Every finding on record at Columbiana Health and Rehabilitation, LLC

Based on interviews, resident record review, review of the facility's investigative file, review of a facility policy titled, Medication Error ., the facility failed to ensure Resident Identifier (RI) #1, a resident with a history of seizures, received his/her Oxcarbazepine 300 mg (milligrams) QID (four times a day) as ordered. On 05/11/2023 at 10 PM, on 05/12/2023 at 4 AM, 10 AM and 4 PM, RI #1 did not receive the Oxcarbazepine as ordered by the physician; and on 05/13/2023, RI #1 began to have seizures and was sent to ER (emergency room ) for evaluation. This medication error was significant due to the drug's classification as an anticonvulsant. This deficient practice affected RI #1, one of three residents sampled for the use of anticonvulsant medications. Findings include: Review of a facility policy titled, Medication Error ., dated 04/2020 revealed the following: . Definitions Medication Error/Discrepancy: . an omission of a vital medication due to a . administering error . Significant: Medication errors . 2. Require hospitalization . 4. Require treatment with a prescription medication . Procedures 1. In the event of a significant medication error . immediate action is taken, as necessary, to protect the resident's safety and welfare. RI #1 was admitted to the facility on [DATE] with a diagnosis of Unspecified Convulsions. A review of RI #1's digitally signed Physicians Orders, dated 05/10/2023, revealed RI #1 had a physicians order for Valproic Acid 250/5 ml (milliliters) to be administered 10 ml by way of his/her PEG (Percutaneous Endoscopic Gastrostomy) tube twice a day, Levetiracetam Oral Solution 100 mg/ml to be administered 6 ml by way of his/her PEG tube twice a day and Oxcarbazepine 300 mg to be administered by way of his/her PEG tube four times a day. RI #1's May 2023 eMAR (electronic Medication Administration Record) documentation did not have the required check mark and initials that would indicate the Oxcarbazepine 300 mg had been administered to RI #1 on 05/11/2023 at 10 PM; and on 05/12/2023 at 4 AM, 10 AM and 4 PM. RI #1's Departmental Notes revealed the following: . 5/11/2023 4:43 PM . will be here for 5 days for Respite . 5/13/2023 10:38 AM . At 0755 (7:55 AM), rsident (resident) was observed resting in bed with seizure activity noted. Resident assisted to left side . Resident has a history of seizures. 5/13/2023 10:45 AM . 0820 (8:20) a.m., call placed to (name of Hospice agency) to notify of continued seizure activity . Awaiting further orders. Responsible party notified of current condition . 5/13/2023 10:47 AM . 0840 (8:40 AM), order received from (name of Hospice agency) Medical Director to administer Ativan 2mg x (times) 4 doses every 15 minutes as needed for seizure activity . Resident continues with seizure activity . 5/13/2023 10:49 AM . 0915 (9:15 AM)-family arrives to facility. Resident continues with seizure activity . 5/13/2023 10:50 AM . 0945 (9:45 AM) Resident continues with seizure activity. Ativan x 4 doses has been administered. (Name of Hospice agency) updated on resident's status. Family wishes for resident to be sent to (name of hospital) for further evaluation . 5/13/2023 10:53 AM . 1012 (10:12) am (a.m.) resident picked up by EMS (Emergency Medical Services) for transport to (name of hospital) and further evaluation . 5/13/2023 3:37 PM . UPON TRANSPORT TO ACUTE CARE, RESIDENT CONTINUED WITH SEIZURE ACTIVITY . E.R. REPORTS RESIDENT WILL BE admitted TO HOSPITAL FOR UNCONTROLLED SEIZURES . A review of RI #1's ED (Emergency Department) Notes, dated 05/13/2023, revealed the following: . HISTORY OF PRESENT ILLNESS . Patient transported by EMS from the nursing home for evaluation after experiencing seizures this morning. (He/She) does have a history of seizures . The paramedic was concerned that (he/she) had had continued seizures and that (he/she) had received Ativan and Versed . ED Clinical Impression Seizures . Assessment & (and) Plan: Seizure disorder . Chief Complaint Patient presents with Seizures HPI (History of Present Illness): Patient . with a history of . Seizures . who presented to the ED via (by way of) EMS d/t (due to) seizures at (his/her) nursing home. Per EMS there were concerns for continued seizures en route to hospital, and (he/she) received ativan and versed . Discussed in detail with (family member) . (family member) also states that she was concerned the nursing home was not giving . seizure meds (medications) . Past Medical History: Diagnosis . Unspecified convulsions . On 05/15/2023, the State Agency received a FRI that stated RI #1's anti-seizure medications were not administered; and substantiated RI #1's Oxcarbazepine 300 mg to be given four times a day was not given as ordered. Review of the facility's investigative file revealed a form titled VERIFICATION OF INVESTIGATION, dated 05/15/2023, which documented the following: . PROVIDE SUMMARY AND OUTCOME OF INVESTIGATION: . Review would indicate that Oxcarbazepine 300 MG was entered into facility system on 5/11/2023 at 4:45 PM. When the order was activated the start date was entered as 5/18/2023 at 10:00 PM. The clerical error was identified on 5/12/2023 . at 7:24 PM . the clerical error resulted in missed does of Oxcarbazepine . Facility is able to verify allegation that medications were missed. Missed medications were a result of a simple clerical error . On 05/18/2024 at 8:45 AM, a telephone interview was conducted with RI #1's responsible party who said RI #1 was admitted to the facility on [DATE] (a Thursday) for respite care. RI #1's responsible said she found out RI #1 was not receiving his/her seizure medications as ordered by the physician when she went to the nursing home to pick up RI #1's belongings. The responsible party said when she was given RI #1's bubble packs of medications, she noticed not enough pills were missing from the pack. RI #1's responsible party said one of the nurses called her two days after RI #1 had been in the facility and informed her RI #1 was seizing. RI #1's responsible party said when she got to the facility, RI #1 was shaking and his/her eyes were rolling in the back of his/her head. RI #1's responsible party said they kept giving RI #1 some kind of medication to help stop the seizures but RI #1 continued to seize, and she finally asked them to send RI #1 out. On 04/18/2024 at 11:49 AM, an interview was conducted with Registered Nurse (RN) #3, the nurse providing care for RI #1 on 05/13/2023. RN #3 said RI #1 was admitted on the anticonvulsant medication Oxcarbazepine. RN #3 said RI #1 did not receive the Oxcarbazepine at 10 PM on the 11th (05/11/2023), and at 4 AM, 10 AM and 4 PM on the 12th (05/12/2023). RN #1 said it looked like the order was put in incorrectly. RN #3 said on 05/13/2023, RI #1 was observed with seizure activity, RI #1's Hospice agency staff (HAS) and RI #1's responsible party were notified, and RI #1 was sent to the hospital for further evaluation. RN #3 said finding from the facility's investigation revealed RI #1 did not receive a couple of doses of his/her anticonvulsant medications. When asked what harm could occur when a resident is not administered their anticonvulsant medications, RN #3 said they could experience seizure activity. On 04/18/2023 at 2:14 PM, a telephone interview was conducted with a member of RI #1's HAS. The HAS member said a facility nurse called one of the on-call HAS members over the weekend and informed them RI #1 had a seizure. The HAS said the harm in RI #1 not receiving his/her anticonvulsant medications as prescribed by the physician would probably be RI #1 was going to have a seizure. On 04/18/2024 at 3:30 PM, a telephone interview was conducted with the Medical Director (MD). The MD said from his understanding when RI #1 was admitted to the facility the person who entered the orders clicked on the calendar on the date for the 11th and the cursor may have dropped to the line below, so the order went in for the start of the seizure medication to start on the 18th instead of the 11th. The MD said the harm in not receiving your seizure medications is the risk of having a seizure and that sounds like that was what happened. The MD said there was an error in putting the order in. The MD said the date was put in incorrectly. On 04/18/2024 at 4:03 PM, the surveyor conducted an interview with the Director of Nursing (DON). The DON said RI #1 was admitted to the facility on [DATE] for Respite care. The DON said RI #1 was admitted on Oxcarbazepine 300 mg to be given QID and the anticonvulsant medications was not transcribed to RI #1's MAR correctly. The DON said the Oxcarbazepine was missed at 10 PM on 05/11/2023 and missed on 05/12/2023 at 4 AM, 10 AM, and 4 PM. The DON said RI #1 did experience a seizure while a resident at the facility and was sent out. The DON said finding from the facility's investigation revealed a clerical error occurred. When asked what harm could occur when a resident is not administered their anticonvulsant medications as ordered, the DON said the resident could have seizures. On 04/18/2024 at 5:02 PM, a telephone interview was conducted with the Consultant Pharmacist (CP). When asked what type error it would be when medications are not administered as ordered by the physician, the CP said a medication error. This deficiency was cited as result of the investigation of complaint/report #AL00044229. ******************************************************* The facility took immediate action: 5/11/23 4:43 PM Resident admitted to facility. Assessment completed per RN. Medication orders entered into electronic medical record. 5/12/23 - New orders reviewed. Noted start date for Oxcarbazepine entered as 5/18/23 in error. Medication order corrected with start date of 5/12/23. 5/13/23 7:55 AM - Resident noted with seizure activity. Assisted to left side. TF (Tube Feeding) placed on hold. Oral secretions noted, suction provided. 5/13/23 8:20 AM - Seizure activity continues. Sponsor notified. Expect Care Hospice notified. 5/13/23 8:40 AM - Expect Care Hospice MD gave orders to administer Ativan 2mg every 15 minutes x 4 doses. 5/13/23 9:15 AM - Seizure activity continues. Resident vomiting. Family arrived at facility. Expect Care Hospice enroute to facility. 5/13/23 9:45 AM - Seizure activity continues. Bleeding noted from mouth. Ativan administered. Hospice notified of current status, still enroute to facility. Sponsor requested resident be sent to ER. 5/13/23 10:12 AM - Resident left facility via EMS to hospital. 5/15/23 - Expect Care Social Worker called facility admissions coordinator to report that family did not wish for resident to return to facility. DON and SW called family to discuss concerns. After discussion, an allegation was reported to ADPH. 5/15/23 - An investigation was initiated regarding the allegations made by family. 5/16/23 - An emergency QAPI meeting was held to discuss the allegation and the ongoing investigation. 5/16/23 - Education was initiated to nursing management regarding medication order input, peer review and submission to pharmacy and clinical meeting guidelines. 5/16/23 - All new medication orders that were obtained between 5/11/23 - 5/15/23 were reviewed to ensure that all were entered into the electronic record correctly. (No other issues were identified.) 5/16/23 - Nurses notes entered between 5/11/23 - 5/15/23 were reviewed for identification of any noted change in the resident' condition with noted seizure activity or medication not available. (No other issues were identified.) **************************************************************** After review and verification of the information provided in the facility's corrective action plan, in-service education records, monitoring tools, and the facility's investigation, as well as staff interviews, the survey team determined the facility implemented corrective actions from 05/12/2023 through 05/16/2023 with ongoing monitoring implemented; thus, past noncompliance was cited.

Based on observations, interviews, resident record review, and review of a facility policy titled, Hand Hygiene, the facility failed to ensure Certified Nursing Assistant (CNA) #9, performed hand hygiene and used Personal Protective Equipment (PPE) in a manner to prevent cross-contamination. On 04/17/2024 CNA #9 failed to perform hand hygiene after removing contaminated gloves, and before handling clean linens while providing incontinent care for Resident Identifier (RI) #5. This deficient practice affected RI #5; one of one resident observed receiving incontinent care. Findings include: Review of a facility policy titled, Hand Hygiene, with an effective date of 06/11/2020, revealed the following: PURPOSE: To provide guidelines to employees for proper and appropriate hand washing techniques that will aide in the prevention of the transmission of infections. STANDARD: Handwashing should be performed between procedures with residents . based upon the principle that . body fluids, secretions, excretions . may contain transmissible infectious agents. PROCESS: . III. Hand Hygiene Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene. Before and after assisting a resident/guest with toileting . After handling soiled or used linens Consistent use by staff of proper hygienic practices and techniques is critical to preventing the spread of infections. RI #5 was originally admitted to the facility on [DATE]. On 04/17/2024 at 2:38 PM, CNA #8 and CNA #9 were observing providing incontinent care for RI #5. CNA #9 while wearing gloves, wiped bowel movement from RI #5's right buttocks, disposed of the incontinence wipe, and disposed of RI #5's wet brief. CNA #9 then straightened the clean linen and secured RI #5's clean brief while wearing the soiled gloves. On 04/17/2024 at 5:45 PM, CNA #9 was asked about hand hygiene and glove use. CNA #9 said, staff were supposed to change gloves and put on a new pair of gloves before touching clean items such as linen. CNA #9 was asked what was the risk of handling clean materials (such as linen) while wearing contaminated gloves. CNA #9 replied, spreading germ and body fluids. CNA #9 was asked when she performed incontinent care on RI #5, did she perform care the correct way. CNA #9 replied no, she did not change her gloves as often as she should have. On 04/18/2024 at 9:15 AM, the Infection Control Preventionist (IP) was interviewed. The IP was asked, according to the facility's policy, when was staff supposed to wash their hands. The IP replied, anytime hands were visibly soiled and before and after patient care. The IP was asked when should staff remove soiled gloves. The IP replied, between residents, before entering a hallway, and during and after perineal care. The IP was asked if staff should wear contaminated gloves when handling clean linen. The IP replied, no. The IP was asked what was the risk of picking up clean linen with dirty/soiled gloves on. The IP replied, spread of infection. On 04/18/2024 at 9:30 AM, the Staff Development Coordinator (SDC) was interviewed. The SDC was asked, according to the facility's policy, when was staff supposed to wash their hands. The SDC replied, before entering a resident room, after glove removal, and staff should sanitize their hands after leaving a resident's room. The SDC was asked what could be the risk of not washing your hands before entering a resident's room. The SDC replied, the spread of infection. The SDC was asked when should staff remove soiled gloves. The SDC replied, before touching clean linens, after perineal care and anytime staff touches a clean surface. The SDC was asked should staff be wearing contaminated gloves when handling clean linen. The SDC replied no. The SDC was asked what was the risk of picking up clean linen with dirty/soiled gloves on. The SDC replied, the linen becomes contaminated, and you could spread infection when placing it on the resident.

Based on observation, record review, interviews, and review of a facility policy titled Intramuscular Medications the facility failed to ensure Employee Identifier (EI) #2 Licensed Practical Nurse (LPN), provided privacy when administering intramuscular medication to Resident Identifier (RI) #15 during morning medication administration on 8/23/22. This deficient practice had the potential to affect RI #15, one of one resident observed receiving intramuscular medication. Findings Include: A facility policy titled Intramuscular Medications with a review date of 4/20 documented .Intramuscular medications are administered in a safe and accurate manner. Procedures . 6. Provide privacy. 7. Select an appropriate site for injection. RI #15 was admitted to the facility 12/7/18. On 8/23/22 at 9:05 AM, EI #2 LPN entered RI #15's room. RI #15 was in bed and RI #15's roommate was observed sitting in the middle of the room watching the nurse. Without closing the privacy curtain around RI #15's bed and between RI #15 and the roommate, EI #2 pulled back the covers and RI #15's gown, exposing RI #15's right leg. EI #2 cleaned the area on RI #15's right upper thigh with an alcohol prep and gave RI #15 an injection. The surveyor asked EI #2 how she should provide for privacy when administering intramuscular medication. EI #2 said, she should pull the privacy curtain. On 8/24/22 at 2:31 PM, the surveyor conducted an interview with EI #1, the Interim Director of Nursing. The surveyor asked EI #1 how should the nurse provide for privacy when administering intramuscular medication. EI #1 said by pulling the privacy curtains.

Based on observation, interviews and review of the facility's policies titled NON-CONTROLLED MEDICATION DESTRUCTION, and STORAGE OF MEDICATIONS AND BIOLOGICALS, the facility failed to ensure one medication card containing seven capsules labeled Ramipril/ [MEDICATION NAME] with an expiration date of 10/12/19 for Resident Identifier (RI) # 2 was not stored on the Medication Cart Two on 10/17/2019. The deficient practice affected one of two medication carts. Findings Include: Review of the facility policies titled, NON-CONTROLLED MEDICATION DESTRUCTION, dated 03/11, revealed, . expired medications . are destroyed or disposed of . and a facility policy titled, STORAGE OF MEDICATIONS AND BIOLOGICALS, dated 3/11, revealed . Procedure . 11. Outdated . medications . are removed from stock, disposed of . RI#2 was admitted to the facility on [DATE]. A [DIAGNOSES REDACTED]. Heart Failure. A Physician Order, dated 08/08/17, revealed on the (MONTH) 1, 2019- (MONTH) 31, 2019 orders, [MEDICATION NAME] 10 mg (milligram) capsule give one capsule by mouth daily. On 10/17/19 at 08:53 AM, the Surveyor observed a medication cart ( a binder labeled Cart Two) with Employee Identifier Number (EI)# 2 that revealed the following: 1. Ramipril / ([MEDICATION NAME]) 10 mg medication card (with 7 capsules remaining) labeled RI #2 with an expiration date of 10/12/19. On 10/17/19 at 9:00 AM, the Surveyor conducted an interview with EI #2, Licensed Practical Nurse. EI #2 was asked, what was the expiration date on the Ramipril card. EI #2 replied, 10/12/19. EI #2 was asked, where should the expired medication be stored. EI #2 replied, in the expired bin that the facility had in the medication storage room. EI #2 was asked, why was the expired medication stored in the medication cart. EI #2 replied, she was not sure; she had not been at the facility in a few days. EI #2 was asked, what was the potentially harm with the expired medication being stored on the medication cart with the resident's unexpired medication. EI #2 replied, the expired medication could be less effective or not as effective as the original dose if it were given. EI #2 was asked, what was the the facility's policy with storing expired medication on the medication cart. EI #2 replied, the expired medication was not to be stored on the medication cart. EI #2 continued, the policy was to remove the expired medication from the medication cart and destroy the expired medication. 10/17/19 04:05 PM, the Surveyor conducted an interview with EI #1, Director of Nursing. EI #1 was asked, where were expired medications stored. EI #1 replied, expired medication were stored in the destruction bin in the medication room. EI #1 was asked, what medications were stored on the medication carts, expired or unexpired. EI #1 replied, unexpired medications for current residents. EI# 1 was asked, why was an expired medication observed on Station Two medication cart on 10/17/19. EI #1 replied, it was previously unobserved by staff and identified that day as an expired medication and removed it from the cart. EI #1 continued, then the medication was replaced with a dose from the back up pharmacy. EI #1 was asked, what was the name of the expired medication observed on Station Two medication cart on 10/17/19. EI #1 replied, she was told the expired medication observed on Medication Cart Two was [MEDICATION NAME] and she was present when a replacement dose was requested from the backup pharmacy for RI #2 on 10/17/2109. EI #1 was asked, what was the potential harm with the expired medication stored on Station Two medication cart on 10/17/19. EI #1 replied, the potential for uncontrolled blood pressures if the expired medication was given to RI #2.

Based on observations, interview and a review of the Food Code U.S. Public Health Service and FDA (Food and Drug Administration) 2013 1. The facility failed to assure thermometers utilized for monitoring hot foods maintained on the trayline were accurately calibrated. One of three thermometers was not properly calibrated for use on the trayline. 2. The facility failed to assure effective cleaning/sanitizing of utensils and equipment to prevent the potential growth of food borne organisms. a. The facility failed to assure flatware (spoons) were air dried prior to use. b. The facility failed to assure the Robo Coupe blender was air dried prior to storage. c. The facility failed to assure dinnerware, sectional plates, was cleaned to sight/touch. d. The facility failed to assure equipment, a Tea urn/spigot (a non Time/Temperature control for safety), was cleaned every 24 hours. The spigot was observed with a brown solid buildup. The above practices posed the potential for food contamination and compromised food safety. This had the potential to affect all 60 residents who received meal trays from dining services. Findings include: 1. A review of the Food Code U.S. Public Health Service and FDA (Food and Drug Administration) 2013 revealed the following: Utensils and Temperature and Pressure Measuring Devices- 4-502.11 Good Repair and Calibration. (A) UTENSILS shall be maintained in a state of repair or condition that complies with the requirements . (B) FOOD TEMPERATURE MEASURING DEVICES shall be calibrated in accordance with manufacturer's specifications as necessary to ensure their accuracy. (B) FOOD TEMPERATURE MEASURING DEVICES shall be calibrated in accordance with manufacturer's specifications as necessary to ensure their accuracy. An observation was made on 11/14/2017 at the noon meal of the trayline temperature being monitored by the cook. The Cook EI #2 was observed to perform tasks with a thermometer which was not properly calibrated and resulted in substandard results. The Certified Dietary Manager (CDM) was interviewed on 11/16/17, relative to the thermometer. The CDM was asked about the regulatory requirement for accuracy of thermometer readings, when calibration should take place, who was responsible and to identify the risk factor. The CDM replied that the thermometer should be calibrated prior to trayline monitoring. The thermometer used was one of three for potential use and that one could not assure food was maintained on the trayline at standard temperatures. 2. The Food Code U.S. Public Health Service and FDA (Food and Drug Administration) 2013 revealed the following: Drying 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried or used after adequate draining as specified in . An observation on 11/14/2017 at 9:35 AM staff was observed processing flatware. The eating utensils were scattered in a flat tray, separated and placed into cylinders (approximately 60 count for spoons). The flatware was transported to the trayline. The CDM, Employee Identifier (EI) #1, removed a group of nested spoons, fanned them out and water droplets were observed inside the spoon bowl and food debris on the backs of the spoons. During an interview with EI #1 on 11/16/2017 at 10:15 AM, validation of the observed water inside the bowl, food debris and nesting was confirmed. EI #1 was asked what would be the potential risk (failure to air-dry). EI #1 verbalized that there would be a potential for bacterial growth. An observation was made on 11/13/2017 at 5:05 PM, of the blender stored on the stand with water pooled on the bottom and water droplets on the sides. At this time EI #1 was asked if the blender was air-dried. EI #1 replied, No it is not. EI #1 was asked: What was the regulatory requirement and the answer was (it) should be air-dried before storage. A review of the Food Code U.S. Public Health Service and FDA (Food and Drug Administration) 2013 revealed the following: Objective 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. On 11/14/2017 at 11:30 AM clean sanitized sectional plates were stored on the trayline. Three of the five were observed with dried food debris. An interview with the EI #1 on 11/16/2017 at 10:00 AM, EI #1 said there was potential risk was for bacterial growth. A review of the Food Code U.S. Public Health Service and FDA (Food and Drug Administration) 2013 revealed the following: Frequency 4-602.11 Equipment Food-Contact Surfaces and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be cleaned: (E)(2) At least every 24 hours for iced tea dispensers . An observation of the tea urn spigot was made on 11/13/2017 at 5:15 PM. EI #1 disassembled the tea urn and the plunger contained a solid brown buildup. EI #1 was asked if the spigot was clean and she stated No ma'am.

Based on observation, record review and interviews, the facility failed to ensure Resident Identifier (RI) #5, a resident with a history of weight loss, received a supplement with the lunch and supper meals on 10/31/16. This affected RI #5, one of eight sampled residents. Findings Include: RI #5 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #5's care plan titled (Name of RI #5) Potential for weight loss r/t [MEDICAL CONDITION]. with a Problem Onset date of 12/24/2013, documented the following approach: .*Provide snacks or supplements . The facility document titled, Dietary Review Form with (Name of RI #5) dated 08/23/2016 at 10:34 a.m., documented: . EATING/NUTRITION Supplements, snacks, and/or extra foods with and between meals Ice Cream @ lunch & supper . SUMMARY Review Summary . Resident receives Ice Cream @ Lunch & Supper . RI #5's Departmental Notes dated 08/23/2016 at 10:35 a.m., documented: Role: Dietary . Resident receives Ice Cream @ Lunch & Supper, . On 10/31/2016, at 11:48 a.m., the surveyor observed RI #5 sitting in the dining room eating (his/her) lunch meal. There was no ice cream observed with RI #5's lunch meal at this time. On 10/31/2016, at 5:30 p.m., the surveyor observed RI #5 sitting in the dining room eating (his/her) supper meal. There was no ice cream observed with RI #5's supper meal at this time. On 11/02/2016 at 10:31 a.m., the surveyor conducted an interview with Employee Identifier (EI) #3, a Certified Dietary Manager (CDM). The surveyor asked EI #3 why RI #5 was supposed to be receiving Ice Cream with lunch and supper. EI #3 replied, (RI #5) had a weight loss around June and that was an approach. The surveyor asked EI #3 why RI #5 didn't receive Ice Cream on (his/her) lunch tray and supper tray on 10/31/2016. EI #3 said, I've told my staff on certain ones not to give it on their tray and the CNAs (Certified Nursing Assistants) know to come and get it. The surveyor asked who is responsible for placing the ice cream on RI #5's tray. EI #3 responded, . It's probably our responsibility . The surveyor asked EI #3 what is the potential harm of RI #5 not receiving the ice cream. EI #3 replied, (RI #5) could lose weight again. On 11/02/2016 at 10:43 a.m., the surveyor conducted an interview with RI #5. The surveyor asked RI #5 if (he/she) received ice cream on (his/her) lunch and supper trays. RI #5 said, I'm supposed to, I think. The surveyor asked RI #5 if (he/she) had been receiving the ice cream. RI #5 replied, No Ma'am. I get drinks and desserts, but not ice cream. The surveyor asked RI #5 if (he/she) would eat the ice cream if they gave it to (him/her). RI #5 said, Oh, yes Ma'am. I like it.

Based on observation, interview and record review the facility failed to ensure the wheelchair (w/c) arm rests on Resident Identifier's (RI) 7, 10 and 11, were not torn, jagged and rough to the touch. RI #'s 7, 10 and 11 were identified by the facility to be on a blood thinning medication. This affected three of twelve sampled residents. Findings Include: The facility policy titled Incidents and Accident, effective date August 26, 2013, documented: PURPOSE: The resident environment remains as free of hazards as possible . Accidents may involve residents . STANDARD: .Examples include but are not limited to; . skin tears .equipment malfunctions causing injury to resident . On 10/31/16, during the initial tour, beginning at 10:30 am, the following observations were made: 1) The right and left w/c arm rests were torn, jagged and rough to the touch on RI # 11's w/c. RI #11 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #11's physician's orders [REDACTED]. .Coumadin 5 MG (milligrams) tablet give 1 tablet PO (by mouth) on FRI (Friday) . .Coumadin 7.5 MG tablet give 1 tablet PO Q (every) Sat (Saturday) DVT (Deep Vein Thrombosis) . .Coumadin 5 MG tablet give 1 tablet PO QPM SMTWTH . 2) RI #7's right w/c arm rest was jagged on the inside of the arm rest and rough to the touch. RI #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #7's physician's orders [REDACTED]. .Aspirin EC (extended capsule) 81 MG One tablet PO daily . 3) RI # 10's left w/c arm rest was torn and jagged and the right w/c arm rest had a small tear and these were rough to the touch. RI #10 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #10's physician's orders [REDACTED]. .Aspirin EC 81 MG Tablet One Tab PO QD (every day) Preventive . On 11/01/16 at 10:10 a.m., Employee Identifier (EI) #1, Director of Nurses, (DON) was asked who was responsible to report if w/c arm rest needed to be repaired. EI #1 replied the 11-7 p.m. shift washes the w/c and the 3-11 shift was good about reporting. EI #1 further commented the Restorative Nurse, should be monitoring that at least weekly. EI #1 was asked what could be the concern for a resident on a blood thinner with arm rests that were torn and jagged. EI #1 replied skin tears, bruising and they could bleed out. On 11/ at 2:00 p.m. EI #2, Restorative Nurse, was asked who was responsible to monitor w/c arm rests for repairs. EI #2 replied there was a w/c wash schedule on 11-7 shift. and those CNA's (Certified Nursing Assistants) should be the ones to report to maintenance. EI #2 was asked what could be the concern of a resident on a blood thinner with arm rests that were torn and jagged. EI #2 replied they could bleed out.

Based on observations, interviews and record review, the facility failed to ensure: 1. five 46 oz (ounce) Ready Care Thickened Diary Drink with a manufacture expiration date of 11/25/15 was discarded by 12/01/2015. 2. a container of peaches with an open date of 12-1-15 was labeled with a use by date. 3. two dietary aides washed their hands according to facility policy. This had the potential to affect 55 of 56 residents who receive meals from the kitchen Findings Include: 1. During the initial tour of the kitchen on 12/1/2015 at 9:48 AM, inside of the facility's refrigerator/cooler, five 46 oz Ready Care Thickened Diary Drink with a manufactures expiration date of 11/25/2015 was observed. Another observation was made on 12/1/2015 at 1:55 PM. The five 46 oz Ready Care Thickened Diary Drink with a manufactures expiration date of 11/25/2015 were no longer in the refrigerator. On 12/1/2015 at 2:00 PM, an interview was conducted with EI (Employee Identifier) # 3, Dietary Manager. EI #3 was asked why should expired food items be discarded. EI #3 explained the food item could be spoiled or contaminated. EI #3 was asked when should expired food items be discarded. EI #3 explained her staff normally discards expired food items when they notice them. EI #3 was asked where were the five 46 oz Ready Care Thickened Diary Drink with the manufacture expiration date of 11/25/2015. EI # 3 stated her staff discarded them on 12/1/2015. EI #3 was asked when should the five 46 oz Ready Care Thickened Diary Drink with the manufacture expiration date of 11/25/2015 have been discarded. EI #3 replied they should have been discarded on 11/25/2015. EI #3 was asked why were they not discarded on 11/25/2015. EI #3 stated they were overlooked. EI #3 was asked what was the potential harm in serving residents food products with expired manufacturing dates. EI #3 explained it could cause an illness or sickness from contamination. On 12/2/2015 at 2:54 PM, an interview was conducted with EI #4, Dietician. EI #4 was asked what was the facility's policy and procedure for labeling thickened liquid items when opened. EI # 4 explained that staff were to write the open date on the carton and within seven days staff was to discard the item per the manufactures recorded date. EI #4 was informed of the Ready Thickened Diary Drink with a manufactures expiration date of 11/25/2015. EI #4 was asked when should they have been discarded. EI #4 replied they should have been discarded on that date. 2. During the initial tour of the kitchen, inside of the facility's refrigerator/cooler, an observation was made of a container of peaches with a labeled date of 12/1/2015. A review of document titled, FOOD CODE U.S. Public Health Service FDA(Food and Drug Administration) 2013 revealed the following: 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking.(B) .at the time the original container is opened .indicate the date or day by which the food shall be consumed .discarded. On 12/2/2015 at 3:00 PM, an interview was conducted with EI #3. EI #3 was informed of a container of peaches with label dated 12/1/2015. EI # 3 was asked what was the date for. EI #3 explained that the label was the date the product was opened. EI #3 was asked what was the facility's policy and procedure for labeling. EI #3 explained staff were to put a opened and use by date on the container. EI #3 was asked was that done. EI #3 stated no. 3. During trayline on 12/2/2015 at 10:41 AM, an observation was made of EI #6, Dietary Aide. EI #6 was observed at the sink in the kitchen washing her hands and turning the faucet knobs off with her fingers, drying her hands off with a paper towel and placing clean gloves on and returning back to her kitchen duties. A review of a facility policy titled, DIETARY SERVICE MANUAL with an effective date of February 1, 2002 revealed the following: .Policy Title: Hand-washing Guidelines .PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses.II. Hand-washing Procedure: g. Dry hands and turn water off with paper towels touching faucet handles . An interview was conducted with EI #6 on 12/2/2015 at 12:44 PM. EI #6 was asked what was the facility's policy and procedure regarding washing hands. EI #6 explained that staff was to rinse first, lather up for 15 seconds, rinse soap off and dry hands off with paper towel and use the paper towel to turn the water off. EI #6 was asked if that was what she did. EI #6 replied no, she did it backwards. EI #6 was asked why should staff use paper towel to turn the faucet knobs off and not use their fingers to turn the knobs after washing their hands. EI #6 explained it was germs again placed on your hands. During trayline on 12/2/2015 at 11:09 AM, an observation was made of EI # 7, Dietary Aide/Cook. EI #7 was observed in the kitchen washing her hands at the sink and after washing her hands, EI #7 turned the faucet knob off with her fingers and proceeded to get paper towel from the motion sensor paper towel dispenser and dried her hands and threw the paper towel in the trash. On 12/2/2015 at 11:24 AM, another observation was made of EI #7 stepping away from the trayline, she took her gloves off and went to the sink to wash her hands. EI #7 washed her hands and turned the faucet knobs off and used the motion sensor paper towel dispenser to acquire paper towel, dried her hands and discarded the paper towel in the trash and placed a pair of clean gloves on and returned to the trayline. On 12/2/2015 at 12:30 PM, an interview was conducted with EI #7. EI #7 was asked what was the facility's policy and procedure regarding washing hands. EI #7 explained turn the water on, soap hands up, rinse off and grab and use paper towel and turn water off and throw paper towel in trash. EI #7 was asked was that what she did during trayline. EI #7 explained that she did it the opposite way so no. EI #7 was asked why should staff use paper towel to turn the faucet knobs off and not use their fingers to turn the knobs off after washing hands. EI #7 explained that it kept down germs and contamination. EI #7 was asked what was the potential harm to residents in not following the facility's policy and procedure for washing hands. EI #7 explained that residents could get sick.

Based on record review,observation and interviews, the facility failed to ensure a licensed staff member changed her gloves and washed her hands after touching a brief contaminated with bloody drainage and before touching a drawer, disposable wipes and performing RI (Resident Identifier) #7's perineal care on 12/02/2015. The facility further failed to ensure a licensed staff member changed gloves or washed her hands after cleaning bm (bowel movement) from RI #5 and before touching the resident's brief and pulling it up on 12/03/2015. The facility further failed to ensure a licensed staff member washed her hands or changed her gloves after applying skin prep to RI #6's unstageable wounds and before touching and applying the clean dressings. This affected RI #5, 6 and 7, three sampled residents observed receiving care from licensed staff members. Findings Include: A review of a document titled Centers for Disease Control and Prevention with a date of May 1, 2014 revealed: .Hand Hygiene Basic .Hand hygiene is one of the most important ways to prevent the spread of infections. Healthcare providers should practice hand hygiene at key points in time to disrupt the transmission of microorganisms to patients including: .after contact with blood, body fluid, or contaminated surfaces (even if gloves are worn); .after removing gloves (wearing gloves is not enough to prevent the transmission of pathogens in healthcare settings). A review of Potter and Perry's Fundamentals of Nursing, Chapter 28, Infection Prevention and Control, page 419 revealed: .Gloves help to prevent the transmission of pathogens by direct and indirect contact.Change gloves and perform hand hygiene between tasks and procedures on the same patient after contact with material that contains a high concentration of microorganisms. Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces . Perform hand hygiene immediately to avoid transfer of microorganisms to other patients or environments. 1.) RI #7 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #7's annual MDS (Minimum Data Set) with an Assessment Reference Date (ARD) of 08/03/2015 revealed a BIMS (Brief Interview for Mental Status) score of three which indicated RI #7 was severely impaired for daily decision making. The MDS also indicated that RI #7 was frequently incontinent of bladder and bowel. The MDS further indicated that RI #7 had one Stage 4 pressure ulcer. On 12/02/2015 at 3:40 PM, EI (Employee Identifier) #10, RN (Registered Nurse) Unit Manager/Infection Control was observed during wound and incontinent care with RI #7. EI #10 washed her hands and donned gloves. The brief was removed by EI #10 and she said it was not wet and small amount of bloody drainage in brief. EI #10 did not change her gloves or wash her hands and opened the drawer and obtained the wipes. EI #10 performed peri care on RI #7. RI #7 was turned to the right side and EI #10 wiped buttock area from front to back. EI #10 said there was bloody drainage to the wipe. EI #10 then took her gloves off and washed her hands. On 12/03/2015 at 2:15 PM, an interview was conducted with EI #10. EI #10 was asked what was the facility's policy on handwashing/gloving when going from dirty to clean. EI #10 said change between procedures. EI #10 was asked what was in the brief of RI #7 on 12/02/2015. EI #10 said small amount of bloody drainage. EI #10 was asked what was the potential harm in not changing her gloves or washing her hands when going from dirty to clean. EI #10 said infection control risk. EI #10 was asked after she removed the brief with bloody drainage what should she have done. EI #10 said changed my gloves and washed my hands. 2) RI #5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #5's most recent Annual MDS with an ARD of 3/16/2015 revealed the resident had a BIMS score of 9, which indicated the resident was moderately cognitively impaired for daily decision making. The MDS also revealed the resident required extensive assistance with toilet use and personal hygiene. On 12/3/2015 at 8:13 AM, EI #2, DON (Director of Nursing) was observed assisting RI #5 with perineal care after the resident had a bowel movement (bm). EI #2 was observed wearing gloves. EI #2 wiped the resident's buttocks from front to back with tissue and disposable wipes while a staff member assisted the resident to a standing position. EI #2 reached down and pulled the resident's brief up without changing her gloves or washing her hands. On 12/3/2015 at 4:28 PM, an interview was conducted with EI #2. EI #2 was asked what she should have done after she cleaned bm from the resident and before she touched the brief and pulled it up. EI #2 said remove her gloves. EI #2 was asked if she washed her hands or changed her gloves after cleaning bm from the resident and before she touched the brief and pulled it up. EI #2 said, No. EI #2 was asked what the potential harm was if she did not change her gloves and wash her hands after cleaning bm from the resident and before touching and pulling the resident's brief up. EI #2 said, Infection. 3) RI #6 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #6's most recent five day MDS with an ARD of 11/25/2015 revealed the resident had a BIMS score of 3, which indicated the resident was severely cognitively impaired for daily decision making. The MDS further revealed the resident required extensive assistance with ADLs (Activities of Daily Living). The MDS also revealed the resident had two unstaged pressure ulcers. On 12/3/2015 at 1:44 PM, EI #12 was observed providing wound care for RI #6. EI #12 applied skin prep to the resident's unstaged wound on the right heel. EI #12 touched and applied the [MEDICATION NAME] dressing to the right heel without changing her gloves or washing her hands. EI #12 followed the same procedure on the resident's left heel. On 12/3/2015 at 3:15 PM, an interview was conducted with EI #12. EI #12 was asked what should have been done after she applied skin prep to RI #6's unstaged wounds and before she touched and applied the [MEDICATION NAME] dressing. EI #12 said, Remove my gloves and wash my hands. EI #12 was asked if she washed her hands or changed her gloves after applying skin prep to the resident's unstaged wounds and before she touched and applied the [MEDICATION NAME] dressing. EI #12 said, No, I didn't. EI #12 was asked why she did not wash her hands or change her gloves after she applied skin prep and before she applied the [MEDICATION NAME] dressing. EI #12 said, I wasn't thinking. EI #12 was asked what the potential harm was if she did not wash her hands or change her gloves after she applied skin prep and before she applied the [MEDICATION NAME] dressing. EI #12 said, Infection. On 12/3/15 at 4:28 PM, an interview was conducted with EI #2. EI #2 was asked what should be done after a nurse put skin prep on an unstaged wound and before touching and applying a clean dressing. EI #2 said, Pulled gloves off, washed hands and put on new gloves. EI #2 was asked if it was an acceptable practice of that facility for a nurse to apply skin prep on an unstaged wound and then touch and apply a clean dressing without changing gloves or washing hands. EI #2 said, No. EI #2 was asked what the potential harm was if a nurse applied skin prep to an unstaged wound and then touched and applied a clean dressing. EI #2 said, She could contaminate the clean dressing.

Based on record review, observation and interview, the facility failed to ensure RI (Resident Identifier) #6 received wound care in a manner to prevent infection. EI (Employee Identifier) #12, RN (Registered Nurse) Wound Nurse was observed placing a clean dressing on the resident's wound without washing her hands or changing her gloves after she applied skin prep to the resident's wound. This affected RI #6, one of two residents observed during wound care. Findings Include: A review of Potter and Perry's FUNDAMENTALS OF NURSING EIGHTH EDITION, CHAPTER 28, Infection Prevention and Control, page 419 revealed: .Change gloves and perform hand hygiene between tasks and procedures on the same patient after contact with material that contains a high concentration of microorganisms. Remove gloves promptly after use, before touching noncontaminated items .Perform hand hygiene immediately to avoid transfer of microorganisms . RI #6 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #6's most recent five day MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 11/25/2015 revealed the resident had a BIMS (Brief Interview for Mental Status) score of 3, which indicated the resident was severely cognitively impaired for daily decision making. The MDS further revealed the resident required extensive assistance with ADLs (Activities of Daily Living). The MDS also revealed the resident had two unstaged pressure ulcers. On 12/3/2015 at 1:44 PM, EI #12 was observed providing wound care for RI #6. EI #12 applied skin prep to the resident's right heel unstaged wound. EI #12 touched and applied the [MEDICATION NAME] dressing to the right heel without changing her gloves or washing her hands. EI #12 followed the same process on the resident's left heel. On 12/3/2015 at 3:15 PM, an interview was conducted with EI #12. EI #12 was asked what should have been done after she applied skin prep to RI #6's unstaged wounds and before she touched and applied the [MEDICATION NAME] dressing. EI #12 said, Remove my gloves and wash my hands. EI #12 was asked if she washed her hands or changed her gloves after applying skin prep to the resident's unstaged wounds and before she touched and applied the [MEDICATION NAME] dressing. EI #12 said, No, I didn't. EI #12 was asked why she did not wash her hands or change her gloves after she applied skin prep and before she applied the [MEDICATION NAME] dressing. EI #12 said, I wasn't thinking. EI #12 was asked what the potential harm was if she did not wash her hands or change her gloves after she applied skin prep and before she applied the [MEDICATION NAME] dressing. EI #12 said, Infection. On 12/3/15 at 4:28 PM, an interview was conducted with EI #2, DON (Director of Nursing). EI #2 was asked what should be done after a nurse put skin prep on an unstaged wound and before touching and applying a clean dressing. EI #2 said, Pulled gloves off, washed hands and put on new gloves. EI #2 was asked if it was an acceptable practice of that facility for a nurse to apply skin prep on an unstaged wound and then touch and apply a clean dressing without changing gloves or washing hands. EI #2 said, No. EI #2 was asked what the potential harm was if a nurse applied skin prep to an unstaged wound and then touched and applied a clean dressing. EI #2 said, She could contaminate the clean dressing.

Based on record review, observation and interview, the facility failed to ensure RI (Resident Identifier) #6 received oxygen according to physician's orders on 12/1/2015 and 12/2/2015. RI #6 was observed wearing O2 (Oxygen) at 3 liters (L) per nasal cannula (NC) on both days, when the physician orders stated the resident was to receive O2 at 2 liters per nasal cannula. This affected RI #6, a resident observed wearing oxygen. Findings Include: A review of the Alabama Board of Nursing Alabama Administrative Code Chapter 610-X-6 Standards of Nursing Practice revealed: .610-X-6-.04 Practice of Professional Nursing (Registered Nurse Practice) (1) The practice of professional nursing includes, but is not limited to: . (g) Executing medical regimens including administering medications and treatments prescribed by a licensed or otherwise legally authorized prescriber. 610-X-6-.05 Practice of Practical Nursing (Licensed Practical Nurse Practice) (1) the practice of practical nursing includes, but is not limited to: . (f) Administering medications and treatments when ordered by a legally authorized prescriber. A review of a facility policy titled, Oxygen Administration with an effective date of December 8, 2005 revealed: .STANDARD: Oxygen should be be administered under orders of the attending physician, . RI #6 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #6's most recent five day assessment with an ARD (Assessment Reference Date) of 11/25/2015 revealed the resident had a BIMS (Brief Interview for Mental Status Score) of 3, which indicated the resident was severely cognitively impaired for daily decision making. The MDS also revealed the resident was receiving oxygen. A review of RI #6's physician's orders for the month of December revealed: .OXYGEN @ (AT) 2L/MIN (MINUTE) PER NC PRN (AS NEEDED) FOR SHORTNESS OF BREATH . On 12/1/2015 at 11:00 AM, during initial tour, RI #6 was observed wearing O2@3L/NC. On 12/1/2015 at 5:13 PM, RI #6 was observed wearing O2@3L/NC. On 12/2/2015 at 8:28 AM, RI #6 was observed wearing O2@3L/NC. On 12/2/2015 at 10:00 AM, RI #6 was observed wearing O2@3L/NC. On 12/2/2015 at 11:59 AM, an interview was conducted with EI (Employee Identifier) #9, LPN (Licensed Practical Nurse),Charge Nurse. EI #9 was asked how many liters of O2 was RI #6 receiving at that time. EI #9 said 3L. EI #9 was asked how many liters should the resident be receiving according to the December physician's orders. EI #9 said the resident should be on 3L because the doctor changed the order that morning. EI #9 was asked how long RI #6 had been on 3L of O2. EI #9 said she knew the resident was on it that day. EI #9 said she should have looked to ensure it was on the right amount of O2 on the other days but she did not check it. EI #9 was asked who was responsible for making sure RI #6's O2 was accurate according to physician's orders. EI #9 said she was. EI #9 was asked who was responsible for making sure RI #6's physician's orders were followed. EI #9 said she was. EI #9 was asked if the resident was getting 3L of O2 on 12/1/2015 and the order was for 2L of O2, were physician's orders being followed. EI #9 said no, because the doctor did not change the order till the morning of 12/2/2015. EI #9 was asked what time was the order written for 3L of O2 on 12/2/2015. EI #9 said 10:18 AM. EI #9 was asked if she turned the O2 to 3L after the physician order was written. EI #9 said she did not change it. EI #9 said EI #10 (Registered Nurse) RN, Unit Manager told her it had changed to 3L. EI #9 was asked what was the potential harm in not following physician's orders. EI #9 said it could cause issues for the resident if she was not following the amount that the doctor said was correct for the resident. On 12/2/2015 at 2:36 AM, an interview was conducted with EI #10. EI #10 was asked how many liters of O2 did RI #6 receive by NC. EI #10 said as of that day, 3L. EI #10 was asked why the resident's order for O2 changed to 3L that day. EI #10 said because of shortness of breath, trouble breathing and a coughing episode. EI #10 was asked what time was the O2 concentrator physically changed to 3L that day. EI #10 said she did not know, she said EI #2, DON (Director of Nursing) told her it was at 3L. EI #10 was asked if RI #6's physician's orders were followed since the resident was on 3L of O2 per NC on 12/1/2015 and 12/2/2015 and the order was for O2 @ 2L/NC. EI #10 said, No ma'am. EI #10 was asked if a physician's order was supposed to be followed as it was written. EI #10 said, Yes ma'am it is. EI #10 was asked who was responsible for making sure RI #6's O2 orders were followed. EI #10 said nursing staff. On 12/3/2015 at 3:11 PM, a telephone interview was conducted with EI #11, LPN. EI #11 was asked if she had taken care of RI #6 on 11/30/2015 on the 7PM to 7 AM shift. EI #11 said yes. EI #11 was asked if she changed the resident's O2 to 3L on the O2 concentrator. EI #11 said no, she did not. EI #11 was asked if anyone changed the O2 that night. EI #11 said not to her knowledge. EI #11 was asked how many liters of O2 was RI #6 receiving according to physician's orders. EI #11 said 2L/NC. On 12/3/2015 at 4:19 PM, an interview was conducted with EI #2. EI #2 was asked how many liters of O2 was RI #6 receiving. EI #2 said right then he was on 3L. EI #2 was asked when was RI #6's O2 order changed to 3L. EI #2 said yesterday. EI #2 was asked why did the O2 order change to 3L. EI #2 said because of coughing episodes and the resident could not get sputum up. EI #2 was asked who physically put the concentrator on 3L when the order was written. EI #2 said she did not put it on 3L. She stated EI #10 told her someone put it on 3L. EI #2 was asked if the resident's physician's orders were followed since the resident was observed wearing O2 at 3L/NC for two days and the physician's orders were for O2 @ 2L/NC. EI #2 said, No, because RI #6 should have been on 2L. EI #2 was asked what was the resident's O2 sat (saturation) before she called the doctor. EI #2 said she did not check it. EI #2 was asked if she did not check the resident's O2 sat, how did she know it needed to be increased. EI #2 said the resident was struggling and she thought it needed to be increased. EI #2 said she probably should have checked the resident's O2 sat. EI #2 was asked if she felt like the resident was struggling with breathing, why would she not check the O2 sat. EI #2 said, I just didn't. EI #2 was asked if the O2 was already on 3L/NC when she called the doctor to get the order. EI #2 said she did not check it.EI #2 was asked when a physician wrote an order, should it be followed as it was written. EI #2 said, Oh yes, definitely.

Based on record review, observation and interview, the facility failed to ensure a CNA (Certified Nursing Assistant), EI (Employee Identifier) #8, knocked on RI (Resident Identifier) #6's door prior to entering on 12/2/2015. The facility also failed to ensure EI #8 was seated when assisting RI #6 with eating during the evening meal on 12/2/2015. The facility further failed to ensure two staff members knocked on RI #5's door prior to entering on 12/3/2015. This affected two of 14 sampled residents who reside in the facility. Findings Include: A review of a facility policy titled, Privacy Upon Entering Resident's Room with an effective date of November 6, 2014 revealed: .PROCESS: 1. Prior to entering Resident's room, knock on door and ask permission to enter. 1. RI #6 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #6's most recent five day assessment with an ARD (Assessment Reference Date) of 11/25/2015 revealed the resident had a BIMS (Brief Interview for Mental Status Score) of 3, which indicated the resident was severely cognitively impaired for daily decision making. On 12/2/2015 at 6:02 PM, EI #8 was observed entering RI #6's room without knocking on the door. EI #8 exited the room at 6:04 PM. At 6:06 PM, EI #8 was again observed to enter RI #6's room without knocking. On 12/2/2015 at 6:08 PM, EI #8 was observed standing at RI #6's bedside, feeding sherbet to the resident. On 12/2/2015 at 6:13 PM, an interview was conducted with EI #8. EI #8 was asked what she should do before she entered a resident's room. EI #8 said knock. EI #8 was asked if she knocked on RI #6's room door before she entered. EI #8 said, Because the door was open, I did not knock. EI #8 was asked if she should have knocked on the door before she entered. EI #8 said,Yes. EI #8 was asked what was the potential harm if she did not knock on a resident's door before entering. EI #8 said it was a privacy issue and the resident could have a guest, wife, husband or lawyer present. EI #8 said she would not want someone to come into her home without knocking. EI #8 was asked in what position should she be in when assisting a resident to eat. EI #8 said she usually stood by the bed. EI #8 was asked in what position she was in when feeding the sherbet to RI #6. EI #8 said she was standing on the right side of the bed. EI #8 was asked if she should have been sitting when feeding RI #6. EI #8 said she sat when she was assisting with feeding in the dining room and she stood when she assisted with feeding on the hall. EI #8 was asked what was the potential harm if she stood and fed a resident. EI #8 said they (the resident) may think that she was rushing them. On 12/3/2015 at 2:47 PM, an interview was conducted with EI #2, DON (Director of Nursing). EI #2 was asked what was supposed to be done before staff entered a resident's room. EI #2 said they should knock on the door and ask permission to enter. EI #2 was asked what was the potential harm if a staff member entered a resident's room without knocking. EI #2 said it was an invasion of privacy. EI #2 was asked how were staff supposed to be positioned when feeding a resident. EI #2 said the staff member was supposed to be sitting. EI #2 was asked what was the potential harm if a staff member stood to feed a resident. EI #2 said the resident may feel rushed, like the staff member was rushing them by standing over them. 2. RI #5 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/3/2015 at 8:10 AM, an observation was made of EI # 2 and EI # 5 entering RI #5's room to assist him/her with toileting without knocking prior to entering RI #5's room. On 12/3/2015 at 8:21 AM, an interview was conducted with EI #2. EI #2 was asked what was the facility's policy and procedure for entering residents' rooms. EI #2 stated that staff was to knock on the resident's door and ask for permission to enter. EI #2 was asked if that was what she did upon entering RI #5's room. EI #2 stated no she did not. EI #2 was asked why should staff knock prior to entering a resident's room. EI #2 explained that it was their private room and their privacy. EI #2 was asked what was the potential harm in not knocking on a resident's door prior to entering. EI #2 explained that it could violate the resident's privacy or if staff was assisting the resident staff could expose the resident or the resident could be behind the door. On 12/3/2015 at 8:26 AM, an interview was conducted with EI #5,CNA. EI #5 was asked what was the facility's policy and procedure for entering a resident's room. EI #5 explained that staff was to knock on the door and tell the resident who they were and what the staff was about to do. EI #5 was asked was that what she did upon entering RI #5's room. EI #5 stated no. EI #5 was asked why should staff knock prior to entering a resident's room. EI #5 stated that it was the resident's home. EI #5 was asked what was the potential harm to the resident not to knock on residents' doors prior to entering. EI #5 explained it was invading the resident's privacy and staff could be interrupting the resident.

Based on observations, interviews and record review, the facility failed to ensure the notice of survey result availability was posted in a common area frequented by all residents in the facility. This had the potential to affect all residents residing in the facility. Findings Include: On 12/01/2015 at 3:00 PM, a Resident Council Group Interview was conducted with 10 residents present. Residents were asked where the survey results were located in the facility. All 10 residents did not know where the survey result report was kept. On 12/1/2015 at 4:20 PM, an observation was made of survey results binder located on a table near the front door with no sign posted. There were no posting of notice of location availability of survey results on the different wings of the facility nor near the dining area. On 12/02/2015 at 8:05 AM, an observation was made of survey results binder located on a table near the front door with no sign posted. On 12/03/2015 at 8:35 AM, another observation was made of the survey results binder located on a table near the front door with no notice posted of survey result availability and location. A review of facility documents titled, Resident Council Meeting Minutes dated October 23, 2014 through November 24, 2015 did not indicate staff educated or discussed survey results or survey results availability to residents attending Resident Council meetings. On 12/3/2015 at 1:30 PM, an interview was conducted with EI (Employee Identifier) #1, Administrator. EI #1 was asked who was responsible for posting notice of survey results availability. EI #1 explained that she was or Social Service but she was primarily responsible. EI #1 was asked how residents knew where the survey results were. EI #1 explained that the facility told the residents in Resident Council and let the family know. EI #1 was asked what about the residents that did not attend Resident Council meetings. EI #1 explained that if the residents did not attend Resident Council meetings the results were on a table in the front lobby. EI #1 also explained that residents were educated at Care Plan meetings. EI #1 was informed of the 10 residents that were present at the Resident Council Group meeting on 12/1/2015. EI #1 was asked why the residents that were present for the meeting did not know where the survey results were located. EI #1 stated that she did not know why they did not know because results were accessible at the front door next to the Resident Family Information board. EI #1 was asked why should there be a posting of the location of survey results. EI #1 explained that results are accessible and that she did not feel that a posting was necessary because they were readily accessible at the Resident Family Information board on the table. At 1:40 PM EI #1 took the surveyor to the private phone room with a closed door. Inside the private telephone room, there was a red paper posted with the location of the survey results. This private telephone room is used by residents that want privacy for placing telephone calls. On 12/3/2015 at 2:30 PM, EI #1 was asked if the facility had documentation that survey information was sent to residents' families. EI #1 stated no they did not have copies of letters or documentation.

Based on record review and interview, the facility failed to ensure the physician order [REDACTED].#10's hypoglycemic medication was accurately transcribed. This affected RI #10, one of 13 residents sampled. Findings Include: The facility's policy titled "Medication Administration Preparation for Medication Administration" dated March 2011 documented " ... Procedures ... 5. Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label. If the label and MAR are different ... the physician's orders [REDACTED]." RI #10 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 9/19/14 at 6:58 AM, the physician made a hand-written note on the facsimile (fax) to change RI #10's [MEDICATION NAME] 2.5-500 milligram (mg) to one tablet everyday. RI #10's "Physician order [REDACTED]." RI #10's Medication Administration Record (MAR) for October 2014 documented " ... [MEDICATION NAME]-[MEDICATION NAME] 2.5-250 MG ONE PO QDAY ... ." In an interview on 10/29/14 at 12:30 PM, Employee Identifier (EI) #1, the Director of Nursing (DON) was asked what is the dosage and frequency of RI #10's [MEDICATION NAME] medication. EI #1 stated it is supposed to be 2.5-500 mg every day. When asked when was the order written, EI #1 replied it was 10/16/14, but it was transcribed incorrectly. RI #10's "Departmental Notes" written by EI #1, the DON dated 10/29/14 1:16 PM, documented " ... During med pass this am (morning) it was noted that resident's oral hypoglycemic medication dosage did not match what was ordered on MAR. MD was notified and correct dosage was verified ... Order was updated on MAR and faxed to pharmacy ... ." The "TRANSMISSION VERIFICATION REPORT" indicated on 10/29/14 at 1:17 PM, RI #10's order for [MEDICATION NAME]-[MEDICATION NAME] 2.5-500 mg one tablet by mouth every day was faxed to the pharmacy by EI #1.

Based on interview and record review, the facility failed to ensure RI (Resident Identifier) #17 was given the opportunity to attend her Care Plan meeting. The facility also failed to ensure an interdisciplinary Care Plan meeting was held for RI #17's quarterly MDS (Minimum Data Set) review in September 2012. This affected one of five residents sampled for Social Services.Findings Include:A review of the facility's policy titled, "Care Plans" (dated 10/01/10) revealed:"Purpose: Plans of Care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals for the resident....The interdisciplinary plan of care committee may consist of:Nursing personnel having knowledge of the residentActivities DirectorSocial Services DirectorDietary Manager/RD (Registered Dietitian)Licensed TherapistsAttending PhysicianThe residentResident's family members, as desired by the residentOther personnel involved in the resident's care are encouraged to participate. ... Process: ... II. Preparation for Care Plan Committee Meetings a) ...The seven day requirement for completion of a care plan, after development of the RAI (Resident Assessment Instrument), applies to admission, quarterly, annual and significant change of condition assessments.... c) The Social Service, or other designee, should inform the residents and families of the scheduled meeting, by mailing Notice of Scheduled Plan of Care Conference to family members or legal representatives, as meeting notice. ... III. Conducting the Interdisciplinary Care Plan Meeting a) The team, including the resident when possible, should present findings from assessments, using information from the RAI, and discuss suggested new goals or approaches, as appropriate. Existing goals and approaches should be reviewed and revised as needed. Any input gained from the resident should be recorded in the plan of care and the resident should sign the care plan acknowledging their involvement. ..."A resident group meeting was held on 01/09/13 at 3:00 PM, with seven residents who were identified by the Activity Director as alert, oriented, and interviewable. The residents were asked if they were invited to attend their Care Plan meetings. RI #17 said she was not even aware of a Care Plan meeting.RI #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].RI #17's Admission MDS assessment (dated 06/19/12) revealed she was able to make herself understood and was able to understand others, with clear comprehension. A review of the MDS calendar revealed RI #17's Quarterly MDS assessment was due on September 4, 2012. (A resident's Care Plan meeting is held after the assessment is completed.) A review of RI #17's Quarterly MDS (dated 09/04/12) was completed. However, a review of RI #17's "Care Plan Attendance Form" revealed the only Care Plan meeting that had taken place regarding RI #17 was in June 2012, upon her admission to the facility. On 01/10/13 at 11:00 AM, RI #17 was asked if it bothered her that she did not get invited to her Care Plan meeting. She replied, "Yes. It does." RI #17 was asked if she would like to have the choice to go. She responded, "Yes." RI #17 was asked if she would attend the meeting if she was invited. She stated, "Yes."On 01/10/13 at 11:25 AM, EI #2 (Director of Social Services) was asked who was responsible for inviting residents to their Care Plan meetings. EI #2 said she was. EI #2 was asked what the process was. EI #2 said she prints out a form that she sends to the sponsor and a copy is placed in the resident's room. EI #2 explained that she also verbally tells all the residents, then reminds the alert residents a day or two before the meeting. EI #2 was asked if RI #17 was invited to her Care Plan meeting. EI #2 said she was not. EI #2 was asked why. She said RI #17's first quarterly Care Plan meeting was due in September 2012, but she could not get any response from the sponsor. EI #2 was asked if the Care Plan meeting took place. EI #2 said it did not, because she could never get in touch with the sponsor. EI #2 was asked if RI #17 received the notice about the meeting. EI #2 replied, "No, because it never got scheduled." EI #2 was asked who was responsible for making sure the Care Plan meeting takes place. She responded, "I am." EI #2 was informed it was a concern that RI #17 did not get invited to her Care Plan meeting. EI #2 said she understood that the time lapse violated RI #17's rights.On 01/10/13 at 12:25 PM, EI #1 (Director of Nursing) was asked who was responsible for inviting residents to their Care Plan meetings. She said EI #2. EI #1 was asked who was responsible for ensuring the Care Plan meetings take place. She said EI #2 and the Care Plan team. EI #1 was asked if she was aware that RI #17's September Care Plan meeting never took place. EI #1 said she was not. EI #1 was asked what EI #2 should have done when the Care Plan meeting was due, but she had not been able to get in touch with the sponsor. EI #1 said they should have had the meeting with RI #17, because she is alert, oriented, and knows what is going on.

Based on observations, record review and interview: FOOD STORAGE; 1) The facility failed to assure that food received frozen remained frozen during storage. ( Food Code 3-501.11.) FOOD TEMPERATURES 2) The facility failed to assure hot foods were maintained at 135 degrees F or above when served from the trayline. 3) The facility failed to assure the dinnerware was clean and in good condition. The above practices posed the potential for food contamination and compromised food safety. These deficient practices had the potential to affect 58 residents who received food from dining services. Findings include: FOOD STORAGE; 1) The facility failed to assure that food received frozen remained frozen during storage. ( Food Code 3-501.11.) On 4/10/2012 at 11:45 AM, the ice cream stored in a chest freezer was observed. Three individual cups, stored in different areas of the freezer, were removed and pressure applied. Three of the three cups were soft to touch and finger indentions remained on the cups. Two of the three cups were selected to measure the internal temperature. The Certified Dietary Manager (CDM), Employee Identifier (EI) # 1 determined the internal temperature of one cup was +10 degrees Fahrenheit (F) and the second cup was + 20 degrees F. The facility documented monitoring of the storage chest freezer revealed for March 1 through March 9, the temperature of the chest measured -10 degrees F. FOOD TEMPERATURES 2) The facility failed to assure hot foods were maintained at 135 degrees F or above when served from the trayline. (Food Code 3-501.16) On 4/11/2012 at 11:55 AM, EI # 3 was observed heating soup on the gas range. She stated the soup was for 2 residents. At 12:00 noon, the soup was served to Resident Identifier # 4. The CDM, EI # 1, determined the temperature of the soup at that point was 130 degrees F. (Substandard) The heat had been turned off on the stove. 3) The facility failed to assure the dinnerware (four of five sectional plates) were clean and in good condition. On 4/10/2012 at 4:15 PM, an observation of the clean plates, stacked on a lowerator, was observed. Plastic sectional plates were inverted upside down on top of the regular plates. A request was made for the CDM, EI # 1, to select 5 plates from the stack. After observation, it was determined 2 plates were badly stained, one contained pooled water (not air dried) and one contained food debris.

Based on observations, record review and interview, it was determined the facility failed to implement the care plan for Resident Identifier (RI) # 2 on two of two meals observed. 1. RI # 2 was identified with a problem of Dysphagia and a planned approach was for the Registered Dietitian to consult monthly. 2. RI # 2 was identified by the facility with a second problem of potential weight loss related to a [DIAGNOSES REDACTED]. Findings include: 1. RI # 2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), dated [DATE], RI # 2 was assessed as having short and long-term memory problems and being severely impaired of cognitive skills for daily decision-making. The resident was identified with swallowing problems and required physical assistance with eating. A review of the care plan revealed the Dysphagia problem onset date was 4/17/2009. The problem had documentation of review from 5/20/09 through 11/9/11. A current approach was documented for the RD (Registered Dietitian) to consult monthly. A review of the facility departmental notes by the RD since the last survey revealed, documentation of contact/ review only once from 11/11/2011 through 4/12/12. She documented an evaluation of weight status and appropriateness of diet consistency on 1/6/2012. The MDS Coordinator EI # 5, the Certified Dietary Manager EI #1 and the on site RD EI # 4 were interviewed on April 12, 2012 at 4:30 PM. It was determined that the care plan approach for the RD to consult monthly was not followed. 2. RI # 2 had a problem of potential weight loss related to the [DIAGNOSES REDACTED]. The last care plan review date was documented as 11/09/11. Multiple approaches for this problem were documented such as provide set-up assistance, cueing, prompting and a divided plate with all meals. The resident was observed dining on 4/10/12 at 5:15 PM and again on 4/11/12, at 12:05 PM. No divided plate was observed to be used. The MDS Coordinator EI # 5, the Certified Dietary Manager EI #1 and the on site RD EI # 4 were interviewed on April 12, 2012 at 4:30 PM. It was determined that the care plan approach to use a divided plate was not followed.

Based on observation, record review and interview, it was determined the facility failed to maintain the outside garbage storage area in a sanitary manner to prevent the harborage and feeding of pests (doors were left open) and free of foul odors. (Food Code 5-502.11) and (Rules of State Board of Health, Bureau of Environmental Services p. 163). This deficient practice had the potential to affect all residents who reside in the facility. Findings include: The Food Code 5-502.11 revealed, "Refuse, Recyclables and Returnables, ...5-502.11 Removal ...shall be removed from the premises at a frequency that will minimize the development of objectionable odors and other conditions that attract or harbor insects and rodents." On 4/11/2012 at 9:45 AM, the outside garbage storage area was observed. Two green dumpsters were contained in a fenced area. The side door of one dumpster was observed open. The second dumpster emitted a foul odor. A request was made for the Certified Dietary Manager, Employee Identifier (EI) # 1, to open the door to the second dumpster. She was asked what she smelled. EI # 1 stepped back and said it smelled like .... A request was made for the facility to provide the waste contract, and the policy/procedure from dietary and maintenance services. On 4/11/2012 at 10:15 AM, the Administrator (EI) # 2 provided a service agreement. The document did not include a description and frequency of garbage pick up. The Administrator stated she did not have a policy/procedure for mal-odors, but she would talk with the people at the co-op. A maintenance policy and procedures relative to preventing the spread of infection, (policy number MP.1-8, item i) documented: "The dumpster lid should be kept closed". Though the lids were closed, access was available through the open door.