, 2017, the Facility's Activities Director was observed present while RI#11 smoked while RI#16, who was wearing portable medical oxygen, was approximately nine feet away. The Facility's Activities Director was in-serviced on June 15, 2017, by Administrator on fire safety, specifically that smokers should not be in the vicinity of portable medical oxygen tanks. 2. During the afternoon and evening of June 14, 2017, Smoking Safety Screen Assessment was completed on all remaining residents in the facility by restorative nurse. All the residents were asked if they smoke. No new smokers were identified. 3. Beginning on second shift on June 14, 2017, the Facility in-serviced all staff in the building on the Facility's new smoking policy, the supervised scheduling smoking times, and the location of the smoking blanket, smoking aprons and facility fire extinguishers. On June 15, 2017, the Facility began in-servicing all staff in the building on proper use of the fire blanket and smoking aprons and fire extinguishers. Facility staff was in-serviced on the new smoking policy, supervised smoking times, and the location and use of the fire blanket and smoking aprons and fire extinguishers upon arrival to work. The Facility's Admission Nurse, Unit Supervisors, Restorative Nurse, Infection Control Nurse, and Staff Development Coordinator have been trained on how to perform the Smoking Safety Screen assessment by the Facility's Director of Nursing. The Facility's expectation is that one of the above-listed nurses will perform the Smoking Safety Screening Assessment on every resident within twenty-four hours of admission and after any other assessment shows a significant change in the resident's condition. 4. Beginning on 06/14/17, the Facility's Administrator is monitoring the smoking logs for completion to ensure compliance with the new smoking policy. Beginning on 06/14/17, the Facility's Director of Nursing is monitoring the Smoking Safety Screens Assessments for compliance to ensure all new admissions have a completed Smoking Safety Screen Assessment. ************************* After reviewing the facility's information provided in their acceptable Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F323 was lowered to an E level on 6/17/2017 at 4:30 PM, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on interviews and review of Employee Identifier (EI) #1, the Administrator's and EI #2, the Director of Nursing Service (DNS)'s job description, the facility's administrative staff failed to ensure the nursing staff assessed Resident Identifier (RI) #6, RI #11, RI #12 and RI #12 to determine if the resident could smoke independently, required assistance and/or supervision of staff to smoke. The administrative staff further failed to ensure precautions were taken for residents' individual safety, as well as the safety of others in the facility by allowing residents who required supervision to maintain disposable lighters on them; allowing residents to smoke without using smoking adaptive equipment (i.e. smoking apron, smoking blanket); and failing to have a fire extinguisher(s) in the designated smoking area. RI #11 was observed smoking in the facility's designated smoking area, while RI #16, a resident with oxygen infusing at 2.5 liters per minute, was within close proximity. EI #3, the Activity Director was noted conversing with RI #11; however, she failed to intervene or ask either resident to move to a different area. RI #20, admitted to the facility on [DATE] was observed to have in his/her possession cigarettes and a lighter. The facility's policy signed by RI #20 on 6/15/2017 forbade residents from keeping cigarettes or lighters in their personal possession. These deficient practices placed RI #6, RI #11, RI #12, RI #13 and RI #20, five of six sampled residents identified by the facility as residents who smoke and RI #16, one of one residents observed in the smoking area while other residents smoked, in immediate jeopardy as it was likely to cause serious injury, harm or death. On 6/14/2017 at 4:42 PM, EI #1, the Administrator and EI #2, the DNS, were notified of the findings of immediate jeopardy level in the area of Administration, F 490. Findings include: Refer to F 323 EI #1, the Administrator's job description dated 2003, documented . The primary purpose of your job position is to direct the day-to-day function of the facility in accordance with current federal, state, and local standards, guidelines and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times . Administrative Functions . Ensures that all employees, residents, visitors and general public follow the facility's established policies and procedures . Make routine inspections of the facility to assure that established policies and procedures are being implemented and followed . Ensure that all facility personnel, residents, visitors, etc., follow established safety and sanitation regulations, to include fire protection/prevention, smoking regulations . During an interview with EI #1, the Administrator on 6/13/2017 at 6:45 PM, she was asked what training had staff received on the facility's smoking policy. EI #1 said, to be honest very little. When asked what was available in the event of a fire in the facility's designated smoking area (located outside the building). EI #1 said the facility did not have fire blankets but there was fire extinguishers on the halls. According to EI #1, inside the building half way down the East and West wing there was a fire extinguisher. In a follow-up interview on 6/17/2017 at 1:31 PM, EI #1 was asked what her responsibilities were as the Administrator of the facility. EI #1 replied to ensure the safety and well being of all residents. EI #1 was asked how she ensured the facility was maintained in a manner to ensure the residents' environment was safe. EI #1 replied she had different department heads to make sure that support happened. EI #1 was asked who was ultimately responsible for the overall safety and well being of every resident in this facility. EI #1 replied, she was. EI #1 was asked was the facility's smoking policy followed related to smoking regulations, assessments, environment and supervision for residents who smoke. EI #1 replied no. EI #2, the Director of Nursing Services' (DNS) job description dated 2003, documented . The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines and regulations that govern our facility, and as may be directed by the Administrator and the Medical Director, to ensure that the highest degree of quality care is maintained at all times . During an interview on 6/17/2017 at 1:40 PM, EI #2, the DNS was asked how she ensured the facility was maintained in a manner to ensure the residents' environment was safe. EI #2 replied to ensure the department heads are doing what they are supposed to do. EI #2 was asked in regards to the smoking incidents what happened. EI #2 replied, we failed to ensure everyone did what they were supposed to do. EI #2 stated the nursing staff failed to ensure the smoking assessments were completed to identify high risk residents who needed supervision; Maintenance and Administration failed to ensure the facility had smoking blankets and fire extinguishers in the courtyard; and the facility failed to ensure a safe environment for the residents that smoke. ************************* On 6/16/2017 at 3:05 PM, the facility submitted an Acceptable Allegation of Compliance, which documented: 1. On June 14, 2017, the Facility implemented a new smoking policy whereby residents will only be allowed to smoke during supervised scheduled smoking breaks in the Facility's designated smoking area- its Courtyard. The policy also does not permit residents to keep cigarettes or lighters in their personal possession. Rather, cigarettes and lighters will be kept by Facility staff and provided to residents during the supervised scheduled smoking breaks. The Facility has also implemented a smoking log that will identify the Facility staff member supervising each supervised smoking break as well as each resident that participated in the supervised scheduled smoking break. The policy was developed by Med Pass and revised by Administrator and Director of Nursing. Smoking Safety Screens Assessments were conducted on RI#6, RI#11, and RI#13 on June 13, 2017 by restorative nurse. The Smoking Safety Screen assessment contains the questions: (1) whether the resident has a cognitive loss; (2) whether the resident has vision deficits; (3) whether the resident has any dexterity problems; (4) how many cigarettes the resident smokes per day; (5) the time(s) the resident likes to smoke; (6) whether the resident can light his or her own cigarette; and (7) whether the resident needs adaptive equipment. The Smoking Safety Screen Assessment reflected that RI#6 was safe to smoke with supervision and that RI#11 and RI#13 were safe to smoke supervised. During the afternoon and evening of June 14, 2017, Smoking Safety Screens Assessments were completed on all remaining residents in the Facility. On June 14, 2017, the Facility's social worker spoke with RI#6, RI#11, and RI#13 to clarify the new smoking policy and supervised scheduled smoke breaks. RI#6, RI#11, and RI#13 acknowledged that they understood the new policy and had no objection to it. On June 14, 2017, the Facility's staff development nurse spoke with the family members of RI#6, RI#11, and RI#13 and explained the new policy and supervised scheduled smoking breaks. The family members of RI#6, RI#11, and RI#13 acknowledged that they understood the new smoking policy and had no objection to it. After speaking with the residents and their families, the Facility collected cigarettes and lighters from all residents in the Facility on the evening of June 14, 2017. On June 13, 2017, the Facility placed four smoking aprons on hooks in the Courtyard. On June 14, 2017, the Facility also placed a fire blanket in the Courtyard along with four fire extinguishers- one on each patio in the courtyard. The smoking blanket, smoking aprons, and fire extinguishers will be available every time RI#6, RI#11, RI#13, and any other resident(s) participate in a supervised scheduled smoking break. The blanket and aprons and facility fire extinguishers will be inspected at the beginning of every smoking break by the staff member supervising the scheduled smoking break to ensure they are in operable condition. Beginning on second shift on June 14, 2017, the Administrator, Staff Development Nurse and Social Worker in-serviced all staff in the building on the Facility's new smoking policy, the supervised scheduling smoking times, and the location and proper use of the smoking blanket and facility fire extinguishers. On June 15, 2017, the Staff Development Nurse and Maintenance Director began in-servicing all staff in the building on proper use of the smoking aprons, fire blanket, and fire extinguishers. All Facility staff have been in-serviced on the new smoking policy, supervised smoking times, and the location and use of the smoking aprons, fire blanket, and facility fire extinguishers prior to working their next shift. This will ensure that the staff providing care to RI#6, RI#11, and RI#13 and the staff supervising the smoking of RI#6, RI#11, and RI#13 have been properly educated on the Facility's new smoking policy, the supervised scheduling smoking times, and the location and use of the smoking blanket and facility fire extinguishers. On June 13, 2017, the Facility's Activities Director was observed present while RI#11 smoked while RI#16, who was wearing portable medical oxygen, was approximately nine feet away. The Facility's Activities Director was in-serviced on June 15, 2017, by Administrator on fire safety, specifically that smokers should not be in the vicinity of portable medical oxygen tanks. 2. During the afternoon and evening of June 14, 2017, Smoking Safety Screen Assessment was completed on all remaining residents in the facility by restorative nurse. All the residents were asked if they smoke. No new smokers were identified. 3. Beginning on second shift on June 14, 2017, the Facility in-serviced all staff in the building on the Facility's new smoking policy, the supervised scheduling smoking times, and the location of the smoking blanket, smoking aprons and facility fire extinguishers. On June 15, 2017, the Facility began in-servicing all staff in the building on proper use of the fire blanket and smoking aprons and fire extinguishers. Facility staff was in-serviced on the new smoking policy, supervised smoking times, and the location and use of the fire blanket and smoking aprons and fire extinguishers upon arrival to work. The Facility's Admission Nurse, Unit Supervisors, Restorative Nurse, Infection Control Nurse, and Staff Development Coordinator have been trained on how to perform the Smoking Safety Screen assessment by the Facility's Director of Nursing. The Facility's expectation is that one of the above-listed nurses will perform the Smoking Safety Screening Assessment on every resident within twenty-four hours of admission and after any other assessment shows a significant change in the resident's condition. 4. Beginning on 06/14/17, the Facility's Administrator is monitoring the smoking logs for completion to ensure compliance with the new smoking policy. Beginning on 06/14/17, the Facility's Director of Nursing is monitoring the Smoking Safety Screens Assessments for compliance to ensure all new admissions have a completed Smoking Safety Screen Assessment. ************************* After reviewing the facility's information provided in their acceptable Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F 490 was lowered to an E level on 6/17/2017 at 4:30 PM, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on observations, staff interviews and a review of the facility's policies titled, Refrigerators and Freezers and Dishwashing Machine Use, a review of inservice training records and staff interviews, the facility failed to ensure dietary staff were trained and knowledgeable with the location of the thermometer in the walk in freezer; recording food temperatures when they are taken; and where to locate the temperature gauge on the dishwasher to ensure correct wash and rinse cycle temperatures for each wash cycle. This had the potential to affect 72 of 75 residents who received meals from the kitchen. Findings Include: 1. The facility's policy titled, Refrigerators and Freezers, with a revised date of December 2014, documented: Policy Statement The facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Policy Interpretation and Implementation . 4. Food Service Supervisors or designated employees will check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening . On 06/13/17 at 7:45 a.m., the surveyor observed there was no thermometer in the walk in freezer. The cook commented there was one in there but it must have fell off. On 06/13/17 at 7:46 a.m., Employee Identifier (EI) #17/Dietary Aide, was asked if she could locate the thermometer in the freezer. EI #17 replied she did not know where it was and she just started working. 2. On 06/13/17 at 8:15 a.m., the surveyor requested to review the food temperatures recorded from the breakfast meal. When the facility's form for calibration of thermometer for meals was reviewed there were no temperatures recorded for the breakfast meal for 06/13/17. On 06/13/17 at 8:16 a.m., EI #17, was asked where were the temperatures from the breakfast meal. EI #17 stated they were in her head and she would write them down later, but she had no documentation. On 06/16/17 at 1:45 p.m., EI #15 was asked who was responsible to document the food temperatures and when were they suppose to be recorded. EI #15 replied the cook and they should be documented when the food temperatures are taken. 3. The facility's policy titled, Dishwashing Machine Use with a revised date of March 2010, documented: Policy Statement Food Service staff required to operate the dishwashing machine will be trained in all steps of dishwashing machine use by the supervisor or a designee proficient in all aspects of proper use and sanitation. Policy Interpretation and Implementation .7. The operator will check temperatures using the machine gauge with each dishwashing machine cycle, and will record the results in a facility approved log. The operator will monitor the gauge frequently during dishwashing machine cycle. On 06/13/17 at 7:55 a.m., EI #18, dietary aide, was observed in the dishwashing area. EI #18 loaded the dishwasher but did not check the gauge for the temperature. EI #18 was asked to locate the temperature gauge. EI #18 was not able to show the surveyor where the gauge was. EI #18 was asked had she been trained on how to use the dish machine. EI #18 replied no. On 06/14/17 at 11:20 am, the Certified Dietary Manger (CDM)/EI #15 provided an inservice training to the kitchen staff before serving the residents their lunch meal. The inservice training titled, In Service 6/14/17 Temperature Logs covered areas that included completing temperature logs and checking the temperatures logs daily, and recording food temperatures.

Based on observations, staff interviews and a review of the facility's policies titled, Food Receiving and Storage, Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices, Refrigerators and Freezers, Sanitation, Food Preparation and Service, Sanitization, Training/Orientation, Dishwashing Machine Use, a review of inservice training records and staff interviews, the facility failed to ensure dietary staff were trained and knowledgeable with: 1) labeling food items with a use by date in the walk in cooler; 2) discarding expired foods and vegetables that had a mold looking substance; 3) cleaning the floors in the walk in cooler and freezer; 4) boxes being stored on the floor in the walk in freezer on 06/16/17 after a delivery on 06/13/17; 5) location of the thermometer in the walk in freezer; 6) wearing hairnets/beard covers while in the kitchen; 7) cross contamination between clean dishes and dirty dishes; 8) storage of everyday use utensils to prevent an accumulation of dirt, dust and a rust colored substance; 9) notify the Dietary Manager when the dishwasher started leaving white colored spots on the dishes after being washed; 10) recording food temperatures when taken; 11) recording the walk in freezer temperature on 06/13/17; 12) a can opener with a build up of a black colored substance on the blade and a rust colored substance on the frame; 13) where to locate the temperature gauge on the dishwasher; and 14) reporting equipment that needed repairs such as the pipe in the walk in freezer that had a build up of ice. This had the potential to affect 72 of 75 residents who received meals from the kitchen. Findings Include: 1) Food items were not labeled with a use by date in the walk in cooler The facility's policy titled, Food Receiving and Storage, with a revised date of July 2014, documented: Policy Statement Foods shall be received and stored in a manner that complied with safe food handling. Policy Interpretation and Implementation .7. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) . On 06/13/17 at 7:37 a.m., during the initial tour in the kitchen the following observations were made: 1- container of sliced tomatoes with the lid not sealed and no use by date. 1- container of carrot salad with the lid not sealed and no use by date. 1- bacon, lettuce and tomato sandwich with no use by date. 1- container of cream of chicken soup with no use by date. 1- bag of shredded cheese no open or use by date. 1- container with boiled eggs that was not sealed and no use by date. 1- container of corn salad with no use by date. 1- small turkey breast wrapped in cellophane with no open or use by date. On 06/13/17 at 1:25 p.m., during an interview with Employee Identifier (EI) #15, Dietary Manager, was asked what was the process when food is opened and needed to be stored in the walk in cooler. EI #15 replied it has to have the production date and a use by date. EI #15 was asked who was responsible to monitor. EI #15 replied the cooks were responsible. EI #15 was asked why were there food items in the walk in cooler without a use by date. EI #15 replied they failed to follow the procedure. EI #15 was asked what was the importance of a use by date. EI #15 replied so staff would know when to discard it. EI #15 was asked what could be the potential concern when food is not labeled with a use by dates. EI #15 replied somebody could get sick. 2) Expired foods and vegetables that had a mold looking substance were discarded. The facility's policy titled, Refrigerators and Freezers, with a revised date of December 2014, documented: Policy Statement The facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Policy Interpretation and Implementation .7. All foods shall be appropriately dated to ensure proper rotation by expiration dates. 8. Supervisors will be responsible for ensuring food items in . refrigerator . are not expired or past perish dates . On 06/13/17 at 7:37 a.m., a container of corn salad was observed in the walk in cooler with a use by date of 06/12/17. There was a single cucumber and several stalks of celery that had a mold looking substance on them. On 06/16/17 at 1:27 p.m., during an interview with EI #15, the surveyor asked who was responsible to monitor fresh vegetables in the walk in cooler to make sure they were not molded. EI #15 replied the cooks and herself. EI #15 was asked why was there a cucumber with mold and celery with a brownish colored substance in the walk in cooler. EI #15 replied it should not be served. 3) The floors in the walk in cooler and freezer were free of dirt and debris. The facility's policy titled, Refrigerators and Freezers, with a revised date of December 2014, documented: Policy Statement The facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Policy Interpretation and Implementation .10. Refrigerators and freezers will be kept clean, free of debris, and mopped with sanitizing solution on a scheduled basis and more often as necessary . On 06/13/17 at 7:39 a.m., the floor in the walk in cooler was observed with dirt, debris and had standing water. The floor in the walk in cooler was observed with an ice build up at the entrance door opening and on the floor. 4) Boxes were not being stored on the floor in the walk in freezer on 06/16/17 after a delivery on 06/13/17. On 06/13/17 at 7:39 a.m., there were several stacks of boxes on the floor in the freezer and walk in cooler. On 06/13/17 at 1:28 p.m., during an interview with EI #15, the surveyor asked when were the boxes put on the floor in the walk in cooler. EI #15 replied during this morning's delivery (06/13/17). EI #15 was asked why were the boxes still on the floor. EI #15 replied they had not had a chance to pull them. EI #15 was asked what could be the potential concern of boxes stacked on the floor. EI #15 replied cross contamination. 5) The thermometer in the walk in freezer was placed for staff to view. The facility's policy titled, Refrigerators and Freezers, with a revised date of December 2014, documented: Policy Statement The facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Policy Interpretation and Implementation . 4. Food Service Supervisors or designated employees will check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening . On 06/13/17 at 7:45 a.m., the surveyor observed there was no thermometer in the walk in freezer. The cook commented there was one in there it just fell off. On 06/13/17 at 7:46 a.m., EI #17, Dietary Aide, was asked if she could locate the thermometer in the freezer. EI #17 replied she did not know where it was and she just started working. 6) Staff and vendors did not wear hairnets/beard covers while in the kitchen. The facility's policy titled, Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices, dated October 2008, documented: Policy Statement Food Services employees shall follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Policy Interpretation and Implementation 1. All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. 12. Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens. On 06/13/17 at 7:35 a.m., upon entrance to the kitchen for the initial tour, the following was observed: EI #17, Dietary Aide, was at the tray line plating breakfast with no hair net on and EI #22, the Dietary Aide, was assembling the trays and did not have a hair net on. On 06/13/17 at 8:10 a.m., a vendor was observed in the kitchen without a hair net or a beard cover. When asked if he was ever told he should wear a hair net or beard cover while in the kitchen, he replied he had never been told he had to wear them. On 06/13/17 at 1:35 p.m., EI #15 was asked why two dietary staff did not have hair nets on while in the kitchen. EI #15 replied EI #22 should have had a hair net on and EI #17 thinks because she is bald does not have to wear one. EI #15 was asked why would a vendor come into the kitchen without a hair net or beard cover. EI #15 replied he is disrespectful. EI #15 was asked why should staff wear hair nets/beard covers while in the kitchen. EI #15 replied so no hair gets into the residents' food. EI #15 was asked who was responsible to monitor staff for hair nets/beard covers. EI #15 replied when she was not there the cooks are responsible. EI #15 was asked what would be the potential concern of not wearing hair nets/beard covers. EI #15 replied contaminated food. 7) Staff changed gloves and washed hands between clean dishes and dirty dishes. The facility's policy titled, Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices, dated October 2008, documented: Policy Statement Food Services employees shall follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Policy Interpretation and Implementation 1. All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. 6. g. During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; . On 06/13/17 at 7:55 a.m., EI #18, a dietary staff, was observed pulling out clean dishes with no gloves on and did not wash her hands prior to pulling out the clean dishes. EI #17, a dietary aide, was observed to come from plating breakfast to the dishwashing room, picked up clean plates from the dry racks with no gloves and no hand washing. On 06/16/17 at 1:40 p.m., EI #15 was asked what was the dishwashing process when going from dirty to clean. EI #15 replied a separate person pulls out clean and another one puts in the dirty. EI #15 was asked why would staff go from dirty to clean and not change their gloves or wash their hands. EI #15 replied they know better. EI #15 was asked what could be the potential harm. EI #15 replied cross contamination. 8) Everyday use utensils were stored to prevent an accumulation of dirt, dust and a rust colored substance. The facility's policy titled, Sanitization, with a revised dated of October 2008, documented: Policy Statement The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation . 2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions . areas that may affect their use or proper cleaning. On 06/13/17 at 8:05 a.m., a container with everyday use utensils (spatulas, cooking utensils) was observed on the clean dish shelf. The bottom of the container contained dirt and dust looking debris and there was also water in the bottom of the container. 9) Report equipment that needed repair such as the pipe in the walk in freezer that had a build up of ice. The facility's policy titled, Refrigerators and Freezers, with a revised date of December 2014, documented: Policy Statement The facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Policy Interpretation and Implementation . 9. Supervisors will inspect refrigerators and freezers monthly for gasket condition, fan condition, presence of rust, excess condensation, and any other damage or maintenance needs. Necessary repairs will be initiated immediately . On 06/13/17 at 7:39 a.m., the walk in freezer door was observed to be ajar. Upon entering the freezer the pipe from the wall to the cooling unit was observed with a thick amount of ice build up that was cascading down below the pipe. The pipe was wrapped with a material that was peeling away from the pipe. On 06/16/17 at 1:43 p.m., EI #15 was asked how long had the pipe in the walk in cooler been a problem. EI #15 replied she did not know. EI #15 was asked who was responsible for monitoring equipment in the kitchen. EI #15 replied the cook and herself. EI #15 was asked if she was aware that the ice had formed around the pipe and hanging into an open box. EI #15 replied no she was not aware and it should not be like that. EI #15 was asked what could be the potential concern. EI #15 replied cross contamination. 10) Food temperatures were recorded when taken. On 06/13/17 at 8:15 a.m., the surveyor requested to review the food temperatures recorded from the breakfast meal. When the facility's form for calibration of thermometer for meals was reviewed there were no temperatures recorded for the breakfast meal for 06/13/17. On 06/13/17 at 8:16 a.m., EI #17, was asked where were the temperatures from the breakfast meal. EI #17 stated they were in her head and she would write them down later, but she had no documentation. On 06/16/17 at 1:45 p.m., EI #15 was asked who was responsible to document the food temperatures and when were they suppose to be recorded. EI #15 replied the cook and they should be documented when the food temperatures are taken. 11) Freezer temperatures were not recorded on 06/13/17. The facility's policy titled, Refrigerators and Freezers, with a revised date of December 2014, documented: Policy Statement The facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Policy Interpretation and Implementation . 2. Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures. . 4. Food Service Supervisors or designated employees will check and record refrigerator and freezer temperatures daily with first opening and at closing in the evening. On 06/13/17 at 7:55 a.m., the surveyor reviewed the Walk in Freezer temperature record. On the day of June 13 the a.m. temperature was not documented. 12) The can opener had build up of a black colored substance on the blade and a rust colored substance on the frame. The facility's policy titled, Sanitization, with a revised dated of October 2008, documented: Policy Statement The food service area shall be maintained in a clean and sanitary manner. Policy Interpretation and Implementation . 2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions . areas that may affect their use or proper cleaning. 11. For fixed equipment or utensils that do not fit in the dishwashing machine, washing shall consist of the following steps: a. Equipment will be disassembled as necessary to allow access of the detergent/solution to all parts; b. Removable components will be scraped to remove food particle accumulation and washed according to manual or dishwashing procedures. On 06/16/17 at 1:47 p.m., EI #15 was asked who was responsible to clean the can opener and how often. EI #15 replied who ever uses it mainly the cooks and it should be done daily after use. EI #15 was asked what would be a potential concern with a black colored substance on the blade and a rust colored substance on the frame. EI #15 replied cross contamination. 13) Staff knew where to locate the temperature gauge on the dishwasher. The facility's policy titled, Dishwashing Machine Use with a revised date of March 2010, documented: Policy Statement Food Service staff required to operate the dishwashing machine will be trained in all steps of dishwashing machine use by the supervisor or a designee proficient in all aspects of proper use and sanitation. Policy Interpretation and Implementation .7. The operator will check temperatures using the machine gauge with each dishwashing machine cycle, and will record the results in a facility approved log. The operator will monitor the gauge frequently during dishwashing machine cycle. On 06/13/17 at 7:55 a.m., EI #18, dietary aide, was observed in the dishwashing area. EI #18 loaded the dishwasher but did not check the gauge for the temperature. EI #18 was asked to locate the temperature gauge. EI #18 was not able to show the surveyor where the gauge was. EI #18 was asked had she been trained on how to use the dish machine. EI #18 replied no. 14) The Dietary Manager was not notified when the dishwasher started leaving white colored spots on the dishes after being washed. The facility's policy titled, Dishwashing Machine Use with a revised date of March 2010, documented: Policy Statement Food Service staff required to operate the dishwashing machine will be trained in all steps of dishwashing machine use by the supervisor or a designee proficient in all aspects of proper use and sanitation. Policy Interpretation and Implementation 1. The following guidelines will be followed when dishwashing: . k. Clean dishwashing machine after each meal. On 06/13/17 at 8:05 a.m., the inside of the dishwashing machine was observed. There was a build up of a white colored substance inside. On 06/16/17 at 2:00 p.m., EI #15 was asked who was responsible to report there were white spots on the dishes after they were washed. EI #15 replied anybody who operates the dishwashing machine. EI #15 was asked why had that not been reported. EI #15 replied she did not know why.

Based on observation of the dumpster area, the facility policy titled Food Related Garbage and Rubbish Disposal, an staff interview, the facility failed to ensure the grounds around the dumpster were free of a cardboard box, two large gray trash cans full of raw garbage and paper and other debris. This had the potential to affect all 75 residents in the facility. Findings Include: The facility policy titled Food Related Garbage and Rubbish Disposal, with a revised dated of July 2014, documented: Policy Statement Food-related garbage and rubbish shall be disposed of in accordance with current state laws regulating such matters. Policy Interpretation and Implementation .7. Outside dumpsters provided by garbage pick up services shall be kept closed and free of surrounding litter. On 06/13/2017 at 8:22 a.m., the following observation was made in the dumpster area. There was a large cardboard box on the ground behind the dumpster. Two large gray trash cans were full of raw garbage and debris. There was paper and other debris on the ground around the dumpster. On 06/16/2017 at 1:25 p.m. Employee Identifier (EI) #15, Dietary Manager, was asked who was responsible to monitor the dumpster area to make sure it is kept clean. EI #15 replied dietary and maintenance but everyone in the facility uses it. EI #15 was asked what could be the potential concern with the shape the dumpster area was in. EI #15 replied pests.