Every finding on record at Crowne Health Care of Mobile

Based on observations, interviews, the 2022 United States (U.S.) Food and Drug Administration (FDA) Food Code, and the facility's policies for DISH SCRAPING and Personal Hygiene Training, the facility failed to prevent the potential for cross contamination by allowing the following:drainage pipes from the prep sink, the three-compartment sink, and the dishwashing machine to extend into the floor drains, insulated coffee cups with stain build-up to be used for service to residents, andmale staff with facial hair to work in the kitchen on 08/25/2026 without facial hair restraints. This had the potential to affect all residents receiving meals from the facility's kitchen, 123 of 123 residents. Findings Include: 1. The 2022 U.S. FDA Food Code included: . 5-402.11 Backflow Prevention. (A) . a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed . During an observation in the dish room on 08/24/2026 at 11:30 AM, the drainpipe from the 3-compartment sink and the drainpipe from the dishwashing machine were each extending into a floor drain, which had a raised segment. When questioned what would happen if the floor drain overflowed, the Dietary Manager (DM) said it would cause a backup, backflow. On 08/24/2026 at 11:33 AM, the food service management company's District Manager stated the drainpipe should end one-half inch above the floor drain to prevent backflow. 2. An undated facility's policy for DISH SCRAPING, included: . PROCEDURE: . 5. Dishware with stubborn food soil . shall be presoaked in a dish sink to loosen dirt prior to ware washing . The 2022 U.S. FDA Food Code included: . 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils.(A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch . During an observation on 08/25/2026 at 2:05 PM, eight insulated coffee cups were observed on top of Unit 1's second cart for use in service. One of the eight cups was badly stained inside the cup. On 08/25/2026 at 2:06 PM, two of seven insulated coffee cups were observed on top of Unit 1's first cart, which had built-up stains inside the cups. On 08/26/2026 at 12:20 PM, the Dietary Manager (DM) was interviewed. The DM said the kitchen employees inspect and monitor the insulated coffee cups for stain or residue build-up once a week. When asked what the potential problem with a stain build-up in the coffee cups, the DM responded that it could cause bacteria and the residents could get sick. On 08/26/2026 at 2:27 PM, the Registered Dietitian (RD) said a stain build-up in the coffee cups had the potential for making residents sick. 3. Review of the facility's policy for Personal Hygiene Training, dated 2013, included: . Procedure . 5. Keep beards and mustaches covered. The 2022 U.S. FDA Food Code included: . 2-402.11 Effectiveness.(A) . FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES . On 08/25/2026 at 12:30 PM, the Cook/Aide was observed entering the kitchen and walking to the middle of the kitchen without wearing a hair net or facial hair restraint and carrying a personal slushie drink with a straw.On 08/25/2026 at 1:02 PM, a Dietary Aide with a short, full beard and mustache was observed in the kitchen without wearing a facial hair restraint. During the same period of time, the Cook/Aide was observed assisting on the hot side of the tray-line. The Cook/Aide was wearing a surgical mask positioned below his upper lip, leaving his mustache uncovered. There was no beard or mustache restraint observed on the Cook/Aide while he assisted with the tray-line. On 08/25/2026 at 1:16 PM, the Dietary Aide was observed not wearing a facial hair restraint while working in the dish room on the clean side, unloading and putting away dishes and trays. During an interview on 08/26/2026 at 12:20 PM, the DM was asked what was the facility policy regarding hair and facial hair restraints for dietary staff. The DM stated the facility requires dietary staff to wear hair restraints that cover their hair, including beards. When asked if there were any employees with beards or facial hair, who were required to wear facial hair restraints, the DM replied the Dietary Aide did occasionally have facial hair. The DM said the employees were trained on this requirement. The DM said she monitored staff to make sure hair/facial hair restraints were worn appropriately. The DM was asked if the Dietary Aide and the Cook/Aide were trained on the facility policy and the DM stated yes. When questioned, the DM said she saw the two employees not wearing facial hair restraints while they worked in the kitchen on 08/25/2026. The DM also said she guess it did not register to them that they needed a facial restraint for their mustaches. The DM said the problem with not wearing facial hair restraints was that hair could get in the food. The DM further said this could potentially affect the residents due to bacteria making the residents sick. During a telephone interview on 08/26/2026 at 2:27 PM, the Registered Dietitian said staff with facial hair working in the kitchen without facial hair restraints/beard protectors could be a hygiene concern and could result in hair getting in the residents' food. The RD further said this could result with facial hair entering food and could result in the residents' getting sick.

Based on a test tray observation, Resident Council Meeting, interviews, and the facility's policy for Conducting Test Trays, the facility failed to ensure Ground Beef and Spanish [NAME] entree served for lunch on 08/26/2026 was at an appetizing temperature. This had the potential to affect all residents served a Mechanical Soft Diet, 36 of 123 residents receiving meals from the kitchen. Findings Included: An undated facility's policy for Conducting Test Trays, included the following; . POLICY: Test trays will be completed .PURPOSE: To assure meal trays are delivered to residents in a timely manner, assuring food is at the proper temperature and quality when it is served to the patient . During the Resident Council Meeting on 08/25/2026 at 10:30 AM, two residents, who eat in their rooms, complained of cold food. During an observation on 08/25/2026 at 1:56 PM, a test tray was sampled and tasted. The Mechanical Soft Diet's Ground Beef and Spanish [NAME] entree was not warm to taste. Margarine placed on top of the Ground Beef and Spanish [NAME] entree did not melt. The Dietary Manager was interviewed on 08/25/2026 at 12:25 PM. The Dietary Manager said residents receiving cold food that was supposed to be hot could cause them to get sick. The Dietary Manager further said it was a dignity thing; they should be getting hot food, they get real upset when the food was not hot. The Registered Dietitian (RD) was interviewed on 08/25/2026 at 2:22 PM. The RD said the problem with residents receiving cold food that it was supposed to be hot and they may not eat it and it could lead to weight loss.

Based on interview, record review, and review of the Alabama Department of Mental Health Preadmission Screening and Resident Review (PASARR) Level I Screening and Determination documentation, the facility failed to ensure compliance with PASARR requirements for Resident Identifier (RI) #16 by failing to ensure completion of the required PASARR Level II Evaluation. RI #16 had a diagnosis of Paranoid Schizophrenia. Despite the Level I screening dated 11/05/2025 identifying the need for a Level II Evaluation, the required evaluation was not completed. The facility's failure to ensure completion of the required PASRR Level II Evaluation affected RI #16, one of three residents reviewed for PASARR compliance. This deficient practice placed RI #16 at risk for not being comprehensively evaluated to determine the need for specialized services and support to address RI #16 mental health needs, as required under PASARR regulations. Findings Include:RI #16 was admitted to the facility on [DATE] with a diagnosis of Paranoid Schizophrenia. The PASARR Level I Determination dated 11/05/2025 documented the following: Quality Assurance (QA) review, the nursing facility applicant required a PASARR Level II Evaluation due to documented serious mental illness diagnoses, including Schizophrenia and Paranoid Schizophrenia. The determination further indicated the resident met the criteria for a Categorical Determination for Convalescent Care and could be admitted to the nursing facility while the required PASARR Level II Evaluation was completed. The PASARR Level I Determination further stated to comply with Federal and State PASARR regulations, the admitting nursing facility must report the resident's admission to the Omnibus Budget Reconciliation Act Of 1987 (OBRA) PASARR Office at the time of admission to initiate the PASARR Level II Evaluation process and determine eligibility for specialized services.On 08/27/2026 at 9:15 AM, an interview was conducted with the Social Worker (SW). The SW acknowledged that RI #16's PASARR Level II follow-up had not been completed timely. The SW stated additional documentation had been requested for completion of the Level II review and that the process had not been followed through by the previous SW. The SW confirmed that RI #16 had a diagnosis of Paranoid Schizophrenia and required PASARR Level II follow-up. The SW stated the omission was identified on 08/26/2026, when the resident's PASARR information was reviewed following the surveyor's inquiry. The SW indicated that follow-up on Level I recommendations were necessary to ensure appropriate care was provided. She acknowledged that failure to complete recommended follow-up for a resident with mental illness could compromise residents' safety. During the interview with the SW, the Administrator (ADM) reported that on 11/05/2025, the previous SW had not followed the PASARR process to completion. The ADM reported that OBRA indicated additional medical documentation was required and that OBRA was awaiting the medical documentation for review. On 08/27/2026 at 10:58 AM, an interview was conducted with the Director of Nursing (DON). She acknowledged that the PASARR Level II had not been completed within the required timeframe. The DON stated additional paperwork had been requested, and the facility did not send the requested paperwork in a timely manner.

Based on observation, interviews, a facility policy titled, Medication Storage, Storage of Medications and Biologicalsthe facility failed to ensure expired medications were not stored in the Unit Two medication storage room and Unit Two Medication Cart One. This deficient practice was evidenced by 11 expired medications identified in the Unit Two medication storage room and one expired medication identified on Unit Two's medication cart one.The medications included:One bottle of Lactulose (also known as Enulose) with an expiration date of 07/20/2026 and opened date of 08/2023;10 bottles of Enulose with expiration dates ranging from 06/2025 through 12/2025;One tube of Triamcinolone Acetate with an expiration date of 12/2025. This affected one of two medication carts and one of two medication storage rooms reviewed during survey.Findings Included:A review of the facility policy titled Medication Storage, Storage of Medications and Biologicals, dated 01/2012 revealed the following:PolicyMedications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations .Procedures .11. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are removed from stock, disposed of according to procedures for medication disposal, .13. Medication storage conditions are monitored on a routine basis and corrective action taken if problems are identified. On 08/26/2026 at 10:54 AM, the Unit Two medication storage room was checked with Unit Manager (UM) #9. The following expired medications were identified: Lactulose (Enulose)- One bottle, expiration date 07/22/2026 was found on Unit Two, medication cart one. The following expired medications were found in the medication storage room for Unit Two; Enulose - Three bottles, expiration date 12/2025. Enulose - Three bottles, expiration date 11/2025. Enulose - Three bottles, expiration date 10/2025. Enulose - Two bottles, expiration date 06/2025. Triamcinolone Acetate (cream) - one tube, expiration date 12/2025.On 08/27/2026 at 10:40 AM, an interview was conducted with Licensed Practical Nurse (LPN) #10 regarding an expired medication identified during the Surveyor's audit on 08/26/2026. LPN #10 confirmed the medication was Lactulose, which had been opened on 08/2023. The medication was located on Unit Two, medication cart one, drawer three. LPN #10 acknowledged the medication had been expired for approximately eight months and remained accessible and available for administration to residents because it was stored on the medication cart. LPN #10 explained that all nurses were responsible for checking medication expiration dates and that the 11:00 PM to 7:00 AM shift was designated to check the medication carts every Wednesday. LPN #10 indicated that (Company Name) Pharmacy had completed the last medication cart inspection approximately two weeks ago and the expired Lactulose must not have been identified during that routine inspection.On 08/27/2026 at 11:00 AM, an interview was conducted with the Pharmacist. The Pharmacist reported that medications had expiration dates printed on their packaging and that the expiration dates were required to be followed as part of the regulation. The Pharmacist confirmed that expired Lactulose and Triamcinolone Acetate should have been removed from the medication cart immediately upon identification and placed in the designated medication destruction boxes.On 08/27/2026 at 11:27 AM, an interview was conducted with Unit Manager #9 regarding the facility's process for identifying and removing expired medications. Unit Manager #9 explained that all nurses were responsible for ensuring Lactulose and Triamcinolone Acetate were stored appropriately and were not expired. Unit Manager #9 explained that medication carts, treatment carts, medication rooms, refrigerators, and other medication storage areas were checked every Wednesday for expired medications. Unit Manager #9 said expired medications identified in the Unit Two, medication storage room, included three bottles of Enulose with an expiration date of 12/2025, three bottles of Enulose with an expiration date of 11/2025, two bottles of Enulose with an expiration date of 10/2025, two bottles of Enulose with an expiration date of 06/2025, and Triamcinolone Acetate (Cream) with an expiration date of 12/2025.

Based on observations, interviews, record review, and facilities policies titled, Glucometer Disinfection, Medication Administration, and Hand Hygiene Policy and Procedure, the facility failed to ensure infection prevention and control practices were followed during resident care on 08/24/2026 and during medication administration pass on 08/26/2026.Specifically: 1) The facility failed to ensure Resident Identifier (RI) #40's oxygen humidifier water bottle was maintained in a sanitary condition. On 08/24/2026 a spider was observed in the empty humified water bottle and the oxygen mask's bag was on the floor.This affected one of 26 sampled residents.2) The facility failed to ensure Licensed Practical Nurse (LPN) #14 did not place a soiled tray on top of the medication cart after checking RI #25's blood glucose level, failed to allow the glucometer to air dry before being stored, and failed to wash his hands after removing the contaminated gloves.3) The facility failed to ensure LPN #13 performed hand hygiene properly and per facility's policy. LPN #13 did failed to use a paper towel to turn off the faucet after performing hand hygiene after administering medications to RI #96. These deficient practices affected two out of five nurses observed during medication administration. Findings Include: 1) A review of the facility policy titled Policy and Procedure for Oxygen Administration dated 07/2016 indicated:Purpose: To administer oxygen to the resident as ordered by the physician and as indicated on an as needed basis for shortness of breath.Equipment:* Oxygen Concentrator with filter. Nasal cannula or facemask as ordered with appropriate tubing Humidifier Bottle . or Pre-filled Humidifier water bottle. Oxygen in use sign. Mole skin for ear piecesProcedure: . Change the humidifier and cannula/mask tubing at least weekly, date and initial the bottle on 11-7 shift on Monday night and prn (as needed) whenever it is changed. RI #40 was admitted to the facility on [DATE] with diagnoses to include Sarcoidosis of Lung. A review of physicians orders indicated effective 02/28/2025 O2 (Oxygen) at 1L (liter)/min (minute) per nasal cannula as needed for comfort. Another physicians order effective 02/28/2025 indicated O2 at 2L/min nasal cannula as needed for SA02 (Oxygen Saturation) less than 90%.On 08/24/2026 at 12:30 PM an observation was made in room of RI #40. He/she was lying in bed with oxygen on per nasal cannula at 2/L. The humidifier water bottle was opened and there was no water in the bottle. The nasal cannula's bag was on the floor.On 08/24/2026 at 1:50 PM surveyor had LPN #15 accompany surveyor to room of RI #40 to assess the oxygen humidifier water bottle. She observed the bag on the floor and the humidifier bottle was empty. She stated she would get some water to add to it. LPN #15 returned to the room with a bottle of sterile water. LPN #15 poured water in the reservoir to rinse the bottle out and a small spider was in the bottle. She poured out the spider and proceeded to fill the bottle with sterile water.On 08/24/2026 at 1:59 PM during an interview with LPN #15, surveyor asked what was the concern with RI #40's mask bag being on the floor, she stated it made it unsanitary. LPN #15 was asked the concern of a spider being in RI #40's humidified water bottle and she stated it was not sanitary.On 08/27/2026 at 2:39 PM during an interview with Registered Nurse, Infection Control Preventionist, (RN/IP) #16 she was asked the potential harm of the spider in the water bottle and she stated infection control. 2) RI #25 was admitted to the facility on [DATE] with diagnoses to include Diabetes Mellitus.On 08/26/2026 at 12:23 PM LPN #14 was observed performing a glucometer check on RI #25. LPN #14 placed the barrier tray on RI #25's bedside table. LPN #14 obtained RI #25's glucose level, placed the soiled lancet, bloody test strip, and glucometer on the tray. LPN #14 walked back to the medication cart with his soiled gloves on and place the barrier tray on top of the medication cart. LPN #14 disposed of the lancet and test strip into the sharps container, wiped the glucometer, and placed the wet glucometer into the medication cart. LPN #14 removed his gloves and did not perform hand hygiene. On 08/27/2026 at 1:43 PM during an interview with LPN #14 he was asked what procedure he used on 08/26/2026 when he performed the glucose check on RI #25. LPN #14 stated after performing the glucose check he returned to the medication cart and replaced the soiled tray on the medication cart. LPN #14 said he should have thrown the trash away and not placed the barrier tray back on the medication cart. When asked what he should have done after sanitizing the glucometer, LPN #14 stated he should have placed it on a paper towel for barrier and allowed it to air dry before placing it back into the cart. On 08/27/2026 at 2:39 PM during an interview with RN/IP #16, she was asked what the potential harm was when staff placed soiled tray and other items including glucometer on medication cart. She stated the potential harm was the infectious material and blood. RN/IP #16 stated, after LPN #14 cleaned the glucometer he should have placed it on a barrier and allowed to air dry for three minutes afterwards. RN/IP #16 said in addition, LPN #14 should have washed his hands after removing his gloves. 3) Review of a facility policy titled, Medication Administration with a revised date of 02/2021 indicated:6.2: MEDICATION ADMINISTRATION-GENERAL GUIDELINESPolicyThe facility maintains equipment and supplies necessary for the preparation and administration of medications to residents.6. Cleanse hands with soap and water before handling medication and before direct contact with resident. A review of Hand Hygiene Policy and Procedure with a revised date of 03/2023 indicated:Purpose: Hand hygiene is recommended to reduce the transmission of infection to residents, staff and visitors in the health-care setting.Procedure: . 6. Hand hygiene technique with soap and water: a. Wet hands with water. Avoid using hot water because repeated exposure to hot water may increase the risk of dermatitis. b. Apply enough soap to cover all hand surfaces. c. Rub hands together vigorously for at least 15-20 seconds . d. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet. RI #96 was admitted to the facility on [DATE] with diagnosis to include Chronic Obstructive Pulmonary Disease.On 08/26/2026 at 9:15 AM during a medication pass observation, LPN #13 was observed administering medication to RI #96. After administering the medication, LPN #13 washed her hands then turned off the faucet with her bare hands and did not use a paper towel.On 08/27/2026 at 2:39 PM during an interview with RN #16/IP she was asked what was the concern when LPN #13 turned off the water faucet with her bare hands after she had washed her hands. RN #16/IP said infection control.

Based on observations, record review and interviews, the facility failed to ensure Employee Identifier (EI) #5, the treatment nurse, did not date and initial Resident Identifier (RI) #67's dressings after the dressings had been placed over the resident's wounds during the wound care observation on 09/18/19. This affected RI #67, one of one residents observed for wound care. Findings Include: RI #67 was admitted to the facility on [DATE] and readmitted on [DATE], with the [DIAGNOSES REDACTED]. On 09/18/19 at 11:11 a.m., the surveyor observed EI #5 provide wound care for RI #67. EI #5 removed the dressings from RI #67's left ischial and sacrum areas, provided wound care to both wounds, covered the wounds with border foam dressings, then wrote the date and initialed the dressings with a black marker. EI #5 then cut the dressing from RI #67's left lower extremity, provided wound care to RI #67's left heel and left lateral ankle, covered the wounds and wrapped them with Kling wrap. After wrapping with Kling wrap, EI #5 placed silicone tape over the wrap and wrote the date and initialed the dressing with a black marker. EI #5 proceeded to clean the wound to RI #67's right inner knee, provided wound care, placed a border foam dressings over the wound then wrote the date and initialed the dressing with a black marker. EI #5 cut the dressing from RI #67's right lower extremity, provided wound care to the wounds on the right lower extremity, covered the wounds with Kling wrap, placed silicone tape over the Kling wrap then wrote the date and initialed the dressing with a black marker. On 09/19/19 at 11:57 a.m., the surveyor conducted an interview with EI #5. The surveyor asked EI #5 what should she have done before placing the dressings over RI #67's wounds. EI #5 said she should have put the date on the dressings prior to putting the dressings on RI #67's wounds. On 09/19/19 at 12:08 p.m., the surveyor conducted an interview with EI #6, the Licensed Practical Nurse (LPN)/Infection Control Nurse. When asked what should the treatment nurse have done before placing the dressings on RI #67's wounds, EI #6 said the dressings should have already been dated.

Based on interviews, record review, a facility policy titled, Grievances/Concerns and review of Resident Identifier (RI) #644's RESIDENT /SPONSOR CARE PLAN INPUT SHEET, the facility failed to promptly ensure a Grievance/Concern Report was initiated when RI #644's sponsor brought a concern/grievance to the facility on [DATE]. This affected RI #644, one of two residents sampled for grievances. Findings Include: RI #644 was admitted to the facility on [DATE]. Review of a facility policy titled, Grievances/Concerns with a revised date of 11/16, revealed the following: . POLICY: . The Facility will promptly investigate grievances/concerns . in an effort to seek a resolution . PR[NAME]EDURES: . 2. The Facility's Social Services Director will serve as the designated Grievance Official with the responsibility for overseeing the grievance process; receiving and tracking grievances through to their conclusion . 7. Upon any grievance/concern . either the individual making the grievance/concern of the Facility staff member receiving the complaint is responsible for initiating the Grievance/Concern Report, detailing the concern . 8. the Grievance Official will distribute the Grievance/Concern Report to the appropriate department or individual for investigation and intervention . 11. The Grievance Official or designee will maintain all Grievance/Concern Reports . 14. All Grievance/Concern Reports will be recorded on the Facility's Grievance/Concern Log . A review of RI #644's RESIDENT/SPONSOR CARE PLAN INPUT SHEET dated 05/14/19, documented: . Resident/Sponsor Concerns: Family came to facility and saw resident hunched over with requests to be put back in bed .Was grievance form filled out? Yes was checked on the sheet. A review of the facility's Grievance /Concern Log for (MONTH) 2019, revealed there was no evidence a Grievance/Concern report had been completed when RI #644's sponsor brought their grievance/concern to the facility on [DATE]. On 09/19/19 at 11:48 a.m., the surveyor conducted an interview with Employee Identifier (EI) #3, the Director of Social Services. The surveyor asked EI #3 who would have filed out the Grievance/Concern report from the 05/14/19 meeting concerning RI #644. EI #3 said that would have been him. The surveyor asked EI #3 what was the purpose for filling out a Grievance/Concern report. EI #3 said the purpose was to address any concerns with the residents or sponsors to improve their stay at the facility. When asked if he was able to locate a Grievance/Concern report for RI #644, EI #3 said no. On 09/19/19 at 12:29 p.m., the surveyor conducted an interview with EI #2, the Director of Nursing (DON). The surveyor asked EI #2 what was the time frame for responding to a person's grievance. EI #2 said the grievance should be written up immediately and an investigation started. When asked if she recalled any Grievance/Concern report being completed for RI #644, EI #2 said no. This deficiency was written as a result of the investigation of complaint/report #AL 346.

Based on observation, record review and interviews, the facility failed to ensure Employee Identifier (EI) #5, the treatment nurse, cleaned/sanitized a pair of scissors after removing the scissors from the pocket of her uniform, and before using the scissors to cut a Kling wrap that was on the inside of Resident Identifier (RI) #67's sacral pressure ulcer during the wound care observation on 09/18/19. This affected RI #67, one of one residents observed for wound care. Findings Include: RI #67 was admitted to the facility on [DATE] and readmitted on [DATE], with the [DIAGNOSES REDACTED]. RI #67's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 08/01/19, identified RI #67 as having pressure ulcers during this assessment period. On 09/18/19 at 11:11 a.m., the surveyor observed EI #5, the treatment nurse, provide wound care to RI #67's sacrum wound. After removing the dressing from RI #67's sacrum wound, EI #5 provided wound care to the area, removed a pair of scissors from the left pocket of her uniform and without cleaning/sanitizing the scissors, cut a Kling wrap, placing the cut wrap in a cup. EI #5 poured Vashe solution over the cut Kling wrap then placed the cut Kling wrap in RI #67 sacrum wound bed. On 09/19/19 at 11:57 a.m., the surveyor conducted an interview with EI #5. The surveyor asked EI #5 when she provided wound care for RI #67 on 09/18/19, where did she remove the scissors from. EI #5 said her pocket. The surveyor asked EI #5 were the pockets considered a clean or dirty area. EI #5 said dirty. When asked what was there a potential for when using an item from a dirty area to perform wound care with, EI #5 said potential for contamination and infection. On 09/19/19 at 12:08 p.m., the surveyor conducted an interview with EI #6, the Licensed Practical Nurse (LPN)/Infection Control Nurse. The surveyor asked EI #6 what were the pockets of a uniform considered. EI #6 said dirty. When asked what was there a potential for when scissors removed from the pocket of a uniform were used when providing wound care to a resident, EI #6 said infection.

Based on an interview, review of Non-Controlled Record of Medication Destruction forms and a review of a facility policy titled, Disposal of Medications, Non-Controlled Medication Destruction, the facility failed to ensure the (MONTH) 2019, (MONTH) 2019, and (MONTH) 2019, Non-Controlled Record of Medication Destruction forms contained the two required signatures. This was noted on three of the nine months of Non-Controlled Record of Medication Destruction forms reviewed. Findings Include: A review of a facility policy titled, Disposal of Medications, Non-Controlled Medication Destruction, dated 01/12, revealed: .3. The registered nurse and/or pharmacist witnessing the destruction, or their preparation for environmental service pickup, ensures that the following is entered on the Record of Medication Destruction form .[NAME] Signature of witnesses, two witnesses required for non-controlled substances . Review of the Record of Medication Destruction forms for Non-Controlled drugs dated (MONTH) 2019, (MONTH) 2019 and (MONTH) 2019, revealed only one signature. On 09/19/2019 at 10:37 a.m., the surveyor conducted an interview with Employee Identifier (EI) #2, the Director of Nursing (DON). EI #2 was asked when reviewing the Non-Controlled Record of Medication Destruction forms for the months of May, (MONTH) and (MONTH) (all for 2019), how many signatures were noted. EI #2 said one. EI #2 was asked how many signatures were required for the Non-Controlled Record of Medication Destruction forms. EI #2 said two. EI #2 was asked why two signatures were not on the Non-Controlled Record of Medication Destruction forms. EI #2 said she failed to sign them.

Based on observations, interviews, medical record review, and review of the facility's procedure titled Procedure for Diet/Supplement/Thickener Orders Matching the Dietary Tray Card and Matching the Tray Served, the facility failed to ensure Resident Identifier (RI) #48's physician's orders [REDACTED]. This affected one of 41 sampled residents whose physician's orders [REDACTED]. Findings Include: A review of the facility's procedure titled, Procedure for Diet/Supplement/Thickener Orders Matching the Dietary Tray Card and Matching the Tray Served, dated 12/12, revealed the following: . 5. The CNA (Certified Nursing Assistant) serving a meal tray makes sure the tray card matches the food served on the tray and/or obtains any items not served per the tray card. RI #48 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #48's current Annual Minimum Data Set (MDS) assessment, dated 06/09/18, revealed RI #48 had short and long term memory loss and was moderately impaired in cognitive skills for daily decision making. The MDS also documented RI #48 required total assistance with Activities of Daily Living. A review of RI #48's (MONTH) (YEAR)'s physician's orders [REDACTED]. Order Date 8/20/15 . Orders MECHANICAL SOFT DIET - DOUBLE PORTIONS WITH ALL MEALS . A review of RI #48's tray card revealed the following: . DIET: .Double Portion . On 08/15/18 at 1:05 PM, RI #48's lunch meal was observed. RI #48's tray card reflected orders for a mechanical soft diet with double portions. RI #48's tray contained the following items: one milk, one tea, one vanilla ice cream, one small bowl of grits, small portion of chopped fish, one small bowl of slaw approximately three quarters of the way full, and a bowl of cobbler approximately three quarters of the way full. RI #48 was fed the meal by Employee Identifier (EI) #4, Certified Nursing Assistant (CNA), and RI #48 consumed 100% of each item on the tray, except for the slaw. On 08/15/18 at 1:12 PM, during an interview with EI #4, the surveyor asked which food items were provided to RI #48 in a double portion. EI #4 stated, None of (his/her) food. The surveyor asked what does the tray card document that the resident should receive. EI #4 stated the tray card reflected mechanical soft diet with double portions. On 08/16/18 at 1:20 PM, the following items were observed on RI #48's tray during lunch: two milks, small bowl of fried okra, two small bowls of fruit, red beans and rice (covering one third of the plate), a small serving of ground sausage, and one slice of buttered garlic bread. On 08/16/18 at 1:32 PM, during an interview with EI #5, Kitchen Manager, the surveyor reviewed the tray card with EI #5 and asked what the resident should receive on his/her trays for breakfast/lunch/dinner. EI #5 stated, Double portions mechanical soft. EI #5 said the bowl of grits the resident received with lunch on 8/15/18 was four ounces. EI #5 also stated the fruit, if filled to the rim of the bowl, was four ounces. The surveyor informed EI #5 of what RI #48 received for lunch on 08/15/18 and 08/16/18, and asked if the resident received double portions for both lunch meals. EI #5 stated, No, (he/she) did not. EI #5 stated, I was standing and observing when the aide asked me if everything was double portions on the resident's lunch tray for today, and I said double everything, and the aide requested it. The surveyor asked what happened. EI #5 stated when she went back to observe the line, RI #48's extra servings were still on top of the steam line where the plates were issued out. The surveyor asked who was responsible to ensure the residents received what had been recommended based on their tray cards. EI #5 said the Dietary Manager and the Kitchen Manager. The surveyor asked what was the potential harm when tray cards are not followed and the residents did not receive what had been recommended. EI #5 said weight loss.

Based on observations, interviews, medical record review, and review of the facility's procedure titled Procedure for Diet/Supplement/Thickener Orders Matching the Dietary Tray Card and Matching the Tray Served, the facility failed to ensure Resident Identifier (RI) #48 received double portions with all meals, which created the potential for altered nutritional status. This affected one of eight sampled residents reviewed for nutrition. Findings Include: A review of the facility's procedure titled, Procedure for Diet/Supplement/Thickener Orders Matching the Dietary Tray Card and Matching the Tray Served, dated 12/12, revealed the following: . 5. The CNA (Certified Nursing Assistant) serving a meal tray makes sure the tray card matches the food served on the tray and/or obtains any items not served per the tray card. RI #48 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #48's current Annual Minimum Data Set (MDS) assessment, dated 06/09/18, revealed RI #48 had short and long term memory loss and was moderately impaired in cognitive skills for daily decision making. The MDS also documented RI #48 required total assistance with Activities of Daily Living. A review of RI #48's (MONTH) (YEAR)'s physician's orders [REDACTED]. Order Date 8/20/15 . Orders MECHANICAL SOFT DIET - DOUBLE PORTIONS WITH ALL MEALS . A review of RI #48's tray card revealed the following: . DIET: .Double Portion . On 08/15/18 at 1:05 PM, RI #48's lunch meal was observed. RI #48's tray card reflected orders for a mechanical soft diet with double portions. RI #48's tray contained the following items: one milk, one tea, one vanilla ice cream, one small bowl of grits, small portion of chopped fish, one small bowl of slaw approximately three quarters of the way full, and a bowl of cobbler approximately three quarters of the way full. RI #48 was fed the meal by Employee Identifier (EI) #4, Certified Nursing Assistant (CNA), and RI #48 consumed 100% of each item on the tray, except for the slaw. On 08/15/18 at 1:12 PM, during an interview with EI #4, the surveyor asked which food items were provided to RI #48 in a double portion. EI #4 stated, None of (his/her) food. The surveyor asked what does the tray card document that the resident should receive. EI #4 stated the tray card reflected mechanical soft diet with double portions. On 08/16/18 at 1:20 PM, the following items were observed on RI #48's tray during lunch: two milks, small bowl of fried okra, two small bowls of fruit, red beans and rice (covering one third of the plate), a small serving of ground sausage, and one slice of buttered garlic bread. On 08/16/18 at 1:32 PM, during an interview with EI #5, Kitchen Manager, the surveyor reviewed the tray card with EI #5 and asked what the resident should receive on his/her trays for breakfast/lunch/dinner. EI #5 stated, Double portions mechanical soft. EI #5 said the bowl of grits the resident received with lunch on 8/15/18 was four ounces. EI #5 also stated the fruit, if filled to the rim of the bowl, was four ounces. The surveyor informed EI #5 of what RI #48 received for lunch on 08/15/18 and 08/16/18, and asked if the resident received double portions for both lunch meals. EI #5 stated, No, (he/she) did not. EI #5 stated, I was standing and observing when the aide asked me if everything was double portions on the resident's lunch tray for today, and I said double everything, and the aide requested it. The surveyor asked what happened. EI #5 stated when she went back to observe the line, RI #48's extra servings were still on top of the steam line where the plates were issued out. The surveyor asked who was responsible to ensure the residents received what had been recommended based on their tray cards. EI #5 said the Dietary Manager and the Kitchen Manager. The surveyor asked what was the potential harm when tray cards are not followed and the residents did not receive what had been recommended. EI #5 said weight loss.

Based on observation, interview, medical record review and a review of the facility's policies titled, Incontinent Care ., Glove Use and Hand Hygiene, the facility failed to ensure licensed staff washed her hands after removing soiled gloves and before leaving the room while performing incontinence care. Further, licensed staff contaminated the disposable wipes container with soiled gloves while performing incontinence care. This affected Resident Identifier (RI) #43, one of one resident observed during incontinence care. Findings Include: A review of the facility's policy titled, Incontinent Care ., with a revised date of 12/2012, revealed the following: . PR[NAME]EDURE: . 9. Remove and dispose of gloves, wash hands. Apply clean gloves . 12. Remove gloves and wash hands prior to leaving the room. A review of the facility's policy titled, Glove Use, with a revised date of 3/2017, revealed the following: . PR[NAME]EDURE: . 9. Hand washing is necessary when gloves are removed. A review of the facility's policy titled, Hand Hygiene, with a revised date of 3/2017, revealed the following: Purpose: Hand hygiene is recommended to reduce the transmission of infection to residents . Procedure: . 3. Perform hand hygiene . after gloves are removed . RI #43 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #43's Significant Change Minimum Data Set assessment, dated 06/04/2018, revealed RI #43 was totally dependent on staff for toileting and personal hygiene needs. On 08/15/18 at 6:15 PM, the following was observed during incontinent care: Employee Identifier (EI) #7, Licensed Practical Nurse/LPN/Treatment Nurse, removed her gloves after wiping stool from RI #43's buttock and applied a new pair of gloves. EI #7 did not wash her hands after removing soiled gloves. EI #7 removed wipes from the wipe dispenser with soiled gloves. EI #7 wiped stool from RI #43's buttocks, removed her gloves and exited the resident's room to obtain additional supplies. EI #7 did not wash her hands prior to leaving the resident's room. On 08/15/18 at 6:40 PM, during an interview with EI #7, the surveyor asked what should be done after gloves are removed. EI #7 stated, Wash your hands. The surveyor asked was that what she had done every time. EI #7 stated, No. The surveyor asked after wiping stool, and removing gloves, what should be done before leaving the room to go get more supplies. EI #7 stated, Wash my hands. the surveyor asked was that what she had done. EI #7 stated, No, I know I didn't. The surveyor asked what should be done to prevent contaminating the wipes dispenser. EI #7 stated, Should have pulled enough out from the start. The surveyor asked what was the potential for harm. EI #7 stated, Infection. On 08/15/18 at 12:25 PM, during an interview with EI #8, Registered Nurse/Infection Control, the surveyor asked during incontinence care, what should be done after wiping stool from the buttocks and removing gloves. EI #8 stated, Wash your hands. The surveyor asked during incontinence care, after wiping stool and removing gloves, what should be done when you leave the room to go get more supplies. EI #8 stated, Wash your hands, anytime you remove gloves, wash your hands. The surveyor asked during incontinence care, what should be done to prevent contaminating the wipes dispenser. EI #8 stated, Have clean field set up, can pull out several wipes and place them on the clean field. If run out of wipes, remove gloves, wash hands and can go back to dispenser. The surveyor asked what was the potential for harm. EI #8 stated, Don't want to cross contaminate, keep dirty and clean separated.

Based on interview, record review, and review of the facility policy titled Care Planning Policy and Procedure, the facility failed to ensure Resident Identifier (RI) # 1's plan of care to have two people assist with Activities of Daily Living (ADLs) was followed. This deficient practice affected RI #1, one of three sampled residents for whom the the plan of care was reviewed. Findings Include: Review of a facility policy titled Care Planning Policy and Procedure, with a revised date of 07/2011, documented: Policy: The care plan is a guide for all staff on a course of action that will attain or maintain a resident's highest practicable level of well being . RI #1 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #1's comprehensive care plans included a plan for . Resident at risk for falls due to immobility, lack of safety awareness and requires . 2 person assist for transfers with a Problem Onset date of 2/15/2013. This care plan indicated RI #1 required two person assistance for repositioning. A Yearly Minimum Data Set assessment, with an Assessment Reference Date of 10/10/2017, documented RI #1 was totally dependent on two plus staff members for bed mobility, transfers, dressing, toileting, and bathing. On 12/12/2017 the state agency received an anonymous complaint alleging RI #1 sustained a fracture when the facility staff dropped him/her. The facility told the complainant they would complete an investigation into the occurrence. Review of the facility's investigative summary related to the incident involving RI #1, dated 12/01/2017, revealed the following: .Our investigation determined that at approximately 11:30 a.m. during morning care on 11/26/17, (Employee Identifier (EI) #5, Certified Nursing Assistant) C.N.A. noted (RI #1) to be screaming out when touched as well as swelling to left arm. This was reported to (EI #4, Licensed Practical Nurse), LPN and upon observation from the nurse the resident's left arm was swollen with bruise on the posterior side of the arm. MD (Medical Doctor) was notified and an order for [REDACTED]. On Thursday (11/23) and Friday (11/24), (EI #6), CNA was assigned to (RI #1) on 7-3 shift. (EI #6) admits she turned and repositioned (RI #1) throughout those shifts without assistance from another staff member. On Saturday (11/26) and Sunday (11/27), (EI #5), CNA was assigned to (RI #1) on 7-3 shift and she also admits she turned, bathed, and repositioned (RI #1) without assistance of another staff member . On November 30, 2017, it was determined that (EI #7) was also not following the plan of care when she provided care to (RI #1) on 11/25/17 on 3-11 shift. They admitted to not reviewing (RI #1's) care plan prior to providing care . On 2/14/18 at 9:45 a.m., the surveyor conducted an interview with EI # 6, the CNA that provided care to RI #1 on 11/23/17 and 11/24/17. The surveyor asked EI #6 how many staff should provide care for RI #1. EI #6 replied two. EI #6 admitted she provided care to RI #1 without the assistance of any other staff. On 2/14/18 at 10:25 a.m., the surveyor conducted an interview with EI #3, Registered Nurse Supervisor at the time of the incident involving RI #1. EI #3 said RI #1's plan of care specified two CNAs for his/her care. On 2/15/18 at 8:00 a.m., the surveyor conducted an interview with EI #7, the CNA that provided care to RI #1 on 11/25/17. EI #7 said two staff should provide care to RI #1. ************************************************************* The facility implemented corrective action to prevent recurrence of the identified deficient practice on 12/4/2018. These corrective actions were verified and included the following: (1) On 11/26/17, the facility obtained an x-ray to RI #1's right arm which revealed a fracture. (2) On 11/27/17, the facility reported to Alabama Department of Public Health Online Reporting System the Injury of Unknown Origin concerning RI #1 having a fracture to the left arm. (3) On 11/28/17 through 12/07/17, the facility began In-service training on following a residents plan of care. (4) On 11/29/17, RI #1 received orders for Occupational Therapy. (5) On 12/1/17 the CNAs caring for RI #1 on 11/23/17, 11/24/17, and 11/25/17 were given a written warning on failure to follow RI #1's plan of care (6) On 12/4/17 the facility provided inservice training to staff on ensuring if resident requires two person assist with ADLs, two people must assist. (7) On 12/4/17 the facility added to their QA (Quality Assurance) three programs titled: Following the Plan of Care, Total Care Resident Monitoring Tool, and The Buddy System. After review of the facility's investigation file, in-service/education records, staff interviews, and QA plan, the facility implemented corrective actions from 11/26/2017 to 12/04/2017. The facility will continue to monitor and/or revise their corrective action plan to prevent recurrence and maintain compliance. This deficiencies were written as a result of complaint/report #AL 480.

Based on interviews, record review, and review of the facility's Investigative Summary related to Resident Identifier (RI) #1's left arm fracture, the facility failed to ensure RI #1, a resident at risk for falls who required the assistance of two staff, did not sustain a fracture to the left arm. Interviews with staff caring for RI #1 revealed RI #1 was not assisted by two staff when ADL (Activities of Daily Living) care was provided to the resident on 11/23/17, 11/ 24/17, and 11/25/17. This deficient practice affected RI #1, one of three residents sampled for falls/accidents. Findings include: RI #1 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #1's comprehensive care plans included a plan for . Resident at risk for falls due to immobility, lack of safety awareness and requires . 2 person assist for transfers with a Problem Onset date of 2/15/2013. This care plan indicated RI #1 required two person assistance for repositioning. A Yearly Minimum Data Set assessment, with an Assessment Reference Date of 10/10/2017, documented RI #1 was totally dependent on two plus staff members for bed mobility, transfers, dressing, toileting, and bathing. On 12/12/2017 the state agency received an anonymous complaint alleging RI #1 sustained a fracture when the facility staff dropped him/her. The facility told the complainant they would complete an investigation into the occurrence. Review of the facility's investigative summary related to the alleged incident involving RI #1, dated 12/01/2017, revealed the following: .Our investigation determined that at approximately 11:30 a.m. during morning care on 11/26/17, (Employee Identifier (EI) #5, Certified Nursing Assistant) C.N.A. noted (RI #1) to be screaming out when touched as well as swelling to left arm. This was reported to (EI #4, Licensed Practical Nurse), LPN and upon observation from the nurse the resident's left arm was swollen with bruise on the posterior side of the arm. MD (Medical Doctor) was notified and an order for [REDACTED]. On Thursday (11/23) and Friday (11/24), (EI #6), CNA was assigned to (RI #1) on 7-3 shift. (EI #6) admits she turned and repositioned (RI #1) throughout those shifts without assistance from another staff member. On Saturday (11/26) and Sunday (11/27), (EI #5), CNA was assigned to (RI #1) on 7-3 shift and she also admits she turned, bathed, and repositioned (RI #1) without assistance of another staff member . On November 30, 2017, it was determined that (EI #7) was also not following the plan of care when she provided care to (RI #1) on 11/25/17 on 3-11 shift. They admitted to not reviewing (RI #1's) care plan prior to providing care . RI #1's Departmental Notes dated 11/26/17 at 11:49 a.m. documented: . Resident laying in bed. CNA notified nurse that resident was in pain and left are was swollen. On observation resident left arm swollen and posteria bruise to arm. Nurse notified supervisor, physician, and responsible party. Resident was given Tylenol 20.3 ML for pain. Received orders for upper arm x-ray. RI #1's Radiology Report, dated 11/26/17, documented: . HUMERUS MINIMUM 2 V (view), LEFT Results: There is a complete oblique fracture involving the neck of the humerus with modest displacement. The shoulder joint is grossly intact. Mild [MEDICAL CONDITION] changes are seen. Conclusion: Left humerus fracture as described . On 2/14/18 at 9:45 a.m., the surveyor conducted an interview with Employee Identifier (EI) # 6, the Certified Nursing Assistant (CNA) providing care to RI #1 on 11/23/17 and 11/24/17. The surveyor asked EI #6 when did she provide care to RI #1. EI #6 replied she provided a.m. care on 11/23/17 and 11/24/17. The surveyor asked EI #6 who assisted her in providing care to RI #1. EI #6 replied she did not have assistance with providing care. The surveyor asked EI #6 how many should assist when providing care to RI #1. EI #6 replied two. On 2/14/18 at 10:25 a.m., the surveyor conducted an interview with EI #3, Registered Nurse Supervisor at the time of the incident involving RI #1. The surveyor asked EI #3 what symptoms RI #1 displayed to warrant an x-ray. EI #3 replied RI #1's left arm was swollen and had facial grimacing. EI #3 said the x-ray revealed that RI #1 had a [MEDICAL CONDITION] arm. On 2/15/18 at 8:00 a.m., the surveyor conducted an interview with EI #7, the CNA that provided care to RI #1 on 11/25/17. EI #7 said two staff should provide care to RI #1. On 2/15/18 at 8:30 a.m., the surveyor conducted an interview with the Medical Director, EI #1. EI #1 said it was possible turning RI #1 could have caused the fracture. EI #1 said by placing pressure on RI #1's arm after being non-mobile for 19-[AGE] years, the bones tend to weaken. ************************************************************* The facility implemented corrective action to prevent recurrence of the identified deficient practice on 12/4/2018. These corrective actions were verified and included the following: (1) On 11/26/17, the facility obtained an x-ray to RI #1's right arm which revealed a fracture. (2) On 11/27/17, the facility reported to Alabama Department of Public Health Online Reporting System the Injury of Unknown Origin concerning RI #1 having a fracture to the left arm. (3) On 11/28/17 through 12/07/17, the facility began In-service training on following a residents plan of care. (4) On 11/29/17, RI #1 received orders for Occupational Therapy. (5) On 12/1/17 the CNAs caring for RI #1 on 11/23/17, 11/24/17, and 11/25/17 were given a written warning on failure to follow RI #1's plan of care (6) On 12/4/17 the facility provided inservice training to staff on ensuring if resident requires two person assist with ADLs, two people must assist. (7) On 12/4/17 the facility added to their QA (Quality Assurance) three programs titled: Following the Plan of Care, Total Care Resident Monitoring Tool, and The Buddy System. After review of the facility's investigation file, in-service/education records, staff interviews, and QA plan, the facility implemented corrective actions from 11/26/2017 to 12/04/2017. The facility will continue to monitor and/or revise their corrective action plan to prevent recurrence and maintain compliance. This deficiencies were written as a result of complaint/report #AL 480.

Based on observations, interview, a review of the facility policy titled, Dish Clearing and Cleaning Safety, a review of an undated/untitled facility policy, and a review of the 2013 Food Code, the facility failed to ensure: 1) a total of 120 meal trays were not observed wet and stored on top of each other in a clean area of the kitchen and 2) a dinner plate with a chipped area on the rim of it and four dinner plates with rough edges were stored on a shelf in the kitchen. These failures had the potential to effect all 128 residents receiving meals from the dietary department. Findings Include: 1) A review of an undated/untitled facility policy revealed the following: . Procedure: .10 . Remove the dishes, inspect for cleanliness and dryness, and put them away if clean . A review of the Food and Drug Administration Food Code 2013, Chapter 4 Protection of Clean Items, page 148, revealed the following: . Drying 4-901.11 Equipment and Utensils, Air-Drying Required. . After cleaning and SANITIZING, EQUIPMENT and UTENSILS: (A) Shall be air-dried . During the initial tour of the kitchen on 6/20/2017 beginning at 10:35 a.m., meal trays were observed wet. EI (Employee Identifier) #1, the Dietary Manager, and the surveyor counted 120 trays that were wet. During the interview with EI #1 on 6/22/2017, at 3:45 p.m., EI #1 was asked why did the meal trays have water on them and were wet nesting. EI #1 said the staff did not let them completely dry. EI #1 was asked had the trays been washed. EI #1 answered yes and then he rewashed them again and let them completely dry in the dish room. EI #1 was asked who was responsible for making sure meal trays were dried before storing them. EI #1 said the person that is pulling the trays. EI #1 was asked what was the facility's policy on storing dishes and trays after they had been washed. EI #1 said to allow them to dry before storing them. EI #1 was further asked what was the concern and the potential negative outcome with trays wet nesting. EI #1 said bacterial growth could cause the residents to get sick and affect them all. 2) A review of a facility policy titled, Dish Clearing and Cleaning Safety with a copyright date of 2013, revealed: . 5. Any broken or chipped dishes or glassware will be carefully removed from service and discarded. During the initial tour of the kitchen on 6/20/2017, beginning at 10:35 a.m., a dinner plate with a chipped area was observed on a shelf in the kitchen. Four plates with rough edges were observed in the same area. During the interview with EI #1 on 6/22/2017, at 3:45 p.m., EI #1 was asked could he explain why the dishes were found in the condition observed. EI #1 answered wear and tear. EI #1 was asked who was responsible for making sure residents dinner plates were in good condition, free of chips, and rough edges. EI #1 said the person pulling the dishes. EI #1 was asked could he explain why those dishes were on the shelf. EI #1 said no. EI #1 was asked what was the facility's policy on the condition of dinnerware for the residents. EI #1 answered any chips or frayed edges should be removed and reported to the Dietary Manager or the kitchen manager. EI #1 was asked what was the concern of serving resident on a plate with a chip on it or frayed edges. EI #1 said they could get cuts, skin tears, and the plates could harbor bacteria.

Based on observations, record reviews, and interviews, the facility failed to ensure: 1. A Tea spigot did not have a black substance on it. 2. Hair was covered in an area of the kitchen near clean dishes. 3. Tray cards that fell to the floor were not picked up, placed on the meal trays, and the staff member washed her hands after picking them up off of the floor. 4. A staff member left trayline, touched the door handle to answer the door, returned to the trayline washed her hands. This had the potential to affect 137 residents who receive a meal from the kitchen. Findings include: 1.) A review of the Food Code U. S. (United States) Public Health Service FDA (Food and Drug Administration) 2013, revealed, . Preventing Contamination from Equipment, . 3-304.11 Food Contact with Equipment and Utensils. FOOD shall only contact surfaces of: (A) EQUIPMENT and UTENSILS that are cleaned as specified under Part 4-6 of this Code and SANITIZED as specified under Part 4-7 of this Code; . Frequency 4-602.11 Equipment Food-Contact Surfaces and Utensils. for safety food such as iced tea dispensers, [MEDICATION NAME] beverage dispenser nozzles, beverage dispensing circuits or lines, water vending equipment, coffee bean grinders, ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. Some equipment manufacturers and industry associations, e.g., within the tea industry, develop guidelines for regular cleaning and sanitizing of equipment. If the manufacturer does not provide cleaning specifications for food contact surfaces of equipment that are not readily visible, the person in charge should develop a cleaning regimen that is based on the soil that may accumulate in those particular items of equipment. A review of a facility policy titled, Cleaning Instructions: Coffee, Beverage, Juice, Frozen Yogurt or Ice Cream Machines, with a copyright date of 2013, revealed, Policy: Coffee makers, urns, juice machines, frozen yogurt and/or ice machines will be cleaned thoroughly following the manufacturer's instructions. If no manufacturer's instructions are available, follow the instructions below.* . Beverage, juice, frozen yogurt and ice cream machines: 1. Follow the manufacturer's instructions. At 2:24 PM on 6/14/2016, the surveyor observed EI (Employee Identifier) #1, the Dietary Manager, remove the tea spigot from the tea dispenser. On the spigot, a residual of a black substance was observed on the grooves of the screw of the spigot. EI #1 proceeded to hand staff member dishwashing the spigot to clean and sanitize. 2.) A review of the Food Code U. S. Public Health Service FDA 2013, revealed, . Hair Restraints 2-402.11 Effectiveness. (A) . FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. 2./3./4.) A review of a facility policy titled, Food Safety and Sanitation, with a copyright date of 2013,revealed, Policy: All local, state and federal standards and regulations are followed in order to assure a safe and sanitary food service department. Procedure: . 2. Employees a. All staff will be in good health, will have clean personal habits and will handle all foods safely. c.Hair restraints are required and should cover all hair on the head. d. All staff will wash their hands just before they start to work in the kitchen and when they have used their hands in an unsanitary way . At 9:15 AM on 6/15/2016, the surveyor was in the kitchen talking to staff in the dishwashing area of the kitchen. EI #2, a Dietary Aide, was observed to have a 4 inch piece of uncovered hair hanging out of her hair restraint under her ear. 3.) A review of the Food Code U. S. Public Health Service FDA 2013, revealed, . Preventing Contamination from Other Sources 3-307.11 Miscellaneous Sources of Contamination. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306. 3./4.) A review of a facility policy titled, Handwashing, with a copyright date of 2013, revealed, Policy: Staff will wash hands as frequently as needed throughout the day following proper hand washing procedures . Procedure: Clean hands and exposed portions of arms . immediately before engaging in food preparation including working with exposed food. 1. When to Wash Hands: . After handling soiled equipment or utensils. During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. After engaging in other activities that contaminate the hands. At 12:05 PM on 6/15/2016, the surveyor was in the kitchen performing an observation of lunch tray line. EI #2 was observed to drop trayline cards on the floor. EI #2 proceeded to pick the cards up, placed the cards on the trays, and continued to work in the kitchen without washing her hands. At 12:22 PM on 6/15/2016, the surveyor was in the kitchen observing lunch tray line. During the tray line, EI #3, a Dietary Aide, was observed to leave tray line and open the door to let another staff member enter. EI #3 did not wash her hands. On 6/16/2016 at 2:35 PM, an interview was conducted with EI #4, a Dietary Aide. EI #4 was asked what was the facility's policy and procedure on hair restraints in the kitchen. EI #4 replied, Before we walk in, (we) put on a hair restraint and beard restraint to be worn at all times, anyone outside the kitchen has to put a hair restraint on or beard restraint. EI #4 was asked what the concern was regarding an observation in the dishwashing area of a worker with hair not fully restrained observed near dishes that were being racked in the dishwashing area. EI #4 stated, She has to immediately stop what she is doing, wash her hands before touching her body, fix hair net, groom hair, or put on a new hair restraint, go back to the dishes and rewash. It's possible to get the hair on the dishes. EI #4 was asked what the facility's policy was on hand washing on the tray line. EI #4 said, Wash before we handle food, hands must be washed at all times. EI #4 was asked what the concern was when items were dropped on the floor and placed back on the tray line without washing hands. EI #4 stated, That's a big no-no, replace it with a new item and wash your hands. If tray cards fell I would go back to rewash my hands because they touched the floor and are dirty. EI #4 was asked when hands should be washed while on tray line. EI #4 said, Before serving the food and after done. EI #4 was asked what the concern was of a worker who was observed on 6/15/2016 to leave the tray line, open a door and return to tray line without washing their hands. EI #4 responded, They are supposed to wash their hands if (they are) open(ing) (the) door, go rewash your hands. On 6/16/2016 at 2:56 PM, an interview was conducted with EI #1. EI #1 was asked what the concern was during the tour of the kitchen of a residual of a black substance observed on the spigot of the tea dispenser. EI #1 stated, It should be cleaned daily. It was debris and could cause somebody to get sick. EI #1 was asked what was the policy and procedure on cleaning the tea dispenser. EI #1 said, Every night they are to take it loose and clean it. Wash the base clean and sanitize. EI #1 was asked what the concern was when the tea dispenser had a black substance observed and tea was dispensed to the residents. EI #1 responded, Could cause a potential hazard and they get sick. EI #1 was asked what was the policy and procedure on hair restraints in the kitchen. EI #1 stated, All hair is to be covered including beards. EI #1 was asked what the concern was of an observation in the dishwashing area of a dietary worker who was observed with hair exposed under the ear area and clean dishes on racks around her. EI #1 said, If hair touches the clean dishes and can cause cross contamination so we have to be careful. EI #1 was asked the concern of an observation made on 6/15/2016 during tray line of EI #2 dropping a stack of tray cards and picking them up from the floor. EI #2 did not wash her hands or change gloves. EI #2 put the stack of tray cards back on the tray line and proceeded to place the individual papers on various trays. EI #1 replied, Dropping papers on dirty floor and putting them on the trays could cause contamination. She (EI# 2) did not follow the policy and procedure. EI #1 was asked the concern of an observation during tray line on 6/15/2016 of EI #3 who was observed to leave tray line and open a door. EI #3 went back to the tray line without washing her hands. EI #1 stated, Never should have got the door, did not wash hands, did not follow policy and procedure, and could cause cross contamination. EI #1 was asked what was the policy on hand washing in the kitchen. EI #1 said, Put paper towels down, turn water on, soap up hands, sing happy birthday while washing (15 seconds), take paper towels off dry hands and use the paper towel to cut the water off (and) dispose pressing garbage can with feet.

Based on observation, interviews, and record reviews, the facility failed to ensure Resident Identifier (RI) #12's Quarterly Minimum Data Set ((MDS) dated [DATE], and the Annual MDS dated [DATE] accurately assessed that the resident had severe contractures of all four extremities. This affected RI #12, one of twenty one residents whose MDS were reviewed. Findings Include: RI #12 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. A review of RI #12's Care Plan with the problem onset dated of 2/24/15 revealed: .Resident is at risk for falls due to decreased mobility .joint contractures to bilateral lower extremities, . A review of an O.T. (Occupational Therapy) Plan of Care for RI #12, dated 12/8/15, revealed, Reason for Referral: This [AGE] year old (resident) was referred to therapy with increasing UE (upper extremity) contracture putting patient at increased risk for skin breakdown and deformity. A review of an O.T. Plan of Care for RI #12, dated 5/12/16, revealed, Reason for Referral: This [AGE] year old (resident) was referred to OT for positioning due to increased contracture with LE (lower extremity) pressure ulcer on Left LE/foot. Need for OT services due to risk for further contractures and skin breakdown. Precautions: High Risk for skin breakdown due to LE contractures and immobility. Underlying Impairments Other(:) Pt (Patient) demo (demonstrates) severe pain / grimacing and yelling out with any joint movement/rom (Range of Motion) (upper and LB (lower body). Pt. demo bilateral hands fisted tightly with ulnar deviation at mcp (Metacarpophalangeal) joints and 90 degrees flexion of mcp L (left) and right U.E. (both) elbows at 90 degrees flexion with limited shoulder rom in flexion / abduction of 20 degrees. A review of a Quarterly MDS for RI #12, with an ARD (Assessment Reference Date) of 2/4/16, revealed RI #12 was coded as having impairment in ROM in upper and lower extremities on one side of the body. A review of an Annual MDS for RI #12, with an ARD of 5/2/16, revealed RI #12 was coded as having no impairment in ROM of the upper extremities and RI #12 had impairment in ROM in both lower extremities. On 6/15/16 at 10:20 AM, during an observation of perineal care being provided for RI #12, the resident was observed with elbows bent and arms positioned across the chest, palmer grips in both hands, and knees bent up. On 6/16/16 a hand-written revision was made to the Quarterly MDS for RI #12 with an ARD of 2/4/16 to indicate impairments in ROM on both sides in upper and lower extremities. On 6/16/16 a hand-written revision was made to the Annual MDS for RI #12 with an ARD of 5/2/16 to indicate impairments in ROM on both sides in upper and lower extremities. On 6/16/16 at 5:45 PM, the surveyor asked EI (Employee Identifier) #14, the MDS Coordinator, about the discrepancy regarding the MDS for RI #12. EI #14 stated rehabilitation therapy started treatment on 5/12/2016 for RI #12. The ARD was 5/2/2016 on the MDS assessment. Therapy had started after the ARD. EI #14 stated that she and the other MDS coordinators had reassessed the MDS with an ARD of 5/2/2016 and the MDS with an ARD of 2/4/16 regarding Range of Motion/Contractures. EI #14 stated both assessments had been modified to reflect both upper and lower extremity contractures. The modification had been done on 6/16/16.

Based on an observation, interviews, and record reviews, the facility failed to ensure a CNA (Certified Nursing Assistant) washed her hands and changed gloves while removing stool from RI (Resident Identifier) #5 during incontinence care. This affected RI #5, one of three residents observed for incontinence care. Findings include: A review of POTTER & PERRY . Fundamentals of Nursing .7th Edition .copyright 2009, revealed: .page 655 .Chapter 34 Infection Prevention and Control . The CDC (Center for Disease Control Prevention) (2002 b) recommends the following: . 2. If hands are not visibly soiled, use an alcohol-based waterless antiseptic agent for routinely decontaminating hands in all other clinical situations: . e. After contact with inanimate objects (including medical equipment) in the immediate area of the client . A review of, POTTER & PERRY . Fundamentals of Nursing .7th Edition .copyright 2009, revealed: .page- 877 to 879 .39-2 .Perineal Care . 3. Apply clean gloves, and assess genitalia for signs of inflammation, skin breakdown, or infection . Discard gloves. Perform hand hygiene . 10. If fecal material is present, enclose in a fold of underpad or toilet tissue .Cleanse buttocks and anus, washing front to back .Cleanse, rinse, and dry area thoroughly. 11. If gloves are soiled, perform hand hygiene and then apply new pair of gloves. 15. Provide perineal care. (7) Gently cleanse scrotum. Lift it carefully, and wash underlining skin folds. Rinse and dry. 17. Remove clean gloves, dispose in proper receptacle, and perform hand hygiene. A review of RI #5's medical record revealed the resident was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #5's Annual MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 5/26/16, indicated RI #5 had a BIMS (Brief Interview for Mental Status) score of 14 out of 15 possible points. This score indicated RI #5 was cognitively intact. RI #5 required extensive assistance with all activities of daily living. RI #5 was coded as always incontinent of bladder and bowel. On 6/15/16 at 8:05 AM, an observation was made of a bath/incontinence care for RI #5. The bath and incontinence care was performed by EI (Employee Identifier) #7, a CNA. EI #7 washed RI #5's face with a wash cloth. EI #7 removed the front of RI #5's adult brief and turned the resident to the left side. RI #5 had a moderate amount of soft brown stool. EI #7 cleaned RI #5's bottom to remove the stool. EI #7 removed her gloves and said she needed to go and get personal wipes. EI #7 left the room and returned with a pack of personal wipes. EI #7 did not wash her hands after removing the gloves used to remove stool from the resident's bottom. EI #7 removed all of the stool from RI #5's bottom. She turned RI #5 onto his/her back. EI #7 did not wash her hands or change her gloves. She proceeded to clean the front of RI #5's perineal area with the contaminated gloves. On 6/15/15 at 4:05 PM, an interview was conducted with EI #7. The surveyor asked EI #7 when should she wash hands and change gloves during incontinence care, especially when stool was present. EI #7 stated, I wash them when stool gets on the gloves. I wash my hands when I enter and leave the room. I wash my hands when I touch anything dirty. The surveyor asked EI #7 when did she wash her hands and change gloves during the incontinence care observation for RI #5. EI #7 stated, I washed them when I entered the room, and when I went out to get the wipes. I washed them when I got the face towel and body towel. I washed them so much. The surveyor shared the above observation with EI #7 and asked what was the concern. EI #7 stated, Yes, I do remember that. The concern is cross contamination. I was very nervous and he/she was rushing me to smoke and telling me to hurry. On 6/16/16 at 4:45 PM, an interview was conducted with EI #8, the Infection Control Nurse for the facility. EI #8 was asked when should staff wash their hands and change gloves during incontinence care. EI #8 stated, Before they start, when they finish, and when they remove their gloves. The surveyor discussed the above observation with EI #8, and asked what was the concern. EI #8 stated, Infection, especially UTIs (Urinary Tract Infections).

Based on observations, interview, and record reviews, the facility failed to ensure a medication error rate was not greater than 5%, as evidenced by an error rate of 10.7%. This was observed on three of twenty eight opportunities observed during medication pass. Findings Include: A review of POTTER AND PERRY FUNDAMENTALS OF NURSING Chapter 35 Medication Administration Page 706 - 707, revealed, Standards . Professional standards, such as the American Nurses Association's Nursing: Scope of Nursing Practice . To prevent medication errors, follow the six rights of medication administration consistently . The six rights of medication administration include the following: 1. The right medication 2. The right dose 3. The right client 4. The right route 5. The right time 6. The right documentation . A review of the medical record revealed RI (Resident Identifier) #4 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #4's Quarterly MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 4/11/16, revealed RI #4 had short and long term memory problems and was moderately impaired of daily decision making. RI #4 was incontinent of bladder and bowel function, and required total assistance with all ADLs (Activities of Daily Living). RI #4 also had a G (Gastrostomy)- Tube and received tube feeding for nutrition. A review of the physician orders [REDACTED]. [MEDICATION NAME] 30 MG (Milligram) PO (By Mouth) DAILY . Order Date 11/18/15 Start Date 11/18/15 . [MEDICATION NAME] 10 GM (Grams)/15 ML(Milliliters) SOLUTION - 30 ML PO DAILY . Order Date 2/12/16 Start Date 2/12/16 . [MEDICATION NAME] 10 MG TABLET PO . A review of the MAR (Medication Administration Record) dated June 2016 revealed, [MEDICATION NAME] 30 MG PO DAILY . Order Date: 11/19/15 Start Date: 11/19/15 . [MEDICATION NAME] 10 GM/15 ML SOLUTION PO DAILY . Order Date: 11/18/15 Start Date: 11/18/15 . [MEDICATION NAME] 10 MG TABLET PO DAILY . Order Date: 2/12/16 Start Date: 2/12/16 . On 6/15/16 at 8:10 AM, an observation was made of medication pass for RI #4 with EI (Employee Identifier) #13, an LPN (Licensed Practical Nurse), administering the medications. The surveyor observed EI #13 administer six medications and one supplement through RI #4's [DEVICE]. The medications included [MEDICATION NAME], and [MEDICATION NAME]. An interview was conducted at 2:55 PM with EI #13. The surveyor asked EI #13 if RI #4 was able to take anything by mouth. EI #13 said RI #4 got a therapeutic tray at lunch and dinner, usually containing soup and a beverage. EI #13 was asked how RI #4 tolerated the PO (by mouth) intake. EI #13 said RI #4 normally tolerated it well. If he/she did not like what was on the tray he/she would not let anyone put anything in his/her mouth. The surveyor asked EI #13 if RI #4 took any of his/her medications by mouth. EI #13 said not to her knowledge. She indicated she did not give the resident anything by mouth. EI #13 was asked if RI #4 had received any medications by mouth on 6/15/16. EI #13 stated not on her shift. The surveyor asked EI #13 to look at the MEDICATION ORDERS FOR [REDACTED]. After viewing the orders, EI #13 stated, For all three meds (medications), it shouldn't say that. EI #13 stated the orders read PO (by mouth) and the medications should have been given through the [DEVICE]. EI #13 was asked if any of RI #4 medications had been given by mouth and she said no. EI #13 was asked why the medications were ordered by mouth. EI #13 stated it was probably a transcription order (error), she didn't know. The surveyor asked EI #13 when chart checks were done at the facility. EI #13 stated she was not sure if chart checks were still done. The surveyor asked EI #13 how were orders processed and who was responsible for verifying the orders were correct. EI #13 stated after an order was written, the yellow copy was placed in a box for data entry to pick up and entered into the system. The surveyor asked EI #13 what were the five rights included in a medication order. EI #13 said the patient, medication, dosage, frequency and route. EI #13 was asked why was it important for those to be included in a medication order. EI #13 said because people had all types of allergies and it was a way of verifying everything added up. EI #13 was asked what would be a concern of not administering a medication according to the physician's orders [REDACTED].

Based on record reviews and interviews, the facility failed to ensure an annual of 12 hours of CNA inservice training was provided. This had the potential to affect 4 of 9 CNA records reviewed for CNA inservice training. Findings include: A review of an undated facility document titled, NURSING SERVICE INSERVICE REQUIREMENTS, revealed, IN ORDER TO COMPLY WITH FEDERAL GUIDELINES . TO ENSURE QUALITY CONTINUING EDUCATION OF OUR STAFF, THE FOLLOWING GUIDELINES ARE NOW IN EFFECT. 1. All CNA'S are to have a minimum of twelve (12.0) hours of inservice material per calendar year or one (1.0) per month of inservice if less than 1 year certified. 4. All nursing staff are required to attend ALL mandatory inservices that are required by STATE and FEDERAL Guidelines and deemed mandatory by the Director of Nursing. A review of an undated facility document from the Employee handbook revealed, . VI (six). EMPLOYEE PARTICIPATION . B. In-Service Training/Meetings In-service training, supervisors' meetings and staff meetings are scheduled for employee development and training. These will help you be aware of current developments that affect your job. You are expected to attend and will be paid for any meeting where attendance is required. On 6/16/2016 at 2:05 PM, a review of CNA training was conducted on EI (Employee Identifier) #'s 9, 10, 11 and 12. EI #9's hire date was 10/01/2013. EI #10's hire date was 9/26/1995. EI #11's hire date was 08/04/2014. EI #12's hire date was 05/15/2015. A review of the CNA files did not indicate the CNAs received a total of 12 hours of annual in-service education. The facility was asked by the surveyor to provide proof the CNA files reviewed had the 12 hours required annually for in-service education. The facility provided sign-in sheets without a total of 12 hours. The surveyor repeatedly asked the facility to provide hours of proof and the facility failed to do so on 4 of 9 employee files reviewed. On 6/16/2016 at 4:33 PM, an interview was conducted with EI #5, Staff Development Coordinator and ADON (Assistant Director of Nursing). EI #5 was asked how many CNA in-service education hours should CNAs receive annually. EI #5 stated, 12 (Twelve). EI #5 was asked who monitored the CNA in-service education training to ensure CNAs received the required training. EI #5 responded, I do. EI #5 was asked how were CNA in-service education training hours being monitored. EI #5 said, I have a CNA log I keep up with. EI #5 was asked what was the facility policy on CNA in-service training. EI #5 said, They are supposed to attend per the handbook. EI #5 was asked if she could provide evidence that 12 hours were provided in CNA in-service training over the past year. EI #5 stated, I can't, I have a make-up list of folks who need to attend. EI #5 was asked what was the concern of not providing in-service training. EI #5 replied, May not know how to provide care. EI #5 was asked how does the facility target an area of weakness of CNAs to ensure these areas target education needed. EI #5 responded, If weak, we pull them in and provide extra training, a minimum of 5 days or more if needed. On 6/16/2016 at 5:00 PM, an interview was conducted with EI #6, the Administrator. EI #6 was asked how many CNA in-service education hours should CNAs receive annually. EI #6 stated, 12. EI #6 was asked who monitored the CNA in-service education training to ensure CNAs received the required training. EI #6 replied, (EI #5's name) Staff Development Coordinator. EI #6 was asked how were CNA in-service education training hours being monitored. EI #6 said, An individual log and logs inservices and annual skills fair. EI #6 was asked what was the facility policy on CNA in-service training. EI #6 stated, What's in the handbook. EI #6 was asked if she could provide evidence that 12 hours were provided in CNA in-service training over the past year. EI #6 replied, We have so many I don't know. EI #6 was asked what was the concern of not providing in-service training. EI #6 stated, Depends on what they miss and perform job duties.