Every finding on record at Chapman Healthcare Center, Inc

Based on record review, interviews, review of a facility INCIDENT INVESTIGATION FORM, and review of a facility investigative summary, the facility failed to ensure the residents' environment remained free of accident hazards by failing to ensure staff's personal medication was stored in a secure location that was not accessible to residents. Specifically, on [DATE], Resident Identifier (RI) #1, who had a diagnosis of Dementia with Behaviors, accessed and ingested an unspecified amount of Acetaminophen (a pain reliever/fever reducer also known as Tylenol) from a bottle belonging to Employee Identifier (EI) #5, a Certified Nursing Assistant (CNA). RI #1 was able to obtain the medication because EI #5 placed her purse, which contained the medication, on a table in the 100 hall lobby and left it unsupervised. Subsequently, RI #1 was transferred to the local Emergency Department (ED) on [DATE] for possible overdose of Acetaminophen. This deficient practice placed RI #1, one of seven residents with wandering behaviors, in immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment or death. On [DATE] at 6:35 PM, EI #2, Administrator, was provided a copy of the immediate jeopardy template and notified of the findings of substandard quality of care at the immediate jeopardy level in the area of Quality of Care, F689-Free of Accidents Hazards/Supervision/Devices. The immediate jeopardy began on [DATE] and continued until [DATE] when the facility implemented corrective actions to address the identified deficient practice, including ongoing monitoring; thus, immediate jeopardy past noncompliance was cited. Findings Include: On [DATE] at 2:56 PM, the facility submitted an initial report to the State Survey Agency via the Alabama Department of Public Health Online Incident Reporting System. This report indicated RI #1 took Tylenol from an employee's purse, ingested them, and was sent to the ED for further evaluation. RI #1 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Dementia with Behavioral Disturbances. A review of RI #1's Significant Change in Status Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of [DATE] indicated RI #1 had both short and long term memory impairment and moderately impaired cognitive skills for daily decision making. A list provided by the facility, dated [DATE], identified RI #1 as a wandering resident. A facility INCIDENT INVESTIGATION FORM, completed [DATE] by EI #6, Licensed Practical Nurse (LPN), documented: .CNA informs writer she found resident on Hall 100 in dining room (with) pills in hand eating them Resident had gotten into another CNA's purse, obtained a bottle of 500mg (milligram) Tylenol (and) had ingested an unknown amount of the medication. The CNA whom the Tylenol belonged to stated there was 25 pills in the bottle . (resident) took between ,d+[DATE] (three to five) Extra Strength Tylenol. Nurse assessed resident. (Up) in w/c (wheelchair) @ (at) table. Mental status checked noted @ baseline .(resident) unable to say what happened. Baseline confusion . A review of the facility's investigative summary, dated [DATE], indicated: .At approximately 7:35 p.m. on Sunday, [DATE], Chapman CNA (EI #7) observed (RI #1) holding Tylenol tablets taken from the purse of CNA (EI #5). (RI #1) could not state if (he/she) had taken any of the Tylenol and, if so, how many. Staff thus sent (RI #1) to the emergency room . Staff also notified Alabama Poison Control. Alabama Poison Control informed staff that given (RI #1's) weight, (he/she) would have had to take at least fifteen tablets of Tylenol to be toxic. RI #1's hospital HISTORY/PHYSICAL EXAMINATION, dated [DATE], documented: .History of Present Illness . patient (RI #1) somehow acquired the purse of . (a facility staff member) and took some pills earlier today. The nurse suspects that it was Tylenol and estimates that patient took about ,d+[DATE] 500mg tablets. Given concern for overdose, patient brought via EMS (Emergency Medical Services) to ED. In ED, patient initially awake and alert at normal baseline mentation. A few hours after arrival, patient reportedly somnolent prompting RN (Registered Nurse) to sternal rub . Patient woke to sternal rub but was noted to be excessively lethargic . RI #1's hospital DISCHARGE SUMMARY, dated [DATE], documented a final diagnosis of Accidental Drug Overdose, suspected Acetaminophen. A written statement made by EI #7, CNA, dated [DATE], that was included in the facility's investigation, documented: . (EI #7) went to Dining Room on hall 100. (EI #7) turned on lights and (RI #1) was at the . (table) with a pill on . (table) and tablets in hands. According to EI #7's statement, EI #7 informed the nurse and also informed EI #5, since the purse belonged to her. In an interview on [DATE] at 5:39 PM, EI #5, CNA, reported she set her purse down in the 100 hall lobby on the table closest to the hallway. EI #5 stated she did not put her purse in the locker where she had been instructed to put her personal items. EI #5 stated she sat the purse down briefly but got busy and forgot about her purse. EI #5 stated she was in another resident's room when EI #7, CNA, told her RI #1 was in her purse. EI #5 stated she ran down to the 100 hall lobby and saw RI #1 with her purse and the pill bottle in his/her hand. EI #5 identified the medication as Acetaminophen 500mg. EI #5 stated RI #1's mouth was red, the same color as the pills. EI #5 stated she did not see RI #1 put the pills in his/her mouth but the resident's mouth was the same color as the pills. EI #5 stated she counted 25 pills in the bottle prior to coming to work. She stated two pills looked like they had been in the resident's mouth because the outer coating color was off the pills. EI #5 stated she should have put her purse in her locker. EI #5 stated the concern with a resident getting in her purse was the resident could get into something harmful. In a follow-up interview on [DATE] at 1:59 PM, EI #5, CNA, reported she laid her purse on the table in the 100 hall lobby at the beginning of her shift on [DATE]. She stated her purse was left unattended for at least three hours. In an interview on [DATE] at 7:39 AM, EI #6, LPN, reported at about 7:30 PM, EI #7, CNA, told her she found RI #1 at the end of the hallway and the resident had gotten into someone's medication. EI #6 assessed the situation. EI #6 stated EI #5 told her that RI #1 took 500mg Tylenol from her purse that she left at the end of the hall. EI #6 assessed RI #1. EI #6 stated RI #1's mental status was okay, but she was concerned that the resident ingested an unknown amount of Tylenol. EI #6 stated she observed the pill having a red coating, and RI #1's mouth was tinted the same color. EI #6 stated she saw one pill on the floor. EI #6 stated EI #7 stayed with RI #1 while EI #8, RN, assessed the situation. EI #6 stated she started the process for sending the resident to the ED. EI #6 stated staff could use lockers provided by the facility to store personal items. EI #6 stated staff were to never leave items in residents' rooms or anywhere a resident had access. EI #6 stated the medication RI #1 ingested could cause liver failure. In an interview on [DATE] at 3:52 PM, EI #8, RN, reported she was working a different hallway the night RI #1 ingested a staff member's medication. EI #8 stated she found the resident sitting in a wheelchair in the 100 hall dining room (lobby) with EI #5, EI #6 and EI #7. EI #8 stated she observed a red pill on the table that EI #5, CNA, identified as Tylenol. EI #8 stated she observed RI #1 with a red mouth. EI #8 stated EI #5 reported the bottle contained 25 pills but the bottle was labeled as a 100 count bottle. EI #8 stated she instructed EI #7, CNA, to stay with the resident. She instructed EI #5 to get the Tylenol and her belongings and report the incident to EI #9, RN Supervisor. EI #8 said she called Alabama Poison Control, who reported the toxicity level for RI #1 was 15 pills. EI #8 stated the resident could have overdosed, become hypertensive, had liver failure, become unresponsive, become sick or died . In an interview on [DATE] at 4:55 PM, EI #9, RN Supervisor, stated she was working another station when EI #5, CNA, reported to her that RI #1 took Tylenol out of her unattended purse. EI #9 reported EI #5 told her the bottle contained 25 pills when she counted them that morning. EI #9 counted 19 recovered pills. EI #5 told EI #9 that RI #1 spit some of the pills out. They recovered pills from the table that were discolored pink, like the pills had been in someone's mouth. They recovered a total of 21 pills. EI #9 stated she looked up the medication on the internet and confirmed it was Tylenol. In an interview on [DATE] at 4:39 PM, EI #10, CNA, reported she did not see the incident, but she had just checked on RI #1 fifteen to twenty minutes prior to the incident. EI #10 stated RI #1 was in the 100 hall lobby looking at the Christmas tree. EI #10 stated RI #1 had been there most of her shift. When asked if she saw any staff belongings in the 100 hall lobby at that time, EI #10 said she did not see any, but she did not look. In an interview on [DATE] at 9:18 AM, EI #3, Director of Nursing (DON), reported EI #8 called her at home to notify her RI #1 got into EI #5's purse, took Tylenol out, and had possibly ingested three pills. EI #3 instructed her to count the remaining pills and call Poison Control. EI #3 stated the purse should have been in EI #5's locker or vehicle. EI #3 stated staff, including EI #5, were instructed during orientation to use lockers for personal items. EI #3 stated residents could get into something harmful or unsafe if staff left personal items where residents had access. In an interview on [DATE] at 7:07 PM, EI #1, Medical Director, reported RI #1 was found in the act of ingesting Tylenol, but they did not know how many the resident ingested. EI #1 sent the resident to the ED. EI #1 stated 4000mg (eight tablets) of Tylenol would be toxic and could cause liver damage or inflammation. In an interview on [DATE] at 8:11 AM, EI #2, Administrator, reported they did not know why EI #5's purse was available to RI #1, because EI #5 had a locker available for use. EI #2 stated EI #5 assured her that the bottle of Acetaminophen 500mg contained 25 pills, although the bottle was labeled for 100 pills. EI #2 stated the bottle of Tylenol was currently in her possession. During the interview, EI #2 was asked to count the pills remaining in the Tylenol bottle. In the presence of the surveyor, EI #2 counted and confirmed 21 pills remained in the bottle, three of which were lighter pink in color with some of the outer coating gone. EI #2 stated it is unknown how many pills RI #1 ingested. EI #2 stated EI #5 should not have had her purse out, because residents could go through the staff's belongings and get something, such as Tylenol. EI #2 stated the bottle of Tylenol had a warning that severe liver damage could occur if more than 4000mg was taken within a 24 hour period. This deficient practice was cited as a result of the investigation of complaint/report number AL00042551. The facility took immediate action to correct the noncompliance by: 1. Alabama Poison Control notified, and RI #1 sent to the ED on [DATE]. 2. Quality Assurance and Performance Improvement (QAPI) meeting held [DATE] concerning the incident. 3. Education done with EI #5 on [DATE] about not leaving personal items in unsecured areas. 4. Education with all staff about not leaving personal items in unsecured areas initiated [DATE] and completed [DATE]. 5. Rounding sheet for each shift, each hall completed and documented for 10 days ([DATE] to [DATE]) to ensure no staff belongings out in any area of the halls/resident areas. Thereafter, supervisors will round throughout their shifts to ensure staff continue to place their belongings in a secure location. 6. RI #1's care plan was reviewed and updated [DATE] to include approaches to verify potentially hazardous areas are kept locked, to check room for items that pose risk daily and remove if noted and monitor common areas are free from environmental issues and locked areas are maintained secure. After review and verification of the information provided in the facility's corrective action plan, inservice/education records, monitoring tools and the facility's investigation, as well as staff interviews, the survey team determined the facility implemented corrective actions from [DATE] through [DATE] with ongoing monitoring implemented; thus, immediate jeopardy past noncompliance was cited.

Based on observations, interviews, and review of the BINAXNOW COVID-19 Ag CARD - INSTRUCTIONS FOR USE, the facility failed to ensure nasal swab specimens were collected from both nostrils of the residents and staff being tested for the COVID-19 virus. This deficient practice had the potential to lead to inaccurate test results, which in turn could lead to an unidentified COVID-19 positive case, resulting in further spread of the COVID-19 virus within the facility. This failure affected all the residents and staff being tested for the COVID-19 virus. Findings include: The BINAXNOW COVID-19 Ag CARD - INSTRUCTIONS FOR USE with a copyright date of 2020, documented . INTENDED USE The BinaxNOWCOVID-19 Ag Card is a lateral flow immunoassay intended for the qualitative detection of nucleocapsid protein [MEDICATION(S)] from [CONDITION(S)]-CoV-2 in direct anterior nasal (nares) Swabs from individuals suspected of COVID-19 . This test is authorized for use at the Point of Care (POC), i.e., in patient care settings . PRECAUTIONS . 13. Inadequate or inappropriate sample collection, storage, and transport may yield false test results . SPECIMEN COLLECTION AND HANDLING . Anterior Nasal (Nares) Swab Only the swab provided in the kit is to be used for nasal swab collection. To collect a nasal swab sample, carefully insert the entire absorbent tip of the swab into the nostril. Firmly sample the nasal wall by rotating the swab in a circular path against the nasal wall 5 times or more for a total of 15 seconds, then slowly remove from the nostril. Using the same swab, repeat sample collection in the other nostril . LIMITATIONS . False negative results may occur if a specimen is improperly collected, transported, or handled . On 1/6/2021 at 11:31 AM, Employee Identifier (EI) #2, the ADON/Infection Preventionist (IP) was observed using the rapid BinaxNOW COVID-19 test to collect a nasal swab specimen from a staff member, EI #11. EI #2 swabbed EI #11's right nostril. EI #2 stated she rotated the swab three times. EI #2 did not rotate the swab five times or more and she did not swab EI #11's left nostril. On 1/7/2021 at 6:49 AM, EI #2, the ADON/IP again used the rapid BinaxNOW COVID-19 test to collect a nasal swab specimen from another staff member, EI #12. EI #2 swabbed EI #12's right nostril, turning the Q-tip five times, but failed to swab the left nostril of EI #12. On 1/7/2021 at 9:02 AM, an interview was conducted with EI #13, the Administrator; EI #1, the DON; and EI #2, the ADON/IP. The ADON/IP, EI #2, said looking at the insert from the Abbott BinaxNOW COVID-19 Ag Card package, both nostrils should be swabbed when collecting a specimen for the COVID-19 test. EI #2 said she had only been swabbing one nostril. When asked what the potential harm was when only one nostril was swabbed, EI #2 said you would not get enough specimen for the sample. When asked what could not getting enough of a specimen sample for a COVID-19 test result in, EI #2 said an inaccurate test result. EI #2 stated since the survey, only two tests had been performed. The Administrator, EI #13, stated the facility has been using the Abbott BinaxNOW COVID-19 Ag Card for testing since the second week of December 2020. During an interview on 1/7/2021 at 6:26 AM, EI #10, a Licensed Practical Nurse (LPN) stated she has been tested weekly in the facility by the ADON, EI #2. When asked how many nares (nostrils) are swabbed, EI #10 said, just the one. In an interview on 1/7/2021 at 12:13 PM, EI #5, a housekeeping staff member said she was being tested for the COVID-19 virus every week at the facility. When asked how many nostrils were being swabbed, EI #5 said one. In an interview on 1/7/2021 at 12:16 PM, EI #6, a Certified Nursing Assistant (CNA) said she too had only been having one nostril swabbed when being tested for the COVID-19 virus. During an interview on 1/7/2021 at 1:10 PM, Resident Identifier (RI) #1 said he/she was being tested for the COVID-19 virus once a week like the nurses. When asked how many of his/her nostrils were being swabbed for the COVID test, RI #1 said he/she would get one nostril swabbed one week then the other nostril swabbed the next week. RI #1 has been in the facility since 2/14/2019. The resident's Quarterly Minimum Data Set (MDS) assessment, with an assessment reference date of 10/15/2020, indicated RI #1 was cognitively intact, with a Brief Interview for Mental Status (BIMS) score of 14. In an interview on 1/7/2021 at 1:48 PM, EI #7, a Registered Nurse (RN) said before today, she had only been getting one nostril swabbed when being tested for the COVID-19 virus. According to EI #7, both nostrils were swabbed on today. During an interview on 1/7/2021 at 1:51 PM, RI #2 said he/she has been tested weekly for the COVID-19 virus with the last test done on Monday (1/4/2021). RI #2 said only one of his/her nostrils had been swabbed at that time. RI #2 has been in the facility since 2/14/2018. The resident's Quarterly MDS with an assessment reference date of 10/28/2020, indicated RI #2 was cognitively intact, with a BIMS score of 15. During an interview on 1/7/2021 at 2:00 PM, RI #3 said when he/she was last tested for the COVID-19 virus only one of his/her nostrils was swabbed. RI #3 was readmitted to the facility on [DATE]. The resident's Quarterly MDS with an assessment reference date of 11/21/2020, indicated RI #3 was cognitively intact with a BIMS score of 15. During an interview on 1/7/2021 at 2:30 PM, RI #4 said he/she has been tested for the COVID-19 virus every week by having a swab put up his/her nose. EI #4 said only his/her right nostril was being swabbed. RI #4 has been in the facility since 8/9/2020. The resident's Quarterly MDS with an assessment reference date of 12/5/2020, indicated RI #4 was cognitively intact with a BIMS score of 15. In an interview on 1/7/2021 at 2:40 PM, RI #5 said he/she had been getting tested for the COVID-19 virus once a week. RI #5 said just one of his/her nostrils was being swabbed for the COVID-19 virus test. RI #5 has been in the facility since 3/3/2020. The resident's Significant Change in Status MDS with an assessment reference date of 12/2/2020, indicated RI #5 was cognitively intact with a BIMS score of 15. On 1/7/2021 at 2:59 PM, an interview was conducted with EI #8 a RN staff member who has been tested for the COVID-19 virus in the facility. EI #8 said the facility used the rapid testing to test for the COVID-19 virus. EI #8 said staff performing the test went up the nostril and twisted the Q-tip around a little bit. When asked how many nostrils were being swabbed, EI #8 said only one. In an interview on 1/7/2021 at 3:09 PM, EI #9, a CNA said she was being tested for the COVID-19 virus weekly. EI #9 said when being tested for the virus staff only swabbed one of her nostrils. In an interview on 1/7/2021 at 3:35 PM, EI #3, a RN Supervisor acknowledged she helped to collect nasal swab specimen samples for COVID-19 testing. EI #3 stated she was shown by the ADON (EI #2) on how to collect the nasal swab specimens. EI #3 said she has only been swabbing one nostril when collecting the specimen for the COVID-19 test. EI #3 stated she knew of the package insert (manufacturer's instructions), but never read it. When asked what the potential could be when the test is not performed according to manufacturer's instructions, EI #3 said a potential for false results. In an interview on 1/8/2021 at 9:20 AM, EI #1, the DON was asked was the packet insert for the rapid Abbott COVID-19 test read, by staff performing the test, to see how many nostrils were to be swabbed. EI #1 said she did not read the packet insert. EI #1 said her focus was on performing the test. EI #1 said the Abbott test had one Q-tip (for swabbing) so she assumed to put the swab up one nostril because that was how the facility had collected the nasal swab specimens before they started using the rapid Abbott BinaxNOW COVID-19 Ag Card test. When asked what she felt the failure was when collecting the nasal swab specimens for the rapid Abbott COVID-19 test, EI #1 said the instructions were not fully read. A telephone interview was 1/8/2021 at 4:03 PM, with EI #4, a RN who helps to collect nasal swab specimens for COVID-19 testing. EI #4 stated she received verbal and -- instructions from EI #2, the ADON on how to collect the nasal swab specimens. EI #4 acknowledged she was told anything about how many nares to swab. EI #4 further acknowledged that she did not read the manufacturer's instructions. EI #4 said she was only made aware on yesterday (1/7/2021) of the number of nostrils that should be swabbed when collecting a specimen sample for the rapid Abbott testing for COVID-19 test. When asked how many nostrils should be swabbed, EI #4 said two. EI #4 stated she was re-educated to insert one swab in both nostrils until resistance is felt, rotate five times then place the Q-tip on the card.

Based on observations, interviews and a review of the facility policy titled, Labeling and Dating Foods, as well as mandated food temperatures from the (YEAR) Food Code, the facility failed to: 1) label and date a container of left-over meat prior to storage on 05/06/19; and 2) serve a potentially hazardous milk-based dessert (cheesecake) at a temperature of 41 degrees or less from the 05/08/19 lunch tray line. This had the potential to affect all 146 residents for whom meals were prepared and served at the time of this survey. Findings Included: 1) A facility policy dated (YEAR), titled, Labeling and Dating Foods (Date Marking) states: Guidelines: All foods stored will be properly labeled according to the following guidelines. Procedure: . 2. Date marking for refrigerated storage food items * Once opened all ready to eat, potentially hazardous food will be re-dated with a use by date according to current safe food storage guidelines . .4. Prepared food or opened food items should be discarded when: .The food item is leftover for more than 72 hours . During the initial tour of the facility on 05/06/19 at 5:30 PM, a Styrofoam box was observed in the reach-in refrigerator. The box was unlabeled (no date or time) and contained five pieces of fried, breaded meat (chicken or fish). On 05/09/19 at 8:37 AM, the Certified Dietary Manager, Employee Identifier (EI) #4, and the Assistant Dietary Manager, EI #3 were questioned about the unlabeled left-over meat, which appeared to be chicken fingers. When asked why it was important to date and label left-over food, EI #3 stated the left-overs posed a potential hazard; without a date, no one would know how long it had been stored. EI #3 stated they rarely had left-over chicken fingers, but if they did, they were thrown away. EI #3 surmised the food was most likely an employee's. 2) The (YEAR) Food Code mandates under regulation 3-501.16, Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) .FOOD shall be maintained: . (2) At . (41 degrees F (Fahrenheit) or less. On 05/08/19 at 11:13 AM, a cart of individually portioned cheesecake was brought to the lunch tray line (from refrigerated storage). The surveyor asked EI #3 what ingredients the cheesecake included. EI #3 stated she had prepared the dessert on the previous day, with a mix and milk. The surveyor then requested a temperature check of the dessert. EI #3 determined the internal temperature of both a regular (cheesecake topped with cherry glaze) and a pureed portion were 44 degrees F each, three degrees above the recommendation of 41 degrees F or less. On 05/09/19 at 8:37 AM, the surveyor asked EI #3 and EI #4 what the goal temperature (for service) was for the cheesecake. Both staff members responded, 41 degrees F or below. When asked if they had served the cheesecake despite this temperature, EI #3 responded, yes. Both staff were aware a temperature above 41 degrees posed a potential hazard.

Based on record reviews and interviews, the facility failed to ensure: 1. Resident Identifier (RI) #140 and RI #58 had care plans for receiving anticoagulation medication and 2. RI #110 had a care plan for nutrition to address the resident's severe weight loss. This affected 3 of 32 residents for which care plans were reviewed. Findings Include: A review of an undated facility form Anticoagulants revealed, .There is no level testing for other anticoagulants, ASA, [MEDICATION NAME], Eliquis, Xarelto, etc. Monitoring for side effects done per assessment of resident: Serious issues: Bruising Prolonged bleed from small cuts Nosebleed Headache Other less serious may include nausea, vomiting, diarrhea, flatulence, cramps and loss of appetite. 1) RI #140 was admitted to the facility 10/31/16 with a [DIAGNOSES REDACTED]. A review of RI # 140's (MONTH) 2019 Physician orders [REDACTED]. BRILINTA 60 MG (milligrams) . BID (two times daily) . A review of RI #140's care plan did not reveal a care plan for anticoagulation medication. RI #58 was admitted to the facility 2/10/18 with a [DIAGNOSES REDACTED]. A review of RI #58;s (MONTH) 2019 Physician order [REDACTED]. ELIQUIS 5 MG 1 Tablet BID . A review of RI #58's care plan did not reveal a care plan for anticoagulation medication. On 5/8/19 at 11:00 AM, an interview was conducted with Employee Identifier (EI) #1, Director of Nursing (DON) EI #1 was asked if RI #140 and RI #58 were receiving anticoagulation medication. EI #1 replied, yes RI #140 was receiving Brilinta and RI #58 was receiving Eliquis. EI #1 was asked if she could show the surveyor each resident's care plan for the anticoagulation medication. EI #1 replied, she did not see it and she did not think the facility had been care planning for anticoagulation medications. EI #1 was asked why were anticoagulation medications not care planned for. EI #1 replied, she was not sure and would talk to those doing care plans and MDS later. On 5/8/19 at 11:30 AM, an interview was conducted with EI #2, Registered Nurse ( RN), Minimal Data Set (MDS) Coordinator. EI #2 was asked who was responsible for care plans. EI #2 replied two of the nurses do them. EI #2 was asked what was the policy for doing care plans. EI #2 replied, they did not have one. EI #2 was asked if RI #140 and RI #58 were receiving anticoagulation medication. EI #2 replied, yes. EI #2 was asked where were the care plans for each. EI #2 replied there was not one. EI #2 was asked why there was no care plan for anticoagulation medication. EI #2 replied, as nurses they know to look for those signs related to anticoagulation medications, nurses do weekly audits and the Certified Nursing Assistants report any changes they may see. EI #2 was asked if anticoagulation medications should be care planned. EI #2 replied, they were learning now, that yes they should. EI #2 was asked what would the risks be in anticoagulation medication not being care planned. EI #2 replied, one may not be familiar with resident on medication and the possible side effects. EI #2 was asked how did the CNAs know what to observe for residents that received anticoagulation medication. EI #2 replied, by the nurse telling them and the CNAs observing residents during care if there was new bruising or bleeding they were to report to the nurse immediately. On 5/09/19 at 10:53 AM, another interview was conducted with EI #1, DON. EI #1 was asked to review the facility form Anticoagulants and then asked to explain the purpose. EI #1 replied It was just some things they should look for. EI #1 was asked if anticoagulation medication was considered a significant medication. EI #1 replied, yes because there was risk for bleeding that may or may not be visible, such as a Gastric Bleed. EI #1 was asked if the monitoring on the facility form be on a care plan for those residents receiving anticoagulation medications. EI #1 replied, yes they should, this was not a replacement for the care plan. EI #1 was asked what would the risk be in anticoagulation medications not being care planned. EI #1 replied, if a resident was on an anticoagulation medication it should be care planned for any one that reviews the resident record to assure there was interventions for a significant medication. 2. RI #110 was readmitted to the facility on [DATE] following a [MEDICAL CONDITION], with repair. A review of the medical record revealed RI #110 had suffered a severe weight loss of 21 pounds (13.6%) between 11/2/18 and 5/3/19. Despite the loss, a care plan related to this nutritional concern could not be found. On 05/08/19 at 4:50 PM, the surveyor asked the MDS/Care Plan Coordinator, EI #2 whether or not a care plan had been developed to address the resident's weight loss. After reviewing the chart, EI #2 responded that she may not have written a care plan. but she could develop one and add it to the chart. When asked if a care plan to address the weight loss was necessary, EI #2 stated she did not think RI #110 needed one because the issue had been addressed in the record by the Registered Dietitian, and it was noted on the resident's weight sheet. EI #2 then verified she had not developed a care plan.

Based on observations, interviews and review of a facility document titled Daily Duties of Housekeeping, and a facility Policy titled, Housekeeping Policies, the facility failed to ensure showers on the 700 hallway were clean, sanitary and free of a black substance on the wall. This was observed one of four days of the survey and affected two of eleven facility showers. Findings Include: A review of a facility document titled Daily Duties of Housekeeping with no date revealed, .3. Clean all . shower . A review of a facility policy titled, Housekeeping Policies with no date revealed, . 12. Spot clean walls/chair as needed in rooms, and bathroom daily. A resident council meeting was held on 5/7/2019 at 1:30 p.m. During the meeting Resident Identifier (RI) #85 and RI #26 complained of the showers on the 700 hall being dirty. On 05/08/2019 at 10:50 a.m., shower number one on hall 700 was observed with a black mole like substance in the tile, eight blocks up from the floor. There was a black substance in the tile grout line. Facing the shower in the right corner in front of shower wall, was dirt like substance. There were black spots under the rail. On 5/8/2019 at 10:52 a.m., in shower number two on the 700 hall, black spots were in tile facing the shower on the side wall, eleven tiles, 11.5 inches up. There were brown steak running down tile under a hand cleaner container on the wall. The cleaner container was opened with no top on it. There was a brown mat with white spots covering the mat. On 05/09/19 10:56 AM, observations were again made of the showers on the 700 hall. Shower I the same as 5/8/19, black/substance mole like on the wall and shower II, same as the day before with a brown substance looking on floor under shower chair. On 5/09/19 at 11:00 a.m., an interview was conducted with RI #85. RI #85 was asked to tell the surveyor about the showers on the 700 hall. RI #85 replied, there was black stuff on the wall. RI #85 was asked what did the shower walls look like. RI #85 replied, look like mole, mildew, and dirt. RI #85 was asked who did she/he tell. RI #85 replied, the people in activities. RI #85 was asked what did she/he think needed to be done with the showers on the 700 hall. RI #85 replied, cleaned up. RI #85 was asked when did she/he tell someone. RI #85 replied, about a month ago. RI #85 was asked how did she/he feel about the showers. RI #85 replied, she/he did not want to stand on the shower mat. RI #85 replied, the lack of cleaning made her/him feel dirty. RI #85 stated other residents felt the same way but were afraid to say anything about it. On 05/09/2019 at 11:08 a.m., an interview was conducted with RI #26. RI #26 was asked to tell the surveyor about the showers on the 700 halls. RI #26 replied there was mold still in the cracks and under the hand rails and there was a jelly feeling when touching it. RI #26 was asked what did the shower walls look like. RI #26 replied, there was black mold and dirt in the cracks of the tiles. RI #26 was asked who did she/he tell. RI #26 replied, she mention it to the owner wife a while ago. RI #26 was asked what did she/he think needed to be done with the showers on the 700 hall. RI #26 replied, they need a brush to clean in the cracks. RI #26 was asked when did she/he tell someone. RI #26 replied, last month at resident council she/he brought up the mold in the showers and several other residents agreed that it was dirty and needed to be cleaned. RI #26 replied, mold had been there since she/he had been here. RI # 26 replied she/he had been here since last September. RI #26 was asked how did the mole like substance in the shower make he/she feel. RI #26 replied, not clean, he/she felt like it was not sanitary. RI #26 said he/she would not allow it in his/her home. On 05/ 9 at 11:23 a.m., an interview was conducted with Employee Identifier (EI) # 5, Housekeeping Environmental Service. EI #5 was asked what did she see on the wall in shower one. EI #5 replied, mold, grime on the shower wall and the brown stuff was caked up soap on the wall. EI #5 was asked what did she see on the wall in shower two. EI #5 replied, it all looked like mold, and caked up soap was on the wall. EI #5 replied, the soap was white but after it sits it turns into brownish color. EI #5 was asked what was on the floor under the shower chair in shower two. EI #5 replied, BM (bowel movement). EI #5 was asked when did she clean the hand rail in the showers. EI #5 replied, daily. EI #5 was asked in shower number two what was on the floor where the floor met the wall. EI #5 replied, dirt. EI #5 was asked why was the black substance on the shower walls. EI #5 replied, she did not know why. EI #5 was asked how long had the black substance been there. EI #5 replied, she was not sure. EI #5 was asked who was responsible for cleaning residents showers. EI #5 replied, she was housekeeping. EI #5 was asked when should the showers be cleaned. EI #5 replied, daily after 1 p.m. EI #5 was asked why should the showers be cleaned. EI #5 replied, to keep down germs and everything. EI #5 was asked when did residents complaint of a dirty showers. EI #5 replied, in (MONTH) and (MONTH) it had been brought up twice to her. EI #5 was asked how often was the shower cleaned along the grout. EI #5 replied, once per week. EI #5 was asked would she take a shower in there. EI #5 replied, she would not take a shower in there. EI #5 was asked had she told someone about the black substance on the wall in the shower. EI #5 replied, yes. EI #5 was asked who did she tell. EI #5 replied, she told her supervisor, EI #6. EI #5 was asked when did she tell her. EI #5 replied maybe three weeks ago. EI #5 was asked what was in the corner in front of the shower. EI #5 replied, dirt. On 5/ 9 at 11:35 a.m., EI #6, Environmental Service Supervisor, was asked what did she see on the wall in shower number one. EI #6 replied, that was a mold stain. EI #6 was asked why was it there. EI #6 replied, probably because the housekeeper did not keep it scrubbed down as well as she should have. EI #6 was asked how long had it been there. EI #6 replied, longer than a week. EI #6 was asked who was responsible for cleaning residents showers. EI #6 replied, EI #5. EI #6 was asked when should the shower be cleaned. EI #6 replied, at the end of each day. EI #6 was asked why should the showers be cleaned. EI #6 replied, because germs being spread. EI #6 was asked when did she receive the resident's complaint of a dirty shower. EI #6 replied (MONTH) or April. EI #6 was asked would she take a shower in there. EI #6 replied, no. EI #6 was asked what did she see in shower number two. EI #6 replied, spots of mold on the wall, under the chair a spot of BM. EI #6 was asked why was the black substance on the wall. EI #6 replied probably because it was not cleaned that well. EI #6 was asked why was the BM there. EI #6 replied, it was left after giving someone a shower. EI #6 was asked what did she see on the floor where the floor met the wall . EI #6 replied dirt. On 5/09/19 11:54 at a.m., an interview was conducted with EI #7 Maintenance Supervisor. EI #7 was asked what was on the wall in shower number one. EI # 7 replied, it looked like caulking has mildew on it. EI #7 was asked how long had it been there. EI #7 replied, last week. EI #7 was asked when was he first told about the shower on the 700 hall. EI # 7 replied, probably 2 weeks ago. EI #7 was asked would he take a shower in there. EI #7 replied, depend on how dirty he was. EI #7 stated, it was what it was, and it did not happen overnight and housekeeping should have pointed it out a long time ago. EI #7 was asked what was on the wall in shower two. EI #7 replied, some missing grout and some mildew. EI #7 was asked what was the process when something needed to be done related to mold and mildew in the showers. EI #7 replied, housekeeping should notice it and notify supervisor and they notify him. RI #7 replied, if he did not know, he could not fix it. EI #7 replied, this had got out of hand there. On 5/09/19 at 12:25 p.m., an interview was conducted with EI #8, Administrator. EI #8 was asked what did she see in shower number one on the wall. EI #8 replied, dirt or mold. EI #8 was asked how long had it been there. EI #8 replied, she was not sure. EI #8 was asked should it be there. EI #8 replied, no.

Based on observations, interviews and a review of the (YEAR) Food Code, and the facility's policy related to the use of the nursing unit refrigerators, the facility failed to ensure out-dated food for residents' use was routinely discarded from two of two nursing station refrigerators. This had the potential to affect residents throughout the facility. Findings include: The (YEAR) Food and Drug Administration Food Code specifies under ,[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking the following: (A) .READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 41 degrees F (Fahrenheit) or less for a maximum of 7 days The Food Code mandates under ,[DATE].17 (B) the following related to commercially processed food: .refrigerated READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PR[NAME]ESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded . (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety . On [DATE] at 6:05 PM, the Surveyor requested staff to show her the contents of the nursing station refrigerators. The Director of Nursing, Employee Indentifer (EI #1), the Registered Nurse Unit Manager, EI #2 and an Environmental Services staff member, EI #3 observed the Station 1 refrigerator which contained the following out-dated, or undated food items as follows: 1) one expired 12-oz package of unopened Deli Ham (labeled with a resident's name), with a date of [DATE], 2) an (undated) container with a ,[DATE] raw tomato. The cut surface of the tomato was covered with a fuzzy residue, ,[DATE] inch in height, 3) three 6-oz containers of yogurt with expired use by dates of [DATE], [DATE] and [DATE], 4) a ,[DATE]-gallon pitcher of orange juice with a date of [DATE] marked on the side, 5) one jar of ranch dressing with an expiration date of [DATE], 6) one 12-oz squeeze bottle of mayonnaise, with an expiration date of [DATE], 7) one 4-oz container of expired Danimal yogurt (staff immediately discarded it) and 8) one 60-oz bottle of cranberry juice marked with a resident's name and a stamped expiration date of [DATE]. On [DATE] at 6:15 PM, EI #2 and EI #3 were asked whose responsibility it was to monitor the refrigerator contents. EI #2 stated it was EI #3. The surveyor asked EI #3 how often she monitored the refrigerator. EI #3 explained she checked the internal temperature of the refrigerator daily, but the dates of the food inside were checked only randomly. When asked why it was important to ensure the stored food was in-date, EI #2 responded it was to prevent bacterial growth. On [DATE] at 6:22 PM, EI #1 accompanied the Surveyor to the Station 2 nursing unit, to check the refrigerator. The following expired food items were found: 1) one 48-oz container of thickened iced tea with a use-by date of [DATE]; and 2) one 4-oz portion (unopened) of thickened iced tea with a use-by date of [DATE]. When asked for a copy of the policy related to the dating, storage and monitoring of residents' food in the nursing refrigerators, EI #1 stated the facility had no policy.

Based on observation of medication administration on 07/24/2018 and a review of a facility policy titled, Handwashing Procedure, the facility failed to ensure Employee Identifier (EI) #5, a Licensed Practical Nurse (LPN), did not contaminate her hands by turning the faucet off with her bare hands and then continuing with medication administration. This affected one of three staff members and two of eight residents, Resident Identifier (RI ) #35 and RI #31, who were observed during medication administration. Findings Include: A review of an undated facility policy titled, Handwashing Procedure documented: . 3. Rinse hands . 4. Dry your hands using a paper towel . 5. Use . paper towel to turn off the faucet. RI #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #35's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/16/2018, revealed RI #35 had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. RI #31 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #31's Significant Change MDS with an ARD of 04/13/2018, revealed RI #31's BIMS score of 7, indicating severely impaired cognition. On 07/24/2018 at 3:50 p.m., during an observation of the medication administration with EI #5, the medication LPN, the following was observed. EI #5 entered RI #35's room and administered the medication. EI #5 then entered the bathroom, washed her hands, and turned the faucet off with her bare hands. EI #5 then exited the room and returned to the medication cart, resuming the medication administration. On 07/24/2018 at 3:55 p.m., EI #5 entered RI #31's room, administered the medication, entered the bathroom and washed her hands. EI #5 then turned the faucet off with her bare hands. EI #5 exited the room and returned to the medication cart to resume medication administration. On 07/24/2018 at 4:00 p.m., an interview was conducted with EI #5. The surveyor asked EI #5 how did she turn the faucet off in RI #35 and RI #31's bathroom after washing her hands. EI #5 explained she used her bare hands. The surveyor asked EI #5 what she should have done. EI #5 said, she should have used a paper towel (to turn off the faucet). The surveyor asked EI #5 why she should have used a towel, to which EI #5 replied, because of contamination.

Based on observation, interview and a review of a facility policy titled Surveillance. The facility failed to ensure towels and gowns did not touch the laundry worker's clothing and sheets did not touch the laundry room floor. This was observed on 5/3/2017 and had the potential to affect 135 residents whose linen was laundered by the facility and 80 residents whose clothes were laundry by the facility. Findings Include: A review of a policy titled, SURVEILLANCE with no revised date revealed POLICY . 2. That personal protective apparel and equipment are provided and appropriately used. On 5/3/2017 at 12:15 p.m., the surveyor observed a worker to wipe her nose on the sleeve of her shirt. She left a wet spot in the area where she wiped her nose. Gowns and towels were touching the workers clothing. Sheets were touching the workers clothing, under the workers chin and touching the floor as they fold sheets. On 5/3/2017 at 12:30 p.m., the surveyor conducted an interview with (Employee Identifier) EI #7, Directory of Environment services. EI #7 was asked when should you wear PPE (personal protective equipment). EI #7 replied, when dealing with blood and emptying dirty stuff. EI #7 was asked why should resident sheets and gowns not touch the workers clothing or under their chins. EI #7 replied, because of germs. EI #7 was asked why were residents clothing items touching worker chins, clothing and touching the floor. EI #7 replied, it should not. EI #7 was asked what was the potential harm when residents clothes touch the workers clothes and under their chins. EI #7 replied, could spread germs. EI #7 was asked did she observed a pillow case fall to the floor and a worker pick it up and fold it. EI #7 replied, yes. EI #7 was asked did she observe workers folding sheets and the sheets were touching the floor. EI #7 replied, yes. On 5/3/2017 at 12:36 p.m., the surveyor conducted an interview with EI #8, housekeeper. EI #8 was asked when should you wear PPE in the laundry room. EI #8 replied, when there was bowel movement, dirty laundry, or blooded items. EI #8 was asked why should resident sheets and gowns not touch the workers clothing or under their chins. EI #8 replied, because of spreading bacteria. EI #8 was asked did she drop a pillow case on the floor and pick it up and fold it. EI #8 replied, yes. EI #8 was asked did she wipe her nose on the sleeve of her shirt. EI #8 replied, yes ma'am. On 5/3/2017 at 12:55 p.m., an interview was conducted with EI #9, laundry aide. EI #9 was asked when should you wear PPE in the laundry room. EI #9 replied, when washing. EI #9 was asked why should residents sheets and gowns not touch the workers clothing and under their chins. EI #9 replied, it would be contaminated. EI #9 was asked did towels touch your clothing. EI #9 replied, yes. EI #9 was asked what was the potential harm when towels and sheets touch your clothing. EI #9 replied, the resident can get sick. On 5/3/2017 at 1:10 p.m., the surveyor conducted an interview with EI #10, laundry aide. EI #10 was asked why should residents sheets and gowns not touch the workers clothing and under their chins. EI #10 replied, contamination. EI #10 was asked what was the potential harm when resident towels and sheets touch the workers clothes and under their chins. EI #10 replied, cross contamination. EI #10 was asked did towels and sheets touch your clothes. EI #10 replied, yes ma'am.

Based on record review and interview the facility failed to ensure [MEDICAL TREATMENT] for Resident Identifier (RI) #15, a resident receiving [MEDICAL TREATMENT], was coded on the Minimum Data Set ((MDS) dated [DATE] and 9/6/16. This affected one of four residents sampled for [MEDICAL TREATMENT]. Findings Include: RI #15 was admitted to the facility 9/04/15 with [DIAGNOSES REDACTED]. A review of RI #15's admit physician's orders [REDACTED].[MEDICAL TREATMENT] T T S (Tuesday Thursday Saturday) . A review of RI #15's Annual MDS with an Assessment Reference Date (ARD) of 9/9/16 was not coded to reflect [MEDICAL TREATMENT]. A review of RI #15's Quarterly MDS with an ARD of 3/8/17 was not coded to reflect [MEDICAL TREATMENT]. On 5/4/17 at 11:50 a.m., an interview was conducted with Employee Identifier (EI) #4, Registered Nurse, MDS Coordinator. EI #4 was asked when RI #15 received an order for [REDACTED].#4 was asked if [MEDICAL TREATMENT] should be coded on the MDS. EI #4 replied yes. EI #4 was asked if [MEDICAL TREATMENT] was coded on the MDS' dated 3/8/17 and 9/9/16; she replied no. EI #4 was asked if [MEDICAL TREATMENT] was not coded on the MDS was that assessment accurate. EI #4 replied no, not for that area only.

Based on observations, interviews, a review of a document of food temperatures and a review of facility policies titled, Monitoring Food Temperatures for Meal Service:, Delivery Guidelines, Food Temperature Sheet and Food Storage (Dry/Refrigerated/Frozen),the facility failed to ensure: 1. staff took the final temperature of the tomato soup and documented the temperatures of the soup and mashed potatoes; 2. dented food cans were in the dented can section, and 3. white turkey meat in the freezer was labeled with an open and use by date. This had the potential to affect 132 of 135 residents receiving meals from the kitchen. Findings Include: 1 ) A review of a facility policy titled, Monitoring Food Temperatures for Meal Service with an edition date of 2011 revealed the following: Guideline: Food Temperatures will be monitored daily to prevent food borne illness and ensure foods are served at palatable temperatures. Procedure: 1. Prior to serving a meal, food temperatures will be taken and documented for all hot and cold foods to ensure proper serving temperatures . A review of a facility document dated 5/3/17 with a recording for food temperatures for the breakfast, lunch and supper mea revealed there was no documentation for the soup or mashed potatoes. On 5/3/2017 at 10:45 a.m., the surveyor observed the cook, EI (Employee Identifier) #5 taking the temperature of the soup. The first soup temperature was 113 degrees. The cook placed the soup back on the stove at 10:50 a.m. At 11:00 a.m., the cook took the temperature of the soup again and it was 126 degrees. The tray line started at 11:10 a.m., and the dietary manager EI #1 put the soup in bowls and placed them on the tray line. On 5/4/2017 at 8:45 a.m., an interview was conducted with EI #1. EI #1 was asked who took the final temperature of the tomato soup on 5/3/2017. EI #1 replied, EI #5. EI #1 was asked was the temperature over 135 degrees. EI #1 replied, no ma'am. EI #1 was asked who wrote down the temperature of the tomato soup. EI #1 replied, nobody. EI #1 was asked what did the facility policy say regarding taking food temperatures and writing them down. EI #1 replied, prior to serving a meal food temperatures will be taken and documented for all hot and cold foods to ensure proper serving temperatures. EI #1 was asked who was responsible for taking food temperatures and writing them down. EI #1 replied, your cook. EI #1 was asked why was there no documentation for the soup or mashed potatoes on 5/3/2017. EI #1 replied, they did not write it down. EI #1 was asked what was the potential harm when food temperatures were not taken or written down. EI #1 replied, if you did not take the food temperature they would not know if they were at the right temperatures, and if they did not write them down they would not know what the temperatures were. On 5/4/2017 at 9:00 a.m., the surveyor conducted an interview with EI #5, the cook. EI #5 was asked who took the final temperature of the tomato soup on 5/3/2017. EI #5 replied, she did. EI #5 was asked what was the final temperature that was taken for the tomato soup. EI #5 replied, 113 degrees. EI #5 was asked who wrote down the temperature of the tomato soup. EI #5 replied, EI #2, Dietary Manager. EI #5 was asked who was responsible for taking food temperatures and writing them down. EI #5 replied, the cook. EI #5 was asked why was there no documentation for the soup or mashed potatoes on 5/3/2017. EI #5 replied, she forgot it and she thought someone else was writing the temperatures down. On 5/4/2017 at 9:02 a.m., an interview was conducted with EI #2, Dietary Manager. EI #2 was asked who took the final temperature of the tomato soup. EI #2 replied, nobody. EI #2 was asked who wrote down the temperatures of the mashed potatoes and soup. EI #2 replied no one. 2) A review of a facility policy titled, Delivery Guidelines with an edition date of 2011 revealed the following: Guideline: Food deliveries will be accepted according to the following guidelines. Procedure: .4. Check shipments for intact packaging and signs of damage, . dented cans . should be rejected. A review of a document titled, Food Storage (Dry/Refrigerated/Frozen) with an edition date of 2011 revealed the following: .4. Dry Storage guidelines to be followed: .dented cans are set aside in a separate labeled area of the storeroom to avoid using them and discarded . On 5/2/2017 at 2:45 p.m., the surveyor observed a four pound can of tuna with a dent in the middle of it. The surveyor also observed two cans of three bean salad with a dent at the side of it and a dent at the rim of the other can. On 5/4/2017 at 9:22 a.m., an interview was conducted with EI #1, Dietary manager. EI #1 was asked what did the facility policy say about dented cans. EI #1 replied, all cans that are dented need to be put in the designated area. EI #1 was asked what dented cans were on the shelf and not in the dented can section. EI #1 replied, three bean salad. EI #1 was asked how many cans were dented. EI #1 replied, two cans. EI #1 was asked who was responsible for removing dented cans from the shelf. EI #1 replied, the stock person. EI #1 was asked what was the potential harm when residents was given food from dented cans. EI #1 replied, the food could be damaged. On 5/4/2017 at 9:25 a.m., an interview was conducted with EI #6, dietary aide. EI #6 was asked what did the facility policy say about dented cans. EI #6 replied, they have to be in the dented can area. EI #6 was asked who was responsible for removing dented cans from the shelf. EI #6 replied, he was. EI #6 was asked when should dented cans be removed from the shelf. EI #6 replied, immediately. EI #6 was asked what was the potential harm when residents was given foods from dented cans. EI #6 replied, the food was not good. 3) A review of a facility document titled, Food Storage (Dry/Refrigerated/Frozen) with an edition date of 2011 revealed the following: .Procedure: 1. General storage guidelines to be followed: All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded . On 5/2/2017 at 3:05 p.m., the surveyor observed white meat turkey in the freezer in a medium bag with no information on the bag. The meat was out of the original container. On 5/4/2017 at 9:32 a.m., an interview was conducted with EI #6, dietary aide. EI #6 was asked what food item was in the freezer with no use by date or other information. EI #6 replied, white meat turkey. EI #6 was asked why was there no information on the bag. EI #6 replied, the cook did not give me any information to put on the bag. EI #6 was asked how large was the bag. EI #6 replied, 5 x 11 or 5 x 12. EI #6 was asked who was responsible for labeling food items. EI #6 replied, he was. EI #6 was asked what does the facility policy say about food items that are taken out of the original container. EI #6 replied, make sure there was a use by date on it. EI #6 was asked what is the potential harm when food items are not labeled and in the freezer. EI #6 replied, it would be no good with no label and they would not know what it was. On 5/4/2017 at 9:38 a.m., an interview was conducted with EI #1. EI #1 was asked why was there no information on the bag. EI #1 replied, when the cook took it out of the original box, they did not write any information on it. EI #1 was asked what was in the bag. EI #1 replied, white meat turkey. EI #1 was asked what did the facility policy say about food items that were taken out of the original container. EI #1 replied, they must have a manufacture date and a use by date on the bag. EI #1 was asked what was the potential harm when food items were not labeled in the freezer. EI #1 replied, they would not know when the food items came in, the food could be old and make the residents sick.

Based on observations and interviews, the facility failed to ensure survey results were in a place readily accessible to residents and further failed to post notice of the availability of survey results in areas of the facility prominent among residents and the public. This affected 135 residents residing in the facility. Findings Include: Observations were made on 05/03/2017 at 9:00 a.m., and 05/04/2017 at 9:15 a.m. of the facility survey results, which were located on the wall to the right of the second entry but were not accessible to residents who used wheelchairs. Observations were made on 05/03/2017 at 9:40 a.m. and on 05/04/2017 at 9:18 a.m., of the facility not having a posting of the location and availability of survey results. On 05/04/2017 at 9:24 a.m., an interview was conducted with EI #3, Medical Records. EI #3 was asked who was responsible for posting survey results. EI #3 said she was. EI # 3 was asked how residents knew where the survey results were located. EI #3 replied, There (they're) right there on the wall when you come in through the front doors on the right. EI #3 was asked where were the postings of where the survey results were located. EI #3 said she guess they did not have any. EI #3 was asked were the survey results accessible for residents in wheelchairs. At 9:28 a.m., the surveyor and EI #3 walked to the location of the survey results. EI #3 replied, No they are not accessible to a resident in a wheelchair. EI #3 was asked should the survey results be in an area accessible to the resident. EI #3 said yes. EI #3 was asked why they were not. EI #3 said she did not know. EI #3 was asked what was the potential harm in not having survey results readily accessible to residents especially residents in wheelchairs. EI #3 said they should be located where the residents can get to them as well as their family. EI #3 was asked should there be a posting of where the survey results were located in the facility. EI #3 said yes.

Based on observation, and interview the facility failed to ensure licensed staff provided privacy during medication administration to Resident Identifier (RI) #14 and #5. This was observed on 5/17/16, and affected two of eight residents observed during the medication pass. Findings Include: 1) RI #14 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 05/17/16 at 3:10 PM, Employee Identifier (EI) #3, a Registered Nurse, was observed obtaining a finger stick blood sugar. She took the glucometer and supplies to RI #14's room and failed to close the door to the room. Without providing privacy, EI #3 obtained the resident's blood sugar. EI #3 returned to the medication cart to prepare a dose of Regular insulin, and came back to RI #14's room. Again without closing the resident's door to provide privacy, EI #3 gave the insulin. On 05/17/16 at 3:30 PM, an interview was conducted with EI #3. The surveyor asked what the policy was for giving insulin. EI #3 explained she was supposed to close the door. EI #3 was asked if she provided privacy with the glucometer check and with giving the insulin. EI #3 replied no. EI #3 was asked what harm would result in privacy not being provided. EI #3 replied, resident dignity. 2) RI #5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 05/17/16 at 4:30 PM, EI #4 (a Licensed Practical Nurse) was observed giving medications per gastrostomy tube to RI #5. She prepared the medications, went into the room, pulled the privacy curtain only half-way, and gave the medications. On 05/17/16 at 4:50 PM, an interview was conducted with EI #4. The surveyor asked EI #4 how was she to provide privacy. EI #4 replied, pull the curtain. EI #4 was asked if the curtain should be pulled completely or only half-way. EI #4 replied, all the way. EI #4 was asked what the harm was in not pulling the curtain completely. EI #4 replied, dignity and exposing the resident to people seeing RI #5.

Based on observation and interview, the facility failed to ensure three staff members did not enter Resident Identifier (RI) #5, #9 and #10's rooms as well as the rooms of three unsampled residents (#207, #205, #216 and #219) without knocking before entering. This was observed on 05/17/16 and affected three of 14 sampled residents and four unsampled residents. Findings Include: 1) On 05/17/16 at 4:00 PM, Employee Identifier (EI) #6, a Certified Nursing Assistant (CNA), was observed going into RI # 5's room without knocking before entering to place gloves in glove boxes. EI #6 was then observed leaving RI #5's room, and go into RI #10's room, again without knocking, to place gloves. EI #6 also entered room [ROOM NUMBER] and #219 to place gloves without knocking before entering. On 05/17/16 at 5:30 PM, an interview was conducted with EI #6. The surveyor asked what was she to do before entering a resident's room. EI #6 replied they were to knock first. EI #6 was asked if she knocked before entering rooms. She replied, no. EI #6 was asked what the harm was in not knocking before entering residents' rooms. EI #6 explained they would be disturbing the residents' privacy. 2) On 05/17/16 at 4:10 PM through 4:15 PM, EI #8 (CNA) was observed going into room [ROOM NUMBER], then into room [ROOM NUMBER] without knocking. EI #8 exited room [ROOM NUMBER], and entered RI #10's room without knocking. She was in the room only briefly before exiting, then entered RI #5's room without knocking. She was in the room briefly and exited the room at 4:15 PM. On 05/17/16 at 5:25 PM, an interview was conducted with EI #8. The surveyor asked what should be done before entering a resident's room. EI #8 replied, knock. EI #8 was asked if she knocked before entering; she replied no. When asked, what the harm was in not knocking prior to entering resident rooms, EI #8 replied, privacy. 3) On 05/17/16 at 4:45 PM, EI #9 was observed entering room [ROOM NUMBER] without knocking before entering. She was in the room briefly, then exited and entered RI #5's room without knocking. At 4:47 PM, EI #9 exited and entered RI #10's room without knocking. EI #9 left RI #10's room and entered RI #9 's room to check and change the resident. EI #9 did not knock before entering. On 05/17/16 at 4:50 PM during an interview, EI #9 was asked what was she to do before entering a resident's room. EI #9 replied she should knock, but sometimes she forgot. EI #9 was asked what was the harm in not knocking before entering a resident's room. EI #9 stated, It is their privacy and their home. I would not want anyone coming into my house without knocking.

Based on observation, record review and interview, the facility failed to ensure Resident Identifiers (RI) #s: 1, 4, 5 and 9 were assessed for the use of full side rails. This was observed on the initial tour 05/17/16, and 05/18/16. This affected three of 14 sampled residents. Findings include: A review of a facility form (dated 05/14/01) titled, Restraint Guidelines revealed: .Before restraints are used, the facility should determine the presence of a medical symptom that would require the use of restraints . A review of the State Operations Manual regarding the use of restraints revealed: . Medical symptoms that warrant the use of restraints must be documented in the resident ' s medical record, ongoing assessments, and care plans. 1) RI #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 05/17/16 during the initial tour at 9:52 am, RI #1 was observed in the bed asleep with both sets of side rails in the up position. On 05/18/16 at 2:10 pm, RI #1 was again observed in the bed asleep with both sets of side rails in the up position. Review of RI #1' s medical record for bed rail use revealed no assessment found for the use of side rails. RI #1's care plan dated on 10/23/15 revealed: Side rails as desired for safety and support . RI #1's most current Minimum Data Set (MDS) with an assessment reference date of 04/06/16, was coded restraints used in bed: bed rail--0. Not used. On 05/18/16 at 3:45 pm, an interview was conducted with Employee Identifier (EI) #14, CNA. The surveyor asked if she took care of (RI #1). EI #14 verified she did. When asked how often and when did the facility utilize full side rails, EI #14 explained they were used to stabilize the resident when standing and protect the residents when they were in the bed. The surveyor asked why RI # 1 had full side rails, EI #14 responded, for the safety and protection RI #1 when he/she had a urinary tract infection [MEDICAL CONDITION]. When asked if RI #1 used both sets of side rails for positioning, EI #14 explained RI #1 used the rails for positioning, but only the top two (at the head of the bed). On 05/18/16 at 4:10 pm, an interview was conducted with EI #15, RN. The surveyor asked EI #15 if she was familiar with RI #1. EI #15 responded she was. When asked why RI #1 had full side rails in place while in bed, EI #15 explained it was the resident's daughter's request after RI #1 had multiple falls and interventions. When asked how long had the side rail use been in place, EI #15 was not sure. The surveyor asked whether full side rails considered a restraint. EI #15 stated she did not consider SR (Side Rails) x 4 to be a restraint. When asked if RI #1 should have been assessed, EI #15 responded, yes. 2) RI #4 was admitted to the facility 10/05/15 with a [DIAGNOSES REDACTED]. On 05/17/16 during the initial tour at 10:00 AM, RI #4 was observed in the bed with both full side rails in the up position. On 05/18/16 at 9:00 AM, RI #4 was observed in the bed with both full side rails in the up position. At 2:15 PM on 5/18/16, RI #4 was observed in the bed with both full side rails in the up position. No assessment was found during a review of RI #4's medical record, for bed rail use. RI #4's Care Plan dated 10/05/15 revealed: Upper siderails up for safety & support . On 05/18/16 at 4:30 PM, an interview was conducted with Employee Identifier (EI) #5, Registered Nurse. The surveyor asked why did RI #4 have both full side rails up. EI #5 explained RI #4 had dementia and was trying to come out of the bed. EI #5 was asked if full side rails were considered a restraint. She replied, yes. EI #5 was asked if RI #4 could walk. EI #5 replied the resident did; the last mini mental score was 7 (severe cognitive impairment) and RI #4 did not realize safety. EI #5 was asked how often RI #4 was assessed for bed rail use. EI #5 replied she did not know. EI #5 was asked what was the risk of full rail restraints. EI #5 replied if RI #4 climbed out of the bed, he/she could get hurt. EI #5 was asked where was the bed rail assessment. She replied, she would look for it. EI #5 was asked to review RI #4's care plan, which revealed Upper side rails, then was asked if the rails on RI #4's bed were upper rails. EI #5 replied, no they were full rails. 3) RI #5 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 05/17/16 during the initial tour, RI #5 was observed in the bed with both full side rails in the up position. RI #5 appeared to be sleeping. On 05/18/16 at 3:30 PM, an interview was conducted with EI #1, the Director of Nursing. EI #1 was asked why did RI #5 have both full side rails up. EI #1 explained they did not have half rails on those beds. EI #1 was asked when were the full rails ordered. EI #1 replied they had never been ordered; it was just the beds. EI #1 was asked if RI #5 had been assessed for a less restrictive restraint. EI #1 replied no, because it was not considered a restraint. EI #1 was asked what was the potential for harm if the resident climbed over the rails. EI #1 replied it would cause more harm because it was further to the floor and there was a possibility of entrapment. 4) RI #9 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 05/17/16 at 5:40 PM, RI #9 was observed in bed with full padded side rails in the raised position. RI #9 was again observed on 05/18/16 at 11:50 AM and 3:25 PM, in bed with full padded side rails in a raised position. A review of RI #9's medical record did not include an assessment for the use of side rails. A review of RI #9's care plan with no date revealed: Side rails for safety and support . On 05/18/16 at 11:30 AM, an interview was conducted with EI #2, the Assistant Director of Nursing (ADON). EI #2 was asked why RI #9 had full padded side rails. EI #9 said because the resident would reach out and hit his/her arms; the rails were protective measures to keep RI #9 from sliding out of the bed. EI #2 was asked would you consider RI #9's side rails to be a restraint. EI #2 said no, because the resident kicked his/her legs and pinched staff. On 05/18/16 at 2:45 PM, an interview was conducted with EI #10, Registered Nurse Minimum Data Set (MDS) Coordinator. When asked why the resident had not been checked on the MDS as having a restraint (side rail use), EI #10 explained if someone could get up (by themselves) the rails could be considered a restraint, but RI #9 could not get up independently. EI #10 was asked if she could tell the surveyor what the side rails were used for. EI #10 explained the rails were used for positioning, for RI #9 to hold on to. EI #10 was asked whether an assessment had been completed for RI #9's use of restraints. EI #10 answered no. EI #10 was asked what was the potential for harm in RI #9 having side rails. EI #10 said it could be a safety issue, a resident flipping over the rails. On 05/18/16 at 3:25 PM, an interview was conducted with EI #9 a Certified Nursing Assistant (CNA). EI #9 was asked how often did she provide care for RI #9. EI #9 said, often. EI #9 was asked when RI #9 was in the bed, what exactly could he/she do to help during the provision of perineal care. EI #9 said RI #9 was previously able to help with turning, but was not able to now. EI #9 was asked if RI #9 was able to help with turning and repositioning. EI #9 said no. EI #9 was asked how long had it been since RI #9 was able to help reposition and turn self. EI #9 was asked what was the potential for harm in having full side rails up. EI #9 said RI #9 could hit hand or head.

Based on observation, interviews and record review, the facility failed to accurately code the current Minimum Data Set (MDS) assessment for Resident Identifier (RI) #18. Neither the resident's eyeglasses, nor a history of falls were included on the 03/11/16 assessment. This affected one of 22 sampled residents. Findings included: RI #18 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly review MDS, with an assessment reference date of 03/11/16, identified RI #18 as having adequate vision without the use of corrective lenses and with no falls since admission or the prior assessment (dated 12/14/15). On 05/19/16 at 9:05 AM and at 2:30 PM, the resident was ambulating in a wheelchair, and wearing glasses. When questioned (at 10:55 AM), RI #18 affirmed the glasses were worn all the time. The Social Service Assessment completed at the time of admission (09/11/15) affirmed the resident had glasses. An Assessment of Risk for Falls evaluation completed prior to the current MDS, documented the resident was wearing glasses on 09/05/15 and on 12/23/15. Nursing notes dated 12/30/15, 01/21/16, 02/16/16 and 03/02/16 each reported falls sustained by RI #18 during attempts to transfer from the wheelchair or while in his/her room. Despite this documentation, the 03/11/16 MDS reflected no falls since admit or prior assessment. On 05/19/16 at 11:05 AM, the surveyor asked the MDS Coordinator (Employee Identifier/EI #10) why the resident's glasses had not been coded on the current MDS. EI #10 was unable to locate an initial nursing assessment in the medical record, but did find evidence of the resident's glasses on the 09/11/15 assessment completed by the Social Worker. When asked why the resident's falls had not been captured on the MDS, EI #10 explained she may have referred to the fall list on the computer, but agreed the falls should have been captured on the 03/11/16 MDS.

Based on interviews and record review, the facility failed to develop a care plan to address the [MEDICAL TREATMENT] needs of Resident Identifier (RI) #18. This affected one of two residents sampled for the need of [MEDICAL TREATMENT]. Findings included: RI #18 has resided in the facility since 09/04/15. Admitting [DIAGNOSES REDACTED]. The resident's most current Minimum Data Set (MDS) with an Assessment Reference Date of 03/11/16, identified an active [DIAGNOSES REDACTED]. The most current physician's orders [REDACTED]. 9 AM - 1 PM; assess site, thrill and bruit q (every) shift; remove dressing 24 hrs (hours) post [MEDICAL TREATMENT]. Despite these findings, the care plan included no mention of the resident's need of or details regarding [MEDICAL TREATMENT]. On 05/19/16 at 11:05 AM, the surveyor asked Employee Identifier (EI) #10, the MDS Coordinator (and Care Plan Coordinator) if she had developed a care plan for RI #18's [MEDICAL TREATMENT]. EI #10 affirmed no separate care plan had been developed. On 05/19/16 at 2:00 PM, the surveyor again interviewed EI #10 regarding the lack of [MEDICAL TREATMENT] information for RI #18. EI #10 explained the residents all dialyze at the same location and she would expect staff to know the needed phone numbers (posted at the nursing station). When asked why she did not have a specific care plan for [MEDICAL TREATMENT], EI #10 did not know, and stated, she would fix one.

Based on observation, interview and record review, the facility failed to provide incontinent care for Resident Identifier (RI) #6, a resident with a history of Urinary Tract Infection [MEDICAL CONDITION] in a manner to prevent cross contamination. A Certified Nursing Assistant (CNA) used a back to front motion with the cloth while providing incontinent care. This affected one of three residents observed for incontinent care. Findings Include: A facility document titled: Policy and Procedure .Incontinent Care .Policy: Incontinent care will be provided with routine dry-ups and prn.(as needed) .Procedure: .7. Remove brief. If a resident is soiled with feces, remove feces first by wiping from anal area up toward back . A facility document titled: CARE PLAN CONFERENCE ATTENDANCE AND NOTES: . Date reviewed: Monday, May 9th, 2016 .5/6/16 Dr. Temple reviewed chart; UTI 4/27/16 tx.(treated) with abx.(antibiotics). A facility document dated and titled: DOS (Date Of Service): 5/4/2016 . PROGRESS NOTE . [DIAGNOSES REDACTED]. RI #6 was re-admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #6's most recent Quarterly Minimum Data Set with an Assessment Reference Date of 02/03/16, documented in Section G Functional Status as RI #6 needing 3. Extensive assistance .2. One person physical assist. Section H Bladder and Bowel Urinary continence 3. Always incontinent 3. Bowel Always incontinent. RI #6's Laboratory Document with a date of 04/29/16, documented MICROBIOLOGY URINE CULTURE Final Organism 1: ESCHERICHIA COLI. RI #6's Physician order [REDACTED]. On 05/18/16 at 8:40 AM, Employee Identifier (EI) #11 (CNA) was observed providing incontinent care for RI #6. While cleaning a bowel movement off of RI #6, she used a back to front motion more than once while providing care. An interview was conducted by phone with EI #11 on 05/18/16 at 11:00 AM. EI #11 was asked when she had provided incontinent care for RI #6. She replied this morning. She was asked if RI #6 had a bowel movement. EI #11 stated, Yes. EI #11 was asked if she was aware she had used a back to front motion with the washcloth moving BM toward the vaginal area and urethral opening. EI #11 stated, Yes, I was nervous; I know better. EI #11 was asked what the potential for harm was if she used a back to front motion. She stated, Can cause a UTI. EI #11 was asked if RI #6 had a UTI. She stated, Yes, I think so. An interview was conducted on 05/19/16 at 9:20 AM, with EI #2 (Assistant Director Of Nursing, Infection Control). She was asked what types of infection she was currently monitoring. She replied, UTI. EI #2 was asked if a CNA should use a back to front motion with the cloth during perineal care. EI #2 stated, No ma'am. She was then asked what the potential for harm was if a CNA used a back to front motion while cleaning a bowel movement off of a resident. EI #2 replied she is re-contaminating the area that she just cleaned.

Based on observation, interview and record review the facility failed to ensure: 1) Two licensed staff did not touch the inside of Resident Identifier (RI) # 15 and 25's medication cup while preparing their medications - furthermore a licensed staff touched the inside of a bag used to crush RI #15's medication and stacked the cups together while she carried them into RI #15's room. 2) Licensed staff did not touch RI #5's dirty medication cups, then return to the medication cart and get the thermometer and go to check RI #10's temperature without washing her hands. This was observed on 5/17/16. 3) A Certified Nursing Assistant (CNA) changed her gloves and washed her hands before touching RI #6's clean brief and clothing. This occurred on 5/18/16 during an observation of incontinent care. This affected 4 of 8 residents observed for medication administration and one of three observations of incontinent care. Findings Include: 1) On 05/17/16, at 3:30 PM Employee Identifier (EI) #12, a Licensed Practical Nurse (LPN), was observed preparing RI #15's medication. She touched the inside of the medication cups and the top of the cup. She also touched the inside of the bag used for crushing RI #15's medication and stacked the medication cups together while she carried them into RI #15's room to administer them. a) RI #15 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An interview was conducted with EI #12 on 05/18/16, at 3:03 PM. The surveyor asked how she should pick up a resident's medication cup. EI #12 replied, from the bottom. She was asked if she was aware she had touched the inside of RI #15's medication cup and the top of the cup. EI #12 stated, Not really. EI #12 was asked if she was aware she stacked the medication cups together. EI #12 stated, No, I was out of body. She was asked what the facility's policy was related to the above questions. She stated, I don't know of any policy. She was asked what the potential for harm was if she touched the inside and the top of a medication cup. EI #12 stated, Germs. She was asked what the potential for harm would be if she stacked the medication cups together. EI #12 replied, one medication could stick to the bottom of another and also contaminate another. EI #12 was asked if she should touch the inside of the bag used to crush a resident's medication. She stated, No. She was then asked what the potential for harm was if she touched the inside of the bag used to crush a resident's medication. EI #12 stated, Germs. During an interview on 05/19/16, at 9:20 AM with the Assistant Director Of Nursing/Infection Control, she was asked what types of infections she was currently monitoring. She (EI #2) replied, Upper Respiratory Infection, Pneumonia and Urinary Tract Infections. EI #2 was asked if a nurse should touch the inside of a resident's medication cup while preparing their medications. She stated, No ma'am. She was then asked if a nurse should touch the inside of a bag used to crush a resident's medication in. She stated, I wouldn't think so. EI #2 was asked what the potential for harm was if a nurse touched the inside of a resident's medication cup or the inside of the bag used to crush it in. She replied it was a mode of transmission for infection. On 05/18/16 at 7:30 AM, EI #13 (Registered Nurse) was observed preparing medications for RI #25. EI #13 touched the inside of the medication cup. b) RI #25 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 5/18/16, at 11:11 AM, an interview was conducted with EI #13. She was asked how she should pick up medication cups. EI #13 replied from the bottom. EI #13 was asked if she touched the inside of a medication cup while preparing RI #25's medication. She stated, Yes I did. EI #13 was asked what the facility's policy was related to picking up the cup. She replied, pick it up from the bottom. She was then asked what the potential for harm was if she touched the inside of a resident's medication cup. EI #13 stated, You can spread germs to the resident. 2) RI #5 was readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. RI #10 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 5/17/16 at 4:50 PM, EI #4 (Licensed Practical Nurse) was observed picking up the used medication cups from RI #5 and discarding them into the trash, then leaving the room and returning to the medication cart. EI #4 then picked up the thermometer and went into RI #10's room to obtain a temperature without washing her hands. On 5/17/16 at 4:50 PM during an interview, EI #4 was asked if she washed her hands after handling the dirty medication cups. EI #4 replied no. EI #4 was asked what the harm was in touching dirty medication cups then taking a thermometer into another resident's room to get a temperature. EI #4 replied spreading germs. On 5/19/16 at 9:20 AM, an interview was conducted with EI #2 (Infection Control Nurse). EI #2 was asked if a nurse should touch dirty, used medication cups and then take a different resident's temperature in another room. EI #2 replied, no Ma'am. EI #2 was asked what was the potential for harm if a nurse touched dirty used medication cups and continued to care for another resident and not wash their hands. EI #2 stated, Mode of transmission of potential contamination; infection. 3) A facility document titled: Policy and Procedure INCONTINENT CARE Policy: Incontinent care will be provided with routine dry-ups and prn (as needed). Procedure: 7.Dispose of soiled brief and cloth in plastic bag. Remove gloves, wash hands, and put on clean gloves. On 5/18/16 at 8:40 AM, EI #11 was observed providing incontinent care for RI #6. She cleaned a bowel movement off of RI #6, removed his/her brief and continued care. EI #11 placed a clean brief and pulled RI #6's clean pants up without changing her dirty gloves and washing her hands. RI #6 was re-admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A phone interview was conducted with EI #11 on 5/18/16 at 11:00 AM. She was asked when she had provided perineal care for RI #6. EI #11 replied this morning. EI #11 was asked if she observed a bowel movement when she began the care. She stated, Yes. She was asked should she have used the same gloves she had used to clean a bowel movement off of RI #6 to apply a clean brief and pull his/her pants up. EI #11 stated, No ma'am I was not; I was nervous. EI #11 was asked if she should have changed the gloves. She stated, Yes ma'am, anytime you touch dirty. EI #11 was asked what the potential for harm was if she did not change soiled gloves and wash her hands. EI #11 replied, if you have a bowel movement on your dirty gloves it could get their clothes dirty and could also give them an infection. RI #5 was readmitted to the facility 2/10/15 with [DIAGNOSES REDACTED]. RI #10 was admitted to the facility 9/28/12 with a [DIAGNOSES REDACTED]. On 5/17/16 at 4:50 PM, EI #4 was observed to pick up used medication cups from RI #5, discard them into the trash, leave the resident's room and return to the medication cart. EI #4 then picked up a thermometer and went into RI #10's room to obtain a temperature, all without washing her hands. On 5/17/16 at 4:50 PM during an interview, EI #4 was asked if she washed her hands after handling the dirty medication cups. EI #4 replied, no. EI #4 was asked what the harm was in touching dirty medication cups, then taking a thermometer into another resident's room to get a temperature. EI #4 replied, spreading germs. On 5/19/16 at 9:20 AM, an interview was conducted with EI #2, the Infection Control nurse. EI #2 was asked if a nurse should touch dirty, used medication cups and then take a different resident's temperature in another room (without washing hands). EI #2 replied, no. EI #2 was asked what was the potential for harm if a nurse touched dirty, used medication cups and continued to care for another resident and not wash their hands. EI #2 stated, Mode of transmission of potential contamination; infection.

Based on observations, interviews, and document reviews, the facility failed to ensure: 1) Dietary staff members were not observed working in the kitchen with hair that was not completely covered by hair bonnets, on 2 of 3 survey days. 2) A dietary staff member was not observed working in the kitchen with one stud earring uncovered by the hair bonnet. In addition, another staff member was not observed wearing a watch while working in the kitchen. This was observed on 1 of 3 survey days. 3) The vent hood over the stove was not observed with a yellow substance on 2 of 3 survey days. 4) Twenty-seven thawed Vanilla Sugar Free Mighty Shakes were not observed in the walk-in cooler without thaw dates, on 1 of 3 survey days. 5) Dietary staff members monitored the water temps (temperatures) of the wash and rinse cycles of the dish machine during operation to assure the machine reached proper temperatures for sanitizing. This was observed on 1 of 3 survey days. 6) A thermometer was inside the walk-in freezer on 1 of 3 survey days. 7) Bacon Bits were not observed in the walk-in freezer, opened and in zip-lock bags, dated 3-26-15 and 4-10-15. This was observed on 2 of 3 survey days. These deficient practices had the potential to affect 135 residents served meals from the kitchen. Findings include: 1) A review of the 2013 U. S. (United States) Public Health Service Food Code revealed, "...Hair Restraints 2-401.11 Effectiveness. (A) Except as provided ... FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, ... that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; ..." During the tour of the kitchen on 4/14/2015 at 2:25 PM, the following was observed: EI #1, a Tray Aide, was observed with hair on the sides and at the nape of her neck uncovered by the hair bonnet. EI #2, a Tray Aide, was observed with hair at the nape of her neck uncovered by the hair bonnet. On 4/15/2015, the following observations were made in the kitchen: At 8:24 AM, EI #5, a Cook, was observed with hair on the sides in the temporal areas, uncovered by the hair bonnet. EI #2 was again observed with hair at the nape of her neck uncovered by the bonnet. At 10:37 AM, EI #6, a Cook, was observed with some hair at the left nape of her neck uncovered by the hair bonnet. On 4/16/2015 at 1:00 PM, an interview was conducted with EI #5, a Cook. EI #5 was asked what the facility's policy was on hair coverings in the kitchen. EI #5 stated, "Hair nets at all times." EI #5 was asked if all hair should be covered while working in the kitchen. EI #5 replied, "Yes, all hair should be covered." EI #5 was asked what the potential harm was of all hair not being covered while working in the kitchen. EI #5 replied, "If not covered, hair could fall in the food and the resident could eat it in the food." An interview was conducted with EI #6, a Cook, on 4/16/2015 at 1:25 PM. EI #6 was asked what the facility's policy was on hair coverings in the kitchen. EI #6 replied, "All your hair has to be completely covered with none hanging." EI #6 was asked why, and she replied, "Because it could get in the food and cause cross-contamination." EI #6 was asked what the potential harm was of all hair not being covered while working in the kitchen. EI #6 stated, "It could make someone sick." On 4/16/2015 at 2:48 PM, an interview was conducted with EI #4, the Dietary Manager. EI #4 was asked what the facility's policy was on hair coverings in the kitchen. EI #4 stated, "A bonnet should cover your entire hair." EI #4 was asked if all hair should be covered while working in the kitchen. EI #4 replied, "Yes, because we don't want any hair getting in the food." EI #4 was asked what the potential harm was of all hair not being covered while working in the kitchen. EI #4 stated, "It could get in the food and cause someone to get sick or some other illness." 2) A review of the 2013 U. S. Public Health Service Food Code revealed, "... Jewelry 2-303.11 Prohibition. Except for a plain ring such as a wedding band, while preparing FOOD, FOOD EMPLOYEES may not wear jewelry including medical information jewelry..." On 4/15/2015 at 10:37 AM, EI #3, the Assistant Dietary Manager, was observed assisting EI #4, the Dietary Manager, with mixing ground beef. EI #3 was observed with a silver, diamond stud earring that was approximately one-half centimeter in size in her right ear, and uncovered by her bonnet. On 4/15/2015 at 10:37 AM, EI #5, a Cook, was observed with a black and silver watch on her right wrist. During the interview on 4/16/2015 at 1:00 PM, EI #5 was asked what the facility's policy was on jewelry in the kitchen. EI #5 replied, "You're not supposed to wear no watch, necklace, big stud earrings or bracelets; just your wedding band." EI #5 was asked what the potential harm was of wearing earrings uncovered, or a watch in the kitchen. EI #5 stated, "They could fall in the food. You may not know (it) and the resident could eat or swallow it. For watches, it could break a loose, the silver pin could fall out and you wouldn't know it." On 4/16/2015 at 2:02 PM, an interview was conducted with EI #3, the Assistant Dietary Manager. EI #3 was asked what the facility's policy was on jewelry in the kitchen. EI #3 stated, "Only a wedding band, no watches. You can wear stud earrings, but none bigger than a dime. If wearing stud earrings, they should be covered with your bonnet." EI #3 was asked what the potential harm was of wearing earrings uncovered, or a watch while working in the kitchen. EI #3 replied, "With earrings uncovered, you could lose the back off the earring and it could fall in the food and the resident could swallow it. With a watch, cross-contamination if the watch band touches a food item." An interview was conducted with EI #4, the Dietary Manager, on 4/16/2015 at 2:48 PM. EI #4 was asked what the facility's policy was on jewelry in the kitchen. EI #4 replied, "One ring is accepted and stud earrings have been accepted." EI #4 was asked what the potential harm was of wearing earrings uncovered, or a watch in the kitchen. EI #4 stated, "Uncovered earrings could come off and fall into the food and cause cross-contamination. With the watch, there's no way of knowing where it's been and could come in contact with the food." 3) A review of the 2013 U. S. Public Health Service Food Code revealed, " ...6-501.14 Cleaning Ventilation Systems, Nuisance and Discharge Prohibition. (A) Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt, and other materials. ..." The following observations were made of the vent hood over the stove: During the tour of the kitchen on 4/14/2015 at 2:25 PM, a moderate amount of a build-up of a yellow substance was observed on the vent hood over the stove. EI #4, the Dietary Manager, informed the surveyor the substance was, "From an accident with a pop-top from a soup can that exploded." She further stated that it had happened over the weekend. A black substance was also observed on the slats of the vent hood. On 4/15/2015 at 8:28 AM, a yellow/ tan colored substance was still observed on the vent hood over the stove, along with the black, dust-like substance on the slats of the vent hood. During the interview with EI #3, the Assistant Dietary Manager, on 4/16/2015 at 2:02 PM, she was asked how often the vent hood over the stove was cleaned. EI #3 stated the vent hood was cleaned once a month, and was last cleaned last month by a named company. EI #3 was asked what was observed on the vent hood on 4/15/15. EI #3 replied, "Some soup had exploded over the weekend (Chicken Noodle Soup), and some build up of grease and dust." EI #3 was asked what the potential harm was of the yellow and black substances on the vent hood over the stove. EI #3 stated, "Once moisture hits it, it could drip into the food and cause cross-contamination, also with the dust particles." On 4/16/2015 during the interview at 2:48 PM, EI #4 was asked when the vent hood over the stove was last cleaned. EI #4 stated she didn't know what the date was and that someone else kept up with the dates. She went on to say another Dietary staff member had cleaned the vent hood on yesterday, 4/15/15. EI #4 was asked what was observed on the vent hood during the tour on 4/14/15, and on 4/15/15. EI #4 replied, "Dried Chicken Noodle Soup." EI #4 was asked what the potential harm was of the yellow and black substances on the vent hood over the stove. EI #4 stated, "It could have loosened and fallen into food items cooked on the stove." 4) A review of the manufacturer's guidelines for Vanilla Sugar Free Mighty Shakes revealed, "... Storage Conditions: KEEP FROZEN Unopened Shelf Life: 15 months Storage After Open: Refrigerated Shelf Life After Open: Up to 14 days @ (at) 34 (symbol for degrees)-40 (symbol for degrees)..." During the tour of the kitchen on 4/14/2015 at 2:43 PM, 27 cartons of Vanilla Sugar Free Mighty Shakes were observed in the walk-in cooler, thawed, and without thaw dates. EI #4, the Dietary Manager, informed the surveyor the thaw dates were unknown. During the interview on 4/16/2015 at 2:02 PM, EI #3 was asked what the policy was on dating Mighty Shakes. EI #3 replied, "You date them when they first come in, then put a thaw date on them. After the thaw dates, they are good for 7 days, I think." EI #3 was asked what the potential harm was of not dating Mighty Shakes when they were thawed. EI #3 stated, "You wouldn't know how long they have been in there and you could give one to someone that was sour." During the interview on 4/16/2015 at 2:48 PM, EI #4, the Dietary Manager, was asked what the policy was on dating Mighty Shakes. EI #4 stated, "They should be dated for the day they come in. After they are pulled from the freezer, they should have a thaw date. Once thawed, they are good for 14 days." EI #4 was asked when were the 27 cartons of Vanilla Mighty Shakes observed during the tour on 4/14/15 thawed. EI #4 replied, "I know they were thawed last week, but they didn't have a date on them, so I couldn't prove that." EI #4 was asked what the potential harm was of not dating Mighty Shakes when they were thawed. EI #4 replied, "They could possibly be outdated." 5) A review of the manufacturer's operation specifications for the dish machine used by the facility dated October, 1998, revealed, "...OPERATION Follow the procedure below to operate your dishwasher properly. ... 5. When tanks are full, check wash tank temperature gauge. Minimum wash temperatures are ...160 (symbol for degrees) F (Fahrenheit)/71 (symbol for degrees) C (Celsius) ...8. Check the rinse pressure and temperature as the racks pass through the final rinse. ... the final rinse temperature MUST be 180 (symbol for degrees) F/82 (symbol for degrees) C minimum. ..." On 4/15/2015 at 8:50 AM, during an observation of dishwashing using the dish machine, EI #16, a Tray Aide, was observed spraying and loading dishes into the dish machine. EI #2, a Tray Aide, was observed removing dishes from the dish machine. EI #16 placed a rack with trays into the dish machine. The temperatures for the wash cycle was observed to be 142 degrees F, and the rinse was observed to reach 170 degrees F. The surveyor asked what the temperatures for the wash and rinse cycles should be. EI #2 stated, "Wash should be 160 degrees and rinse 180 degrees." Neither of the Dietary staff observed the temperatures of the dish machine during the wash and rinse cycles. The surveyor asked EI #2 how they monitored temperatures for the dish machine, and she stated, "Normally we look at (the) gauges, and the wash to 160 degrees and rinse 180 degrees." EI #16 placed a rack with plates into the dish machine. The wash cycle temp only reached 138 degrees F, and the rinse cycle only reached 159 degrees F. EI #16 then placed a rack with bowls in to the dish machine. The wash and rinse temps were observed to be 130 degrees and 152 degrees, respectively. EI #2 removed the bowls and placed them on a shelf to air dry. EI #16 placed a flat rack with silverware into the dish machine. The temperatures were observed to be 128 degrees F for the wash cycle, and 148 degrees for the rinse cycle. An interview was conducted with EI #2 on 4/16/2015 at 1:29 PM. EI #2 was asked how often should staff monitor the gauges on the dish machine during use and why. EI #2 replied, "Normally the person pulling the dishes from the dish machine takes the temp and write it on the log sheet. You do this 3 times a day with breakfast, lunch and supper." EI #2 was asked if they looked at the gauges at any other times during the day when washing the dishes. EI #2 stated, "If I'm pulling, I'll check it about every 15 minutes, or if it catch my eye. Normally everybody is supposed to watch, but if you are washing the dishes, you are really busy trying to keep the dishes moving and the machine on." EI #2 was asked what the potential harm was of not monitoring the temperature gauges during use of the dish machine. EI #2 replied, "The dishes may not be clean. If the temps are right, the plates are really hot and you can barely pick them up." EI #2 was asked what the potential harm was of inadequate temps during dishwashing. EI#2 stated, "They (dishes) will still be nasty, pretty much. They may look clean, but they will still be nasty." EI #2 was asked what happened yesterday, during the dishwashing observation. EI #2 replied, "Normally if we keep it (dish machine) going, it stays at the right temp. Yesterday, it just wouldn't get to the right temp." An interview was conducted with EI #3, the Assistant Dietary Manager, on 4/16/2015 at 2:02 PM. EI #3 was asked how often should staff monitor the gauges on the dish machine during use, and why. EI #3 stated, "They should monitor at least 3 times (a day), at breakfast, lunch and dinner. While doing the dishes, at least every 5 minutes to see what the temp is. They may not do it, but it should be done to make sure we are keeping accurate temps." EI #3 was asked what the potential harm was of not monitoring the temperature gauges during use of the dish machine. EI #3 replied, "You could be putting up dishes that are nasty. Cross-contamination because (the) water was not at the accurate temp." EI #3 was asked what the potential harm was of inadequate temps during dishwashing. EI #3 stated, "Wash temp and rinse temp not hot enough to kill the bacteria, and serving food on/in dishes to patients that are not clean." During the interview on 4/16/2015 at 2:02 PM, EI #4, the Dietary Manager, was asked how often staff should monitor the gauges on the dish machine during use, and why. EI #4 replied, "We generally do it once during the dishwashing cycle, but we should monitor more often." EI #4 was asked what the potential harm was of not monitoring the temperature gauges during use of the dish machine. EI #4 stated, "What happened yesterday. The temperatures may fall and we could be using dishes that are not sanitized." EI #4 was asked what the potential harm was of inadequate temps during dishwashing. EI #4 replied, "Residents may get sick from something that was not sanitized properly." 6) A review of the facility's policy titled, "Refrigerator/Freezer Temperatures," dated 2011 revealed, "Guideline: In order to ensure all perishable food stuff stays fresh and palatable, temperatures will be recorded on all refrigerators and freezers in use, including unit refrigerators in nourishment rooms. ... 2. Each refrigeration and freezer unit in the main kitchen is checked at department opening and before any food product is used for the day. ... Temperatures are taken from the thermometer located inside the unit. ..." During the tour of the facility on 4/14/2015 at 2:52 PM, there was not a thermometer observed inside the walk-in freezer. An interview was conducted with EI #3, the Assistant Dietary Manager, on 4/16/2015 at 2:02 PM. EI #3 was asked what the facility's policy was of thermometers inside the freezers and coolers. EI #3 stated, "We're always supposed to have one inside the freezer and cooler ..." EI #3 was asked why a thermometer was needed inside the freezer or cooler, and she replied, "To make sure the temps are correct." During the interview on 4/16/2015 at 2:48 PM, EI #4, the Dietary Manager, was asked what the facility's policy was of thermometers inside the freezers and coolers. EI #4 replied, "There should be one inside all freezers and coolers." EI #4 was asked why a thermometer was needed inside the freezer or cooler, and she stated, "To ensure the equipment is working properly." EI #4 was asked why a thermometer was not observed in the walk-in freezer during the tour of the kitchen on 4/14/15. EI #4 replied, "That was an oversight." 7) A review of the facility's policy dated 2011 and titled, "Labeling/Dating Foods(Date Marking)," revealed, "Guideline: All foods stored will be properly labeled according to the following guidelines. Procedure: ... 2. Date marking for refrigerated storage food items ... * Once a case is opened, the individual, refrigerated food items are dated with the date the item was received into the facility and placed in/on the proper storage location utilizing the "first in-first out" method of rotation. * Once opened, all ready to eat potentially hazardous food will be re-dated with a use by date according to current safe food storage guidelines or by the manufacturer's expiration date. 3. Date marking for freezer storage items ... * Frozen food packages removed from the case will be dated with the date the item was received into the facility and will be stored using the "first in-first out" method of rotation. * Once a package is opened, it will be re-dated with the date the item was opened and shall be used by the safe food storage guidelines or by the manufacturer's expiration date. 4. Prepared food or opened food items should be discarded when: * The food item does not have a specific manufacturer expiration date and has been refrigerated for 7 days ... 5. Freezing stops the date marking clock. ... The freezing date and the thawing date must be clearly labeled on the container. ..." On 4/14/2015 at 2:52 PM, "Bacon Bits," were observed inside the walk-in freezer in a zip locked plastic bag. The Bacon Bits were soft to touch, and, "Not Frozen," per EI #4, the Dietary Manager. The bag was labeled, "Bacon Bits 3-26-15." No other date was observed on the plastic bag. On 4/15/2015 at 8:28 AM, a plastic Ziploc bag, labeled "Bacon Bits 3-26-15, was observed inside the walk-in freezer. A second bag was also observed as labeled, "Bacon Bits 4-10-15." No other dates were observed on the bags. During the interview on 4/16/2015 at 2:02 PM, EI #3, the Assistant Dietary Manager, was asked if the bags with the Bacon Bits were properly labeled. EI #3 replied, "No, because it should have had the date it came in and the date it was opened. It should have had 2 dates on it." EI #3 was asked how long Bacon Bits could be kept, once opened. EI #3 stated, "It depends on the manufacturer's date. It will say use by a certain date. If that date is not on the bag, you wouldn't know when it needed to be discarded." During the interview on 4/16/2015 at 2:48 PM, EI #4, the Dietary Manager, was asked what did the dates that were observed on the Bacon Bits bags indicate. EI #4 replied, "The date they were opened." EI #4 was asked how long the Bacon Bits were good after they were opened. EI #4 replied, "I don't know."

Based on observations, interviews, and document reviews, the facility failed to ensure dietary staff: 1) Knew how to accurately calibrate thermometers used to test tray line food temperatures; 2) Were knowledgeable of appropriate temperatures of food items on the tray line and temperatures for reheated food items during the trayline observation; and 3) Were knowledgeable of the appropriate number of times food items could be reheated. These deficient practices were observed on 1 of 3 survey days, and had the potential to affect 135 residents served meals from the kitchen. Findings include: A review of the facility's policy dated 2011 and titled, "Monitoring Food Temperatures for Meal Service," revealed, "Guideline: Food temperatures will be monitored daily to prevent food borne illness and ensure foods are served at palatable temperatures. Procedure: 1. Prior to serving a meal, food temperatures will be taken and documented for all hot and cold foods to ensure proper serving temperature. Any food item not found at the correct holding/serving temperature will not be served but will undergo the appropriate corrective action listed below. ... 3. Proper procedures are followed to ensure that food temperatures are accurately and safely obtained according to safe food handling practices. These procedures include the following steps: a. A properly functioning and calibrated thermometer will be used when taking temperatures (manufacturer's directions and/or manual guidelines are followed for calibrating thermometers at least monthly). ... 4. If the serving/holding temperature of a hot foot item is not at least 135 (symbol for degrees) F(Fahrenheit) or higher ...when checked prior to meal service, the item will be reheated to at least 165 (symbol for degrees) F for a minimum of 15 seconds. The item may be reheated only once ..." 1) On 4/15/2015 at 10:42 AM, the surveyor asked EI #5, a Cook, to calibrate the thermometer prior to checking the temps (temperatures) of the food items. During the calibration of the thermometer, EI #5 placed the thermometer in a glass with ice and water. The temp was observed to be 0 degrees F on the thermometer. EI #5 got a second thermometer, and during calibration, this thermometer was also observed to read 0 degrees F when placed in the ice water. The surveyor asked EI #6, a Cook, what the temperature of the thermometer should read during calibration, and she stated, "30 degrees." EI #5 informed the surveyor, "I didn't know it (thermometer gauge) turned." The surveyor asked what temperature the food items on the tray line should be, and EI #5 stated, "Food temps should be 139 degrees." EI #4, the Dietary Manager, calibrated the thermometer at this time. On 4/16/2015 at 12:50 PM, EI #5 was asked how often training was done on checking food temps on the tray line and calibrating thermometers. EI #5 replied, "Once a week." EI #5 was asked who provided the training, and she stated, "(EI #4-DM)." EI #5 was asked what had she been trained regarding calibrating thermometers. EI #5 replied, "To put water and ice in a glass and turn the dial on (the) thermometer to 32 degrees. She taught me that yesterday after you called for her, and I remembered." On 4/16/2015 at 1:10 PM, an interview was conducted with EI #6. EI #6 was asked how often training was done on checking food temps on the trayline, and she stated, "Usually once a month." EI #6 was asked how often training was done on calibrating thermometers. EI #6 stated, "Every time someone new starts, everybody is retrained to make sure they know how to calibrate them." EI #6 was asked who provided the training, and she stated, "The supervisor, (EI #4), and the Dietitian ..." EI #6 was asked what had she been trained regarding calibrating thermometers. EI #6 replied, "To calibrate once a week, or if you drop the thermometer, to re-calibrate it. It's supposed to be on 32 degrees. Yesterday, I said 30 degrees, but you made me nervous and I knew it wasn't that." On 4/16/2015 at 2:40 PM, EI #4, the Dietary Manager was interviewed. EI #4 was asked how often training was done on checking food temps on the tray line. EI #4 stated, "Informally daily. It's an ongoing process. Formally, we try to have an in-service at least once a month. This is also informally, but we try to get everyone together and seated for them to listen and not be working at the time." EI #4 was asked who provided the training and she stated, "Myself, or (EI #3, the Assistant Dietary Manager) or our Registered Dietitian." EI #4 was asked what the staff was trained regarding calibrating thermometers. EI #4 replied, "They need to fill a cup with ice, add water. Place the thermometer in the ice/water and set the dial to 32 degrees." 2) and 3) During the tray line observation on 4/15/2015 at 10:54 AM, baked un-breaded livers were observed at a temperature of 102 degrees F and were replaced back into the oven. On 4/15/2015 at 11:25 AM, the livers were removed and observed to be 110 degrees F at this time. EI #5 plated some of the livers at this time but was interrupted by the surveyor. The livers were put on top of the stove this time and covered. On 4/16/2015 at 11:30 AM, the livers were observed to be at a temperature of 138 degrees F. The surveyor interrupted EI #3, the Assistant Dietary Manager, prior to her placing the livers on the tray line, and asked her what the concern was with the livers. EI #3 stated, "Reheated twice and reheated temp should have been 165 degrees." During the interview on 4/16/2015 at 12:50 PM, the surveyor asked EI #5, a Cook, what she had been trained in regards to reheating food items. EI #5 stated, "If it's not at the right temp, you reheat it a second time. If it's not at 165 degrees, you can't use it. We were taught this yesterday, after you were in the kitchen." During the interview on 4/16/2015 at 1:10 PM, EI #6, a Cook, was asked what she had been trained in regards to reheating food items. EI #6 replied, "When reheating food, it's got to reach 165 degrees the first time you reheat it, for 15 seconds. If not 165 degrees, you have to throw it out ..."

Based on interviews, record review, and observation, the facility failed to ensure the brakes on the wheels of Resident Identifier (RI) #1's bed were functioning properly to prevent it from rolling/moving. Interviews with facility staff revealed it had been reported to A Licensed Practical Nurse, Employee Identifier (EI) #2, that the brakes on the wheels of RI #1's bed had not been functioning properly. EI #2 failed to report to maintenance staff the problem with RI #1's brakes not functioning properly, and there were no corrective measures put in place to prevent an accident from occurring. A Certified Nursing Assistant (CNA), EI #1, stated she turned and repositioned RI #1to the right side of the bed on 07/17/2011. EI #1stated when she turned the resident the bed " ...rolled away ... " causing the resident to fall out of the bed onto the floor. RI #1 sustained four centimeter (cm) laceration (A jagged wound or cut) to the left side of her forehead above her left eyebrow. According to the facility's documents, RI #1 sustained a laceration to the left of her forehead above the left eyebrow. RI #1 was sent out to the local emergency room (ER) for medical treatment. RI #1 ' s laceration was glued and RI #1 was sent back to the facility with instructions to keep the area dry for 72 hours. One of three sampled residents with falls, RI #1, was affected by this deficient practice. Findings Included: RI #1 was originally admitted to the facility on [DATE], and readmitted [DATE], with [DIAGNOSES REDACTED]. A review of RI #1's medical record revealed a Quarterly Minimum Data Set (MDS) with an assessment reference date of 5/1/2010, which revealed a BIMS (Brief Interview for Mental Status)score of 3. According to "CMS's RAI (Resident Assessment Instrument) Version 3.0 Manual, page C-14, a score of 0 - 7 indicates a resident has a severe impairment. In Section G - Functional Status, RI #1 was assessed as being totally dependent for bed mobility and required one person to physically assist her with bed mobility. Also, RI #1 was totally dependent on the facility staff for dressing, eating, toilet use, personal hygiene and bathing and was identified to be totally incontinent of bowel and bladder. The "Occurrence Investigation Report " dated 7/17/11 at 9:12 AM states, " ...CNA was performing a.m. care & when turing resident he be shifted causing resident to fall to floor. 4cm Laceration noted to head above (L) eyebrow ... Were there any environment issues that contributed to the event? Equipment Malfunction ... Summary of corrective action taken to prevent a reoccurrence: Maintaince (Maintenance) notified of improper bed locks ... Wheels were taken off of bed ... Additional Comments: Resident's bed changed & Maintence (Maintenance) to take off wheels from bed. Only injury was laceration to side of left eye. CT (Computed Tomography) of head Negative. Nero (Neurological) checks to be done. " Nurses Notes dated 7/17/11 at 9:12 a.m., documented: "Summoned to room by CNA. Resident lying on floor @ (at) bedside. CNA stated, 'when I turned her the bed rolled away.' Resident lying on L (left side). Laceration noted to head just above L eyebrow. Ice applied. Supervisor was notified. Resident with eyes open BP (blood pressure) 130/80, R (respirations) 20 & (and) unlabored. 9:35 a.m., Sponsor & 2nd (second) contact notified & phone call to 911 to request transportation as ordered. 9:47 a.m. (name of city) Firemedic here to transport resident. Resident opens eyes to command. No change in level of consciousness noted. 11:07 a.m., Phone call from (name of hospital) report given by (name of person) stated, 'Laceration above L eye was glued & do not get wet for 72 hours. 11:20 a.m., Phone call to Dr. (name) and condition report given. 11:40 a.m. Returned to room via (by way of) stretcher. Eyes open. In bed siderails up T (temperature) 98.2 -(degrees Fahrenheit) - P (pulse) 89 R (respirations) 20 b/p 174/87. Pupils equal & react to light. No nausea or vomiting noted. Family members @t bedside." On 7/26/11 at 1:50 p.m., the surveyor conducted an interview with EI #4, the primary CNA assigned to take care of RI #1 on 7/17/11. EI #4 said she was. However, they (the facility) had an extra CNA working that day which was EI #1, the CNA assigned to give RI #1 a bath on 7/17/11, on the 7 a.m. - 3 p.m. shift. EI #4 said she was bathing the roommate of RI #1 when she heard (EI #1) hollering for help. EI #4 said she immediately stopped what she was doing and went over to the other side of the room to see what was going on. EI #4 said (RI #1) had fallen out of bed on the floor. EI #4 said (RI #1) was between the curtains and the two beds. EI #4 said the curtains were pulled when all of this happened. The surveyor asked EI #4 what did EI #1 say happened? EI #4 said EI #1 told her that she was taking off RI #1's top and the side rails were down. (EI #1) said she was pulling RI #1 toward her with the bed pad and the bed started moving toward the door and RI #1 fell out of the bed. The surveyor asked EI #4 why did the bed that RI #1 was lying in roll? EI #4 said the locks on the wheels were not working properly. The wheels would not lock. There were no brakes on the wheels. The surveyor asked EI #4, since the incident on 7/17/11, what has the facility done to prevent RI #1's bed from rolling? EI #4 said all of the wheels had been taken off of (RI #1's) bed. The surveyor asked EI #4 who did she report the incident to. EI #4 said she reported the incident to (EI #2), a LPN. On 7/27/11 at 9:00 a.m. the surveyor conducted an interview with EI #1, the extra CNA assigned to care for RI #1 on 7/17/11. The surveyor asked EI #1 was she RI #1's primary CNA on 7/17/11, the day the resident fell out of bed? EI #1 stated, "No sir, I was an extra aide that day. (EI #4) was her primary CNA ... I went in the room to bathe (RI #1) ... I let the siderails down to take her (RI #1) left arm out of the shirt because her left arm is contracted. I pulled her (RI #1) over with the pad toward me. Her top part of her body started coming out of the bed. I started trying to get her upper body back on the bed, then the bed started rolling toward the door. I called (EI #4) for help. The curtains were pulled between the two beds and the resident (RI #1) fell out of bed." The surveyor asked EI #1 why was the bed rolling toward the door? EI #1 stated, "There were no brakes, locks on the wheels at all at the time this happened." The surveyor asked EI #1 how did she know there were no brakes on the wheels. EI #1 stated, "I have worked with her (RI #1) before and there were no locks on the wheels. So, I had to push the bed against the dresser toward the door to keep it from rolling." The surveyor asked EI #1 did she report the bed did not have locks / brakes to anyone, i.e. charge nurse, supervisor or maintenance. EI #1 stated, "I remember once before I told (EI #2) LPN, (Licensed Practical Nurse), I told her that." The surveyor asked EI #1 how long the wheels on the bed had not had locks or brakes. EI #1 stated, "I can't answer that because I don't know. The surveyor asked EI #1 what date did she tell EI #2 the wheels did not lock. EI #1 stated, "I don't know. I don't remember the date." The surveyor asked EI #1 after she told EI #2 the wheels did not lock, what did (EI #2) do? EI #1 stated, "Nothing to my recollection because the bed didn't get fixed. There have been times when (EI #2) has helped me turn and position (RI #1) and the bed has moved. I have also helped other CNA's with turning and positioning (RI #1) and the bed has moved ... they (other CNA's) said they have been in RI #1's room and the bed shifted and moved but (RI #1) did not fall out of bed ... this been going on for at less one month, I know for sure. " The surveyor asked EI #1 what has the facility done to prevent a reoccurrence of this accident /incident. EI #1 stated, "They (maintenance) checked the beds and removed the wheels off the bed. Now the bed sits flat on the floor. They made (RI #1) a two person assist with turn, positioning and bathing." The surveyor asked EI #1 did she receive any inservice or training after the accident / incident on 7/17/11, involving RI #1. EI #1 stated, "No sir, but they are doing them now. I was inserviced the next day by the Staff Development Coordinator (EI #5)." The surveyor asked EI #1 had RI #1 or any other residents fallen out of bed recently as a result of the wheels on the bed failing to lock or having no brakes. EI #1 stated, "No, not to my recollection." On 7/27/11 at 10:15 a.m. the surveyor conducted an interview with EI #2, the LPN assigned to care for RI #1 on 7/17/11, during the 7 a.m. - 3 p.m. shift. The surveyor asked EI #2 how did RI #1 fall out of bed on 7/17/11? EI #2 said EI #1 told her she (EI #1) was taking RI #1's clothes off and getting ready to bathe her (RI #1) and the bed rolled toward the door way. EI #2 said when she got in the room (RI #1) was on her left side on the floor and did not have any clothes on. EI #2 said they got a sheet and put it over her RI #1. EI #2 said RI #1 had blood coming from her left eyebrow and EI #2 looked RI #1 over and checked her b/p (blood pressure) & pulse. RI #2 said she applied pressure to the laceration and she told one of the CNA's to go get an ice pack. The surveyor asked EI #2 what caused RI #1 to fall out of bed. EI #2 said the bed moved. The surveyor asked EI #2 why did the bed move or shift? EI #2 said she did not know but later they swapped the bed out for another bed. EI #2 said her supervisor had two housekeepers to swap the bed out. They were trying to get a safer bed, one that would lock. EI #2 said the wheels on the second bed would not stay locked. It would pop up when she locked the wheels. EI #2 said maintenance came in on Sunday and took the wheels off the beds (both beds). The first bed's wheels would not lock, that's why RI #1 fell out of bed. EI #2 said she hadn't. EI #2 said the SDC (EI #5) told her that some CNA's told her (EI #5) they had reported problems with RI #1's bed not locking, or the brakes not working to her (EI #2). EI #2 stated maybe someone told her RI #1's bed would not lock and she forgot it. The surveyor asked EI #2 what have the facility done to prevent a reoccurrence of the incident / accident that occurred with RI #1? EI #2 said they had taken the wheels off the bed and have two (2) staff members to provide care to RI #1 now. EI #2 said she told EI #4 and EI #1 to work over the side rails and not let it down, try to keep the side rail up and not hurt their backs. The surveyor asked EI #2 did the facility conduct any inservices on this incident to implement preventive measures from reoccurring. EI #2 said no, she didn't recall anything being done. The surveyor asked EI #2, prior to the incident involving RI #1, how long had the wheels on RI #1's bed not locked or had brakes? EI #2 said she did not know, she did not know they (the wheels) would not lock. The surveyor informed EI #2 several staff members said they reported to her RI #1's wheels on her bed did not lock. The surveyor asked EI #2 what she did about that. EI #2 said if they told her she wrote it in the maintenance log for repair or told maintenance. EI #2 said she did not remember anyone telling her about RI #1's bed not locking. The surveyor asked EI #2 if she could get a copy of the log record and EI #2 said she would. However, EI #2 failed to provide the surveyor with a copy of the maintenance log record. On 7/28/11 at 11:50 a.m., the surveyor conducted an interview with the SDC, (EI #5). The surveyor asked the SDC what did she know about what happened to RI #1? EI #5 stated, "I was told the CNA (EI #1) was taking (RI #1's) shirt off and the bed moved, it rolled away from her toward the door. The patient (RI #1) stated to roll off the bed and onto the floor. There was a laceration to the resident's forehead." The surveyor asked EI #5 what caused the bed to roll according to EI #1. EI #5 stated, "She (EI #1) said the brakes were not locked on the wheels. (EI #1) said when (RI #1) started to roll off the bed she called for help. She (EI #1) tried to brace (RI #1) to keep her from falling as much as she could." The surveyor asked EI #5 what maintenance said about (RI #1's) bed. EI #5 stated, "The brakes did not work." The surveyor asked EI #5, to her knowledge, how long had the brakes not worked or function properly on RI #1's bed? EI #5 stated, "That was the first time I was aware of it. When I talked to (EI #1) and (EI #4) CNA's, they said they had reported the wheels not locking to EI #2 a while back here." The surveyor asked EI #5 when did the CNA's EI #1 and EI #4 say they reported to EI #2 that RI #1's wheels on her bed did not lock? EI #5 stated, "They (EI #1 and EI #4) did not say when they reported it. But they did report it to EI #2 and the wheels had been without brakes a long time and (EI #2) knew about it." The surveyor asked EI #5 had she inserviced the staff in regards to reporting beds with malfunctioning equipment, wheelchairs, Geri-chairs, bed wheels that do not lock, or siderails that do not lock? EI #5 stated, "Yes sir, but it's on going, I haven't inserviced all of the staff." On 7/27/11 at 3:25 p.m. the surveyor conducted an interview with the Director Of Nursing (DON), EI #3. The surveyor asked EI #3 who is responsible for checking the locks on the wheels of each resident's bed in the facility to ensure they are functioning properly? EI #3stated, "The Administrator can answer that, but I think it's maintenance's responsibility." The surveyor asked EI #3did the facility has a policy about brakes on the beds functioning properly to prevent accidents? EI #3 stated, "No, we don't have a policy like that." The surveyor asked EI #3 why RI #1 ' s bed rolled. EI #3stated, "Because there were not any brakes on the wheels of the bed." The surveyor asked EI #3why were there not any brakes on the wheels of the bed of RI #1? EI #3stated, "I don't know." On 8/1/11 at 8:52 a.m. the surveyor conducted a phone interview with a maintenance staff member, EI #6. The surveyor asked EI #6 who was the nurse that called him on 7/17/11, when RI #1 fell out of bed due to the wheels/brakes not functioning properly? EI #6 stated, "It was the head nurse, I don't know her name." The surveyor asked EI #6 what the nurse told him. EI #6 stated, "She (the head nurse) said that I needed to come in and check the brakes on a patient's bed. I believe this was on a Sunday, 7/17/11. I was on call that weekend." The surveyor asked EI #6 what happen when he got to the facility and checked the brakes on (RI #1's) bed on 7/17/11? EI #6 stated, "The brakes were not working on her bed. So we replaced that bed with another bed. Then we found out the brakes did not work on that bed. So all of the wheels were taken off the bed. The first bed we removed the wheels and nursing put her back in that bed." The surveyor asked EI #6 was it safe to place RI #1 back in the same bed? EI #6 stated, "Yes, there were no wheels on it and the bed would not move." The surveyor asked EI #6 when he said it (the bed) would not move, did he mean it would not roll if pushed against by staff? EI #6 stated, "Yes." EI #6 stated, "We (maintenance staff) went around and checked the nursing home and checked every bed. If we found a bed that the brakes did not work, we corrected it by removing the wheels and the bed will not move at all." The surveyor asked EI #6 how often will maintenance or whoever is designated to check the beds do this. EI #6 stated, "I believe we are going to check the beds once every month. The nursing staff is suppose to write in the maintenance log if the brakes don't work or if there is any problems we need to fix. But the maintenance staff will continue every month to check all the beds for any problems or other repairs needed." This deficiency was written as a result of the investigation of complaint #AL 743.