Every finding on record at Cherokee County Health and Rehabilitation Center

Based on observation, interview, record review, recipe review and facility policy review, the facility failed to serve food that was palatable and at an acceptable temperature to four of five residents (Resident (R) 5, R47, R144, and R139) reviewed for food palatability out of 36 sampled residents. This failure had the potential to affect 156 residents who consumed food prepared from the facility's kitchen and could result in residents skipping meals and experiencing weight loss. Findings include:Review of the facility's policy titled, Timely Meal Service, dated 02/05/2024, indicated, Policy: Food will be delivered promptly to ensure safe, palatable, and high-quality food served at the proper temperature. Procedure . 6. Food will be served at preferable temperatures (hot foods hot and cold foods cold) as discerned by the patients/residents and customary practice (not to be confused with proper holding temperatures). Review of the facility's undated policy titled, Standardized Recipes, indicated, Policy: Standardized recipes will be used when preparing menu items. Procedure . 3. Cooks/chefs are expected to use and follow recipes provided.1. Review of R5's undated admission Record, located in the resident's electronic medical record (EMR) under the Profile tab revealed R5 was admitted on [DATE].Review of R5's quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 12/02/2025 and located in the resident's EMR under the MDS tab revealed the facility assessed the resident to have a Brief Interview for Mental Score (BIMS) of nine out of 15 which indicated R5 was moderately cognitively impaired.During an interview on 12/09/2025 at 10:57AM, R5 stated that the hot foods on his/her meal tray tasted cold. He/she stated that he used to be in the last room on the hall, so his/her tray was always served last. He/she stated that now that he/she has moved to the middle of the hallway, the hot foods on his/her meal tray were maybe a little bit warmer.2. Review of R47's admission Record located in the resident's EMR under the Profile tab revealed R47 was admitted on [DATE]. Review of R47's quarterly MDS with an ARD of 11/04/2025 and located in the resident's EMR under the MDS tab revealed the facility assessed the resident to have a BIMS score of 14 out of 15 which indicated R47 was cognitively intact.During an interview on 12/09/2025 at 9:40 AM, R47 stated that the hot foods on his/her meal tray tasted lukewarm.3. Review of R144's undated admission Record located in the resident's EMR under the Profile tab revealed R144 was admitted on [DATE].Review of R144's quarterly MDS with an ARD of 11/25/2025 revealed the facility assessed the resident to have a BIMS score of 13 out of 15 which indicated R144 was cognitively intact.During an interview on 12/09/2025 at 10:07 AM, R144 stated that the food on his/her meal tray did not taste good and that the hot foods on the tray tasted cold.4. Review of R139's admission Record located in the resident's EMR under the Profile tab revealed R139 was admitted on [DATE].Review of R139's quarterly MDS with an ARD of 11/04/2025 and located in the resident's EMR under the MDS tab revealed the facility assessed the resident to have a BIMS score of 15 out of 15 which indicated R139 was cognitively intact.During an interview on 12/08/2025 at 10:56 AM, R139 stated the hot foods on his/her meal tray do not taste hot. R139 stated the meatloaf and squash served last night tasted like they were raw. The resident also stated the food did not have any seasoning.Review of the facility's monthly Resident Council Meeting minutes, provided by the facility, revealed the following food palatability concerns:During the 11/18/2025 meeting a resident voiced a concern that the fish served was tough. The dietary department's follow-up plans for this concern were, Spoke with cooks on cooking times.During the 06/24/2025 meeting a resident voiced a concern that the food was too salty. The dietary department's follow-up plans for this concern were, Making sure recipes are followed.4. Observation on 12/10/2025 at 12:16 PM revealed a requested test tray was placed in an enclosed meal delivery cart for the 300 and 500 hallways. Food temperatures on the kitchen tray line were monitored and were at acceptable levels of 135 degrees Fahrenheit (F) and above for the hot foods and 41 degrees F and below for cold foods. The food was placed on heated plates prior to being placed in the enclosed meal delivery cart. At 12:52 PM, the last resident meal was delivered. After the last resident meal was delivered, the test tray was removed from the enclosed delivery cart in the presence of the Dietary Manager (DM). Continued observation revealed the DM used a calibrated facility thermometer, obtained the temperatures of the food on the test tray, and tasted one of the food items. The chicken alfredo spinach flatbread on the test tray registered at 134.2 degrees F. This writer tasted the chicken alfredo spinach flatbread and had no concern with the temperature; however, it was very spicy. The DM also tasted the flatbread and stated it was spicy. The temperature of the [NAME] salad on the test tray, which contained feta cheese, was 63.0 degrees F. This writer tasted the salad, and it tasted warm. The DM declined to taste the salad; however, he/she stated it was his/her expectation salads be served to residents at a temperature of 50 degrees F or lower. The DM stated the temperature of the salad was too high.Review of the facility's recipe titled, Chicken Spinach [NAME] Flatbread, provided by the facility, revealed the ingredients used to prepare this menu item included baby spinach, flatbread, alfredo mix sauce, roasted chicken breast chopped into bite size pieces, and mozzarella cheese.During an interview on 12/10/2025 at 1:30 PM, [NAME] (C)1 stated he/she prepared the chicken spinach alfredo flatbread that was served during the 12/10/2025 lunch meal. C1 stated when he/she prepared this menu item, he/she used fajita chicken strips not roasted chicken breast as specified in the recipe. C1 also stated he/she added pepper, onion powder, garlic powder, and salt to the alfredo sauce mix, and added pepper, salt and garlic powder to the chicken fajita strips. These added seasonings were not listed on the recipe for this menu items. C1 confirmed he/she did not follow the recipe when preparing the chicken spinach alfredo flatbread. During an interview on 12/10/25 at 1:45 PM, the DM confirmed C1 did not follow the recipe when preparing the chicken spinach alfredo flatbread that was served during the 12/10/2025 lunch meal. The DM stated the staff were expected to follow recipes when preparing menu items.

Based on observation, interview, and facility policy review, the facility failed to ensure two kitchen ovens, and two kitchen drawers' housing food preparation and service equipment were kept clean. Additionally, the facility failed to ensure food was stored off the floor and failed to label, date, and cover stored food. These failures had the potential to create an environment for food-borne illnesses which could affect 156 residents who consumed food prepared from the facility's kitchen.Findings include:Review of the facility's policy titled, Dietary Cleaning and Sanitizing Dietary Areas and Equipment, revised on 03/29/2010, indicated, Policy: All kitchen areas and equipment shall be maintained is [sic] a sanitary manner and be free of build-up of food grease or other soil. The facility will provide a sanitary foodservice that meets State and Federal regulations.Review of the facility's undated policy titled, Cleaning Instructions: Ovens, indicated, Policy: Ovens will be cleaned as needed and according to the cleaning schedule (at least one every two weeks). Spills and food particles will be removed after each use.Review of the facility's titled, Dietary Food Storage, revised on 09/15/2015, indicated, Policy: Sufficient storage facilities are provided to keep food safe, wholesome and appetizing. Food is stored, prepared and transported at an appropriate temperature and by methods designed to prevent contamination. Procedures: . 13. Food is stored a minimum of six (6) inches above the floor on clean racks, dollies or other clean surfaces, and is protected from splash, overhead pipes or other contaminations . 16. Refrigerated packaged foods that have not been completely used can be stored up to seven (7) days, and then must be discarded. Items will be dated with the date received, date opened, and date seven (7) days after opening. If item is placed in another container, it must also be clearly and accurately labeled.1. Observation on 12/08/2025 from 11:35 AM to 11:55 AM with the Dietary Manager (DM), during the initial kitchen inspection revealed the interior cooking compartments and doors of the kitchen's two convection ovens were unclean with a heavy accumulation of dried and burned food spills, grease, and debris. Additionally, the inner storage compartments of two kitchen drawers which had food preparation and service equipment stored in them including serving scoops, serving spoons, scissors, metal ice/food scoops, and thermometers were unclean with dried substances and loose food debris. Continued observation revealed the kitchen's walk-in refrigerator contained a box of sausage patties that were stored uncovered, open to air and was not protected from possible contamination. Also, cheese slices that had been removed from their original packaging were stored in an undated and unlabeled container. Observation of the kitchen's walk-in freezer revealed a box of bread sticks, a box of dinner rolls, a box of cheese omelets, and a box of churros were all stored directly on the freezer floor. During an interview on 12/08/2025 at 11:55 AM, the DM confirmed the observations. The DM stated the ovens and drawers should be cleaned each week and as needed. The DM also stated when staff placed food into storage, the food should be completely covered, dated, labeled, and stored off the floor.

Based on record review, interview, and policy review, the facility failed to ensure the resident and resident representative (RP) received a written notice of transfer that included all required information for two of three residents (Resident (R) 6 and R60) reviewed for facility initiated emergent transfer to the hospital out of 36 sampled residents. In addition, the transfer notice document did not identify the specific reason the resident was being transferred to the hospital. This failure had the potential to affect the resident and/or RP not having the knowledge of where and why a resident was transferred.This was cited as a result of the investigation of complaint #474077.Findings include:Review of the facility's policy titled Transfer and Discharge including Against Medical Advice (AMA) dated 03/16/2025 indicated, .3. The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: a. The specific reason and basis for transfer or discharge.10. Emergency Transfer to Acute Care. G. Provide a notice of transfer.to the resident and representative. 1. Review of R6's admission Record located in the resident's electronic medical record (EMR) under the Profile tab revealed R6s was admitted to the facility on [DATE]. Review of R6's Progress Note, dated 12/08/2025 and located in the resident's EMR under the Progress Notes tab revealed on 12/08/2025 at 3:44 PM, R6's skin was red, blotchy, and the resident was itching all over. The resident also had some audible wheezing at this time. The resident's physician ordered the resident to be sent to the hospital emergency room (ER). Emergency Medical Service (EMS) arrived at approximately 8:00 PM and transported the resident to the hospital. Further review of R6's Progress Notes revealed no documentation that the resident and the RP were provided with the written transfer notice. During an interview on 12/09/2025 at 4:30 PM, the facility's Bookkeeper stated that nursing sends the documents with the resident to the hospital. He/she stated that the RP was notified via phone on 09/28/2025. During an interview on 12/09/2025 at 4:59 PM, the Director of Nursing (DON) confirmed that there was no documentation in the EMR that the written transfer notice was provided to the resident and the RP at the time of the transfer to the hospital. Review of R6's Notice of discharge date d 09/28/2025 and provided by the DON revealed that there was no documentation on the document that the resident and RP received the written transfer notice. The Notice of Discharge document indicated the RP was notified via phone on 09/28/2025. The Notice of Discharge document indicated the reason for transfer was Inability to meet resident's needs instead of the specific reason of experiencing an allergic skin reaction and difficulty breathing. 2. Review of R60's undated admission Record located in the resident's EMR under the Profile tab indicated R60 was admitted to the facility on [DATE]. Review of R60's Progress Note, dated 11/02/2025 and located in the resident's EMR under the Prog [Progress Notes] tab reflected R60 had been transferred to the emergency room (ER) on 11/02/25 for pallor, diaphoresis, lethargy, low blood pressure, and dark malodorous urine. Review of R60's Notice of Discharge, dated 11/02/2025 and provided by the facility, revealed the reason for discharge was Inability to meet resident needs. Discharge notice issued via phone.Copy of notice mailed to[blank] Review of R60's Progress Note, dated 12/03/2025 and located in the resident's EMR under the Prog Notes tab indicated R60 had been transferred to the ER on [DATE] at 1:50 PM for diaphoresis, lethargy, low blood pressure, and complaints of pain to the site of the urinary stent. Review of R60's Notice of Discharge, dated 12/03/2025 and provided by the facility revealed the reason for discharge was Inability to meet resident needs. Discharge notice issued via phone.Copy of notice mailed to [blank]. During the interview on 12/11/2025 at 6:57 PM, the DON stated it was his/her expectation that when a resident was transferred to the hospital, the nurse should document in the EMR Progress Notes that the resident and the RP were given the written transfer notice. The DON confirmed that there was no evidence in the EMR that the residents and the RPs received the written transfer notice for any of the residents who were transferred to the hospital.

Based on record review, interview, review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure an accurate Minimum Data Set (MDS) was submitted to include the correct PASSAR Level II status for two of 36 sampled residents (Resident (R) 10, and R35). The failure to code the MDS correctly could potentially lead to inaccurate federal reimbursements, and inaccurate assessment and care planning of the residents.Findings include:Review of the facility's policy titled, Resident Assessment - Coordination with PASARR Program, revised 11/28/17, indicated Recommendations, such as any specialized services, from a PASARR level II determination and/or PASARR evaluation report will be incorporated into the resident's assessment, care planning, and transitions of care. Review of the RAI manual, dated 10/2024 and located at https://www.cms.gov/files/document/finalmds-30-rai-manual-v1191october2024.pdf, revealed .It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [Interdisciplinary] completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment.When determining the response to items that have a look-back period relating back to the Admission/Entry, Reentry, or Prior OBRA [Omnibus Budget Reconciliation Act] or scheduled PPS [prospective payment system] assessment, whichever is most recent, staff must only consider those assessments that are required to be submitted to iQIES. PPS assessments that are completed for private insurance and Medicare Advantage Plans must not be submitted to iQIES and therefore should not be considered when determining the 'prior assessment.'.Skilled Nursing Facility stays billable to Medicare Part A. Does not include stays billable to Medicare Advantage HMO (Health Management Organizations) plans.Skilled Nursing Facility stays billable to Medicare Part A. Does not include stays billable to other payers (e.g., Medicare Advantage plans) . 1. Review of R10's admission Record located in the resident's electronic medical record (EMR) under the Profile tab indicated the resident was admitted to the facility on [DATE] with diagnoses which included vascular dementia, post-traumatic stress disorder (PTSD), and bipolar disorder. Review of R10's significant change in status MDS located in the resident's EMR under the MDS tab with an Assessment Reference Date (ARD) of 10/10/2025 indicated the resident was unable to complete the Brief Interview for Mental Status (BIMS) and had an assessment of mental status conducted by staff that indicated moderate cognitive impairment. The assessment revealed Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? The facility marked No. Review of R10's PASRR [PASARR] Level II Service Determination, dated 11/07/2025 and located in the resident's EMR under the Misc [miscellaneous] tab revealed R10 had Serious Mental Illness (MI) diagnoses of bipolar disorder and PTSD. 2. Review of R35's admission Record located in the resident's EMR under the Profile tab indicated the resident was admitted to the facility on [DATE] with diagnoses of bipolar disorder, mood disorder, major depressive disorder, anxiety disorder, and panic disorder. Review of R35's annual MDS located in the resident's EMR under the MDS tab with an ARD of 01/28/2025 indicated the resident had a BIMS score of 14 out of 15 which indicated R35 was cognitively intact. The assessment revealed Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? [marked] No. Review of R35's PASRR Level II Service Determination, dated 03/18/2019 and located in the resident's EMR under the Misc tab revealed R35 had serious mental illness (SMI) diagnoses of PTSD, panic disorder, bipolar disorder, major depressive disorder, anxiety disorder, and mood disorder. During an interview on 12/11/2025 at 12:42 PM, the Social Services Director (SSD) reviewed R35's EMR and stated R35 did have a PASSR II. The SSD reviewed R35's annual MDS dated [DATE] and confirmed it was marked NO for PASSR Level II SMI. The SSD stated It should have been marked Yes. It is not accurate. During an interview on 12/11/2025 at 12:56 PM, Social Services Assistant (SSA) 2 reviewed R10's EMR and stated [R10] was admitted with a level I. SSA2 reviewed the PASRR Level II Service Determination form dated 11/07/24 and stated I don't know if it's a PASSR II. I don't know how to read it. SSA2 asked the SSD and stated [R10] is level II according to PASSR II signed [DATE]. SSA2 reviewed the MDS dated [DATE] and stated It was marked No for PASSR II and should have marked Yes. Most likely it was overlooked.

Based on observations, interviews, record review, and facility policy, the facility failed to follow professional standards of practice when a Licensed Practical (LPN) Nurse prepared a resident's medications, and then another nurse administered the medications to the resident. administered medications that he/she did not personally prepare Additionally, the LPN documented on the medication administration record (MAR) the administration of the medications even though the LPN was not the nurse who administered the medications. The deficient practice could result in medication errors.Findings include:Review of the facility's policy titled, Medication Administration, dated 11/2022, revealed Observe the five R's [rights] in giving medications: Resident, Medication, Dosage, Time, and Method / Route of administration. The policy does not specify a strict policy that medications can only be administered by the nurse who prepared them or that the nurse who administered the medications was document the administration in the eMAR. Review of the Alabama Board of Nursing, Administrative Code, Chapter 610-X-6, Standards of Nursing Practice, 610-X-6-.07, dated 11/14/22, revealed The registered nurse or licensed practical nurse shall have applied knowledge of medication administration and safety, including but not limited to: Safety precautions, including but not limited to: Right patient, Right medication, Right time, Right dose, Right route, Right reason, Right documentation. Documentation of medication administration shall comply with the principles of documentation and include safety precautions of medication administration, controlled drug records per federal and state law, and facility policy. During an observation on 12/09/2025 at 9:16 PM of the medication administration being completed by LPN2 revealed the LPN prepared medications to administer to resident (R) 21. LPN2 prepared eight pills in a medication cup and a cup of clear fluid and handed them to Unit Manager (UM) 5. UM5 was standing in front of the medication cart across from LPN2. UM5 entered R21's room and administered the medications to R21. UM5 did not observe LPN2 prepare the medications or verify medications in the cup or the cup of clear fluid. The cup of clear fluid contained polyethylene glycol mixed with water. The pill cup contained nitrofurantoin 100 milligrams (mg), vitamin C 500mg, atorvastatin 40mg, famotidine 20mg, sertraline 100mg, buspirone 7.5mg, memantine 10mg, and propranolol 20mg. LPN2 then asked UM5 if R21 had taken all of the medications. LPN2 then signed off the medications as administered in the electronic medication administration record (eMAR). During an interview on 12/09/2025 at 9:18 PM, LPN2 stated UM5 administered the medications because he/she was helping out due to a time crunch. During an observation on 12/09/2025 at 9:44 PM of the medication administration being completed by LPN2 revealed the LPN prepared medications to administer to R132. LPN2 prepared six pills and an inhaler and handed them to UM5. UM5 was standing in front of the medication cart across from LPN2. UM5 entered R132's room and administered the medications to R132. UM5 did not observe LPN2 prepare the inhaler or verify pills in the cup. LPN2 remained in the hallway at the medication cart. The pill cup contained atorvastatin 10mg, two 5mg tablets of melatonin, fenofibrate 160mg, hydrocodone-acetaminophen 10/325mg, and sucralfate 1gm. The inhaler was Bryna (budesonide/formoterol fumarate) 160mg/4.5 micrograms (mcg) and administered 2 puffs. LPN2 then asked UM5 if R132 had taken all the medications. LPN2 then signed off the medications as administered in the eMAR. During an interview on 12/09/2025 at 9:44 PM, when asked why UM5 administered the medications to R132, LPN2 stated [he/she] don't want this [racial slur] in his/her room. During an interview on 12/10/2025 at 2:59 PM, the Director of Nursing (DON) revealed nurses were expected to administer medications that he/she prepared themselves and not to administer medication prepared by someone else. During an interview on 12/10/2025 at 3:41 PM, the Administrator stated she was not sure if a nurse could hand another nurse a cup of pills to administer to a resident. During an interview on 12/11/25 at 2:45 PM, the Assistant Director of Nursing (ADON) stated nurses could not administer medication if they could not verify all the rights of medication administration.

Based on observation, record review, and interview, the facility failed to honor resident requests to be transferred from the bed to the wheelchair for one of five residents (Resident (R) 7) reviewed for Activities of Daily Living (ADL) assistance out of 36 sampled residents. This failure had the potential for the resident to experience a decline in mobility and increased depression.Findings include:A review of R7's admission Record located in the resident's electronic medical records (EMR) under the Profile tab revealed the resident was admitted to the facility on [DATE] with diagnoses that included stage IV sacral ulcer, klebsiella pneumonia, muscle weakness, and difficulty walking. Review of 7's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/23/2025 and located in the resident's EMR under the MDS tab revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of eleven out of 15 which indicated the resident was moderately cognitively impaired. The resident was dependent on staff for all areas of care and required two plus people for transfers with the aid of mechanical lift. Review of R7's Care Plan located in the resident's EMR under the Care Plan tab revealed the care plan directed staff to encourage the resident to attend activities, peer socialization, utilize a mechanical lift for all transfers, and that the resident preferred to sit in bed or chair. The resident was not care planned for refusal of care/transfers. Review of R7's Physicians Order, dated 08/25/2025 and located in the resident's EMR under the Orders tab revealed the resident was to use the mechanical lift for transfers. Review of R7's Documentation Survey Report, dated for September 2025 and October 2025, provided by Unit Manager (UM) 2 revealed there was not documented evidence the resident had been transferred from the bed to his/her wheelchair via mechanical lift. Continued review revealed no documented evidence that the resident had refused to be transferred from the bed to wheelchair. Review of R7's Activities of Daily Living Sheet, dated November 2025 and located in the resident's EMR under the Tasks tab revealed the resident was dependent on staff for all care needs and did not refuse any cares. Review of R7's Restorative Notes, dated from 11/17/2025 through 12/11/2025 and provided by the Restorative Aide failed to reveal any documentation that he/she had recommended the resident increase his/her strength by occasionally getting out of bed or the resident's refusal of the recommendations. During an interview on 12/08/2025 at 12:45 PM, R7 stated he/she had been in bed since his admission to the facility a few months ago. The resident expressed a desire to be out of bed and in his/her wheelchair Observation on 12/08/2025 at 12:50 PM revealed R7 was sitting in bed with head of bed (HOB) elevated at 45 degrees, bilateral side rails in upright position. Observation on 12/08/2025 at 1:30 PM revealed R7 was in bed in a high position with bilateral side rails up. Observation on 12/09/2025 at 10:00 AM revealed R7 was in bed with bilateral side rails. Observation on 12/09/2025 at 2:23 PM revealed R7 remained in bed positioned on his/her right side with a positioning device facing the door. Observation on 12/10/2025 at 11:56 AM revealed R7 was sitting up in bed with bilateral side rails in place. During a subsequent interview on 12/10/2025 at 11:56 AM, stated he/she was still agreeing to transfer to the wheelchair via mechanical lift for short periods of time so that he/she can use his/her computer in the room. During a follow-up interview on 12/10/25 at 2:00 PM, R7 stated that none of the staff had offered to assist. During an interview on 12/10/2025 at 8:45 AM, Certified Nurse Aide Restorative, Restorative Aide (RA) 1 revealed that he/she provided passive range of motion exercises to the resident twice a week. The RA stated that he/she has encouraged the resident to increase his/her activity by transferring from the bed to the wheelchair with the mechanical lift, but the resident has refused. However, the RA stated that he/she had failed to document the guidance he/she had given the resident about being out of bed and did not document the resident's refusals. During an interview on 12/10/2025 at 10:30 AM, with Student Nurse (SN) 1 stated that he/she had provided care to R7 on 12/09/25 on the day shift. SN1 stated that he/she offered the resident to get up but the resident refused. The SN stated the resident's refusal was not documented. During an interview on 12/11/2025 at 12:35 PM, the Unit Manager (UM) 1 stated the staff should offer to assist the resident with transfers from the bed to the wheelchair via the mechanical lift. The UM stated it was important to encourage the resident to increase his/her mobility to prevent a decline. If the resident refuses any aspect of care such as transfers from bed to wheelchair the staff must document the refusal. UM1 reviewed the resident's activity sheet and realized the staff had not documented any transfer refusals made by R7. UM1 stated he/she was unaware that the resident had requested assistance to get up so that he/she could utilize the computer in his/her room.

Based on record review, interview and policy review, the facility failed to ensure that one of one resident reviewed for restorative services (Resident (R) 5) out of 36 sampled residents, received the restorative care prescribed by physical therapy (PT) and occupational therapy (OT) during the restorative nursing program. This deficient practice had the potential for the resident to experience a decline in physical abilities.Findings include:Review of the facility's policy titled, Restorative Nursing Documentation dated 06/08/2023 indicated, Purpose: The facility maintains complete, accurate, and organized documentation of restorative treatments and the response to those treatments. Policy, 2. Treatment provided as part of a restorative nursing program will be documented on a daily basis.b. if the treatment is refused or withheld, the documentation will reflect the reason for not providing treatment. During an interview on 12/09/2025 at 11:06 AM, R5 stated that he/she went to rehab; however, they spend 55 minutes doing arm and leg exercises but only five minutes letting the resident stand up. R5 stated that he/she wanted to work on standing and pivoting to his/her chair. During an interview on 12/10/2025 at 8:43 AM, the Rehab Director stated that R5 was currently receiving restorative nursing. He/she stated that R5 was discharged from physical therapy (PT) on 09/26/2025 and from occupational therapy (OT) on 09/11/2025. Review of R5's Care Plan located in the resident's electronic medical record (EMR) under the Care Plan tab revealed that R5 was to participate in the restorative program of OT 2x/week x 12 [two times a week for 12 weeks] dated 09/12/2025 and was to receive PT restorative program 2x week x 12 weeks dated 09/29/2025. Interventions indicated to document effectiveness of restorative program and encourage the resident to perform strengthening exercise per PT and OT guidelines. Review of R5's PT Functional Maintenance Program dated 09/26/2025 and provided by the Rehab Director revealed, Restorative would have resident perform seated therapeutic exercised to tolerance with 1-2 [pound] weights. Resident to perform sit to stand transfers x [times] 3 with max assist x 2. Attempt to ambulate to tolerance with RW [rolling walker] and max [maximum] assist x 2 with wheelchair close by. The document indicated the Certified Nurse Aide-Restorative Aide (CNRA) had been instructed in the above maintenance plan with his/her signature and dated 09/30/2025. Review of R5's OT Therapy Maintenance Program dated 09/11/2025 and provided by the Rehab Director revealed, Resident to complete stretching of green/blue theraband 3 x 15 reps [repetitions], resident to complete bending of red/green therapy bar 3 x 20 [reps], resident to complete bicep curls 3 x15 [reps] with 2 pound weights and resident to complete pegboard exercise with wrist weights .5 pound to one pound. The document indicated the CNRA had been instructed in the above maintenance plan with his/her signature and dated 09/12/2025. Review of R5's Restorative Nursing Care assessment dated [DATE] and provided by the CNRA revealed the resident refused to participate; however, there was no documentation as to why the resident refused to participate. Review of R5's Restorative Nursing Care assessment dated [DATE] and provided by the CNRA indicated 25 minutes of Range of Motion (ROM) and 15 minutes of transfer exercises were provided. The note at the bottom of the document indicated R5 stood two times at the handrail and attempted to stand more but was unable to. The assessment further indicated R5 did chest and shoulder, bicep curls with dumbbell, flex bar, chest pulls with theraband, leg kicks, marching and ankle pumps with ankle weights. Review of R5's Restorative Nursing Care assessment dated [DATE] and provided by the CNRA indicated 25 minutes of ROM and 15 minutes of transfer exercises were completed. The note at the bottom of the document indicated R5 stood two times at the handrail. The assessment also indicated the resident completed chest and shoulder exercises, bicep curls with dumbbells, flex bar, peg board, chest pulls with theraband, leg kicks, marching and ankle pumps with ankle weights. Review of R5's Restorative Nursing Care assessment dated [DATE] and provided by the CNRA indicated 25 minutes of ROM and 15 minutes of transfer exercises were completed. The note at the bottom of the document indicated that the resident stood three times at the handrail but was attempted several times, did chest and shoulder exercises, bicep curls with dumbbells, flex bar, chest pulls with theraband, peg board, leg kicks, marching and ankle pumps with ankle weights. Review of R5's Restorative Nursing Care assessment dated [DATE] and provided by the CNRA indicated 25 minutes of ROM and 15 minutes of transfer exercises were completed. The note at the bottom of the document indicated that the resident stood two times at the handrail but was attempted several times, did chest and shoulder, bicep curls with dumbbell, flex bar, chest pulls with theraband, leg kicks, marching and ankle pumps with ankle weights. Review of R5's Restorative Nursing Care assessment dated [DATE] and provided by the CNRA indicated 25 minutes of ROM and 15 minutes of transfer exercises were completed. The note at the bottom of the document indicated that the resident stood two times at the handrail but was attempted several times, did chest and shoulder press, bicep curls with dowel, flex bar, chest pulls with theraband, peg board, leg kicks with ankle weights. Review of R5's Restorative Nursing Care assessment dated [DATE] provided by the CNRA indicated 25 minutes of ROM and 15 minutes of transfer exercises were completed. The note at the bottom of the document indicated that resident stood three times at the handrail but was attempted several times, did chest and shoulder press exercises, bicep curls with dowel, flex bar, chest pulls with theraband, peg board, leg kicks with ankle weights. Review of R5's Restorative Nursing Care assessment dated [DATE] and provided by the CNRA indicated 25 minutes of ROM and 15 minutes of transfer exercises were completed. The note at the bottom of the document indicated resident had doctor's appointment and when the resident returned from the doctor's appointment, he/she told the Certified Nurse Aide (CNA) it was to late for therapy and then he/she went and played BINGO. During an interview on 12/10/2025 at 8:50 AM, CNRA stated that R5 usually came to the restorative program on Tuesdays and Thursdays. During restorative, he/she got arm and leg exercises and if R5 felt strong, he/she tried to stand. During an interview and record review on 12/10/2025 at 1:17 PM, R5's restorative documentation was discussed with the CNRA. Review of the PT and OT Functional Maintenance program specific instructions for R5's restorative nursing revealed that the restorative documentation did not indicate how many repetitions for each exercise was to be completed, what color of TheraBand was used, or what weight of the dumbbell was used. The CNRA confirmed that the restorative documentation did not indicate what color of therabands were used, what the weight of the ankle weights was, how many repetitions were completed for each exercise, and if the resident wore hand weights when using the peg board. In addition, the restorative documentation note did not indicate why the PT instruction to ambulate to tolerance with the rolling walker and max assist of two persons with the wheelchair close by was not documented as attempted or the reason why it was not attempted. During the review of the dates of the documentation to support when restorative nursing was provided, the CNRA confirmed that R5 had not received restorative nursing two times week. During an interview on 12/10/2025 at 1:30 PM, the Director of Nursing (DON) reviewed R5's PT and OT therapy maintenance program and the specific guidelines indicated by PT and OT for R5 to complete during his/her restorative nursing session. The DON confirmed that the restorative nursing documentation lacked specific information to indicate that the PT and OT maintenance program instructions were being implemented as directed and R5's response to the recommended exercise or refusal of the exercises and the reason for the refusal. The DON confirmed that based on the lack of specific documentation from restorative, it would be difficult to determine and evaluate resident's progress.

Based on observation, record review, interview and policy review, the facility failed to document the monitoring and assessing of residents' dialysis access site and failed to document on residents' condition for one of one resident reviewed for dialysis (Resident (R) 5) when he/she returned to the facility post dialysis treatment out of 36 sampled residents. The facility's deficient practice had the potential for the resident to experience a decline in his/her medical condition.Findings include:Review of the facility's policy titled Dialysis dated 09/10/2025 indicated, Purpose: To provide a continuance of care for the resident while he/she is receiving dialysis and promote communication between the SNF [Skilled Nursing Facility] and dialysis center. Procedure: J. Vital signs should be done prior to leaving and on return from dialysis.K. Dialysis access site should be assessed or dressing checked for bleeding, signs of infection and any abnormalities. During an interview on 12/09/2025 at 11:05 AM, R5 stated that he/she goes to the dialysis center on Monday, Wednesday, and Friday. During an interview on 12/10/2025 at 10:30AM, Unit Manager (UM) 1 stated that a folder was sent with [R5] to take to the dialysis center with him/her and if the folder did not come back, the nurse was to call the dialysis center. Review of R5's undated admission Record located in the resident's electronic medical record (EMR) under the Profile tab indicated R5 was admitted on [DATE] and readmitted on [DATE] with diagnoses which included End Stage Renal Disease (ESRD). Review of R5's Physician Orders located in the resident's EMR under the Orders tab revealed and order dated 08/26/2025 of Obtain vital signs prior to and upon return from dialysis on Monday, Wednesday, and Friday. Observe pressure dressing to left upper arm x [times] 2 hours post return from dialysis.for s/s [signs and symptoms] of increased bleeding. Review of the R5's Care Plan located in the resident's EMR under the Care Plan tab revealed, [R5] has Potential for complications related to dialysis with interventions Check vital signs and shunt, when resident returns from dialysis, observe for elevated blood pressure, SOB [short of breath], or chest pain, observe for nausea and vomiting, observe for signs of infection or clotting of the access area, observe for swelling, pain, redness, or drainage of the shunt, observe skin for discolorations, dryness, or pruritis, perform post dialysis blood pressure upon return to the facility every hour x 2 readings, then every 4 hours x2 readings. Observation on 12/10/2025 at 3:09 PM revealed R5 returned form the dialysis center. Review of his/her Dialysis Binder provided by the facility revealed a Communication Form dated 12/10/2025 at 9:00AM which indicated vitals were taken before the resident went to dialysis; however, there was no documentation of the resident's vitals or any assessment when he/she returned. Review of R5's undated next Communication Sheets located in the binder upon the resident's return from the dialysis center revealed no documented evidence that the resident was assessed including obtaining his/her vital signs. Review of R5's Communication Sheets dated 12/01/2025, 11/28/2025, 11/26/2025, 11/24/2025, 11/21/2025, 11/19/2025, 11/17/2025, 11/15/2025, 11/12/2025, 11/10/2025, 11/05/2025, 10/31/2025, 10/27/2025, 10/22/2025, 10/08/2025, 10/06/2025, 09/24/2025, 09/19/2025, 09/17/2025, and 09/12/2025 located in the Dialysis Binder provided by the facility revealed R5's pre-dialysis assessment and vital signs were completed; however, there was no documented evidence the resident received the ordered post-dialysis assessment of his/her condition including vital signs upon his/her return to the facility. Review of R5's Dialysis Binder provided by the facility revealed an undated document titled Dialysis Communication Log which had handwritten instructions that indicated, vitals are to be taken before the resident leaves facility. Vital signs are to be taken upon arrival from dialysis. These are to be charted upon departure and arrival. If sheet does not return from dialysis, call and have them fax it over. Please always sign the 'Facility Representative' line. During an interview on 12/10/2025 at 10:49 AM, UM1 reviewed the communication sheets and confirmed that the nurses failed to follow the instruction sheet and complete a post assessment of the resident upon return to the facility which included the resident's vital signs and assessment of the resident's dialysis access site.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a medication error rate of less than 5%. Observations during medication administration revealed 35 opportunities with two total medication errors, resulting in an error rate of 5.71%. During observations, Licensed Practical Nurse (LPN) 2 administered bothR147 and R42 incorrect dosages of medications. These failures had the potential to cause adverse drug reactions in the event of overdosing or lack of effectiveness of the medications in the event of underdosing.Findings include:Review of the facility's policy titled, Medication Administration, dated 11/2022, revealed, Medications are prepared, administered, and documented only by Licensed Nurses in accordance with current Alabama Board of Nursing Licensure, Licensed Pharmacist or other persons authorized by law and regulations as ordered by the physician. 1. Review of R147's Medication Administration Record (MAR), dated December 2025 and located in the resident's EMR under the Orders tab revealed he/she was admitted to the facility on [DATE], with diagnoses including anxiety disorder, hypokalemia, dysphagia, edema, major depressive disorder, and dementia. Review of R147's December 2025 MAR revealed the order for potassium chloride extended release (ER) (potassium supplement), 40 milliequivalent (meq) daily at bedtime, which originated on 10/05/2025. During an observation on 12/09/2025 at 9:27 PM of the medication administration completed by LPN2 revealed the LPN pulled a medication card out of the medication cart for R147 that contained potassium chloride 10-meq capsules. LPN2 entered R147's room and administered two 10-meq capsules of potassium chloride to the resident, then returned to the cart and signed the administration of the medication as completed. During an interview on 12/09/2025 at 11:00 PM, LPN2 confirmed he/she administered two 10-meq capsules of potassium chloride to R147 and confirmed the order on the MAR and in the resident's record was 40 meq. LPN2 confirmed he/she should have administered 40 meq of potassium chloride to R147 instead of 20 meq. 2. Review of R42's MAR, dated December 2025, revealed he/she was admitted to the facility on [DATE] with diagnoses including mood disorder and anxiety disorder. Review of R42's December 2025 MAR revealed the orders for fluticasone propionate nasal suspension (for nasal congestion) 50 microgram/activation (mcg/act), two sprays in nostril two times daily for nasal congestion, which originated on 08/01/2024. During an observation on 12/09/2025 at 9:35 PM of a medication administration completed by LPN2 revealed the LPN pulled a container out of the medication cart for R42 that contained fluticasone 50 mcg. LPN2 entered R42's room and administered one spray of fluticasone each nostril, then returned to the cart and signed the order as completed. He/she then moved on to the next resident. In an interview on 12/09/2025 at 10:22 PM, LPN2 confirmed he/she had administered only one spray of fluticasone to each nostril. LPN2 confirmed he/she should have administered two sprays in each nostril of R42. In an interview on 12/10/2025 at 2:59 PM, the Director of Nursing (DON) stated medications were to be administered as ordered by the physician.

Based on record review, interviews, and review of facility policy, the facility failed to identify a concern as a grievance for one of 36 sampled residents (Resident (R) 178). Family Member (F) 178 requested a meeting with the facility and voiced a concern on behalf of R178 related to the physical condition of the resident upon the resident's discharge from the facility; however, the facility did not identify the concern as a grievance and did not provide any resolution to the concern. The failure has the potential to affect resident and/or family members by not having their grievances/concerns resolved in a timely manner. This was cited as a result of the investigation of complaint #474077.Findings include:Review of the facility's policy titled Grievance Policy and Procedure – Investigation Procedure, dated August 2024 reads as follows .Any resident, their representative, sponsor, advocate, or family member may file a concern, complaint, or grievance regarding a resident's treatment, medical care, behavior of another resident, staff member, theft of property, etc., without fear of reprisal in any form.The [Facility Name] will assess and investigate all concerns, complaints and grievances voiced and filed with the facility.A copy of all reports must be signed and will be made available to the resident and/or sponsor, advocate or family member filling the grievance form.The resident and/or family member will be informed of the results of the investigation within ten working days of the date the grievance was received. Review of R178's admission Record, provided by the facility revealed the resident was admitted to the facility on [DATE] and discharged from the facility on 03/23/2023 to home with the services of home health. Review of the facility's Grievance/Concern Log for the year 2023 failed to reveal any grievances/concerns were filed for this R178. Review of the facility's undated administrative notes of the meeting held with the F178 revealed Unit Manager (UM) 2 interviewed all staff members present on the day of the resident's discharge. The document failed to include statements from the staff members present when the resident was discharged . The document failed to contain any information that F178 was informed of the results of the facility's investigation. During an interview on 12/09/2025 at 12:40 PM, F178 stated he/she requested a meeting with the administrative staff regarding the condition of R178 when he/she was discharged from the facility. F178 stated the facility failed to notify him/her that R178 had developed a pressure ulcer during the resident's five-day respite stay at the facility. F178 stated the resident was discharged from the facility wearing only a tee shirt and adult diaper. When the resident arrived home, he/she was completely saturated with urine. F178 also stated that he/she did not receive a response from the facility regarding the resolution of his/her concerns. During an interview on 12/11/2025 at 4:54 PM, the Director of Nursing (DON) stated F178 requested a meeting with administration to discuss his/her concern about the condition in which R178 was discharged from the facility and the fact that he/she did not receive notification that the resident had developed a pressure ulcer during the resident's stay. The (DON) stated F178's concern should have been considered a grievance. The Director of Nursing acknowledged the grievance procedure was not followed

Based on record reviews and interviews, the facility failed to ensure two Certified Nursing Assistants (CNAs) assisted (Resident Identifier) RI #120 with toileting needs on 10/15/19 which resulted in an avoidable fall. This had the potential to affect one of three sampled residents whose falls were reviewed. Findings Included: RI #120 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/18/19 pm, during the initial tour of the facility, RI #120 revealed to the surveyor falling off the bed when the bed pan was being removed on 10/15/19. A review of a fall incident report dated 10/15/2019 at 6:28 PM revealed: . resident on the floor . The fall incident report further revealed: TYPE of Injury Abrasion, Redness and Pain to right Knee . 2 cm x 1 cm abrasion to left great toe, redness noted to top of right foot, redness noted to bilateral knees . A review of a facility document titled, Activities of Daily Living (ADL) Assistance Legend, ADL Support Provided, with a print date of 11/21/19 revealed, RI #120 was a 3, which indicated a Two+ person physically assist. A review of RI #120's Quarterly (Minimum Data Set) MDS with an Assessment Reference Date of 10/08/2019 revealed under section G 2, Toilet use: support provided 3, Two+ persons physical assist. On 11/20/19 at 3:39 p.m., an interview was conducted with Employee Identifier (EI) #3, CN[NAME] EI #3 was asked what happened when RI #120 had a fall on 10/15/19. EI #3 replied, she went to assist RI #120 off the bed pan. EI #3 added, when she went to get the resident off the bed pan, the resident slid off the bed. EI #3 was asked, what happened next. EI #3 replied, she made sure RI #120's head was not on the floor and that RI #120 was comfortable on the floor. EI #3 pulled the emergency light in the resident's bathroom. EI #3 stated that she did not leave the resident in the room alone. EI #3 was asked what happened next. EI #3 stated that she stuck her head out the resident's doorway and called for other CNAs to help her. EI #3 stated that the resident was assessed before being lifted from the floor. EI #3 was asked, how many CNAs normally assisted the resident to use the bed pan. EI #3 replied, two. EI #3 was asked, why did RI #120 need two people to assist him/her on the bed pan. EI #3 replied he/she was assessed to need two people. EI #3 was asked, when she put RI #120 on the bed pan on (MONTH) 15, was this a two person assist or one person assist. EI #3 replied, one. EI #3 was asked, why did only one person assist RI #120 with the bed pan when it required two. EI #3 replied, they were very busy and her mind was saying one person would be faster and the other CNAs could be helping someone else. EI #3 was asked what part of RI #120's body was hurt. EI #3 replied, RI #120's foot and knee. EI #3 was asked, what did RI #120's care plan say, one or two person assist. EI #3 replied, two. EI #3 was asked what was the potential harm to the resident when the resident was a two person assist and one person provided care. EI #3 replied, they could fall, get hurt, or cut. EI #3 added, a lot of things could happen. EI #3 was asked, was RI #120's fall avoidable or unavoidable. EI #3 replied, avoidable. EI #3 was asked when should residents be free from falls. EI #3 replied, at all times. EI #3 was asked, why was it important that residents be free from falls. EI #3 replied, because they can get hurt or injured. EI #3 added, it was better for their well-being if they did not fall. On 11/21/19 at 8:42 a.m., an interview was conducted with EI #4, CN[NAME] EI #4 was asked to tell the surveyor what happened regarding RI #120's fall on 10/15/19. EI #4 replied, she did not know much about the fall. EI #4 stated, she was taking a cart back to the kitchen and as she returned and opened the front door at station five she saw EI #5 hollering to get the nurse. EI #4 was asked, what did she do next. EI #4 stated that she called a supervisor for help. EI #4 was asked, how often did she take care of RI #120. EI #4 replied, everyday when she was at work. EI #4 was asked, when putting RI #120 on and off the bed pan, how many staff should assist RI #120. EI #4 replied, two. EI #4 was asked how did she know RI #120 required two person assist. EI #4 replied, it was in the care plan. EI #4 was asked what was the potential harm to the resident when RI #120 was a two person assist and only one person assisted him/her. EI #4 replied, the resident could get hurt or injured. EI #4 was asked why should RI #120 be free of an avoidable fall. EI #4 replied, because of the resident's rights. On 11/21/19 at 9:03 a.m., an interview was conducted with EI #5, CN[NAME] EI #5 was asked to tell the surveyor what happen the day of RI #120's fall. EI #5 stated that she and another CNA came out of a room into the hall. EI #5 stated, a resident came out of the room and said they need help down there. EI #5 went into RI #120's room and observed RI #120 off the bed on the floor between the bed and wall. EI #5 said RI #120 could turn on the call light if he/she needed toileting. EI #5 was asked, what was the potential harm to the resident when RI #120, a two-person assist, was assisted by one person. EI #5 replied, the resident could be injured. EI #5 was asked, why should RI #120 be free from any avoidable fall. EI #5 replied, because of RI #120's right as a resident was for us to follow RI #120's Plan of Care. On 11/21/19 at 10:37 a.m., an interview was conducted with RI #120. RI #120 was asked, what happened on 10/15/19 when the fall occurred. RI #120 stated he/she was getting off the bedpan and there was just one CNA assisting him/her, and he/she was a two person assist. RI #120 was asked did she/he know the CNA's name. RI #120 replied, EI #3. RI #120 was asked, who were the CNAs on the day of the fall. RI #120 replied, EI #3 and EI #4. RI #120 was asked, how did it make him/her feel when one person assisted her/him and she/he required two for assistance. RI #120 replied, it did not make him/her feel good. RI #120 was asked, how many people normally assisted him/her now when using the bed pan. RI #120 replied, two. RI #120 was asked how often did one staff member assist him/her off the bed pan before the fall. RI #120 replied, once. RI #120 was asked, what had the facility done to prevent another fall. RI #120 replied, fall mats and two people assist him/her. RI #120 was asked when staff assisted he/she on and off the bed pan was he/ she afraid. RI #120 replied, no because there were two doing it. On 11/21/19 at 11:00 a.m., a telephone interview was conducted with EI #2, Registered Nurse Supervisor. EI #2 was asked, how many people should assist RI #120 getting on and off the bed pan. EI #2 replied, two. EI #2 was asked, how did she know it took two. EI #2 replied, the care plan. EI #2 was asked, how did staff know whether RI #120 was a one or two person assist. EI #2 replied, by their direction and training. EI #2 was asked to tell what happened the day of the fall. EI #2 stated that she was not in the room. EI #2 replied, a CNA assisted the resident off the bedpan by herself, and RI #120 rolled off the bed. EI #2 was asked, what did she do. EI #2 stated that they assessed the resident and told other staff to write a report. On 11/21/19 at 11:50 a.m., the surveyor conducted an interview with EI #1, Director of Nursing. EI #1 was asked, how many CNAs should assist RI #120 when putting RI #120 on and off the bed pan. EI #1 replied, two. EI #1 was asked, how many assisted RI #120 on the day of the fall. EI #1 replied, one. EI #1 was asked, what type of assistance did RI #120's MDS say under toileting. EI #1 replied, extensive. EI #1 was asked, what has been put in place since the fall for RI #120. EI #1 replied, education, training, and check-off with EI #3. EI #1 was asked, why was it important that the MDS toileting needs be followed. EI #1 replied, for safety and to prevent injuries. EI #1 was asked if RI #120's MDS toileting needs were followed. EI #1 replied, no. EI #1 was asked, how many staff normally help RI #120 with getting on and off the bed pan. EI #1 replied, two.

Based on observations, interviews and review of facility's policies titled Dietary _ Food Storage, Dietary Dish Machine, and Date Marking for Food Safety, the facility failed to ensure: 1. chicken breasts and biscuits were wrapped properly in the freezer; 2. a loaf of bread was not expired on a counter; 3. a scoop was not left in the corn meal and; 4. bowls were not wet nesting at the tray line. This had the potential to affect 164 of 164 residents who received meals from the kitchen. Findings include; 1. A review of a facility policy titled, Dietary_Food Storage, with a Revised date of [DATE] revealed; .19. Freezer Temperature: g . Wrap product so it is airtight . On [DATE] at 10:55 a.m., the surveyor observed twenty three chicken breasts and 20 biscuits were in a medium size box in a plastic bag in the outside freezer. The plastic bag were opened in each box exposing the chicken breasts and biscuits. On [DATE] at 9:37 a.m., the surveyor conducted an interview with (Employee Identifier) EI #1, Certified Dietary Manager. EI #1 was asked what items were not properly sealed in the freezer. EI #1 replied, biscuits were not tied up and chicken patties. EI #1 was asked why were the biscuits and chicken breasts not sealed properly. EI #1 replied, the bags was not tied. EI #1 was asked what was the facility policy on sealing food items in the freezer. EI #1 replied, they have to make sure that it was sealed. EI #1 was asked who was responsible for sealing food items in the kitchen. EI #1 replied, the last one that had the box of biscuits opened and herself. EI #1 was asked how should bags be sealed in the freezer. EI #1 replied, they tied them with the corners and closed the box. EI #1 was asked when biscuits and chicken breasts were not sealed properly what was this the potential harm for. EI #1 replied, something could get into the food and freezer burn. EI #1 was asked when biscuits and chicken breasts were left opened in the freezer was this a good quality food. EI #1 replied, no. 2. A review of a facility policy titled, Date Marking for Food Safety, with a revised date of [DATE], revealed: II: Policy Explanation and Compliance Guidelines: 2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. On [DATE] at 6:04 p.m., the surveyor observed a loaf of wheat bread on a counter top with a use by date of [DATE]. On [DATE] at 9:46 a.m.,the surveyor conducted an interview with EI #1. EI #1 was asked what was on the table expired. EI #1 replied, a half loaf of whole wheat bread. EI #1 was asked why was the bread expired on the table. EI #1 replied, she did not know. EI #1 was asked was it a whole loaf . EI #1 replied, no. EI #1 was asked were residents served bread from the loaf of bread. EI #1 replied, possible, it was a half of a loaf. EI #1 was asked who was responsible for removing expired food items such as bread in the kitchen. EI #1 replied, the bread company. EI #1 was asked what was the facility policy on expired food items. EI #1 replied, throw it out. EI #1 was asked when was the bread inspected last for an expired date. EI #1 replied, on Friday by the bread man [DATE]. EI #1 was asked what was the expiration date on the bread. EI #1 replied, [DATE]. EI #1 was asked why should residents not be given expired food items. EI #1 replied, possible illness. 3. A review of a facility policy titled, Dietary_Food Storage, with a revised of date of [DATE] revealed: Policy .Food is stored, prepared and transported at an appropriate temperature and by methods designed to prevent contamination. Procedures: . 6.Scoops are not to be stored in the food containers, but are kept covered in a protected area near the containers On [DATE] at 6:04 p.m., the surveyor observed a scoop left in the corn meal bag. The scoop was touching the corn meal. 4. A review of a facility policy titled, Dietary Dish Machine with an revised date of [DATE] revealed: .Procedure: .10. Allow the dishes to air dry on the dish racks. On [DATE] at 11:20 a.m., the surveyor observed water in a small bowl and water in three large bowls with water in them. There was a large amount of water on top of bowls which were turned down. The surveyor observed the bowls holder with a large amount of water dripping to the floor. On [DATE] at 10:00 a.m., EI #2 was asked why were bowls wet at the tray line. EI#2 replied, she did not know. EI #2 was asked what was the facility policy on wet dishes. EI #2 replied, they were supposed to air dried until they were fully dried. EI #2 was asked did she inspect the bowls for dryness before she used them. EI #2 replied, no. EI #2 was asked why she did not inspect the bowls before using them. EI #2 replied, she did not think they were going to be wet. EI #2 was asked were the bowls wet. EI #2 replied, the top ones were. EI #2 was asked how should bowls be allowed to dried. EI #2 replied, air dried. EI #2 was asked who was responsible for making sure bowls were dry at the tray line. EI #2 replied, the dish washing staff were supposed to make sure they were dried before they stack them up and the servers were supposed to look to make sure they are dried. EI #2 was asked why should food not be placed in wet bowls. EI #2 replied, she was not sure. On [DATE] 10:04 a.m., the surveyor conducted an interview with EI #1. EI #1 was asked why were bowls wet at the tray line. EI #1 replied, she did not know. EI #1 was asked how should bowls be allow to dry. EI #1 replied, air dried. EI #1 was asked why should food not be placed in wet bowls. EI #1 replied, due to bacterial growth.

Based on observation, interviews with staff, and a review of the dish machine policy Operating Parameters, the facility failed to ensure the chlorine concentration was monitored and met specifications of 50 parts per million (ppm) and wash water temperatures were greater than 120 degrees Fahrenheit/F to consistently sanitize dishes and utensils processed through the dishmachine. This affected all 173 residents for whom meals were prepared and served at the time of this survey. Findings Included: The facility's Operating Parameters for the chemical sanitizing dish machine specifies a minimum wash temperature of 120 degrees Fahrenheit (F). Directives from the service technician for the dish machine (received 09/06/17) specified a minimum (chlorine) chemical sanitizing concentration of 50 ppm. During the initial tour of the kitchen on 09/05/17 at 4:50 p.m., the Dishwasher Temperature/Chemical Record contained no documentation of the chemical concentration for the first five days of September. Neither had staff monitored the chlorine concentration during the months of August or July, 2017. On 09/06/17 at 9:45 a.m., the surveyor observed staff in the process of washing dishes. Wash water temperatures registered 110, 111 and 111 degrees F for three racks of dishes observed. Staff continued to remove and put away the clean dishes despite the suboptimal wash temperatures. The surveyor requested a staff member handling the processed dishes, Employee Identifier (EI) #1, to check the concentration of chemical sanitizer on the surface of a Dinex lid; it registered 0 ppm on the test strip. A check of a second utensil processed through the machine likewise registered 0 ppm, at which time, EI #1 primed the container of sanitizer. Following this, a third test strip registered significantly less than 50 ppm. On 09/06/17 at 9:50 a.m., staff continued to process dishes and utensils through the machine and place them into storage. Another (fourth) test strip registered less than 50 ppm on the surface of a bowl as it emerged from the machine. EI #1 again primed the container of chlorine sanitizer, holding the release button approximately 10 seconds. On 09/06/17 at 9:54 a.m., the Certified Dietary Manager (EI #2) checked the concentration of chemical sanitizer with two different test strips for two cycles of the machine. Both test strips registered 0 ppm chlorine. The specifications (print) on the dish machine data plate affixed to the lower side of the machine was illegible due to wear. EI #2 affirmed the goal concentration of chlorine was 50 ppm. A seventh check of the chlorine concentration was made by EI #1, using a test strip on a droplet of water on the surface of a meal tray processed through the machine. It registered less than 25 ppm. Staff continued to put away dishes. The pump of the chemical sanitizer was again primed, for nearly 2 minutes. The next rack of utensils (Dinex lids) registered 200 ppm, at 10:00 a.m. EI #2 directed EI #1 to document the chlorine concentration--the first documentation for this day. On 09/06/17 at 10:00 a.m., the surveyor asked EI #1 if she checked the chemical concentration very often. EI #1 explained a space had not been given on the previous documentation sheets for this value. When asked what was the purpose of checking the chlorine concentration, EI #1 stated it was to ensure the sanitizer worked. On 09/06/17 at 5:10 p.m., the surveyor asked the Dietary Manager, EI #2, what potential hazard could result from the inadequate (less than 120 degree F) wash water temperatures in the dish machine, as well as low or no concentration of chlorine. EI #2 explained the dishes would not be sanitized. When asked why dish room staff had not been monitoring the chlorine concentration over the past two months, EI #2 stated it had not been requested on the previous documentation logs.

Based on observation, interview, record review and review of facility policy CONTAMINATED LAUNDRY PPE (personal protective equipment) USAGE the facility failed to ensure: 1. staff did not feed Resident Identifier (RI) #19 and RI #20 at the same time, touching both residents' personal items, utensils, cups and straws without sanitizing or washing her hands between the two residents. This was observed on 9/6/17 during the lunch meal and affected two of five residents being fed by staff. 2. Laundry staff wore personal protective equipment (ppe)/aprons while sorting soiled clothing and linens. This was observed on 9/6/17 and had the potential to affect 176 residents residing at the facility. Findings Include: 1. RI #19 was admitted to the facility 4/9/12 with a [DIAGNOSES REDACTED]. A review of RI #19's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 8/8/2017 revealed RI #19 totally dependent with assistance of one for eating. RI #20 was admitted to the facility 1/11/12 with a [DIAGNOSES REDACTED]. A review of RI #20's Quarterly MDS with an ARD date of 6/20/2017 revealed RI #20 totally dependent for eating. On 9/6/17 from 11:30 a.m., until 12:00 p.m., Employee Identifier (EI) #5, Licensed Practical Nurse was observed feeding both RI #19 and RI #20 the lunch meal. EI #5 was sitting between the two residents. EI #5 was observed giving RI #20 food then picking up RI #20's cup with her left hand and holding the straw with her right hand and gave fluids to RI #20. EI #5 finished with RI #20 then turned to RI #19 giving a mouthful of food. EI #5 was observed touching the clothing protector and lap cover of RI #19, then giving RI #19 fluids holding the cup and straw. EI #5 then turned back to RI #20 and gave a spoonful of food. EI #5 then stood and held RI #20's cup with her left hand and the straw with her right hand and gave RI #20 fluids. No hand sanitizing was noted between the two residents after EI #5 had touched the clothing protector and lap cover, cup and straw for RI #19 and the cup and straw for RI #20. On 9/6/17 at 3:00 p.m., an interview was conducted with EI #5. EI #5 was asked if she should touch RI #20's straw then touch RI #19's clothing protector and lap cover, cup and straw without sanitizing her hands. EI #5 replied, no she should have washed her hands in between. EI #5 was asked what the harm was in touching the straws and clothing covers for one resident then turning to touch the straw for another resident. EI #5 replied infection, contamination. On 9/7/17 at 9:30 a.m., an interview was conducted with EI #4, Infection Control Nurse. EI #4 was asked how should staff handle the residents' utensils, cups and straws when feeding two residents at the same time. EI #4 replied, they should not touch the same equipment for both residents without washing their hands. EI #4 was asked what the harm could be in feeding two residents at the same time. EI #4 replied, cross contamination if they do not sanitize or wash their hands between handling each one's equipment or items. 2. A review of facility policy CONTAMINATED LAUNDRY PPE (Personal Protective Equipment) USAGE revealed: . RULES .The use of thick chemical resistant aprons are required when handling contaminated laundry . On 9/6/16 at 2:30 p.m., an observation was made of the laundry area. EI #6 and EI #8, laundry aides, were observed sorting laundry from rolling carts to barrels. Both were removing soiled linens and clothing both had on gloves but no aprons covering their clothing. As they were pulling the soiled clothing and linens from the carts and placing in the barrels the soiled clothing and linens were observed touching their uniforms/clothing. Both staff then went to the dryers and were observed removing the linens from the dryers with the clean linens observed touching their uniform/clothing. On 9/6/17 at 2:45 p.m., an interview was conducted with the laundry aide, EI #6. EI #6 was asked if her uniform was considered clean or dirty. EI #6 replied, dirty. EI #6 was asked what the risk was when she sorted clothes and linens without an apron. EI #6 replied, the soiled clothes and linens could touch her clothing then the clean clothes could touch her clothes which would contaminate them. On 9/6/17 at 3:00 p.m., an interview conducted with EI #7, Environmental Services Manager. EI #7 was asked what was the policy on sorting laundry. EI #7 replied, they should have on aprons and gloves. EI #7 was asked if the staff had on aprons. EI #7 replied, no. EI #7 was asked if aprons were available. EI #7 replied, yes. EI #7 was asked what was the harm in not wearing the aprons while sorting the laundry. EI #7 replied, transferring could soil their clothing, then the soiled from their clothing could get on the clean clothes and linens. On 9/7/17 at 9:30 a.m., an interview was conducted with EI #4, Infection Control Registered Nurse. EI #4 was asked how should the laundry staff handle sorting clothing and linens. EI #4 replied, they should wear gloves and a gown or apron and they should not have dirty touching their clothing. EI #4 was asked if laundry staff uniforms would be considered clean or dirty. EI #4 replied, dirty. EI #4 was asked what was the risk if while sorting dirty laundry the laundry touched the staffs uniform, then handling the clean laundry the clean touched the staff uniform. EI #4 replied, spreading of infection and cross contamination.

Based on observation, interview, record review and review of facility policy Oxygen Administration - Nasal Cannula, the facility failed to ensure continuous Oxygen was provided as ordered on [DATE] for Resident Identifier (RI) #19 while the resident was in the dining room for meals. This was observed on 9/6/17 at lunch and supper and on 9/7/17 at breakfast. This affected one of five residents observed using Oxygen. Findings Include: A review of facility policy Oxygen Administration-Nasal Cannula with a revised date of 1/12/2011 revealed: .Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's order . RI #19 was admitted to the facility 4/9/12 with [DIAGNOSES REDACTED]. A review of RI #19's Physician Orders dated August 2017 revealed: .start date 7/14/16 OXYGEN @ (at) 2 - 4 L/M (liters per minute) PER N/C (nasal cannula) PRN (as needed) . A review of a facility form titled PHYSICIan order for [REDACTED]. On 9/6/17 from 11:30 a.m., until 12:00 p.m., RI #19 was observed at the dining room being fed the lunch meal. No oxygen was observed to be in use. RI #19 did not appear in any respiratory distress. On 9/6/17 from 5:15 p.m., until 5:45 p.m., RI #19 was observed in the dining area being fed the supper meal. No oxygen was observed being used. RI #19 did not appear in any respiratory distress. On 9/7/17 at 8:10 a.m., RI #19 was observed in the dining area being fed the breakfast meal. No oxygen was observed being used. RI #19 did not appear in any respiratory distress. On 9/7/17 at 9:20 a.m., an interview was conducted with Employee Identifier (EI) #3, Registered Nurse. EI #3 was asked what RI #19's current Oxygen order was. EI #3 replied, it was now continuous, the prn order was changed to continuous on 9/3/17. EI #3 was asked when RI #19 was at meals in the dining area was oxygen being used. EI #3 replied, RI #19 had not been having oxygen on while eating in the dining room. EI #3 was asked if a resident had a continuous order of oxygen should the resident have the oxygen during meals when out of the resident room. EI #3, replied yes. EI #3 was asked if the continuous order was being followed if the resident did not have the oxygen when out of the room for meals. EI #3 replied, no. EI #3 was asked if the physician's orders was being followed. EI #3 replied, no. EI #3 was asked what the harm was in not following physician's orders. EI #3 replied, possible insufficient oxygenation.

Based on record review and interview, the facility failed to ensure a back-up plan was in place and utilized on 8/25/2016 when the computer system shut down facility wide and medications were administered late to 65 of 182 residents. This had the potential to affect all residents who reside in the facility. Findings Include: A complaint was alleged that the facility's computer system went down on 08/25/2016 in the whole building and some of the residents received their medications late. A review of a facility document titled, Medication Error Report (Name of Facility) with a date of 08/26/2016 revealed there was a facility wide medication error on 8/25/2016 due to the computer system being down and some medications were administered late. A review of a facility document titled, Physician order [REDACTED]. On 09/13/2016 at 3:04 p.m., an interview was conducted with EI (Employee Identifier) #11, LPN(Licensed Practical Nurse). EI #11 was asked what the back-up plan was for administering medications when the computer system was down. EI #11 said she was told if the system did not come back up soon, they were going to print MARs (Medication Administration Records). EI #11 stated the system had never been down that long. EI #11 was asked what the usual back-up plan was when the computers were down. EI #11 said medical records usually printed a MAR indicated [REDACTED]. EI #11 was asked if this (the computers going down and the medication being late) was facility wide. EI #11 said yes. EI #11 was asked what the potential harm was in not putting a back-up system in place when the computers went down. EI #11 said adverse reactions to not receiving medication on time. On 09/13/2016 at 5:48 p.m., an interview was conducted with EI # 12, ADON (Assistant Director of Nursing). EI #12 was asked what the back-up plan was when the computers went down. EI #12 said usually when they knew, they printed the MAR indicated [REDACTED]. EI #12 was asked if there was a back-up plan on 08/25/2016. EI #12 said she was not given one. EI #12 was asked if medications were given late on 08/25/2016. EI #12 said yes ma'am, some were late. EI #12 was asked if this (the computers going down and the medication being late) was facility wide. EI #12 said yes ma'am. EI #12 was asked what the potential harm was in not putting a back-up system in place when the computers went down. EI #12 said adverse reactions to not getting diabetic medications and [MEDICAL CONDITION] medications and an increase in behaviors. On 09/15/2016 at 11:07 a.m., an interview was conducted with EI #2, DON (Director of Nursing). EI #2 was asked what the back-up plan was when the computers went down. EI #2 said normally if there was an anticipated problem, MARs were printed so the nurses would have an actual printed MAR. EI #2 was asked on 08/25/2016 when the computers went down, what were the nurses expected to do. EI #2 said the nurse could have pulled the charts and given medication from the doctor's order off the charts. EI #2 said it would have taken a long time, but they could have done it. EI #2 was asked if medications were given late on 08/25/2016. EI #2 said yes ma'am, some were. EI #2 was asked if this (the computers going down and the medication being late) was facility wide. EI #2 said yes ma'am. EI #2 was asked what the potential harm was in not putting a back-up system in place when the computers went down. EI #2 said residents not getting their medications in a timely manner. On 09/15/2016 at 12:33 p.m., an interview was conducted with EI #1, Administrator. EI #1 was asked what back-up plan was in place to give medication on 08/25/2016 when the computer system went down. EI #1 said normally, they would have printed MARs. EI #1 said they did not print MARs because IT (Information Technology) said it would take longer to print MARs than the system would be down. EI #1 was asked if medications were given late on 08/25/2016. EI #1 said some, yes. EI #1 was asked why a back-up plan not used. EI #1 said they were following IT's advice. EI #1 was asked what the potential harm was in not putting a back-up system in place when the computers went down. EI #1 said the potential could be medication pass would be late. This deficiency was written as a result of complaint/report #AL 646.

Based on observations, record reviews, and interviews the facility failed to ensure: 1. a dented can was not located on the shelf with regular food cans, 2. a food product, grits, located in dry storage was sealed properly and 3. eleven magic cups were frozen solid. This had the potential to affect 177 of 182 residents who receive meals from the kitchen. Findings Include: A review of a facility's policy titled, Dietary_Food_Ordering_Receiving with a revised date of 3/25/2010 revealed: .Procedures: .Reject food when: . c. Boxes/packages/cans are torn, broken, dented, and/or damaged . 1) On 9/12/2016 at 5:30 p.m., the surveyor, along with EI (Employee Identifier) #5, assistant dietary manager, observed one can of diced peaches, weighing 105 ounces in with regular food cans. On 9/15/2016 at 10:40 a.m., an interview was conducted with EI #5. EI #5 was asked what dented can items was in with regular cans. EI #6 replied diced peaches. EI #5 was asked why was a dented can in with regular cans. EI #5 replied it was a mistake of putting it on the wrong shelf. EI#5 was asked where are dented cans placed. EI #5 replied on the bottom shelf and there was a label that said dented cans. EI #5 was asked who was responsible for making sure dented cans were in the areas they needed to be. EI #5 replied whoever put up the stock at that time. EI #5 was asked what was the facility's policy regarding dented cans. EI #5 replied any dented cans should not be used to serve residents. EI #5 continued to say they should be placed in the dented can area to be returned to the vendor. EI #5 was asked when should dented cans be removed from the shelf. EI #5 replied when they were received. EI #5 was asked why should dented cans be removed from regular cans. EI #5 replied that food can be contaminated within because of metal. EI #5 was asked what was the potential harm when dented cans were in with regular cans. EI #5 replied contaminated food served to the residents can cause them to be sick. A review of a facility's policy titled, Dietary_Reusable Food Storage Containers with a revised date of 03/30/2010 revealed: .Procedures: 1. Leftover foods and foods that cannot be restored in their original container will be stored in non-porous containers that can be completely sealed. 2) On 9/12/2016 at 5:30 p.m., the surveyor, along with the assistant dietary manager, toured the dry storage area. A five pound bag of Quick Grits was opened, it was not sealed or placed in another container. On 9/15/2016 at 11:01 a.m, an interview was conducted with EI #5. EI #5 was asked what item was in dry storage opened. EI #5 replied grits. EI #5 was asked why was it opened. EI #5 replied someone opened it to get grits out and did not put it back into the proper container. EI #5 was asked who was responsible for making sure items were sealed properly after opening. EI #5 replied the employee who opened it. EI #5 was asked what was the facility's policy on opened food items. EI #5 replied, anything that was opened should be put in a container, dated and labeled. EI #5 was asked what was the potential harm when a food item was opened and not sealed properly. EI #5 replied they can get contaminated. 3) On 9/12/2016 at 5:40 p.m., the surveyor, along with the dietary assistant manager, observed 11 vanilla magic cups in the ice cream cooler. The magic cups were soft when touched. On 9/15/2016 at 11:10 a.m., an interview was conducted with the dietary assistant manager. EI #5 was asked what items were in the ice cream cooler and was not frozen solid. EI #5 replied magic cups. EI #5 was asked how hard were the items. EI #5 replied they were soft. EI #5 was asked how many were not frozen. EI #5 replied 9 or 10. EI #5 was asked what was the facility's policy on magic cups. EI #5 replied they were supposed to be frozen to zero degrees. EI #5 was asked why should they be kept frozen. EI #5 replied it would be perishable if not frozen. EI #5 was asked who was responsible for making sure they were placed in the cooler. EI #5 replied the person who was putting the stock away. EI #5 was asked what was the potential harm when magic cups were not frozen solid and given to the residents. EI #5 replied the perishable item can cause the resident to be sick.

Based on observation, interviews and record review, the facility failed to ensure RI (Resident Identifier) # 18 did not self administer a breathing treatment on 09/14/2016, without first being assessed to determine if he/she could safely administer this treatment. This affected RI #18, one resident observed self administering medication. Findings Include: RI # 18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 09/14/2016 at 10:58 a.m. an observation was made of RI #18 lying in bed with his nebulizer mask on and receiving a breathing treatment. RI #18 was asked if he/she gave him/herself the nebulizer treatments. RI #18 explained the nurse placed the medication into the nebulizer machine and he/she turned it on and off by himself/herself. A review of a facility policy titled, Medication_Self-Administration with a revised date of 02/07/2013, revealed the following: Purpose: The purpose of this procedure is to establish uniform guidelines concerning the self-administration of drugs. General Guidelines: 1) A resident may not be permitted to administer or retain any medication in his/her room unless specifically ordered by physician. Resident must have a Self- Administration Assessment completed . and a written order from the attending physician before being able to self-administer any medication. Further review of a document titled, Physicians Medical Examination and Assessment with a date of 05/31/2016 revealed RI #18 was not to self-administer his/her medications and required continuous supervision. A review of RI #18's September 2016 Physician order [REDACTED]. .[MEDICATION NAME] 0.083% INHAL (Inhalation) SOLN (Solution)-GIVE PER NEB (Nebulizer) Q (every) 4H (hour) PRN (As needed) . A review of RI #18's most recent annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 06/07/2016 revealed RI #18 had a BIMS (Brief Interview for Mental Status) score of 15, indicating the resident was cognitively intact. On 09/15/2016 at 9:25 a.m. an interview was conducted with EI #8, LPN (Licensed Practical Nurse). EI #8 was asked if she was RI #18's nurse on 09/14/2016. EI #8 said yes. EI # 8 was asked did RI #8 receive a nebulizer treatment on 09/14/2016 around 10:30 a.m. to 11:00 a.m. EI #8 said RI #18 had received a treatment between 9:00 a.m. to 11:00 a.m. EI #8 was asked how was RI #18's nebulizer treatment to be administered. EI #8 explained when RI #18 requested it, they put the medication into the nebulizer bottle and put the mask on and left the nebulizer on for 15 minutes. EI #8 was asked when was RI #18 assessed to self administer his/her nebulizer treatment. EI #8 said she had not assessed RI #18. EI #8 was asked to review RI #18's chart to verify if the resident had a consent form to self-administer medication. EI #8 reviewed RI #18 's chart and located a completed Physicians Medical Examination and Assessment form. EI #8 was asked if the form documented RI #18 could self administer his/her medications. EI #8 said no, it documented he/she could not. EI #8 was asked why a nurse should stay with RI #18 while he/she was receiving a nebulizer treatment. EI #8 said to make sure RI #18 received it and for safety reasons. EI #8 was asked what was the potential harm in allowing a resident who had not been assessed for self-administering medications to administer their own medication. EI #8 said they could do it the improper way.

Based on observation, interview and record reviews, the facility failed to ensure a test tray on the 600 hall was not cold on 9/14/2016. This affected two of the ten residents who ate meals in their rooms on the 600 hall on 9/14/2016. Findings Include: A review of a facility policy titled, Test Tray with a date of 01/15/2014 revealed: Purpose: .(name of the nursing home) strives to provide the residents with . hot food.Procedure: .8. For food temps that are found to be out of compliance should be corrected immediately. A review of another policy titled, Dietary_Sanitation_Infection Control with a revised date of 06/28/2010 revealed: . 7. During transportation from the kitchen to the dining rooms, resident's rooms or feeding areas, care is taken to keep hot food hot . On 9/14/2016 at 12:18 p.m., the surveyor and EI (Employee Identifier) #6, dietary manager went to the 600 hallway to temp the food on the tray. After all the resident's trays were passed out, the dietary worker took the temperatures of the foods. At 12:45 p.m., temperatures were taken. The pureed meat loaf was 103 degrees F (Fahrenheit), pureed squash was 101 degrees F, the mashed potatoes was 102 degrees F, the pureed bread was 99 degrees F and the butterscotch pudding was 68 degrees F. The surveyor and the dietary manager tasted the food and it was cold. On 9/15/2016 at 10:31 a.m., an interview was conducted with EI #6. EI #6 was asked did she take the temperatures of the pureed foods on 9/14/2016. EI #6 replied yes. EI #6 was asked what was the temperatures of the foods. EI #6 replied, they ranged from 97 degrees F to 103 degrees F. EI #6 was asked how did the food taste. EI #6 replied pretty good. EI #6 was asked how was the temperatures of the food that she tasted. EI #6 replied unsatisfactory it was cold. EI #6 was asked what was the facility's policy on the temperatures of food being served to residents. EI #6 replied it should be reheated to 165 degrees F. EI #6 was asked what was the potential harm when residents received cold food. EI #6 replied the resident could become ill.

Based on interviews and record review, the facility failed to ensure an ongoing program of group activities was available to residents throughout each calendar day. This affected four, Resident Identifer (RI) #18, 19, 20, and 21, four of 25 sampled residents reviewed for activities. Findings Include: A review of a facility policy entitled, Activity Program with a revised date of [DATE] revealed the following: Policy: The facility shall provide for an ongoing program of activities . The activity program shall include programs that provide opportunities for engaging in normal pursuits, including physical, social, diversional, intellectual, and spiritual needs . Procedures: . Activity programs shall be offered at a variety of times throughout the day, including morning, afternoon .evenings and weekends . The calendar shall offer activities at hours convenient to residents . On [DATE] at 3:00 p.m., during the resident group interview, RI (Resident Identifier) #18, 19, 20 and 21 said there were not enough group activities offered to residents. RI #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #18's annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 15, indicating RI #18 was cognitively intact. On [DATE] at 11:00 a.m., an interview was conducted with RI #18. RI #18 was asked what activities were available after 2:00 p.m. RI #18 said none, bible study on Wednesday at 6:00 p.m. RI #18 was asked what activities were provided to him/her throughout the day on the weekend. RI #18 said the facility had only one lady working in activities on the weekend, so it was probably hard for her to have more than one activity on the weekend. RI #18 was asked how many activities were provided throughout the weekend. RI #18 said Sunday school in the morning and church at 2:00 p. m. and that was it. RI #18 was asked were there more activities available throughout the day after 2:00 p.m. RI #18 said no there was not. RI #18 was asked would he/she like more activities available during the weekend and after 2:00 p.m. during the weekday. EI #18 said yes. RI # 19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #19's most recent quarterly MDS with an ARD of [DATE] revealed a BIMS score of 15, indicating RI #19 was cognitively intact. On [DATE] at 11:10 a.m. an interview was conducted with RI #19. RI #19 was asked what activities were available after 2:00 p.m. RI #19 said after 2:00 p.m. there was none. RI #19 was asked what activities were provided to him/her throughout the day on weekends. RI #19 said none. RI #19 was asked how many activities were provided throughout the weekend. RI #19 said none. RI #19 was asked were more activities available throughout the day after 2:00 p.m. RI #19 said none after 2:00 p. m. RI #19 was asked if he/she would like more activities available during the weekends and after 2:00 p.m. during the weekday. RI #19 said anything more would be better. RI #19 further explained he/she needed more to do since his/her daughter died and would like more to do than lie in bed thinking about his/her daughter. RI #20 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #20's most recent quarterly MDS with an ARD of [DATE] revealed a BIMS score of 15, indicating RI #20 was cognitively intact. On [DATE] at 10:35 a.m. an interview was conducted with RI #20. RI #20 was asked what activities were available after 2:00 p.m. RI #20 said none after 2:00 p.m. RI #20 was asked what activities were provided throughout the day on weekends. RI #20 said not much goes on on the weekend and they did not have 10:00 a.m. activities on the weekend, they only had a 2:00 p.m. activity. RI #20 was asked how many activities were provided throughout the weekend. RI #20 said just one on the weekend. RI #20 was asked were more activities available throughout the day after 2:00 p.m. RI #20 said after 2:00 p.m. they did not have anything. RI #20 was asked would he/she like more activities available during the weekend and after 2:00 p.m. during the week. RI #20 explained there was only one activity person working on the weekend and that person could not do it all, but yes he/she would like more activities. RI #21 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #21's most recent quarterly MDS with an ARD of [DATE] revealed a BIMS score of 15, indicating RI #21 was cognitively intact. On [DATE] at 8:50 a.m., an interview was conducted with RI #21. RI #21 was asked were there more activities available throughout the day after 2:00 p.m. RI #21 said no. RI #21 was asked had he/she spoken with anyone about his/her interest in having more activities available throughout the day and weekend. RI #21 said yes, she/he had spoken with the Activity Director. RI #21 was asked would he/she like more activities available during the weekend and after 2:00 p.m. during the week. RI #21 said yes and further explained there were not enough activities for seven days. A review of the facility's [DATE] calendar for stations one, two, four and five revealed there were no activities scheduled after 2:00 p.m. for ,[DATE], ,[DATE]/, ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] and ,[DATE]. A review of a facility document titled, Resident Council Meeting dated [DATE], revealed documentation of RI #21 stating he/she did not get to participate in all activities that were held when out of the facility. Further review of Resident Council Meeting minutes dated [DATE] revealed a resident stated they were not always up to attend the 10:00 a.m. activity. The Activity Director informed the resident that they could attend the 2:00 p.m. activity instead. No other times were offered. On [DATE] at 11:25 a.m., an interview was conducted with EI (Employee Identifier) #7, Activity Director. EI #7 was asked had any residents requested for more activities. EI #7 said no one had. EI #7 was asked in regard to the residents that requested more activities in the Resident Council minutes, what she did concerning their request. EI #7 said she scheduled RI #21's activities around his/her [MEDICAL TREATMENT]. EI #7 was asked what ongoing meant to her. EI #7 explained it meant continuous and to search for new ideas. EI #7 was asked what ongoing group activity the facility had for residents on the weekend. EI #7 explained they had a 10:00 a.m. social, 2:00 p.m. spiritual and sandwich club at 3:00 p.m. EI #7 was asked what evidence she had for an ongoing activity program. EI #7 explained the activity calendar was her evidence. EI #7 was asked how many activity staff was available on the weekends. EI #7 said one. EI #7 was asked was there a reason why the facility had only one activity staff on the weekends. EI #7 said that was the way it had always been. EI #7 was asked with residents voicing an interest in having more ongoing group activities and more activities available on weekends, was the current activity program meeting their needs. EI #7 said no, but they would be looking to improve it next month. EI #7 was asked why she had only two activities available on certain days for 10:00 a.m. and 2:00 p.m. EI#7 explained that was the way it had been for years. EI #7 was asked why residents should have an ongoing activity program. EI #7 explained it was important for residents to remain social and to provide all that the resident needs. EI #7 was asked what was the potential harm in not providing an ongoing activity program for residents. EI #7 explained the resident can become depressed, have an increase in behavior and may isolate themselves.