Every finding on record at Crowne Health Care of Ft Payne

Based on observation, interview, and facility policy review, the facility failed to maintain a clean, comfortable, homelike environment; specifically, shower rooms had numerous tiles discolored with a black, mold-like substance. This had the potential to affect 104 residents that utilized shower rooms of 110 total residents residing in the facility. This was cited as a result of the investigation of complaint/report 2792622.Findings included:The facility's undated policy titled, Nursing Home Shower Room Cleaning, indicated, To maintain a safe, hygienic, and dignified environment for residents and prevent the spread of infection through routine daily cleaning and disinfection. The policy continued, Deep Cleaning: Perform once daily (typically at the end of the shift or during designated quiet hours). The policy also indicated, Maintenance Reporting: Report any maintenance hazards (water leaks, mold, loose grab bars, slow or clogged drains) to Facilities/Maintenance immediately.An observation on 08/11/2026 at 3:55 PM revealed the Hall 2 shower room stall tiles had shades of black discoloration consistent with a mold-like substance. The left wall had 100 black discolored wall tiles; the front wall had 80 black discolored wall tiles, and the right wall had 80 black discolored wall tiles.During an interview on 08/12/2026 at 9:51 AM, the District Manager entered the Hall 2 shower room and stated it appeared to have been a week or two since the shower stall was deep cleaned. She stated she did not know what the dark substance was on the tiles of the shower stall. She stated she was very unsatisfied with the cleaning. The District Manager stated her expectation was that there should be nothing on the wall tile, and that housekeeping staff should be signing off on a clip board assignment sheet once the cleaning was complete.During an interview on 08/12/2026 at 10:20 AM, the Director of Nursing (DON) entered the Hall 2 shower room and stated the tiles needed replacing or scrubbing. An observation on 08/11/2026 at 4:03 PM revealed the Hall 3 shower room had an open floor plan without a shower stall. The tiles had shades of black discoloration consistent with a mold-like substance. The right wall had 102 black discolored tiles; the front wall had 18 black discolored tiles; and the floor had 26 black discolored tiles. The shower faucet fixture was surrounded by eight discolored tiles. During an interview on 08/12/2026 at 9:53 AM, the District Manager entered the Hall 3 shower room and stated there should be nothing on the walls. She stated that if housekeeping staff could not get the dark substance off the walls with daily cleaning, then it should have been reported to maintenance. During an interview on 08/12/2026 at 10:24 AM, the DON entered the Hall 3 shower room and stated she did not know the last time the dark substance was cleaned off the walls, but it had not been done daily.During a concurrent observation and interview of the C Hall shower room on 08/12/2026 at 8:53 AM, Housekeeper (HK) #15, revealed the C Hall shower room tiles had shades of black discoloration consistent with a mold-like substance. The left wall had 66 black discolored tiles; the front wall had 88 black discolored tiles; and the right wall had 77 black discolored tiles. HK #15 stated she did not know what the dark substance was, but it got better with deep cleaning. During an interview on 08/12/2026 at 10:02 AM, the District Manager entered the C Hall shower room and stated it needed to be cleaned. She stated that the shower room did not appear as if it had been cleaned daily. She stated she did not know what the dark substance on the tiles was.During an interview on 08/12/2026 at 10:12 AM, the DON entered the C Hall shower room and stated that the tiles needed to be replaced because they looked black and dark. She stated housekeeping staff cleaned the shower room but did not clean enough to get rid of the dark substance. The DON stated it had been like that for years and should be cleaned daily to prevent the dark substance on the walls. The DON stated it needed a hard brush for scrubbing to get the tiles clean. The DON stated housekeeping staff had not communicated to her that the tiles needed to be replaced.During an interview on 08/14/2026 at 2:36 PM, the Maintenance Director stated the last time housekeeping staff told him about the dark substance on the tiles in the shower rooms was about a year prior. He stated he cleaned the tiles himself to demonstrate to the housekeeping staff that it could be cleaned. He stated that if the housekeeping staff did not keep cleaning the tiles, they would get worse.During an interview on 08/14/2026 at 3:25 PM, the Administrator (ADM) stated her expectation for the cleaning of shower rooms was that they were to be sprayed daily and wiped down every other day, or sooner if needed. The ADM stated she did not want the shower rooms to have the potential to grow anything.

Based on observation, interview, facility policy review, and facility document review, the facility failed to ensure food served to residents had an appetizing taste and temperature for 1 of 2 test trays sampled. This was cited as a result of the investigation of complaint/report 2724763 Findings included: A facility policy titled, Food Temperatures, dated 2023, indicated, 4. Foods should be transported as quickly as possible to maintain temperatures for delivery and service. If food transportation time is extensive, food should be transported using a method that maintains temperatures (i.e. [id est, that is], hot/cold carts, pellet systems, insulated plate bases and domes, etc. [et cetera, and so forth]). A facility document titled, Grievance/Concern Log, revealed a concern dated 12/14/2025 of food being cold. The document indicated the concern was resolved on 12/15/2025. The Grievance/Concern Log also revealed a concern dated 05/19/2026 of oatmeal not warm. The document indicated the concern was resolved on 05/19/2026. During a concurrent interview and observation of the first-floor dining room on 08/13/2026 at 7:21 AM, staff were observed passing breakfast trays to residents. At 7:49 AM, sample tray was removed from the food cart. The food was tasted by surveyors, the Dietary Manager (DM), and the Assistant Kitchen Manager (AKM). The DM stated the eggs were cold and the oatmeal did not taste good. The AKM stated the eggs and oatmeal were not hot and did not meet her expectations for either temperature or taste. During an interview on 08/14/2026 at 3:33 PM, the Director of Nursing stated that she expected residents to be served warm meals. She stated she did not know the exact temperature, but residents should not be served cold or lukewarm food. During an interview on 08/15/2026 at 9:12 AM, the Administrator stated she expected residents to get warm meals at appropriate temperatures. She stated she expected food to be cooked thoroughly and presented well.

Based on interview, record review, and facility policy review, the facility failed to honor a resident's preference to not have the Director of Nursing (DON) enter their room for 1 (Resident #15) of 6 residents reviewed for abuse. This was cited as a result of the investigation of complaint/report 2724786.Findings included: The facility's Resident Handbook, section titled, II. Your Rights as a Resident, specified, Each resident has a right to make choices about aspects of his or her life in the Facility that are significant to the resident and the Facility shall accommodate these choices as practicable. An admission Record revealed the facility admitted Resident #15 on 09/12/2024. According to the admission Record, the resident had a medical history that included diagnoses of intermittent explosive disorder, major depressive disorder, generalized anxiety disorder, adjustment disorder with mixed anxiety and depressed mood, bipolar disorder, dementia with behavioral disturbances, and insomnia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/11/2026, revealed Resident #15 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. Resident #15's Care Plan included a problem statement, started 10/02/2024, for behavioral symptoms of hoarding, including retaining empty shoeboxes, multiple shoes on the floor, boxes of stuffed items, multiple bags of artificial sweeteners, rotten fruit, unrefrigerated salad dressing containers from meal trays, silverware, and complete meal trays until the next meal was served. Interventions directed staff to educate the resident on the health hazards associated with keeping unrefrigerated food and meal trays for more than one to two hours in the room (initiated 10/02/2024) and to notify family/sponsor to assist with removing unnecessary items (initiated 10/02/2024). The care plan did not include any intervention to accommodate the resident's stated preference to restrict the DON from entering their room. A Minimum Data Set (MDS) Coordinator Progress Note, dated 07/14/2025 at 9:45 AM, indicated the MDS Coordinator and the DON went to Resident #15's room and explained excessive items were a fire hazard and fall risk, and some needed to be cleaned out. The note indicated Resident #15 did not want items removed, as the resident used all the items. MDS Coordinator Progress Notes, dated 07/14/2025 at 10:57 AM, indicated the MDS Coordinator, the DON, and certified nursing assistants (CNAs) explained to Resident #15 the room needed to be cleaned for fall risks, pests, and fire hazards and that Family Member (FM) #16, who was their guardian, was aware. The note indicated Resident #15 continued to be upset during room cleaning, allowed staff to go through items, and attempted to remove items from the garbage can. On 08/14/2026 at 1:50 PM, Licensed Practical Nurse (LPN) #7 stated Resident #15 disliked the DON and became very upset during room cleaning in July of 2025. During an interview on 08/15/2026 at 9:14 AM, the Social Services Assistant (SSA) stated she had a good rapport with Resident #15 and confirmed that the resident told her weeks after the incident that the DON pulled a trash can from them, and since then they hated the DON and did not want the DON in their room. During an interview on 08/15/2026 at 2:22 PM, Social Worker (SW) #17 confirmed the facility had no specific policy for accommodating resident requests to avoid certain staff and stated they usually assigned staff that had a better rapport with the resident. SW #17 confirmed awareness that since the previous year, Resident #15 did not want the DON in their room. During an interview on 08/15/2026 at 2:50 PM, Resident #15 stated the DON continued to peek into their room weekly and sometimes would come into the room monthly to clean despite their objections. During an interview on 08/15/2026 at 3:00 PM, the SSA stated everyone knew that Resident #15 did not like the DON, and the resident did not want the DON in their room. During an interview on 08/15/2026 at 10:23 AM, the DON stated Resident #15 disliked the DON, the resident would tell the DON not to speak to them, and the resident said, I don't like you. The DON stated Resident #15 hated her, and she knew it. The DON said she would go in Resident #15's room and just peek around the curtain during grand rounds but did not have any dealings with Resident #15. During an interview on 08/15/2026 at 3:16 PM, the Administrator (ADM) stated the process of accommodating a resident's preferences should be honored. The ADM stated if a resident did not want a specific staff member providing care, that preference should be respected, and the staff member should not go into the resident's room. The ADM stated she was not aware the DON continued to enter Resident #15's room. The ADM acknowledged that the DON should not be going into that room and that another manager should have been designated to check on Resident #15 during rounds instead.

The following deficiency represents an incident of past non-compliance that was subsequently corrected prior to this survey. Based on interview, record review, facility document review and facility policy review, the facility failed to protect the residents' rights to be free from sexual abuse for 2 (Resident #24 and Resident #59) of 6 residents sampled for abuse. This was cited as a result of the investigation of complaint/report 3121131.Findings included: Cross-reference F609 and F610. A facility policy titled, Abuse Policy, dated February 2026, revealed, It is the policy of [facility name] that each resident has the right to be free from verbal, sexual, physical, and mental abuse, misappropriation of resident property, and exploitation as defined in the federal nursing home regulations. The policy defined Sexual Abuse as Non-consensual sexual contact of any type with a resident. Examples of sexual abuse include, but are not limited to, unwanted intimate touching of any kind especially of breasts or perineal area; all types of sexual assault or battery, such as rape, sodomy, and coerced nudity; forced observation of masturbation and or/ pornography; and taking sexually explicit photographs and/or audio/video recordings of a resident(s) and maintaining and/or distributing them (e.g. [exempli gratia, for example] posting on social media). This would include, but is not limited to, nudity, fondling, and/or intercourse involving a resident. Generally, sexual contact is nonconsensual 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. A Resident Face Sheet revealed the facility admitted Resident #24 on [DATE]. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of vascular dementia, sexual dysfunction, paranoid schizophrenia, bipolar disorder, mental disorder, and anxiety disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. Resident #24's Care Plan History included a problem statement dated [DATE] that indicated the resident had inappropriate sexual behaviors like inappropriate touching and making sexual comments and was not aware that the behaviors were inappropriate at the time due to their dementia. Interventions directed staff to explain that sexual comments were not acceptable and redirect the conversation (initiated [DATE]), monitor/track behaviors as indicated (initiated [DATE]), report any changes in mood and behavior to the resident's physician and social services for review (initiated [DATE]), and remind the resident to keep his/her hands to themselves (initiated [DATE]). A court document, regarding Letters of Guardianship and Conservatorship dated [DATE], revealed that Resident #24 had a court appointed as guardian due to the resident being an incapacitated person in need of protection. A Resident Progress Note, dated [DATE] at 3:44 PM and authored by Licensed Practical Nurse (LPN) #13, revealed that Resident #24 was observed actively kissing another resident. The Resident Progress Note revealed that the resident's physician, the facility Administrator (ADM), the Director of Nursing (DON), an unnamed supervisor, and the resident's representative were notified. A Resident Progress Note, dated [DATE] at 1:43 PM and authored by LPN #14, revealed that Resident #24 was observed touching another resident's breast while speaking with them in the unit dining room. The Resident Progress Note revealed that Resident #24 was redirected by facility staff, and the resident walked to their room. The Resident Progress Note revealed that the DON, Social Services, and resident's physician were notified. A Resident Face Sheet revealed the facility admitted Resident #59 on [DATE]. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of dementia, amnesia, paranoid schizophrenia, bipolar disorder, and anxiety disorder. A significant change MDS, with an ARD of [DATE], revealed Resident #59 had a BIMS score of 3, which indicated the resident had severe cognitive impairment. Resident #59's Care Plan included a problem statement dated [DATE] that indicated the resident may not be able to remember current events, may become disoriented to time and place, and had auditory hallucinations, disorganized thinking, and inattention wandering. Interventions directed staff to observe for and document episodes of paranoid behavior (initiated [DATE]), observe whereabouts and redirect as needed (initiated [DATE]), and observe and report any auditory hallucinations, delusions, and rejection of care (initiated [DATE]). A court document, regarding Letters of Guardianship and Conservatorship dated [DATE], revealed that Resident #59 had a court-appointed guardian due to being an incapacitated person in need of protection. A Resident Progress Note, dated [DATE] at 1:51 PM and authored by LPN #14, revealed that Resident #59 was observed talking to another resident in the unit dining room while the other resident had their hand on Resident #59's breast. The Resident Progress Note revealed that Resident #59 was redirected by facility staff. The Resident Progress Note revealed that the DON, Social Services, and resident's physician were notified. During an interview on [DATE] at 2:47 PM, the DON stated any inappropriate touching or unwanted kissing of one resident to another would be considered sexual abuse. During a telephone interview on [DATE] at 2:48 PM, the ADM stated that any kissing, touching, or anything that could be misconstrued as unwanted, including if a resident were incapacitated and unable to make their own decisions, should be reported as sexual abuse. The ADM stated they would normally file a report with the State agency and investigate the incident. The ADM stated that investigating and reporting allegations of sexual abuse was important to each resident's safety, and it was the responsibility of the facility to ensure the safety of the resident. The ADM stated they could not recall who the other involved resident was with Resident #24 on [DATE] or [DATE], but based on how the notes were written, the incidents should have been reported. During an interview on [DATE] at 3:08 PM, the DON stated that the other resident involved in the incidents on [DATE] and [DATE] was likely Resident #59. The DON stated that Resident #24 and Resident #59 were flirtatious with each other and very involved with each other. The DON stated that Resident #59 never ran away or tried to avoid Resident #24, so the facility did not investigate the documented concerns. The DON stated that it seemed like puppy love, but the resident's behaviors escalated, which resulted in Resident #59 being moved from the unit. The DON stated that both residents had dementia, but they were able bodied and never tried to get away from each other. During an interview on [DATE] at 2:01 PM, LPN #13 stated that Resident #24 frequently sought out residents and frequently needed to be redirected. LPN #13 stated she could not recall who the other resident was in the incident on [DATE] with Resident #24 but later stated that it was Resident #59. LPN #13 stated that Resident #59 would not have the mental capacity to consent to a sexual relationship. During a telephone interview on [DATE] at 2:00 PM, Certified Nursing Assistant (CNA) #9 stated that Resident #24 frequently wandered and was very drawn toward residents of the opposite sex and would go out of their way to find Resident #59 on the unit to be near the resident. CNA #9 stated that she had not witnessed any intimate interactions between Resident #24 and Resident #59, but she had been informed of an incident between the two residents. CNA #9 stated that following that incident, she was instructed to ensure that Resident #24 and Resident #59 were not around each other. During a follow-up interview on [DATE] at 2:36 PM, LPN #13 stated that she had witnessed Resident #24 attempt to pursue residents of the opposite sex on the unit and go into other resident's rooms. LPN #13 stated that Resident #24 was observed kissing Resident #59 on [DATE] and that the residents were in Resident #24's room at the time of the incident. LPN #13 stated that she removed Resident #59 from Resident #24's room and told Resident #24 that they could not have residents of the opposite sex in their room. LPN #13 stated that she informed the ADM and DON, and she was told to watch Resident #24. LPN #13 stated that several residents were moved off the unit due to Resident #24's behaviors and that she and the CNA staff took turns watching Resident #24 to ensure other residents were safe. During an interview on [DATE] at 9:51 AM, the ADM stated that the incidents on [DATE] and [DATE] involving Resident #24 and Resident #59 should have been reported to the State agency and should have been investigated as allegations of sexual abuse. The ADM stated that she did not recall either incident until she read them in Resident #24's progress notes. The ADM stated that she could not recall details of the incident involving Resident #24 and Resident #59. The ADM was not able to state if an investigation was conducted regarding either incident. During an interview on [DATE] at 10:46 AM, the Medical Director (MD) stated that he was familiar with Resident #24 and that the resident had a long history of sexual behaviors, which became worse after the resident developed dementia. The MD stated that Resident #24 had been involved in several incidents with Resident #59 and that the two residents were attracted to each other. The MD stated that he expected the facility to inform him of any sexual behaviors a resident displayed. Review of Plan of Corrections Reportable on 3-23-26 F600, revealed the facility developed and implemented corrective actions on [DATE] and corrected the failed practice as follows: The facility held an Emergency Quality Assurance (QA) meeting on [DATE]. An audit of current residents involved in previous resident-on-resident incidents remaining in the facility had behavior documentation and progress notes reviewed for the past 30 days on [DATE] to determine if the resident was exhibiting behaviors that may provoke a reaction by residents or others, (which include, but are not limited to: verbally aggressive behavior, such as screaming, cursing, bossing around/demanding, insulted to race or ethnic group, intimidating; physically aggressive behavior, such as hitting, kicking, grabbing, catching, pushing/shoving, biting, spitting, threatening gestures, throwing objects; sexually aggressive behavior such as saying sexual things, inappropriate touching/grabbing; taking, touching, or rummaging through others' property; and wandering into others' rooms/space). Three residents were identified with current behaviors that may provoke a reaction by residents or others. The identified residents had behavior monitoring initiated and review conducted by the interdisciplinary team (IDT) to determine if an increased level of supervision was needed. The facility revised their behavior management policy and procedure to include a new system beginning on [DATE]. When abnormal behavior is identified, staff will initiate behavior tracking/behavior tracking care plan containing the known targeted behavior(s) with individualized interventions based on the resident's preferences and choices that may be effective in reducing or controlling each known targeted behavior. If the resident has behaviors that may provoke a reaction by residents or others, the IDT will determine if the resident should be placed on an increased level of supervision. The Behavior Management team was educated beginning on [DATE] by the ADM on the revised Behavior Management policy and new system components. All facility staff and contracted staff were educated, beginning on [DATE] by Staff Development, and education continued until all staff were educated on the revised Behavior Management policy and new system components. Staff development/QA monitored compliance by reviewing two residents identified as having behaviors that may provoke a reaction by resident or others to ensure that behavior tracking was initiated with individualized interventions; the IDT initiated a Behavior Tracking Evaluation to determine if an increased level of supervision was needed during tracking; the IDT reviewed behaviors at the completion of tracking to determine if any increased level of supervision was needing to be continued; a banner was placed in the electronic system and plan of care was addressed accordingly based on the level of supervision determined as needed; upon completion of the behavior tracking the resident's behavior management care plan was updated with individualized interventions found to be effective in managing the resident's known behavior. The review was completed weekly for four weeks, then monthly for five months, and documented on a monitoring tool. In addition, Staff Development/QA monitored the facility morning meeting form weekly for eight weeks, then monthly for four months that the IDT discussed review of the electronic behavior widget, including behaviors with no effective interventions at each morning meeting to initiate behavior tracing. The review was documented on a monitoring tool and placed with the plan of correction in the Administrator's office. After review and verification of the facility's corrective actions, to include the facility's investigation, monitoring tools, facility audits, staff education, and interviews with facility staff regarding the education provided, the survey team determined the facility implemented the above corrective actions beginning on [DATE] and conducted ongoing education and monitoring; therefore, past noncompliance was cited.

Based on interview, record review, facility document review, facility policy review, the facility failed to report allegations of resident abuse for 2 (Residents #24 and #59) of 6 residents sampled for abuse. Specifically, the facility failed to report allegations of sexual abuse that occurred on 03/20/2025 and 03/24/2025 between Resident #24 and Resident #59 (who were deemed incapable of making informed decisions). This was cited as a result of the investigation of complaint/report 3121131.Findings included: Cross-reference F600. A facility policy titled, Abuse Policy, dated February 2026, revealed, It is the policy of [the facility] that each resident has the right to be free from verbal, sexual, physical, and mental abuse, misappropriation of resident property, and exploitation as defined in the federal nursing home regulations. The policy revealed, [the facility] will investigate any suspected or reported alleged instance of resident abuse, neglect, injuries of unknown source, misappropriation of a resident's personal property or exploitation and report such instances to the Alabama Department of Public Health in accordance with the rules and regulations of the Alabama Department of Public Health as required by law. 1. A Resident Face Sheet revealed the facility admitted Resident #24 on 10/09/2024. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of vascular dementia, sexual dysfunction, paranoid schizophrenia, bipolar disorder, mental disorder, and anxiety disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/23/2026, revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. A Resident Progress Note, dated 03/20/2025 at 3:44 PM and authored by Licensed Practical Nurse (LPN) #13, revealed that Resident #24 was observed actively kissing another resident. The Resident Progress Note revealed that the resident's physician, the facility Administrator (ADM), the Director of Nursing (DON), an unnamed supervisor, and the resident's representative were notified. A Resident Progress Note, dated 03/24/2025 at 1:43 PM and authored by LPN #14, revealed that Resident #24 was observed touching another resident's breast while speaking with them in the unit dining room. The Resident Progress Note revealed that Resident #24 was redirected by facility staff, and the resident walked to their room. The Resident Progress Note revealed that the DON, Social Services, and resident's physician were notified. A Resident Face Sheet revealed the facility admitted Resident #59 on 11/15/2022. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of dementia, amnesia, paranoid schizophrenia, bipolar disorder, wandering, and anxiety disorder. A significant change MDS, with an ARD of 03/12/2025, revealed Resident #59 had a BIMS score of 3, which indicated the resident had severe cognitive impairment. A Resident Progress Note, dated 03/24/2025 at 1:51 PM and authored by LPN #14, revealed that Resident #59 was observed talking to another resident in the unit dining room while the other resident had their hand on Resident #59's breast. The Resident Progress Note revealed that Resident #59 was redirected by facility staff. The Resident Progress Note revealed that the DON, Social Services, and resident's physician were notified. During an interview on 08/12/2026 at 2:01 PM, LPN #13 stated that Resident #24 frequently sought out residents and frequently needed to be redirected. LPN #13 stated she could not recall who the other resident was in the incident on 03/20/2025 with Resident #24 but later stated that it was Resident #59. LPN #13 stated that Resident #59 would not have the mental capacity to consent to a sexual relationship. During a follow-up interview on 08/14/2026 at 2:36 PM, LPN #13 stated that when the incident occurred on 03/20/2025 with Resident #24 and #59, she informed the ADM and DON, and she was told to watch Resident #24. LPN #13 stated that several residents were moved off the unit due to Resident #24's behaviors and that she and the certified nursing assistant staff took turns watching Resident #24 to ensure other residents were safe. During a telephone interview on 08/11/2026 at 2:48 PM, the ADM stated that any kissing, touching, or anything that could be misconstrued as unwanted, including if a resident were incapacitated and unable to make their own decisions, should be reported as sexual abuse. The ADM stated they would normally file a report with the State agency and investigate the incident. The ADM stated they could not recall who the other involved resident was with Resident #24 on 03/20/2025 or 03/24/2025, but based on how the notes were written, the incidents should have been reported. During a follow-up interview on 08/15/2026 at 9:51 AM, the ADM stated that the incidents on 03/20/2025 and 03/24/2025 involving Resident #24 and Resident #59 should have been reported to the State agency. The ADM stated that it was a failure on the facility's part, and the incidents should have been reported.

Based on interview, record review, and facility policy review, the facility failed to investigate allegations of abuse for 2 (Residents #24 and #59) of 5 residents sampled for abuse. Specifically, the facility failed to investigate allegations of sexual abuse that occurred on 03/20/2025 and 03/24/2025 between Resident #24 and Resident #59 (who were deemed incapable of making informed decisions). This was cited as a result of the investigation of complaint/report 3121131.Findings included: Cross-Reference F600. A facility policy titled, Abuse Policy, dated February 2026, revealed, It is the policy of [the facility] that each resident has the right to be free from verbal, sexual, physical, and mental abuse, misappropriation of resident property, and exploitation as defined in the federal nursing home regulations. The policy revealed, [the facility] will investigate any suspected or reported alleged instance of resident abuse, neglect, injuries of unknown source, misappropriation of a resident's personal property or exploitation and report such instances to the Alabama Department of Public Health in accordance with the rules and regulations of the Alabama Department of Public Health as required by law. The policy continued, The facility must also initiate an immediate investigation and take all necessary steps to prevent further potential abuse. 1. A Resident Face Sheet revealed the facility admitted Resident #24 on 10/09/2024. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of vascular dementia, sexual dysfunction, paranoid schizophrenia, bipolar disorder, mental disorder, and anxiety disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/23/2026, revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated severe cognitive impairment. A Resident Progress Note, dated 03/20/2025 at 3:44 PM and authored by Licensed Practical Nurse (LPN) #13, revealed that Resident #24 was observed actively kissing another resident. The Resident Progress Note revealed that the resident's physician, the facility Administrator (ADM), the Director of Nursing (DON), an unnamed supervisor, and the resident's representative were notified. A Resident Progress Note, dated 03/24/2025 at 1:43 PM and authored by LPN #14, revealed that Resident #24 was observed touching another resident's breast while speaking with them in the unit dining room. The Resident Progress Note revealed that Resident #24 was redirected by facility staff, and the resident walked to their room. The Resident Progress Note revealed that the DON, Social Services, and resident's physician were notified. A Resident Face Sheet revealed the facility admitted Resident #59 on 11/15/2022. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of dementia, amnesia, paranoid schizophrenia, bipolar disorder, wandering, and anxiety disorder. A significant change MDS, with an ARD of 03/12/2025, revealed Resident #59 had a BIMS score of 3, which indicated severe cognitive impairment. A Resident Progress Note, dated 03/24/2025 at 1:51 PM and authored by LPN #14, revealed that Resident #59 was observed talking to another resident in the unit dining room while the other resident had their hand on Resident #59's breast. The Resident Progress Note revealed that Resident #59 was redirected by facility staff. The Resident Progress Note revealed that the DON, Social Services, and resident's physician were notified. During an interview on 08/11/2026 at 3:08 PM, the DON stated that the other resident involved in the incidents on 03/20/2025 and 03/24/2025 was likely Resident #59. The DON stated that Resident #24 and Resident #59 were flirtatious with each other andvery involved with each other. The DON stated that Resident #59 never ran away or tried to avoid Resident #24, so the facility did not investigate the documented concerns. The DON stated that it seemed like puppy love, but the resident's behaviors escalated, which resulted in Resident #59 being moved from the unit. During a telephone interview on 08/11/2026 at 2:48 PM, the ADM stated that investigating and reporting allegations of sexual abuse was important to each resident's safety, and it was the responsibility of the facility to ensure the safety of the resident. During an interview on 08/15/2026 at 9:51 AM, the ADM stated that the incidents on 03/20/2025 and 03/24/2025 involving Resident #24 and Resident #59 should have been investigated as allegations of sexual abuse. The ADM stated that she did not recall either incident until she read them in Resident #24's progress notes. The ADM stated that she could not recall details on the incident involving Resident #24 and Resident #59 and could not recall any staff being interviewed related to the incidents on 03/20/2025 or 03/24/2025. The ADM was not able to state if an investigation was conducted regarding either incident.

Based on observation, interview, record review, facility document review, and facility policy review, the facility failed to ensure staff signed out a narcotic at the time it was administered and ensure the reconciliation of controlled substances during the required end-of-shift narcotic count for 1 (Hall 1 Medication Cart) of 3 medication carts reviewed during the medication storage task.Findings included: A facility policy titled, Medication Administration Procedures Controlled Medication Administration, dated 12/2019, revealed, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility in accordance with federal and state laws and regulations. The policy further specified, 3. When a controlled medication is to be administered, the licensed nurse removing the medication immediately enters the following information on the controlled drug record: A. Date and time of removal; B. Amount removed; C. Signature. Further review revealed, 6. At each shift change, or upon change in authorized nurse, a physical inventory of all controlled medications is conducted by two licensed nurses and is documented on an audit record (shift-to-shift count). 7. Any discrepancy in controlled substance medication counts is reported to the Director of Nursing immediately. During an observation on 08/12/2026 at 2:46 PM of Hall 1 Medication Cart with Licensed Practical Nurse (LPN) #5, a random narcotic check of hydrocodone-acetaminophen (APAP) 10-325 milligrams (mg) for Resident #27 revealed there were twenty-two tablets on the narcotic card while the Controlled Drug Record listed twenty-three tablets. Resident #27's 08/2026 Medication Administration Record [MAR] revealed staff documented that one tablet of hydrocodone-APAP 10-325 mg was administered to the resident on 08/12/2026 at 11:10 AM. Further review revealed the Controlled Drug Log had not been updated at the time of removal, contrary to facility policy. During a concurrent interview, LPN #5 stated she counted the narcotics with the off-going nurse (LPN #2) at shift change and must have just missed it. She confirmed that the Controlled Drug Record revealed one additional tablet and acknowledged the discrepancy was not caught during the required end-of-shift count. During an interview on 08/12/2026 at 4:26 PM, LPN #2 stated she administered hydrocodone-APAP at 11:10 AM (on 08/12/2026) to Resident #27 and forgot to sign it out on the controlled drug record. She stated she completed a narcotic count with another nurse, and the discrepancy was not detected during the reconciliation. During an interview on 08/12/2026 at 3:23 PM, the Director of Nursing (DON) stated that all controlled medications must be signed out at the time of removal and verified during the two-nurse narcotic count at shift change. During an interview on 08/15/2026 at 10:46 AM, the DON stated her expectation was that narcotic counts were completed carefully during shift changes, off-going staff announced the count from the controlled drug record, and the oncoming nurse verified the medication cards match the controlled drug record. During an interview on 08/15/2026 at 11:32 AM, the Administrator stated her expectation was for nurses to document removal of controlled medications immediately and perform proper narcotic counts at every shift change.

Based on interviews, review of Resident Identifier (RI) #87's medical record and the facility's policy titled Notice of Discharge to Ombudsman, the facility failed to issue a 30-day notice of discharge to RI #87 and/or RI #87's representative when the facility determined they could no longer meet the needs of the resident. This deficient practice affected RI #87, one of one sampled resident reviewed for facility-initiated discharges. Findings include: The facility's policy titled Notice of Discharge to Ombudsman with a revised date of (MONTH) (YEAR), documented Policy: To comply with Federal regulations before a facility transfers or discharges a resident the facility must notify the resident and the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and in a manner they understand . Policy Explanation and Guidelines: . 2. Facility-initiated transfers and discharges - In situations where the facility has decided to discharge the resident while the resident is still hospitalized ; the facility must send a notice of discharge to the resident and resident representative . RI #87 was admitted to the facility on [DATE]. RI #87's physician's orders [REDACTED]. RI #87's Minimum Data Set with an assessment reference date of 10/27/2019 indicated the resident had an unplanned discharge with return anticipated to an acute hospital on [DATE]. An email dated 10/30/2019 at 3:47 PM, from Employee Identifier (EI) #1, the facility's Social Worker Director to the Local Ombudsman regarding RI #87 documented Ms. (Local Ombudsman), (RI #87) discharged to (local hospital) on 10-27-2019. The hospital was planning on discharging (RI #87) back to the facility today . (EI #7), (RI #87's) attending her (here) at the facility came into the facility this afternoon . (EI #7) stated she would not accept (RI #87) back . We have notified the hospital that we would not be able to accept (RI #87) back into the facility due to there not being an attending physician for (RI #87). We wanted to make you aware of this situation. In an interview on 11/14/2019 at 9:51 AM, EI #1, the facility's Social Worker Director, explained on 10/30/2019, the hospital's Case Manager notified the facility that RI #87 was ready to be discharged from the hospital. When asked who was responsible for providing the resident and/or the resident's representative the 30-day notice of discharge, EI #1 stated she was. When asked if RI #87 and/or RI #87's representative was given a 30-day notice of discharge, EI #1 said no. EI #1 explained a written notice of discharge to the resident and resident's representative was to ensure the resident would have suitable accommodations available upon discharge. During an interview on 11/14/2019 at 10:42 AM, RI #87's representative acknowledged that she did not receive a 30-day discharge notice from the facility when it was determined the facility could no longer meet the resident's needs. During an interview on 11/14/2019 at 4:54 PM, EI #4, the Administrator stated he became aware on 10/30/2019 that RI #87's Primary (Attending) Physician, EI #7, could no longer meet the needs of RI #87. EI #4 was asked was RI #87 and/or RI #87's representative provided with a written 30-day notice of discharge. EI #4 answered, no. When asked why not, EI #4 stated he was under the impression that arrangements and placement had already been secured for RI #87 at another skilled nursing facility. In an interview on 11/14/2019 at 3:08 PM, EI #7, RI #87's Primary Physician acknowledged he informed the facility's Administrator, EI #4, on 10/30/2019 that he could no longer meet the needs of RI #87. EI #7 stated it would have been the responsibility of the facility to issue the resident a written 30-day discharge notice. In an interview on 11/14/2019 at 2:30 PM, the Case Manager at the local hospital stated RI #87 was discharged from the hospital to another skilled nursing facility on 11/4/2019.

Based on interviews, review of Resident Identifier (RI) #87's medical record and the facility's policy titled Crowne Healthcare of Fort Payne Bed Hold Policy and Procedure, the facility failed to ensure Resident Identifier (RI) #87 and/or RI #87's representative was provided written notice of the facility's bed-hold policy when RI #87 was transferred to the local hospital on [DATE]. This deficient practice affected RI #87, one of one sampled resident whose closed record was reviewed for discharge to the hospital. Findings include: The facility's policy titled Crowne Healthcare of Fort Payne Bed Hold Policy and Procedure dated (MONTH) (YEAR), documented I. Purpose To inform every resident or resident representative of the opportunity to hold a bed in the event of temporary, medically necessary, hospitalization or therapeutic leave. II. Policy Each resident or resident representative will be given a written copy of our bed hold policy upon admission, changes to the policy, at the time of transfer of a resident for hospitalization or therapeutic leave. In cases of emergency transfer, at the time of transfer means the Social Services Department or designee will provide the family, surrogate, or representative written notification of our bed hold policy within 24 hours of the transfer . RI #87 was admitted to the facility on [DATE]. RI #87's physician's orders [REDACTED]. RI #87's Minimum Data Set with an assessment reference date of 10/27/2019 indicated the resident had an unplanned discharge with return anticipated to an acute hospital on [DATE]. In an interview on 11/14/2019 at 9:51 AM, Employee Identifier (EI) #1, the facility's Social Worker Director, was asked when was RI #87's transferred to the hospital. EI #1 answered, the resident was sent out on 10/27/2019 by way of ambulance because of a medical reason. When asked who was responsible for ensuring the resident or resident's representative received written bed-hold policy information, EI #1 replied she was. EI #1 stated the facility's policy indicated the written notification should be given to the resident or the resident's representative within 24 hours of transfer. EI #1 further stated the nurse on the floor usually gave the written bed-hold policy information and a copy of paperwork would be given to her. When asked if she received a copy of the paperwork, EI #1 said no. When asked if RI #87 and/or RI #87's representative was provided written notification of the facility's bed-hold policy when the resident was transferred to the local hospital on [DATE], EI #1 said not that she was aware of. During an interview on 11/14/2019 at 10:42 AM, RI #87's representative was asked if she received written notification of the facility's bed-hold policy when RI #87 was transferred to the local hospital on [DATE]. RI #87's representative said no. RI #87's representative explained the facility usually held the resident's bed for three days and she paid the difference if she wanted the resident to come back to the facility. RI #87's representative stated the resident had been in the facility for eight years and she wanted to hold the resident's bed. On 11/14/2019 at 11:44 AM, a telephone interview was conducted with EI #2, a Licensed Practical Nurse (LPN). EI #2 was asked who was the nurse that took care of RI #87 prior to the resident being sent to the local hospital on [DATE]. EI #2 stated she was. When asked if she provided RI #87 or RI #87's representative bed hold policy information, EI #2 stated she did not give any bed hold policy information. EI #2 stated she forgot to give a copy to the family representative. EI #2 was asked what would be the concern of not providing RI #87 or RI #87's representative written bed-hold policy information, EI #2 stated the resident may not have a bed to come back to at the facility. According to EI #2, she notified the Director of Nursing (DON) the next day that she had forgot to give RI #87's representative bed hold policy information. In an interview on 11/14/2019 at 2:50 PM, EI #3, the DON stated one to two later after RI #87 was transferred to the hospital, EI #2, a LPN informed her that she (EI #2) had forgot to send the bed hold policy information with the ambulance attendants and RI #87's representative. EI #3 stated it was on 10/31/2019 when she first saw RI #87's representative and by then it had been communicated to RI #87's representative that RI #87's Primary Physician, EI #7, could no longer meet the needs of the resident. When asked should RI #87 and/or RI #87's representative have received written information on the facility's bed-hold policy when the resident was transferred to the hospital on [DATE], EI #3 answered yes. During an interview on 11/14/2019 at 4:54 PM, EI #4, the Administrator was asked if RI #87 and/or RI #87's representative received bed hold policy notification after the resident was transferred to the hospital on [DATE]. EI #4 stated no. When asked why not, EI #4 stated it was an oversight on the discharging nurse.

Based on observations, interviews, a review of the 2013 Food Code, and a review of a facility document titled, DISH MACHINE TEMPERATURE LOG SANITIZER (DISH ROOM), the facility failed to assure: 1. dishes and utensils were effectively sanitized to destroy potential food borne organisms. (Staff failed to follow correct dishwashing procedures by monitoring the chemical concentration with a test strip) and 2. the iced tea urn dispenser spigot was broken down and cleaned at least every 24 hours, as evidenced by an observed build-up around the plunger. These deficient practices had the potential to affect all 102 residents receiving meal trays from dining services. Findings Include: 1. A review of the Food Code U.S. Public Health Service and FDA (Food and Drug Administration) 2013 revealed the following: . 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitization . (A) A chlorine solution shall have .Concentration Range MG/L .50-99 . A review of the facility form titled, DISH MACHINE TEMPERATURE LOG SANITIZER (DISH ROOM) for the month of August 2017, revealed the method used for sanitizing was achieved by the chemical concentration. The monitoring data had been recorded on the log for the Breakfast meal. A request was made to the Dietary Manager (Employee Identifier) EI #2, for a Dietary Aide, EI #4 to demonstrate the test strip monitoring technique. Documentation revealed EI #4 had documented chemical concentrations of 50 ppm (parts per million) on 8/14, 8/17 and 8/21. On 8/23/2017 at 9:30 a.m., EI #4 was requested to demonstrate how she got 50 ppm. EI #4's response was that she looked at (the) tempt (temperature) gauge. Chemical concentration is monitored using test strips. On 8/23/2017 at 10:00 a.m, EI #4 told EI #2 that she failed to receive training for monitoring chemical concentration. 2. The Food Code U.S. Public Health Service and FDA (Food and Drug Administration) 2013 revealed the following: Frequency 4-602.11 Equipment Food-Contact Surfaces and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be cleaned: . (E) . surfaces of UTENSILS and EQUIPMENT contacting FOOD that is not TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cleaned: (1) At any time when contamination may have occurred; (2) At least every 24 hours for iced tea dispensers . An observation of an iced tea urn was made on 8/22/2017 at 3:18 p.m. The spigot assembly was broken apart by staff to reveal a build-up of solid matter with a dark color. EI #2 was asked if the spigot had been cleaned daily. EI #2 said No. A review of the facility Shift Daily/Weekly Cleaning Schedule revealed documentation for Tea Equipment was initialed for both first and second shifts for August 20, 21, and 22.

Based on observations, interviews and a review of the facility Diet Spreadsheet (pre-planned menu) and the recipe used to prepare Ham & Beans, the facility failed to ensure the recipe and preparation corresponded with the designed quantity of meat (Ham) to use for the lunch meal on 8/23/2017. This had the potential to affect 102 residents who received meal trays in the facility on 8/23/2017. Findings Include: A document review of the Diet Spreadsheet (pre-planned menu) and corresponding recipe revealed staff should use 19 pounds and 13 ounces (oz.) of diced buffet Ham to serve 90 portions of Ham & Beans using an 8 oz. spoodle portion size. The menu plan was to serve Ham & Beans on all meal trays. An observation on 8/23/2017 at 10:15 a.m., during the preparation for the lunch meal, an observation was made of the prepared Ham & Beans in the oven. The amount of Ham appeared sparse. The Cook, (Employee Identifier), EI #1 was asked, how had she prepared the Ham & Beans. EI #1 responded she used four cans of beans and one package (10 pounds) of Diced Ham. The Dietary Manager, EI #2 said the amount of Ham included in preparation was only one-half of that planned per the recipe. On 8/23/2017 at 10:40 a.m., EI #2 phoned the Consultant Dietitian, EI #3, who stated that she was unaware of discrepancies between the spread sheet, menu and recipe.

Based on observations, interviews and record review the facility failed to ensure a Licensed Staff, Registered Nurse (RN) administered Resident Identifier (RI) # 17's Insulin as documented on the physician's orders [REDACTED]. The RN gave 8 units of Humalog Insulin instead of the documented ordered dose of 12 units. This affected one of 25 observations of Medication Administration during the survey. Findings Include: A facility Policy Titled: Medication Administration-General Guidelines .Procedures 1. Medications are administered only by licensed nursing . 2. Medications are administered in accordance with written orders of the attending physician . 16. Read medication label and compare with medication administration record . A facility Policy Titled: Medication Administration .PREPARATION FOR MEDICATION ADMINISTRATION Policy Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so .Procedures .5. Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label. If the label and MAR are different and the container is not flagged indicating a change in directions, or if there is any other reason to question the dosage or directions, the physician's orders [REDACTED]. A review of Potter and Perry, Fundamentals of Nursing, Eighth Edition, copyright 2013, chapter 23 Legal Implications in Nursing Practice, page 305, revealed the following: . Health Care Provider's Orders . Nurses follow health care providers' orders unless they believe the orders are in error or harm patients . RI #17 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 09/13/16, at 3:50 p.m. the surveyor observed Employee Identifier (EI) # 1 RN preparing to administer Humalog Insulin to RI #17. She prepared 8 units of Insulin as documented on the Medication label and administered the Insulin to RI #17. During the reconciliation of the medication pass observation the surveyor observed the Physician order [REDACTED].HUMALOG 100 UNITS/ML VIAL GIVE 12 UNITS SUBQ (Subqutaneous) TID (three times a day) AC (before meals) . The MAR also documented .HUMALOG 100 UNITS/ML VIAL GIVE 12 UNITS SUBQ TID AC .Order Date: 4/25/16 . The original documented order for 4/25/16 documented .1. D/C Humalog insulin 8 U SQ TID AC 2. Humalog Insulin 12 u SQ TID AC . An interview was conducted with EI #1 RN on 09/14/16, at 9:45 a.m. She was asked whose Insulin she administered with the surveyor observing on 09/13/16, at 3:50 p.m. EI #1 replied, RI #17. She was asked how many units she gave RI #17. EI #1 replied 8 units. EI #1 was asked what the MAR and the Physician order [REDACTED]. She replied 12 units. EI #1 was asked what was documented on the Insulin label to be given. She replied 8 units. EI #1 was asked what dose should have been given. She replied 12 units. EI #1 was asked why she administered 8 units. She replied that she got bumfuzzled and gave the dose that was on the bottle. EI #1 was asked what she should have done before administering the 8 units. She replied compare the label with the MAR and the Physician Order. She was asked why she did not. EI #1 replied she guess she was nervous. She was asked who was responsible for checking the medications from the pharmacy with the MAR and the Physician orders. EI #1 replied the Nurse giving the medication. EI #1 was asked what the potential for harm was if the wrong dose of Insulin was given. She stated, Resident would not get their right dose of Insulin. EI #1 was asked what the facilities policy was related to administering medications. EI #1 stated, I'm not positive but as a Nurse I know I'm suppose to follow the standard of practice. EI #1 was then asked what should be done if the MAR, Physician order [REDACTED]. EI #1 replied, Contact the Pharmacy for confirmation, place a bright green direction change sticker on the label. The pharmacy will send the new medication with the new label. An interview was conducted with EI #2, Director of Nursing on 09/14/16, at 2:00 p.m. EI #2 was asked who was responsible for reconciling Physician orders, MARS and labels on the medications. She replied the night shift Nurses, the Nurse giving the medication and the Pharmacy. EI #2 was asked if she was aware EI #1 had given the wrong dose of insulin to RI #17. She replied, yes. EI #2 was asked to review RI #17's Physician orders, MARS, and Insulin label on his/her bottle and tell the surveyor what was documented on each of them. She replied, the Physician orders [REDACTED]. EI #2 was asked what should have been done for the discrepancy. She replied, the nurse should have pulled the sticker from the bottle, placed a green change of direction sticker on the bottle label and checked the Physician order [REDACTED]. EI #2 was asked what the potential for harm was if the Physician order, MAR and the label on the medications had discrepancies. EI #2 replied, the wrong dose of insulin could be given to the resident.

Based on observation, interview and record review the facility failed to honor the food preference as documented on the tray card for Resident Identifier (RI) # 1's breakfast tray on 09/13/16. This affected one of 14 sampled residents whose meals were observed. Findings Include: A review of facility policy Resident Food Preferences revealed Policy Statement Nutritional assessments will include an evaluation of the individual food preferences .4. the resident's clinical record . will document the resident's likes and dislikes and special dietary instructions . RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's most recent Quarterly Minimum Data Set with an Assessment Reference Date of 8/29/16 revealed RI #1 with a Brief Interview for Mental Status (BIMS) of 15 indicating cognitively intact. On 9/13/16 at 8:15 a.m. RI #1 was observed eating breakfast. An 8 oz. (ounce) carton of fat free milk was observed on RI #1's tray. A review of RI #1's tray card revealed Beverages: water 8 fl (Fluid) oz; Coffee 8 fl oz; Milk 2%: 8 fl oz; . A review of a facility form Resident's Diet Information dated 7/14/16 revealed .Food Likes, Fortified Foods, Supplements and Beverages Served With the Following Meals: Breakfast 8 oz. Water, 8 oz Coffee, 4 oz Juice, 8 oz 2% Milk; Lunch 8 oz. Water, 8 oz. Coffee On Tray, 8 oz. 2% Milk; Supper 8 oz. Water, 8 oz. Coffee on Tray, 8 oz. 2% Milk. A review of facility form titled Resident Profile dated 8/24/16 revealed .Beverages Drink .Milk 2% . On 9/13/16 at 5:00 p.m. a brief interview was conducted with RI #1. RI #1 was asked what milk was normally received for meals. RI #1 replied 2%. RI #1 was asked what type milk was received this morning. RI #1 replied Fat Free. On 9/14/16 at 11:30 a.m. an interview was conducted with Employee Identifier (EI) # 3, Dietary Manager. EI #3 was told RI #1 had Fat Free milk on breakfast tray, she was then asked if that was the correct milk for the resident. EI #3 replied no. EI #3 was asked what was the potential for harm for the resident receiving fat free milk instead of the 2% milk. EI #3 replied there was no harm, the resident did not receive her preference. EI #3 was asked who was responsible for assuring the food preferences were honored. EI #3 replied sometimes the Certified Nursing Assistants will let us know, and at times the residents will let us know. EI #3 added, the preferences were on the diet card, when the dietary aide prepared the tray they should have gone by the card.

Based on observations, interviews and record review the facility failed to ensure the Pharmacy reconciled Resident Identifier (RI) #17's Insulin order on 4/25/16, to match the new documented Physician order. This affected one of 25 observations of medication administration during the survey. Findings Include: A facility Policy Titled: Medication Administration-General Guidelines .Procedures 1. Medications are administered only by licensed nursing, medical, pharmacy . 2. Medications are administered in accordance with written orders of the attending physician . 16. Read medication label and compare with medication administration record . RI #17 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 09/13/16, at 4:00 p.m. the surveyor observed Employee Identifier (EI) #one preparing to administer Humalog Insulin to RI #17. She prepared 8 units of Insulin as documented on the Medication label and administered the Insulin to RI #17. During the reconciliation of the medication pass observation the surveyor observed the Physician order [REDACTED].HUMALOG 100 UNITS/ML VIAL GIVE 12 UNITS SUBQ TID (three times a day) AC (before meals) . The MAR also documented .HUMALOG 100 UNITS/ML VIAL GIVE 12 UNITS SUBQ TID AC .Order Date: 4/25/16 .The original documented order for 4/25/16 documented .1. D/C Humalog insulin 8 U SQ TID AC 2. Humalog Insulin 12 u SQ TID AC . A review of the original Physician orders [REDACTED]. An interview was conducted with EI #2 Director of Nursing on 09/14/16, at 2:00 p.m. EI #2 was asked who was responsible for reconciling Physician orders, Medicaiton Administration Records (MARS) and labels on the medications. She replied the night shift Nurses, the Nurse giving the medication and the Pharmacy. EI #2 was asked what the potential for harm was if the Physician order, MAR and the label on the medications have discrepancies. She replied, the wrong dose of insulin could be given to the resident. EI #2 was asked to observe the original Physician order [REDACTED]. EI #2 stated, yes. A phone interview was conducted with the EI #4 Nurse Consultant Pharmarcist for the facility on 09/14/16, at 2:25 p.m. She was asked who was responsible for assuring medication labels, Physician orders [REDACTED]. EI #4 replied the Pharmacy consultants come to the facility and reconcile all medicaitons once a year and do match backs. The facility should ensure they all match. EI #4 was asked when new orders are sent to the Pharmacy from the facility if the label is made to match the medication with the order. She replied, yes the preparer will match the label with the new order right then. EI #4 was asked if she was aware the Insulin order for RI #17 was changed on 4/25/16 from 8 units of insulin to 12 units of insulin and the label documented 8 units during the survey. She replied no that was not how it should be, the label should match the Physician order [REDACTED].#4 was asked if she was aware RI #17's Humalog insulin label sent on 09/06/16 documented 8 units Subcutaneous three times a day. She replied, no.

Based on observations, interviews and record reviews, the facility failed to ensure batteries for the mechanical lifts were charged and operational for transfers. Resident Identifier (RI) #7, an alert and oriented resident, who required the use of the lift for transfers, stated sometimes the batteries for the lifts were frequently not charged. This had the potential to effect 22 of 105 residents who require the lifts for transfer. Findings included: A Hoyer Journey manufacturer's manual revealed: . 8. Charging Instructions . 4. Charging in automatic and will fully charge the batteries over a period of eight to twelve hours. Resident Identifier (RI) #7 was admitted on [DATE] with a [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/03/2015 revealed RI #7 had a Brief Interview of Mental Status (BIMS) of 15 indicating he/she was cognitively intact. RI #7 required two plus person extensive assistance with transfers and was frequently incontinent of bladder and always incontinent of bowel. RI #7's physician's orders [REDACTED]. An ADL/MOBILITY Care Plan with a review date of 08/2015 for RI #7 revealed: Hoyer lift x 2 for transfers . An URINARY/BOWEL Care plan with a review date of 08/2015 for RI #7 indicated: . Resident able to voice need to toilet . Observations were made on three of four days of the survey (08/ 5, 08/26/2015 and 08/28/2015) that revealed that two Hoyer lifts were left unplugged, resulting in the batteries not being charged. On 08/26/2015 at 11:43 AM, RI #7 was interviewed. RI #7 was asked how many times did the Hoyer lifts not function properly. RI #7 stated the batteries on the lifts were frequently not charged and on 08/26/2015 the batteries were changed five or six times before they found a battery that was charged enough to transfer me. RI #7 said this occurs day and night. On 08/26/2015 at 8:05 AM, an interview was conducted with EI #6, a Maintenance staff member. EI #6 was asked how many batteries were available for the Hoyer lifts. EI #6, said six or seven batteries. EI #6 asked if the Maintenance Department received complaints regarding batteries not working. EI #6, said yes, because they were not charged correctly. EI #6, was asked who was responsible for ensuring batteries were charged. EI #6, said the nurses and CNAs. On 08/26/2015 at 9:00 PM, an interview was conducted with EI #7, CNA. EI #7 was asked has there ever been a time when using a Hoyer lift that it did not work. EI #7 stated yes because the battery dies sometimes and a new battery has to obtained. On 08/26/2015 at 9:40 PM, an interview was held with EI #s 8 and EI #9, CNAs. Both CNAs were asked if there had ever been a time when the Hoyer lifts did not work. Both CNAs stated there had been times because the batteries had not been charged in order for it to work. On 08/27/2015, at 8:45 AM an interview was conducted with EI #10, LPN(Licensed Professional Nurse)/Staff Educator. EI #10 was asked who was responsible for ensuring the Hoyer lift batteries were charged and working. EI #10 said it was everyone's responsibility. EI #10 was asked if it was an acceptable practice of this facility for lift batteries not to be charged and not working. EI #10 said no this is not acceptable. (This deficiency is being written as a result of complaint/ report #AL 196)

Based on observation, interviews and record reviews, the facility failed to ensure Employee Identifier (EI) #11, Registered Nurse (RN), closed the Medication Administration Record (MAR) and entered an unsampled resident's room and closed the door. This affected one of four medication nurses observed during medication pass on 8/26/15. The facility further failed to ensure staff pulled RI #6's privacy curtain when administering an insulin injection while RI #6's roommate was present. This was observed one of four days of the survey. Findings Include: A review of the facility's Medication Pass Procedure titled, Know ORDER, MAR and MED Label MATCH without a date revealed: . 5. Cover MAR if cart is unattended . On 8/26/15 at 8:15 AM, the surveyor observed EI #11, during medication pass, to enter and unsampled residents room and close the door while leaving the MAR open on the medication cart. An interview was conducted with EI #11 on 8/26/15 at 8:20 AM. EI #11 was asked if she left the MAR open when entering the unsampled resident's room. EI #11 stated that she forgot to shut it. EI #11 was asked what was the potential harm of leaving the MAR open when away from the medication cart. EI #11 replied someone could see the name of the resident and medications the resident is on. EI #11 was asked what does the facility's policy/procedure say about leaving the MAR open when away from the medication cart. EI #11 said the facility policy/procedure says to close the MAR when away from the medication cart. An interview was conducted with the Director of Nursing (DON) EI #1, on 8/27/15 at 8:00 AM. EI #1 was asked what does the facility's policy/procedure say about leaving the MAR open when the medication cart is unattended. EI #1 said if the nurse is out of sight of the medication cart, the MAR should be covered or closed. EI #1 was asked if it was an acceptable practice for the medication pass nurse to leave the MAR open when the medication cart is unattended. EI #1 stated, No. EI #1 was asked what was the potential harm of leaving the MAR open on the unattended medication cart. EI #1 said the MAR is confidential information another person could see and it would be a Health Insurance Portability and Accountability Act (HIPAA) violation. 2. RI #6 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a document titled Physician Orders for the month of August 2015 revealed the following: .[MEDICATION NAME] R INSULIN 6UNITS (6 UNITS) TID (three times daily) AC( before meals) . On 8/26/15 at 12:05 PM, an RN, EI #2, administered RI #6's insulin while the roommate was present. EI #6 did not pull RI #6's privacy curtain. A review of the most recent Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/28/2015, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating that resident was cognitively intact. On 8/26/15 at 12:45 PM, an interview was conducted with RI #6. RI #6 was asked did EI #2 RN, pulled RI #6's privacy curtain when giving medicines. RI #6 replied, I didn't pay it any attention but she just closes the door. She doesn't worry about the curtains cause it's just me and my roommate. On 8/28/15 at 8:09 AM, an interview was conducted with RI #6. RI #6 was asked how did it make him/her feel when EI #2 did not pull the privacy curtain when giving his/her medication. RI #6 replied, he/she was used to getting insulin and medicine without the nurse pulling the privacy curtain, but the nurse would close the door. On 8/28/15 at 9:45 AM., EI #2 was asked should the privacy curtain be pulled when providing nursing care to resident if another resident is present. RI #2 stated the privacy curtain should be pulled when providing an injection and any procedure that exposes the resident. EI #2 stated she did not pull RI #6's privacy curtain during the insulin injection because she was nervous. EI #2 was asked what was the potential harm in not pulling the privacy curtain when administering injections and medications to residents while there roommates are present in the room. EI #2 stated dignity and privacy for the resident.

Based on observation and interview, the facility failed to ensure that staff knocked on Resident Identifier (RI) #13's door prior to entering. This affected one of 18 sampled residents. Findings included: RI #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a most recent Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/17/15, revealed RI #13 had long and short term memory problems and was moderately impaired in daily decion making. On 8/26/15 at 3:40 PM, a Certified Nursing Nursing (CNA) was observed entering RI #13's room without knocking. An interview was conducted on 8/26/15 at 4:00PM with EI #12, a CNA. EI #12 was asked if she knocked on RI #13's door prior to entering. EI #12 stated, no. EI #12 was asked what was the facility's policy and procedure regarding entering a resident's room. EI #12 stated that staff was to knock and tell them who they were. EI #12 was asked why should staff knock on resident's doors prior to entering. EI #12 explained that the resident may be scared and may not know that person. EI #12 was asked if that was what she did. EI #12 stated, No Ma'am. EI #12 was asked what was the potential harm in not knocking on residents doors prior to entering. EI #12 explained they may be getting dressed or may be in the bathroom. EI #12 stated it was their privacy. On 8/27/15 at 10:28 AM, an interview was conducted with the Director of Nursing (DON), EI #1. The DON, EI #1 was asked what was the policy and procedure regarding entering resident's rooms. EI #1 explained that staff was to knock and wait for an answer. EI #1 was asked why should staff knock on resident's doors prior to entering. EI #1 explained for privacy, dignity and respect and letting residents know that staff were entering their room. EI #1was askes what was the potential harm in staff not knocking on doors prior to entering residents' rooms. EI #1 explained that she did not know if it was harmful, just respect for staff to enter because the resident may be startled.

Based on an observation, interviews and record reviews, the facility failed to ensure a Registered Nurse, Employee Identifier (EI) #11, locked the medication cart prior to entering an unsampled resident's room. After entering RI #11's room, EI #11 closed the door, leaving the medication cart unattended and unsecured. According to the facility's policy and procedure on medication administration, the medication cart should be closed and locked when out of sight of the nurse. This affected one of four medication nurses observed during medication pass on 08/26/2015. Findings included: A review of the facility's Medication Administration Policy titled, .MEDICATION ADMINISTRATION - GENERAL GUIDELINES dated 2011 revealed: . 11. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse . On 08/26/2015 at 8:15 AM, the surveyor observed EI #11 during medication pass enter an unsampled resident's room and closed the door. The medication cart was left unlocked. An interview was conducted with EI #11 on 08/26/2015 at 8:20 AM. EI #11 was asked if she left the medication cart unlocked when entering the resident's room. EI #11 stated, I forgot to lock it. EI #11 was asked what was the potential harm of leaving the medication cart unlocked when away from the medication cart. EI #11 replied someone could get into the cart and take the medications. EI #11 was asked what does the facility's policy about locking the medication cart. EI #11 stated the facility policy says to lock the medication cart while away. An interview was conducted with the Director of Nursing (DON), EI #1 on 08/27/2015 at 8:00 AM. EI #1 was asked what does the facility's policy say about locking the medication cart when the cart is unattended. EI #1 said if the nurse is out of sight of the medication cart, the medication cart should be locked. EI #1 was asked if it was an acceptable practice for the medication nurse to leave the medication cart unlocked when unattended. EI #1 stated, No. EI #1 was asked what was the potential harm of leaving the medication cart unlocked when the cart is unattended. EI #1 said it was a risk for another resident, visitor, or employee to get inside the medication cart.

Based on observations, interviews and record review, the facility failed to ensure two Certified Nursing Assistants (CNAs), Employee Indentifer (EI) #13 and #14 washed their hands after removing their gloves during incontinence care for Resident Identifier (RI) #13 on 08/27/2015. RI #13 has a history of Urinary Tract Infections. This affected one of three residents observed for incontinent care. Findings included: A review of Potter & Perry, FUNDAMENTALS OF NURSING, 8th Edition, Chapter 28, Infection Prevention and Control, page 419 indicated, . Change gloves and perform hand hygiene between tasks and procedures on the same patient after contact . A review of the CDC Centers for Disease Control and Prevention for Hand Hygiene Basics revealed, . Healthcare providers should practice hand hygiene at key points in time to disrupt the transmission of micro organisms to patients including; after contact with blood, body fluids, or contaminated surfaces (even if gloves are worn); . before invasive procedures; and after removing gloves (wearing gloves is not enough to prevent the transmission of pathogens in healthcare settings) . RI #13 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #13's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/17/2015 revealed RI #13 was moderately cognitively impaired for daily decision making. RI #13 was totally dependent on staff for activities of daily living and always incontinent of bowel and bladder. RI #13's B &B (Bowel and Bladder) care plan, with a Problem Onset date of 04/08/2012 documented, Altered B & B status related to being totally incontinent of bladder and bowel . Hx (History) of UTI's (Urinary Tract Infection) . On 08/27/2015 at 9:20 AM, incontinent care was observed on RI #13. Certified Nursing Assistants (CNA) EI #13, and EI# 14 performed incontinent care on RI #13. Both CNAs changed their gloves, but did not wash their hands at any time after cleaning urine and stool from RI #13. EI #13 applied skin barrier cream to RI #13's perineal and buttocks and applied a clean incontinent brief without washing her hands. On 08/27/2015 at 10:28 AM, an interview was conducted with EI #14, an CNA. EI #14 was asked at what time during incontinence care should hands be washed. EI #14 said before and after care, while cleaning a resident, and after finishing the care for the resident. EI #14 was asked if she washed her hands during RI #13's incontinence care. EI #14 said she only washed her hands before starting the incontinence care and after incontinent care was completed. EI #14 was asked what was the potential harm for not washing her hands during incontinence care. EI #14 stated it could cause an infection. On 08/27/2015 at 10:32 AM, an interview was conducted with EI #13, a CNA. EI #13 was asked at what time during incontinence care should hands have been washed. EI #13 said before and after care, cleaning the resident and finishing the care. EI #13 was asked did she wash her hands during RI #13's incontinence care. EI #13 said no because she forgot. EI #13 was asked what was the potential harm to the resident when hands are not washed during incontinence care. EI #13 stated it could cause infection. On 08/28/2015 at 9:03 AM, an interview was conducted with EI #1, Director of Nursing (DON). EI #1 was asked when should hands be washed during incontinence care. EI #1 said when entering the room before gloving and anytime gloves are changed. EI #1 was asked if it was an acceptable practice of that facility for a CNA to clean urine and stool during incontinence care, apply skin cream and a clean brief and not wash their hands. EI #1 said, no, this could cause a risk of infection.

Based on observation and interview, the facility failed to post notice of availability as to where the most recent survey of the facility results were located. This deficient practice was observed three of four days of the survey. This had the potential to affect all residents who resided in the facility. Findings included: On tour of the first floor on 8/25/2015 at 5:55 PM, 8/26/15 at 6:20 PM, and 8/28/2015 at 4:00 PM, there were no posting of where the survey results were located. On 8/28/15, an interview was conducted with EI #1 (Employee Identifier) DON (Director of Nursing). EI #1 was asked who was responsible for placing a notification of where the survey results were posted, letting the residents know where to find the survey results. EI #1 replied the DON. EI #1 was asked where in the facility was notification of the survey results posted. EI #1 replied, she did not know. EI #1 was asked where were the state results located. EI #1 stated the state results were located near the elevator, which as across from the resident's name board. EI #1 was asked was there a notification sign letting the residents know where the book was located. EI #1 replied there was no sign. EI #1 was asked were the state results easily accessible to the residents. EI #1 replied, If they do not go to the elevator they would not see it. EI #1 was asked why was there no notification sign letting the resident know where they could find the state results. EI #1 replied, she thought it was accessible.