Every finding on record at Cottage of the Shoals

Based on interviews, medical record review and a review of a facility policy titled, .Authorization for Release of Information, the facility failed to ensure RI (Resident Identifier) #80's representative was allowed access to the entire requested medical records. This deficient practice affected RI #80, one of two sampled residents. Findings Include: A review of a facility policy titled, .Authorization for Release of Information, with a revision date of [DATE], revealed: .PROCESS 1. REQUESTS BY .LEGAL REPRESENTATIVE: 1.1 Provide access to . all records . pertaining to a .resident . as soon as possible . 1.2 Provide copies of records to . legal representative in the form or format requested, . within two (2) working days of a request. RI #80 was admitted to the facility on [DATE] and expired in the facility on [DATE]. On [DATE], a complaint was submitted to the State Agency that indicated the facility had violated RI#80's rights when the facility failed to produce the resident's entire and complete medical record that was requested on [DATE]. According to the complaint, the facility failed to produce the MAR (Medication Administration Record), TAR (Treatment Administration Record), ADL (Activities of Daily Living), behavior logs, psychiatric service progress notes, UDA (User Defined Assessments), or physician order [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE] at 9:06 AM, an interview was conducted with RI #80's representative. RI #80's representative said a request was made for RI #80's medical records, but they did not receive the medical records within 72 hours. RI #80's representative stated the first request for medical records was submitted to the facility on [DATE] and medical records were received on [DATE]. RI # 80's representative further stated, after reviewing the medical records there were things that were missing which included the MAR, TAR, ADL, UDA Assessment as referred to in the nursing notes and the physicians order statements. RI#80's representative stated a second request for medical records was requested on [DATE] for the MAR and TAR. On [DATE] another set of medical records were received but the MAR and TAR were still missing, as well as the other records requested. On [DATE] a third letter was sent certified mail stating that they were still missing medical records and never got a response. On [DATE] at 10:24 AM an interview was conducted with EI (Employee Identifier) #1, Administrator. EI #1 was asked, what did she know about a request for medical records made by RI #80's representative in 2019. EI #1said, we (the facility) had a request made from RI #80's attorney in 2019. EI #1 was asked if ADL documentation was a part of the medical records. EI #1 said, yes. EI #1 was asked, were the ADL's records provided. EI #1 said, no. EI #1 was asked, residents have the right to access their medical records, since the entire record for RI #80 was not provided were his rights violated. EI #1 said, yes. EI #1 was asked, how should the facility ensure that resident medical records are complete and that requests are provided in a timely manner. EI #1 said, through audits and performance improvements. This deficiency was cited as a result of the investigation of complaint/report number AL 989.

Based on interviews, medical record review and a review of a facility policy titled, .Authorization for Release of Information, and a facility document titled, HEALTH INFORMATION RECORD DOCUMENTS LIST, the facility failed to ensure RI (Resident Identifier) #80's ADL (Activity of Daily Living) documentation was in the medical record when requested by RI#80's representative. This deficient practice affected RI #80 one of two residents sampled for medical record release. Findings Include: A review of a facility policy titled, .Authorization for Release of Information, with a revision date of [DATE], revealed: .PROCESS 1. REQUESTS BY PATIENT/RESIDENT/LEGAL REPRESENTATIVE: 1.1 Provide access to . all records . pertaining to a .resident . as soon as possible . 1.2 Provide copies of records to . legal representative in the form or format requested, . within two (2) working days of a request. A review of a facility document tilted, HEALTH INFORMATION RECORD DOCUMENTS LIST, with a date of [DATE], documented, . ADL (Activities Daily Living) Flow Record . and ADL Documentation Supplement . as part of the medical record. RI #80 was admitted to the facility on [DATE] and expired in the facility on [DATE]. On [DATE] a complaint was submitted to the State Agency that indicated the facility had violated RI#80's rights when the facility failed to produce the resident's entire and complete medical record that was requested on [DATE]. On [DATE] at 10:24 AM an interview was conducted with EI (Employee Identifier) #1, Administrator. EI #1 was asked if ADL documentation was a part of the medical records. EI #1 said, yes. EI #1 was asked, were the ADL records provided. EI #1 said, no. EI #1 was asked, do the ADL records exist. EI #1 said, she could not put her hands on them. EI #1 was asked should she (the facility) have had the ADL records. EI #1 said, yes. EI #1 was asked how long was the facility supposed to keep medical records. EI #1 said 5 years. EI #1 was asked was the medical record complete if they did not have the ADL documentation. EI #1 said, no. EI #1 was asked should RI #80's medical record contain ADL documentation. EI #1 said, yes. EI #1 was asked, since she was not able to produce RI #80's ADL documentation was the medical record complete. EI #3 said, no This deficiency was cited as a result of the investigation of complaint/report number AL 989

Based on observations, medical record review and a review of facility policies titled, IC203 Hand Hygiene, Fingerstick Glucose Measurement, and Medication Administration: Injectable (IM, Sub-Q, Z-Track), the facility failed to ensure Employee Identifier (EI) #3, an Licensed Practical Nurse (LPN): 1. washed or sanitized (used an alcohol based hand rub) her hands before applying gloves to obtain Resident Identifier (RI) #63's fingerstick blood sugar (FSBS); 2. applied gloves before cleaning a glucometer used to obtain RI #63's FSBS, and; 3. did not pull-down RI #63's clothing and adjust his/her covers wearing the same gloves worn during an insulin injection. These deficient practices affected RI #63, one of eight residents observed during medication administration by EI #3, one of three nurses observed. Findings include: A review of a facility policy titled, IC203 Hand Hygiene, with Revision Date: 11/15/20, documented: POLICY Adherence to hand hygiene practices is maintained by all Center personnel. This includes hand washing with soap and water when hands are visibly soiled and after exposure to known or suspected Clostridioides difficile or infectious diarrhea (i.e., Norovirus) and the use of alcohol based hand rubs for routine decontamination in clinical situations. Per the Centers for Disease Control (CDC), when the hands are not visibly dirty, alcohol-based hand sanitizers are the preferred method for hand hygiene. PURPOSE: 1. Perform hand hygiene: 1.1 Before patient care; 1.2 Before an aseptic procedure; 1.3 After any contact with blood or other body fluids, even if gloves are worn; 1.4 After patient care; 1.5 After contact with the patient's environment. A review of a facility policy titled, Fingerstick Glucose Measurement, with Revision Date: 6/1/21, revealed: . 8. Cleanse hands. 9. Put on gloves. A review of a facility policy titled, Medication Administration: Injectable (IM, Sub-Q, Z-Track), with Revision Date: 6/1/21, documented: . 8. Remove gloves. 9. Perform hand hygiene. RI #63 was readmitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/4/21 at 3:13 PM, EI #3, LPN, was observed during medication administration for RI #63. EI #3 opened and closed the medication cart drawer, locked the medication cart, engaged the computer privacy screen, knocked on RI #63's door and opened the door. She then pulled gloves from a box on the wall, placed a plastic cup on the overbed table and the applied gloves without washing or sanitizing her hands and obtaining RI #63's FSBS. EI #3 was then observed back at the medication where she obtained a Clorox wipe and began cleaning the glucometer with her bare hands before placing it in a cup to dry. EI #3 returned to RI #63's room. EI #3 applied gloves, administered RI #63's insulin injection, pulled down RI #63's clothing and adjusted the covers while still wearing the gloves worn during the administration of the insulin injection. On 8/5/21 at 3:56 PM, an interview was conducted with EI #3, LPN. EI #3 was asked when she should wash or gel (sanitize) her hands during medication pass. EI #3 said before preparing the medications and if she touched anything such as the cart, computer, or knocked on doors that she should gel (santize) or wash her hands before putting on her gloves and when taking them off she should wash or gel (sanitize) them again. EI #3 was asked did she gel (sanitize) or wash her hands after locking the medication cart, engaging the privacy screen on her computer and after knocking on and opening RI #63's door before she applied her gloves to obtain RI #63's FSBS. EI #3 said no. EI #3 was asked why not. EI #3 replied she was nervous. EI #3 was asked what was the concern with applying her gloves after touching those things. EI #3 stated her hands were contaminated from touching those objects and contaminated the gloves. EI #3 was asked if she wore gloves when cleaning RI #63's glucometer. EI #3 said no. EI #3 was asked what was the concern with that. EI #3 said contamination because there could have been blood on the glucometer. EI #3 was asked if she removed her gloves after giving RI #63's insulin injection before pulling down his/her clothing and adjusting the covers. EI #3 replied no. EI #3 was asked what was the concern with touching clothing and covers with gloves worn while giving an injection. EI #3 stated there could have been blood from giving the injection that could have gotten on the gloves and contaminated the clothing and covers. EI #3 was asked what was the concern with the things being discussed. EI #3 answered infection control. On 8/5/21 at 3:56 PM, an interview was conducted with EI #2, Registered Nurse (RN)/Assistant Director of Nursing (ADON)/Infection Control Preventionist (ICP). EI #2 was asked when should a nurse wash or gel (santize) her hands during medication pass. EI #2 said after contact with a patient, if visibly soiled, before she gave it, after she gave it or when she came in contact with any potentially contaminated surface. EI #2 was asked when should a nurse wash or gel (sanitize) her hands when obtaining a FSBS. EI #2 stated when she went into the room she should wash her hands, after she obtained the FSBS and when she cleaned the equipment. EI #2 was asked how should she clean the glucometer. EI #2 replied with a Clorox or Sani wipe and she should wear gloves. EI #2 was asked what was the concern with a nurse applying gloves without gelling (sanitizing) or washing her hands prior to obtaining a FSBS. EI #2 said her hands were contaminated and by touching the gloves she would be passing along germs. EI #2 was asked when should a nurse wash or gel their hands when wearing gloves. EI #2 stated before she put them on and after she took them off. EI #2 was asked should a nurse pull down a resident's clothing and adjust their covers while wearing the same gloves worn when giving an injection. EI #2 said no, because they are contaminated and dirty. EI #2 was asked should a nurse clean a glucometer with her bare hands after it had been used to obtain a FSBS. EI #2 stated no, because they were dirty. EI #2 was asked what were the concerns with those things. EI #2 answered infection control.

Based on observation, interviews, record review and review of a facility policy titled, Hand Hygiene, the facility failed to ensure a licensed nurse did not turn off the faucet with her left bare hand prior to putting on gloves to remove a [MEDICATION NAME] medication patch, and prior to putting on gloves to administer a [MEDICATION NAME] medication patch to Resident Identifier (RI) #43. This deficient practice affected one of eight residents and one of five licensed nurses observed during medication administration pass. Findings Include: A review of a facility policy titled, Hand Hygiene, with a review date of 11/15/2018, revealed, . Process . 2. Hand hygiene techniques: 2.1 To wash hands with soap and water: .Rinse hands with warm water and dry thoroughly with a disposable towel. Use clean, dry, disposable towel to turn off faucet . RI #43 was admitted to the facility on [DATE]. On 5/14/19 at 9:50 a.m., the surveyor observed Employee Identifier (EI) #1, a Registered Nurse, during a medication administration pass on the front hall of the facility. The surveyor observed EI #1 as she entered into RI #43's bathroom, washed her hands with soap and water, turned off the faucet with her left bare hand, dried her hands with a paper towel, put on gloves, and began removing a [MEDICATION NAME] medication patch from RI #43's left side back area. On 5/14/19 at 9:53 a.m., the surveyor observed EI #1 as she reentered into RI #43's bathroom, washed her hands with soap and water, turned off the faucet with her left hand, dried her hands with a paper towel, put on gloves, dated/initialed RI #43's [MEDICATION NAME] medication patch, and applied RI #43's [MEDICATION NAME] medication patch to the right back side area. On 5/14/19 at 10:34 a.m., an interview was conducted with EI #1. EI #1 was asked what did you do after you washed your hands with soap and water, prior to putting on gloves to remove a [MEDICATION NAME] from a RI #43's left back side area, and prior to putting on gloves to administer a [MEDICATION NAME] medication patch to RI #43. EI #1 stated that she turned off the faucet with her left bare hand, and did not use a disposable towel to turn the faucet off. EI #1 was asked what she should have done after she washed her hands with soap and water, and prior to removing RI #43's [MEDICATION NAME] medication patch, and after administering RI #43's [MEDICATION NAME] medication patch. EI #1 stated that after she washed her hands with soap and water, she should have turned the faucet off with a disposable paper towel, prior to drying her hands, and putting on gloves. EI #1 was asked what would be the concern if a nurse turned the faucet off with her left bare hand after washing her hands with soap and water, prior to putting on gloves to remove a [MEDICATION NAME] from a resident, and prior to putting on gloves to administer a [MEDICATION NAME] medication patch to a resident. EI #1 stated that the faucet had germs and this could cause an infection to the resident. On 05/14/19 at 10:10 a.m., an interview was conducted with EI #2, Registered Nurse/Infection Control Preventionist. EI #2 was asked what was the facility policy on hand washing with soap and water. EI #2 stated you should wash your hands with warm water and soap, rub hands vigorously, rub hands outside the water for twenty seconds, rinse hands with warm water, dry thoroughly with a disposable towel, and use a clean dry disposable towel to turn off the faucet. EI #2 was asked what would be the concern if a nurse turned the faucet off with her left bare hand, prior to putting on gloves to remove a [MEDICATION NAME] from a resident, and prior to putting on gloves to administer a [MEDICATION NAME] medication patch to a resident. EI #2 stated this could put the resident at risk for infection.

Based on record review and interview, the facility failed to ensure an allegation of physical abuse was reported to the State Agency within two hours. This affected one of two abuse records reviewed during the survey and Resident Identifier (RI) #66. Findings Include: On 8/2/18 at 9:46 a.m. the surveyor reviewed the online incident report involving an allegation of physical abuse concerning RI #66. This incident involved an allegation that a visitor was witnessed to forcibly pull on RI #66's arm and then speak loudly to the resident. The incident was witnessed on 6/23/18 at 9:00 a.m., but was not reported to the State Agency until 6/25/18 at 1:24 p.m. On 8/2/18 at 11:16 a.m. an interview was completed with Employee Identifier (EI) #2, Administrator/Abuse Coordinator. EI # 2 stated the allegation of abuse concerning RI #66 occurred on 6/23/18 at 9:00 a.m. and was reported to the State Agency on 6/25/18 at 1:24 p.m. EI #2 stated it should have been reported on 6/23/18 within two hours. EI #2 was asked why it was not reported within two hours. EI #2 stated she was unsure if it needed to be reported. EI #2 was asked why allegations of abuse should be reported within two hours. EI #2 stated for the safety of the resident.

Based on observations, interview, review of the facility policies titled, Dry Storage and Refrigerated/Frozen Storage and a review of the Food and Drug Administration (FDA) Food Code 2013, the facility failed to ensure: 1. spices were maintained with lids intact to prevent potential contamination; 2. a dented can of jellied cranberry sauce was not stored in circulation for future use; and 3. refrigerated lemonade was labeled with prepared and use by dates. These failures had the potential to affect all 86 residents who receive meals from the kitchen. Finding Include : 1. Review of the facility policy titled, Dry Storage, revised on 12/01/15, revealed the following: POLICY Products stored in dry storage areas are maintained in a safe and sanitary manner. PURPOSE To prevent damage, spoilage, contamination and infestation of products. PROCESS . 2. Food Storage: . 2.5 Dry bulk items . are stored in seamless metal or plastic containers with tight fitting covers or lids . During the initial tour of the kitchen, on 6/19/2017 at 6:20 p.m., the spice rack was observed with containers of spices with open lids, including lemon pepper, ground ginger and onion powder. Employee Identifier (EI ) #3, the Dietary Manager, was interviewed on 6/21/17 at 5:30 p.m. EI#3 said cooks were responsible for maintaining the spice rack. EI#3 agreed the spices had open lids, which could lead to cross-contamination. 2. Review of the FDA Food Code 2013, pages 60 and 411, revealed the following: . Chapter 3 Food . 3-202.15 Package Integrity. Food packages shall be in good condition and protect the integrity of the contents so that the FOOD is not exposed to ADULTERATION or potential contaminants . Annex 3 - Public Health Reasons/Administrative Guidelines . 3-202.15 Package Integrity. Damaged . packaging may allow the entry of bacteria or other contaminants into the contained food . Packaging defects may not be readily apparent . Close inspection of cans for imperfections or damage may reveal punctures or seam defects. In many cases, suspect packaging may have to be inspected by trained persons using magnifying equipment . Suspect cans must be returned . During the initial tour of the kitchen, on 06/19/2017 at 6:10 p.m., a dented can of jellied cranberry sauce was observed stored in the in-use can rack. EI #3 was interviewed on 6/21/2017 at 5:25 p.m. EI #3 said he was responsible for putting stock away on the rack. EI #3 agreed there was a dented can of jellied cranberry sauce on the production rack. 3. Review of the facility policy titled, Refrigerated/Frozen Storage, with a review date of 10/01/2015, revealed the following: POLICY Food stored under refrigeration/freezer storage are maintained in a safe and sanitary manner. PURPOSE To prevent damage, spoilage, and contamination of products. PROCESS 1. Refrigeration: . 1.5 Prepared foods are labeled and dated with name of product, date prepared, and use by date During the initial tour of the kitchen, on 06/19/2017 at 6:00 p.m.,. an open container with a blue top with the appearance of lemonade was observed with no dates or label for use-by or opened dates. EI #3 was interviewed on 6/21/2017 at 5:30 p.m EI #3 said dietary aides were responsible for maintaining dates on labels for items in the refrigerator. EI #3 said the potential harm in storing items in the refrigerator without a label would be the item could be out of date.

Based on record review, interview, and review of the Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure Resident Identifier (RI) #s 2, 3, 7, and 11's Minimum Data Set (MDS) assessments included a completed assessment of the residents' pain. This affected four of 15 residents for whom MDS assessments were reviewed. Findings Include: Review of the Centers for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.14, dated October 2016, revealed the following: . SECTION J: HEALTH CONDITIONS Intent: The intent of the items in this section is to document a number of health conditions that impact the resident's functional status and quality of life. The items include an assessment of pain which uses an interview with the resident or staff if the resident is unable to participate. The pain items assess the presence of pain, pain frequency, effect on function, intensity, management and control . RI #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of RI #2's Significant Change in Status MDS assessment, with an Assessment Reference Date (ARD) of 10/28/2016, revealed Section J, related to pain, had not been completed. The assessment indicated the resident pain assessment interview should be conducted, but the questions related to pain presence, frequency, effect on function, and intensity were not completed. The staff assessment of pain was also not completed. RI #3 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of RI #3's quarterly MDS assessment, with an ARD of 4/15/2017, revealed Section J, related to pain, had not been completed. The assessment indicated the resident pain assessment interview should be conducted, and indicated RI #3 experienced pain frequently. However, the questions related to pain intensity were not completed. The staff assessment of pain was also not completed. RI #7 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of RI #7's Admission MDS assessment, with an ARD of 12/15/2016, revealed Section J, related to pain, had not been completed. The assessment indicated the resident pain assessment interview should be conducted, but the questions related to pain presence, frequency, effect on function, and intensity were not completed. The staff assessment of pain was also not completed. RI #11 was readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of RI #11's Admission MDS assessment, with an ARD of 12/02/2016, revealed Section J, related to pain, had not been completed. The assessment indicated the resident pain assessment interview should be conducted, but the questions related to pain presence, frequency, effect on function, and intensity were not completed. The staff assessment of pain was also not completed. Employee Identifier (EI) #1, Clinical Reimbursement/MDS Coordinator, was interviewed on 06/21/2017 at 11:10 a.m. EI #1 reviewed RI #s 2, 3, 7, and 11's MDS assessments and agreed the pain component of these residents' assessments had not been assessed. EI #1 said the section of the MDS related to pain should be completed at least by the ARD of the assessment. EI #1 said it was possible the nursing staff had not entered the data by the ARD, so the information had not automatically pulled over when they closed out the assessments. EI #1 said the MDS office was ultimately responsible for ensuring the accuracy and completeness of MDS assessments. EI #2, the facility's Corporate Nurse, who was also present during this interview, stated staff should be reviewing the assessments to ensure every portion was completed.

Based on observation, record review, and interviews, the facility failed to ensure ten ounces of fluid were provided with meals in accordance with the pre-planned menu. This affected Resident Identifier (RI) #s 9,11,12, and 20, four of six residents for whom meals were observed. Findings include: A review of the facility's pre-planned menus for 07/12/2016 through 07/14/2016 for all diets, revealed 10 ounces of fluids were to be provided with each meal (3/4 cup beverage and 1/2 cup beverage). During meal observations on 7/13/2016 at 5:13 p.m., it was observed a hydration cart was sent to the hall with meal trays. The cart contained 8 ounce cups and the following beverage choices: lemonade, tea, water, and milk. 1) RI #9 was admitted to the facility on [DATE] and most recently readmitted on [DATE]. RI #9's [DIAGNOSES REDACTED]. RI #9's Significant Change in Status Minimum Data Set (MDS)Assessment, dated 04/15/2016, indicated RI #9 had severe cognitive impairment and required supervision and set-up for eating. RI #9's lunch meal was observed on 7/13/2016 at 12:12 p.m. RI #9 received 8 ounces of lemonade with the meal. No other fluids were provided. 2) RI #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 07/13/2016 at 11:49 a.m., RI #11's lunch meal was observed. RI #11 received 8 ounces of lemonade only; no other fluids were provided. 3) RI #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #12's Admission Minimum Data Set Assessment, dated 05/21/2016, indicated RI #12 was cognitively intact and required set-up and supervision for eating. RI #12's lunch meal was observed on 7/13/2016 at 12:15 p.m. The only beverage on RI #12's tray was 8 ounces of tea. RI #12's evening meal was observed on 7/13/2016 at 5:17 p.m. The only beverage provided with the meal was an 8 ounce glass of tea. 4) RI #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #20's Admission Minimum Data Set Assessment, dated 07/01/2016, documented RI #20 had moderately impaired cognition and required set-up and supervision for eating. RI #20's lunch meal was observed on 7/13/2016 at 11:56 a.m. The only fluids provided on RI #20's meal tray was an 8 ounce glass of lemonade. RI #20's evening meal was observed on 7/13/2016 at 5:43 p.m. RI #20 received 8 ounces of water, but no other beverages were provided. Employee Identifier (EI) #5, Dietary Manager, was interviewed on 7/14/16 at 3:02 p.m. EI #5 was asked about the fluids planned on the menu and how they ensured residents received adequate fluids with meals. EI #5 said during meals they send out carts of different beverages, but the amounts provided were up to the resident. She further explained residents also have water at bedside. EI #5 was asked how many fluids should be included with meals according to the planned menus. EI #5 said when they placed the beverages on the trays (prior to changing their procedure to hydration carts), they always placed two beverages on the trays. EI #5 confirmed the pre-planned menu listed fluids. EI #6, the facility's Registered Dietitian, was interviewed on 7/14/16 at 5:33 p.m. When asked how many fluids should be provided with each meal, EI #6 said there was no policy that specified the amount. She said they let the residents dictate what they want. When asked about the fluids listed on the pre-planned menu, EI #6 stated she thought the cups they used were 12 ounce cups. She requested the surveyor ask the Dietary Manager to verify the size by measuring how much they would hold. EI #6 explained staff should be offering all beverages on the cart and encouraging residents to drink them. At 5:50 PM on 7/14/16, EI #5, the Dietary Manager, was asked to check the amount of fluid the cups sent on the hydration carts with meals would hold. She stated she had already checked. She then tested both the cup and mug they use with an 8 ounce scoop. Each cup held 8 ounces. EI #5 said she thought the cups would hold about 9 ounces, only if full to the rim. During an interview with EI #8, the Administrator, on 07/14/2016 at 6:34 p.m., EI #8 said they keep carts with different beverages on the hall throughout the meal. She explained if they provided a resident three or four different beverages and they did not drink it, it would be wasted.

Based on observations, record review, and interviews, the facility failed to ensure pureed bread was prepared and served during the 7/13/2016 lunch meal. This had the potential to affect all 15 residents with physician's orders [REDACTED]. Findings include: A review of the facility's pre-planned menu for Dysphagia Puree diets revealed residents with orders for a pureed diet were planned to receive one #16 scoop of pureed biscuit on 7/13/2016 for the lunch meal. On 07/13/2016 at 10:30 a.m., the surveyor entered the kitchen to observe trayline proceedings. When staff were checking temperatures, it was noted there was no pureed bread prepared. Staff began plating trays at 11:10 a.m All trays on the first cart received the regular consistency herbed biscuit. No trays received any pureed bread. The first cart left the kitchen at 11:18 a.m At 11:19 a.m. on 07/13/2016, Employee Identifier (EI) #7, a cook, was asked what bread residents with pureed diet orders should have received. She stated bread crumbs and left the line to prepare them. She said there were residents on the first cart that should have received the pureed bread but had not. She also stated all residents received the regular consistency biscuits. EI #5, Dietary Manager, was interviewed on 07/14/2016 at 3:02 p.m When asked what bread/starch was planned for the 07/13/2016 lunch meal for residents with pureed diet orders, EI #5 said pureed bread. She said she thought staff probably forgot because they were nervous.

Based on observation, record review, and interview, the facility failed to ensure pepperoni pizza, prepared as the alternate for the 07/13/2016 lunch meal, was checked for holding temperature to ensure it was at a temperature of 135 degrees Fahrenheit (F) or greater prior to serving. This had the potential to affect all residents who chose the alternate meal. Findings include: A review of the facility's policy titled Production Tools, revised 05/05/2013, revealed the following: .PROCESS . 4. Holding temperatures for all hot and cold foods are taken . prior to meal service . A review of the 07/13/2016 lunch menu revealed pepperoni pizza was the alternate meal choice. On 07/13/2016 at 10:30 a.m., the surveyor entered the kitchen to observe trayline proceedings. At 10:30 a.m., staff were observed removing the pepperoni pizza from the oven and placing it on the counter. Staff then checked the temperature of the pizza. After checking the temperature, staff cut the pizza into 18 slices, covered with foil, and placed it back into the oven. At 11:09 a.m., staff again removed the pizza from the oven and placed it on a lid on the steam table. Staff began plating trays at 11:10 a.m The holding temperature for the pizza was not checked prior to meal service. The first cart was complete and left the kitchen at 11:18 a.m. During an interview with Employee Identifier (EI) #5, the Dietary Manager, on 07/14/2016 at 3:02 p.m., EI #5 stated temperatures of foods should be checked prior to meal service to ensure the foods are not in the danger zone. EI #5 said they checked the temperature of the pizza prior to the last cart leaving the kitchen.

Based on record review and interview, the facility failed to ensure the Activity Director provided evidence RI (Resident Identifier) #15 received one to one in room activities on an ongoing basis. This affected RI #15, one of three sampled residents observed for activity participation. Findings Include: A review of a facility policy titled, Program Design, with a revision date of 07/01/2014, revealed: POLICY Recreation services will be designed to meet residents'/patients' interests, abilities, and preferences through group and individual programs and independent leisure activities. PROCESS . 4. Individual and independent programming is offered for residents who are unable or unwilling to participate in activities within the group setting, and/or prefer independent leisure involvement. RI #15 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #15's Quarterly MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 05/21/2016, revealed the resident had a BIMS (Brief Interview for Mental Status) score of 4, which indicated the resident was severely cognitively impaired for daily decision making. A review of RI #15's activities care plan, last revised on 03/16/2016, revealed: Focus Resident exhibits or is at risk for limited meaningful engagement related to social isolation . Interventions . Provide one to one visits 3x (times) per week . A review of RI #15's January RECREATION ACTIVITY LOG revealed no activity participation for that month. A review of RI #15's March 2016 RECREATION ACTIVITY LOG revealed no activity participation for that month. A review of RI #15's May 2016 RECREATION ACTIVITY LOG revealed no activity participation for that month. A review of RI #15's June 2016 RECREATION ACTIVITY LOG revealed no activity participation for that month. On 7/13/2016 at 3:31 p.m., an interview was conducted with EI (Employee Identifier) #2, Activity Director. EI #2 was asked to tell the surveyor about RI #15's activity plan. EI #2 said they did one to one with RI #15 three times a week. EI #2 was asked where she would document the activity participation. EI #2 said on the activity log. EI #2 was asked what RI #15's activity participation logs for January, March, May, and June 2016 indicated regarding RI #15's activity involvement. EI #2 said RI #15's activities did not get documented. EI #2 was asked what it usually meant when something was not documented. EI #2 said that it probably did not happen. EI #2 was asked why it would not be reflected on the logs that the resident received activities. EI #2 said she did not have a good answer for that. EI #2 was asked who was responsible for filling out the activity log. EI #2 said she was. EI #2 was asked what the potential harm would be if the resident did not receive any activity participation for four months. EI #2 said the resident would probably feel unwanted and not cared for.

Based on observation, interview, and record review, the facility failed to ensure Resident Identifier (RI) #10's Admission Minimum Data Set (MDS), with an Assessment Reference Date of 06/16/2016, was accurately coded to reflect the resident's communication ability. This affected RI #10, one of 20 sampled residents for whom MDS assessments were reviewed. Findings include: RI #10 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. RI #10's Nursing Assessment, dated 06/16/2016, documented RI #10 was unable to answer how often he/she experienced pain during the previous five days. The Nursing Assessment also documented RI #10 had unclear speech and was sometimes understood. However, RI #10's Admission MDS, also dated 06/16/2016, indicated RI #10 had clear speech but was rarely or never understood. During the initial tour of the facility on 7/12/16 at 8:30 a.m., RI #10 was observed in bed. RI #10 was nonverbal. Employee Identifier (EI) #1, responsible for MDS assessments, was interviewed on 07/14/2016 at 1:55 p.m. EI #1 said she usually completed Section B of the MDS, related to communication. When asked how it was determined RI #10 had clear speech, EI #1 said the nursing assessment probably documented clear speech. EI #1 then referred to the computer and stated, You know I'm not sure why this is like that . My best guess is it was an electronic error. EI #1 said RI #10 did have unclear speech and it was documented as such on the nursing assessment. She explained the information did not cross over to the MDS correctly. EI #1 said she was responsible for reviewing the MDS to make sure it was accurate. EI #1 explained, the 0/3, indicating clear speech but rarely or never understood, on the MDS assessment would definitely cause questions. EI #1 said the MDS was not accurate.

Based on observation, record review, and interview, the facility failed to ensure a care plan was developed for Resident Identifier (RI) #10 with specific approaches to address impaired communication abilities. This affected RI #10, one of 20 sampled residents for whom care plans were reviewed. Findings include: A review of the facility policy titled, Care Plans, reviewed 03/01/2016, revealed the following: POLICY A comprehensive, individualized care plan will be developed by the interdisciplinary team for each patient. The care plan will include measurable objectives to meet patient needs and goals as identified by the assessment process . PRACTICE STANDARDS . 2. The comprehensive care plan is: . 2.2 Based on Nursing Assessment, subsequent assessments/evaluations, Care Area Assessment (CAA), and other observations . RI #10 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. RI #10's Admission MDS, dated [DATE], indicated RI #10 had both short and long term memory impairment and had severely impaired cognitive skills for daily decision making. This assessment also documented RI #10 had clear speech but was rarely or never understood. The Care Area Assessment Summary indicated RI #10 triggered for communication and a care plan would be developed. However, review of RI #10's current comprehensive care plans, revealed there was no care plan addressing impaired communication. During the initial tour of the facility on 7/12/16 at 8:30 a.m., RI #10 was observed in bed. RI #10 was nonverbal. Employee Identifier (EI) #1, responsible for MDS assessments and Care Plans, was interviewed on 07/14/2016 at 1:55 p.m. EI #1 said she usually completed Section B of the MDS, related to communication. EI #1 stated RI #10's communication was addressed by anticipating needs due to impaired cognition but could not locate a care plan for RI #10's impaired communication. EI #1 explained they normally develop a care plan specifically for impaired communication. When asked why it was important to develop a care plan to address communication deficits, EI #1 explained it was important to address any kind of deficiency to see if there was something the facility could do to help the resident better understand or better communicate their needs.

Based on observations, record reviews, and interview, the facility failed to ensure a CNA (Certified Nursing Assistant) changed her gloves and washed her hands after incontinent care and before touching a clean brief. This affected RI (Resident Identifier) #13, a resident who the facility identified as having a history of UTIs (Urinary Tract Infections). Findings Include: A facility policy titled: Hand Hygiene from facility manual titled Infection Control Policies and Procedures, with a revised date of 4/11/16, revealed: POLICY Adherence to hand hygiene practices is maintained by all Center personnel . PURPOSE To improve hand hygiene practices and reduce the transmission of pathogenic microorganisms. PROCESS 1. Wash hands with soap and water in the following situations: . 1.3 Immediately after contact with blood, body fluids . 2. Decontaminate hands using an alcohol based hand rub OR wash hands with soap and water in the following clinical situations: . 2.4 After contact with patient's intact skin; 2.5 After contact wih blood, body fluids or excretions, mucous membranes, non-intact skin . 2.6 When moving from contaminated body site to a clean body site during patient care. A facility document titled: CLINICAL COMPETENCY VALIDATION Perineal Care, revised 01/2014, revealed . CRITICAL ELEMENTS: .7. If present, removes feces with toilet paper . 9. Washes hands and applies clean gloves . RI #13 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Significant Change in Status MDS (Minimum Data Set), with a ARD (Assessment Reference Date) 4/9/16, revealed RI #13 was always incontinent of bowel and bladder and required extensive assistance with two plus person assist for personal hygiene. A 2016 Interdisciplinary Care Plan indicated Problems/Issues . Actual UTI . r/t (related to) . incont (incontinence) of B/B (Bowel/Bladder) .hx (history) UTI . On 7/13/2016 at 11:43 a.m., incontinent care was observed for RI #13. EI (Employee Identifier) #3,CNA, and EI #4, CNA, entered the resident's room to check resident for incontinence. During incontinence care, the resident was observed to have a large amount of urine and BM (bowel movement). After performing incontinent care of bowel and bladder, EI #3, CNA, failed to remove the dirty gloves and wash or sanitize her hands before placing clean brief on RI #13. On 7/14/16 at 2:24 p.m., an interview was conducted with EI #9, RN (Registered Nurse)/Infection Control. EI #9 was asked at what point during incontinent care would a CNA be expected to change gloves and wash hands. EI #9 said during incontinent care staff should wash hands and change gloves when they come into contact with a brief. EI #9 also stated before applying a clean brief staff should wash their hands because if not it could result in the transmission of germs and bacteria to other residents.

Based on observations, record reviews, and interview, the facility failed to ensure a CNA (Certified Nursing Assistant) changed her gloves and washed her hands after incontinent care and before touching a clean brief. This affected RI (Resident Identifier) #13, a resident who the facility identified as having a history of UTIs (Urinary Tract Infections). Findings Include: A facility policy titled: Hand Hygiene from facility manual titled Infection Control Policies and Procedures, with a revised date of 4/11/16, revealed: POLICY Adherence to hand hygiene practices is maintained by all Center personnel . PURPOSE To improve hand hygiene practices and reduce the transmission of pathogenic microorganisms. PROCESS 1. Wash hands with soap and water in the following situations: . 1.3 Immediately after contact with blood, body fluids . 2. Decontaminate hands using an alcohol based hand rub OR wash hands with soap and water in the following clinical situations: . 2.4 After contact with patient's intact skin; 2.5 After contact wih blood, body fluids or excretions, mucous membranes, non-intact skin . 2.6 When moving from contaminated body site to a clean body site during patient care. A facility document titled: CLINICAL COMPETENCY VALIDATION Perineal Care, revised 01/2014, revealed . CRITICAL ELEMENTS: .7. If present, removes feces with toilet paper . 9. Washes hands and applies clean gloves . RI #13 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Significant Change in Status MDS (Minimum Data Set), with a ARD (Assessment Reference Date) 4/9/16, revealed RI #13 was always incontinent of bowel and bladder and required extensive assistance with two plus person assist for personal hygiene. A 2016 Interdisciplinary Care Plan indicated Problems/Issues . Actual UTI . r/t (related to) . incont (incontinence) of B/B (Bowel/Bladder) .hx (history) UTI . On 7/13/2016 at 11:43 a.m., incontinent care was observed for RI #13. EI (Employee Identifier) #3,CNA, and EI #4, CNA, entered the resident's room to check resident for incontinence. During incontinence care, the resident was observed to have a large amount of urine and BM (bowel movement). After performing incontinent care of bowel and bladder, EI #3, CNA, failed to remove the dirty gloves and wash or sanitize her hands before placing clean brief on RI #13. On 7/14/16 at 2:24 p.m. an interview was conducted with EI #9, RN (Registered Nurse)/Infection Control. EI #9 was asked at what point during incontinent care would a CNA be expected to change gloves and wash hands. EI #9 said during incontinent care staff should wash hands and change gloves when they come into contact with a brief. EI #9 also stated before applying a clean brief staff should wash their hands because if not it could result in the transmission of germs and bacteria to other residents.

Based on observation, interview and record review, the facility failed to ensure commercially prepared milkshakes were labeled to identify the date of thaw and the use-by date. This had the potential to affect all those residents to whom milkshakes were served at the time of this survey. Findings included: The facility "'Use By' Dating Guideline" (dated 05/01/11) specifies for refrigerated frozen shakes are to be dated as follows: "Date carton when removed from freezer 'Use by' date of 14 days once thawed - use labels for individual items when removed from the carton." During the initial kitchen tour on 05/05/15 at 7:35 AM, a tray of partially thawed, 4-ounce cartons of commercially prepared milkshakes were stored in the reach-in refrigerator. None of the cartons contained either a thaw date, or a use-by date (14 days after thawed). On 05/05/15 at 4:45 PM, one undated milkshake was sent with a resident's tray on the second supper meal cart. At this time, the surveyor questioned the Food Service Director, Employee Identifier (EI) #3 and the Registered Dietitian, EI #4, if any of the milkshakes were dated. EI #3 explained if the cartons of milkshake were loose (out of the case) in the reach-in refrigerator, they were supposed to have a date. When asked how staff on the hall knew when to discard thawed milkshakes, EI #3 stated they assumed all milkshakes were thrown away after three days, although the manufacturer's recommendations for milkshake storage was 14 days. EI #3 stated the CNAs on the hall may date the milkshakes and place them in the resident's personal refrigerator in his/her room. When asked who monitored each resident's refrigerator for old food, EI #3 and EI #4 responded, "room partners," other staff or family. When asked what potential hazard could result from serving out-dated milkshakes, EI #3 stated, "Food poisoning." On 05/05/15 at 5:00 PM, the surveyor, EI #3 and EI #4 checked the reach-in refrigerator in the Dietary Department. Twelve 12 loose cartons of milkshakes were stored on a tray, none of which contained a thaw or use-by date.

Based on observation, record review and interview, the facility failed to ensure Resident Identifier (RI) #12's oxygen concentrator filter was free of an accumulation of dust-like substance. This was observed on 3 of the 3 days of the survey and affected 1 of 2 residents sampled for oxygen concerns. Findings Include: A review of a facility policy titled "SECTION 6- MAINTENANCE" included: "...Routine Maintenance cleaning the cabinet filter...1. Remove filter and clean as needed. Note: Environmental conditions that may require more frequent cleaning of the filters include...: high dust... 2. Clean the cabinet filter with vacuum...or wash in warm soapy water... . Dry the filter..." On 4/9/2015 RI #12 was readmitted to the facility with [DIAGNOSES REDACTED]. A review of a facility form titled "Order Summary Report" dated May 5, 2015 for RI #12, revealed: "Oxygen via NC (Nasal Cannula) at 2 L (liters) PRN (as needed) for O2 (oxygen) sat (saturation) < (less than) 90%. every 4 hours as needed. ...clean filter on oxygen concentrator weekly every day shift every Saturday." A review of RI #12's most recent Minimum Data Set with a Assessment reference Date of April 16, 2015 revealed a Brief Interview for Mental Status score of 11, indicating moderately impaired cognitive status; a further review revealed RI #12 coded for oxygen use. On 5/5/2015 at 7:50 AM during the initial tour of the facility, RI #12's oxygen concentrator filter was observed with an accumulation of a thick dust-like substance. On 5/6/15 at 9:30 AM an observation was made of RI #12's oxygen concentrator filter with a thick accumulation of dust-like substance. On 5/7/15 at 7:40 AM an observation was made of RI #12's oxygen concentrator filter with an accumulation of a thick dust-like substance. On 5/7/15 at 8:20 AM, an interview was conducted with Employee Identifier (EI) #1 Registered Nurse, Unit Supervisor. EI #1 was asked to describe the filter on RI #12's oxygen concentrator. EI #1 stated, "This is filthy, and the tank is dirty too." EI #1 was asked if she felt this accumulation had built since 5/2/15 (Saturday). EI #1 replied no, I feel like it was skipped. EI #1 was asked, with the tubing being dated 5/2/15, when should the filter have been cleaned? EI #1 replied, "Then" (on 5/2/15). EI #1 was asked what was the policy for cleaning the filters. EI #1 explained the day shift nurses, on Saturdays were responsible for cleaning the filters. EI #1 was asked what was the potential for harm in the filter not being cleaned. EI #1 replied the resident would not get the oxygen as needed with the [DIAGNOSES REDACTED]. On 5/7/15 at 8:50 AM an interview was conducted with EI #2, a Licensed Practical Nurse. EI #2 was asked if she changed the tubing and cleaned the filter on RI #12's tank. EI #2 replied, "I changed the tubing, but may have forgot the filter." EI #2 was asked what was the policy for changing and cleaning the oxygen tubing and cleaning the filter. EI #2 replied, staff were check and clean weekly on the Saturday day shift. EI #2 was asked what was the potential for harm in the filter not being cleaned. EI #2 replied the resident might not get the oxygen they needed and could get bacteria.

Based on observations, interviews and review of the facility policy, the facility failed to ensure: 1) Staff performing tray line duties on 05/28/2014 for the evening meal did not have uncontained hair hanging loose down her back; and 2) staff knew how to test the concentration of the sanitizing solution in the three compartment sink per the manufacturers instructions. This had the potential to affect all 93 residents receiving meals from the kitchen. Findings include: 1) Review of the facility's policy titled "2.2 Personal Hygiene" with a revision date of 10/06/2013 revealed the following: "...PROCESS... 6. Hair restraints are worn and completely cover hair from front to back..." On 5/28/2014 at 4:02 PM the surveyor observed EI (Employee Identifier) #1, the Assistant Food Service Supervisor, calibrating thermometers in the kitchen. She was wearing a hair net over a pony tail, but the hair in the back was loose. The hair down her back had come loose from the pony tail and was hanging below her neck line. EI #1 was then observed to take tray line temperatures of all foods on the tray line and then serve the foods without her hair restrained. EI #2, the Food Service Supervisor, was interviewed on 05/28/2014 at 5:00 PM. When asked if he noticed an employee with her hair not contained EI #2 identified EI #1 the Assistant Food Service Supervisor and stated ten percent of her hair was not contained. When asked what could happen if hair was hanging loose EI #2 stated possible contamination. EI #4, the Registered Dietitian, was interviewed on 5/29/2014 at 2:50 PM. When asked what the policy for hair nets was, she explained staff should wear a hair net when entering the kitchen and all hair should be in the hair net. When asked what potential harm could occur if hair nets were not worn correctly, EI #4 explained hair could get in the food, serving utensils or on the trays. 2) Review of the facility's policy titled "4.3 Manual Warewashing and Sanitizingd (Sanitizing)" with a revision date of 10/01/2010 revealed the following: "...PURPOSE To ensure all food preparation equipment and serviceware are cleaned and sanitized. PROCESS... 3. If chemically sanitizing...designee tests the solution strength during each wash period using quaternary test strips. 3.1 Water temperature in the third sink is room temperature, approximately 65-75 (degrees) F (Fahrenheit)..." Review of the manufacturer's specific instructions (posted on wall in kitchen) revealed the following: "...Sanitation Range Testing... Testing solutions should be at room temperature- 65 (degrees) F-75 (degrees) F..." Review of the "Quat Sanitizer Technical Data Sheet" provided by dietary staff revealed the following: "...General Information: ...Quat Test Strips should be read at room temperature (75 (degrees) F), higher temperatures will result in inaccurate readings..." On 5/28/2014 at 1:20 PM staff tested the concentration of the sanitizing solution. She had just finished washing the dishes. The temperature of the water she tested was 100 degrees on two separate readings. On 5/29/2014 at 8:05 AM EI #3, dietary staff, was observed to prepare the three compartment sink for use. She used an automatic dispenser to prepare the sanitizing solution of Quaternary Ammonium. She tested the concentration by placing the test paper directly into the third sink. The surveyor tested the water temperature which read 116 degrees. After testing the concentration EI #3 stated the concentration was fine and began washing items. EI #3 was interviewed on 5/29/2014 at 8:17 AM. When asked what steps were taken to check the concentration with the strips, EI #3 explained the third sink was sanitizer mixed with hot water and should read 70-400 parts per million. She then stated they test the concentration of the sanitizer to make sure the dishes are getting clean. EI #4, the Registered Dietitian, was interviewed on 5/29/2014 at 2:50 PM. When asked what was the correct way to test the Quaternary Ammonium concentration using strips, she stated they should check the temperature of the water, which should be 60-75 degrees. If within range they would then submerge the strip into the water for ten seconds. When asked how they could ensure their sanitizer was at the appropriate concentration if staff did not know how to test it correctly, EI #4 explained, "We can't know it is right if we don't test it correctly." She then stated they could get bacteria or viruses if the concentration was not tested correctly.