Every finding on record at Coosa Valley Healthcare Center

Based on observations, interviews, and review of the facility's policy titled, PREPARATION AND GENERAL GUIDELINES, the facility failed to ensure: 1) a licensed nurse did not place Resident Identifier (RI) #53's medication on the over bed table, then into her pocket, prior to placing the medication back into the medication cart; and 2) a licensed nurse washed her hands prior to preparing RI #31's medications. These failures affected RI #s 31 and 53, two of five residents, and two of four nurses, observed during medication administration observations. Findings Include: 1) On 6/12/19 at 4:34 p.m., during medication administration observations, Employee Identifier (EI) #3, a Licensed Practical Nurse, removed medication (eye drops) from the medication cart, placed the medication on RI #53's overbed table, then stored the medication in her pocket while administering other medications. EI #3 then returned to the medication cart and placed the eye drops back inside. A phone interview was conducted on 6/13/19 at 11:42 a.m. with EI #3. EI #3 was asked, what should be done before laying medication and supplies on the resident's overbed table. EI #3 stated, Usually it's cleaned off and I put a paper towel there. EI #3 was asked, did you do that yesterday. EI #3 stated, No ma'am. EI #3 was asked, after administering RI #53's eye drops, what did she do with them. EI # 3 stated, I put them in my pocket, then returned them to the med (medication) cart. EI #3 said she was not supposed to store things in her pocket because it could become contaminated. 2) A review of the facility's policy titled, PREPARATION AND GENERAL GUIDELINES, effective (MONTH) (YEAR), revealed: . MEDICATION ADMINISTRATION-GENERAL GUIDELINES Procedures . A. Preparation . 2) Handwashing and Hand Sanitation : The person administering medications adheres to good hand hygiene, which includes washing hands thoroughly: * before beginning a medication pass * prior to handling any medication . On 6/13/19 at 8:23 a.m., EI #4, a Licensed Practical Nurse, left the medication cart and went into the medication room, touching the door handles to the medication room and refrigerator. She then returned to the medication cart and began preparing medications for RI #31 without washing her hands. An interview was conducted on 6/13/19 at 9:10 a.m. with EI #4. EI #4 was asked, before starting to prepare medications, what should be done. EI #4 stated, Wash my hands. EI #4 was asked what she should have done after returning from the medication room, before continuing to prepare RI #31's medications. EI #4 stated, Wash my hands. EI #4 was asked, what is the potential for harm. EI #4 stated, Cross Contamination.

Based on observation, interviews, and review of the facility policy titled . SUBJECT: Food and Supply Storage Procedures and review of the (YEAR) Food Code, the facility failed to ensure: 1.) a dented can of pineapple chunks was removed from stock rotation; 2.) Glucerna TF was not stored past the manufacturer's use by date; and 3.) raw chicken was not stored directly over coed/prepared pork tenderloins. These failures had the potential to affect all 60 residents receiving meals from the dietary department. Findings include: Review of the undated facility policy titled . SUBJECT: Food and Supply Storage Procedures revealed the following: . POLICY: Dry Storage * . Remove Dented Cans and place in dented can area for credit and discard. * Remove from storage any items for which the expiration date has expired. * . Store cooked meat above raw meat. On [DATE] at 8:38 AM a can of pineapple chunks was observed on a shelf in the dry storage area in rotation for use. The can had a large dent on the bottom, side of can. The dry storage area also had two cases of expired tube feeding formula (Glucerna 1.2 Cal). The cases had a manufacturer's use by date of [DATE]. On [DATE] at 8:49 AM a rack containing trays of cooked pork tenderloins and raw chicken was observed in the walk-in cooler. The rack had a plastic tray with cooked pork tenderloins, and on each of the three shelves above the cooked pork were sheet pan of raw chicken breasts with blood-colored juices on the pans. Employee Identifier (EI) #1, Dietary staff, confirmed the raw chicken was stored over top of the cooked pork and said raw items should not be stored over cooked items because it could cause contamination.- EI #2, the Dietitian, was interviewed on [DATE] at 8:29 AM. EI #2 said it was important to ensure canned food items did not have dents because of the possibility of the seal being compromised. EI #2 also stated items should be checked on an ongoing basis for use by dates. EI #2 said the Glucerna should not have been stored past the use by date because it exceeded the manufacturer's quality standard. when asked how cooked and raw meat should be stored, EI #2 said raw meat should always be stored on the bottom, with cooked meat above it due to the potential for contamination.

The facility failed to ensure Resident Identifier (RI) #12 was assessed to determine the need for side rails and the risk of entrapment prior to utilizing two upper side rails. Further the facility failed to obtain informed consent prior to applying side rails for RI #12. This affected RI #12 one of one resident sampled for siderail use but had the potential to affect 28 of 64 total residents in the facility identified by staff as using side rails. Findings include: RI #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #12's Quarterly Minimum Data Set Assessment, with an Assessment Reference Date of 03/22/2018, indicated RI #12 had short and long term memory impairment and severely impaired cognitive skills for daily decision making. This assessment also documented RI #12 as totally dependent on staff for bed mobility and transfers. RI #12's comprehensive care plans included a care plan for Falls, with a modify date of 01/11/2018. This care plan included an intervention for . 2. SIDE RAILS RAISED x (times) . The care plan did not specify the number or size of siderails to be used. On 6/6/18 at 9:30 AM RI #12 was observed in bed with 1/4 (quarter) side rails up times two. Employee Idenifiter (EI) #3, Registered Nurse (RN), was interviewed on 6/07/18 at 3:43 PM. When asked what purpose RI #12's side rails served, EI #3 said they were for safety. When asked which siderails should be used, EI #3 said the top ones, but was unsure what size rails should be used. EI #3 said the care plan should reflect the size of siderails and which ones to use, but after reviewing RI #12's care plans, said they did not reflect that. EI #3 also confirmed RI #12 was not able to use the side rails. When asked if she could provide evidence the resident was assessed to determine the risk of entrapment, EI #3 said she could provide a fall risk assessment, but it did not address entrapment, only confusion and falls. When asked if residents should be assessed to determine if side rails were appropriate for them, EI #3 said the facility only used one size of side rail, and it was not individualized for each resident's needs. EI #5, the Interim Director of Nursing, was asked to explain the facility's process for determining whether a resident requires the use of siderails on 6/07/18 3:52 PM . EI #5 said she came to the facility in mid (MONTH) of (YEAR) and had determined the facility was not using an assessment tool for siderails. She also said she was working on a policy, but neither the policy or the assessment for siderails had been implemented yet. When asked how the size of siderail a resident requires should be determined, EI #5 said therapy should be involved in that decision, but that had not yet been implemented. During a follow-up interview with EI #5 on 6/07/18 at 4:55 PM, the Interim Director of Nursing said RI #12 should have two top siderails up, but did not know what size. EI #5 further stated RI #12 had not been assessed for the risk of entrapment; nor did the facility have informed consent for the use of the side rails. On 6/07/18 at 5:18 PM, EI #5 stated the facility did not currently have a policy addressing siderail use. She further said none of the 28 residents identified by the facility as utilizing siderails had informed consent for the use of their side rails.

Based on observation, record review and interviews, the facility failed to ensure an individualized care plan was developed to address Resident Identifier (RI) #12's use of side rails. This affected one of 16 sampled residents for whom care plans were reviewed. Findings include: RI #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #12's Quarterly Minimum Data Set Assessment, with an Assessment Reference Date of 03/22/2018, indicated RI #12 had short and long term memory impairment and severely impaired cognitive skills for daily decision making. This assessment also documented RI #12 as totally dependent on staff for bed mobility and transfers. RI #12's comprehensive care plans included a care plan for Falls, with a modify date of 01/11/2018. This care plan included an intervention for . 2. SIDE RAILS RAISED x (times) . The care plan did not specify the number or size of siderails to be used. On 6/6/18 at 9:30 AM RI #12 was observed in bed with 1/4 (quarter) side rails up times two. Employee Idenifiter (EI) #3, Registered Nurse (RN), was interviewed on 6/07/18 at 3:43 PM. When asked what purpose RI #12's side rails served, EI #3 said they were for safety. When asked which siderails should be used, EI #3 said the top ones, but was unsure what size rails should be used. EI #3 said the care plan should reflect the size of siderails and which ones to use, but after reviewing RI #12's care plans, said they did not reflect that. EI #4, the Minimum Data Set/ Care Plan Coordinator, was interviewed on 6/07/18 at 4:18 PM. EI #4 said the purpose of a resident's care plans was to ensure you know everything the resident needs, including all care needs. She explained the approaches should reflect the personal choices, likes, dislikes, diagnoses, and care areas for each resident. EI #4 said all care plans should be patient centered. When asked if RI #12's care plans were individualized for the use of side rails, EI #4 said, no not for side rails.

Based on observations, interviews and review of a facility policy titled, Gloving, the facility failed to ensure a licensed staff member wore gloves when administering a subcutaneous injection to Resident Identifier (RI) #7 on 6/06/2018. This affected one of three residents observed for subcutaneous injections during medication administration observations. Findings include: Review of a facility policy titled: Gloving, with an effective date of 8/2005 revealed: . I. Indications A. To reduce the possibility that personnel will become infected with microorganisms, to reduce the likelihood that personnel will transmit their own endogenous microbial flora to resident . II. A. All employees who come in direct contact with blood or body fluids are to wear gloves . B. Gloves should be worn for any procedure requiring aseptic technique. On 6/06/18 at 4:32 PM, Employee Identifier (EI) #6, Licensed Practical Nurse (LPN), was observed administering a subcutaneous injection to RI #7. EI #6 did not wear any gloves for the administration of the injection. EI #6 was interviewed on 6/07/18 at 3:39 PM. When asked what the facility's policy indicated about when gloves should be worn, EI #6 was unsure; however, after reviewing the policy, EI #6 said gloves should be worn anytime a procedure requires aseptic technique. EI #6 said gloves should be worn when administering a subcutaneous injection to prevent cross contamination.

Based on record reviews, observations, interviews and a review of facility policies titled Food And Supply Storage Procedures, Cleaning and Sanitizing Flatware, Trayline/Taste/Temperature Record, Product Labeling and Dating, and review of a document titled 'Menu Week, the facility failed to ensure: 1. chicken wings, beef burgers and fish patties were sealed in a box in the freezer, 2. chocolate icing in a container in dry storage was sealed, 3. dented cans were not stored with regular cans, 4. a mighty shake in the cooler had not expired, 5. utensils in a canister were not wet and the staff did not wrap the utensil while wet, 6. milk temperatures were taken and recorded on the temperature guide sheet, 7. a jar of jelly was labeled with an open and use by date and stored in the refrigerator, and 8. pimentos in the refrigerator were labeled with an open and use by date. Finding Include 1) A review of a facility policy titled Food and Supply Storage Procedures with a reviewed date of 7/16/16 revealed: POLICY: . Frozen Storage .Wrap food tightly to prevent freezer burn . On 4/3/17 at 4:55 p.m., the surveyor along with the Dietician, Employee Identifier (EI) #3, toured the freezer. The surveyor observed a box of beef burgers, fish patties and chicken wings opened in a box. The plastic in each box was opened and not sealed. On 4/6/17 at 10:00 a.m., the surveyor conducted an interview with EI #3. EI #3 was asked what food items were in the freezer in a box and not sealed. EI #3 replied, chicken wing pieces, fried chicken patties and fish patties. EI #3 was asked who was responsible for making sure food items were sealed after use. EI #3 replied, the staff and maybe the dietary coordinator's job was to go back and check. EI #3 was asked when should food items be sealed. EI #3 replied, soon as possible. EI #3 was asked why were the food items left opened. EI #3 replied, they had a catering job and someone just threw it in there. EI #3 was asked what was the facility's policy on leaving food items opened in the freezer. EI #3 replied, it was supposed to be covered. EI #3 was asked what was the potential harm to the residents when food items were exposed in the freezer and the food was given to the residents. EI #3 replied, food borne pathogen, food borne illness and it affected the quality of food. EI #3 was asked what was on the chicken wings. EI #3 replied, freezer burn. 2) A review of a policy titled Food and Supply Storage Procedures with no date revealed; POLICY: Dry Storage . Store bulk materials in . approved containers that have tight fitting lids . On 4/3/17 at 4:55 p.m., the surveyor, along with the EI #3, observed chocolate fudge icing in dry storage with the left side of the container not sealed properly. On top of the container was a dead spider like bug. On 4/6/17 at 10:07 a.m., an interview was conducted with EI #3. EI #3 was asked what item in the dry storage area was not sealed properly. EI #3 replied, chocolate fudge. EI #3 was asked why was it not sealed properly. EI #3 replied, it was just an accident. EI #3 was asked who was responsible for making sure food items were sealed properly in the dry storage. EI #3 replied, all staff and coordinators were the one to finalize those things. EI #3 was asked what was on top of the container of chocolate icing. EI #3 replied, hair. EI #3 was asked what was the potential harm when items were not sealed properly. EI #3 replied, food borne pathogen, food borne illness and poor quality food. On 4/6/17 at 2:15 p,m., an interview was conducted with EI #4, the Dietary Manager. EI #4 was asked who was responsible for making sure food items were sealed properly in the dry storage area. EI #4 replied, he was. EI #4 was asked what was the facility's policy on sealing food items. EI #4 replied, whatever you use, when you are done with it close it. EI #4 was asked what was the potential harm when items are not sealed properly. EI #4 replied, food can get contaminated and cross contamination. 3) A review of a policy titled Food and Supply Storage Procedures with no date revealed: POLICY: Dry Storage . Remove any dented cans and place in designated dented can area . On 4/3/17 at 4:55 p.m., the surveyor along with the EI #3 observed three cans of carnation vitamin D evaporated milk and one can of pulmo care therapeutic care. The carnation milk was dented at the side and the pulmo care was dented at the top. On 4/6/17 at 10:13 a.m., an interview was conducted with EI #3. EI #3 was asked did she see any dented cans in the dry storage. EI #3 replied, she did. EI #3 was asked why should dented can be placed in a separate location. EI #3 replied, because of food borne pathogen and quality of food. On 4/6/17 at 2:15 p.m., an interview was conducted with EI #4, the dietary manager. EI #4 was asked where were dented cans stored. EI #4 replied, in a section on the kitchen counter. EI #4 was asked who was responsible for removing dented cans from the shelves. EI #4 replied, the sanitation person. EI #4 was asked when should dented cans be removed from the regular cans section. EI #4 replied, they should never be placed on the shelves. EI #4 was asked what was the potential harm when food from dented can were used to serve to the residents. EI #4 replied, contamination and spoilage. 4) A review of a policy titled Food and Supply Storage Procedures with no date revealed: POLICY: Dry Storage . Remove from storage any items for which the expiration date has expired . On 4/3/17 at 4:55 p.m., the surveyor along with EI #3 observed a mighty shake in the cooler with a use by date of March 29, 2017 on the container. On 4/6/17 at 10:22 a.m., an interview was conducted with EI #3. EI #3 was asked what was the facility's policy on out of date mighty shakes in the cooler. EI #3 replied, if not used by the use by date, throw it out. EI #3 was asked who was responsible for checking the dates on the mighty shakes. EI #3 replied, staff, and the dietary coordinator checked the dates. EI #3 was asked why should expired mighty shakes be removed from the cooler. EI #3 replied, food borne pathogen and poor quality. EI #3 was asked what was the potential harm when expired mighty shakes are given to the residents to consume. EI #3 replied, food borne illness, poor quality and resident dissatisfaction. EI #3 was asked was the observed mighty shake out of date. EI #3 replied, yes. 5) A review of a facility policy titled Cleaning and Sanitizing Flatware with an effective date of 8/1/04 revealed: POLICY: All flatware will be cleaned and sanitized after every use . 5. Allow flatware to air dry . On 4/4/17 at 11:05 a.m., the surveyor observed staff taking silverware out of a canister and wrapping them into napkins. Some of the silverware in the canister was wet. The two staff members were wrapping the wet silverware (spoons and forks) with a napkin. On 4/6/17 at 10:35 a.m., an interview was conducted with EI #5, the dietary coordinator. EI #5 was asked how should utensil be allow to dry. EI #5 replied, we have a fan for them to sit under and air dry. EI #5 was asked what was the facility's policy on drying utensils. EI #5 replied, put them in the green basket and turn them up side down and let them dry. EI #5 was asked who was responsible for making sure utensils were cleaned and air dry properly. EI #5 replied, all staff was responsible. EI #5 was asked should utensil be wrapped wet. EI #5 replied, no ma'am. EI #5 was asked did she wrap the utensils wets. EI #5 replied, yes ma'am. EI #5 was asked why did she wrap wet utensils. EI #5 replied, she was talking and wrapping at the same time. EI #5 was asked what was the potential harm when there was water on utensil and the utensils were in a canister. EI #5 replied, bacteria. 6) A review of a policy titled Trayline/Taste/Temperature Record with an effective date of 8/1/04 revealed: POLICY: Items intended for patient food service are listed on the Patient Tray Service log and temperature record . Menu items: List all items being served for the meal beside the appropriate heading, including Milk, . Record temperature for each item . A review of a document titled Menu Week which used by the cooks, with no effective date, revealed an area for food temperatures to be documented. There was no documentation of milk temperature or no documentation of the milk was written down. On 4/4/17 at 11:05 a.m., the surveyor observed staff taking the temperature of the food. The cook did not take the temperature of the milk nor did she write a milk temperature down. On 4/6/17 at 1:37 p.m., the surveyor conducted an interview with EI #6, the dietary coordinator. EI #6 was asked who was responsible for taking the temperature of the milk and writing it down. EI #6 replied, she was. EI #6 was asked who took the temperature of the milk or wrote it down during the lunch meal on 4/4/17. EI #6 replied, no one. EI #6 was asked what was the facility's policy on taking milk temperatures and writing them down. EI #6 replied, take one milk and take the temperature of it and make sure it was 40 degrees and below and the write the temperature down. EI #6 was asked why was it important to take milk temperatures. EI #6 replied, milk have to be a certain temperature to send to the patient. EI #6 was asked when should you take milk temperature. EI #6 replied, at the beginning of tray line. EI #6 was asked what was the potential harm when temperatures were not taken and milk was given to the residents. EI #6 replied, it could be spoil or hot which cause milk to spoil. EI #6 continue to say it could harm the resident. 7) A review of a policy titled Product Labeling and Dating with an effective date of 8/1/04 revealed: POLICY . PROCEDURE .Put item name on label . Date received/cooked/opened recorder . Any product without a Discard date tag must be discarded . On 4/3/17 at 4:55 p.m., the surveyor observed a four pound container of grape jelly was opened, sitting on a kitchen shelf with no opened or use-by date on it. On 4/6/17 at 1:30 p.m., an interview was conducted with EI #6, the dietary coordinator. EI #6 was asked what items on the shelf in the kitchen had no open or use-by dates on their containers on Monday April 3, 2017. EI #6 replied, the jelly. EI #6 was asked who is responsible for labeling containers (items) with open and use-by dates. EI # 6 replied, the salad person normally at that table, plus the dietary coordinator. EI # 6 was asked where should jelly be stored after use. EI # 6 replied, in the refrigerator. EI #6 was asked when should these containers be labeled with open and/or use-by dates. EI #6 replied, food items should be labeled on the day of opening. EI #6 was asked why was it important to have these opened dates and/or use-by dates on the containers. EI #6 replied, in order to know if the food was spoiled and to protect patients from spoiled foods. EI #6 was asked what was the company's policy on labeling items with an opened and/or use-by dates. EI #6 replied, opened then labeled immediately. EI #6 was asked what potential harm could occur from not having open an/or use-by dates on containers of food. EI #6 replied, food could get spoiled or contaminated which could be harmful to residents. 8) A review of a policy titled Product Labeling and Dating with a an effective date of 8/1/04 revealed: POLICY: Product labeling and dating of prepared and processed items. PROCEDURE: . Any product . must be labeled . Put Item Name on the label . Record date on Discard Date Line . On 4/3/17 at 5:00 p.m., the surveyor observed a medium tray of pimentos in the refrigerator with no open or use by date. On 4/6/17 at 1:47 p.m., the surveyor conducted an interview with EI #6. EI #6 was asked why was there no open or use by date on the pimentos in the refrigerator. EI #6 replied, whoever used it forgot to put the date on it. EI #6 was asked what was the facility's policy on placing a use by date on food items. EI #6 replied, Anything opened you have to label. EI #6 was asked why was there no open date or use by date on the pimentos. EI #6 replied, whoever opened the pimentos did not put a date on them. EI #6 was asked who was responsible for putting a use by date on food items. EI #6 replied, the cook, salad maker or whoever opened the container. EI #6 was asked when should food items be labeled. EI #6 replied, immediately after opening. EI #6 was asked what was the potential harm when residents were served food which did not have an opened or use by date on it. EI #6 replied, you did not know when it was opened, how long it has been there, and you did not want to give the residents spoil foods.

Based on observations, interviews and review of a facility policy titled Promoting /Maintaining Resident Dignity, the facility failed to ensure staff knocked on residents' doors prior to entering the residents room. This was observed on three of four days of the survey, affected Room Locator (RL) #1, RL #2, RL #3, RL #4, RI #5 and affected two of three units in the facility. Findings Include: A review of a facility policy titled Promoting /Maintaining Resident Dignity, with a revision date of 8/15/15 documented the following: POLICY: It is the practice of this facility to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect. Compliance Guidelines: .11. Respect the resident's living space, personal possessions. Knock on door prior to entering room . On 4/3/17 at 7:00 p.m., the surveyor observed Employee Identifier (EI) #10 walk into RL #1, then walk into RL #2, and then walk into RL #3 without knocking. On 4/4/17 at 12:05 p.m., the surveyor observed EI #11 walk into RL #4 without knocking. On 4/5/2017 at 11:05 a.m., the surveyor was conducting a resident interview with EI #5 and observed a staff member enter RL #5 without knocking. On 4/6/17 at 2:10 p.m., an interview was conducted with EI #11, a Registered Nurse (RN). EI #11 was asked if she remembered entering RL #4 without knocking. EI #11 replied, yes. EI #11 was asked how was she trained to enter a resident's room. EI #11 replied, to knock first. EI #11 was asked what was the facility's policy on entering a residents room. EI #11 replied, to knock first. On 4/6/17 at 3:15 p.m., an interview was conducted with EI #10, a Certified Nursing Assistant (CNA). EI #10 was asked how she was trained as a CNA to enter a resident's room. EI #10 replied, to knock then wait for them to give permission to come in. EI #10 was asked what was the facility's policy on how to enter a resident's room. EI #10 replied, to knock and wait for permission to come in. The surveyor asked EI #10 what type of issue was it to enter a resident's room without knocking. EI #10 replied, a dignity issue. On 4/6/17 at 3:40 p.m., an interview was conducted with EI #12, a Licensed Practical Nurse (LPN). EI #12 was asked if she remembered entering RI #5's room yesterday while the surveyor was in the room. EI #12 replied, yes. EI #12 was asked if she knocked on the door before entering. EI #12 replied, she thought she did. EI #12 was asked what was the training the facility gave in regards to entering a resident's room. EI #12 replied knock and wait for acknowledgement. EI #12 was asked what was the policy upon entering a resident's room. EI #12 replied, knock and introduce yourself. EI #12 was asked what was the potential harm of not knocking when entering a resident's room. EI #12 replied, being disrespectful and invading their privacy.

Based on observations, interview and review of a facility document titled Cart List, the facility failed to ensure a plaster like substance was not hanging from the dining room ceiling on three of four days of the survey. This had the potential to affect 13 of 74 residents who eat meals in the dining room. Findings Include: On 4/4/17 at 8:07 a.m., and 12:35 p.m., the surveyor observed a plaster like substance hanging from the ceiling in the dining room. At 12:35 p.m., the surveyor observed a resident sitting under the ceiling where the plaster was hanging. On 4/5/17 at 4:00 p.m., the surveyor observed the plaster continued to hang from the ceiling. On 4/6/17 at 2:00 p.m., an interview was conducted with EI (Employee Identifier)#7, a maintenance staff member. EI #7 was asked what was hanging from the ceiling in the dining room. EI #7 replied, plaster ceiling flaking. EI #7 was asked why was it hanging. EI #7 replied, moisture being absorbed into the plaster. EI #7 was asked what was the facility's policy on the up keep of the ceiling. EI #7 replied, remove flakes of plaster and patch it. EI #7 was asked when were rounds last made on observing the ceiling. EI #7 replied, daily and a couple times a day. EI #7 was asked what was the potential harm when there was plaster hanging from the ceiling and a resident was sitting under the hanging plaster. EI #7 replied, worst harm would be plaster falling into the food.

Based on interviews and record review, the facility failed to ensure: 1) Resident Identifier (RI) #2's height was coded on RI #2's 2/25/16, Initial Minimum Data Set (MDS) assessment, 2) RI #4's height and [MEDICAL TREATMENT] status was coded on RI #4's 7/22/16, Significant Change MDS assessment, and 3) RI #5's catheter was coded on RI #5's 10/21/16, Annual MDS assessment. These deficient practices affected RI # 2, RI #4 and RI #5, three of 15 residents whose MDS assessments were reviewed. Findings Include: 1) RI #2 was readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. RI #2's Admission Assessment, dated 2/15/16, revealed RI #2 had an admission height of 64 inches. A review of RI #2's Initial MDS assessment with an Assessment Reference Date (ARD) of 2/25/16, revealed RI #2's height was not captured during this assessment period. On 4/6/17 at 1:49 p.m., the surveyor conducted an interview with EI (Employee Identifier) #8, the MDS Coordinator. The surveyor asked EI #8 should there be a weight and height on the MDS. EI #8 replied, Yes. That is asked on all of them. The surveyor asked EI #8 was RI #2's height coded on RI #2's Admission MDS assessment dated [DATE]. EI #8 said RI #2's height was not on the MDS. EI #8 said the area had 0's and she did not know why. The surveyor asked EI #8 should RI #2's height be on the MDS. EI #8 replied, Yes Ma'am. The surveyor asked EI #8 was RI #2's 2/25/16 MDS assessment an accurate assessment. EI #8 said no, it would not be accurate without the height being on it. 2) RI #4 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. RI #4's [MEDICAL TREATMENT]/[MEDICAL CONDITION] care plan, no date, revealed RI #4 started [MEDICAL TREATMENT] 8/2014. A review of RI #4's Significant Change MDS assessment with an ARD of 7/22/16, revealed RI #4's height nor [MEDICAL TREATMENT] status was captured during this assessment period. On 4/6/17 at 1:49 p.m., the surveyor conducted an interview with EI #8. The surveyor asked EI #8 was RI #4's height recorded on RI #4's Significant Change MDS dated [DATE]. EI #8 said no, there were 0's on the MDS. The surveyor asked EI #8 should the height be recorded. EI #8 replied, Yes Ma'am, it should be recorded. The surveyor asked EI #8 was RI #4 on [MEDICAL TREATMENT]. EI #8 said yes. EI #8 said RI #4 had been on [MEDICAL TREATMENT] since 2014. The surveyor asked EI #8 should RI #4, being on [MEDICAL TREATMENT], have captured on the 7/22/16 MDS. EI #8 said yes. The surveyor asked EI #8 did she see where the [MEDICAL TREATMENT] status captured on the MDS. EI #8 said she did not. The surveyor asked EI #8 was this MDS assessment an accurate assessment for RI #4. EI #8 replied, no, not with the [MEDICAL TREATMENT] not being on the MDS. 3) RI #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #5's most recent annual MDS with an ARD of 10/21/2016, revealed RI #5's Foley catheter status was not captured during this assessment period. The Foley was placed on 8/22/16, and should have captured on the 10/21/16 MDS. On 4/16/17 at 4:10 p.m., the surveyor and EI # 8 had a discussion on when RI #5's Foley catheter was placed. It was agreed from reviewing the resident's chart that the catheter was placed on 8/22/16. The MDS dated [DATE] was reviewed. In section H, Bladder & (and) Bowel, Field H0100, A. Indwelling catheter was coded, 0, On 4/16/17 at 4:25 p.m., an interview was conducted with EI #8. EI #8 was asked who was responsible for coding the MDS. EI #8 replied, she was. EI # 8 was asked was RI #5's 10/21/16 MDS coded correctly in regards to the catheter. EI #8 replied, no ma'am. EI # 8 was asked why the catheter was not checked on 10/21/16 in Section H0100. EI #8 replied, an error, an oversight. EI #8 was asked when should it be coded if a person was using a catheter. EI #8 replied, on the assessment that was due. EI #8 was asked why should a catheter be coded if a resident was using a catheter. EI #8 replied, it tells you they have a catheter and it was important to know that. EI #8 was asked why was it important to code correctly on the MDS. EI #8 replied, the MDS gives you a picture of the resident. EI #8 stated when looking at the MDS, you should be able to know everything about the resident.

Based on observations, record review and interview, the facility failed to ensure care plans were developed for Oxygen usage for Resident Identifier (RI) #9 and RI #17. This affected two of 15 sampled residents whose plans of care were reviewed. Findings Include: 1) Resident Identifier (RI) #9 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of RI #9's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/5/17 revealed under Section O: Special Treatments, Procedures, and Programs for Respiratory Treatment, RI #9 was using Oxygen during this assessment period. A review of RI #9's April physician's orders [REDACTED]. . O2 (oxygen) @ (at) 4L(liter)/min (minute) via (by way of) NC (nasal cannula) A review of RI #9's care plans revealed that RI #9 did not have an Oxygen care plan. On 4/6/17 at 1:49 p.m., the surveyor conducted an interview with Employee Identifier (EI) #8, the MDS Coordinator. The surveyor asked EI #8 was RI #9 using Oxygen. EI #8 said she thought RI #9 was put on Oxygen. The surveyor asked EI #8 if RI #9 had a care plan for the Oxygen usage. EI #8 replied, No Ma'am. The surveyor asked EI #8 should RI #9 have a care plan for the Oxygen usage. EI #8 replied, yes. 2) RI #17 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A Quarterly MDS assessment with an ARD of 2/9/17, revealed RI #17 was receiving Oxygen during this assessment period. On 4/3/17 at 5:22 p.m., during the initial tour of the facility, RI #17 was observed with Oxygen on at 2 Liters per minute by way of a nasal cannula/Concentrator. On 4/4/17 at 4:41 p.m., RI #17 was again observed with the Oxygen on at 2 Liters per minute by way of a nasal cannula/Concentrator. On 4/5/17 at 2:42 p.m., RI #17's Oxygen remained at 2 Liters per minute by way of a nasal cannula/Concentrator. On 4/6/17 at 8:22 a.m., RI #17 was again observed with Oxygen on at 2 Liters per minute by way of a nasal cannula/Concentrator. On 4/6/17 at 1:49 p.m., the surveyor conducted an interview with EI #8. The surveyor asked EI #8 who was responsible for developing care plans. EI #8 said she was. The surveyor asked EI #8 should residents receiving Oxygen, whether routine or as needed (PRN) have a care plan developed for the oxygen usage. EI #8 replied, Yes Ma'am. The surveyor asked EI #8 did RI #17 use Oxygen. EI #8 said RI #17 did. The surveyor asked EI #8, looking at RI #17's care plans, was a care plan developed for the Oxygen usage. EI #8 said RI #17 did not have a care plan for the Oxygen usage. On 4/6/17 at 4:03 p.m., the surveyor conducted an interview with the Director of Nursing, EI #2. The surveyor asked EI #2 should a resident receiving Oxygen have a care plan developed. EI #2 replied, Yes. The surveyor asked EI #2 what was the rationale for having a care plan. EI #2 said to communicate with the staff members the needs of the resident.

Based on observation, interviews, record review, and review of Potter and Perry's FUNDAMENTALS OF NURSING, the facility failed to ensure a licensed nurse, Employee Identifier (EI) #9, did not crush Resident Identifier (RI) #16's 9:00 a.m. medications together on 4/22/16. This deficient practice affected RI #16, one of two residents observed for Gastrostomy tube medication administration, and EI #9, one of three medication nurses observed during the medication pass. The facility's RESIDENT CENSUS AND CONDITIONS OF RESIDENTS form, dated 4/3/2017, documented nine residents in the facility with tube feedings. Findings Include: A review of Potter and Perry's FUNDAMENTALS OF NURSING, Ninth Edition, with a copyright date of 2017, page 636, Unit V, Foundations for Nursing Practice documented: . 16. b. Do not mix medications together; administer each separately . RI #16 was originally admitted to the facility on [DATE]. The most recent Quarterly Minimum Data Set assessment with an Assessment Reference Date of 2/1/17, assessed RI #16 as having short and long term memory problems with severely impaired cognitive skills for daily decision making. This assessment also indicated RI #16 had a feeding tube during the assessment period. RI #16's April 2017 physician's orders [REDACTED].#16's PEG (percutaneous gastrostomy) tube at 9:00 a.m. daily. On 4/4/17 at 8:50 a.m., the surveyor observed EI #9 crush all of the above medications together and poured the crushed medications into a medication cup. EI #9 poured 10 cc's (cubic centimeters) of water into RI #16's syringe then poured the crushed medications into the syringe. On 4/6/17 at 1:23 p.m., the surveyor conducted an interview with EI #9. The surveyor read back the observation of the medication pass done for RI #16 on 4/3/17, and asked EI #9 how should crushed medications be prepared. EI #9 replied, Separately. The surveyor asked EI #9 why did she crush RI #16's medications together. EI #9 said it was just her error and her nerves. The surveyor asked EI #9 what was the standard of practice for administering crushed medications. EI #9 said the medications should be administered separately. On 4/6/17 at 4:03 p.m., the surveyor conducted an interview with the Director of Nursing, EI #2. The surveyor asked EI #2 what was the standard of practice for administering crushed medications. EI #2 replied, To crush the medication individually .

Based on observations, interview and review of a facility policy titled Nursing Staff Posting Sheet, the facility failed to ensure the daily staffing form for the nursing home was documented with the hours worked on the form for four of four days of the survey. This had the potential to affect all 74 residents who reside in the facility. Findings Include: A review of a facility policy titled Nursing Staff Posting Sheet with a revision date of 6/27/2016 revealed the following: POLICY: . Policy Explanation and Compliance Guidelines: 1. The nursing staffing information will contain the following information: . d. The total number and actual hours worked by the following staff: . 2. The facility will post the nurse staffing total number at the beginning of each shift . On 4/3/17 at 4:55 p.m., the staffing form for the nursing home was observed for the day and the evening shift and did not have the hours worked documented on the form. On 4/4/17 at 8:00 a.m., the staffing form for the nursing home was observed for the day shift and did not have the hours worked documented on the form. On 4/4/17 at 4:30 p.m., the staffing form for the nursing home was observed for the evening shift and did not have the hours worked documented on the form. On 4/5/17 at 8:40 a.m., the staffing form for the nursing home was observed for the day shift and did not have the hours worked documented on the form. On 4/5/17 at 3:25 p.m., the staffing form for the nursing home was observed for the evening shift and did not have the hours worked documented on the form. On 4/6/17 at 8:20 a.m., the staffing form for the nursing home was observed for the day shift and did not have the hours worked documented on the form. On 4/6/17 an interview was conducted with Employee Identifier (EI) #1, Clinical Coordinator. EI #1 was asked who was responsible for filling out the daily staffing form. EI #1 replied, she was responsible to fill it out during the week. EI #1 was asked if she filled out the form for all four days of the survey. EI #1 replied, yes. EI #1 was asked what information was required to be documented on the form according to the regulation. EI #1 replied the census, date, number of registered nurses, number of licensed nurses, number of certified nursing assistants, hours worked and the facility name. EI #1 was asked if the staffing forms for 4/3/17, 4/4/17, 4/5/17 and 4/6/17, were documented correctly according to regulation. EI #1 replied no. EI #1 was asked why was it important to have the information documented accurately. EI #1 replied so they (facility) knew how many people were working.

Based on observation, record review and interview the facility failed to ensure an one gallon containers of salad dressing was labeled with opened or use by date. This was observed during the initial tour of the kitchen on 05/24/2016. Furthermore the facility failed to ensure four male staff members covered their facial hair while working in the vicinity of food preparation and service on 05/25/2016. This had the potential to affect all residents in the facility. Findings include: 1. The Food Code, U.S. Public Health Service, 2013, 3-501.16, documented: . TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: . (2) at 5 degrees C (centigrade) (41 degrees F) or less. . 3-501.17 . at the time the original container is opened in a FOOD ESTABLISHMENT and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold or discarded based on the time/temperature and time combinations specified . On 5/24/2016 at 10:00 AM, during the initial tour of the kitchen there was opened and partially used condiments, one gallon container of Honey Dijon mustard, a package of croissants and one gallon of Hot Sauce that was stored in the walk-in cooler. None of the containers had a date to signify when the containers were opened or a use by date. On 5/26/16 at 9:30 AM, Employee Identifier (EI) #4 stated all opened containers should have an opened or use by date on the container. 2. The undated facility Food service Dress Code, .Men .Hairnet or Valley Medical ( Name of Nursing Home) cap Bard Guard if needed . During the observation of food service from the tray line on 5/25/16 at 11:35 AM, three different male staff members, EI #s 1, 2, & 3 were observed to be in the food preparation area and service area. None of these employees had their facial hair covered. In an interview on 5/26/16 at 9:30 AM, EI #4 stated the male staff members should have covered their facial hair but that was not done.

Based on interviews and record review, the facility failed to ensure all residents were offered snacks at bedtime with a time span of greater than 14 hours between supper and breakfast meals. This affected 10 of 10 residents who attended the Resident Group Interview on 06/03/2015 and had the potential to affect all residents allowed to have oral intake. Findings include: Review of the facility's policy SUBJECT: Individual Nourishments, effective 08/01/2004, revealed the following: POLICY: Between/during meal nourishments are served to patients whose nutritional needs cannot be met through three meals per day, as part of the modified diet order, as deemed necessary by dietitian, or as ordered by the physician. Nursing Home and TCU (Transitional Care Unit) between snack time meals (between meal snack times) are 0900 (9:00 AM), 1400 (2:00 PM), and HS (hour of sleep). Review of the undated document Snacks/ Supplements Documentation revealed the following: . REMEMBER: ALL SNACKS/SUPPLEMENT INTAKE MUST BE RECORDED. REMINDER: It is a State policy that ALL RESIDENTS BE OFFRERED (offered) A SNACK BEFORE THEY GO TO BED. This must also be recorded on the ADL (Activities of Daily Living) sheet. If they do not get a specified snack at night from dietary, offer resident(s) a snack from the unit kitchen. Record the snack from the unit kitchen underneath where you document the meals. During a Resident Group Interview conducted on 06/03/2015 at 10:00 AM, ten of ten residents in attendance stated they were not offered nighttime snacks. The residents stated the kitchen staff will bring you something if you request it, but if you don't request it, you don't get anything. Review of the ADL logs for all residents in attendance for the Resident Group Interview on 06/03/2015 revealed no HS (Hour of Sleep) snacks had been documented as offered for the month of May 2015. Review of the Cart Delivery Schedule revealed the time span between supper and the breakfast meal the following morning was fourteen and a half hours for the Nursing Home residents. On 06/03/2015 at 11:20 AM, Employee Identifier (EI) #9, the Food Service Director, was interviewed about snacks. EI #9 stated the set snack times were 10:00 AM, 2:00 PM, and 6:30 PM. He stated only the people with orders for snacks receive them unless requested. EI #5, a Registered Nurse Supervisor, was interviewed on 06/05/2015 at 9:00 AM. EI #5 was asked when snacks were scheduled to be served. EI #5 said every morning, afternoon, and evening if diabetic. When asked who on her unit received HS snacks, EI #5 provided a list of only 9 residents with physician ordered HS snacks. On 6/05/2015 at 10:55 AM, in a meeting with the Administrator (EI #6), the Assistant Administrator, and a Registerd Nurse (RN), EI #11, evening snacks were discussed. They were asked if the residents are offered snacks at HS (after supper). EI #6 said, she was sure the residents can get the snacks, if they ask for them. When asked for the documentation, EI #11 said that they had changed the page of the ADL monitoring and had left off the snack monitoring section.

Based on observations, interview, and review of facility policies, the facility failed to ensure: 1) items were not stored past their use-by-date; 2) dented cans were not stored with inventory for future use; 3) staff tested the concentration of the sanitizing agent in the three compartment sink in accordance with manufacturer recommendations; 4) items stored in the coolers were labeled with use-by-dates and an item name; 5) dietary staff washed hands and changed gloves between tasks in an attempt to prevent potential cross contamination; 6) staff did not wear hoop-style earrings not contained by a hairnet; 7) staff obtained the temperature of fried chicken prior to serving in order to ensure the temperature was 135 degrees Fahrenheit (F) or greater; 8) pureed green beans for the 06/04/2015 lunch meal were reheated to 165 degrees F for 15 seconds prior to serving; and 9) the handles of the thermometer as well as a serving utensil did not enter the food during meal service. These failures had the potential to affect all 77 residents receiving meals from the dietary department. Findings include: 1) Review of the facility's policy titled SUBJECT: Food and Supply Storage Procedures, effective 08/01/2004, revealed the following: POLICY: Dry Storage. * Remove from storage any items for which the expiration date has expired. During the initial tour of the kitchen on 06/02/2015 beginning at 3:45 PM, the surveyor observed 3 packages of guacamole seasoning mix dated 05Feb2015 still on the shelf for use in the dry storage room. The surveyor asked Employee Identifier (EI) #9, the Food Service Director (FSD), what the date was, and EI #9 said he did not know. EI #9, the FSD, was interviewed on 06/05/2015 at 10:35 AM. EI #9 stated anyone in the kitchen was responsible for checking to ensure items were not stored past their use-by-dates. EI #9 stated they should have thrown the packs of guacamole seasoning mix away. 2) Review of the facility's policy titled SUBJECT: Food and Supply Storage Procedures, effective 08/01/2004, revealed the following: POLICY: Dry Storage. * Remove Dented Cans and place in dented can area for credit and discard. During the initial tour of the kitchen on 06/02/2015 beginning at 3:45 PM, the surveyor observed a 15 ounce can of cut baby corn and a 14.5 ounce can of sliced carrots. Both cans were dented, but remained on the shelf for use. EI #9, the FSD, was interviewed on 06/05/2015 at 10:35 AM. EI #9 explained their policy was to remove the dented cans and place on a rack for credit because if the seal was compromised, it could become contaminated. 3) Review of the manufacturer's information for the facility's sanitizing agent revealed the following: . FREQUENTLY ASKED QUESTIONS. Why should I titrate (test) at room temperature? * It is because of the limit of the test strip, not the product. Quat (Quaternary Ammonium Compound) test strips are sensitive and they should be read at room temperature (75 degrees F.); higher temperatures will result in inaccurate readings. On 06/02/2015 at 4:00 PM, during the initial tour of the kitchen, the surveyor observed EI #9, the FSD, test the concentration of the sanitizer in the three compartment sink. EI #9 obtained a test strip and placed it directly into the third sink, without checking the temperature of the water. EI #9 stated the water should be between 75 and 100 degrees F. The surveyor tested the temperature of the water EI #9 had tested and it measured 100 degrees F. Staff then began utilizing the three compartment sink to manually wash dishes. During an interview with EI #9, the FSD, on 06/05/2015 at 10:35 AM, EI #9 stated you should check the temperature of the water to see if the temperature is correct and then test the concentration with a test strip. 4) Review of the facility's policy titled SUBJECT: Product Labeling and Dating, effective 08/01/2004, revealed the following: POLICY: Product labeling and dating of prepared and processed items. PROCEDURE: Prepared Product *Any prepared product that is placed in a cooler, freezer, or dry storage must be labeled with the attached dating label. * Put item name on label. Review of the attached dating label revealed a place for an item name as well as a discard date. During the initial tour of the kitchen on 06/02/2015 beginning at 3:45 PM, the surveyor observed the following items in the cooler without use-by-dates: pimento and cheese salad tuna salad chicken salad banana pudding peaches fruit cocktail strawberry topping (prepared 05/06/2015) apples (prepared 05/18/2015) EI #9, the FSD, stated all of the items should have had a three day use-by-date. Also during the initial tour, the surveyor noted a container of marinade without a use-by-date and eight cakes without any item name or date. EI #9, the FSD, was interviewed on 06/05/2015 at 10:35 AM. EI #9 stated open containers and leftovers should be labeled with an item name and a use-by-date. When asked why it was important to properly label items, EI #9 stated you do not want anyone getting sick. 5) Review of the facility's policy titled SUBJECT: Gloves: Usage, effective 08/01/2004, revealed the following: POLICY: All food service workers shall use single use gloves to keep food safe by keeping a barrier between hands and food. This is never to replace handwashing. Hands must be washed before putting on gloves and when changing to a new pair. PROCEDURE: Food handlers must change gloves: *As soon as they become soiled or torn * Before beginning a different task. *After handling raw meat, seafood or poultry and before handling ready-to eat food. During trayline observations on 06/03/2015 at 10:45 AM, the surveyor observed EI #10, the Head Cook, begin battering raw pork chops. Wearing gloves, EI #10 placed the raw pork chops into a deep fryer. EI #10 then removed her gloves but did not wash her hands to remove cooked chicken from a deep fryer. After removing the chicken from the fryer, EI #10 donned a new pair of gloves, but did not wash her hands. EI #10 entered the dish room to handle clean utensils and retrieved a ladle. EI #10 placed the ladle into a pot of gravy, removed her gloves, then finally washed her hands. EI #9, the FSD, was interviewed on 06/05/2015 at 10:35 AM. EI #9 explained staff should wash hands before applying new gloves and any time they change tasks. After discussing the observation of EI #10, EI #9 stated it could cause cross contamination. 6) Review of the facility's policy titled SUBJECT: Uniformed Dress Code General Safety Rules, revised 08/01/2004, revealed the following: POLICY: Personal cleanliness and a neat appearance are essential for the food service worker. PROCEDURE: . Jewelry should be limited to wedding rings, service pins, watches or button-type earrings. Many pieces of jewelry collect soil and are potential safety hazards. During trayline observations on 06/03/2015 beginning at 10:35 AM, the surveyor observed EI #12, a cook, serving plates while wearing hoop-style-earrings not contained by a hairnet. During an interview with EI #9, the FSD, on 06/05/2015 at 10:35 AM, EI #9 stated all staff should know not to wear earrings because it could fall in the food. 7) Review of the facility's policy titled SUBJECT: Trayline/ Taste/ Temperature Record, effective 08/01/2004, revealed the following: POLICY: Items intended for patient food service are listed on the Patient Tray Service log and temperature record. PROCEDURE: .Action: Menu items: Record all items being served for the meal beside the appropriate heading. Record temperature for each item. During trayline observations on 06/03/2015 beginning at 10:35 AM, the surveyor observed staff checking temperatures of items prior to meal service. However, the chicken legs added to the steam table after the initial set of temperatures were not checked to verify safe temperatures. The chicken legs were plated and placed on trays on the second cart. The second cart left the kitchen at 11:51 AM. The surveyor asked EI #12 what the temperature of the chicken legs had been, and EI #12 stated she had not checked the temperature. The temperature log listing for fried chicken was blank; no temperature was recorded. During an interview with EI #9, the FSD, on 06/05/2015 at 10:35 AM, EI #9 stated all items should be checked prior to serving to make sure they are not in the danger zone or people could get sick. 8) Review of the facility's policy titled SUBJECT: Food Handling Guidelines, effective 08/01/2004, revealed the following: POLICY: Food is handled according to acceptable methods designed to avoid contamination. Reheating: . * Reheat the following foods to 165 degrees F for 15 seconds: - Any food that has been cooked and cooled, and will be reheated for hot holding. During trayline observations on 06/03/2015 beginning at 10:35 AM, the surveyor observed staff checking to ensure foods were at acceptable temperatures. The pureed green beans measured 130 degrees F and were removed from the line to reheat. At 11:05 AM, the pureed green beans were placed back on the steam table. The temperature of the pureed green beans after reheating them was 147 degrees F. The green beans remained on the line for meal service. During an interview with EI #9, the FSD, on 06/05/2015 at 10:35 AM, EI #9 stated the pureed green beans should have been reheated to 165 degrees or someone could get sick. 9) During trayline observations on 06/05/2015 beginning at 10:35 AM, the surveyor observed EI #12, a cook, taking temperatures of items on the steam table. EI #12 allowed the plastic handle of the thermometer to touch the top of the pureed chicken. The handle of the thermometer entered the pureed noodles as well as the pureed green beans. EI #12 placed the thermometer on the counter and did not clean the plastic handle portion of the thermometer between items. Also, while serving resident trays, EI #12 allowed the handle of the scoop used to serve the pureed green beans to enter into the food. EI #12 continued serving with the same scoop. EI #9, the FSD, was interviewed on 06/05/2015 at 10:35 AM. When asked what part of the thermometer should come in contact with food when checking temperatures, EI #9 said the probe. EI #9 said if the plastic handle entered the food it should be cleaned. EI #9 also stated if the handle of a serving utensil goes into the food when serving the utensil should be replaced because it could cause potential cross contamination.

Based on staff interview and record review the facility failed to develop a bookkeeping system for Resident Trust Funds which provided residents access to their Resident Trust Fund petty cash on weekends and nights. This had the potential to affect twenty of twenty residents with Resident Trust Fund accounts. Findings include: The facility's policy titled: Resident Trust Fund dated 6/17/14, stipulates: .Residents, who have deposited funds with the facility, will have ready and reasonable access to those funds, when needed.Residents should have access to petty cash, on a routine basis, and be able to arrange for access to larger funds, when needed . On 6/5/15 at 9:10 AM, a Resident Account Review was done with the bookkeeper, Employee Identifier (EI) #2. When asked how residents access the petty cash fund, EI #2 said during business hours from 7:30 AM - 4:30 PM on Monday through Friday. EI #2 was asked how a resident acquires petty cash on the weekends and/or at night. EI #2 said there is no one here to give them petty cash. EI #2 said, We have not had petty cash from the Resident Trust funds available at the nursing facility because they (residents) come and see me on Fridays before we close at 4:30 PM.

Based on interviews and record reviews the facility failed to increase the Surety Bond to cover the balance of the Resident Trust Fund Account. This had the potential to affect twenty of twenty residents with Resident Trust Fund accounts. Findings include: The facility's Policy and Procedure, titled Resident Trust Fund dated 6/17/14 stipulated: . Policy Explanation and Compliance Guidelines: .7. The facility will purchase a surety bond that is equal to or greater than the balance in the residents' trust fund account to include any fees that may be refundable. On 6/5/15 at 9:10 AM, a Resident Account Review was done with the bookkeeper, Employee Identifier (EI) #2. She was asked, if the Resident Trust Fund was covered by a surety bond. EI #2 provided a surety bond in the amount of $25,000.00. When reviewing the ledger balance, it was noted to be in the amount of $30,977.02. The bank balance for the Resident Trust Fund account for 3/31/15, the previous quarter, was in the amount of $28,090.03. The surveyor asked EI #2 if she had any plans of increasing the surety bond insurance amount. EI #2 said, Now, we do. The Administrator, EI #6, and the surveyor discussed these problems. EI #6 presented the surveyor with a letter dated 06/05/2015 that reiterated the facility's surety bond did not cover the amount of the Resident Trust Fund.

Based on observations, interviews and record review, the facility failed to ensure hazardous materials were not left in open and unlocked shower rooms, accessible to residents. This affected two of three shower rooms on two of four halls. Findings include: On 06/05/2015 at 3:15 PM, Employee Identifier (EI) #6, the Administrator , stated there was no facility policy for the storage of disinfectants or cleaning materials. During the initial tour of the facility on 06/02/2015 at 4:10 PM, a bottle of Asepti-HB cleaner was noted in one of the downstairs shower rooms. Another bottle of cleaner, shampoos and soaps were also in the shower room, which was not locked. On 06/03/2015 at 9:47 AM, the upstairs shower room was observed with the door open. The door had a key style lock, but was not in use. Inside the shower room, the surveyor observed a four ounce can of Granulex spray and several bottles of lotion. The items were within reach on a cart. On 06/03/2015 at 1:00 PM and 06/04/2015 at 11:00 AM, the cleaner was still observed in the downstairs shower room. Review of the Safety Data Sheet for the Asepti-HB revealed the following: .Recommended use: Disinfectant Restriction on use: Reserved for industrial and professional use. SECTION 2. HAZARDS IDENTIFICATION. Caution Hazard Statements: Causes eye irritation. SECTION 4. FIRST AID MEASURES In case of eye contact: Rinse with plenty of water In case of skin contact: Rinse with plenty of water. If swallowed: Rinse mouth. Get medical attention if symptoms occur. If inhaled: Get medical attention if symptoms occur. Review of the Material Safety Data Sheet for the Granulex spray revealed the following: . SECTION 5- Health Hazard Data PRIMARY ROUTES OF ENTRY: Inhalation. HEALTH HAZARDS: ACUTE: Do not inhale aerosol products. EYE CONTACT: Wash with water. EI #7, a Certified Nursing Assistant, was interviewed on 06/04/2015 at 1:45 PM. EI #7 stated they used the disinfectant in the shower room to clean it after giving residents showers. EI #7 stated the cleaner should not be left out after it is used. EI #7 stated the bottle said keep out of reach of children so it could be dangerous. On 06/04/2015 at 2:00 PM, EI #8, the Assistant Administrator, stated cleaning products should be locked in a cabinet when not in use. EI #5, a Registered Nurse Supervisor, was interviewed on 06/05/2015 at 9:00 AM. When asked what types of things should not be accessible to residents in the shower room, EI #5 stated there should not be any chemicals or cleaning products left in the shower room. EI #5 also stated the Granulex spray should not be stored in the shower room. EI #7 explained these items could pose a risk to the residents if inhaled or ingested.

Based on record review and interviews, the facility failed to ensure four side rails were not implemented for Resident Identifier (RI) #5 on 04/07/2015, the day of admission, due to RI #5's risk of falls. Further the facility failed to obtain a physician's order, identify a medical symptom necessitating the use of the restraint, and attempt lesser restrictive devices prior to restraining RI #5. This affected RI #5, one of one resident sampled with restraints. Findings include: Review of the facility's policy SUBJECT: Restraints, revised 06/2014, revealed the following: POLICY: The resident has the right to be free from physical. restraints. Restraints are also not to be used unless they are required to treat the resident's medical symptoms. Physical restraints are any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom from movement or normal access to one's body. Convenience is any action taken by the facility to control a resident's behavior or manage a resident's behavior with a lesser amount of effort by the facility and not in the resident's best interest. The least restrictive measure will be utilized at all times. A specific required medical symptom must be shown, symptoms are being treated, and how the use of the restraint will assist resident in highest level of function. This includes considering the least restrictive therapeutic intervention is one that provides the resident with maximum amount of freedom of movement. No one can use a restraint for discipline, convenience, or in the event of absence of medical symptoms. Physician order and evaluation must be in place prior to initiation of restraints. RI #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Restraint Release Form included in RI #5's medical chart was signed and dated on 04/07/2015. The Restraint Release Form documented the following: . Our philosophy of providing residents with the highest possible quality of care and life is reflective of the belief that it is essential for our residents to maintain their dignity and independence by being permitted to take the normal risks of everyday life. Restraints used in an attempt to remove these normal risks of living violate the rights of residents, greatly reduce their quality of life, and present significant physical and psychological risks. For the following reasons and in accordance with the new federal and state laws, restraints used in our facility will only be considered to treat a medical symptom/condition that endangers the physical safety of the resident or other residents under the following conditions: 1. As a last resort measure after a trial period where less restrictive measures have been undertaken and proven unsuccessful; 2. With a physician order; . If a restraint is deemed necessary, the goal will be to use the least restrictive type of restraint for the shortest period of time possible. Review of RI #5's Interdisciplinary Interventions revealed the following was implemented on 04/07/2015 upon RI #5's admission into the facility: 4/7/15. FALL LEVEL 3 Bed alarm when no family present Bed rails up x (times) 4 per family request. The immediate interventions were signed by Employee Identifier (EI) #1, the admitting Registered Nurse (RN). EI #1, the admitting RN, was interviewed on 06/05/2015 at 11:39 AM regarding the use of four side rails for RI #5. During the interview, EI #1 stated she had implemented the four siderails for RI #5 upon admission because the family requested it. EI #1 stated she told the family it could be worse for the resident if the resident were to climb over the rails but had not documented the conversation anywhere. When asked what steps should be taken if a family requests siderails, EI #1 stated she was not sure they would get a physicians order but would just write it at the family's request. EI #1 stated she felt the siderails were necessary to keep RI #5 in the bed because if awake, RI #5 hollers and tries to get up. Review of RI #5's Admission Minimum Data Set (MDS) Assessment, dated 04/14/2015, revealed RI #5 had severe cognitive impairment. The assessment also indicated bed rail restraints were used for RI #5 daily. RI #5's falls care plan listed an intervention of side rails raised x 4 at family request. Four side rails were also listed on RI #5's Certified Nursing Assistant (CNA) Summary Sheets. Review of RI #5's medical record and incident reports indicated RI #5 sustained a fall on 05/31/2015. Staff present at the time of the incident documented RI #5 climbed over the four bed rails and landed on the floor beside the bed. RI #5 sustained a head injury with left frontal scalp with soft tissue swelling. EI #3, the CNA assigned to RI #5 the night of the incident, was interviewed on 06/05/2015 at 8:30 AM. EI #3 stated she was at the desk on 05/31/2015 and heard a thud in RI #5's room. EI #3 said she found RI #5 on the other side of the bed and recalled that all four side rails were up on the bed. When asked why RI #5 had side rails, EI #3 said it was due to RI #5's fall risk. EI #3 said RI #5 was unable to lower the side rails. EI #3 also stated RI #5 attempted to climb over the side rails on a nightly basis. EI #4, the Licensed Practical Nurse (LPN) assigned to RI #5 on 05/31/2015, was interviewed on 06/05/2015 at 8:08 AM. EI #4 was asked what she could recall about the incident on 05/31/2015. EI #4 said a CNA came to her at shift change and said RI #5 fell . EI #4 went to RI #5's room and observed a knot on RI #5's head. EI #4 said she thought the siderails were up, two on the top and two on the bottom, covering the entire length of the bed. When asked why RI #5 had the side rails, EI #4 said it was due to RI #5's fall risk, and explained she had never seen RI #5 lower them. EI #5, the RN Supervisor, was interviewed on 06/05/2015 at 9:00 AM. The surveyor asked when the order was written for RI #5's four side rails. EI #5 explained it should have been written upon admission, but after reviewing the chart, stated there was no physician's order for the side rails. When asked if RI #5's side rails were considered a restraint, EI #5 said because the family wanted it, it was not considered a restraint. EI #5 then clarified that the siderails were always considered a restraint but because the family wanted them used, it was okay. EI #5 then reviewed the facility's policy on restraints. When asked what medical symptoms required the use of the side rails, EI #5 said RI #5's cognition and noncompliance with the use of the call light. EI #5 then explained that at one point the facility attempted to keep RI #5 in reach of staff but had to discontinue that because they did not have enough staff. EI #5 stated RI #5 really needed one on one supervision but said it was not possible with the census. EI #5 was asked what lesser restrictive alternatives could have been attempted. EI #5 said if they had fall mats available for use, it would be wonderful. She also stated if the facility had enough staff for one on one it would be great. EI #5 said she thought allowing RI #5 to get up and walk instead of climbing over the rails could be less restrictive. EI #6, the Administrator, was interviewed on 06/05/2015 at 10:00 AM. EI #6 stated the reason RI #5 was restrained was because of family request and said RI #5's medical condition was just compromised cognition. EI #6 said that, at family request, the facility had not attempted a lesser restrictive alternative. When asked what purpose the four side rails served, EI #6 said the family felt it would prevent RI #5 from getting out of bed.

Based on observation, interview and record review, the facility failed to ensure prescription Granulex Spray was not stored in an unlocked area, not designated for medication storage and accessible to residents. This affected one of three Shower Rooms on one of four halls. Findings include: Review of the facility's policy titled MEDICATION STORAGE IN THE FACILITY, revised 08/2014, revealed the following: POLICY Medications, treatments and biologicals are stored safely, securely, and properly following manufacturer's recommendations or facility policy. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. PROCEDURE . 2. Only licensed nurses, the Consultant Pharmacist, and those lawfully authorized are allowed access to medications. Medication rooms, carts, and medication supplies are locked. On 06/03/2015 at 9:47 AM, the upstairs shower room was observed with the door open. The door had a key style lock, but was not in use. Inside the shower room, the surveyor observed a four ounce can of prescription Granulex spray, not labeled with a resident's name. Also an empty bottle of prescription Ketoconazole Shampoo was noted on a cart in the shower room, labeled with a pharmacy label for a specific resident. Employee Identifier (EI) #5, a Registered Nurse Supervisor, was interviewed on 06/05/2015 at 9:00 AM. During the interview, EI #5 stated Granulex Spray should not be in the shower room. EI #5 said no medications should be stored in there because they needed to be stored in an area with a lock. EI #5 explained the items could pose a hazard to residents if inhaled or ingested.

Based on interviews and record review, the facility failed to provide stand by assistance (SBA) and contact guarded assistance (CGA) for Resident Identifier (RI #1) on 03/06/13 during her morning shower. This failure resulted in RI #1 sustaining a fall with fracture, which required surgical intervention. This affected one of three residents sampled with a history of falls. Findings include: A review of the facility's policy: "Falls Prevention" (updated 06/12) revealed the "Purpose: To identify residents/patients at high risk for falls and implement measures to assist in avoiding actions, which can cause falls." RI #1 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the "Functional Maintenance Plan" dated 09/07/12, revealed the patient's level of function when discharged from therapy was: T/F (Transfer), sit to stand with SBA (Stand by Assist)/CGA (Contact Guarded Assist) for safety. The current maintenance plan included: "provide A (assist) and cues as needed for safety with T/F and mobility. Encourage gait to pt (patient) tolerance with RW (rolling walker) CGA..." The Minimum Data Set with an Assessment Reference Date of 02/09/13, revealed RI #1's Brief Interview for Mental Status was a 15 (indicating RI #1 was cognitively intact). The section on the MDS regarding the resident's activities for daily living, revealed the resident required the assistance of one person for bed mobility, transfer, walking in room and corridors. RI #1 also needed the assistance of one person for toileting and dressing. RI #1 required the physical assist of one staff in part of the bathing activity. A review of RI #1's "Fall Risk Assessment Form" dated 11/21/12 (post fall), revealed a total score for fall risk was 16. A score of 13 to 18 placed the resident at level two fall risk. On 11/29/12, RI #1 was reassessed and scored an 18. This score also placed the resident at a level two for fall risk, identifying an unsteady gait/balance, requiring an assistive device. A review of the facility's fall investigation dated 03/06/13, revealed RI #1 fell in the shower at 6:10 AM. A review of the statement made by the CNA assisting RI #1 at the time of her fall (Employee Identifier/EI #3), dated 03/06/13, revealed: EI #3 told resident, "Don't get up twice, turned back, resident got up and fell after being told not to get up." A review of the second CNA witness statement (EI #2) dated 03/06/13, revealed EI #2 heard EI #3 tell RI #1 not to get up, that she (EI #3) was coming to dry the resident off. According to this statement, the resident said she was finished. EI #2's documentation revealed she heard EI #3 call for help, the resident had fallen. A review of the Licensed Practical Nurse's (LPN) (EI #9) statement dated 03/06/13, revealed she was called to the shower room. Upon entering the shower, EI #9 found RI #1 on the floor, in the doorway of the shower. RI #1 had a hematoma to the right side of her forehead and was complaining of pain and an inability to move the right hip. The physician was notified and the resident was transferred to the emergency room . A review of the hospital discharge summary dated 03/11/12, revealed the resident fell at the nursing home, sustaining a fracture to the right (hip) femoral neck. RI #1 was admitted to the hospital and placed on bed rest, traction, and analgesia. On 03/08/13, RI #1 underwent surgical intervention to the right hip (Hemiarthroplasty). On 03/26/13 at 7:00 AM, the LPN (EI #9) was interviewed. EI #9 was asked what she saw when she entered the shower room. EI #9 said RI #1 was on the floor; she had a hematoma on her head and was complaining of hip pain. EI #9 was asked who else was in the shower room. EI #9 said there was a resident outside the door waiting to come in, but she did not know who else was in the room. EI #9 was asked how many residents the CNAs generally took into the shower room at one time. EI #9 said maybe two, saying she was usually out on the hall helping to make beds and finish up her shift. On 03/26/13 at 7:40 AM, a CNA (EI #2) was interviewed. EI #2 was asked how many people were in the shower room the day RI #1 fell . EI #2 said four. EI #2 was asked who was in the shower room. EI #2 named two residents, RI#1 and RI #5. EI #2 said she was going out and EI #3 was in the shower room. EI #2 was asked if she had left EI #3 with two residents in the shower. EI #2 replied RI #5 was sitting in the gerichair and RI #1 was seated on a shower chair in the shower. EI #2 was asked where was the other CNA (EI #3) when she left the shower room. EI #2 said RI #5 was sitting in the doorway of the shower/tub room. EI #3 was coming around RI #5's gerichair, going toward the shower, to RI #1. On 03/26/13 at 9:30 AM, EI #3 was interviewed. EI #3 was asked how many residents were in the shower/tub room on 03/06/13 at 6:10 AM. EI #3 said there were two residents, RI #1 and RI #5; RI #5 was sitting in a gerichair with her feet elevated and extended into the shower/tub room and RI#1 was in the shower. EI #3 was asked what happened when RI #1 fell . EI #3 said she was taking RI #5's hair down and told RI #1 not to get up. EI #3 said she was looking at RI#5 and taking down RI #5's hair. When she (EI #3) looked up, RI #1 was standing up. EI #3 said she tried to get around RI #5's geri chair, but could not get to RI #1 before she fell . EI #3 was asked how they determine each resident's needs (ADLs). EI #3 said she checks the chart to see what the residents' needs are (based on Therapy's assessment). EI #3 and the surveyor reviewed the resident's "Functional Maintenance Plan" (FMP) dated 09/07/12. EI #3 was asked what SBA meant. EI #3 said it meant for someone to be with the resident, watch and encourage her to do as much as she can. On 03/27/13 at 12:30 PM, EI #3 was asked what CGA (Contact Guarded Assist) meant. EI #3 said she could not say, because she did not know. On 03/26/13 at 10:30 AM, the surveyor observed maintenance staff (EI #11) measure the distance from the doorway of the shower/tub room to the shower where RI #1 fell . The distance was 102.5 inches/8.54 feet. On 03/26/13 at 12:05 PM, the Physical Therapist (PT) EI #12, was interviewed. EI #12 was asked what therapy's role was with the FMP. EI #12 explained the PT and the Physical Therapist Assistant set up the FMP for all the residents on therapy. EI #12 was asked if the level of function needed at the time of discharge from therapy was carried over to the nursing home FMP. EI #12 said, "Yes." EI #12 was asked how would the restorative staff know to continue the FMP listed when released from Therapy. EI #12 said this was the resident's level of function at the time of discharge from therapy, and should be continued. EI #12 said the instruction at the bottom of the FMP is to help staff prevent the resident's decline. EI #12 was asked when would a resident come off the FMP. EI #12 said therapy would not take the resident off the FMP, as this was their communication; they would not discontinue it. EI #12 was asked how a resident would come off the FMP. EI #12 said the resident would have to be referred back to therapy for an evaluation. EI #12 was asked how close the staff would need to be for CGA and SBA. EI #12 explain that CGA required staff to be close enough to touch the resident; SBA required staff to be within one to two feet of the resident. EI #12 was asked if eight and one half feet from a resident be too far. EI #12 said SBA, is to stand beside the resident.