Every finding on record at Cordova Health and Rehabilitation, LLC

Based on observation, interviews, record reviews, and the facility policy titled Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, and review of a Facility Reported Incident (FRI) received by the Alabama Department of Public Health, the facility failed to provide adequate supervision and appropriate interventions to prevent sexual abuse perpetrated by Resident Identifier (RI) #325 against RI #82, a resident with known manipulative romantic behaviors, history of entering male residents' rooms, and history of consenting to sexual relationships. Multiple of the facility's staff were aware of RI #82's behaviors of entering male residents' rooms and manipulative romantic behaviors. The facility did not develop or implement interventions to address RI #82's repeated behaviors and ensure he/she was protected. The facility did not develop interventions to establish the level of supervision needed to ensure RI #82's safety. On 06/03/2024 staff heard a resident yelling no, no, let me go. Two staff members entered RI #325's room and found RI #82 on the floor beside RI #325's bed. RI #325 was observed on the bed with his/her pants down and penis exposed just inches away from RI #82's face. RI #325 was holding RI #82 by the hair of his/her head pushing RI #82's face toward his/her penis. RI #82 cried and told the staff broken, broken. RI #82 was transferred to the Emergency Department for examination for sexual assault. RI #82 was treated for a right sprained ankle. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death. The Immediate Jeopardy (IJ) was cited in reference to 483.12 Freedom from Abuse, Neglect, and Exploitation. On 11/18/2024 at 4:44 PM, the Administrator (ADM), Assistant Director of Nursing (ADON), the Corporate Nurse (CN), the Regional Administrator (RADM) and the Administrator in Training (AIT) were provided a copy of the Immediate Jeopardy (IJ) template and notified of the finding of substandard quality of care at the immediate jeopardy level in the area of Freedom from Abuse, Neglect, and Exploitation at F 600- Free from Abuse and Neglect. The IJ began on 06/03/2024 and continued until 11/20/2024 when the survey team verified onsite that corrective actions had been implemented. On 11/21/2024 the immediate jeopardy was removed, F 600 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This affected RI #82, one of 11 residents sampled for abuse. This deficiency was cited as the result of the investigation of complaint/report #AL00048048. Findings include: Cross-Reference F 610. On 06/03/2024 at 8:16 PM, the State Agency received a complaint/report through the Online Incident Reporting System that reported: Category: Abuse - Sexual . Date and time of incident or alleged incident: 06/03/2024 . Time: 07:15 PM . Narrative summary of incident: It was reported that a male/female resident was heard yelling in resident (RI #325)'s room. Upon arrival, resident (RI #82) was observed on (his/her) back in the floor (fully clothed) and resident (RI #325) kneeling over (him/her) with (his/her) penis out . A review of a document titled Alabama Uniform Incident/Offense Dated 06/03/2024, documented: .Type of Incident or Offense .Sexual Misconduct . Narrative . The victim, RI #82, . stated he/she had gone to RI #325's room to have a conversation . once inside RI #82 stated that RI #325 kept putting his/her hands on him/her and pulled his/her pants down grabbing him/her around his/her private area. RI #82 stated that RI #325 pulled his/her hair and forced him/her into the floor at which time RI #325 . forcefully tried to insert his/her private part into RI #82's mouth . A review of facility policy titled Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation dated May 01, 2023 revealed: Purpose: . The facility's policy strictly prohibits the abuse, neglect, exploitation . The following are definitions of specific types of abuse: . 2. Sexual- Sexual abuse, is a non-consensual sexual contact of any type with a resident/guest and includes, but not limited to, sexual harassment, sexual coercion, or sexual assault. Sexual contact may be considered non-consensual: if the resident either appears to want the contact to occur but lacks the cognitive ability to consent: or does not want the contact to occur . Determination of capacity cannot necessarily be based on a diagnosis alone . Sexual contact can include touching of . breasts, genitalia, groin, inner thighs, or buttocks with intent to cause sexual satisfaction or excitement to either person. Sexual harassment can include sexual advances, request for sexual favors, and other verbal or physical conduct of a sexual nature . III. Prevention Policies and Procedures . d) The facility will make all reasonable efforts to minimize instances of abuse, but in cases where such an instance occurs, the facility will use the event as an opportunity to develop new interventions in an attempt to prevent a re-occurrence . RI #82 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #82 had diagnosis of Hemiplegia and Hemiparesis Following Infarction Affecting Right Dominant Side, Aphasia Following Cerebral Infarction, and Depression. A review of RI #82's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/13/2024 documented that RI #82's Brief Interview for Mental Status (BIMS) score was 99 which indicated that he/she was unable to complete the interview. The MDS documented that RI #82 had short- and long-term memory problems. A review of facilities Departmental Notes for RI #82 revealed Social Service's notes that documented: A note dated 07/27/2022 signed by the Social Services Director (SSD) documented IDT (interdisciplinary team) met to review behaviors. Resident's roommate is accusing resident of bringing men into their room to have sex. Resident denies . A note dated 08/17/2022 signed by the SSD documented IDT met to review behaviors. Resident was caught going into other resident's rooms and going through their things. Resident also caught trying to go into other male resident's rooms. A note dated 09/28/2022 signed by the SSD documented IDT met to review behaviors. Resident going into other male resident's rooms. A note dated 10/06/2022 signed by the SSD documented Resident is seeking a relationship with another male resident . A note dated 01/04/2023 signed by the SSD documented IDT met to review behaviors. Resident presenting manipulating behaviors toward another male resident. Resident is in a mutually willing relationship with another male resident and will ask male resident for money, and male resident gives him/her money from his/her personal account. A note dated 01/25/2023 signed by the SSD documented IDT met to review behaviors. Resident is manipulating other male residents. Resident will state he/she is in a relationship with other willing male residents. Once male residents receive their money for the month she/he will manipulate male resident into giving him/her money. A note dated 02/23/2023 signed by the SSD documented IDT met to review behaviors. Resident is manipulating another male resident into giving him/her money . A note dated 05/10/2023 signed by the SSD documented IDT met to review behaviors. Resident going into other resident's rooms . A note dated 07/19/2023 signed by the SSD documented IDT met to review behaviors. Resident got into a verbal disagreement with another male resident due to no longer wanting to be socially involved with him/her. A note dated 07/26/2023 signed by the SSD documented IDT met to review behaviors. Resident also witnessed by staff kissing another male resident . A note dated 08/02/2023 signed by the SSD documented IDT met to review behaviors. Resident was viewed by staff being inappropriate with another male resident. A note dated 08/09/2023 signed by the SSD documented IDT met to review behaviors. Resident is approaching different men in the facility in an attempt to get money from them . A note dated 08/16/2023 signed by the SSD documented IDT met to review behaviors. Resident was witnessed by staff being inappropriate with another male resident in a public area . A note dated 08/30/2023 signed by the SSD documented IDT met to review behaviors. Resident is approaching other male residents and asking them for money. A review of RI #82's comprehensive care plan indicated care plans were developed for: .Exhibits behaviors entering other resident's rooms without permission . start date of 08/17/2022 . Exhibits behaviors r/t (related to) resident manipulates male residents into believing he/she is romantically interested in them . start date 02/15/2023 . Sexual expressions r/t consensual desires with opposite sex . start date of 07/31/2023 . The comprehensive care plan did not include the level of supervision needed to ensure RI #82's safety or when and how RI #82 was to be monitored. RI #325 was admitted to the facility on [DATE] with diagnoses that included Vascular Dementia with Mood Disturbance. A review of RI #325's Admission MDS with an ARD of 03/13/2024 documented that RI #325's BIMS score was 13 of 15 which indicated intact cognition. On 11/15/2024 at 9:45 AM an interview was conducted with the Social Service Director (SSD). The SSD said that RI #82 was care planned for sexually manipulating behaviors and going into other residents' rooms. The SSD said the IDT had discussed RI #82's manipulating behaviors, and the SSD had multiple conversations with RI #82 about the risks of going in and out of male residents' rooms. The SSD said she had observed RI #82 several times going into male residents' room and redirected RI #82 out of the room and educated him/her on the risks. The SSD said she saw RI #82 in RI #325's room at least two different occasions before the incident. The SSD said after RI #82 was noted entering male residents' rooms the facility did not develop or implement any interventions other than to monitor and continue to redirect him/her out of rooms when observed. On 11/18/2024 at 9:10 AM a follow-up interview was conducted with the SSD. The SSD said RI #82's behaviors of going into male residents' rooms was discussed during the IDT meeting multiple times. The SSD said the team decided to address the behavior by redirecting RI #82 and monitor more. The SSD said staff would know to monitor RI #82 by being aware to watch him/her and it was not documented anywhere. The SSD was asked, how would the staff be aware. The SSD replied, after the meeting the CNA that worked with RI #82 was notified to be aware of this behavior and to redirect him/her out of rooms. The SSD said nothing could have been done differently unless the facility provided RI #82 with one on one monitoring. The SSD said something bad could have happened as a result of RI #82's continued behaviors. On 11/15/2024 at 4:50 PM an interview was conducted with Nursing Assistant (NA) #18 who had worked with RI #82 for approximately six months and was familiar with his/her daily pattern. NA #18 said she had observed RI #82 in RI #325's room a few times prior to the incident that occurred on 06/03/2024. NA #18 said the two residents would visit in the room about 15 minutes, and she (NA) would be outside RI #325's doorway to monitor and ensure the safety and protection of RI #82. NA #18 said this was something she chose to do when on duty and not providing care for other residents. NA #18 said RI #82 walked around the facility daily in the afternoon. NA #18 said on 06/03/2024 RI #82 left his/her room around 6:45 PM and NA #18 assumed he/she was going to walk but she now thought he/she must have went to RI #325's room because the incident was witnessed soon after. On 11/13/2024 at 2:51 PM Licensed Practical Nurse (LPN) #12 was interviewed. LPN #12 said when walking down the hallway about 12 feet past RI #325's room, she heard a female voice saying no, no, let me go. LPN #12 said she was unclear which room the voice was coming from, or if it was a resident's television. LPN #12 said she was approximately two doors from RI #325's room when she heard the noise and motioned for Certified Nursing Assistant (CNA) #13 who was located further down the hallway to come help. LPN #12 said she entered the room first and CNA #13 followed her. LPN #12 said when they entered the room, they pulled the curtain open and RI #82 was on the floor and his/her right leg (affected side from prior stroke) was bent almost to the floor in an unnatural position. LPN #12 said RI #325 had his/her left hand on top of RI #82's head and was pushing RI #82's head toward his/her exposed penis. LPN #12 said RI #325 was not letting RI #82 loose. LPN #12 said RI #82 was crying and continued to say, no, no. LPN #12 said what she observed was mental and sexual abuse and a reasonable person in a similar situation as RI #82 would feel victimized. A review of RI #82's Departmental Notes revealed an entry dated 06/03/2024 at 9:33 PM by Registered Nurse (RN) #14. The note documented: At (approximately) 7pm . Charge nurse reported she heard No and Help me coming from another residents room . When she pulled the curtain, she seen (RI #82) on the floor . (RI #325) hands were in his/her hair, (RI #325) had his/her bottoms pulled down to his/her penis noted to be erect and inches away from (RI #82's) mouth . On 11/14/2024 at 12:13 PM an interview was conducted with RN #14 who said a staff called her on the phone after the incident occurred and reported that RI #325 had tried to get RI #82 to do sexual things to him/her and got aggressive but they intervened. RN #14 said she had seen the two residents sitting together in the gazebo or in social settings but that was all. RN #14 said this was the first time that she was aware that RI #82 had entered RI #325's room. On 11/13/2024 at 5:12 PM an interview was conducted with Medication Administration Certified (MAC) #21 who said she sat with RI #82 after the incident. MAC #21 said after the incident RI #82 was clearly upset and crying and said no more like he/she thought it was his/her fault. MAC #21 said she sat with RI #82 for 15 to 20 minutes and the ambulance arrived to transport RI #82 to the hospital. MAC #21 said RI #82 was still upset when he/she was on the stretcher and was saying I am sorry, no more, no more. On 11/16/2024 at 2:40 PM an interview was conducted with the ADON. When asked what protective measures were put in place to prevent potential abuse with RI #82, ADON said redirecting him/her out of male residents' rooms. The ADON said she redirected RI #82 out of male rooms several times previously and instructed him/her to visit in a public area. In addition to the facility redirecting RI #82, he/she was also educated, and the ADON said the Responsible Party (RP) was involved and spoke to RI #82 about not going into male residents' rooms. The ADON said the interventions of providing redirection and education were not effective and the facility could have placed staff on the hall for closer monitoring. During a follow up interview with the ADON on 11/17/2024 at 4:57 PM, she said a reasonable person would feel in a similar situation as RI #82 would feel violated. On 11/18/2024 at 12:38 PM an interview was conducted with RI #82's responsible party (RP) via phone. RI #82's RP said what she gathered regarding the incident from speaking with RI #82 and what RI #82 told the police was that RI #325 invited RI #82 into his/her room. RI #82's RP said that RI #82 said that RI #325 asked him/her in, then pulled the curtain, and was trying to force him/her to perform oral sex on RI #325. RI #82's RP said RI #82 said RI #325 forced him/her down to the floor and hit him/her in the face he/she had a bruise. RI #82's RP said RI #325 was definitely forceful because RI #82 had injury to his/her right leg. RI #82's RP said the facility could prevented the abuse if they had someone at end of the hall supervising. ************************************************ On 11/20/2024, the facility submitted an acceptable removal plan, which documented: F 600 Removal Plan 11/20/24 1. Immediate action(s) taken for the resident(s) found to have been potentially affected include: A. On 11/18/2024 RI #82 was placed back on 1:1 observation at 5:31 pm. RI #82 will not be left unsupervised until deemed safe by facility medical director. The facility will communicate to the medical director after there is no behaviors that increase her vulnerability for sexual abuse. B. RI #82 care plans were reviewed and revised by MDS coordinator on 11/18/2024 to include 1:1 supervision. C. RI #325 was placed on 1:1 supervision on 6/3/2024 until discharged to hospital then discharged home to family. Resident has not returned to the facility. D. On 6/3/2024 at 8:40 pm RI #82 was assessed by RN Unit Manager and noted to have right ankle pain. 2. Identification of other residents having the potential to be affected: A. This had the potential to affect all residents that resided in the facility. B. On 11/18/2024 management nursing staff completed a facility audit to identify any other residents with known manipulative romantic behaviors, history of consenting to sexual relationships with other residents and history of entering male residents' rooms without supervision. None were identified. 3. Actions taken/systems to be put into place to reduce the risk of future occurrences include: A. On 11/18/2024 the Regional Administrator provided 1:1 in-service education to Administrator and DON regarding the abuse policy, distressed behavior management program and identification and notification of new or worsening behaviors that increase residents' vulnerability to sexual abuse. The facilities abuse policy has always included that all residents have the right to be free from sexual abuse/abuse, identification of sexual abuse/abuse, and immediately protecting resident when sexual abuse/abuse is suspected. B. On 11/18/2024 education was initiated by Staff Development Nurse with 110 out of 112 facility staff (1 LPN and 1 CNA on FMLA) regarding abuse policy to include protecting residents from sexual abuse and identifying behaviors that increase residents vulnerability to sexual abuse, by use of notification of new or worsening behaviors from NM.II-24B (exhibit 2) the form will be reviewed in the morning to reduce the risk of abuse. No staff will be allowed to work unless they have been in serviced. CNA's will communicate behaviors to the nurse, the nurse will implement immediate appropriate intervention will document on the electronic medication administration (EMAR) record under resident task. The Director of Nursing or the assistant director of nursing will review resident task history each business day during morning meeting to ensure the appropriate intervention to maintain the safety of the resident. MDS coordinator will then update resident care plans to reflect the new behavior of the resident with the appropriate care plan. To start on 11/20/24. The facilities abuse policy has always included that all residents have the right to be free from abuse/sexual abuse is suspected. New hires will continue to be educated on the abuse policy to include identifying sexual abuse and protecting residents when suspected sexual abuse occurs. C. On 11/18/2024 Emergency QAPI meeting was held with all key personnel (Administrator, Director of Nursing, Department Heads, Regional Administrator and Regional Nurse Consultant). QAPI meeting discussed residents are kept safe from all types of abuse/sexual abuse and neglect. This was done by educating staff on who to report abuse to, when to report abuse and what to report. D. There are no residents known to the facility to be demonstrating with known manipulative romantic behaviors, history of consenting to sexual relationships with other resident, and history of entering male residents' rooms without supervision besides resident RI #82. Any sexually inappropriate behavior will be reported immediately to the Administrator or DON. The facility will immediately initiate the abuse protocol to include immediate protection of residents, notification of local police, MD/CRNP, ADPH and responsible parties followed by complete investigation. Facility requests for IJ removal plan to be effective on 11/20/2024. this plan was written by Regional Nurse Consultant and Administrator. **************************************************************** After review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team determined the facility implemented the immediate corrective actions as of 11/20/2024. 29671

Based on interviews, record review, and review of facility policies titled, Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, and Incidents and Accidents, the facility failed to thoroughly investigate an incident of abuse to prevent further occurrences. After staff witnessed an incident of sexual abuse on 06/03/2024 involving RI #82 and RI #325, the Director of Nursing (DON) reported the 06/03/2024 incident to the Administrator (ADM). There was no evidence the investigation included interviews with either resident involved. The investigation failed to identify that the facility's failure to provide supervision to RI #82, a resident with a known history of romantically manipulative behaviors and history entering male resident rooms without supervision. Because the facility's investigation failed to identify potential contributing factors, the facility was unable to develop and implement any new measures or actions to prevent recurrence. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death. The Immediate Jeopardy (IJ) was cited in reference to 483.12 Freedom from Abuse, Neglect, and Exploitation. On 11/18/2024 at 4:44 PM, the Administrator (ADM), Assistant Director of Nursing (ADON), the Corporate Nurse (CN), the Regional Administrator (RADM), and the Administrator in Training (AIT) were provided a copy of the Immediate Jeopardy (IJ) template and notified of the finding of substandard quality of care at the immediate jeopardy level in the area of Freedom from Abuse, Neglect, and Exploitation at F 610- Investigate/Prevent/Correct Alleged Violations. The IJ began on 06/03/2024 and continued until 11/20/2024 when the survey team verified onsite that corrective actions had been implemented. On 11/21/2024 the immediate jeopardy was removed, F 610 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. These failures affected RI #82 and RI #325. This deficiency was cited as the result of the investigation of complaint /report #AL00048048. Findings include: Cross-Reference F 600. Review of the facility's abuse policy titled, Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, with an effective date of 05/01/2023, revealed the following: . PURPOSE: This policy is concerned with all incidents . involving residents. The facility will investigate and document all incidents . involving residents . The investigation protocol for incidents . is set forth in Section VI of this Policy . For purpose of this Policy, the following terms shall have the following meanings: A. Abuse. The definition of abuse encompasses a broad scope of behavior . Any act considered abusive towards an alert oriented resident should also be considered abusive to the cognitively impaired or nonresponsive . The following are definitions of specific types of abuse: . 2. Sexual- Sexual abuse, is a non-consensual sexual contact of any type with a resident and includes, but not limited to, sexual harassment, sexual coercion, or sexual assault. Sexual contact may be considered non-consensual: if the resident either appears to want the contact to occur but lacks the cognitive ability to consent: or does not want the contact to occur. Determination of capacity cannot necessarily be based on a diagnosis alone . Sexual contact can include touching of . inner thighs, or buttocks with intent to cause sexual satisfaction or excitement to either person. Sexual harassment can include sexual advances, request for sexual favors, and other verbal or physical conduct of a sexual nature . III. Prevention Policies and Procedures . d.) The facility will make all reasonable efforts to minimize instances of abuse, but in case where such an instance occurs, the facility will use the event as an opportunity to develop new interventions in an attempt to prevent a reoccurrence . IV. Identification of Resident Incidents . a) The facility's employees . may become aware of resident/guest incidents . The facility will investigate all incidents or allegations regardless of how the facility became aware of the incident or the source of the allegation . VI. Investigations and Facility Response to Incidents . b) Investigation . Steps Notify the Administrator of any unusual situation in the facility, whether reportable or not immediately . Immediately consider and put into place interventions to protect the resident . involved . and other facility resident . The Administrator is responsible for conducting a thorough investigation and obtaining witness statements. A complete and thorough investigation must be conducted on all incidents . whether reportable or not . to determine the cause of the . incident. The outcomes of the investigation must also determine whether or not the incident was abusive or neglectful in nature. If reportable to the State Agency, the facility will make an investigation report within five (5) working days to the State Agency. This report will be in writing and will contain: .9. What the facility did to immediately correct the problem. 10. Actions taken by the facility following the investigation. A facility policy titled, Incidents and Accidents, with an effective date of 05/01/2023, revealed the following: . STANDARD: An incident is an occurrence that may not be consistent with the routine operation of the facility . PROCESS: . II. Documentation . b) An Incident/Accident report should be completed. c) Develop a brief investigation plan including obvious interviewees, questions to be asked and information to be gathered . RI #82 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. A review of RI #82's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/13/2024 revealed a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident was unable to complete the interview and noted RI #82 to have short- and long-term memory problems. RI #325 was admitted to the facility on [DATE] with a diagnosis of Vascular Dementia, with Mood Disturbance. A review of RI #325's Admission MDS with an ARD of 03/13/2024 revealed a BIMS score of 13 of 15 which indicated intact cognition. A review of facilities Departmental Notes revealed incidents with RI # 82 on 08/17/2022, 09/28/2022, 01/25/2023, 07/31/2023, 02/23/2024, 08/02/2023, and 08/16/2023 where the Interdisciplinary Team (IDT) met to review RI #82's sexual behaviors to include: manipulating male residents, exhibiting inappropriate behaviors with male resident in public, and expressing desire to be intimate with a male resident. The facility did not investigate, develop interventions, or implement protective measures to address repeated behaviors. A review of the facility's investigative file revealed a document titled VERIFICATION OF INVESTIGATION with DATE OF INCIDENT of 06/03/2024 documented: . DETAILED DESCRIPTION OF INCIDENT/ALLEGATION: It was reported by (Licensed Practical Nurse (LPN) #12) that she heard yelling coming from the room of (RI #325). (LPN #12) and (Certified Nursing Assistant (CNA) #13) entered the room, and observed the curtain pulled blocking the view of his/her bed. Once they pulled the curtain, they saw RI #325 lying . with his/her penis exposed and RI #82 in the floor beside the bed with his/her face near (RI #325's) penis and his/her hand behind his/her head. Note neither eyewitness confirm there was any actual sexual contact between the two. RESIDENT INTERVIEW SUMMARY: RI #325 did not provide any comments to charge nurse immediately following the interaction. Nurse noted resident was masturbating in his/her room at the time she tried to interview . RI #82 was questioned on 6-4-2024 but due to her severe cognitive impairments, she was unable to provide any reliable information that would contribute to the outcome of this investigation. PROVIDE SUMMARY AND OUTCOME OF INVESTIGATION: Outcome: On 06/03/2024 (RI #325) was observed in his/her room, lying on his/her side with his/her penis exposed and his/her hand behind the head of (RI #82) by (LPN #12) and (CNA #13). (RI #82) was observed on the floor beside the bed, on one knee and the other out to his/her side. It is unknown how or why (RI #82) was in (RI #325's) room although resident does ambulate throughout the facility independently. It was reported by the two eyewitnesses that (RI #325) seemed to be attempting to have (RI #82) perform oral sex on him/her. (RI #325) reportedly had his/her hand behind his/her head but neither witness could confirm any actual sexual contact took place as (RI #82) was fully dressed. Given the testimony of the eyewitnesses, it is the opinion of this investigator that an allegation of sexual abuse is inconclusive. However, it was discovered that (RI #325) had his/her hand on the back of (RI #82's) head, and he/she was noted to have a sprained ankle upon returning from the hospital. Therefore, it is the opinion of this investigator that an allegation of physical abuse is substantiated. IDENTIFY APPROPRIATE RECOMMENDATIONS / INTERVENTIONS FOR EACH CAUSAL OR CONTRIBUTING FACTOR LISTED: CAUSAL / CONTRIBUTING FACTORS AND OBSERVATION (May include information from witness interviews, medical record review ., etc.) Factor 1: dx (diagnosis) of vascular dementia. SPECIFY RECOMMENDATIONS /INTERVENTIONS TAKEN TO PREVENT REOCCURENCE . (RI #325) discharged to family from hospital. SIGNATURE OF ADMINISTRATOR . (ADM's name) . WITNESS INFORMATION: IDENTIFY ALL INDIVIDUALS WHO MAY HAVE PERTINENT KNOWLEDGE EITHER PRIOR TO, DURING, OR AFTER ALLEGED EVENT . There was no information entered on this portion of the document that included space for name of witness and summary of testimony. Further review of the facility's investigative filed revealed handwritten statements from LPN #12 and CNA #13. LPN #12's statement was dated 06/06/2024 and indicated she saw RI #325's penis exposed and he/she had RI #82 by the hair and was pushing his/her face to his/her exposed penis. CNA #13's statement was not dated and indicated she saw RI #82 bent over RI #325 while RI #325's pants were down. The investigative file did not include additional interviews or statements from staff or residents. On 11/14/2024 at 10:11 AM, an interview was conducted with the ADM who said it was in his opinion that the allegation of sexual abuse was inconclusive, and the allegation of physical abuse was substantiated. The ADM said he came to the determination that sexual abuse was inconclusive because RI #82 was fully clothed and there was not intercourse. The ADM added, there could have been something orally but it could not be determined based on interviews. The ADM said he was not aware either resident had any previous sexual behaviors. The ADM said the root cause was determined to be to discourage residents from going to other resident's rooms. The ADM added, it was important to keep in mind that RI #82 was in RI #325's room, and he could not rule out whether RI #82 initiated something sexual. The ADM said RI #82's family decided to press charges. 11/15/2024 at 3:28 PM a follow-up interview was conducted with the ADM. The ADM said the facility's investigation could not determine if RI #82 had been invited into RI #325's room because RI #325 had already been transferred to the hospital and did not return and RI #82 was not a credible or reliable source due to his/her cognitive impairment in his dealings with RI #82 due to aphasia. The ADM said he was not aware that RI #82 had a history of entering RI #325's room. On 11/17/2024 at 4:45 PM, another follow-up interview was conducted with the ADM. The ADM was asked was he able to conduct a thorough investigation. The ADM responded, yes, except for not talking to RI #82 due to him/her being hard to understand and the ADM could not make out what was being said. The ADM said he was unable to interview RI #325 because RI #325 did not return to the facility. A review of a document titled Alabama Uniform Incident/Offense Dated 06/03/2024, documented: .Type of Incident or Offense . Sexual Misconduct . Narrative . The victim, RI #82, . stated he/she had gone to RI #325's room to have a conversation . once inside RI #82 stated that RI #325 kept putting his/her hands on him/her and pulled his/her pants down grabbing him/her around his/her private area. RI #82 stated that RI #325 pulled his/her hair and forced him/her into the floor at which time RI #325 . forcefully tried to insert his/her private part into RI #82's mouth . ***************************************************** On 11/20/2024, the facility submitted an acceptable removal plan, which documented: F610 Removal Plan 11/20/24 1. Immediate action(s) taken for the resident(s) found to have been potentially affected include: A. Regional Administrator and Regional Nurse Consultant provided 1:1 in-service education to Administrator, DON and ADON regarding Abuse/Sexual Abuse policies implemented, including conducting a thorough investigation, to include contributing factors to the occurrence and take appropriate corrective action based on investigation results and contributing factors, completion of Abuse Questionnaire NM.II-20exh.A (exhibit 1 see attached) and collecting and retaining resident statements to determine a clear time of occurrence of events and that all staff responding appropriately per the abuse policy; identification of prospective residents who may pose a risk of sexual abuse to other residents due to their behaviors and planning for management of those behaviors. This was completed on 11-18-24. B. Director of Nursing re-interviewed RI #82 on 11/18/2024. RI #325 was unable to be interviewed by facility staff due to RI #325 discharge to the hospital on 6/3/24, then discharged to home from the hospital on 6/6/2024. 2. Identification of other residents having the potential to be affected: A. This had the potential to affect all residents. Regional nurse consultant and Regional Administrator reviewed for all previous investigations from 6-3-2024 through 11-28-2024. None were identified that the Regional Administrator or Regional Nurse Consultant disagreed with the investigation outcome. This was completed on 11-18-24. 3. Actions taken/systems to be put into place to reduce the risk of future occurrences include: A. QAPI completed on 11-18-24 with administrator for understanding the administrator's responsibility regarding facility policies being implemented and followed. Regional Administrator will sign off on facility reportable investigations to include sexual abuse investigations for compliance to the facilities abuse/sexual abuse policy, QAPI policy, behavior monitoring policy and notification policy are implemented/conducted according to the policy. B. The Administrator was educated by the regional nurse consultant to utilize the Verification of Investigation (VOI) form to conduct a consistent and thorough investigation of alleged abuse. The VOI includes detained description of events/allegation, BIMS score, Resident interview summary, immediate resident protection initiated, and the related. See attached. C. Facility requests for IJ removal plan to be effective on 11-20-24. **************************************************************************************************************************** After review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team determined the facility implemented the immediate corrective actions as of 11/20/2024. 29671 48195

Based on observation, interview, medical record review, the facility's policy for Sanitation Principles, and the United States (U.S.) Food and Drug Administration (FDA) 2022 Food Code; the facility failed to prevent the potential for cross-contamination by allowing: 1. staff who were chewing gum to assist residents with meals, 2. clean pots and pans to be stored on a rusty wire shelving rack, 3. a dirty floor in the storeroom for thickened liquids and nutritional supplements and additionally allowing a delivery of nutritional supplements to be placed on the dirty floor, 4. wooden shelving with gaps along the floor line, which could not be cleaned beneath, in the thickened liquids and nutritional supplement storeroom, and 5. the double sink used for food preparation to have a direct connection to the sewer. Findings include: The facility's policy for Sanitation Principles, dated 08/10/2018, included the following: . PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses. STANDARD: Food service areas should be maintained in a clean and sanitary manner. The current . Food Code should be utilized as guidelines for the department. PROCESS: a. Kitchens . should be kept clean, free from litter and rubbish, and protected from rodents, roaches, . b. shelves and equipment should be kept clean, maintained in good repair, and should be free from breaks, corrosion, open seams, cracks . 1. Chewing Gum The U.S. FDA 2022 Food Code included the following: . 1-201.10 Statement of Application and Listing of Terms. (A) The following definitions shall apply in the interpretation and application of this Code. Food means a raw, cooked, or processed edible substance, . or chewing gum. 2-401 Food Contamination Prevention 2-401.11 Eating, Drinking, or Using TOBACCO PRODUCTS. (A) . an EMPLOYEE shall eat, . only in designated areas where the contamination of exposed FOOD; clean . UTENSILS, and LINENS; . or other items needing protection can not result. Resident Identifier (RI) #323 was admitted to the facility on [DATE]. Resident Identifier (RI) #322 was admitted to the facility on [DATE]. During a dining observation in the facility's dining room for the lunch meal on 11/12/2024 at 11:48 AM, Employee Identifier (EI) #7 CNA (Certified Nursing Assistant) was actively chewing gum and opening/closing her mouth when assisting residents with condiments. EI #7 CNA was observed chewing gum and hovering over RI #322's Puree lunch meal while assisting the resident. On 11/12/2024 at 11:50 AM, EI #7 CNA was chewing gum with her mouth opening and closing while setting up RI #323's Puree lunch meal. On 11/12/2024 at 11:52 AM, EI #8 CNA was observed chewing gum with her mouth opening and closing while setting up residents' lunch meal trays. On 11/12/2024 at 12:07 PM, EI #7 CNA was actively chewing gum while feeding RI #323 his/her Puree lunch meal. EI #7 CNA was widely opening and closing her mouth during the process of feeding RI #323, with her mouth almost over the resident's plate. EI #7 CNA's open and closing mouth was directly over a bowl of puree food and later directly over a Magic Cup dessert she held in her hand to feed RI #323 with a spoon. During a dining observation in the facility's dining room on 11/13/2024 at 11:45 AM, the Restorative Nurse was observed chewing gum. During an interview on 11/14/2024 at 11:05 AM, EI #7 CNA said she assisted with meals in the dining room on 11/12/2024. EI #7 CNA said she did not normally chew gum during work, like she was doing on Tuesday, 11/12/2024. EI #7 CNA said somebody just gave her a piece of gum before she went into the Dining Room. When asked if she was allowed to chew gum while assisting residents with meals, EI #7 CNA said she was not sure about that. Upon being asked the problem with chewing gum while assisting residents with their meals, EI #7 CNA said maybe spit on the food, which could cause cross contamination. During an interview on 11/14/2024 at 11:13 AM, EI #8 CNA said she assisted with meals in the dining room on 11/12/2024. EI #8 CNA said she did not normally chew gum during work, as she was doing on Tuesday. EI #8 CNA said someone gave her a piece and she just stuck it in her mouth. When asked if she was allowed to chew gum while assisting residents with meals, EI #8 CNA said she was not sure, but normally she does not chew gum in the Dining Room. EI #8 CNA further said she should have spit it out before going in the Dining Room. Upon being asked the problem with chewing gum, EI #8 CNA said spit or something coming out of your mouth could get on their food or anything. During an interview on 11/14/2024 at 11:22 AM, the Restorative Nurse said she assisted with meals in the dining room on Wednesday, 11/13/2024. The Restorative Nurse said she did not normally chew gum during work, like she was doing on Wednesday. The Restorative Nurse further said she was nervous and someone was passing around a pack of gum. When asked if she was allowed to chew gum while assisting residents with meals, the Restorative Nurse said it had never really come up or been addressed before. Upon being asked the problem with chewing gum, the Restorative Nurse said I can see where it could be unclean. The Restorative Nurse further said one should definitely not be chewing while standing over and setting up the tray. During an interview about resident dining on 11/14/2024 at 12:52 PM, the Dietary Manager was asked the problem with staff serving meals to residents in the dining room, assisting residents with meal set-up, and feeding residents while chewing gum. The Dietary Manager said that would be an infection control issue. During an interview about resident dining on 11/14/2024 at 1:11 PM, the Registered Dietitian (RD) was asked the problem with staff serving meals to residents in the dining room, assisting residents with meal set-up, and feeding residents while chewing gum. The RD said that could create cross contamination and physical contamination. 2. Pot and Pan Shelving The U.S. FDA 2022 Food Code included the following: . 4-101.19 Nonfood-Contact Surfaces. NonFOOD-CONTACT SURFACES of EQUIPMENT that are exposed to splash, spillage, or other FOOD soiling or that require frequent cleaning shall be constructed of a -RESISTANT, nonabsorbent, and SMOOTH material. 4-201 Durability and Strength 4-201.11 Equipment and Utensils. EQUIPMENT and UTENSILS shall be designed and constructed to be durable and to retain their characteristic qualities under normal use conditions. 4-903 Storing 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) . cleaned EQUIPMENT and UTENSILS, . shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; . During the initial kitchen tour on 11/12/2024 at 10:55 AM, the storage rack for clean pots and pans had a build-up of rust on the wire shelves. Clean pans were sitting on this shelving. When a finger was rubbed along the wire shelf, a reddish substance transferred to the finger. The Dietary Manager was asked to describe the substance on the racks. The Dietary Manager said, Dirt and rust. When asked the potential problem, the Dietary Manager said dirt and rust can contaminate the pans. The Registered Dietitian (RD) was interviewed about kitchen concerns on 11/14/24 at 1:18 PM. The RD said rust touching the clean pans could lead to contamination of the pans and increased germ exposure. 3. Dirty Floor The U.S. FDA 2022 Food Code included the following: . 3-305 Preventing contamination from the premises 3-305.11 Food Storage. (A) . FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination . 6-501.12 Cleaning, Frequency and Restrictions. (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. During the initial kitchen tour on 11/12/2024 at 10:45 AM, the storeroom for thickened liquids and supplements had a very dirty floor. The floor needed sweeping. The floor had a build-up of dirt stain and had several paper scraps upon it. A supplement delivery was stored on the floor. The Dietary Manager was interviewed about kitchen concerns on 11/14/24 at 1:02 PM. The Dietary Manager said the dirty floor could contaminate the items sitting on the floor. The Registered Dietitian (RD) was interviewed about kitchen concerns on 11/14/24 at 1:18 PM. The RD said the dirty floor in the Thickened Liquids and Supplements Storeroom could attract pests and dirt could be transferred from the floor to the food containers. 4. Wooden Shelving with Gaps The U.S. FDA 2022 Food Code included the following: . 6-201 Cleanability 6-201.11 Floors, Walls, and Ceilings. . floors, floor coverings, walls, . shall be designed, constructed, and installed so they are SMOOTH and EASILY CLEANABLE. 6-201.13 Floor and Wall Junctures, Coved, and Enclosed or Sealed. (A) In FOOD ESTABLISHMENTS in which cleaning methods other than water flushing are used for cleaning floors, the floor and wall junctures shall be coved and closed to no larger than 1 mm [millimeter] (one thirty-second inch). During the initial kitchen tour on 11/12/2024 at 10:45 AM, the storeroom for thickened liquids and supplements had a very uneven floor. The Dietary Manager said the floor was supposed to be replaced when the kitchen floor was recently re-tiled. The wooden shelving could not be cleaned beneath and the shelving had gaps on the wooden edge along the floor line. The Registered Dietitian (RD) was interviewed about kitchen concerns on 11/14/24 at 1:18 PM. The RD said since the wooden shelving has gaps along the floor line and it cannot thoroughly be cleaned beneath, it could result in a pest infestation. During a follow-up interview on 11/14/24 at 5:20 PM, the Director of Maintenance said the floor in the Thicken Liquids and Supplement Storeroom was supposed to be tiled along with the rest of the kitchen floor, but the company putting in the floor did not do it. 5. Food Preparation Sink The U.S. FDA 2022 Food Code included the following: . 5-402.11 Backflow Prevention. (A) . a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. During the initial kitchen tour on 11/12/2024 at 10:55 AM, an observation was made of a double sink for food preparation with cabinet built around its base. The cabinet had 2 doors. Upon looking into the cabinet, a drain pipe was observed going from the double sink and into the wall, but no air gap was seen. The Director of Maintenance was interviewed in the kitchen on 11/14/2024 at 11:50 AM. The Director of Maintenance was asked if there was a backflow device or a special drain to prevent a direct connection between the sewer and the food preparation double sink or if the county code allowed the current plumbing for the food preparation double sink. The Director of Maintenance said he would have to check on that and he might need to check with the plumber. During a follow-up interview on 11/14/24 at 5:20 PM, the Director of Maintenance said he still needed to contact their plumber to find out what method of backflow prevention was in use for the food preparation double sink. 29671

Based on observation, interview, the facility's policy for Sanitation Principles, and the United States (U.S.) Food and Drug Administration (FDA) 2022 Food Code; the facility failed to ensure the Three-compartment Pot and Pan Sink was in good repair for use. Two of three drain levers did not work, resulting in the rinse sink and the sanitizing sink being unable to hold water. This had the potential to affect 108 of 108 residents receiving meals from the kitchen. Findings include: The facility's policy for Sanitation Principles, dated 08/10/2018, included the following: . PURPOSE: To prevent the spread of bacteria that may cause food borne illnesses. STANDARD: Food service areas should be maintained . The current . Food Code should be utilized as guidelines for the department. PROCESS: . b. equipment should be . maintained in good repair . The U.S. FDA 2022 Food Code included the following: . 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair . During the initial kitchen tour on 11/12/2024 at 10:55 AM, the Three-compartment Pot and Pan Sink was observed to not be set up for use. The Dietary Manager said it was out of order. The Dietary Manager further said the levers don't work so the sinks cannot hold water and the water slowly leaks out. The Dietary Manager said the Three-compartment Pot and Pan Sink had been out of order since March or April of 2024, when the kitchen floor was redone. The Dietary Manager said they were using the dishroom to scrap and wash the pans and then they were sanitizing the pans by putting them through the dishmachine. During an interview on 11/14/2024 at 1:02 PM, the Dietary Manager said the Three-compartment Pot and Pan Sink should not have been out of working order for so long. The Dietary Manager further said it was a basic piece of kitchen equipment. The Registered Dietitian (RD) was interviewed on 11/14/24 at 1:18 PM. The RD agreed the Three-compartment Pot and Pan Sink was a basic piece of kitchen equipment. The RD also said we have a system for Maintenance called TELS, so it should have been addressed by now. During a follow-up interview on 11/14/2024 at 5:29 PM, the Dietary Manager was asked how would pans be washed if the dishmachine broke down. The Dietary Manager said we would have to keep refilling the sinks, the rinse sink and the sanitizing sink of the Three-compartment Pot and Pan Sink. During an interview on 11/14/2024 at 5:20 PM, the Director of Maintenance was asked why the Three-compartment Pot and Pan Sink had not been repaired. The Director of Maintenance said he did not know. The Director of Maintenance further said when we put it back in after the new kitchen floor was installed, they (Dietary management) said something about the two levers.

Based on observation, interview, the facility's policy for Sanitation Principles, and the United States (U.S.) Food and Drug Administration (FDA) 2022 Food Code; the facility failed to ensure one large return vent in the Dining Room and seven of thirteen exit vents on C and D halls were clean. The facility also failed to ensure one of two clocks on C Hall was working. In addition, the facility failed to ensure five of six vinyl covered chairs in the front lobby and front hallway did not have torn or cracked upholstery. This affected two of four halls and one of one dining room. Findings include: The facility's policy for Sanitation Principles, dated 08/10/2018, included the following: . PURPOSE: To prevent the spread of bacteria . STANDARD: . areas should be maintained in a clean and sanitary manner. PROCESS: . b. equipment should be kept clean, maintained in good repair, and should be free from breaks, corrosion, open seams, cracks . The U.S. FDA 2022 Food Code included the following: . 6-501.11 Repairing. PHYSICAL FACILITIES shall be maintained in good repair. 6-501.12 Cleaning, Frequency and Restrictions. (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. 6-501.14 Cleaning Ventilation Systems, Nuisance and Discharge Prohibition. (A) Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt, and other materials. 1. Dining Room Vent Beginning at 11:34 AM on 11/12/2024, 32 residents were observed receiving lunch in the Dining Room. At 11:58 AM, a large wall vent, approximately 1.5 by 3 feet in size, was observed near the emergency exit door at the back of the Dining Room. The wall vent was badly corroded with rust at the bottom third of the vent and heavily covered with dust, which could be removed by touch. Beginning at 11:32 AM on 11/13/2024, 40 residents were observed receiving lunch in the Dining Room. At 12:09 PM, the large wall vent near the exit door of the Dining Room was still thickly layered with dust that could be removed by ones' finger. On 11/14/2024 at 11:42 AM, the Director of Maintenance was interviewed beside the large wall vent near the exit door in the Dining Room. The Director of Maintenance said the large wall vent was a return vent. The Director of Maintenance also said the substances on the vent's grill were rust, dirt, and dust. When asked the problem of rust, dirt, and dust on the vent grill, the Director of Maintenance said it could affect the performance of the ventilation system. Upon being asked if this was homelike, the Director of Maintenance said no. On 11/14/2024 at 12:52 PM, the Dietary Manager was interviewed. When asked about the large vent near the exit door in the Dining Room, the Dietary Manager said the substances on the vent's grill were paint, rust, and dust. Upon being asked if this helped to create a homelike environment, the Dietary Manager said no. On 11/14/2024 at 01:11 PM, the Registered Dietitian (RD) was interviewed. When asked about the large vent near the exit door in the Dining Room, the RD said the substances on the vent's grill were rust and grime. The RD further said there have been various things placed in front of that vent, so it has not been extremely visible to her. When asked the problem with having rust, dirt, and heavy dust on the vent's grill; the RD said possible cross contamination. Upon being asked if this helped to create a homelike environment, the RD said no, it does not help. 2. Hallway Vents On 11/14/2024 at 10:48 AM, three ceiling vents on C Hall (part of the front hall), between room [ROOM NUMBER] and the Social Services' office, were observed to have a build-up of a dark black substance beside each vent. There were six ceiling vents (of the same type) on C Hall. On 11/14/2024 at 10:50 AM, four ceiling vents on D Hall, between rooms [ROOM NUMBERS], were observed to have a build-up of a dark black substance beside each vent. There were seven ceiling vents (of the same type) on D Hall. On 11/14/2024 at 11:42 AM, the Director of Maintenance was interviewed. While observing the three ceiling vents on C Hall and then the four ceiling vents on D Hall, the Director of Maintenance said these were exit vents. The Director of Maintenance said the dark substance around the hallway ceiling vents was dust. The Director of Maintenance further said we have a lot of dust coming through the vent systems. When asked how this could affect the residents, the Director of Maintenance said allergies and respiratory issues. The Director of Maintenance additionally said Maintenance could do more cleaning of the vents. 3. Clock On 11/12/2024 at 10:25 AM, a clock on the archway wall in the front hallway on C Hall, between rooms [ROOM NUMBERS], was not working. The clock was stopped at 6:14. On 11/13/2024 at 11:28 AM, the clock on the archway wall in the front hallway on C Hall was still not working. The clock was stopped at 6:14. This was one of two clocks on C Hall. On 11/14/2024 at 10:56 AM, the clock on the archway wall in the front hallway on C Hall was still not working. The clock was stopped at 6:14. On 11/14/2024 at 11:42 AM, the Director of Maintenance was interviewed. When asked the problem with having a clock on the front hall being out of order and reading 6:14, the Director of Maintenance said the residents would not get the correct time, if they were depending on that clock, to arrive at Activities on time. 4. Vinyl Upholstered Chairs On 11/12/2024 at 12:29 PM, two vinyl covered chairs in the front hallway by the conference room were both observed to have badly cracked seat cushions, so that the seat cushion surfaces were rough and not smooth. The larger of the two chairs was missing a large section of brown, vinyl upholstery on the right armrest, approximately half of the vinyl upholstery on the right arm rest was missing. On 11/14/2024 at 10:58 AM, a brown, vinyl covered chair in the seating area near the front door was observed. The chair was used by residents at the jigsaw puzzle table. The chair had a tear in the vinyl seat, which was partially covered with clear tape. On 11/14/2024 at 04:05 PM, one vinyl covered chair by the front entrance was observed to have a badly cracked seat cushion, so that the seat cushion surface was rough and not smooth. Another vinyl covered chair in the seating area near the front entrance was observed to be missing a section of brown, vinyl upholstery on the right armrest, approximately 1.5 by 3 inches in size. A total of six vinyl upholstered chairs were observed on the front hall of the facility. On 11/14/2024 at 11:42 AM, the Director of Maintenance was interviewed. Upon observing the vinyl upholstered chairs on the front hall of the facility, the Director of Maintenance said the torn seat cushions and the missing sections of upholstery could possibly result in injury and also in the transfer of fluids. The Director of Maintenance additionally said the chairs were not easily cleanable. The Director of Maintenance further said the residents could be affected by possible cross contamination because the chairs could not be properly cleaned. Upon being asked if this was homelike, the Director of Maintenance said no. This tag was cited as a result of investigation/complaint # AL00048132.

Based on record review, interviews, documents titled Online Incident Reporting System Report and a facility policy titled Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation the facility failed to report allegations related to physical and verbal abuse within 2 hours to the state agency on 04/09/2024, 07/03/2024 and 10/27/2024. This affected Resident Identifiers (RI) #27, #43 and #91. This deficient practice affected three of eleven residents sampled for abuse. Findings Include: A review of a policy titled Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation with an effective date of May 01, 2023, documented the following: .b) Investigation and Reporting Steps .All allegations of abuse and instances that result in serious bodily injury must be reported with 2 hours. 1. A review of a document titled Online Incident Reporting System Report documented RI #91 reported an allegation of verbal abuse regarding RI #27 threatening RI #91 on 04/09/2024 and the facility notified the State Agency on 04/10/2024 at 1:02: PM. The report indicated that RI #27 was placed on 1:1 on 04/09/2024 until transferred for psychiatric evaluation on 04/10/2024. RI #91 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's Disease, Dementia and Type 2 Diabetes Mellitus with Hyperglycemia. RI #27 was readmitted to the facility on [DATE] with diagnoses to include Human Immunodeficiency Virus, Chronic Obstructive Pulmonary Disease, Type Two Diabetes Mellitus with Diabetic Nephropathy and Vascular Dementia An interview was conducted with the ADM on 11/15/2024 at 5:23 PM. The ADM stated he became aware of the allegation of verbal abuse involving RI #91 and RI #27 on 04/10/2024. The ADM was asked why the incident was not reported on 04/09/2024. He responded that if the incident was witnessed/occurred on 04/09/2024 it should have been reported to the State agency on 04/09/2024. This was cited as a result of investigation of complaint/report number AL00047516. 2. A review of a document titled Online Incident Reporting System Report documented RI #43 reported an allegation of verbal abuse on 10/27/2024 and the facility notified the State Agency on 10/28/2024 at 9:38 PM. The allegation was that CNA #20 cursed at RI #43. The report indicated CNA #20 was immediately removed from the room and suspended pending investigation. RI #43 was admitted to the facility on [DATE] with diagnoses to include Dementia, Major Depressive Disorder, Alcohol Abuse and Adjustment Disorder with Depressed Mood. An interview was conducted with the Assistant Director of Nursing (ADON) on 11/16/2024 at 10:56 AM. The ADON stated it was reported to her on 10/27/2024 at 12:20 AM and she reported it to the State Agency on 10/28/2024 at 09:30 AM. She further said abuse was to be reported in two hours and it was not reported within the two-hour timeframe, and it should have been. The ADON said the allegation was reported late to the State Agency because she did not have a key to the ADM's office to access the computer codes and that the ADM was out of the country. She further said that when it was reported to the ADM it was late reporting. The ADON further stated the allegation was not substantiated due to lack of evidence. An interview was conducted with the ADM on 11/16/2024 at 11:21 AM. The ADM stated he it was reported to him on 10/27/2024 at 12:20 AM and was reported to the State Agency on 10/28/2024 at 9:39 AM. He further said it was not reported within the two-hour timeframe and he reported it when he became aware. This deficiency was cited as the result of the investigation of complaint /report number AL00049463. 29671

Based on record review, interview, and review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure Resident Identifier (RI) #2's completed Minimum Data Set (MDS) assessments was transmitted to the CMS system. This affected RI #2, one of 22 sampled residents whose MDS assessments were reviewed. Findings include: Review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2024, revealed the following: CHAPTER 5: SUBMISSION .OF THE MDS ASSESSMENTS Transmitting Data: Providers must transmit all sections of the MDS 3.0 required for their State-specific instrument, including the Care Area Assessment (CAA) Summary (Section V) and all tracking or correction information. Transmission requirements apply to all MDS 3.0 records used to meet both federal and state requirements. . Assessment Transmission: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 + 14 days). All other MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days) . RI #2 was admitted to the facility on [DATE]. On 11/14/2024 at 11:30 AM, record review revealed RI #'s 2's 09/23/2024 annual MDS assessment was not transmitted to CMS after it was completed on 10/07/2024. The MDS Coordinator, was interviewed on 11/14/2024 at 1:59 PM. During the interview, she indicated that she had completed the MDS for RI #2, which was dated 09/23/2024. She said the assessment was started on 09/23/2024 and completed on 10/07/2024. The MDS coordinator said that the MDS was not transmitted to CMS after it was completed on 10/07/2024. When asked why the MDS should be transmitted she said to ensure accuracy and to provide accurate information to CMS.

Based on interviews, record review, and the Centers for Medicare & Medicaid Services (CMS)Center) Long- Term Care Resident Assessment Instrument 3.0 Manual, the facility failed to 1) ensure Resident Identified (RI) #60's Annual Minimum Data Set (MDS) assessment dated [DATE] section A1500 was coded accurately to reflect RI #60's Preadmission Screening and Resident Review (PASRR) Level II. 2) ensure RI #82's Annual MDS assessment dated [DATE] section A1500 was coded accurately to reflect RI #82's PASRR Level II. This deficient practice affected two of 22 sampled residents whose MDS was reviewed. Findings include: Review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2024, revealed the following: A1500: Preadmission Screening and Resident Review (PASRR) . Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD or related condition 1) RI #60 was admitted to the facility on [DATE] with a diagnosis of Generalized Anxiety Disorder, Post-Traumatic Stress Disorder, Chronic, Developmental Disorder. A review of RI #60's Annual MDS dated [DATE] documented: . A1500 Preadmission Screening and Resident Review (PASRR) . Is the resident currently considered by the state level II PASRR . was marked 0 indicating No. A review of RI #60's PASRR Level II Service Determination dated 11/27/2018 documented: . Section I: Diagnosis . X marked for Serious Mental Illness (MI) specify: PTSD . X marked for Related Condition (RC) specify: DD . On 11/14/2024 at 1:56 PM an interview was conducted with the MDS Coordinator. When asked if RI #60 was marked on the MDS as a Level II, she said no. In referencing RI #60's Level II document, the MDS Coordinator noted where RI #60 's document revealed he/she was a Level II. When asked what the importance of the MDS being marked correctly, she said to ensure accuracy of the MDS data. 2) RI #82 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis Depression. On 11/18/2024 at 10:00 AM, a review of RI #82's Annual MDS dated [DATE] documented: . A1500 Preadmission Screening and Resident Review (PASRR) . Is the resident currently considered by the state level II PASRR . was marked 0 indicating No. A review of RI #82's PASRR Level II Service Determination dated 05/25/2022 documented: .Section I: Diagnosis X marked for Serious Mental Illness (MI) specify: Depression . On 11/18/2024 at 11:20 AM a follow up interview was conducted with MDS Coordinator. When asked if RI #82 was marked on the MDS as a Level II, she said no. In referencing RI #82's Level II document, MDS coordinator noted where RI #82's document revealed he/she was a Level II. When asked why RI #82's MDS was not marked as being a Level II, she said this was an error and that it should have been marked.

Based on observation, interview, medical record review, and the facility's policy for Enhanced Dining; the facility failed to ensure residents' lunch meals were not left upon transport trays when served to residents in the dining room on Tuesday, 11/12/2024 and Wednesday, 11/13/2024. This affected 40 of 40 residents receiving meals in the facility's dining room. Findings include: The facility's policy for Enhanced Dining, dated 02/23/2011, included the following: PURPOSE: To improve resident/guest(s) quality of life by allowing them to enjoy dining in a non-institutional environment, when possible. STANDARD: To the extent possible, the facility should provide a dignified environment at mealtime, . PROCESS: To enhance the resident/guest(s) dining experience, and ultimately the resident/guest(s) appetite, the following strategies may be considered: . e. Use of china or attractive dishes, with elimination of food trays . Resident Identifier (RI) #14 was admitted to the facility on [DATE]. During a dining observation on 11/12/2024 at 11:34 AM, the facility's dining room was filled with 32 residents seated at tables with green linen tablecloths and centerpieces of either silk flowers or small pumpkins. The dining room was decorated for the Fall/[NAME] season, eight staff were present, and quiet conversations were ongoing. At 11:45 AM, the first cart of meal trays entered the dining room from the kitchen and service of lunch began. At 11:46 AM, nine staff members were serving lunch to the residents, table by table. All residents in the dining room were being served with the meal plate, silverware, and other food items remaining on the transport tray. Each meal tray was placed directly on the table in front of the resident. Plate lids and trash/wrappers were placed on a separate cart parked by the dishwashing room entrance. During a dining observation on 11/13/2024 at 11:32 AM, the facility's dining room was filled with 40 residents seated at tables with green linen tablecloths. Eleven staff members were present. The dining room was decorated for Fall/[NAME] and corresponding themed centerpieces were on the tables. Quiet conversations were ongoing among the residents and staff present. At 11:38 AM, thirteen staff were in the dining room and by 11:40 AM, the lunch meal service began with the arrival of the first cart from the kitchen. Again, all items were left on the transport tray. At 11:50 AM, one of the staff providing service was identified as the Restorative Nurse. On 11/13/2024 at 5:10 PM, the Registered Dietitian (RD) and the Dietary Manager were questioned if the residents or the Resident Council had been asked if it was okay to serve them meals on trays in the dining room. Neither the RD nor the Dietary Manager was aware of the residents being asked that question. The RD said it would make sense to take the items off the tray for a more enhanced dining experience. On 11/13/24 at 5:49 PM, an interview was conducted with RI #14, the Resident Council President. RI #14 said he/she had been Resident Council President for about five years. When asked if anyone had ever discussed the topic of leaving trays on the tables in the dining room, he/she said no. During an interview on 11/14/2024 at 11:22 AM, the Restorative Nurse said she assisted with meals in the dining room on Wednesday, 11/13/2024. When asked if taking the food items off the tray for service in the dining room had ever been discussed, the Restorative Nurse said no, we have always just set the tray down on the table. The Restorative Nurse further said she did not know if the residents had ever been asked if they were okay with their meals being left on the trays during dining room service. The Restorative Nurse was asked if you went to a restaurant with a tablecloth and centerpiece on the table, would you expect the server to place the service tray with your food on it onto the table before you. The Restorative Nurse shook her head no and said even in a fast-food restaurant, you take your food off the tray. During an interview on 11/14/2024 at 12:52 PM, the Dietary Manager was asked how could serving meals on trays in the dining room negatively affect residents. The Dietary Manager said they might not feel like they were at home. During an interview on 11/14/2024 at 1:11 PM, the RD was asked how could serving meals on trays in the dining room negatively affect residents. The RD said it could seem less homelike. 29671

Based on observation, interview and record review, the facility failed to ensure Employee Identifier (EI) #7, a Licensed Practical Nurse (LPN) washed her hands prior to putting gloves on. Without washing or sanitizing her hands, EI #7 put gloves on and administered an inhaler medication to Resident Identifier (RI) #45. This deficient practice affected RI #45, one of four residents observed for medication administration. Findings include: RI #45 was admitted to the facility on [DATE]. RI #45 has a medical history to include a [DIAGNOSES REDACTED]. RI #45's Physician order [REDACTED]. During medication pass observation on 10/3/2019 at 8:09 AM, EI #7, a LPN put on gloves without washing or sanitizing her hands and administered an inhaler medication, [MEDICATION NAME], to RI #45. In an interview on 10/3/2019 at 12:00 PM, EI #7, a LPN was asked when should she wash her hands when wearing gloves. EI #7 answered, before putting them on and after taking them off. When asked did she wash her hands before putting gloves on to administer RI #45's inhaler medication, EI #7 replied, no. When asked should she have washed her hands, EI #7 said yes.

Based on observation, interview, the (YEAR) Food Code, and the facility's policies for Food Preparation Guidelines, Food Receipt and Storage, and Cleaning of Miscellaneous Equipment and Utensils, the facility failed to ensure the potential for cross-contamination did not occur due to food items and supplies being stored less than six inches off the floor and the accumulation of dust on the ceiling and walls of the walk-in cooler. The facility further failed to maintain the cold temperature of an individual carton of skim milk at 41 degrees F (Fahrenheit) or below during the resident lunch trayline on 9/5/2018. This had the potential to affect 108 residents receiving meals from the kitchen, 108 of 111 residents. Findings Include: The facility's policy for Food Preparation Guidelines, dated 8/15/2009, included the following: . Process: . g. Food should be protected from contamination, while being stored, prepared, and served to residents. To prevent growth of pathogenic organisms: 1. Refrigerated at or below 41 . (degrees) F, . The facility's policy for Food Receipt and Storage, dated 8/23/2017, included the following: . Purpose: Food should be . stored properly to prevent food borne illnesses. Process: . II. Storage of Foods: . c. Items in storage rooms . should be kept at least 6 inches from the floor. The facility's policy for Cleaning of Miscellaneous Equipment and Utensils, dated 8/23/2017, included the following: 34 . Refrigerator (weekly) . 2. Wash thoroughly inside and outside of refrigerator . 5. Wash walls . 6. Rinse and sanitize . The (YEAR) Food Code recommendations of the United States (U.S.) Public Health Service and the U.S. Food and Drug Administration included: . Preventing Contamination from the Premises 3-305.11 Food Storage. (A) . FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (centimeters) (6 inches) above the floor. 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) . TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: . (2) At 5 . (degrees) C (Centigrade) (41 .(degrees) F) or less. 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (C) NONFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, . 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) . EQUIPMENT . shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm (centimeters) (6 inches) above the floor. I. Potential Cross-Contamination On 09/04/18 at 03:11 PM, during the initial tour of the kitchen with Employee Identifier (EI) #1, the Dietary Manager (DM), items in the dry store room were observed to be stored less than six inches from the floor. The bottom shelf, as measured with a ruler by EI #1, was four and five-eighths inches from the floor and held the following items: two open boxes of pudding packs, an opened bag of onions, a case of oatmeal, a case of fruit cocktail and a case of juice concentrate. In addition, a heavy plastic shelving unit's bottom shelf was approximately 1 inch or less from the floor and there were dirt particles on the floor beneath it, as observed through the grated bottom shelf. The shelving unit had small equipment and catering items stored on the bottom shelf. On 09/04/18 at 03:14 PM, EI #1 was asked what was the problem with having food items and other things stored less than 6 inches from the floor. EI #1 said the problem would be possible contamination from water, dust, and dirt. On 09/04/18 at 03:19 PM, the walk-in cooler was observed to have milk, produce, and other food items stored on shelves. Balls of grey material were noted on the ceiling of the walk-in cooler and at the top of the walls near the ceiling. The coverage of grey material on the cooler wall was heavier above the door frame. The balls of grey material were also attached to the top of the plastic air curtains hanging over the walk-in cooler door. EI #1 was asked to use a paper towel to check if the grey balls could be wiped from the ceiling. EI #1 was able to remove grey material from the surface with a wipe of the paper towel. On 09/04/18 at 03:22 PM, EI #1 was asked what were the grey balls attached to the ceiling and walls of the walk-in cooler. EI #1 said it was dust and that it should not be there. When asked what was the problem of the dust being in the walk-in cooler with food items such as cheesecakes, which were on the top shelf and lightly covered with aluminum foil, EI #1 said it could contaminate food. On 09/05/18 at 10:20 AM, EI #1 when asked why the walls of the walk-in cooler were not cleaned, EI #1 said it had been overlooked. EI #1 was asked if the dust laden walk-in cooler walls should have been cleaned on (MONTH) 31, (YEAR), but were not since the cleaning of the walls had been overlooked. EI #1 said yes. On 09/06/18 at 10:34 AM, EI #2, the Registered Dietitian (RD) was interviewed. When asked what would be the problem with the walk-in cooler's ceiling and walls being dirty with dust, EI #2 said the potential contamination of the food stored in the walk-in cooler. Upon being asked what was the problem with food items stored less than six inches from the floor, EI #2 said potential contamination from routine cleaning. In addition, EI #2 was asked what was the problem with shelving that is too low to the floor. EI #2 said one is unable to clean under the shelving. II. Cold Holding During the observation of tray line for the residents' lunch service on 09/05/18 at 10:55 AM, two cartons of individual skim milk were observed on a cart in the tray assembly area. The milk cartons were placed outside of and next to an insulated cooler filled with individual cartons of milk. A check of one of the two cartons revealed a temperature of 38 degrees F. During the lunch preparation on 09/05/18 at 11:59 AM, individual skim milk cartons were observed placed outside of and next to the insulated cooler. Prior to the end of the lunch tray line on 09/05/18 at 12:11 PM, EI #2, the RD, was asked to check the temperature of one of the skim milk cartons. The skim milk temperature was 53 degrees F. EI #1, the DM, was interviewed on 09/05/18 at 01:23 PM. When asked how were individual cartons of milk kept cold during the preparation of residents trays, EI #1 said they were kept in the insulated cooler. EI #1 was asked why two cartons of skim milk were kept on the outside of the insulated cooler with no means of keeping them cool. EI #1 said she did not know, but guessed that EI #4, the Dietary Aide, was separating them from the rest of the milks. EI #1 was asked the reason for the difference in temperature of milk cartons placed beside the insulated cooler, at 10:55 AM being 38 degrees F and at 12:11 PM being 53 degrees F. EI #1 said it was due to the length of time the milk sat there because it was not stored in the insulated cooler. Upon being asked what was the problem with the skim milk temperature rising above 41 degrees F during the patient tray line, EI #1 said the time/temperature abuse of a potentially hazardous food. EI #4, the Dietary Aide, was interviewed on 09/06/18 at 10:23 AM. When asked why was skim milk placed outside of the insulated cooler, EI #4 said she only has a couple residents that used skim milk and she had never really thought about it getting warm. When asked what temperature milk should be held at, EI #4 said 36 to 38 degrees F, definitely not more than 42 degrees F. Upon being asked what was the problem with milk getting too hot while sitting on the tray line, EI #4 said bacteria could grow and cause illness like nausea, upset stomach, and diarrhea.

Based on observation, a test tray, interview, the (YEAR) Food Code, and the facility's policies for Tray Assembly and Food Preparation Guidelines, the facility failed to ensure hot food items were served hot and further failed to ensure equipment designed to maintain the cold temperature of individual cartons of skim milk was used during the lunch trayline on 9/5/2018. This affected Resident Identifier (RI) #28, RI #61, fifteen of fifteen residents attending Resident Council on 9/5/2018 at 1:00 PM, and had the potential to affect 108 residents receiving meals from the kitchen, 108 of 111 residents. Findings Include: The facility's policy for Tray Assembly, dated 2/1/2002, included: . Purpose: . provide foods that are at proper temperature . Process: . e. equipment designed to maintain temperature should be used. The facility's policy for Food Preparation Guidelines, dated 8/15/2009, included: . Purpose: . Food should be palatable, attractive, and at the proper temperature, as determined by the type of food, to ensure resident's satisfaction. Process: . g. Food should be . , while being . served . 1. Refrigerated at or below 41 . (degrees) F (Fahrenheit), . The (YEAR) Food Code recommendations of the United States (U.S.) Public Health Service and the U.S. Food and Drug Administration included: . 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) . TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 . (degrees) C (Centigrade) (135 . (degrees) F) or above, . or (2) At 5 . (degrees) C (41 .(degrees) F) or less. I. Hot Food RI #28 was admitted to the facility on [DATE] and readmitted on [DATE]. On the annual Minimum Data Set (MDS), dated [DATE], RI #28's Brief Interview for Mental Status (BIMS) score was 15, which indicated the resident was cognitively intact. During the initial tour on 9/4/18, RI #28 said breakfast was always cold, especially the eggs. RI #61 was admitted to the facility on [DATE]. On the quarterly MDS, dated [DATE], RI #61's BIMS score was 13, which indicated the resident was cognitively intact. During an interview on 9/4/18 at 5:48 PM, RI #61 said all three meals were cold. RI #61 said the eggs and the coffee were served cold. The resident had asked the facility staff to heat up the eggs, but they are still cold according to RI #61. On 09/05/18 at 10:46 AM, an observation revealed the plate warmers were not plugged in. In order for the plates to be hot for the lunch tray line, Employee Identifier (EI) #1, the Dietary Manager (DM), stated the plate warmers should have been turned on after the dishes were washed from breakfast, around 10:15 to 10:30 AM. EI #1 plugged in the two plate warmers and checked the temperature settings, which per EI #1 were both set on high. On 09/05/18 at 10:52 AM, the accuracy of the facility's electronic thermometer was verified. A temperature of 32.7 degrees Fahrenheit (F) was measured via the ice water slush method. On 09/05/18 at 10:55 AM, the holding temperatures on the steam table for the resident lunch trayline were checked by EI #3, the AM (morning) Cook, and included the following: ham - 185 degrees F fried okra - 139 degrees F pureed ham - 189 degrees F pureed fried okra - 189 degrees F At 11:15 AM, the resident lunch trayline assembly was ongoing and the first meal cart left the kitchen. EI #3 was serving the hot foods from the steam table onto plates that were placed onto insulated underliners and covered with insulated domes. The surveyor felt heat from the plate warmer unit, but when holding a hand approximately one inch from the top plate did not feel any warmth. At 11:17 AM, EI #3 pulled seven plates out of the plate warmer and set them on the serving ledge to use for the ongoing trayline lunch service. At 11:20 AM, it was observed that the resident trays going to the main dining room did not have insulated underliners. At 11:56 AM, EI #3 pulled eight plates out of the plate warmer and set them on the serving ledge to use while preparing resident trays for the fifth delivery cart. At 12:03 PM, EI #3 pulled seven plates out of the plate warmer for use for the final plating. At 12:14 PM, the test trays, a regular diet and a puree diet, were prepared and placed on the last lunch cart. At 12:16 PM the last cart left the kitchen and at 12:17 PM it arrived on the resident hall. At 12:22 PM, the last resident lunch tray was served. The test trays were sampled with EI #1 and EI #2, the Registered Dietitian (RD), on 09/05/18 at 12:23 PM. Both the regular and puree ham and fried okra were cold. The plates from both the regular test tray and the puree test tray were touched directly and they both were cool to touch. Resident Council met on 9/5/2018 at 1:00 PM with fifteen residents in attendance. Fifteen of fifteen residents said the hot food was served cold. During an interview on 09/06/18 at 10:05 AM, EI #1 said the purpose of having a plate warmer was to keep food hot. EI #1 was asked what were the manufacturer's instructions for the length of time required for plates to be in the warmer to achieve the optimum temperature to help maintain hot food. EI #1 said she did not know what the manufacturer's guidelines were, but ideally 30 minutes to one hour based on her experience. When asked what was the problem with not having the plate warmers plugged in, EI #1 said the food will not hold a hot temperature. When asked what would be the problem with taking up to eight plates out of the plate warmer at a time when plating residents' food, EI #1 said the plates would cool down. On 09/06/18 at 10:34 AM, EI #2, the RD, was interviewed. When asked by what means did she assure food was served warm. EI #2 said by following established policies and procedures, using the equipment available, and working with Nursing for timely delivery of trays. EI #2 was asked what would be the problem with taking up to eight plates out of the warmer at a time when plating residents' food. EI #2 said the plates would cool down. When asked what was the problem with the plate warmer not being plugged in a timely manner. EI #2 said the plates would not have time to heat. When asked how did the fact that heated plates were being allowed to cool down affect the food temperature. EI #2 said the food would possibly be cold. EI #2 was asked if the temperature of the ham and the fried okra was warm on the trays tested with the surveyor on 9/5/18. EI #2 said no. II. Cold Food During the observation of tray line for the residents' lunch service on 09/05/18 at 10:55 AM, two cartons of individual skim milk were observed on a cart in the tray assembly area. The milk cartons were placed outside of and next to an insulated cooler filled with individual cartons of milk. A check of one of the two cartons revealed a temperature of 38 degrees F. During the lunch preparation on 09/05/18 at 11:59 AM, individual skim milk cartons were observed placed outside of and next to the insulated cooler. Prior to the end of the lunch tray line on 09/05/18 at 12:11 PM, EI #2, the RD, was asked to check the temperature of one of the skim milk cartons. The skim milk temperature was 53 degrees F. EI #1, the DM, was interviewed on 09/05/18 at 01:23 PM. When asked how were individual cartons of milk kept cold during the preparation of residents trays, EI #1 said they were kept in the insulated cooler. When asked why two cartons of skim milk were kept on the outside of the insulated cooler with no means of keeping them cool, EI #1 said she did not know. EI #1 was asked the reason for the difference in temperature of milk cartons placed beside the insulated cooler, at 10:55 AM being 38 degrees F and at 12:11 PM being 53 degrees F. EI #1 said it was due to the length of time the milk sat there because it was not stored in the insulated cooler. Upon being asked what was the problem with the skim milk temperature rising above 41 degrees F during the patient tray line, EI #1 said the time/temperature abuse of a potentially hazardous food. EI #2, the RD, was interviewed on 09/06/18 at 10:34 AM. When asked if individual cartons of milk should be stored with no way of being kept cool, EI #2 said no. When asked what was the problem with individual cartons of milk being stored on the tray line so that the milk temperature exceeded 41 degrees F, EI #2 said potential time/temperature abuse. Upon being asked how time/temperature abuse could potentially affect the residents, EI #2 said it had the potential to sour the milk and make it non-palatable.

Based on observations, interviews, medical record reviews and review of facility policies titled, Hand Hygiene, Medication Administration and Contact Precautions, the facility failed to ensure: 1) a Licensed Practical Nurse (LPN) washed her hands and changed her gloves appropriately during the medication administration and also place a barrier between the over bed table and medication supplies for Resident Identifier (R) #110; 2) a sign was posted outside RI #1's room to notify staff, residents and visitors to check with the nurse prior to entering the room and 3) a Certified Nursing Assistant (CNA) placed on appropriate Personal Protective Equipment (PPE) prior to entering the room of RI #1. 1)This affected 1 of 5 residents and 1 of 5 nurses during the observations of medication administration. 2) This affected 1 of 1 sampled resident on contact isolation. Findings Include: The facility's policy titled, Hand Hygiene, effective date 9/1/17, included: . The following is a list of some situations that require hand hygiene. After removing gloves . The facility's policy titled, Medication Administration- General Guidelines, date 03/11, included, Procedures 6. Cleanse hands with soap and water before handling medications and before and after direct contact with resident. 1.) RI #110 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 09/05/18 at 4:09 PM, during a medication pass observation, the surveyor made the following observations while Employee Identifier (EI) #6, Licensed Practical Nurse (LPN) was administering medications to RI #110. 1. She placed two syringes containing insulin and two alcohol wipes on RI #110's unclean overbed table, without a barrier, 2. She did not wash her hands and change her gloves after administering the first insulin injection in RI #110's right lower abdomen and before administering the second insulin injection to RI #110's right outer arm. 3. She removed gloves and applied clean gloves without washing her hands after giving the injections, operated the bed control with her left hand while wearing a glove worn to apply RI #110's topical cream to her/his right hip and then returned to the medication cart while still wearing the same soiled gloves. When the gloves were removed, she gelled her hands. On 09/06/18 at 3:09 PM, an interview was conducted with EI #6, LPN. EI #6 was asked should syringes containing insulin and alcohol wipes be placed on an unclean overbed table. EI #6 said no, not without a barrier. EI #6 was asked did she place RI #110's syringes and alcohol wipes on the overbed table without a barrier. EI #6 stated, she did. EI #6 was asked when should she wash her hands when using gloves. EI #6 replied before and after. EI #6 was asked when should she wash her hands and change her gloves during injections. EI #6 said before and after removing her gloves. EI #6 was asked did she wash her hands after giving RI #110's insulin injections and before applying gloves to administer RI #110's cream to her/his hip. EI #6 replied, no. EI #6 was asked when should she wash her hands and change gloves during topical cream administration to the hip area. EI #6 said before and after. EI #6 was asked what was the concern with not washing her hands and changing gloves when indicated and placing items on an unclean surface. EI #6 answered infection control. On 09/06/18 at 7:40 PM, an interview was conducted with EI #7, Registered Nurse (RN)/Director of Nursing/ Infection Control Coordinator. EI #7 was asked when should a nurse change her gloves and wash her hands during multiple injections, medications by mouth and topical cream administration. EI #7 said she should remove gloves and wash hands between the two injections and wash hands and put gloves on before topical cream and then wash hands after. EI #7 was asked should a nurse place syringes and alcohol wipes on an unclean surface prior to administration. EI #7 answered no. 2. Review of the facility policy titled, Contact Precautions, effected date 9/1/17, included: . II. Gloves and Hand Hygiene . A. Gloves should be worn when entering the room . C. Gloves should be removed before leaving the resident . and hand hygiene should be performed immediately. III. Gowns A gown should be donned prior to entering the resident room . A. The gown should be removed before leaving the resident room . RI #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A review of the (MONTH) (YEAR) Physician Orders revealed RI #1 began treatment for [REDACTED]. The orders further revealed the resident was placed on contact isolation related to lice at that time. 09/05/18 12:10 PM, Employee Identifier (EI) #8 CNA, entered RI #1's room. There was no sign on the door for staff, residents and visitors to see the nurse prior to entering the room. EI #8 entered the room with the lunch tray. She did not put gloves and a gown on. Nor did she place her hair in a net/cap. EI #8 placed the tray on overbed table and exited the room. There surveyor asked the CNA was she RI #1's CNA that day. EI #8 replied, yes she was. 09/05/2018 at 12:55 PM, another CNA was observed entering the resident's room after she placed a gown, hair net and gloves on. She entered the room and retrieved the lunch tray. 09/05/2018 at 4:45 PM, EI #8 was interviewed. She was asked what type of isolation was RI #1. EI #8 replied, contact isolation for lice. She was asked what did the facility Policy & Procedure say regarding contact isolation. EI #8 replied, to put a gown on, cap & gloves and hair net before entering the room. She was asked when she entered the resident's room on 09/05/2018 at 12:10 what did she do. EI #8 said she took the lunch tray in and she did not put a gown, gloves or hair net on. She was asked why should she have put PPE on before entering the room. EI #8 replied, for her protection and the resident is on contact isolation. She further commented she did not have anyone to hold the lunch tray for her. EI #8 was asked what she normally did when delivering the meal tray. She reported she would get another staff member to hold the tray so she could put the PPE on. EI #8 was asked had she been in-serviced on isolation precautions. She replied, yes every three months and prn (as needed). On 09/06/2018 at 7:40 PM, EI #7 RN DON/ Infection Control was interviewed. She was asked what did the facility P & P document regarding contact isolation. EI #7 said to put on gloves before entering and remove gloves before leaving the room and gown prior to entering and remove prior to exiting the room. When asked what did the facility P&P document regarding a sign for staff, visitors, residents, EI #7 said there should be a sign to check with the nurse prior to entering, per HIPAA compliance. When asked who was responsible for ensuring the sign was on the door, EI #7 replied, the nurses and all staff. The DON was asked what were staff to do before entering a contact isolation area. She reported, put PPE on per facility policy . When asked why, EI #7 replied, you do not want to get infected and carry to anyone else. EI #7 was asked when and by whom were the staff in-serviced regarding PPE & isolation precautions. She reported the staff were inserviced by her and staff development yearly and as needed.

Based on observation, interview, and document review, the Dietary Service Manual guideline, Hand-washing Guidelines, and the 2013 Food Code included the following: the facility failed to ensure the potential for cross-contamination did not occur due to: a.) Employee Identifier (EI) #8, a dietary aide, not utilizing proper hand washing when going from soiled dishes to the clean side of the dishwasher. Also when EI #8 dripped water from her hands onto cleaned dishes. b.) The handle of a scoop resting in the contents of the flour bin. This had the potential to affect 94 residents receiving meals from the kitchen, 94 of 95 residents in the facility. Findings include: a.) The facility's Hand-washing Guidelines, dated 2/1/02, from the Dietary Service Manual included the following: . Purpose: To prevent the spread of bacteria that may cause food borne illness. Standard: One hand-washing sink should be available in the dietary department to allow for hand sanitation by dietary employees. Process: I. Frequency of Hand-washing: Hands should be washed in the following situations: . After hands have touched anything unsanitary, i.e. (id est meaning that is) . soiled utensils or equipment, dirty dishes, . II. Hand-washing Procedure: . b. Moisten hands with water and apply soap to hands . The 2013 Food Code of the United States Public Health Service (USPHS) and the Food and Drug Administration (FDA) included the following: . 2-301.12 Cleaning Procedure. (A) . FOOD EMPLOYEES shall clean their hands . for at least 20 seconds, using a cleaning compound in a HANDWASHING SINK . 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands . before . working with .clean EQUIPMENT and UTENSILS, . 2-301.15 Where to Wash. FOOD EMPLOYEES shall clean their hands in a HANDWASHING SINK . and may not clean their hands in a sink used for . WAREWASHING, . 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) . cleaned . UTENSILS, . shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, . or other contamination; . During a kitchen observation on 8/9/17 at 12:01 PM, resident meal trays from service earlier in the lunch meal were being scraped and pre-rinsed in the dishwashing area by EI #8, a dietary aide. After pre-rinsing dirty plates and bowls, EI #8 used the sprayer to rinse his/her hands and then went to the clean side of the dishroom to get paper towels to dry his/her hands. To get the paper towels, EI #8 reached over a tray of cleaned bowls, plates, and silverware and the water seen dripping from his/her hands onto these items was evident. EI #8 then used his/her hand to raise the handle on the clean side of the dishmachine to open it and to pull the rack of cleaned items out. EI #8 repeated these actions three times during the observation. At 12:08 PM, EI #8 was interviewed with EI #6, the Registered Dietitian, present. When asked what would be the problem with rinsing your hands and then with your hands dripping reach over clean dishes to get a paper towel, EI #8 said, Cross-contamination. When asked where are you supposed to wash your hands, EI #8 pointed to the kitchen area and said at the handwashing sink. b.) The 2013 Food Code of the USPHS and the FDA included the following: . 3-304.12 In-Use Utensils, Between-Use Storage. During pauses in FOOD . dispensing, FOOD . dispensing UTENSILS shall be stored: (A) . in the FOOD with their handles above the top of the FOOD . (B) In FOOD that is not TIME/TEMPERATURE CONTROL FOR SAFETY FOOD with their handles above the top of the FOOD within containers or EQUIPMENT that can be closed, such as bins of sugar, flour, . (E) In a clean, protected location . During the initial tour of the kitchen with EI #7, the Dietary Manager, on 8/8/17 at 9:55 AM, a scoop was observed in the flour bin with its handle in the flour. EI #7 said it should not be in there.

Based on record review and a review of a facility policy titled, Person Centered Care Plans, observations and interview, the facility failed to ensure RI (Resident Identifier) #1, a resident requiring total ADL (Activity of Daily Living) care had a Care Plan developed to ensure adequate nail care during personal care such as baths/grooming. This affected one of 11 sampled residents whose ADL Care Plans were reviewed. Findings Include: A review of a facility policy titled, Person Centered Care Plans with an effective date of November 28, 2016 revealed the following: PURPOSE: Person centered plans of care are developed .to coordinate and communicate care approaches and goals of the resident . RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's most recent quarterly MDS (Minimum Data Set) with a ARD (Assessment Reference Date) of 07/06/2017 revealed RI #1 had a BIMS (Brief Interview for Mental Status) score of 4, indicating the resident was severely impaired cognitively for daily decision making. Further review of RI #1's MDS revealed the resident was totally dependent on staff for bathing. A review of RI #1's ADL Care Plan revealed: .REQUIRES ASSISTANCE TO COMPLETE DAILY ACTIVITIES OF CARE SAFELY: R/T (Related To) [MEDICAL CONDITION] . Goal .ASSIST WITH BATHING FACE, UPPER BODY . RI #1's ADL Care Plan interventions for bathing were reviewed and did not include nail care. On 08/10/2017 at 1:32 p.m., an interview was conducted with EI (Employee Identifier) #4, MDS Coordinator, RN (Registered Nurse). EI #4 was asked when Care Plans were developed for personal care and bathing, what care did the Care Plan address. EI #4 explained they say assist with bathing or assist with baths as scheduled and they have interventions that fires out to the CNA's computer and it tells the CNAs the days the resident is to receive baths. EI #4 was asked if a resident required total care should nail care be provided or referenced in the ADL Care Plan. EI #4 said, Yes ma'am. EI #4 was asked in reviewing RI #1's ADL Care Plan, should nail care have been included with bathing/grooming. EI #4 said,Yes ma'am. EI #4 was asked why it was not included in RI #1's ADL Care Plan. EI #4 said, It was an oversight. EI #4 was asked why nail care should be included with RI #1's ADL Care Plan. EI #4 explained it was a part of personal care for RI #1 and for RI #1's nails to be cleaned and filed because it could cause skin tears and dignity.

Based on observations and interview, the facility failed to ensure RL (Room Locators) 1-13's commode bolts were covered, or walls were free of holes and scratched and chipped paint, or a resident's floor was free of deep cracks and an air conditioner unit was free of a water leak. This affected five of 35 rooms located on station one and eight of 27 rooms located on station two. Two of two stations of the facility. Findings Include: On 08/08/2017 and 08/10/2017, Room Locators 1-13 were observed with the following concerns: RL #1: Bathroom commode with bolts sticking up on both sides without caps (station one) RL #2: Bathroom commode with bolts sticking up on both sides without cap (station one) RL #3: Bathroom commode with bolts sticking up on both sides without caps (station two) RL #4: Bathroom commode with bolts sticking up on both sides without caps (station two) RL #5: Bathroom commode with bolts sticking up on both sides without caps and side B air conditioning unit leaking water (station two) RL #6: Bathroom commode with bolts sticking up on both sides without caps (station two) RL #7: Bathroom commode with bolts sticking up on both sides without caps (station two) RL #8: Bathroom commode with bolts sticking up on both sides without caps (station one) RL#9: Bathroom commode with bolts sticking up on both sides without caps (station one) RL #10: Bed A wall observed with a hole the size of a quarter (station two) RL #11: Bed B wall observed with a hole the size of a thumb tack (station two) RL #12: Bed B wall observed with chipped and scratched paint (station two) RL #13: Resident floor observed with deep crack in floor (station one) On 08/10/2017 beginning at 2:18 p.m. and ending at 2:57 p.m., observations were made by both surveyor and EI (Employee Identifier) #9, maintenance supervisor, of the above maintenance concerns. EI #9 was asked how long the commode bolts were when he observed them. EI #9 stated they were two and a half inches long. On 08/10/2017 at 2:43 p.m., an interview was conducted with EI #9. EI #9 was asked why commode/toilet bolts should be covered. EI #9 replied, So there is not a skin tear or injury. EI #9 was asked why walls should be free of holes and scrapped and scratched paint. EI #9 replied, It's their home and it's respectful to keep their home up. EI #9 was asked how often he made maintenance rounds. EI #9 explained he made rounds every day and went by work orders or when residents stopped him. EI #9 was asked why air conditioning units should be free of water leaks. EI #9 replied, Because someone could slip and fall. EI #9 was asked how he was made aware of needed repairs. EI #9 explained it would be placed on a work order system. EI #9 was asked was he aware of the commode/toilet bolts not having a cap/cover. EI #9 said no. EI #9 was asked should it have been reported to him. EI #9 said yes. EI #9 was asked were the bathrooms observed by him on 08/10/2017 used by residents. EI #9 replied, Yes ma'am. EI #9 was asked what was the potential harm of resident's bathrooms having commode bolts with no caps. EI #9 replied, If they step on them it could cause a skin tear. EI #9 was asked how it looked cosmetically for commode bolts to be uncovered. EI #9 explained it did not look good and it was not uniformed. EI #9 was asked what was the potential harm in walls having holes and scraped and scratched paint. EI #9 explained there was no harm but it looked ugly. EI #9 was asked why floors should be free of deep cracks. EI #9 replied, It could be unstable someone could stubble (stumble).

Based on interview, medical record review, and documentation review, the facility failed to provide evidence of any documentation for notification to Resident Identifier (RI) #18 regarding Medicare Non-Coverage prior to the end of RI #18's twenty-one day stay at the facility for rehabilitation therapy. This affected one of three residents sampled for Notice of Medicare Non-Coverage. Findings include: Centers for Medicare and Medicaid (CMS) documentation received from the facility included: . 260 - Expedited Determinations of Provider Service Terminations (Rev. (Revised) 2711, Issued: 05-24-13, Effective: 08-26-13, Implementation: 08-26-13) . 260.2 - Scope . The expedited determination process is available to beneficiaries . whose Medicare covered services are being terminated in the following settings. All beneficiaries receiving services in these settings must receive a Notice of Medicare Non-Coverage (NOMNC) before their services end . Skilled Nursing Facilities (SNFs) --Includes services under a Part A stay, . A NOMNC must be delivered by the SNF at the end of a Part A stay . 260.3.3 - Provider Delivery of the NOMNC . Providers must deliver the NOMNC to all beneficiaries eligible for the expedited determination process per . 260.2. A NOMNC must be delivered even if the beneficiary agrees with the termination of services. RI #18 was readmitted to the facility on [DATE] and discharged on [DATE] with billing to Medicare. The 7/11/17 Physician order [REDACTED]. RI #18's initial Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/18/17 revealed the resident's hearing was adequate, speech was clear, and vision was adequate. In addition, the resident was able to make himself/herself understood and had clear comprehension of others. Also, EI 18's Brief Interview for Mental Status (BIMS) score of 13 indicated the resident was cognitively intact. A nursing note for EI #18, dated 7/31/17 at 6:43 PM, documented the following, . Resident d/c (discharged ) home with Home Health to follow. On 8/10/17 at 1:55 PM, Employee Identifier (EI) #5, the Administrator, was asked if the facility had a Notice of Medicare Non-Coverage (CMS form # -NOMNC) signed by RI #18, which should have been given to the resident at least two days prior to the proposed end of service. EI #5 said the facility did not have a signed NOMNC for RI #18. EI #5 further said if it is determined upon admission that the resident is a 20 day stay, then we do not do the letter because it is the resident's decision to not stay past the 20 days. In an interview on 8/10/17 at 3:40 PM, EI #5 said there was no documented note to indicate RI #18's decision to leave the facility. When asked if the resident had used up all her coverage, EI #5 said, No.

Based on record review and a review of a facility policy titled, Nail Care, observations and interviews, the facility failed to ensure RI (Resident Identifier) #1, a resident requiring total assistance with bathing received nail care during scheduled baths. RI #1 was observed with a brown substance underneath the fingernails three of three days of the survey. This affected one of one resident observed for grooming/personal hygiene care. Findings Include: A review of a facility policy titled, Nail Care with an effective date of October 1, 2010 revealed the following: .PURPOSE: Routine nail care helps reduce the potential for infection .prevents possible injuries and promotes a feeling of well being for the resident. STANDARD: Nail care is a routine part of grooming . RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's most recent quarterly MDS (Minimum Data Set) with a ARD (Assessment Reference Date) of 07/06/2017 revealed RI #1 had a BIMS (Brief Interview for Mental Status) score of 4, indicating the resident was severely impaired cognitively for daily decision making. Further review of RI #1's MDS revealed the resident was totally dependent on staff for bathing. A review of RI #1's Care Plan revealed: .REQUIRES ASSISTANCE TO COMPLETE DAILY ACTIVITIES OF CARE SAFELY: R/T (Related To) [MEDICAL CONDITION] . Goal .ASSIST WITH BATHING FACE, UPPER BODY . On 08/08/2017 at 5:37 p.m., an observation was made of RI #1's fingernails with a brown substance underneath the nails while eating his/her dinner meal. On 08/09/2017 at 11:54 a.m., RI #1 was observed lying in bed eating lunch. RI #1's fingernails were observed with a brown substance underneath the nails. On 08/10/2017 at 8:35 a.m., another observation was made of RI #1's fingernails with a brown substance underneath the nails as he/she was repositioned and checked for incontinence by a CNA (Certified Nursing Assistant). On 08/10/2017 at 8:35 a.m., an interview was conducted with EI #2, CNA. EI #2 was asked what was under RI #1's fingernails. EI #2 said it looked like food. EI #2 was asked who was responsible for cleaning and trimming RI #1's nails. EI #2 said RI #1's CNA. EI #2 was asked who RI #1's CNA was for 08/10/2017. EI #2 said EI #3. EI #2 was asked who was responsible for RI #1's overall personal care. EI #2 said his/her CNA. On 08/10/2017 at 9:10 a.m., an interview was conducted with EI #3, CNA. EI #3 was asked what she had observed under RI #1's fingernails when she entered RI #1's room at 8:50 a.m. EI #3 said food. EI #3 was asked why RI #1's nails should be clean and free of food or a brown substance. EI #3 stated, Because of germs and it's nasty. EI #3 was asked who was responsible for ensuring nail care was provided to RI #1. EI #3 said CNAs. EI #3 was asked what was the potential harm of RI #1 having long fingernails with a brown substance underneath the nail. EI #3 said RI #1 could scratch him/her self which could cause an infection. On 08/10/2017 at 1:32 p.m., an interview was conducted with EI #4, MDS Coordinator, RN (Registered Nurse). EI #4 was asked since RI #1 receives care from both hospice and long term care should nail care be provided. EI #4 explained normally our routine is when providing a bath, nail care should be included. On 08/10/2017 at 3:46 p.m., a telephone interview was conducted with EI #3. EI #3 was asked when did she provide bath/grooming care to RI #1 the week of 08/08/2017. EI #3 explained she did on 08/08, 08/09 and 08/10/2017. EI #3 was asked when providing a bath to RI #1 was she to provide nail care. EI #3 said when she provided a bath.

Based on observations, record review, facility policy review, staff interviews and the Fundamentals of Nursing, Ninth Edition, the facility failed to ensure two licensed staff did not place their ungloved fingers inside a medication cup to pick up the medication cup, did not place one cup of medication inside another medication cup and did not place an ungloved finger inside a medication crush packet. This affected RI (Resident Identifier) #20 and RI #21, two of 6 residents observed during medication administration. This also affected two licensed nurses out of five nurses observed during medication administration. Findings include: On 08/08/2017 an observation was made by the surveyor during medication administration for RI #20. EI (Employee Identifier) #11, LPN (Licensed Practical Nurse) placed [MEDICATION NAME] 100 mg by mouth (po) and [MEDICATION NAME] 20 milligrams (mgs.) po and 30 milliliters(ml.) of water into a medication cup. EI #11 placed the medication cup with [MEDICATION NAME] 20 mg inside the cup with [MEDICATION NAME], and used an ungloved finger to pick up the medication cup at two different times. On 8/8/2017 at 4:45 PM a second observation of medication administration was made. EI #10, LPN, was observed placing an ungloved finger into a medication packet to open the packet cup and carried the medication into RI #21's room to administer the medication to the resident. A review of a document titled, Fundamentals of Nursing,Ninth Edition, Potter and Perry Nursing Manual, Unit 5, Foundations for Nursing Practice, page 632 revealed: .Correct Administration .Use aseptic technique and proper procedures when handling and giving medication . EI #1, DON (Director of Nursing) was interviewed on 08/09/2017 at 12:35 p.m. The surveyor ask what was the facility's policy regarding picking up medication cups. EI #1 stated there is no policy. The surveyor asked what was the proper way to pick up a medication cup. EI #1 said pick up from the bottom of the cup. The surveyor asked should a nurse place her ungloved finger inside of a medication crush packet to open. EI #1 stated no. The surveyor asked EI#1 what was the potential harm to the residents when ungloved fingers were placed inside the medication cups to pick up and inside a crushed packet to open. EI#1 stated there was potential for infection. On 8/10/2017 at 10:00 a.m., an interview was conducted with EI #10. EI#10 was asked what was the proper way to pick up a medication cup. EI #10 stated pick it up on the bottom. EI #10 was asked, should you have placed your fingers inside the medication cup to pick it up. EI # 10 stated, No. EI #10 was asked, should an ungloved finger be placed inside a medication crush packet to open it. EI #10 stated, No. The surveyor asked should medication cups be stacked inside another cup of medication to carry into a resident's room. EI #10 stated, No .you need a barrier when you put it on the resident's table. EI #10 was asked, why did she place her fingers inside the medication cups to pick them up. EI #10 said , I don't know. I really don't know. EI #10 was asked why were the cups stacked one inside another and medication crush packets opened by placing fingers inside. EI #10 replied, Because I could not find the tray. I was having trouble opening the packet, I couldn't get it opened properly. The surveyor asked, what was the potential harm to a resident when ungloved fingers were placed inside medication cups, crush packets and cups placed inside one another. EI#10 stated, Cross contamination, the residents could get sick if the nurse is carrying germs. This affected two of 6 residents observed during medication administration.

Based on observations, record review and interview: 1. The facility failed to prevent potential Time/Temperature harm as evidenced by milk and frozen/thawed shakes not held or stored at the correct temperature. 2. The facility failed to assure equipment/utensils were properly cleaned and processed between use to prevent: *Nesting of spoons and a failure to air dry *Food debris adhering to food contact surfaces for two of four sectional plates. 3. The facility failed to prevent potential cross-contamination as evidenced by: *a. During operation of the dishmachine, dietary staff, on the clean side, failed to practice good personal hygiene by a failure to change gloves/wash hands after touching their hair and face. *b. Dietary staff was observed to potentially contaminate clean/sanitized food trays by transporting the trays for storage, stacked, and braced against the apron and body. *c. Dietary staff failed to store wiping cloths in a sanitizing solution when not in use. The above practices posed the potential for food contamination and compromised food safety. This had the potential to affect all 108 residents receiving meal trays from dining services. Findings include: 1. The facility failed to prevent potential Time/Temperature harm as evidenced by milk and frozen/thawed shakes were not held or stored at the correct temperature. The 2013 Food Code by the United States Public Health (USPHS) and the Food and Drug Administration (FDA) included the following: 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under ¶ (B) and in ¶ (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: . (2) At 5 degrees C (Centigrade) or less. The milk box storage area was observed on 7/25/2016 at 5:10 p.m. The Certified Dietary Manager (CDM), EI #5, was requested to tempt the milk using a facility thermometer. The milk carton was warm to touch. EI #5 was asked to verbalize the reading, which was 46 degrees F (Fahrenheit). EI #5 was asked, what should the temperature register and she said 41 degrees F. On 7/25/2016 at 5:20 p.m., the walk-in refrigerator was observed. Stored in this area were shakes which were purchased frozen and had been thawed. A shake carton was picked up and felt warm. EI #5 was requested to measure the temperature. It registered 45 degrees F. EI #5 stated that it should be 41 degrees F or below. During an interview on 7/27/2016, the CDM, EI #5 stated the potential harm when time/temperature were abused was for biological contamination. 2. The facility failed to assure equipment/utensils were properly cleaned and processed between use to prevent: *Nesting of spoons and a failure to air dry * Food debris adhering to food contact surfaces for two of four sectional plates. The 2013 Food Code by the United States Public Health (USPHS) and the Food and Drug Administration (FDA) included the following: 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and sanitizing, equipment and utensils (A) Shall be air-dried . On 7/26/2016 at 11:27 a.m., dietary staff were observed at the trayline placing silverware into paper sleeves to place on individual food trays. Silverware in the cylinders contained spoons which were nested. Three nested spoons were removed and the CDM was requested to spread/separate the spoons. Water droplets and moisture were observed in the bowl of the spoons. The 2013 Food Code by the United States Public Health (USPHS) and the Food and Drug Administration (FDA) included the following: 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment Food-Contact Surfaces and Utensils shall be clean to sight and touch . On 7/26/2016 at 11:25 a.m., two of four plastic sectional plates were observed with stain or food debris. The CDM, EI #5, removed debris adhering to the surface with a thumb nail. On 7/27/2016 at 1:20 p.m., EI #5, CDM, was asked what was the potential harm in using unclean plates. EI #5 said, potential physical or biological contamination. 3. The facility failed to prevent potential cross-contamination as evidenced by: *a. During operation of the dishmachine dietary staff, on the clean side, failed to practice good personal hygiene by a failure to change gloves/wash hands after touching her hair and face. On 7/26/2016 at 10:25 a.m., dietary staff, EI #1, on the clean side of machine dishwashing was observed to scratch/rub the left side of her face/hair with the index finger. The employee failed to wash her hands after touching her face/hair per facility policy titled, Hand-washing Guideline, policy number DS.V.10 with an effective date of February 1, 2002. The policy directed staff: Hands should be washed in the following situations: .After hands have touched the face, nose, hair . *b. Dietary staff was observed to potentially contaminate clean/sanitized food trays by transporting the trays for storage, stacked and braced against the apron and body. On 7/26/2016 at 10:25 a.m., Employee Identifier (EI) #1 was observed to transport clean sanitized trays, held against her apron and body for storage. On 7/27/2016 at 1:10 p.m., EI #5, CDM, was asked what the harm was for staff carrying the trays braced against the apron and body. EI #5 stated there was potential for cross-contamination. *c. Dietary staff failed to store wiping cloths in a sanitizing solution when not in use. The 2013 Food Code by the United States Public Health (USPHS) and the Food and Drug Administration (FDA) included the following: 3-304.14 Wiping Cloths, Use Limitation. (B) Cloths in-use for wiping counters and other equipment surfaces shall be: (1) Held between uses in a chemical sanitizer solution . On 7/25/2016 at 4:54 p.m., a wet wiping cloth was observed on the counter in front of the microwave. There was no employee using the cloth. On 7/27/2016 at 1:10 p.m., EI #5 was asked what was the regulatory requirement for using wiping cloths. EI #5 stated, they should be stored in a sanitizing solution when not in use due to a potential for cross-contamination.